Question

A 63-year-old diabetic, morbidly obese female patient is complaining of diffuse upper right quadrant pain that becomes more intense after eating. Sonography indicates a large number of stones in her gallbladder. The physician has scheduled her for an open cholecystectomy with common bile duct exploration.

What surgical wound classification would be expected in this case?

How must the patient’s comorbidities be taken into account during closure?

How is her wound expected to heal?

Answer 1

What surgical wound classification would be expected in this case?

answer 1:

introduction:The surgical wounds are classified as a clean, clean contaminated, contaminated and dirty which are also described as class I, class II ,class III and class IV respectively depending on the degree of contamination of the wound by pathogens/ bacteria.

procedure description:

The patient is scheduled for an open cholecystectomy with common bile duct exploration.

In the procedure of open cholecystectomy and bile duct exploration, there is an incision made on the abdomen to expose the gallbladder and the common bile duct. The gallbladder is excised and an incision is made in the common bile duct to check for the presence of gallstones. This procedure involves controlled biliary spillage. It is the presence of the infection in the bile and biliary spillage which determines the classification of the surgical wound.

classification explanation.

Biliary procedures with a controlled entry into the biliary tract and presence of non infected bile are classified as a clean contaminated wound.class II. The surgical wound classification expected in this case of open cholecystectomy with common bile duct exploration is clean contaminated wound class II.

exception:

As expected in this case, the surgical wound expected here be clean contaminated wound if the bile encountered on common bile duct exploration is non infected .while it would be classified as contaminated wound  if the bile encountered in the common bile duct exploration is grossly infected bile/ purulent bile/massive biliary spillage occurs during surgery.{the infection of the bile, presence or absence of bacteria in the bile changes the wound classification from clean contaminated wound class II to contaminated wound class III}

so to conclude,the expected surgical wound classification here is clean contaminated woundclassII but if the bile encountered is grossly infected or purulent it will change the surgical wound classification to contaminated wound class III.

How must the patient’s comorbidities be taken into account during closure?

answer 2:

The patient is a 63-year-old diabetic, morbidly obese female patient. The patient comorbidities and factors predisposing the patient to  poor wound healing are diabetes ,obesity, age ,female sex and the clean contaminated nature of the surgery.

In view of these morbidities, the following precautions must be taken by the surgical team during wound closure.

1.Strict aseptic precautions to prevent the risk of wound infection as the patient is old,obese and  diabetic must be taken by the surgical team.The risk of infection can be decreased by using pre-operative antibiotics, strict blood sugar control before the surgery and and intraoperative neutralizing insulin drip followed by post operative blood sugar control.

2.Adequate irrigation of the main wound with normal saline solution to remove contamination of  the bile /skin commensals must be done before closure and stone spillage cleared.

3.Adequate wound homeostasis must be ensured before closure to prevent the postoperative wound hematoma formation and subsequent infection of the surgical wound.

4. the surgeon must confirm the absence of patient hypotension ,hypoxemia and hypothermia during wound closure by confirming/collaborating with the anesthetic team as these factors affect the blood supply and oxygenation of the wound during closure and subsequent wound healing.

5.Use of adequate length of the suture material for closure. The ideal recommended length of the suture material for the closure of the abdomen is 4 :1 where 1 represents the length of the suture line.Suture material taken for closure should be at least 4 times the length of the suture line

6.Suturing technique: Use of tension free closure by keeping a distance of at least 5 -8mm from the fascial edges on both sides and 4-5 millimeter distance between the two adjacent sutures to prevent ischemic pressure necrosis of the approximated fascial edges.

7.The suturing technique recommended is such that there is minimum tension on the suture line and must follow the practices of the place.The commonly used technique during closure is the  use of continuous interlocking sutures with self locking knots or the less preferred interrupted closure to distribute the tension of wound closure.

The use of self locking knots. compared to conventional knots evenly distribute the tension without decreasing the suture strength{There is a greater reduction in the suture strength seen in the traditional conventional knots around 40% as compared to the self locking knots which decrease the suture strength by about 5 to 10%)

7.Placement of suction drainage in  the main wound in anticipation of serosanguinous discharge due to subcutaneous hematoma/seroma that tends to cause wound disruption.

The use of retention sutures for abdominal closure and layered closure preference over single layer closure are some controversial considerations in the surgical technique during wound closure and merit consideration as per the surgical practices of the place.

The use of post operative abdominal binder immediately has also been reported to decrease the incidence of the wound closure  complications by distributing the tension evenly along the wound suture line.

How is her wound expected to heal?

The patient is a 63-year-old diabetic, morbidly obese female patient.

The patient comorbidities and factors predisposing the patient to  poor wound healing are diabetes ,obesity, age,female sex and clean contaminated nature of the wound.

In view of these factors,poor wound healing is expected in the postoperative period with the increased risk of skin necrosis, wound infection,wound dehiscence, wound disruption and postoperative hernias.

,Some of the complications expected are listed below

1.skin necrosis can occur due to poor blood supply especially along the edges of the suture line causing skin blackening and ulceration.

2.serosanguinous wound drainage:There is Increase of seroma and  hematoma formation due to the subcutaneus fat lysis and bleeding in the subcutaneous fat respectively causing wound discharge.

3.wound infection with purulent wound discharge and opening up of wound due to the diabetes /contamination by spillage/skin contamination and poor blood supply on account of obesity/ diabetes/age.

4. wound disruption and wound dehiscence:There is tendency of the deeper disruption of the wound as well due to the necrosis of the approximated fascial edges due to poor blood supply and tension at suture line and this tends to cause the wound breakage either partially or totally causing bowel evisceration and burst abdomen.

5. post operative incisional hernia :Postoperative abdominal distention with/without respiratory distress,wound infection,seroma/haematoma formation tend to cause the breaking of the fascial sutures, disruption of the suture line partly/totally and post-operative hernias.