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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
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
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
©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
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.
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
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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The third article in this series on surgical wound care discusses the types of dressings currently available, and selection of the correct dressing for a particular wound type. There is an abundance of information on the types of dressings available. Wound management for the individual patient must be decided using best evidence and taking into account patients' increased involvement in their care, new technology and the push to mobilize early, leading to early discharge from hospital. The nurse needs to have a good knowledge of the types of dressings available, the properties of individual dressings and a sound understanding of wound healing, in order to make an informed decision on wound management. General factors such as safety, comfort, pain management and convenience must be borne in mind when deciding which dressing is the best for individual patients, given that dressings now have to be cost-effective as well as clinically effective.
Post-operative bleeding is a life-threatening complication encountered following cardiac surgery. In cases where bleeding cannot be controlled by correcting clotting derangements and using standard surgical techniques, packing the chest may be an important salvation method. The aim was to determine the outcome of patients having primary chest packing in theatre for intractable bleeding following heart surgery. The method used was retrospective analysis of patients' medical records. Over a 9-year period, 6890 patients had open-heart surgery at the Manchester Royal Infirmary. Twenty (0.29%) of these patients had their chests packed prior to leaving theatre, 19 for uncontrolled bleeding, and one for inaccessible bleeding. Five (25%) of these patients required one further packing. The majority of patients (85%) survived. None developed a sternal wound infection. The conclusion drawn was that chest packing could be a life-saving procedure following heart surgery.
Delayed primary closure (DPC) is an accepted method in the management of contaminated abdominal wounds. Clinical factors predicting its success have not been studied. Over a 14-year period 181 patients presenting to a single surgeon with Class IV abdominal wounds were managed by a standardized protocol. Initial saline gauze packing was left undisturbed until the wound was visually inspected on postoperative day 3. Clean wounds were closed using SteriStrips. Visible purulence was managed by dressing changes. There were 103 males and 78 females with an average age of 48.5 years (range, 11-92 years). DPC was performed on 144 patients of whom four (2.8%) developed wound infections. The factors associated with the development of wound pus before DPC in the remaining patients were: requirement for mechanical ventilation for more than 72 hours, presence of severe pre-existing systemic disease, and trauma. Other diagnoses, length and type of incision, and presence of shock had no effect on outcome. An intra-abdominal abscess developed in 11 patients with early wound purulence versus none in those undergoing DPC (P < 0.001). DPC is a safe wound management technique that can be effectively applied in the large majority of patients with dirty abdominal wounds. The appearance of wound purulence before DPC is a harbinger that identifies those patients at risk for late intra-abdominal infections.
Introduction: Most surgical wounds are closed primarily, but some are allowed to heal by secondary intention. This usually involves repeated packing and dressing of the raw wound surfaces. Although the long-term care of such wounds has devolved to the care of nurses in the community or out-patient setting, the initial wound dressing or cavity packing is done by the surgeon in the operating theatre. Many surgeons are unaware of the growth of the discipline of wound care, and still use traditional soaked gauze for dressing and packing open surgical wounds and cavities. Results: This review summarises the some of the modern alternatives available and the evidence--or the lack of it--for their use in both the acute and chronic setting.