What is the most appropriate management for a patient with a history of laparotomy (surgical incision into the abdominal cavity) and lysis (separation of adhesions) for adhesive intestinal obstruction, who now presents with discharge from the wound?

Management of Post-Laparotomy Wound Discharge

Wound inspection is the most appropriate initial management step for a patient presenting with discharge from a laparotomy wound. 1

Rationale for Wound Inspection as First-Line Management

Direct wound inspection must be performed first because it allows immediate differentiation between superficial complications (seroma, superficial infection) and life-threatening complications such as fascial dehiscence or enterocutaneous fistula. 1 This critical distinction cannot be made through imaging or empiric dressing changes alone and directly impacts morbidity and mortality. 1

Key Assessment Points During Wound Inspection

The following must be evaluated during direct inspection:

• Fascial integrity: Gently probe the wound to assess whether the fascia has dehisced, which would indicate wound dehiscence requiring urgent surgical intervention. 1
• Wound edge characteristics: Assess for erythema, induration, and separation of wound margins. 1
• Systemic signs: Check for fever, tachycardia, or signs of peritonitis to determine the need for aggressive intervention. 1

Algorithmic Approach After Initial Inspection

If Superficial Wound Infection or Seroma is Present:

• Initiate daily dressing changes with wound care. 1
• Consider antibiotics if cellulitis is present. 1

If Fascial Dehiscence is Suspected:

• Obtain immediate surgical consultation for operative repair to prevent evisceration. 1

If Deep Abscess is Suspected Without Fistula:

• CT-guided drainage may be appropriate before considering operative intervention. 1

Why Other Options Are Inappropriate as Initial Management

Daily dressing (Option A) assumes the wound complication is benign without first establishing the diagnosis, which can delay recognition of fascial dehiscence or enterocutaneous fistula and significantly increase morbidity and mortality. 1

Abdominal CT scan (Option C) may be indicated after wound inspection if deep abscess or fistula is suspected, but should not precede direct wound assessment. 1

Wound exploration (Option D) is premature without first performing bedside wound inspection to determine if operative intervention is necessary. 1

Critical Pitfall to Avoid

Never assume wound discharge is benign without direct inspection, as this can delay recognition of fascial dehiscence or enterocutaneous fistula, which significantly increases morbidity and mortality if not promptly identified. 1 The presence of any drainage may indicate deeper complications including fascial dehiscence or enterocutaneous fistula that would be catastrophically worsened without proper assessment. 2