When a seroma is detected, remove the staples or stitches in the area of concern and explore the wound. It is essential to ensure fascial integrity, as serous wound drainage may be a sign of impending evisceration. After these measures are taken, cleanse and lightly pack the wound to permit drainage.
Hematoma requires identification of the source of bleeding
Hematoma represents blood or a blood clot within the tissues beneath the skin. It may be caused by persistent bleeding of a vessel, although the pressure within the wound and the pressure produced by the dressing often provide tamponade on the bleeding source, in which case the hematoma forms with no active bleeding.
Hematoma is usually caused by small bleeding vessels that were not apparent at the time of surgery or were not cauterized or ligated at the time of closure. For this reason, it is important to achieve good hemostasis and a “dry” wound before closing the skin.
When hematoma is suspected, open the wound enough to permit adequate exposure and identify the source of bleeding. Evacuate as much blood and clot as possible because blood is an ideal medium for bacterial growth. If active bleeding is found, use a silver nitrate applicator or handheld cautery pen to accomplish hemostasis at bedside. If bleeding is more severe, or the source cannot be visualized, consider returning to the operating room for more extensive exploration.
Once hemostasis is achieved, irrigate the wound copiously and institute local wound care.
How common is infection?
Before it is possible to address this question, it is necessary to clarify the terminology of infection. Contamination and colonization are different entities. The first refers to the presence of bacteria without multiplication. The latter describes the multiplication of bacteria in the absence of a host response. When infection is present, bacterial proliferation produces clinical signs and symptoms.
Postoperative abdominal wound infection occurs in about 5% of cases but may be more common in procedures that involve a greater level of contamination.7 One study found a 12% incidence of wound infection, but the rate declined to 8% when antibiotic prophylaxis was instituted.4
Several other studies have examined determinants of infection. For example, a large Cochrane review found no real differences in infection rate by preoperative skin preparation technique or agent, but it did observe that one study had demonstrated the superiority of chlorhexidine to other cleansing agents.8
Cruse and Foord also noted the slight superiority of chlorhexidine, as well as the efficacy of clipping abdominal hair immediately before surgery.7
When identifying organisms, look for the usual suspects
The offending pathogens in infection are usually endogenous flora found on the patient’s skin and within hollow organs (vagina, bowel). The organisms most commonly responsible for infection are Staphylococcus (aureus, epidermidis), enterococci, and Escherichia coli. However, the bacteria identified in the wound may not be the causative organism.
Most infections typically become clinically apparent between the fifth and 10th postoperative days, often after the patient has been discharged, although they may appear much earlier or much later. One of us (Dr. Perkins) had a patient who presented with a suppurative infection after undergoing hysterectomy for endometrial carcinoma 5 months earlier.
Cellulitis is common
Wound cellulitis, a common, nonsuppurative infection of skin and underlying connective tissue, is generally not severe. The wound assumes a brawny, reddish brown appearance associated with edema, warmth, and erythema. Fever is not always present.
It is important to remember that cellulitis may surround a deeper infection. Although needle aspiration of the leading edge has been advocated, it yields a positive culture in only 20% to 40% of cases.
In the absence of purulent drainage, treat cellulitis with antibiotics, utilizing sulfamethoxazole-trimethroprim, a cephalosporin, or augmented penicillin, and apply warm packs to the wound.
If purulent drainage is seen, or the patient fails to improve significantly within 24 hours, suspect an abscess or resistant organism.
11 key strategies for preventing wound complication
- During preoperative evaluation, assess the patient for risk factors, comorbid conditions, and medications that can impair healing
- If the patient is morbidly obese and planning to undergo an elective, nonurgent procedure, consider instituting a plan for preoperative weight loss
- Advise smokers to “kick the habit” 1 or 2 months before surgery
- Avoid using electrocautery in the “coagulation current” setting when incising the fascia
- When approximating the fascia, take wide bites of tissue (1.5 to 2 cm from the edge)
- Avoid excessive suture tension when closing the fascial layer (“Approximate, don’t strangulate”)
- Obtain good hemostasis before closing the wound; consider placing a drain in an obese patient
- In a high-risk patient who has multiple risk factors, consider retention sutures
- Minimize or avoid abdominal distention during the postoperative period with:
- Assess the wound for infection early, and treat infection promptly
- Remember to administer prophylactic antibiotics