What are the postoperative concerns for a patient with right-sided abdominal pain, leukocytosis (elevated white blood cell count), and neutrophilia (elevated neutrophils) three weeks after large ventral hernia repair?

Postoperative Concerns After Large Ventral Hernia Repair

This patient presenting with right-sided abdominal pain, leukocytosis (WBC 10.8), and neutrophilia three weeks post-ventral hernia repair requires urgent evaluation for infectious complications, particularly mesh infection, intra-abdominal abscess, or anastomotic complications if bowel work was performed. 1

Primary Diagnostic Concerns

Infectious Complications

• Mesh infection or deep surgical site infection is the most critical concern at this timeframe, as elevated CRP and leukocytosis are predictors of postoperative infectious complications after abdominal surgery 1
• Intra-abdominal abscess formation must be ruled out, as CRP has remarkably higher sensitivity and specificity than WBC or neutrophil count alone for detecting abscess formation after abdominal surgery 1
• The combination of right-sided pain with leukocytosis suggests localized infection rather than systemic sepsis, though progression must be monitored 1

Non-Infectious Complications

• Bowel obstruction or internal herniation through fascial defects can present with pain and mild leukocytosis, though elevated serum lactate would suggest ischemia (not mentioned in this case) 1
• Seroma or hematoma can cause localized pain but typically would not cause significant neutrophilia at three weeks 1

Immediate Diagnostic Workup

Laboratory Assessment

• Obtain C-reactive protein (CRP) and procalcitonin levels immediately, as these have superior diagnostic accuracy compared to WBC count alone for identifying postoperative infectious complications 1
• CRP ≥5 mg/dL has high specificity for postoperative complications and should raise elevated clinical suspicion 1
• Serum lactate levels should be measured to assess for bowel ischemia, though normal lactate does not exclude internal herniation 1
• Blood cultures if fever is present or sepsis is suspected 1

Imaging Studies

• CT abdomen and pelvis with IV contrast is mandatory for evaluating postoperative complications, with sensitivity of 85.7-100% and specificity of 94.8-100% for intra-abdominal pathology 1, 2
• Look specifically for: fluid collections, bowel wall thickening >5mm, free air suggesting perforation, mesh-related complications, and signs of bowel obstruction 1
• Ultrasound can identify fluid collections but CT is superior for comprehensive evaluation 1

Clinical Interpretation of Leukocytosis

Understanding the WBC Pattern

• Neutrophilia with lymphopenia is highly suggestive of severe illness requiring surgical intervention, with specificity of 94.9% when neutrophils >9.0 × 10⁹/L combined with lymphopenia <1.4 × 10⁹/L and eosinopenia <0.04 × 10⁹/L 3
• The neutrophil-to-lymphocyte ratio provides more sensitive prediction than total WBC count alone; a ratio ≥3.5:1 has 88% sensitivity for acute surgical pathology 4
• WBC of 10.8 is mildly elevated but the neutrophil predominance is the critical finding that suggests ongoing infection or inflammation 5, 6, 3

Risk Stratification

High-Risk Features Requiring Urgent Intervention

• Fever, tachycardia, tachypnea with hypoxia, hypotension, or decreased urine output indicate sepsis and mandate immediate surgical exploration 1
• Peritoneal signs (though often absent in obese patients or those with thick abdominal walls) 1
• Bowel wall thickening >10mm on imaging carries significantly higher mortality risk 1

Moderate-Risk Features Requiring Close Monitoring

• Persistent or worsening pain despite conservative management 1
• Progressive elevation of inflammatory markers (CRP, procalcitonin) 1
• Inability to tolerate oral intake 1

Management Algorithm

Initial Conservative Management (if hemodynamically stable)

• Broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic organisms should be initiated if infection is suspected 1
• Anti-pseudomonal beta-lactam (piperacillin-tazobactam) or carbapenem as first-line therapy 1
• Bowel rest with IV hydration 1
• Serial clinical examinations every 4-6 hours 1

Indications for Surgical Intervention

• Signs of perforation, ischemia, or peritonitis mandate immediate surgical exploration 1
• Failure to improve with 24-48 hours of conservative management 1
• Identified abscess requiring drainage (may be amenable to percutaneous drainage if accessible) 1
• Confirmed mesh infection typically requires mesh removal and debridement 1

Critical Pitfalls to Avoid

• Do not rely on WBC count alone—CRP and procalcitonin provide superior diagnostic information for postoperative complications 1
• Normal CRP does not exclude complications—clinical judgment must prevail if symptoms are concerning 1
• Tachycardia in postoperative patients should be taken as a serious warning sign, especially in obese patients where peritoneal signs may be unreliable 1
• Delayed imaging or intervention in the setting of clinical deterioration significantly increases morbidity and mortality 1
• Leukocytosis and elevated lactate occur late in bowel ischemia—do not wait for these markers to exclude internal herniation 1