POST-OPERATIVE WOUND COMPLICATIONS Dear Viewers, Greetings from “Surgical Educator”. Today I have uploaded a video on “POST-OPERATIVE WOUND COMPLICATIONS”. I have discussed about seroma,hematoma,wound infection,wound dehiscence,entero-cutaneous fistula and necrotizing fasciitis- about which all surgeon’s must have a working knowledge. I have restricted my discussion to the essential minimum an undergraduate medical student must know. You can watch all my surgical teaching video casts in the following link: Surgicaleducator.blogspot.com Thank you for your support.

1. POST-OPERATIVE
WOUND
COMPLICATIONS
Dr.B.Selvaraj MS;Mch;FICS;
Professor Of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia

2. POST-OPERATIVE WOUND
COMPLICATIONS- CAUSES
Seroma
Hematoma
Superficial Wound infection
Wound dehiscence- Burst abdomen
Entero-cutaneous fistula- Fecal fistula
Necrotising fasciitis

3. CLINICAL APPROACH
Reviewing the details of the operative procedure allows you to
evaluate the wound intelligently.
Check the VS
Communicate with the nursing staff about the details of the
wound care, and verify regarding the drains or special wound
management.
Evaluate the patient for signs of systemic infection, local infection,
or unexpected wound drainage.
R/O wound complications that might require immediate surgical
attention.

4. HISTORY/SYMPTOMS
Review the details of the surgical procedure. Review the method of closure
(staples or sutures, retention sutures, open packing, drains)
Determine the timing of the complication in relation to surgery
Foul smelling serous drainage with crepitus in the first 12 hours may
indicate necrotizing fasciitis.
Salmon-colored serosanguinous fluid draining within the first week after
abdominal surgery implies wound dehiscence.
Drainage suggestive of intestinal contents is probably an enterocutaneous
fistula, which can present from days to weeks following abdominal surgery.
Risk factors for wound complications include malnutrition, steroids,obesity,
smoking, diabetes mellitus, ischemia, infection, a technically inadequate
method of wound closure, and emergency or multiple surgeries.

5. Physical Exam/Signs
Dressings should be changed daily. Inspect the wound for
surrounding erythema, skin breakdown, bleeding, or obvious
drainage. Characterize and quantify drainage.
Palpate the wound gently to elicit skin blanching, tenderness,
crepitus, or drainage. The four classic signs of wound infection are
redness, swelling, heat, and pain (rubor, tumor, calor, dolor)
Wounds should not be opened casually when wound dehiscence is
suspected. Hematomas and superficial wound infections may require
exploring the wound more deeply.

6. INVESTIGATIONS
WBC: Can be elevated in wound infection
Hb: Can be decreased in large hematomas.
Gram stain and wound culture: Particularly when clostridia (gram-
positive rods) are suspected; antibiotic sensitivities are important.
Albumin/prealbumin: Assess nutritional status.
Obstruction series: Erect CXR and two-view abdominal plain film.
Postoperative free air may be present for up to a week. Look for gas
in the soft tissues.
CT abdomen/pelvis: Requires oral and IV contrast. Consider water-
soluble gastrograffin oral contrast if suspicious of bowel leak.
Extravasation of oral contrast into the wound confirms entero
cutaneous fistula.

7. SEROMA
Etiopathogenesis Clinical features Diagnosis Treatment
A seroma is a
pocket of clear
serous fluid that
develops after
extensive surgical
dissection that
disrupt lymphatic
channels, which
leak into a closed
space.
Seromas are
particularly
common after
hernia mesh
repairs, after
axillary and
inguinal
dissections, and
after raising skin
flaps for plastic
surgery.
Dx is by clinical
examination of the
wound. When
necessary, can
be confirmed by
USG abdomen or
simple needle
aspiration
90% of seromas will
resorb within 6 weeks
and should be left
alone. Symptomatic,
persistent, or infected
seromas will require
aspiration and
drainage. Antibiotics
are indicated only if
infection is suspected.

8. SEROMA

9. HEMATOMA
Etiopathogenesis Clinical features Diagnosis Treatment
- Inadequate
intraoperative
hemostasis
-In patients who are
anticoagulated in
the perioperative
period.
- bloody wound
drainage or
- an expanding
mass and is a
clinical dx made
at the bedside.
Dx is by clinical
examination
-Tx is usually
supportive with pain
control, ice packs,
and local compression
- Surgical evacuation
if it is rapidly
increasing in size,
neck hematoma
compromising airway
and hematoma in
contaminated areas.

