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Any 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 , severe pain, and marked separation of edges.

42 OBG Management | October 2009 | Vol. 21 No. 10

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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 He also practices ObGyn at Mallory surgery. Requirements include: page 44 Community Health Center in Canton, • understanding of (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 or use of Dr. Pattillo is Professor of Obstetrics and dehiscence and Gynecology and Director of medication (TABLE 2, page 46) Gynecologic Oncology at Morehouse page 46 School of Medicine in Atlanta, Ga. • 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 • 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 , 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 , 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 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, -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 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 serous wound drainage cial space, if there is oozing on the muscle may be a sign of impending evisceration. bed) and apply a pressure to help After these measures are taken, cleanse and prevent hematoma. Although a drain is not lightly pack the wound to permit drainage. a substitute for precise hemostasis or careful surgical technique, it may be helpful when Hematoma requires identification of there is concern about oozing or a “wet” sur- the source of face, or when the patient is markedly obese. Hematoma represents blood or a blood clot Some practitioners have expressed con- within the tissues beneath the skin. It may cern over the risk of bacterial migration and be caused by persistent bleeding of a vessel, infection with placement of a drain, but oth- although the pressure within the wound and ers, including us, advocate use of a drain in the pressure produced by the dressing often the subcutaneous space to help remove resid- provide tamponade on the bleeding source, ual blood, fluid, and other debris to prevent in which case the hematoma forms with no the formation of dead space and infection active bleeding. and promote wound closure and healing. In Hematoma is usually caused by small a small study, Gallup and associates dem- bleeding vessels that were not apparent at onstrated a decreased incidence of wound the time of surgery or were not cauterized or

46 OBG Management | October 2009 | Vol. 21 No. 10 Table 3 3 prophylactic antibiotic regimens

Procedure Antibiotic Single intravenous dose Hysterectomy and urogynecologic Cefazolin 1 g or 2 g procedures, including those that Clindamycin plus gentamicin, a 600 mg plus 1.5 mg/kg, 400 mg, involve mesh quinolone, or aztreonam or 1 g, respectively Metronidazole plus gentamicin or 500 mg plus 1.5 mg/kg or 400 mg, a quinolone respectively

SOURCE: American College of Obstetricians and Gynecologists5 ligated at the time of closure. For this reason, tion technique or agent, but it did observe that it is important to achieve good hemostasis one study had demonstrated the superiority and a “dry” wound before closing the skin. of chlorhexidine to other cleansing agents.8 When hematoma is suspected, open Cruse and Foord also noted the slight the wound enough to permit adequate ex- superiority of chlorhexidine, as well as the posure and identify the source of bleeding. efficacy of clipping abdominal hair immedi- Evacuate as much blood and clot as possible ately before surgery.7 because blood is an ideal medium for bacte- rial growth. If active bleeding is found, use a When identifying organisms, silver nitrate applicator or handheld cautery look for the usual suspects pen to accomplish hemostasis at bedside. If The offending pathogens in infection are usu- bleeding is more severe, or the source cannot ally endogenous flora found on the patient’s be visualized, consider returning to the oper- skin and within hollow organs (, bow- ating room for more extensive exploration. el). The organisms most commonly respon- Once hemostasis is achieved, irrigate sible for infection are Staphylococcus (aureus, the wound copiously and institute local epidermidis), enterococci, and Escherichia wound care. coli. However, the bacteria identified in the Abdominal wound wound may not be the causative organism. infection occurs in Most typically become clini- about 5% of cases How common is infection? cally apparent between the fifth and 10th and typically Before it is possible to address this question, postoperative days, often after the patient becomes clinically it is necessary to clarify the terminology of in- has been discharged, although they may ap- apparent between fection. Contamination and colonization are pear much earlier or much later. One of us the fifth and 10th different entities. The first refers to the pres- (Dr. Perkins) had a patient who presented postoperative days ence of bacteria without multiplication. The with a suppurative infection after undergo- latter describes the multiplication of bacteria ing hysterectomy for endometrial carcinoma in the absence of a host response. When in- 5 months earlier. fection is present, bacterial proliferation pro- duces clinical signs and symptoms. Cellulitis is common Postoperative abdominal wound infec- Wound cellulitis, a common, nonsuppurative tion occurs in about 5% of cases but may be infection of skin and underlying connective more common in procedures that involve a tissue, is generally not severe. The wound as- greater level of contamination.7 One study sumes a brawny, reddish brown appearance found a 12% incidence of wound infection, associated with edema, warmth, and erythe- but the rate declined to 8% when antibiotic ma. Fever is not always present. prophylaxis was instituted.4 It is important to remember that cel- Several other studies have examined de- lulitis may surround a deeper infection. Al- terminants of infection. For example, a large though needle aspiration of the leading edge Cochrane review found no real differences in has been advocated, it yields a positive cul- main text continued on infection rate by preoperative skin prepara- ture in only 20% to 40% of cases. page 50

