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Surgical exploration of cavities, sinuses, and specific antibiotic therapy are fundamental for the control fo cutaneous infection. Topical treatment will vary based on evaluation of the lesion, experience of the health care team, and the environment.
Most surgical wounds heal uneventfully--the dehisced surgical incision is definitely the exception to the rule. However, management of a dehisced incision is a fairly common home care challenge that must be understood. This month's column answers the questions: Why do some incisions dehisce, and what, if anything, can be done to prevent dehiscence? Are there early warning signs to look for? How should a dehisced wound be managed?
The aim of this study was to examine the effect of decontamination as compared to placebo medication on post-gastrectomy treatment costs. The results of a prospective double-blind placebo-controlled multicenter trial indicate that perioperative i.v. prophylaxis with cefotaxim and topical decontamination with polymyxin B, tobramycin, vancomycin and amphotericin B from the day before surgery until the 7th postoperative day is most effective in the prevention of esophagojejunal anastomotic leakage following total gastrectomy. For the cost analysis, only patients who had been decontaminated according to the study protocol (n = 90) were compared to the non-decontaminated patients (n = 103). The esophagojejunal leakage rate was 10.6% in placebo patients (n = 103) and could be reduced significantly to 1.1% in decontaminated patients (n = 90, P = 0.0061; two-tailed Fisher's exact test). There was only one asymptomatic leakage detected on Gastrografin swallow. The pulmonary infection (P = 0.0173) and overall complication rates (p = 0.0238) were significantly reduced in the decontamination group as well. During the observation period, 9 (8.7%) patients in the placebo group and 3 (3.3%) in the decontaminated group died (P = n.s.). Patients were followed up for the initial 42 postoperative days and treatment costs were calculated for this time period only. The parameters compiled in the study pertaining to use of medical resources formed the basis for the determination of the postoperative treatment costs. These were the costs for decontaminating drugs, intravenous antibiotics, reoperations and non-surgical reinterventions as well as daily treatment costs of the general ward, the intensive care unit (ICU) and rehabilitation. The average costs per patient in the placebo group amounted to DM 20,000 while the costs for decontaminated patients were only DM 16,200, which was due to a significantly lower number of patients requiring treatment in the ICU (P = 0.0082), significantly fewer patients requiring i.v. antibiotics (P = 0.0232) and fewer patients with reoperations (P = 0.0909). The prophylaxis employing decontaminating drugs in the amount of DM 400 lowered post-gastrectomy treatment costs by DM 3800 or 19%. The prophylaxis can be recommended, because it lowers morbidity, mortality and the costs of total gastrectomy.
Despite advances in preoperative care, the rate of surgical wound dehiscence has not decreased in recent years; 1%-3% of patients experience wound dehiscence. A nursing goal for the postoperative patient is always prevention of wound dehiscence. Recognition of risk factors is essential. For example, older males with ascites are at very high risk. Prevention of wound infection and mechanical stress on the incision are important. Management of dehisced wounds may include immediate surgery if bowel is protruding from the wound. If surgery is not needed, management is essentially the same as that of any other wound through maintenance of a moist wound environment, reduction of bioburden and pain, and promotion of granulation tissue. Mortality rates associated with dehiscence have been reported between 14% and 50% (Hanif et al., 2000; Waqar et al., 2005). One of the complications (morbidity) of dehisced wounds is an incisional hernia, which develops in an estimated 43% of patients (van't et al., 2004). Researchers followed 126 patients who had wound dehiscence repair for a mean of 37 months and found that 31% of the hernias were diagnosed more than 2 years postoperatively. Nurses need to ensure adequate nutrition and reduced tension on the abdomen, and implement measures to prevent incisional infections.
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The authors evaluate two groups of patients after laparotomy where during the postoperative period complete dehiscence of the laparotomic wound occurred. In the first group A the laparotomies were closed in anatomical layers by individual silon stitches, in group B for closure a single layer continuous PDS loop suture was used. After introduction of this technique the percentage of dehiscent laparotomies declined from 2,2% to 1,2%.