I had disagreement with my attending regarding management of the patient
with fascial dehiscence.
70 yo generally healthy moderately obese WM underwent uneventful APR 10
days ago 4 wks after preoperative XRT+chemo for 5 cm low rectal adenoCA.
Postopeartive period was overall uncomplicated except for some serous fluid
drainage from the upper part of the wound which was a midline incision from
the umbilicus down to the pubis. Staples were d/c'd on POD#10 and upper 4
cm of the wound broke open and there was a 3 cm fascial defect palpable
deep in the wound. No bowel was seen. I chose to manage this controlled
evisceration conservatively with dressing changes. My attending did not
agree with me and decided to take the pt to the OR. His main argument was
that in presence of the colostomy there is an increased risk of wound
infection and intraabdominal sepsis in the patient with fascial dehiscence.
On exploration, we found that loops of the small bowel were adherent to the
peritoneum, fascia was attenuted, and there was no signs of wound infection
or peritonitis. The adhesions were taken down, the fascia was reclosed,
full thickness of abdominal wall but above the peritoneum retention sutures
were placed, and skin was left open.
What would you do?