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Difficulty: MediumPreoperative and Postoperative Care

A 71-year-old woman is assessed by the on-call physician in the surgical ward on postoperative day 6 following a subtotal colectomy with end ileostomy for severe ischemic colitis. Her medical history is notable for severe chronic obstructive pulmonary disease and poorly controlled type 2 diabetes mellitus. While attempting to transition from her bed to a chair, she experiences a forceful, prolonged coughing spasm. She immediately reports a sudden "tearing" sensation in her lower abdomen. Shortly thereafter, the primary nurse observes a copious amount of salmon-colored fluid soaking the patient's abdominal binder. Removal of the binder and superficial dressings reveals viable, intact loops of small intestine protruding through a complete dehiscence of the midline fascial closure. Arrange the following management steps in the most appropriate chronological order for this patient.

  1. 1Place the patient in a supine position with the hips and knees flexed
  2. 2Cover the protruding viscera with sterile dressings moistened with warm saline
  3. 3Establish intravenous access for aggressive crystalloid resuscitation and broad-spectrum antibiotics
  4. 4Transfer the patient urgently to the operating room for surgical exploration and fascial closure

Answer

The correct sequence for managing postoperative wound evisceration is to first place the patient supine with flexed hips and knees, then cover the exposed bowel with sterile, saline-moistened dressings, followed by initiating intravenous fluid resuscitation and antibiotics, and finally transporting the patient to the operating room for emergent surgical closure.
Wound evisceration (protrusion of intra-abdominal organs through a dehisced surgical incision) is a surgical emergency often preceded by a gush of salmon-colored (serosanguineous) fluid. The correct physiological and chronological approach prioritizes limiting further herniation (supine, flexed knees), preserving the viability of already exposed organs (saline-moistened sterile dressings), providing necessary systemic support (IV fluids and antibiotics), and finally, delivering definitive mechanical correction (emergent laparotomy).

Step-by-Step Solution

1
Reduce intra-abdominal pressure.
The patient is placed in a supine position with flexed hips and knees.
Flexing the hips and knees relaxes the abdominal wall musculature, which decreases intra-abdominal pressure and minimizes the risk of further bowel protrusion.
2
Protect the exposed viscera.
The protruding bowel is covered with sterile, saline-moistened dressings.
Exposed bowel is at high risk for severe desiccation and ischemia; moist dressings preserve tissue viability and prevent further environmental contamination.
3
Medically optimize for imminent surgery.
Intravenous access is secured to administer crystalloids and broad-spectrum antibiotics.
Evisceration leads to massive insensible fluid losses and a high risk of intra-abdominal infection, necessitating hemodynamic support and antimicrobial prophylaxis.
4
Provide definitive surgical care.
The patient is transported to the operating room.
Wound evisceration is a surgical emergency; the definitive intervention is an exploratory laparotomy with washout and primary fascial closure.

Key Concept

Stepwise management of postoperative abdominal wound evisceration
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Topics

Preoperative and Postoperative Care

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