Post operative wound complications -different techniques of care- V. Chigharoe, M.D Resident general surgery AZP hospital, Suriname Introduction • • • • Definition wound Healing process Postoperative wound complications Clinical manifestations/treatment and prevention • Surgical site infections • The Surinamese setting Definition: wound A wound is a disruption of the normal structure and function of the skin and skin architecture. Acute wounds refer to those wounds where wound physiology is normal and healing is anticipated to progress through the normal stages of wound healing, whereas a chronic wound is defined as one that is physiologically impaired (e.g ischemic/venous/neuropathic ulcers/ infected surgical sites) Venous ulcus Ischemic ulcus Healing process • Normal healing through a sequence of physiological events that include hemostasis, inflammation, epithelialization, fibroplasia, and maturation To ensure proper healing, the wound bed needs to be well vascularized, free of devitalized tissue, clear of infection and moist. Wound complications • • • • • • • Seroma Hematoma Wound or fascial dehiscence Surgical site infection Allergic reaction Nerve injury Miscellaneous problems Hematoma and seroma Hematoma: collection of blood, more common than seroma (inadequate hemostase/bleeding diathesis, use of anticoagulants) Seroma: collection of serous fluid due to inadequate control of lymphatics during dissection Frequently seen under split-thickness skin grafts and in areas with large dead spaces (e.g., axilla, groin, neck, or pelvis). seroma hematoma • Both hematomas and seromas can cause the incision to separate and predispose to wound infection since bacteria can gain access to deeper layers and multiply uninhibited in the stagnant fluid Clinical manifestation • Few days after or delayed • asymptomatic or manifest as swelling, pain, and/or drainage • If infected: fever, erythema, wound induration and leukocytosis are also likely • Diagnosis primary made by examination, or ultrasound for subfascial collections Treatment hematoma/seroma • Small hematomas and seromas can be managed expectantly • Drainage of large collections (under sterile conditions) • incidental by means of needle aspiration or • permanent by removing sutures Prevention • proper hemostasis • Prophylactic drainage in case of: - large potential (dead) spaces - Obesitas - clinical suspects for wound infection Wound/Fascial dehiscence Definition: partial or total disruption of any or all layers of the operative wound • Early or late postoperative • Partial or complete dehiscence • superficial or deeper fascial planes Abdominal evisceration Risk factors for dehiscence • Systemic factors such as DM, cancer, immunosuppression • Local factors: - inadequate closure - increased intra-abdominal pressure (ileus) - deficient wound healing (infection/seroma/hematoma/drains) Clinical manifestations • Leakage of serosanguineous fluid from the wound. • Evisceration in case of abdominal incisions dehiscence Treatment/prevention • Thoracic/sternal dehiscence: exploration/debridement/ mediastinal irrigation (placement of drains)/re-closure • Abdominal dehiscence: partial expectant/elective procedure (hernia) • With evisceration exploration/abdominal lavage/re-closure (with full-thickness retention sutures of No. 22 wire or heavy nylon) Sternal dehiscence Prevention “ Dehiscence is often the result of using too few stitches and placing them too close to the edge of the fascia” • Sutures must be placed 2–3 cm from the wound edge and about 1 cm apart • Modern synthetic suture materials (polyglycolic acid, polypropylene, and others) are clearly superior to catgut for fascial closure • If infected, polypropylene degrades later than polyglycolic acid Surgical site infection (SSI) • SSI in stead of surgical wound infections, includes also extension of infection through deeper adjacent layers rather than the skin • SSI most common nosocomial infection (38%) Clinical criteria of SSI • A purulent exudate draining from a surgical site • A positive fluid culture obtained from a surgical site that was closed primarily • The surgeon's diagnosis of infection • A surgical site that requires reopening SSI types • Incisional Superficial and deep • Organ/dead space Pathogenesis/risk factors SSI • Inoculation of endogenous patient flora, skin flora and viscus (mostly polymicrobial) • Exogenous flora (personnel/OR environment) Risk factors: • The nature and number of organisms contaminating the surgical site • The health of the patient • The skill and technique of the surgeon Clinical manifestation/diagnosis • Symptoms include localized erythema, induration, warmth, and pain at the incision site. Purulent wound drainage and separation of the wound may occur • Fever and leucocytose systemic evidence of infection Treatment • Infected wounds are opened, explored, drained, irrigated, débrided and dressed open • Incision and drainage • Mechanical debridement • Deep wounds need wet-to-dry packing, up to 3 times daily • Wound dressings if granulation starts • Antibiotics only if adjacent tissue inflammation or systemic signs are present Wound dressings • Broad-spectrum antibiotics, further defined by culture and sentivity Topical agents( e.g povidone-iodine, sodium hypochlorite, hydrogen peroxide) may impede wound healing • Delayed closure or closure by secondary intention Allergic reaction • Local rash, redness, itching • Therapy: removal of allergen (adhesives/ointment) • Supportive treatment: antihistamine Allergic reaction Nerve injury • Pain, loss of sensation, and muscle weakness Prevention: proper dissection /avoidance nerve • neurectomy if already damaged Miscellaneous Problems Chronic local postoperative pain: consider the appearance of stitch abscess, a granuloma, an occult incisional hernia or a neuroma Therapy: exploration under local anesthesia The surinamese setting • Usage of AB-prophylaxe very subjective • Longer duration AB postoperative regarding many comorbidities • Frequent lack of available AB due to poor financial hospital status • wound complications grossly seen more often than industrialized countries (no data obtained) Thank you for your attention ？