Physicians and surgeons evaluate the wounds or incisions after an operation or surgery.
Question: how should they evaluate and do medical recordings on these postoperative skin wound or incision?
Here are my thoughts, perceptions, opinions and recommendations and these are what I usually do in my practice.
If I have these findings and I note them down in my charts:
- Wound dry
- Wound edges well co-aptated
- No redness or erythema
- No discoloration – no purplish or blacklist discoloration to suggest necrosis
- No unusual bulge to suggest fluid collection underneath the wound
I will make an evaluation of “wound healing well.”
Wound healing well – one week after minilap open cholecystectomy – note the scab formation on the inner side of the wound. This is not necrosis.
Wound well healed – one week after appendectomy.
Wound well healed – one week after total mastectomy and axillary dissection.
Wound well healed one week after bilateral total mastectomy and axillary dissection.
Wound well healed – one week after thyroidectomy.
Wound well healed several months after thyroidectomy.
If there is redness or erythema, the possibilities are and their accompanying findings:
- Inflammation – such as caused by stitch reaction
- Infection – tenderness, fluctuant mass indicating an abscess, purulent discharge
Redness caused by inflammation from stitch reaction.
After drainage of infection.
Stitch inflammation with dehiscence (gaping wound).
After drainage of infection
Infection – as evidenced by redness and pus.
If there is discoloration of wound edges, the possible scenarios are suspicion for necrosis; beginning necrosis; and established necrosis. The necrosis has to be differentiated from scabs formation.
Suspicion for flap necrosis or start of necrosis
Established flap necrosis.
If there is unusual bulge suggestive of fluid collection, the latter can be a seroma, hematoma or pus.
Bulge on the side.
Showing hematoma causing the bulge (on needle aspiration).
Bulge on the side of the wound and after aspirating, yielding seroma (yelllowish fluid to distinguish it from blood of hematoma and pus from infection or abscess).