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Difficulty: EasyPreoperative and Postoperative Care

A 65-year-old man presents to the outpatient surgical clinic 6 days after undergoing an emergency laparotomy and omental patch repair for a perforated duodenal ulcer. He reports worsening, throbbing pain at his surgical site that began yesterday. His temperature is 38.2°C (100.8°F), blood pressure is 128/78 mm Hg, heart rate is 90/min, and respiratory rate is 14/min. Physical examination shows a midline abdominal incision closed with surgical staples. The inferior one-third of the incision is erythematous, indurated, and exquisitely tender to palpation. Thick, yellowish fluid is spontaneously draining from between two of the staples in this area. The remainder of the abdominal examination is unremarkable, with normal bowel sounds and no rebound tenderness. Which of the following is the most appropriate next step in management?

  1. A
    Order a computed tomography scan of the abdomen and pelvis
  2. B
    Admit the patient for empiric intravenous broad-spectrum antibiotics
  3. Remove the surgical staples and open the involved portion of the incisionAnswer
  4. D
    Swab the wound exudate for bacterial culture and prescribe oral antibiotics
  5. E
    Perform a duplex ultrasound of the lower extremities

Answer

The most appropriate next step is to remove the surgical staples and open the involved portion of the incision.
The most appropriate next step in management for a patient presenting with a superficial surgical site infection (SSI) is to remove the staples and open the involved portion of the incision. This patient presents on postoperative day 6 with classic signs of a superficial SSI, including fever, localized erythema, induration, tenderness, and spontaneous purulent drainage. These infections involve the skin and subcutaneous tissue. The definitive treatment is source control, which is achieved by opening the wound, draining the purulent collection, and packing the wound to allow for healing by secondary intention. Systemic antibiotics are generally not required for uncomplicated superficial SSIs unless there are signs of severe systemic illness or extensive surrounding cellulitis.

Step-by-Step Solution

1
Identify the postoperative complication based on the clinical presentation.
The patient has a superficial surgical site infection (SSI), indicated by the fever, localized erythema, induration, and purulent drainage on postoperative day 6.
Superficial SSIs typically present between postoperative days 4 and 7 with classic signs of localized inflammation at the incision site.
2
Determine the primary management strategy for a superficial SSI.
The definitive treatment is source control via mechanical wound opening.
Systemic antibiotics cannot penetrate undrained purulent fluid collections effectively, so physical drainage is the mandatory standard of care.
3
Select the option that provides the necessary source control.
Removing the surgical staples and opening the involved portion of the incision is the correct choice.
This allows the purulent material to drain and the wound to subsequently heal safely by secondary intention.

Key Concept

The primary management of a superficial surgical site infection is immediate source control, achieved by opening the wound and allowing it to heal by secondary intention.
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Topics

Preoperative and Postoperative Care

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