IHI, Institute for Healthcare Improvement, and JCAHO patient safety goals are to prevent surgical site infections. IHI estimates 2.6% of 30 million operations are complicated by surgical site infections. Integrity of host defenses is one important determinant of risk for surgical site infection; another is the environment of the wound.

CLINICAL PRESENTATION:

57 year old male was admitted for small bowel obstruction. Medical history includes poorly controlled diabetes, heavy alcohol and smoking use. Upon opening the abdomen, small bowel contents, cirrhosis of the liver, large quantity of ascetic fluid, metastatic cancer, intra-abdominal sepsis was found. Considerable granulation made it impossible to close the surgical site. Porcine mesh was selected to cover the abdominal contents. Wound extended from the sternum to the pubic symphysis in excess of 34 cm long. Width was 12 cm and undermining of peri wound edges was 7 cm. Intraoperative wound culture grew E. Coli, Klebsiella pneumoniae, alpha strep, and Enterococcus species.

METHODOLOGY:

The goal was to protect fragile porcine mesh, promote closure during this terminal event. A bacteriostatic foam constructed of polyvinyl alcohol, PVA, with Methylene blue and Gentian Violet was used to provide a moist healing environment, to remove infection and self debride necrotic tissue in conjunction with gauze and negative pressure wound therapy. Over 125 cc an hour of ascetic fluid was removed with negative pressure.

RESULTS:

During 9 post-op weeks, the porcine mesh remained intact, the surgical wound closed slowly, surgical site remained free of infection. Patient remained free of drug resistant organisms and systemic infection.

CONCLUSION:

With the use of PVA and NPWT, the surgical wound with porcine mesh covering abdominal contents of a patient with multiple co-morbidities including metastatic cancer, ventilator dependent, progressed toward closure prior to expiring. Final measurement was 21 long x 6.5 wide x 3.2 undermining.