The patient is seen for nonhealing wound on the lower central abdomen. The patient has had a history of laparotomy for the possibility of an acute abdomen and peritonitis 13 years ago. She developed recently a nodule at the inferior end of the surgical excision site which was biopsied and showed scar formation as well as a history of a nylon suture being present at this site. Subsequent to the 8 mm punch biopsy the wound would not heal and the area became very tender and inflamed. He cellulitis developed that involved the abdomen spreading up to the costal margin and to the iliac crest. This was treated orally with a 14 day course of Levaquin and responded to that therapy. The area around the site became very tender and inflamed to touch and also with contraction of the abdominal muscles. This has continued over time although seems to be slowly improving.

On physical exam there is a 14 mm x 10 mm deep sharply marginated ulceration with fibrinous material at the base. It is surrounded by 3 mm of erythema but no pearly appearance. There is tenderness to touch especially superiorly. The patient demonstrates discomfort when she bends her knees to her abdomen or sits up from a laying prone position. The working diagnosis is a nonhealing ulceration possibly due to an atypical bacterial infection such as mycobacteria, anaerobic bacteria, deep fungal infection an outside possibility of hydramine gangrenosum.

The wound was debrided and explored. One percent lidocaine with one 100,000 epinephrine was used to anesthetize the area and subsequently Marcaine solution was also injected locally. The patient tolerated this without too much discomfort. It was noted that much of the pain previously experienced by the patient was relieved by local infiltration. The wound was prepped with alcohol and Hibiclens and explored with the fibrinous material being removed from the base of the wound. It became apparent that with there was a deep fistulous tract at the base the wound that extended deep from the ulceration and somewhat superiorly. A hemostat was easily probed to the 3 cm mark without discomfort or resistance. A 20-gauge needle on a 3 cc syringe was used to aspirate around the ulceration and there is no evidence of abscess or purulent return. The wound was packed with iodoform gauze after he bacterial culture for a robe and anaerobic infection was obtained.

The postop diagnosis is a fistulous track mmost likely secondary to previous laparotomy. I suspect that the scar tissue is somehow impinging and adherent to the abdominal muscles and when these contracted there is a great deal of pain produced. I discussed this with the patient and we discussed a consultation with a general surgeon to evaluate this possibility.