Initial Management of Post-Laparotomy Wound Discharge
Wound inspection is the initial appropriate management for a patient presenting with discharge from the middle of a surgical wound following laparotomy for adhesive intestinal obstruction.
Rationale for Wound Inspection First
The presence of wound discharge in the middle of a laparotomy incision requires immediate clinical assessment to determine the nature and severity of the complication. Direct wound inspection allows you to differentiate between superficial wound complications (infection, seroma) versus more serious complications such as fascial dehiscence or enterocutaneous fistula 1.
Key Assessment Points During Inspection
During wound inspection, you must evaluate:
- Fascial integrity: Probe gently to assess whether the fascia has dehisced, which would indicate wound dehiscence requiring urgent surgical intervention 1
- Character of discharge: Determine if the fluid is serous (suggesting seroma), purulent (indicating infection), or enteric (suggesting fistula formation) 2
- Wound edges: Assess for erythema, induration, and separation of wound margins 1
- Systemic signs: Check for fever, tachycardia, or signs of peritonitis that would necessitate more aggressive intervention 1
Why Not the Other Options Initially?
Daily Dressing Alone
Daily dressing without initial inspection is inappropriate because you cannot determine the severity of the complication or guide further management without first examining the wound 1.
Abdominal CT Scan
While CT imaging may eventually be needed if enterocutaneous fistula or intra-abdominal abscess is suspected, it should not precede clinical wound inspection 1. CT is most useful when wound inspection suggests deeper pathology requiring anatomical delineation 1.
Immediate Wound Exploration
Formal wound exploration in the operating room is premature without first performing bedside inspection. Most wound complications can be initially assessed and many can be managed at the bedside 2. Operative exploration is reserved for confirmed fascial dehiscence, suspected fistula requiring surgical repair, or when bedside assessment reveals concerning findings 1.
Algorithmic Approach After Initial Inspection
If superficial wound infection or seroma: Initiate daily dressing changes with wound care, consider antibiotics if cellulitis present 1
If fascial dehiscence suspected: Immediate surgical consultation for operative repair to prevent evisceration 1
If enteric content suspected: Obtain abdominal CT to evaluate for fistula tract and intra-abdominal collections, then plan definitive management which may include nutritional support and delayed surgical repair 2
If deep abscess suspected without fistula: CT-guided drainage may be appropriate before considering operative intervention 1
Critical Pitfall to Avoid
The most dangerous error is assuming wound discharge is benign without inspection, as this can delay recognition of fascial dehiscence or enterocutaneous fistula. Both complications significantly increase morbidity and mortality if not promptly identified 1, 2. In patients with adhesive obstruction who underwent lysis of adhesions, the risk of inadvertent enterotomy (3-17.6% in laparoscopic series) makes fistula formation a real concern that must be excluded 3.