obgmanagement.com Vol. 21 No. 10 | October 2009 | OBG Management 47 Surgical techniques / Wound complication

Biologic phases of wound healing—overlapping and interdependent

It was pioneering Scottish surgeon John Hunter who noted that “injury alone has in all cases the tendency to produce the disposition and means of a cure.”15 Unlike the tissue regeneration that occurs primarily in lower animals, human wound healing is mediated by collagen deposition, or scarring, which provides structural support to the wound. This scarring process may itself cause a variety of clinical problems. Wound healing is characterized by overlapping, largely interdependent phases, with no clear demarcation between them.

Failure in one phase may have a negative t n e

impact on the overall outcome. m e

In general, wound healing involves g a two phases: inflammation and prolif- n eration. Within these phases, the follow-

ing processes occur: scar maturation, r OBG Ma wound contraction, and epithelialization. o

These repair mechanisms are activated in ell f w response to tissue injury even when it is le F surgically induced. Rob Inflammation triggers increased blood flow and migration of neutrophils, Inflammatory phase monocytes, macrophages, and other cells into the wound. The initial response to tissue injury is inflammation, which is mediated by various amines, enzymes, and other substances. This inflammation can be further broken down into vas- by complement factors and cytokines. A specific im- cular and cellular responses. mune response follows, aimed at destroying specific The first burst of blood acts to cleanse the wound antigens, and involves both B- and T-lymphocytes. of foreign debris. It is followed by vasoconstriction, which is mediated by thromboxane 2, to decrease blood Proliferative phase loss. Vasodilation then occurs once histamine and Proliferation is characterized by the infiltration of serotonin are released, permitting increased blood flow endothelial cells and fibroblasts and subsequent to the wound. The surge in blood flow accounts for the collagen deposition along a previously formed fibrin increased warmth and redness of the wound. Vasodila- network. This new, highly vascularized tissue assumes tion also increases capillary permeability, allowing the a granular appearance—hence, the term “granulation migration of red blood cells, platelets, leukocytes, tissue.” plasma, and other tissue fluids into the interstitium of Collagen that is deposited in the wound under- the wound. This migration accounts for wound edema. goes maturation and remodeling, increasing the ten- In the cellular response, which is facilitated by sile strength of the wound. The process continues for increased blood flow, cell migration occurs as part of months after the initial insult. an immune response. Neutrophils, the first cells to enter All wounds undergo some degree of contraction, but the wound, engage in phagocytosis of bacteria and the process is more relevant in wounds that remain open debris. Subsequently, there is migration of monocytes, or involve significant tissue loss. macrophages, and other cells. This nonspecific immune Last, the external covering of the wound is restored response is sustained by prostaglandins, aided by epithelialization.

