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PREOPERATIVE DIAGNOSIS: Large abdominal wall abscess.
POSTOPERATIVE DIAGNOSIS: Large abdominal wall abscess.
PROCEDURE: Debridement of abdominal wall abscess with placement of abdominal wound VAC
FINDINGS: Large amount of fat necrosis and fluid. An extensive debridement procedure was performed with some granulation tissue able to be found at the base of the wound. No mesh was seen from the previous ventral abdominal hernia repair. Wound VAC was then placed.
INDICATIONS: The patient is a 44-year-old female who presented to the emergency room with the complaint of a draining fluid collection from her abdominal wall. In May 2009, the patient had undergone a ventral abdominal hernia repair. Postoperatively, the patient slowly developed a fluid collection in that area. The patientâ€™s fluid collection became very large in size and was seen in the hospital September 2009. The patient was scheduled to undergo a percutaneous drainage of this fluid collection but she left the hospital against medical advice before this procedure was performed. Over the previous 2 weeks, the patient states that she has had sudden drainage from this area. On exam, the area is noted to be purulent fluid with foul odor. There was also concern about ascites in the intraabdominal compartment. The patientâ€™s ascites was drained with clear fluid returned. The patient has had no abdominal complaints and has been tolerating their diet and having regular bowel movements. I discussed this thoroughly with the patient and the patientâ€™s partner that it would probably be best to first perform an incision and drainage and debridement of her abdominal wound. I also explained to the patient that, at that time, if the previously placed mesh is identified it will likely be left in place at this time and we will allow for this current infection to resolve. The procedure of incision, drainage and debridement of abdominal wound abscess was explained thoroughly to the patient and the patientâ€™s partner. Risks including but not limited to bleeding, infection were explained thoroughly to the patient. All questions were answered and informed consent was obtained.
PROCEDURE: The patient was brought to the operating suite, placed in the supine position. After adequate sedation was obtained, the patientâ€™s abdomen was prepped and draped in a normal sterile fashion. Previously draining site on the patientâ€™s skin at approximately midpoint of her previous incision was dilated and auctioned thoroughly with return of a large amount of serosanguinous and slightly cloudy purulent fluid. The cavity was noted to be very large in size. The skin overlying the cavity was then opened with an elliptical excision of the patientâ€™s previous incisional scar. The incision ended up being approximately 15 cm in length. This was not the length of the entire previous incision but was the length of the wound cavity. The patientâ€™s cavity was noted to be from 15-20 cm in a superior interior direction to 10-15 cm in a medial to lateral orientation. The patient was noted to have a large amount of fibrinous fat necrosis material in the cavity. This material was then evacuated; the patient was noted also to have a large amount of fat necrosis in the wound bed. Pulse irrigation was aggressively performed that allowed for debridement of the superficial fat necrosis of the wound bed. After pulse lavage with almost 9 liters of saline, the patient was noted to have a nice healthy appearing granulation bed. Hemostasis was confirmed throughout the wound. The abdomen was again irrigated with 3 more liters of saline with gentamicin mixture. Again, no further areas of bleeding were identified. A large abdominal wound VAC was then placed and noted to have a good seal and suction. The patient tolerated the procedure well. Instrument, lap and needle counts were correct.
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