A laparotomy wound usually remains tender for 7 to 10 days after an operation. If it is abnormally tender and indurated, and the patient is also febrile, and does not feel well, he has pus somewhere. His abdominal wall and his peritoneal cavity are two of the places where it can be. Finding it may not be easy, and you can easily overlook an intraperitoneal abscess under a healing incision. Be guided by the severity of his symptoms. More than a little anorexia, fever, and malaise, should make you suspect an abdominal abscess. Antibiotics alone will not cure it. If many of your wounds become infected, try delayed primary closure! (9.8)
POSTOPERATIVE WOUND INFECTION If a patient's wound is red, painful, and tender, and discharges pus, it is infected. Take a Gram stain of the pus, and give him a broad-spectrum antibiotic while you wait for the result of culture, if this is possible. If it is not draining, sedate him with pethidine and diazepam, and start by removing one to three skin sutures on the ward. This will show you the extent of the infection. If it seems to be deeper, but is still extraperitoneal, press the sides of the wound, and probe suspicious areas with sinus forceps. Don't open up the deeper layers of all infected wounds from top to bottom, or remove the deeper stitches. His peritoneum will probably have healed in spite of the infection, but the sutures in the fascial layers will probably pull away. If pus flows adequately, drainage should be adequate. Irrigate his wound with saline or 1/4 strength hydrogen peroxide, or hypochlorite solution. Pack it with dry gauze, or gauze soaked in a mild antiseptic or half strength saline, and change this 1 to 3 times daily.
CAUTION ! (1) Be sure to make a wide enough opening to release the pus. (2) If possible test his HIV status (Chapter 28a).
If his wound SMELLS PUTRID, or you see NECROTIC MUSCLE or fascia, when you remove skin sutures, suspect an ANAEROBIC INFECTION. Give him metronidazole and chloramphenicol.
If his wound is TENSE, SWOLLEN, and BRUISED, with old blood exuding from between the sutures, suspect a haematoma. Sedate him, remove a few of his skin sutures, and wash out old blood and clot with a syringe of saline. Lift out more clots with a swab. Irrigate the wound with saline or hydrogen peroxide, and leave it open for a few days.
If his wound discharges a LITTLE BROWNISH FLUID WHICH SMELLS MOUSEY, suspect GAS GANGRENE (54.13). This is commoner than you probably think. Obvious gas in the tissues is uncommon, so that gas gangrene is often missed. Remove most or all of his skin sutures, make a Gram film of the exudate, and look for Gram-positive bacilli (you are unlikely to have the facilities for anaerobic culture). Treat him thoroughly. Give him benzyl penicillin 10 megaunits daily as four 6- hourly doses for 5 days. And give him metronidazole 400 mg orally and 1 g rectally 8-hourly. Clean his wound with iodine, remove any dead tissue, and isolate him from the other patients.