Management of Cesarean Wound Disruption

Contributor: Francis Nuthalapaty, MD   
Last Update: 8/1/2009

Background:
Disruptions of the laparotomy incision following cesarean are common. Available data suggest that wound infections complicate 3% – 15% of cesarean laparotomy incisions and seromas and/or hematomas complicate an additional 3% – 14%.

Disrupted laparotomy incisions are generally managed in one of two ways: healing by secondary intention or reclosure. As compared to healing by secondary intention, reclosure of the disrupted wound provides faster healing, improved patient comfort and decreased cost. The purpose of this guideline is to provide clinicians with guidance on appropriate management of wound disruptions and recommendations for wound reclosure.

Initial Wound Evaluation:
Whenever a wound complication is suspected, the following initial evaluation should occur:

• Open all or part of the incision either bluntly or sharply with scalpel / scissors
• Evacuate any seroma and/or hematoma
• Confirm that the rectus fascia is intact (if fascia appears disrupted or a definitive determination cannot be made, the patient should be sent to OB Triage for further evaluation)
• Debride the wound of any devitalized or infected tissue
• Irrigate the wound with saline
• Pack the wound with saline moistened gauze and cover with a dry dressing
• Provide patient with necessary supplies and instruct patient or health care partner on technique for wet-to-dry dressing changes 2 times per day.
• In the absence of cellulitus, antibiotic therapy is not recommended.
• Schedule the patient for a follow-up visit in 4-5 days.

Wound Reclosure Technique:
The patient should be evaluated for possible wound reclosure at the time of the office visit 4-5 days following initial wound disruption. Only wounds with a healthy-appearing bed of granulation tissue (red, no exudate or necrosis, evidence of neovascularization) should be closed using the following technique. Wounds not meeting this criterion should be debrided as needed and may be reassessed for reclosure at a later time or allowed to heal by secondary intention. The patient should be scheduled for the secondary wound closure procedure at the OB triage unit.

• Prep the skin with a povidine-iodine solution (use chlorhexidine if iodine allergy). Do not allow prep solution to enter the wound.
• Administer a field block to the closure site using 1% lidocaine hydrochloride and a 25-gauge needle

1. Inject through skin circumferentially approximately 3 – 4 cm from the incision margins.
2. Also inject into the deeper subcutaneous tissue if wound depth is > 2.5 cm
3. No more than 30 cc of anesthetic should be required.

    

• If wound depth is < 2.5 cm, use the following superficial closure technique (detailed in diagram below):

1. 2-0 polypropylene suture on a straight cutting needle
2. Vertical mattress sutures, 2 cm apart
3. Enter only the skin and superficial subcutaneous tissue
4. The far portion of the stitch should be placed 2 cm from the skin edge and the near portion 5 mm from the skin edge.
5. Sutures should be placed at a 1 cm depth.
6. Place Steri-stripes between sutures to further reapproximate the skin edges.

    

• If wound depth is > 2.5 cm, use the following en bloc closure technique:

1. #1 polyprophylene suture on a curved cutting needle (CT-X)
2.  Simple interrupted sutures, 2cm apart
3. The suture should enter the skin 3-4 cm from the skin edge and the entire thickness of the wound should be incorporated.
4. If the entire wound depth cannot be incorporated in a single pass, use a figure-of-eight technique (see diagram below).
5. Place Steri-stripes between sutures to further reapproximate the skin edges.

    

• Patient should be evaluated on a weekly basis for quality of wound healing. If recurrence of wound complication is noted, sutures should be removed, the wound debrided, and allowed to heal by secondary intention.

• In the absence of recurrent complications, sutures may be removed once complete healing is confirmed by:

1. Complete reapproximation of skin edges
2. Complete epithelialization
3. Absence of visible granulation tissue

    

• Complete healing should be anticipated by day 16 – 23 following reclosure.

 

Billing / Coding Recommendations:
The following CPT codes are recommended for the initial wound care and the secondary closure procedures.

Initial Wound Care:
Selective debridement of wound surface area < 20 cm = CPT 97597
Selective debridement of wound surface area > 20 cm = CPT 97598

Secondary Closure:
Complex wound repair = CPT 13160

References:

Wechter ME, Pearlman MD, Hartmann KE. Reclosure of the disrupted laparotomy wound: a systematic review. Obstet Gynecol. 2005 Aug;106(2):376-83.
Sarsam SE, Elliott JP, Lam GK.Management of wound complications from cesarean delivery. Obstet Gynecol Surv. 2005 Jul;60(7):462-73.

Dodson MK, Magann EF, Sullivan DL, Meeks GR. Extrafascial wound dehiscence: deep en bloc closure versus superficial skin closure. Obstet Gynecol. 1994 Jan;83(1):142-5.

Dodson MK, Magann EF, Meeks GR. A randomized comparison of secondary closure and secondary intention in patients with superficial wound dehiscence. Obstet Gynecol. 1992 Sep;80(3 Pt 1):321-4.