10. HEMATOMA

11. Superficial Wound Infection
 No Antibiotics
Prophylactic
Antibiotics
 Therapeutic
Antibiotics

12. Superficial Wound Infection
Etiopathogenesis Clinical features Diagnosis Treatment
- It is a local
infection in the
subcutaneous
tissues beneath the
incision.
- Wounds are
classified by risk for
contamination. The
risk for wound
infection increases
exponentially by the
type of the wound
- Risk factors
include obesity,
hypothermia,hypox
ia,ischemia,
smoking, and
diabetes.
- Manifests as
erythema,tenderne
ss ,purulent wound
drainage, fever and
leucocytosis.
-Dx is by clinical
examination
- The need for
wound culture
depends on the
clinical context.
(When in doubt,
obtain a C&S)
-Tx is draining the
infection by opening
the incision.
- Antibiotics depend
on the clinical
context. Evidence
indicates
that wound infections
are best prevented by
preoperative
antibiotics within 1
hour of incision.

13. Superficial Wound Infection

14. Wound Dehiscence-Burst Abdomen
Etiopathogenesis Clinical features Diagnosis Treatment
-Wound dehiscence
is disruption or
loss of continuity of
a surgically closed
layer of skin or
fascia.
- Evisceration is a
frank fascial
disruption resulting
in exposure of
abdominal contents.
- Wound tension,
ischemia, poor
nutrition, steroids,
obesity, and
infection are the
most common risk
factors.
- You can see
abdominal contents
lying outside the
abdominal cavity
- It is a clinical
diagnosis
-DehiscenceSkin
alone or fascia
alone may open
- Evisceration
both are open
-Salmon-colored
serosanguinous
fluid in 1st postop
week impending
dehiscence
Dehiscence:
-Early recognition &
stable patient 
immediate operative
closure
- Late recognition &
unstable patient
healing by 2nd
intention
-Evisceration:cover
with saline pad
initially and then
emergency surgery

15. Wound Dehiscence-Burst Abdomen

16. ENTEROCUTANEOUS FISTULA
Etiopathogenesis Clinical features Diagnosis Treatment
-It is an abnormal
communication
between the bowel
lumen and the skin,
with drainage of
bowel contents to
the outside.
- Gastrocutaneous,
Enterocutaneous
and Colocutaneous
fistulas
- occur most
commonly in
patients with
Multiple
abdominal
injuries, multiple
surgeries, or a
“damage control”
abdomen (skin and
fascia left open to
granulate because
abdomen cannot be
closed).
- Bowel contents
and air bubbles
draining into the
wound make the
clinical diagnosis.
-A fistula may be
confirmed by CT
scan with oral
contrast, a small
bowel series with
contrast looking for
extravasation of
contrast into the
wound, or sinogram
-Treatment consists
of bowel rest, TPN,
correction of
electrolytes,acid
suppression and
wound care
- Octrotide to reduce
secretions.
-Low output fistulas
heal in weeks to
months if no distal
obstruction
-High ouput fistulas
need surgical closure

17. ENTEROCUTANEOUS FISTULA

18. NECROTISING FASCIITIS
Etiopathogenesis Clinical features Diagnosis Treatment
-Develops as a
progressive, rapidly
spreading,
inflammatory
infection, is a
surgical emergency.
-Occurs in the deep
fascia with
secondary necrosis
of the subcutaneous
tissues.
-Present with early
and rapid spread
of dusky, bluish
purple skin with
subcutaneous
emphysema and a
foul smelling, gray
serous fluid.
-Tissue destruction
and sepsis occur
within hours and
become lethal if
not treated
immediately.
- Early recognition
is imperative.
- classic organisms
responsible are ß-
haemolytic
streptococci,
coagulase-negative
staphylococci,
or Clostridium
perfringens.
- In many infections
a polymicrobial
profile will be
cultured
-Emergent surgical
debridement of all
nonviable tissue.
- Broad spectrum
antibiotics are
initiated, and
aggressive fluid
resuscitation is
mandatory
- Ex: Fournier’s
gangrene &
Meleney’s gangrene

19. NECROTISING FASCIITIS
FOURNIER’S GANGRENE MELENEY’S GANGRENE

20. THANK YOU
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