Complicated abdominal wound

Patient: 66 y/o male with gunshot to the abdomen producing jejuna injuriesX2 which were primarily closed , past medical history of hypertension, weight 120kg, height 72 inches. Treated with 24 hours of Cefotetan. Closed with running #1 LOOP Maxon.

Treatment

Post-op day 3: abdominal wound dehiscence. Laparotomy showed some intra-abdominal turbid fluid collection which grew Enterococcus (cultures were final on POD #5) and intact jejunum. All stitches on the right fascia were “pulled through.” The patient had a irrigation of the abdominal cavity, debridement of the fascia and closure with nylon retention sutures and buttons. Cefotetan was resumed. Intravenous feedings of 25kcal/kg started.

Post-op Day 5: after coughing episode, omentum and small bowel found protruding from the lower end of the wound. Return to OR where abdominal cavity did NOT show any major fluid residual, repairs are intact, and a large Vicryl mess was placed “without tension.” Antibiotics changed to Gentamicin and Piperacillin. (E. fecalis abd/ Pseudomonas aeruginosa in sputum and BAL with infiltrate on CXR) Cefotetan stopped.

The patient, until POD#6 was extubated within 8 hours of each procedure.

Post-op Day 6: Vicryl mess found pulled loose from R sided fascia. The patient was treated with a “vacuum pack” for 3 days and then as an open abdomen.

Post-op Day 12: The patient has an open abdomen AND a distal colonic fistula in the inferior aspect of the wound.

Currently, WBC count 10K, Tmax 100.4F. The patient remains on TPN. He is on the ventilator and still has signs and symptoms of a pneumonitis, but is requiring LESS ventilatory support. He also has a percutaneous tracheostomy. His Gentamicin and Piperacillin are stopped and further cultures are pending. (GNR in sputum)

NOTE: The patient is in a university hospital on an active trauma service. The same attending surgeon performed 3 of the 4 closures. The residents have not always been the same one. Certainly this is an opportunity to impugn the closure techniques and surgical judgment ( I haven’t been the “cutter”, but the involved parties are carefully reviewing everything), but I am most interested in what your surgical judgment would guide you to do now.

THANK YOU FOR REVIEWING THIS DIFFICULT CASE.

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