Approach to postoperative wound complications: Clinical sciences

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Introduction0:00–0:53

Postoperative wound complications involve the disruption of anatomical layers that were manipulated or closed during surgery, and include wound disruptions such as evisceration, dehiscence, seroma, or hematoma; abnormal communications known as fistula; and wound infections, which can be superficial or deep.
There are some risk factors that can predispose the patient to postoperative wound complications. These include factors that contribute to poor healing, like smoking, malnutrition, and chronic steroid use, as well as conditions like diabetes or anemia, and ascites.
Other risk factors don’t affect the healing but increase the risk of bleeding, such as coagulopathy or receiving anticoagulation.
When assessing a patient with signs and symptoms suggestive of postoperative wound complication, you should first perform an ABCDE assessment to determine whether your patient is unstable or stable.

Unstable patient0:53–1:31

If the patient is unstable, start with acute management to stabilize them. This means that you might need to intubate the patient, obtain IV access, or administer fluids before continuing with your assessment.
At this step, you should look for signs of conditions that cause instability, such as abdominal compartment syndrome, sepsis, or severe blood loss.
Alright, now that unstable patients are taken care of, let’s talk about stable patients. For a stable patient, your first step is to start supportive care.

Stable patient1:31–2:09

This means that you need to obtain IV access for fluid resuscitation, administer pain medication, wound care, and in some cases, NPO status for bowel rest with nutritional support if needed.
Keep in mind though that oral or enteral nutrition is preferred in most cases, and should be instituted as soon as possible.
Once these important steps are done, obtain a focused history and physical examination. Let’s start with wound disruptions, which occur when the integrity of the surgical closure has been compromised.

Wound disruptions2:09–6:42

Wound disruptions include evisceration, dehiscence, and fluid collection. Now, evisceration is the most severe of the three.
Patients might report a history of straining or a popping sensation. Additionally, you might find that they had abdominal surgery, and possibly a history of a previous infection or fluid collection affecting the abdominal incision.
On the other hand, the physical exam typically reveals a complete opening of all layers of an incision with the spilling of abdominal contents.
If you see this, you can diagnose evisceration, which is a surgical emergency.The next type of wound disruption is dehiscence.
A dehiscence can happen with any incision, however, there are types of surgeries in which it is more common, such as in hernia surgery, vascular surgery, and any emergency surgery.
Patients may report a history of previous infection or fluid collection, a feeling like a wound is opening, an increasing amount of drainage or the need to change their dressing more often, or sudden pain at the incision.
On exam, you’ll see a partial or complete opening of incision similar to evisceration, However, unlike evisceration, the abdominal contents are contained.
Additionally, there might be a possible change in wound contour; bulging or incisional swelling; drainage; and tachycardia, possibly related to dehydration.If you see these findings, consider dehiscence.
Evaluation of these patients includes ordering labs like CBC, ESR, CRP, BMP, and albumin. Labs might show leukocytosis, elevated CRP and ESR, hypoalbuminemia, and anemia.
Additionally, imaging like ultrasound or CT scan can be done to look for an underlying cause. Imaging might show disrupted tissue layers, the air in the soft tissue, or signs of a fluid collection or infection.
If you see any of these, the diagnosis is dehiscence. Okay, let’s move on to the final type of wound disruption, called fluid collection, which can be a seroma or a hematoma.
When assessing for fluid collection, patients may report a history of surgical drains, coagulopathy or anticoagulation medications, pain, and finally reduced function like reduced joint movement.
On physical exam, while there is little to no opening of the incision, you might notice fluctuant incisional swelling. Additionally, in some cases, you might see drainage or discoloration of the surrounding skin.If you see these findings you should consider fluid collection around or near the surgical site, and order labs like CBC, ESR, CRP, BMP, and albumin; as well as imaging like an ultrasound or a CT scan.
Alright, there are two options here. First, labs might be normal, while imaging shows an anechoic fluid collection without discernible walls, which might compress surrounding tissue.
If you see these findings, you can diagnose a seroma, which is a clear fluid collection. Here’s a clinical pearl!
If fluid collection is left untreated, it could lead to wound dehiscence, which can result in an evisceration. Okay, let’s go back a step and talk about the other option.
Labs might be normal, with possibly decreased hemoglobin and hematocrit which indicate severe bleeding. Imaging tends to show a well-defined, heterogeneous collection with possible hyperemia, edema, and compression of surrounding tissue.
In this case, the diagnosis is a hematoma, which is a collection of blood. Speaking of hematoma, here’s a high yield fact to keep in mind!
If the individual underwent neck surgery, progressive difficulty breathing should set off alarms for an expanding anterior neck hematoma.
This can happen because there is a limited amount of space for swelling and fluid in the neck, so the airway gets compressed.
This is a life-threatening complication and requires immediate surgical intervention. Now that we’re done with wound disruptions, let’s go back to history and physical and talk about abnormal communication.

