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Difficulty: EasyPreoperative and Postoperative Care

A 45-year-old woman is evaluated on postoperative day 5 following an elective open cholecystectomy for symptomatic cholelithiasis. Her postoperative course was initially uncomplicated, but today she reports new-onset pain at the surgical incision site. Her temperature is 38.5°C (101.3°F), blood pressure is 122/78 mm Hg, pulse is 88/min, and respirations are 14/min. Physical examination of the abdomen reveals normal bowel sounds and no generalized tenderness. The surgical incision has a 3-cm area of erythema and fluctuance at its inferior aspect. Gentle palpation yields purulent discharge from between the skin staples. There is no surrounding induration or crepitus. Which of the following is the most appropriate next step in management?

  1. Remove the skin staples to open and pack the woundAnswer
  2. B
    Initiate empiric broad-spectrum intravenous antibiotics
  3. C
    Order a contrast-enhanced CT scan of the abdomen
  4. D
    Insert a nasogastric tube and initiate bowel rest
  5. E
    Perform a bilateral lower extremity venous ultrasound

Answer

Remove the skin staples to open and pack the wound
This patient has a simple superficial surgical site infection (SSI), which typically presents between postoperative days 4 and 7 with fever, localized erythema, and purulent drainage. Because there are no systemic signs of severe sepsis, deep fascial involvement, or extensive cellulitis, the definitive treatment is source control. This is achieved by removing the staples or sutures to open the incision, allowing the purulent fluid to drain, and packing the wound to heal by secondary intention.

Step-by-Step Solution

1
Evaluate the patient's clinical presentation, vital signs, and postoperative timeline.
The patient has a fever on postoperative day 5 with localized erythema, fluctuance, and purulent discharge at the surgical site.
To accurately identify the most likely source of the postoperative fever.
2
Determine the severity and depth of the identified infection.
The infection appears superficial, lacking signs of systemic toxicity, deep space involvement, or extensive surrounding cellulitis (>5 cm).
Management pathways differ significantly between simple superficial surgical site infections and deep or systemic infections.
3
Select the appropriate intervention for a simple superficial surgical site infection.
Wound opening and packing is chosen over systemic antibiotics or advanced imaging.
Source control via mechanical drainage is the primary and definitive treatment for simple superficial wound infections.

Key Concept

The primary management of a simple superficial surgical site infection is source control by opening the wound to allow for drainage and secondary intention healing.
Estimated Time:50s
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Topics

Preoperative and Postoperative Care

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