Fascial dehiscence - management - Forum

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Lady Surgeon

Fascial dehiscence - management - Ärzteforum

Post#1 »

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?


Grandpa Phil

Re: Fascial dehiscence - management - Ärzteforum

Post#2 »

Similar cases and dilemmas are discussed on this List quite frequently- one
very recently. As then- I would support non-operative treatment in your
patient.

The chance of hernia following re-suture of the abdomen is very high; add
to this the potential morbidity of the re-operation; add to it the fact
that the underlying reason for dehiscence is still present during
re-operation; add to it that the "excuses" of your attending are sheer
nonsense.

The dogmatic rush to re-operate "contained" non-eviscerated dehiscenses, or
to re-suture full blown eviscerations (instead of using laparostomy
methods) is responsible for the high reported mortality for abdominal wound
dehiscence.


Anyway -it is clear that in any discussion with your attendings you are
correct.

BTW: only today I came across your paper in Current Surgery.

User avatar
Resident

Re: Fascial dehiscence - management - Ärzteforum

Post#3 »

I would do what my attending said, even if he were wrong.

Poland

Re: Fascial dehiscence - management - Ärzteforum

Post#4 »

I do not know whether this is international joke or only Poland one:

'There are only two rules in the unit:
1. The chief is always right.
2. If the chief is not right see item 1.'

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