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For Personal Use Only ® Dowden Health Media CopyrightFor personal use only Any infection that arises immediately adjacent to the fascia may have an intra-abdominal component. Extensive exploration is warranted to assess fascial integrity. Signs of deep infection include fever, severe pain, and marked separation of wound edges. 42 OBG Management | October 2009 | Vol. 21 No. 10 For mass reproduction, content licensing and permissions contact Dowden Health Media. SurgIcal TechnIQues How to avert postoperative wound complication—and treat it when it occurs Avoid wound infection and dehiscence with the help of thorough preoperative assessment, careful technique, tried-and-true strategies, and a few novel products espite advances in medicine and surgery over the James D. Perkins, MD past century, postoperative wound complication Dr. Perkins is Affiliate Assistant remains a serious challenge. When a complica- Professor of Obstetrics and D Gynecology at the University of tion occurs, it translates into prolonged hospitalization, Mississippi Medical Center in lost time from work, and greater cost to the patient and Jackson, Miss, and Adjunct Clinical Assistant Professor of Obstetrics the health-care system. Classification of and Gynecology at Morehouse Prevention of wound complication begins well before School of Medicine in Atlanta, Ga. surgical wounds He also practices ObGyn at Mallory surgery. Requirements include: page 44 Community Health Center in Canton, • understanding of wound healing (see page 48) and Miss. the classification of wounds (TABLE 1, page 44) Risk factors for Roland A. Pattillo, MD • thorough assessment of the patient for risk factors for poor wound healing impaired wound healing, such as diabetes or use of Dr. Pattillo is Professor of Obstetrics and dehiscence and Gynecology and Director of corticosteroid medication (TABLE 2, page 46) Gynecologic Oncology at Morehouse page 46 School of Medicine in Atlanta, Ga. • antibiotic prophylaxis, if indicated (TABLE 3, page 47) • good surgical technique, gentle tissue handling, and The authors report no financial Necrotizing fasciitis: relationships relevant to this article. meticulous hemostasis • placement of a drain, when appropriate Worst of the worst • awareness of technology that can enhance healing page 53 • close monitoring in the postoperative period T n • intervention at the first hint of abnormality. E m E In this article, we describe predisposing factors and g A n preventive techniques and measures, and outline the MA most common wound complications, from seroma to de- obg hiscence, including effective management strategies. R o F n ›› SHARE YOUR COMMENTs A m Preop, do you provide antibiotic R o prophylaxis routinely? Conditions and drugs that impair healing E-MAIL [email protected] Preexisting medical conditions may limit healing, espe- LLY B o FAX 201-391-2778 M cially conditions associated with diminished delivery obgmanagement.com Vol. 21 No. 10 | October 2009 | OBG Management 43 SurgIcal technIQues / Wound complIcatIon Table 1 Classification of surgical wounds Because steroids, NSAIDs, and chemo- therapy agents impede wound healing, and CLASS I – Clean wounds (infection rate <5%) anticoagulants may interfere with granula- • Created under ideal operating room conditions tion, it is crucial to review the patient’s medi- • Usually an elective surgical incision made under aseptic conditions and not predisposed to infection cations well in advance of surgery. • Uninfected wound with no inflammation • No entry into oropharyngeal cavity, respiratory tract, alimentary tract, or genitourinary tract • Always closed primarily and usually not drained Nutrition plays a critical role CLASS II – Clean–contaminated wounds (infection rate 2–10%) The importance of nutrition cannot be over- • Entry into oropharyngeal cavity, respiratory tract, alimentary tract, stated. A significant percentage of patients or genitourinary tract under controlled conditions without unusual are thought to have some degree of nutri- contamination or significant spillage, e.g., hysterectomy, appendectomy tional deficiency preoperatively. This defi- • Minor break in surgical technique ciency may alter the inflammatory response, • No evidence of infection impair collagen synthesis, and reduce the CLASS III – Contaminated wounds (infection rate 15–20%) tensile strength of the wound. • Fresh, open, traumatic wound or injury, e.g., soft-tissue laceration, open fracture Because healing requires energy, deficits • Surgical procedures that involve gross spillage from gastrointestinal tract in carbohydrates may limit protein utiliza- • Genitourinary or biliary tract procedures in the presence of infected urine or bile tion, and deficiencies of vitamins and micro- • Major break in surgical technique 2 • Incisions that encounter acute, nonpurulent inflammation nutrients can also interfere with healing. NOTE: Microorganisms multiply so rapidly that a contaminated wound may progress Obesity, too, increases the risk of postop- to infection within 6 hours. erative wound complication. Markedly obese CLASS IV – Dirty or infected wounds (infection rate >30%) patients have a thick, avascular, subcutane- • Traumatic wounds more than 4 hours old ous layer of fat that compromises healing.3 • Wounds that are heavily contaminated or clinically infected before surgery, e.g., tubo-ovarian abscess • Perforated viscera • Neglected traumatic wounds in which devitalized tissue or foreign material is Meticulous technique required retained NOTE: Infection that is present at the time of surgery can increase the postoperative infection Good surgical technique and appropriate risk by an average of fourfold. use of antibiotics are critical components of SOURCE: Centers for Disease Control and Prevention and the American College of Surgeons successful wound healing. When placing the incision, avoid the moist, bacteria-laden subpannicular crease of oxygen and nutrients to healing tissues. in the markedly obese. Diabetes can damage the vasculature During a procedure, handle tissue gen- and may impair healing if the blood glucose tly, keep it moist, and make minimal use of level is markedly elevated in the periop- electrocautery to reduce tissue injury and erative period. Such an elevation impedes promote healing. Keep operating time and transport of vitamin C, a key component of blood loss to a minimum, and debride the collagen synthesis. wound of any foreign material and devital- Malignancy and immunosuppressive ized tissue. disorders may prevent optimal healing by Multiple studies have demonstrated that compromising the immune response. judicious use of prophylactic antibiotics sig- Bacterial vaginosis, a common polymi- nificantly decreases the incidence of wound crobial infection involving aerobic and an- infection, particularly in relation to hysterec- aerobic bacteria, appears to be associated tomy and vaginal procedures and when en- with postoperative febrile morbidity and try into bowel is anticipated.4,5 A number of surgical-site infection, particularly after hys- prophylactic regimens are given in TABLE 3. terectomy.1 Current guidelines recommend Meticulous hemostasis at the time of that medical therapy for bacterial vaginosis closure is imperative. When complete he- be instituted at least 4 days before surgery mostasis cannot be confirmed, place a small and continued postoperatively. drain in the subcutaneous space (or subfas- 44 OBG Management | October 2009 | Vol. 21 No. 10 SurgIcal technIQues / Wound complIcatIon Table 2 Risk factors for poor wound healing breakdown when a drain was placed.6 and dehiscence A closed-suction drain, such as a Jack- son-Pratt or Hemovac model, helps mini- Poor wound healing mize wound complication when it is placed • Advanced age in the subcutaneous layer. (Avoid a rubber • Hypoxia/severe anemia • Medications Penrose drain because it may allow bacteria - chemotherapy to enter the wound.) It is imperative that the - immunosuppressive drugs drain exit the body via a separate site and - steroids - nonsteroidal anti-inflammatory drugs not through the incision itself. We advocate - anticoagulants removal when less than 30 mL of fluid accu- • Poor nutritional status mulates in the reservoir over 24 hours. • Diabetes • Arterial-venous disease • Dehydration • Obesity Fluid within the wound does • Immunocompromised state not always indicate infection • Malignancy • History of radiation therapy Wound collections are not necessarily indic- ative of infection; collections of fluid within Abdominal wound dehiscence the wound may represent a serous transu- • Obesity • Malnutrition date, blood, pus, or a combination of these. • Marked anemia If the fluid is not addressed, however, fulmi- • Advanced age nant infection may be the result. • Uncontrolled diabetes • Pulmonary disease • Uremia Seroma is usually painless • Malignancy A seroma is a collection of wound exudates • Infection within the dead space. Seroma typically in- • Abdominal distention (straining, coughing, ascites) • History of radiation therapy volves thin, pink, watery discharge and mini- • Chemotherapy mal edge separation. In some cases, there • Use of corticosteroids may be surrounding edema but generally • Poor surgical technique (type of incision, type of suture, method and strength of closure, use of electrocautery in “coagulation current” setting) little to no tenderness. When a seroma is detected, remove the SOURCE: Carlson,11 Cliby12. staples or stitches in the area of concern and explore the wound. It is essential to ensure fascial integrity, as
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