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Difficulty: MediumPreoperative and Postoperative Care

A 65-year-old man is evaluated on the surgical ward. He is on postoperative day 6 following an emergent exploratory laparotomy for a perforated duodenal ulcer. His medical history is significant for type 2 diabetes mellitus, obesity, and a 40-pack-year smoking history. Over the past 24 hours, he has had several paroxysms of severe coughing. A few minutes ago, while attempting to transition from his bed to a chair, he felt a sudden "tearing" sensation in his abdomen followed by a gush of salmon-colored fluid from his surgical site. On examination, the surgical dressing is saturated. Removal of the dressing reveals complete separation of the fascial edges with loops of small bowel protruding through the abdominal wound. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respirations are 20/min.

Arrange the following management steps in the most appropriate chronological order for this patient's acute complication.

  1. 1Assist the patient into a supine position with the hips and knees flexed
  2. 2Cover the protruding viscera with sterile dressings moistened with normal saline
  3. 3Establish intravenous access for fluid resuscitation and broad-spectrum antibiotics
  4. 4Transport the patient to the operating room for emergent fascial closure

Answer

The correct chronological sequence is: 1) Position the patient supine with flexed hips and knees, 2) Cover the viscera with sterile saline-moistened dressings, 3) Establish IV access for fluids and antibiotics, and 4) Transport to the OR.
Wound evisceration is a surgical emergency characterized by the protrusion of intra-abdominal organs through a dehisced fascial closure. It typically occurs 5 to 8 days postoperatively, often preceded by a gush of serosanguineous (salmon-colored) fluid. Risk factors include obesity, diabetes, smoking, and conditions that increase intra-abdominal pressure (e.g., severe coughing). Management must follow a strict, sequential protocol to minimize morbidity. The immediate priority is to prevent further evisceration by placing the patient supine with hips and knees flexed to relax the abdominal wall. Next, the exposed bowel must be protected from desiccation and injury by covering it with sterile, saline-moistened dressings. Once the bowel is protected, the patient is prepared for surgery with intravenous fluid resuscitation and broad-spectrum antibiotics. Finally, the patient is transported to the operating room for definitive exploration, washout, and secure fascial closure.

Step-by-Step Solution

1
Assist the patient into a supine position with the hips and knees flexed.
Intra-abdominal pressure is reduced.
This patient was transitioning to a chair. Placing him supine with bent knees minimizes tension on the abdominal musculature and prevents further evisceration.
2
Cover the protruding viscera with sterile dressings moistened with normal saline.
The exposed bowel is protected from the environment.
Exposed serosa can quickly desiccate and become necrotic. Dry dressings should be avoided as they can adhere to and damage the bowel.
3
Establish intravenous access for fluid resuscitation and broad-spectrum antibiotics.
The patient is medically optimized for emergent surgery.
Fluid resuscitation maintains perfusion, and antibiotics are necessary to prevent intra-abdominal infection and sepsis following exposure of the peritoneal cavity.
4
Transport the patient to the operating room for emergent fascial closure.
Definitive surgical management is provided.
Evisceration is a surgical emergency that requires immediate return to the operating room for abdominal exploration, irrigation, and secure closure.

Key Concept

The immediate management of postoperative wound evisceration involves reducing abdominal tension, protecting the exposed bowel with moist sterile dressings, and emergent surgical closure.
Estimated Time:1m 0s
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Topics

Preoperative and Postoperative Care

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