Approach to postoperative wound complications: Clinical sciences

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. 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. 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 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.