48 OBG Management | October 2009 | Vol. 21 No. 10 Surgical techniques / Wound complication

or sutures from the area. Local exploration 11 key strategies for preventing wound complication is mandatory, and fascial integrity must be confirmed. If a pocket of pus is found, open • During preoperative evaluation, assess the patient for risk factors, the wound liberally to determine the extent comorbid conditions, and medications that can impair healing of the pocket and permit as much evacuation • If the patient is morbidly obese and planning to undergo an as possible. Wound culture is optional. Insti- elective, nonurgent procedure, consider instituting a plan for tute local wound care and consider adjuvant preoperative weight loss antibiotics in selected cases. • advise smokers to “kick the habit” 1 or 2 months before surgery • avoid using electrocautery in the “coagulation current” setting Ensure fascial integrity when incising the fascia Any infection that arises immediately adja- • When approximating the fascia, take wide bites of tissue cent to the fascia may have an intra-abdom- (1.5 to 2 cm from the edge) inal component, although that is unlikely. • avoid excessive suture tension when closing the fascial layer Extensive exploration is warranted to assess (“Approximate, don’t strangulate”) fascial integrity. • Obtain good hemostasis before closing the wound; consider If intra-abdominal infection is suspect- placing a drain in an obese patient ed, order appropriate imaging. • In a high-risk patient who has multiple risk factors, consider Patients who have deep infection usually retention sutures exhibit frank, purulent discharge; fever; and • Minimize or avoid abdominal distention during the postoperative severe pain. Marked separation of wound period with: edges is often present as well, as is an elevat- - good pulmonary toileting ed white blood cell count. - gradual ambulation As with superficial infection, the key to - a nasogastric tube (as needed) therapy is liberal exploration, drainage of • assess the wound for infection early, and treat infection promptly the abscess cavity, and mechanical wound • remember to administer prophylactic antibiotics debridement. Irrigate the wound copiously using a dilute mixture of saline and hydrogen peroxide to remove any remaining debris. In the absence of purulent drainage, Avoid povidone-iodine solution because it treat cellulitis with antibiotics, utilizing sul- inhibits normal tissue granulation. famethoxazole-trimethroprim, a cephalo- The wound may be left open to heal by sporin, or augmented penicillin, and apply secondary intention, or it may be closed sec- warm packs to the wound. ondarily after 3 to 6 days, provided there is no If purulent drainage is seen, or the patient evidence of infection and a healthy granulat- fails to improve significantly within 24 hours, ing bed is present. suspect an abscess or resistant organism. Consider adjuvant antibiotics, especially when the patient is immunocompromised. Most wound infections If the wound has pronounced edema and are superficial unusual discoloration, consider a serious in- Approximately 75% of all wound infections fection such as necrotizing fasciitis. involve the skin and subcutaneous tissue lay- ers. Superficial infection is more likely to occur when there is an undrained hematoma, exces- Wound dehiscence raises risk sively tight sutures, tissue trauma, or a retained of evisceration foreign material. Edema, erythema, and pain Dehiscence of the abdominal incision occurs and tenderness may be more pronounced than when the various layers separate. Dehiscence with cellulitis. A low-grade fever may be pres- may be extrafascial (superficial disruption of ent, and incisional discharge typically occurs. the skin and subcutaneous tissue only) or may Drainage is the cornerstone of manage- involve all layers, including peritoneum (com- ment and requires the removal of staples plete fascial dehiscence or burst abdomen).

50 OBG Management | October 2009 | Vol. 21 No. 10 Earn Free

When bowel or omentum extrudes, the term evisceration is appropriate. CME In several reviews of the literature, the inci- dence of dehiscence ranged from 0.4% in earlier 9–12 Credits studies to 1% to 3% in later reviews. Despite advances in preoperative and postoperative care, suture materials, surgical technique, and Click on audio/video at antibiotics, fascial dehiscence remains a seri- srm-ejournal.com ous problem in abdominal surgery.

What causes wound disruption? To a great extent, abdominal wound break- down is a function of surgical technique and Access latest webcasts/ method of closure. Although the conven- podcasts on: tional wisdom is that dehiscence occurs less frequently with a transverse incision than with a vertical one, this assumption is being New rules, new tools in challenged. A small study by Hendrix and associates found no differences in the rate of HT treatment during the dehiscence by type of incision.13 That finding menopausal transition suggests that the incidence of dehiscence is inversely related to the strength of closure. Selection of the appropriate suture ma- Potential risks associated terial also is important. In addition, use of electrocautery in the “cutting current” mode with IVF and known strategies when the abdomen is opened causes less tis- sue injury than “coagulation current.” The for reducing them latter has a greater thermal effect, thereby weakening the fascial layer. Patient characteristics that influence wound Enhancing contraceptive integrity include comorbidities such as dia- success among patients betes and malignancy, recent corticosteroid administration, and malnutrition. Although infection may accompany su- Showcased at the recent perficial wound separation, its role in com- plete dehiscence is unclear. 37th annual meeting of the Conditions that cause abdominal dis- American Society tention, such as severe coughing, vomiting, of Reproductive Medicine ileus, and ascites, may contribute to dehis- cence, particularly when the closure method is less than satisfactory. Some authors have found a greater in- cidence of wound disruption when multiple risk factors are present. In patients who had eight or more risk factors, wound disruption was universal.11,12

Management entails debridement, irrigation, and closure In partnership with When extrafascial dehiscence occurs, me-

