Fascial Disruption Case File

Fascial Disruption Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 34

A 55-year-old woman complains of profuse serosanguineous drainage from her abdominal incision site that has persisted over 4 hours and has soaked several large towels. The patient states that the incision had been somewhat red and tender for several days. She underwent a staging laparotomy for ovarian cancer 7 days previously. She states that her vaginal bleeding was scant, and she denies the passage of blood clots or foul smelling lochia. Her past medical history is significant for type 2 diabetes mellitus, and her surgical history is unremarkable. On examination, her weight is 270 lb, blood pressure (BP) is 100/70 mm Hg, heart rate (HR) is 80 beats per minute, respiratory rate (RR) is 12 breaths per minute, and she is afebrile. The thyroid is normal to palpation. The heart and lung examinations are normal. The remainder of the physical examination is unremarkable except for the abdominal incision.

» What is the most likely diagnosis?

» What is the most appropriate therapy?

ANSWER TO CASE 34:

Fascial Disruption                                           

Summary: A 55-year-old obese woman complains of a 4-hour history of profuse serosanguineous drainage from her abdominal incision site. She had undergone staging surgery for ovarian cancer 7 days previously.

• Most likely diagnosis: Surgical site infection (deep incisional) with fascial disruption.
• Most appropriate therapy: Immediate surgical closure and broad-spectrum antibiotic therapy.

ANALYSIS

Objectives

1. Know the classic presentation of surgical site infection (SSI) with fascial disruption.
2. Understand that both fascial disruption and fascial evisceration are surgical emergencies.
3. Know the risk factors for wound disruptions.
4. Describe measures to prevent SSIs.

Considerations

This 55-year-old diabetic woman underwent ovarian cancer staging surgery 7 days previously. She now complains of 4 hours of profuse and continuous serosanguineous drainage from her abdominal incision. This is the typical presentation for fascial disruption. Because the rectus fascia is interrupted, the peritoneal fluid escapes through the wound. If this were only a superficial fascial separation, caused by a seroma or other small fluid collection in the subcutaneous fat tissue, then the patient would have only complained of a limited amount of drainage. The patient does not have intestines or omentum penetrating through the incision; thus, an evisceration is not suspected. Nevertheless, deep SSI with fascial disruption is a surgical emergency requiring immediate surgical repair. Broad-spectrum antibiotic therapy is usually administered. This patient has numerous risk factors for fascial dehiscence including obesity, diabetes, cancer, and a probable vertical incision. The time frame from the surgery is fairly typical, which is usually 7 to 10 days following surgery.

APPROACH TO:

Wound Complications                                             

DEFINITIONS

WOUND DEHISCENCE: A separation of part of the surgical incision, but with an intact peritoneum.

FASCIAL DISRUPTION: Separation of the fascial layer, usually leading to a communication of the peritoneal cavity with the skin.

SEROSANGUINEOUS: Blood-tinged drainage.

EVISCERATION: A disruption of all layers of the incision with omentum or bowel protruding through the incision.

SURGICAL SITE INFECTION (SSI): Infection related to the operative procedure that occurs at or near the surgical incision within 30 days of an operation.

Deep SSI involves (involves) the deep soft tissue such as fascia or muscle.

CLINICAL APPROACH

Wound Disorders

Wound complications include superficial separation, dehiscence, and evisceration. Separations of the subcutaneous tissue anterior to the fascia are usually associated with infection or hematoma. They affect about 3% to 5% of abdominal hysterectomy incisions. The affected patient usually presents with a red, tender, indurated incision and fever 4 to 10 days postoperatively. The treatment is opening the wound and draining the purulence. A broad-spectrum antimicrobial agent is recommended, with wet-to-dry dressing changes. The wound may be allowed to close secondarily, or be approximated after several days.

Fascial disruption, separation of the fascia but not the peritoneum, occurs in about 1% of all abdominal surgeries, and about 0.5% of abdominal incisions. It is more common with vertical incisions, obesity, intra-abdominal distension, diabetes, exposure to radiation, corticosteroid use, infection, coughing, and malnutrition. This condition often presents as profuse drainage from the incision 5 to 14 days after surgery. SSI with fascial disruption requires repair as soon as possible with the initiation of broad-spectrum antibiotics.

Evisceration is defined as protrusion of bowel or omentum through the incision, which connotes complete separation of all layers of the wound. This condition carries a significant mortality due to sepsis, and is considered a surgical emergency. When encountered, a sterile sponge wet with saline should be placed over the bowel, and the patient taken to the operating room. Antibiotics should be immediately started. The presentation is similar to that of wound dehiscence.

Prevention

Antibiotic prophylaxis is the single most important factor in preventing a SSI. Typically, it is a single dose of first generation cephalosporin such as cefazolin 1g given IV about 15 to 60 minutes prior to surgical incision. An additional dose is given for prolonged open abdominal cases (> 4 hours) or if the estimated blood loss exceeds 1500 mL. Doubling of the dose is recommended for obese patients (> 35 BMI [body mass index]). For penicillin allergic individuals, a combination of clindamycin and gentamicin is a reasonable choice. Antibiotics should be given for clean-contaminated surgeries such as hysterectomies (because of entry into the vaginal area); however, antibiotic prophylaxis is not given for clean uncomplicated cases (no entry into vaginal or uterus) such as laparoscopic oophorectomy. Antibiotics are not recommended for hysteroscopy, missed or incomplete abortion, or IUD insertion; it is recommended for pelvic organ prolapse surgery and/ or stress urinary incontinence surgery and for induced (therapeutic abortion). Hair on the skin should not be routinely removed, and if required, then electric clippers rather than razors should be used immediately before the incision.

