Introduction Post operative wound complications - different techniques of care-

Post operative wound complications
-different techniques of care-
V. Chigharoe, M.D
Resident general surgery
AZP hospital, Suriname
Definition wound
Healing process
Postoperative wound complications
Clinical manifestations/treatment and
• Surgical site infections
• The Surinamese setting
Definition: wound
A wound is a disruption of the normal
structure and function of the skin and skin
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
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
Frequently seen under split-thickness skin
grafts and in areas with large dead spaces
(e.g., axilla, groin, neck, or pelvis).
• 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
• incidental by means of needle aspiration or
• permanent by removing sutures
• 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,
• Local factors:
- inadequate closure
- increased intra-abdominal pressure (ileus)
- deficient wound healing
Clinical manifestations
• Leakage of serosanguineous fluid from the
• Evisceration in case of abdominal incisions
• Thoracic/sternal dehiscence:
exploration/debridement/ mediastinal
irrigation (placement of drains)/re-closure
• Abdominal dehiscence: partial
expectant/elective procedure (hernia)
• With evisceration
lavage/re-closure (with full-thickness retention sutures of No.
22 wire or heavy nylon)
Sternal dehiscence
“ 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
• 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
• 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
Allergic reaction
• Local rash, redness, itching
• Therapy: removal of allergen
• 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
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
Thank you for your attention