Abnormal communications6:42–8:16

An abnormal communication after surgery usually refers to a fistula which is an aberrant pathway between two body parts or between fluid-filled spaces and the skin.
These patients may report a history of chronic drainage at or near the incision site or a history of deep infection or abscess.
Those with metabolic disturbances or malnutrition have a higher risk of fistula formation as well. On exam, these patients tend to have continuous drainage.
You might also find a tract formation or granulation tissue around the area of drainage; skin changes or breakdown around the output site, or possibly elevated temperature.With these findings, you should consider a fistula.
Just like before, evaluation of these patients includes ordering labs like CBC, ESR, CRP, BMP, and albumin, as well as imaging like ultrasound, CT scan, or fistulogram.
Now, labs are usually normal, but sometimes patients might have leukocytosis, hypoalbuminemia, and electrolyte abnormalities due to dehydration.
When it comes to imaging, it usually shows a fluid collection or an aberrant communication through the tissue layers. If you see these findings, the diagnosis is a fistula.

Wound infections8:16–11:01

Ok, now that wound disruptions and abnormal communications have been covered, let’s go to our final category of wound complications which is infection.
Importantly, wound infections are not only a wound complication, but they can also lead to other wound complications including disruptions, abnormal communications, and even unstable illness.
For postoperative infection in general, history might reveal previous surgery; long duration of surgery; an open surgical approach; and pain.
Their operative history or report may include a classification of contaminated, dirty, or infected procedures, which is the most concerning risk factor.
Here’s a clinical pearl! Clean-contaminated wounds include surgical opening of a dirty lumen, like bowel or bronchus, without gross spillage.Additional risk factors to keep in mind include prophylactic perioperative antibiotics; intraoperative hypothermia or hyperglycemia; and perioperative transfusion.
On physical exam, these patients may have any of the five characteristic signs of inflammation: rubor, calor, tumor, dolor, and functio laesa.
You might also find purulent drainage, fever, tachycardia, or tachypnea. So, if you see these findings, consider surgical infections.
As before, your next step involves ordering labs like CBC, ESR, CRP, BMP, albumin, and additionally wound and blood cultures.
As for imaging, you should order an ultrasound or CT scan. Now, labs might reveal leukocytosis, elevated ESR, and CRP, but usually negative blood cultures as the infection hasn’t spread beyond the local tissue.
Imaging, in this case, is not required, but some may use ultrasound or CT scan to exclude an underlying fluid collection that needs drainage.
So, in this case, the patient has a superficial infection. On the flip side, labs might show leukocytosis, elevated ESR, and CRP but positive cultures.
These patients can be further evaluated with ultrasound or CT scan, where findings can include fluid collections, surrounding edema, soft tissue stranding or cobblestoning from subcutaneous edema around the site of infection, or abscess.
If you see any of these findings, the diagnosis of a deep infection, organ space infection, or an abscess is considered.

Review11:01–12:02

Alright, as a quick recap… The three main types of postoperative wound complications include wound disruptions, abnormal communications, and infections.
Unstable patients need to be stabilized before doing any workup. On the other hand, stable patients require supportive care before obtaining a history and physical.
Now, if the patient has signs and symptoms of a wound disruption with abdominal spillage, they have an evisceration, which is a surgical emergency.
However, if the patient does not have spillage of abdominal contents, they probably have a dehiscence or fluid collection, which can either be a seroma or hematoma.
On the other hand, if the patient has evidence of abnormal communication, they likely have a fistula. And finally, if the patient has signs and symptoms of an infection, they need to be evaluated for postoperative wound infection, which can be superficial, deep, organ space infection, or an abscess.