CASE CORRELATION See also Case 24 (Necrotizing Fasciitis).

COMPREHENSION QUESTIONS

34.1 Which of the following is a risk for wound dehiscence?

A. Diabetes mellitus

B. Use of monofilament suture

C. Horizontal incision

D. Addison disease

34.2 Which of the following is the most common reason for fascial disruption?

A. Suture becomes untied

B. Suture breakage

C. Suture tears through fascia

D. Defective suture material

E. Suture hydrolytic process

34.3 A 59-year-old woman who had staging surgery for ovarian cancer is noted to have clear serous drainage from her incision. The surgeon is concerned that it may represent lymphatic drainage versus a fistula from the urinary tract. Which of the following studies of the fluid would most likely help to differentiate between these two entities?

A. Creatinine level

B. Leukocyte count

C. pH

D. Hemoglobin level

E. CA-125 level

34.4 A 38-year-old woman had an abdominal hysterectomy for symptomatic uterine fibroids, namely menorrhagia that had failed to respond to medical therapy. One week later, she complains of low-grade fever and lower abdominal pain. On examination, she is noted to have a temperature of 100.8°F (38.22°C) and the Pfannenstiel (low transverse) incision is red, indurated, and tender. Which of the following is the best therapy for this condition?

A. Oral antibiotic therapy and follow up in 1 week

B. Observation

C. Opening the incision and draining the infection

D. Antibiotic ointment to the affected area

E. Interferon therapy

34.5 A 40-year-old woman is undergoing a laparoscopic salpingectomy. Which of the following is accurate regarding antibiotic prophylaxis?

A. Cefazolin 1 g IV should be given

B. Erythromycin IV should be given if penicillin allergic

C. An additional dose should be given if the patient is obese

D. No antibiotics are required

ANSWERS

34.1 A. Diabetes is associated with an increased risk for fascial separation because it is more difficult for wounds to heal in patients with this disease. The integrity of blood vessels is disrupted in a wound; this, along with the fact that diabetics typically have poor blood circulation, makes it more difficult to adequately perfuse the wounded area (blood contains the necessary clotting factors and immunoglobulins required to heal a wound and prevent infection). As a result, diabetics are also at a greater risk for a serious infection. A vertical incision as opposed to a transverse incision is associated with a greater risk of fascial disruption. Addison disease is a state of hypocortisolism, whereas Cushing disease is a state of hypercortisolism. Since increased cortisol levels are associated with immunosuppression, wound dehiscence would be more likely to occur in Cushing disease, not Addison disease.

34.2 C. Fascial breakdown (disruption) is not usually due to suture breakage or knot slippage, but rather due to the suture tearing through the fascia. It is more common with vertical incisions, obesity, intra-abdominal distension, diabetes, exposure to radiation, corticosteroid use, infection, coughing, and malnutrition. This condition requires immediate repair and broad-spectrum antibiotics. Fascial disruption and evisceration typically occur between 5 and 14 days postoperatively.

34.3 A. Fluid may appear to be serous and can be clinically indistinguishable between urine and peritoneal fluid. A creatinine level may distinguish between urine and lymphatic fluid. The creatinine level would be significantly more elevated in urine.

34.4 C. This patient has a superficial wound infection. The best treatment is to open the wound and drain the purulence. A broad-spectrum antimicrobial agent is recommended, with wet-to-dry dressing changes. The wound can be allowed to close secondarily or be approximated after several days. Observation in the face of infection would not be the best management and may lead to septicemia. Ointments and oral antibiotic therapy are not sufficient treatment options until the drainage is removed.

34.5 D. Because the uterus and vagina are not entered, and there is no overt infection, no prophylactic antibiotics are required. If the patient were penicillin allergic, then clindamycin and gentamicin should be given. For obese patients with BMI exceeding 35 kg/m3, then a doubling of the cephalosporin dose should be considered.

    CLINICAL PEARLS    

» Fascial disruption is a concern when copious amounts of serosanguineous fluid are draining from an abdominal incision. » An SSI with fascial disruption or evisceration should be immediately repaired. » The most common time period in which fascial disruption or evisceration occurs is 5 to 14 days postoperatively. » A superficial wound separation usually occurs due to infection or hematoma, and is treated by opening the wound and using wet-to-dry dressing changes. » Obesity, malnutrition, and chronic cough are risk factors for fascial disruption.

REFERENCES

Centers for Disease Control and Prevention. Definitions of healthcare associated infections; August 2015. www.cdc.gov; Accessed 08.10.2015. Hoffman BL. Surgeries for benign gynecologic conditions. In: 

Hoffman B, Schorge J, Schaffer J, Halvorson L, Bradshaw K, Cunningham F, eds. In: Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill; 2012. 

Katz VL. Preoperative counseling and management. In: Lentz GM, Lobo RA, Gersenson DM, Katz VL, eds. Comprehensive Gynecology. 5th ed. St. Louis, MO: Mosby-Year Book; 2012.

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