WhiteCoat

What’s the Diagnosis #3

WARNING – GROSS PICTURE BELOW

You probably know what this is, but can you spell it? What are risk factors for it? And how do you manage it?

Think about it for a minute and then scroll down for the answer.

Wound dehiscence

Answer: Wound dehiscence with evisceration (the bulge from the wound at the 1:00-2:00 position is bowel)

A good nursing article about wound dehiscence is here.

The following are excerpts about wound dehiscence taken from Sabiston’s Textbook of Surgery, 18th ed.

Wound dehiscence occurs in approximately 1% to 3% of patients who undergo an abdominal operation – usually 7 to 10 days postop.
It may be related to technical errors in placing sutures too close to the edge, too far apart, or under too much tension.
A deep wound infection is one of the most common causes of localized wound separation.
Many factors contribute to wound dehiscence including technical errors in fascial closure, emergency surgery, advanced age, wound infection, obesity, chronic steroid use, previous wound dehiscence, malnutrition, radiation therapy, and other systemic diseases such as diabetes or renal failure.

Dehiscence may occur without warning. Evisceration, such as in this case, makes the diagnosis obvious. Serosanguinous drainage precedes wound dehisence in 25% of patients. Probing the wound with a sterile, cotton-tipped applicator or gloved finger may also detect the dehiscence.

Treatment depends on the extent of fascial separation and the presence of evisceration or significant intra-abdominal contamination (intestinal leak, peritonitis). A small dehiscence may be managed by packing the wound with saline-moistened gauze and using an abdominal binder. If evisceration occurs, cover the intestines with a sterile, saline-moistened towel and contact the surgeon immediately. The patient will require urgent surgical closure of the wound.

Management of wound dehiscence may involve placing absorbable mesh, skin grafts, and/or flaps to reconstruct the abdominal wall.
Wound vacuums remove interstitial fluid, lessen bowel edema, decrease wound size, reduce bacterial colonization, increase perfusion, and improve healing. Successful closure of the fascia can be achieved in 85% of cases of abdominal wound dehiscence.

11 Responses to “What’s the Diagnosis #3”

  1. Danimal says:

    Yurk! Maybe a “Warning! Graphic” in the title might be in order? Not all of your readers are in your industry, doc!

  2. MysteryMedic says:

    Unfortunately you forgot one “cause” that I know of personally. A self-removal/manipulation of staples to cause dehiscence and evisceration was done by a family member because it was an instant admission for pain control, surgery, and more pain control. Sadly he died a few years ago. The doctors just kept writing the scripts and he kept filling them. He overdosed on a speedball because he couldn’t get the pills (the high of choice) he was normally prescribed. He had several admissions for dehiscence. I still don’t understand how we can require ID for OTC pseudoephedrine but not a narc script. Didn’t mean to hijack this but it just reminded me of someone that needed help, that everyone knew needed it, and never got it.

    I hope your rock is OK…

  3. April says:

    Pretty nice post. I just came by your site and wanted to say
    that I have really enjoyed reading your posts. In any case
    I’ll be subscribing to your blog and I hope you post again soon!

  4. Gak. Yak. This is a perfect example of why I decline patient attempts to frequently drop ‘em and show. Just because I am “in the field”…

    To MysteryMedic:

    He overdosed on a speedball because he couldn’t get the pills (the high of choice) he was normally prescribed.

    Maybe he couldn’t get the drugs of choice (narcotics) and that is sad but your connection might be spurious. Speedballing includes heroin and some from of stimulant, usually cocaine in the street definition, or so methinks. The patient might have *also* enjoyed speedballs as well as straight narcotics. Jes sayin’…

    Either way, I hear your cry.

    WC, man o’ man this post taught me to be on guard. Not such a bad thing so I ain’t complainin’.

    There but for the grace of what-the-f-ever goeth I in the shoes of these folks.

  5. cynic says:

    You just need a bigger stapler.

  6. Katherine says:

    Not that I would know the diagnosis, but I browse with pictures turned off, and the name came up where the picture would have been. Does keep me from being grossed out until my curiosity gets the better of me though :P

  7. Kim says:

    Maybe there’s something wrong with me, that pic just doesn’t look that gross.

    If only 85% of cases achieve successful closure, what happens to the other 15%? I assume infection, if not already present, is a huge problem?

  8. Don Salva says:

    Whoaaa, that’s some nasty…shit! No pun intended.

    I’ve seen my fair share of corpses and autopsies visiting my close cousin who’s a medical examiner.

    But this one, on an actual living human being, that’s just…I don’t know…gives me a strange feeling.

  9. steinwayrn says:

    Unfortunately, I have experienced this first hand. After getting over the initial panic of there is a HUGE hole in my belly, I went to the ER. After 7 1/2 weeks of twice daily wet-to-dry dressings on myself, I am now the proud owner of a pretty impressive scar.

    You forgot to mention the complications following closure of the opening. I have had to had 3 subsequent surgeries d/t abdominal adhesions…I’m just waiting until I become the next victim of small bowel obstruction d/t adhesions.

    In my case, I blame the surgeon—or the surgeon’s PA to be exact. But, I can’t really prove that he was at fault. No, I didn’t sue…not in my nature. But, I have a fun story to tell :)

  10. horsetech says:

    I appreciate the fact that whoever this patient is took the time to pose for a picture. :) I’ve seen lots of cool stuff that I wish I had pictures of, but I never have a camera with me and I rarely have the time/free hand for photography anyway.

    P.S. What does it say about me that I’d rather look at the eviscerated part (oooh, guts, cool!) than the blotchy skin and almost pendulous belly button below? I guess it’s good I’m in equine, not human, medicine.

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