A 68-year-old male is evaluated on postoperative day 6 following an emergent exploratory laparotomy and bowel resection for perforated diverticulitis. He has a history of poorly controlled diabetes mellitus and chronic obstructive pulmonary disease. While coughing forcefully, he feels a sudden "giving way" sensation in his abdomen. The nurse reports a large amount of salmon-colored fluid draining from the surgical site. Physical examination reveals a separation of the midline fascial closure with a segment of small intestine protruding through the defect. His blood pressure is 130/80 mm Hg and pulse is 95/min. Arrange the following management steps in the most appropriate chronological sequence for this patient.
- 1Place the patient in a supine position with the hips and knees flexed.
- 2Cover the eviscerated bowel with sterile, saline-moistened dressings.
- 3Initiate intravenous fluid resuscitation and empiric broad-spectrum antibiotics.
- 4Transport the patient to the operating room for emergent surgical exploration and closure.
Answer
The correct sequence is: Place the patient in a supine position with flexed knees -> Cover the bowel with saline-moistened dressings -> Initiate IV fluids and antibiotics -> Transport to the operating room.
The appropriate management of postoperative wound evisceration requires immediate actions to prevent further injury followed by definitive surgical repair. The first step is to place the patient supine with hips and knees flexed to decrease intra-abdominal pressure and prevent further evisceration. Next, the exposed bowel must be immediately covered with sterile, saline-moistened dressings to prevent desiccation and ischemia. Once the bowel is protected, the patient should be medically stabilized with intravenous fluids and broad-spectrum antibiotics. Finally, the patient is transported to the operating room for definitive fascial closure.
Step-by-Step Solution
Key Concept
Wound evisceration is a surgical emergency characterized by the protrusion of abdominal viscera through a dehisced fascial closure. Management follows a strict sequence: relieve abdominal tension (positioning), protect the bowel (moist dressings), medically optimize (fluids/antibiotics), and perform definitive surgical closure.
Alternative Method
In cases where immediate transport to the operating room is delayed, continuous monitoring of the bowel's viability and repeated moistening of the dressings are essential.
Estimated Time:1m 30s