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Abstract

The authors present a case of a surgical wound that was inappropriately packed to the extent that a significant and major deterioration occurred in the expected healing by secondary intention. This is intended to alert surgeons to the fact that careful supervision is required of such seemingly simple and straightforward tasks as the topical treatment of open wounds by inexperienced caregivers.
Can J Plast Surg Vol 17 No 4 Winter 2009 e2727
When a pack becomes a plug
Michael SG Bell MD FRCSC1, Daniel McKee BSc2, Paul J Hendry MD MSc FRCSC3
1The Department of Surgery, Division of Plastic Surgery, The Ottawa Hospital-Civic Campus; 2University of Ottawa, Faculty of Medicine; 3The
Department of Surgery, Division of Cardiac Surgery, The Ottawa Hospital-Civic Campus, Ottawa, Ontario
Correspondence: Dr Michael SG Bell, 402-1919 Riverside Drive, Ottawa, Ontario K1H 1A2. Telephone 613-739-5424,
fax 613-739-7168, e-mail msgbell@cyberus.ca
Packing of wounds is a long-established tradition in surgery
(1). Delayed primary closure with frequent packing changes
is an accepted way of providing local wound debridement, and
is standard practice (2,3). Packing has many variations; diverse
mechanical absorptive dressings and chemicals are employed
with varied accompanying marketing claims, which supposedly
speed up the healing process (4,5).
In the case of deep wounds that contract and form a some-
what narrow-necked sinus in the process of spontaneous clos-
ure, irrigation is often used in the last phase until the sinus
eventually heals in. The authors present a most unusual case of
a patient post-coronary artery bypass graft surgery with an
infected sternotomy requiring debridement and a muscle flap
reconstruction.
CASE PRESENTATION
A patient developed delayed drainage from the lower end of his
coronary artery bypass graft surgery incision approximately six
weeks after an apparently successful closure. There seemed to
be no association with residual necrotic tissue because the bone
and adjacent costal cartilages had been already debrided. It was
thought that the wound would simply close in with simple
loose packing and dressing.
Unfortunately, a rather zealous nurse working for an
independent home care facility embarked upon the process of
tightly packing and expanding this sinus, which initially meas-
ured 1.2 cm in diameter (Figure 1). The sinus opening had
been expanded to admit two fingers within a period of two
weeks of this treatment. In addition a remarkably large (4.4 cm
× 6.2 cm × 10 cm) fluid cavity developed, dissecting between
the pectoralis major muscle and the skin, creating a plane that
had previously been sealed (Figure 2).
Fortunately, the patient required hospitalization for a
depressive episode, and in this sheltered environment, looked
CASE REPORT
©2009 Pulsus Group Inc. All rights reserved
MSG Bell, D McKee, PJ Hendry. When a pack becomes a plug. Can
J Plast Surg 2009;17(4):e27-e28.
The authors present a case of a surgical wound that was inappropriately
packed to the extent that a significant and major deterioration occurred in
the expected healing by secondary intention. This is intended to alert
surgeons to the fact that careful supervision is required of such seemingly
simple and straightforward tasks as the topical treatment of open wounds
by inexperienced caregivers.
Key Words: Sinus drainage; Sinus wounds; Surgical packing; Wound packing
Quand un paquetage chirurgical cause une
occlusion
Les auteurs décrivent ici une plaie chirurgicale dont le paquetage a été
incorrectement effectué, au point où une détérioration significative et
majeure est survenue au cours du processus de guérison secondaire. Cet
article vise à alerter les chirurgiens au fait qu’une supervision étroite
s’impose lors de tâches en apparence simples, comme le traitement topique
des plaies ouvertes par des professionnels de la santé inexpérimentés.
Figure 2) Computed tomography scan, left chest wall abscess,
September 17, 2007
Figure 1) Initial sinus after spontaneous drainage of a seroma
Bell et al
Can J Plast Surg Vol 17 No 4 Winter 2009e28
after by experienced surgical nurses who used very light appropri-
ate packing, the wound progressively closed in as expected and
eventually healed with an umbilicated scar (Figures 3, 4 and 5).
The images demonstrate how over-packing of a wound to
the point of causing a plug can result in a major reversal of the
wound healing process. Indeed, packing can progressively
enlarge shallow wounds if it is done in an inappropriately
aggressive way.
The present case should remind us all that interventions in
medicine should first do no harm, and even simple tasks such
as dressings and packing of wounds require appropriate super-
vision. Sinuses are probably best irrigated only, or treated with
a wound vacuum system. Ill-advised packing can have deleteri-
ous consequences, as seen here.
REFERENCES
1. Hepburn H. Delayed primary suture of wounds. BMJ 1919;1:181-3.
2. Bender J. Factors influencing outcome in delayed primary closure of
contaminated abdominal wounds: A prospective analysis of 181
consecutive patients. Am Surg 2003;69:252-6.
3. Charalambous C, Zipitis CS, Keenan DJ. Outcome of primary chest
packing and delayed sternal closure for intractable bleeding
following heart surgery. Cardiovasc J S Afr 2002;13:231-4.
4. Foster L, Moore P. Acute surgical wound case 3: Fitting the dressing
to the wound. Br J Nurs 1999;8:200-10.
5. Dinah F, Adhikari A. Gauze packing of open surgical wounds:
Empirical or evidence-based practice? Ann R Coll Surg Engl
2006;88:33-6.
Figure 3) Sinus closing, January 2008
Figure 5) Computed tomography scan showing considerable improve-
ment, January 11, 2008
Figure 4) Sinus healing complete
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