Appendicectomy wound dehiscence

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  Picture from Nucleus Medical Art, Inc.UPMC

Wound dehiscence is the parting of the layers of a surgical wound. Either the surface layers separate or the whole wound splits open.

I wrote and published the pictures with the consent of the patient. Actually pt’s guardian, friend, ‘boss’ took the pictures with his hand phone and given me to publish (of course with the pt’s consent).

  • An appendicectomy (or appendectomy) is the surgical removal or excision (to remove by cutting) In surgery, an excision is the complete removal of the vermiform appendix . This procedure is normally performed as an emergency procedure, when the patient is suffering from acute Appendicitis.
  • Appendicitis is a condition characterized by inflammation of the Vermiform appendix. It is a surgical emergency. Most cases require removal of the inflamed appendix, either by laparotomy or laparoscopy.

History_

  • Appendicectomy done in a Government Hospital.
  • STO or Stitches out at a GP.
  • After all stitches were out, some discharge oozed out of the wound, the doctor squeezed and dabbed with gauze.
  • At last the whole wound opened itself, wound dehiscence occurred.
  • The doctor panic and allegedly told the pt and his ‘boss’ that the pt is going to die and advised to go back to the government hospital.
  • The ‘boss’ called my wife and asked whether I could treat this pt or not.
  • My wife called me to help her friend. I asked them to come to the clinic.
  • I immediately attended him as an emergency pt.

On examination_

  • The normal appendicectomy done with the usual surgical wound through Mc Burney’s point.
  • IMG0061A

  • The wound was quite big, about 12 cm in diameter.
  • Pus discharge present, could see the infected abdominal muscles as the base.
  • Wound margins are wide open and almost circular because of the surrounding scars.
  • His abdomen and chest skin is full with scars resulted from the scalded wound because of the childhood accident with the hot water.
  • As the abdominal muscles are intact, not the complete dehiscence and the pt refused to go  to the hospital, I accepted to treat him.

Treatment_

  • After daily dressing and controlling the infection, I found out that it will take a long time as the surrounding skin is not healthy and pulling the margins far apart.
  • IMG0056A

  • The pt is staying in far place and could not come for daily dressings. Although I requested to come on alternative days, at first they came twice a week and later once a week only as the pt cannot com alone and the friend is very busy.
  • I searched the surgical books, internet and even wish to call my youngest brother, Consultant Surgeon working in Myanmar for consultation. As he is my youngest brother and was my previous student (I was a Demonstrator/Assistant Surgeon in Surgery) I was reluctant to consultant with him.
  • I realized that his wound could not be treated with the usual orthodox surgical wound treatment routine so I decided that I need to invent or treat him in my own way to heal faster. I discuss the pros and cons with the pt and his ‘boss’. They agree with me and let me to treat with the unusual, my own strategy.
  • Usually me need to do daily dressing, stop all antibiotics after 2 weeks, and only go for secondary suture after all the infection is gone.
  • IMG0057A

  • I already observed that as the wound margins are pulled by the surrounding scar, once there is no more infection and if we tried to do secondary suture, the margins would be fixed and difficult to pull to the centre of the wound. We usually need to release it with the surgical scalpel (knife), cutting the granulation tissue.
  • As the base of the wound was occupied by the raw infected abdominal muscles there was no much chance of expecting for the healing with granulation tissue from below.
  • I tried to pull the edges/margins of the wounds but his unhealthy skin with old scar was very sensitive and vesicles and wounds appear within 1-2 days.
  • I tried to wrap around with multi-tailed cloth and pts’ friend bought very long towels to wrap around the tummy. His scary abdominal could not withstand and multiple bruises and vesicles appeared.
  • At last I decided to stitch up the wound with big intervals so that I could do the dressings, put the gauze between them. As I even could not control the copious discharge, I cleaned with H2O2, Eusol, Irrigate with Normal Saline solution and inserted the Povidone Iodene soaked gauzes.
  • IMG0077A

  • It works a miracle. Copious discharge became less and less and later dried up and so I put in the sutures left between my old sutures. The wound healed in another two weeks and I removed the stitches.
  • Note: I treated this pt F.O.C.  

 

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