Why Wound Gape ? - Optimising Post Surgical Wound Healing

1. Why wound gape ?? - Optimising Wound post surgical wound
healing
TASK SERIES
EPISODE W – WHEN, WHAT, WHY?
26TH JULY 2023
Moderators
Dr Komal Chavan
Dr Niranjan Chavan

2. PANELISTS
Dr. Kasture Donimath Dr banashree bhadra
Dr. Jayamala kumaravel Dr meenal chidgupkar
Dr. aastha ialawani Dr vineeta awasthi
Dr anand bhagade Dr rajashri paladi

3. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
67 publications in International and National Journals with 162 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-
2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)

4. CASE:1 WOUND GAPE

5. 25 yrs female married since 1 yr primigravida referred from primary centre i/v/o non -
reactive NST to our hospital.
O/E- General condition- fair, afebrile
Pulse-82/min, BP-120/80 mm hg
CVS- S1S2+, RS- AEBE, Clear

6. P/A- Uterus full term
FHS- present, regular at 90 bpm
Cephalic fixed
2/10/40
P/V- Os 3 cm dilated
30 % effaced, membrane +
ARM done- thick MSAF +
Station -1

7. Patient immediately taken for emergency LSCS in view of MSAF with fetal distress.

8. On day 13 of emergency LSCS patient came for caesarean suture removal.
Per Abdomen - Soft uterus well contracted.
Per Vaginal - No active bleeding.
Vertical mattress suture opened, wound not healthy.

9. • What to be done next? DR. KASTURI DONIMATH

10. • Patient was re-admitted
• Blood investigations sent, Wound swab sent for culture sensitivity
• CBC- Hb-12.3
TLC- 9800
Platelet- 330000
• RFT- BUN- 9
Creat- 0.8
• LFT- T.billi- 0.6
SGOT- 20
SGPT- 18
• PT/INR- 11 / 0.9
• RBS- 89

11. • What points to be kept in mind to start a drug empirically till the wound swab
report is awaited?
- DR. JAYAMALA KUMARAVEL

12. • On Day 4 patient taken up for debridment.
• Post debridment wound healthy.

13. • Patient was given Inj Piptaz and Inj Metronidazole for 3 day and then taken for
secondary suturing.
• Patient was advised prone position, explained hygeine.
• Patient discharged on Tab Linezolid and Tab Metro.
• On day 14 of secondary suturing ASR done.
• On day 15 of secondary suturing CSR done.
Wound Healthy
• P/A - Soft, Uterus well contracted.
• PV - Lochia healthy.

14. • What to be done in morbidly obese pattients to decrease the wound gape?
- DR. AASTHA IALAWANI

15. Subcutaneous Drain
In cases where wound depth is more than 4 cm, use
of subcutaneous drain will be helpful to drain out
fat liquification.
Layered suturing is preferred.

16. CASE: 2 PERINEAL TEAR

17. • 20yr G2P1L1 post dated pregnancy (at 40 weeks gestation by 1st scan) was
admitted to maternity ward for planned induction of labour.
On examination.
• General condition was fair
• No pallor, icterus, edema
• Pulse-88 bpm
• Bp- 110/70 mm of hg

18. Temperature- 98 f
RR - 22 breath per minute
P/A - Uterus term size,
Cephalic ppt,
4/5 palpable, with no contractions.
FHS 140 bpm, regular
P/V - Os admits tip of finger,
Cervix soft, Uneffaced, posterior
Station -2.
• Induced with 2 doses of tab misoprostol 25mgm kept in posterior fornix after
p/v examination. and bishop scoring at 4 am and 10am.Patient landed up with
perineal tear while delivery.

20. • What is a perineal tear?
DR. ANAND BHAGADE

21. Perineal tears:
Lacerations of perineum are the result of
overstreching or too rapid streching of the
tissues, especially if they are poorly extensile
and rigid.
Perineal injuries are more common in
primigravida than multigravida.