October 2009 | OBG Management 51 Surgical techniques / Wound complication

Advances in wound management offer help and promise

Vacuum-assisted closure thetic materials—both absorbable setting and in the repair of ventral The vacuum-assisted wound closure and nonabsorbable varieties—have hernia, but is a relatively new addition system is a device that speeds been employed to bridge the defect, to the management of fascial defects healing and reduces the risk of but their use sometimes leads to associated with wound breakdown. complication. It consists of a sponge adhesions, infection, and cutane- dressing that can be sized to fit an ous fistula.T hese risks are of special Growth factors open wound and connected to an concern when the wound is already Wound healing is regulated by a apparatus that generates negative contaminated or otherwise number of entities, including cyto- pressure. The device enhances compromised. kines and growth factors, so it is no healing by removing excess fluid One alternative is human surprise that research has turned its and debris and decreasing wound acellular dermal matrix (AlloDerm, focus on them. In a preliminary study, edema. LifeCell Corp). Tung and colleagues investigators found that separated argenta and associates reported described its use for repair of a fas- abdominal wounds closed faster successful use of this system to cial defect in a previously irradiated when recombinant human plate- expedite healing in three cases of patient whose postoperative let-derived growth factor BB was wound failure.16 It can be employed course was complicated by pelvic topically administered than they did in the home-health setting by nurses infection.17 This dermal matrix, a when they were left open to close by trained in its use. basement membrane taken from secondary intention.18 cadaveric skin, promotes neovascu- although their use is not com- Human acellular dermal matrix larization and is thought to be associ- monplace in wound management, Occasionally, breakdown of a wound ated with a lower incidence of infec- research suggests that growth factors creates marked fascial defects that tion and adhesions than is traditional may one day be helpful adjuncts in preclude secondary closure. Syn­ mesh. It is widely used in the burn the care of wound complications.

chanical debridement and irrigation are catastrophic complication that is associated usually the only measures necessary before with a mortality rate of about 20%. It typically deciding how to close the wound—even if in- occurs between the third and seventh post- fection is present. Remove all foreign mate- operative days, although later occurrences rial and excise any devitalized tissue. have been reported. As for the method of closure, the choice Warning signs of impending eviscera- is usually between secondary closure and tion include serous drainage in the absence leaving the wound open to heal by second- of obvious infection, and a “popping” sensa- ary intention. An alternative to the latter is tion on the part of the patient—a feeling that wound closure after several days, once a something is “giving way.” healthy granulating bed develops. If evisceration occurs, cover exposed Dodson and colleagues described a bowel with packs soaked in saline or po- technique of superficial wound closure that vidone-iodine and prepare the patient for can be performed at the bedside using local emergency surgery. Institute both hydration anesthesia, with little discomfort to the pa- and broad-spectrum antibiotics. tient.14 Wound separation caused by a small Before replacing the abdominal con- hematoma or sterile seroma especially lends tents, thoroughly irrigate the peritoneal cav- itself to this type of immediate closure. ity and inspect the bowel carefully, excising any necrotic tissue. Complete fascial dehiscence is a Reapproximate the fascia using inter- “catastrophic” complication rupted #1 or #2 monofilament suture. Also Complete dehiscence of the fascia and extru- consider placing retention sutures, particu- sion of intra-abdominal contents is a serious larly when the patient has multiple risk fac-

52 OBG Management | October 2009 | Vol. 21 No. 10 tors for wound complications (Figure). Leave Figure Consider retention sutures for high-risk patients the wound open, prepared for later closure. If the abdomen cannot be closed be- cause of peritonitis or bowel edema, or there is an insufficient amount of fascia remain- ing, approximate the abdominal wall using bridging sutures over a gauze pack as a tem- porizing measure until reconstruction can be performed. Consultation with a plastic sur- geon or trauma specialist is recommended.

Necrotizing fasciitis: Worst of the worst Necrotizing fasciitis is a dangerous, synergis- tic, bacterial infection involving the fascia, Retention sutures are placed in interrupted fashion to support the primary suture subcutaneous tissue, and skin. The culprits line and are carried through the full thickness of the tissue, from the abdominal wall skin through the fascia and, if possible, the peritoneum. A rubber bolster are multiple bacterial pathogens that include placed across each suture keeps the suture from cutting into the skin (inset).

