Holly M. Hovan MSN, RN-BC, APRN, CWOCN-AP
An abdominoperineal resection (APR) is an operation in which a surgeon removes the anus, rectum, and sigmoid colon, usually to treat low rectal cancers.
Despite modern precautions and protocols in place, surgical site infection (SSI) continues to be a risk. SSIs are the most common and costly of all hospital-acquired infections, with an estimated annual cost of $3.5 to $10 billion in the United States.1 Johns Hopkins Medicine reports that up to 3% of people who undergo a surgical procedure will develop an SSI.2 Additionally, SSIs can increase hospital length of stay by up to 9.7 days.1 Other complications of surgical wounds include osteomyelitis, gangrene, periwound dermatitis, periwound edema, wound dehiscence, and hematomas.
Surgical procedures were performed on 63% of hospitalized patients in 2011. Surgical procedures performed included appendectomy, cesarean delivery, cholecystectomy, debridement (wound, burn, or infection), dilation and curettage, and others.3 Wound dehiscence, which is the separation of surgical edges and can be a cause of SSI, occurs in approximately 0.5% to 3.4% of abdominopelvic operations and has a mortality of approximately 40%.4
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Postoperative complications may be reduced or prevented by following proper hand washing procedures and by encouraging the patient to implement pulmonary exercises, maintain proper hydration, and begin early ambulation and leg exercises. Patient education is paramount in reducing the occurrence and severity of complications during healing.
Infection is the most common wound care complication and is caused by any break in the skin that allows bacteria to enter. SSIs normally occur within 30 days after surgery and are categorized as superficial incisional, deep incisional, and organ or space. Bacterial species may include Staphylococcus, Streptococcus, and Pseudomonas. Treatment with antibiotics or sometimes additional surgery may be warranted depending on the severity of the infection.
Signs of infection in a surgical wound include erythema, stalled healing, fever, pain, warmth, and swelling. A pocket of pus and disintegrating tissue, called an abscess, may also develop.2 Patients should be educated on the signs of infection so that they can receive immediate treatment and prevent worsening infection.
The various risk factors for SSIs include emergency surgery, abdominal surgery, operations taking longer than two hours, chronic medical conditions, smoking, cancer, obesity, a compromised immune system, and diabetes. Physicians should educate patients on what they can do to reduce the risk of SSI, for example, smoking cessation before surgery.2
Managing SSIs can involve a multitude of management strategies. SSIs may require antibiotic therapy, wound drainage, aggressive debridement, and close monitoring.
Dehiscence is a condition in which the surgical site gradually comes apart or becomes completely open in response to various factors, such as poor suturing, stress on the wound area, a compromised immune system, or infection. Signs of dehiscence in a surgical wound are pain, redness, swelling, bleeding, drainage, and a feeling of sudden painful pulling.
It is important to educate patients on ways to avoid incision dehiscence, such as maintaining a balanced diet, staying hydrated, being careful when coughing, sneezing, or laughing, refraining from smoking, avoiding lifting, adhering to good wound care practices, and preventing constipation. Management of dehiscence may include antibiotics, debridement, re-suturing, and the use of wound closure devices.5
Hematomas are not as common after surgery as SSIs or wound dehiscence; however, when they do occur, they may lead to infection and/or wound dehiscence. A hematoma is a collection of clotted or nonclotted blood outside of the blood vessel (artery, capillary, vein) that spreads into tissues. Symptoms of hematoma in a surgical wound are headache, neurological problems (weakness on one side, difficulty speaking, confusion), nail pain, and abdominal pain. Hematomas can take one to four weeks to resolve.
Potential risk factors for hematomas are age, sex, body mass index, smoking, combined surgery, and diabetes. Preventing hematomas involves adjunctive measures, such as drain placement, application of tissue sealant, and use of compression stockings.
Managing hematomas after surgery involves use of a warm compress in the affected area two to three times a day. This will help the blood reabsorb. Patients should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), massaging, bumping, and/or compressing the area. Depending on the severity of the hematoma, surgical drainage may be needed.
A seroma develops when sterile, clear bodily fluids build up under the skin at the SSI site. There may be swelling, pain, and tenderness. This complications can occur one to two weeks after surgery. Although seromas are generally not dangerous, they may need to be treated by draining with a syringe and needle or by placing a drain.
Risk factors for seroma development are extensive surgery, procedures that disrupt large amounts of tissue, and a history of seromas after surgery.
There are various strategies to prevent seroma development. Surgical drainage systems and compression garments may help reduce the risk of seroma development. Educate patients on the signs of seroma development so they can seek treatment if one develops.
Given that SSIs are the most common and costly of hospital-acquired infections, there should be adherence to guidelines and recommendations to reducing SSI occurrence. It is important when assessing patients with risk factors that interventions are implemented and education is provided before discharge home to promote better long-term outcomes.
1. Loyola University Health System. Surgical site infections are the most common and costly of hospital infections: guidelines for preventing surgical site infections are updated. ScienceDaily. January 19, 2017. Accessed September 27, 2021. www.sciencedaily.com/releases/2017/01/170119161551.htm
2. Johns Hopkins Medicine. Surgical site infections. Accessed September 2, 2021. https://www.hopkinsmedicine.org/health/conditions-and-diseases/surgical-...
3. Pfuntner A, Wier LM, Stocks C. Most frequent procedures performed in U.S. hospitals, 2011. Healthcare Cost and Utilization Project statistical brief #165. Agency for Healthcare Research and Quality; 2013. Accessed September 2, 2021. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb165.pdf
4. Shanmugam VK, Fernandez SJ, Evans KK, et al. Postoperative wound dehiscence: predictors and associations. Wound Repair Regen. 2015;23(2):184-190. doi:10.1111/wrr.12268
5. Krasner D. Chronic Wound Care 5. HMP Communications; 2012:1-50.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.