22. • What are the causes of perineal tear?
- DR. BANASHREE BHADRA

23. • A big baby compared to the size of the mother's pelvis.
• Malpresentation of the baby like occipitoposterior position or face presentation.
• Average sized baby with a narrow maternal vaginal outlet.
• Forceps delivery or other instrumental deliverie.
• Shoulder Dystocia.

24. • What are the types of perineal tear?
- DR. RAJASHRI PALADI

26. • What is the technique to suture 1st and 2nd degree perineal tear?
- DR. VINEETA AWASTHI

29. • What precautions to be taken before next delivery?
- DR. MEENAL CHIDGUPKAR

31. • How to prevent a perineal tear?
- DR. KASTURI DONIMATH

33. CASE: 3 EPISIOTOMY GAPE

34. • 26 year old Primigravida, 39.3 weeks gestation , came with
complaint of pain in abdomen since 5-6 hours and with
PV leak since an hour.
• No c/o per vaginal bleed.
• No c/o decrease fetal movement.
• No c/o of PMS of PIH.
• No h/o of any major medical and surgical illness.
• No h/o of blood transfusion and drug allergy.

35. • O/E :
• GC – Fair
• Afeb
• P- 88/ min
• Bp- 110/70 mm hg
• Cvs – S1 S2 +
• RS – AEBE
• P/A – Uterus ~ full term
Cephalic fixed
FHS + 138 bpm/ regular
Activity 2/10/10

36. P/V- Os 4 cm dilated
60% effaced
Vertex ppt
Membrane absent
Leak +
Show +
Station (-2)
Pelvis adequate
Pt. was monitored hourly for FHS and started on inj. Pitocin @ 8 drops/min

37. • After 5 hours she became fully dilated, fully effaced, stationed (+2)
• Pt. was fully dilated for an hour, therefore outlet forceps was applied i/v/o
maternal exhaustion
• Left mediolateral episiotomy was given
• Male child of 3.2kg delivered
• Baby cried immediately after birth
• Placenta expelled out spontaneously and completely with all the membranes
• Uterus was well retracted
• Episiotomy sutured under AAP & LA
• No active bleeding

38. • Pt. was started on Cap. Amox & T-metro & ointment Metrogyl P. &
Lignox for LA.
• On Day 3, Pt. started having fever spike.
• On L/E episiotomy gape +.
• Serosanginuous discharge +.

39. • What to do next?
- DR. JAYAMALA KUMARAVEL

40. • Wound swab for culture & sensitivity.
• Fever profile.
• All routine investigations.
• IV antibiotics (Inj. Xone & Inj. Metro).
• Daily B.D. Betadine douching.

41. • How to maintain perineal hygeine?
- DR. AASTHA IALAWANI

43. CASE:4 BURST ABDOMEN

44. • A 25 yr old female P2L2 with post LSCS 14days.
• LCSC done in view of previous LSCS with IUFD in transverse lie in labor.
• On 4th post op day patient started having fever.
• Abdominal distention of more than 2 cm was noted.
• Soaking of wound dressing was noticed. On removal of dressing, discharge from
wound site seen. Pus sent for culture and sensitivity
• Alternate stitch removal done.
• On 7th day complete wound dehiscence occurred.

45. • What is the diagnosis?
- DR. VINEETHA AWASTHI

46. BURST ABDOMEN

47. • What are the predisposing factors?
- DR. MEENAL CHIDGUPKAR

49. • What are the treatment options?
• - DR. KASTURI DONIMATH

50. • For most patients immediate re-suture (usually with a mass closure) with the
placement of deep retention sutures.
• Pre-operative broad spectrum antibiotics should be given.
• Deep bites of tissue, using plenty of suture material, and avoid excessive
tension on the wound.
• Close the skin fairly loosely and consider using a superficial wound drain.
• In the presence of gross wound sepsis, leave the skin open and pack.