Post-Op Day 5 Wound Dehiscence After Emergency LSCS - Management

Step 1: Immediate Assessment

• Superficial (skin + subcutaneous only, fascia intact) - most common after LSCS
• Deep/Fascial (fascia involved) - less common but surgical emergency
• Evisceration (bowel/omentum protruding) - rare, emergency OR

• Depth and length of wound opening
• Signs of infection: erythema, edema, purulent discharge, necrosis, foul odor
• Seroma or hematoma
• Systemic signs: fever, tachycardia, hypotension (sepsis?)
• Fascial integrity - gently probe or assess with imaging if uncertain

• Evisceration
• Suspected fascial dehiscence
• Signs of necrotizing fasciitis (pain out of proportion, crepitus, bullae, rapid spread, severe systemic toxicity)

Step 2: Investigations

Step 3: Management

A) Superficial Dehiscence (no fascial involvement)

1. Wound care:
   • Open and explore the wound fully to define extent
   • Thorough irrigation with normal saline or dilute povidone-iodine
   • Debride all necrotic/devitalized tissue
   • Loose packing with saline-soaked or antimicrobial gauze (e.g. Betadine-soaked)
   • Change dressings 1-2x daily
2. Antibiotics:
   • Wound infection without systemic sepsis: oral broad-spectrum antibiotics guided by culture (e.g. Amoxicillin-Clavulanate, or Co-trimoxazole + Metronidazole empirically)
   • Systemic sepsis, deep infection, or GI/perineal involvement: IV broad-spectrum (e.g. Piperacillin-Tazobactam or Cefoperazone-Sulbactam + Metronidazole)
3. Definitive wound closure:
   • Once the wound is clean (granulating, no slough, culture-negative or organism controlled): secondary closure (delayed primary closure)
   • Typically takes 5-10 days of wound care before re-closure is possible
   • Negative pressure wound therapy (NPWT/VAC dressing) can significantly accelerate granulation and reduce time to closure - supported by meta-analysis (PMID 37726017)

B) Fascial Dehiscence

• Urgent return to OT is the default treatment to prevent evisceration and bowel injury
• Re-suture fascia using tension-suture technique (e.g., Smead-Jones or retention sutures)
• If peritoneal contamination or adhesions make re-entry unsafe, manage as open abdomen with temporary abdominal closure and plan for delayed reconstruction
• Sabiston Textbook of Surgery recommends: "In the immediate postoperative period, urgent return to the operating room should be considered default treatment to minimize treatment delay and to avoid further complications such as evisceration or bowel injury"

Step 4: Identify & Correct Predisposing Factors

• Anemia: Transfuse if Hb < 8 g/dL; optimize nutrition
• Hyperglycemia: Tight glycemic control (target < 180 mg/dL)
• Malnutrition: High-protein diet, consider nutritional supplements
• Steroids/immunosuppression: Review and minimize if possible
• NSAID use: Avoid as they impair wound healing

Step 5: Obstetric-Specific Considerations

• Confirm the uterine closure is intact - wound dehiscence at this stage warrants excluding uterine scar dehiscence (rare but serious); ultrasound is the first step
• Check lochia - foul-smelling lochia alongside wound dehiscence may indicate endometritis contributing to the wound problem
• Breastfeeding: Choose antibiotics safe for lactation (avoid fluoroquinolones; Co-amoxiclav and cephalosporins are generally safe)

Key Risk Factors in This Patient (Emergency LSCS)