Why Wound Gape ? - Optimising Post Surgical Wound Healing

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? 26 TH 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 C itations National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-202 2 ) 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 - S oft, 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 1 st 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 .

19. What is a perineal tear ? DR. ANAND BHAGADE

20. 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 .

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

22. 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 .

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

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

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

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

27. CASE: 3 EPISIOTOMY GAPE

28. 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.

29. 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

30. 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

31. 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

32. 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 +.

33. What to do next? - DR. JAYAMALA KUMARAVEL

34. Wound swab for culture & sensitivity. Fever profile. All r outine i nvestigations. IV antibiotics (Inj. Xone & Inj. Metro). Daily B.D. Betadine douching.

35. How to maintain perineal hygeine ? - DR. AASTHA IALAWANI

36. CASE:4 BURST ABDOMEN

37. 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 4 th 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 7 th day complete wound dehiscence occurred .

38. What is the diagnosis? - DR. VINEETHA AWASTHI

39. BURST ABDOMEN

40. What are the predisposing factors? - DR. MEENAL CHIDGUPKAR

41. What are the treatment options ? - DR. KASTURI DONIMATH

42. 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 loos ely and consider using a superficial wound drain . In the presence of gross wound sepsis, leave the skin open and pack .