What is the optimal wound closure strategy for a patient with diabetes, a body mass index (BMI) of 40, and fecal contamination during an emergency Hartmann's procedure for perforated diverticulitis?

Optimal Wound Closure Strategy After Emergency Hartmann's Procedure in a Diabetic Patient with BMI of 40

For a diabetic patient with BMI of 40 who underwent emergency Hartmann's procedure for perforated diverticulitis with fecal contamination, the optimal approach is delayed primary closure of the skin with the fascia already closed primarily, as this strategy has the lowest complication rate.

Rationale for Delayed Primary Closure

• In cases of perforated diverticulitis with fecal contamination, the surgical site is considered contaminated, significantly increasing the risk of surgical site infections 1
• For patients with high-risk factors such as diabetes and obesity (BMI of 40), the risk of wound complications is substantially higher, making primary skin closure inadvisable 1, 2
• Leaving the skin open while the fascia is closed primarily allows for drainage of potential contamination and reduces the risk of deep wound infections that could compromise the fascial closure 1, 3

Timing of Delayed Closure

• The optimal timing for delayed primary closure is typically 3-5 days post-operation, once the wound shows healthy granulation tissue without signs of infection 2
• Daily wound assessment should be performed to evaluate for:
  • Absence of purulent drainage 2
  • Healthy granulation tissue formation 3
  • No signs of surrounding cellulitis 2
  • Normalization of inflammatory markers (WBC count, CRP) 2

Wound Management Until Closure

• The open wound should be managed with:
  • Regular sterile dressing changes (typically once or twice daily) 3
  • Negative pressure wound therapy (NPWT) can be considered to accelerate granulation tissue formation and reduce edema, particularly beneficial in obese patients 1, 3
  • Careful monitoring for signs of infection including increasing erythema, purulent drainage, or systemic signs of infection 2

Special Considerations for This Patient

• Diabetes management is crucial during the perioperative period to optimize wound healing:
  • Maintain strict glycemic control (target blood glucose 140-180 mg/dL) 2
  • Monitor blood glucose levels frequently 2
• The patient's obesity (BMI of 40) increases the risk of:
  • Deep wound infections 3
  • Fascial dehiscence 1
  • Poor tissue perfusion at the wound edges 2

Alternatives and Their Limitations

• Primary skin closure carries a high risk of surgical site infection in this contaminated case with high-risk factors (diabetes, obesity) 1
• Leaving both skin and fascia open would require subsequent complex closure and increase the risk of ventral hernia formation 1
• Damage control surgery with temporary abdominal closure would be excessive for a case where the fascia could be closed primarily 1

Long-term Considerations

• The patient should be counseled that the stoma reversal rate after Hartmann's procedure is approximately 47%, with many patients having permanent stomas 4
• When stoma reversal is performed, the laparoscopic approach has shown benefits with lower complication rates compared to open reversal 5, 6
• Factors associated with higher complications during eventual stoma reversal include higher BMI and higher ASA scores, both relevant to this patient 7

Common Pitfalls to Avoid

• Attempting primary skin closure in a contaminated field with high-risk factors (diabetes, obesity) significantly increases the risk of wound complications 1
• Inadequate glycemic control during the perioperative period impairs wound healing and increases infection risk 2
• Insufficient wound care and monitoring during the open wound phase can lead to deeper infections 3
• Premature closure of the skin before adequate control of contamination can lead to abscess formation 1