How to avert postoperative wound complication—and treat it when it occurs

TABLE 2

Risk factors for poor wound healing and dehiscence

Conditions and drugs that impair healing

Preexisting medical conditions may limit healing, especially conditions associated with diminished delivery of oxygen and nutrients to healing tissues.

Diabetes can damage the vasculature and may impair healing if the blood glucose level is markedly elevated in the perioperative period. Such an elevation impedes transport of vitamin C, a key component of collagen synthesis.

Malignancy and immunosuppressive disorders may prevent optimal healing by compromising the immune response.

Bacterial vaginosis, a common polymicrobial infection involving aerobic and anaerobic bacteria, appears to be associated with postoperative febrile morbidity and surgical-site infection, particularly after hysterectomy.¹ Current guidelines recommend that medical therapy for bacterial vaginosis be instituted at least 4 days before surgery and continued postoperatively.

Because steroids, NSAIDs, and chemotherapy agents impede wound healing, and anticoagulants may interfere with granulation, it is crucial to review the patient’s medications well in advance of surgery.

Nutrition plays a critical role

The importance of nutrition cannot be overstated. A significant percentage of patients are thought to have some degree of nutritional deficiency preoperatively. This deficiency may alter the inflammatory response, impair collagen synthesis, and reduce the tensile strength of the wound.

Because healing requires energy, deficits in carbohydrates may limit protein utilization, and deficiencies of vitamins and micronutrients can also interfere with healing.²

Obesity, too, increases the risk of postoperative wound complication. Markedly obese patients have a thick, avascular, subcutaneous layer of fat that compromises healing.³

Meticulous technique required

Good surgical technique and appropriate use of antibiotics are critical components of successful wound healing.

When placing the incision, avoid the moist, bacteria-laden subpannicular crease in the markedly obese.

During a procedure, handle tissue gently, keep it moist, and make minimal use of electrocautery to reduce tissue injury and promote healing. Keep operating time and blood loss to a minimum, and debride the wound of any foreign material and devitalized tissue.

Multiple studies have demonstrated that judicious use of prophylactic antibiotics significantly decreases the incidence of wound infection, particularly in relation to hysterectomy and vaginal procedures and when entry into bowel is anticipated.^4,5 A number of prophylactic regimens are given in TABLE 3.

Meticulous hemostasis at the time of closure is imperative. When complete hemostasis cannot be confirmed, place a small drain in the subcutaneous space (or subfascial space, if there is oozing on the muscle bed) and apply a pressure dressing to help prevent hematoma. Although a drain is not a substitute for precise hemostasis or careful surgical technique, it may be helpful when there is concern about oozing or a “wet” surface, or when the patient is markedly obese.

Some practitioners have expressed concern over the risk of bacterial migration and infection with placement of a drain, but others, including us, advocate use of a drain in the subcutaneous space to help remove residual blood, fluid, and other debris to prevent the formation of dead space and infection and promote wound closure and healing. In a small study, Gallup and associates demonstrated a decreased incidence of wound breakdown when a drain was placed.⁶

A closed-suction drain, such as a Jackson-Pratt or Hemovac model, helps minimize wound complication when it is placed in the subcutaneous layer. (Avoid a rubber Penrose drain because it may allow bacteria to enter the wound.) It is imperative that the drain exit the body via a separate site and not through the incision itself. We advocate removal when less than 30 mL of fluid accumulates in the reservoir over 24 hours.

TABLE 3

3 prophylactic antibiotic regimens

Fluid within the wound does not always indicate infection

Wound collections are not necessarily indicative of infection; collections of fluid within the wound may represent a serous transudate, blood, pus, or a combination of these. If the fluid is not addressed, however, fulminant infection may be the result.

Seroma is usually painless

A seroma is a collection of wound exudates within the dead space. Seroma typically involves thin, pink, watery discharge and minimal edge separation. In some cases, there may be surrounding edema but generally little to no tenderness.