Streptococcus pyogenes, staphylococcal spe- Rob Flewell for OBG Management cies, gram-negative aerobes, and anaerobes. The infection typically originates at a local- ized area, spreads along the fascial planes, and ultimately causes septic thrombosis of Laboratory evaluation includes a white the vessels penetrating the skin and deeper blood cell count. Biopsy also is recommend- layers. The result is necrosis. The associated ed. If necrotizing fasciitis is present, biopsy mortality rate is approximately 20%. will reveal necrosis and thrombi of vessels The patient who has necrotizing fasci- passing through the fascia. itis typically displays severe pain; anesthetic, Treatment of necrotizing fasciitis requires edematous skin; purple, necrotic wound intravenous, broad-spectrum antibiotics, in- edges; hemorrhagic bullae; and crepitus. cluding penicillin, that are adjusted according Frank necrosis subsequently develops, to the findings of the wound culture and sen- with surrounding inflammation and edema, sitivity test. Cardiovascular and fluid-volume and leads to systemic toxicity, with fever, he- support is critical, as is wide surgical debride- modynamic abnormality, and shock. In ad- ment of all necrosed skin and fascia. The latter, vanced stages, gangrene is present. in fact, is the cornerstone of therapy.

References 1. Lin L, Song J, Kimber N, et al. The role of bacterial infection. A 10-year prospective study of 62,639 14. Dodson MK, Magann EF, Sullivan DL, Meeks GR. vaginosis in infection after major gynecologic surgery. wounds. Surg Clin North Am. 1980;60:27–40. Extrafascial wound dehiscence: deep en bloc closure Infect Dis Obstet Gynecol. 1999;7:169–174. 8. Edwards PS, Lipp A, Holmes A. Preoperative skin versus superficial skin closure. Obstet Gynecol. 2. Williams JZ, Barbul A. Nutrition and wound antiseptics for preventing surgical wound infections 1994;83:142–145. healing. Surg Clin North Am. 2003;83:571–596. after clean surgery. Cochrane Database Syst Rev. 15. Brunicardi FC, Andersen DK, Billiar TR, Dunn 3. Perkins JD, Jackson RA. Risks and remedies when 2004;(3):CD003949. DL, Hunter JG, Pollock RE. Chapter 8: Wound healing. your surgical patient is obese. OBG Management. 9. Baggish MS, Lee WK. Abdominal wound In: Schwartz’s Principles of Surgery. 8th ed. New York: 2007;19(10)34–54. disruption. Obstet Gynecol. 1975;46:530–534. McGraw-Hill; 2005. 4. Kamat AA, Brancazio L, Gibson M. Wound 10. Poole GV Jr. Mechanical factors in abdominal 16. Argenta PA, Rahaman J, Gretz HF 3rd, Nezhat F, infection in gynecologic surgery. Infect Dis Obstet wound closure: the prevention of fascial dehiscence. Cohen CJ. Vacuum-assisted closure in the treatment of Gynecol. 2000;8:230–234. Surgery. 1985;97:631–640. complex gynecologic wound failures. Obstet Gynecol. 5. American College of Obstetricians and Gynecologists. 11. Carlson MA. Acute wound failure. Surg Clin North 2002;99:497–501. Antibiotic prophylaxis for gynecologic procedures. ACOG Am. 1997;77:607–636. 17. Tung CS, Zighelboim I, Scott B, Anderson ML. Human Practice Bulletin #104. Washington, DC: ACOG; 2009. 12. Cliby WA. Abdominal incision wound breakdown. acellular dermal matrix for closure of a contaminated 6. Gallup DC, Gallup DG, Nolan TE, Smith RP, Clin Obstet Gynecol. 2002;45:507–517. gynecologic wound. Gynecol Oncol. 2006;103:354–356. Messing MF, Kline KL. Use of a subcutaneous closed 13. Hendrix SL, Schimp V, Martin J, Singh A, Kruger 18. Shackelford DP, Fackler E, Hoffman MK, Atkinson drainage system and antibiotics in obese gynecologic M, McNeeley SG. The legendary superior strength S. Use of topical recombinant human platelet-derived patients. Am J Obstet Gynecol. 1996;175:358–362. of the Pfannenstiel incision: a myth? Am J Obstet growth factor BB in abdominal wound separation. Am 7. Cruse PJE, Foord R. The epidemiology of wound Gynecol. 2000;182:1446–1451. J Obstet Gynecol. 2002;186:701–704.

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