Journal of the College of Physicians and Surgeons Pakistan
ISSN: 1022-386X (PRINT)
ISSN: 1681-7168 (ONLINE)
Affiliations
doi: 10.29271/jcpsp.2026.08.1081ABSTRACT
Objective: To evaluate the outcomes of radical excision of infected Pfannenstiel (gynaecological and obstetric) surgical wounds.
Study Design: A descriptive case study.
Place and Duration of the Study: Department of Obstetrics and Gynaecology, Lady Reading Hospital, Peshawar, Pakistan, from December 2023 to June 2024.
Methodology: A total of 80 female patients with culture-confirmed infected lower abdominal surgical wounds following obstetric or gynaecological procedures, who had failed debridement (three or more), were included in the study. Patients' primary outcomes were assessed in terms of whether the wound healed after a single radical excision and the number of days spent in the hospital after the procedure. The mean difference between the duration of stay before and after radical excision was determined by using the Paired T-test. Secondary outcomes were complications at long-term follow-up at one and three months.
Results: The mean age was 38.70 ± 16.66 years. The prior surgical procedures included elective gynaecological (46.7%) and emergency C-section (30%). The primary outcome of wound healing was observed in 86.7% (26 patients) within 2 weeks, with 13% healed by the end of the third week. Prior hospital stay was 10.793 ± 8.36 days. The mean difference between the duration of stay before and after radical excision was statistically significant, with a mean difference of 8.1 days (p <0.001, 95% CI: -5.55 to -11.97). The mean difference in scar size between the preoperative and postoperative measurements was 10.367 cm, representing a statistically significant decrease (p <0.001, 95% CI: -9.124 cm to -11.609 cm). Complications were observed in four patients, with three having partial wound dehiscence and one patient leading to delayed wound healing (>21days).
Conclusion: Radical wound excision offers a one-step streamlined procedure, enabling swift resumption of regular activities and minimising hospitalisation duration. Additionally, it alleviates the strain on both patients and healthcare systems.
Key Words: Radical excision, Surgical site infection, Wound debridement.
INTRODUCTION
Surgical site infections (SSIs) are associated with surgical procedures and typically manifest within the first 30 days postoperatively1, when the wound fails to follow the normal biological processes of healing.2-4 This may be due to deficient nutritional environmental factors,5,6 influence of medicines,7,8 or genetic factors.9 The global incidence of SSI, ranging from 3 to 15%, makes it the most common postoperative complication even in hospitals with advanced facilities and standard preoperative preparation and antibiotics prophylaxis protocols.10,11
SSIs not only burden patients physically and emotionally but also impose significant financial strain on families and the healthcare system. This is attributed to prolonged hospital stays, the need for repeated surgeries, extended recovery times, increased hospital and community care costs and delayed resumption of normal activities.11,12 Additionally, SSI following a caesarean section is linked to a maternal mortality rate of up to 3%.13
This study focuses on managing persistent infected wounds that have undergone multiple failed debridements using an innovative radical excision procedure. Radical excision is a one-step, deep excision of infected tissue, suturing and discharge of patients, allowing them to shorten their hospital stay, promote early healing, and expedite the return to normal activities. An innovative procedure led to one-step surgery management of the infected wound. The objective of this study was to evaluate the outcomes of radical excision of infected Pfannenstiel (gynaecological and obstetric) surgical wounds.
METHODOLOGY
This descriptive study was conducted at the Department of Obstetrics and Gynaecology, Lady Reading Hospital, Peshawar, Pakistan, from December 2023 to June 2024. Ethical approval was obtained from the hospital’s Institutional Ethical Board (Ref. No. 40/LRH/MTI; dated 14 February 2024), after conduc-ting a pilot study. The Centres for Disease Control and Prevention (CDC) criteria for identifying SSIs were applied by the consultant for patient wound selection. The CDC categorisation included no SSI, superficial incisional SSI, and deep incisional SSI. The study included 30 female patients with infected lower abdominal wounds following obstetric or gynaecological procedures who were classified as having deep incisional SSI according to the CDC criteria and had undergone three unsuccessful debridements. In this study, failure was defined as no noticeable improvement in the wound bed (e.g., reduction in necrotic tissue or signs of granu-lation tissue formation) within 2 weeks, or after 2 surgical debridements. Patients who underwent gynaecological midline surgeries, malignant conditions, or refused to give consent were excluded from the study.
Data were collected using a designated form. Preoperative assessment variables included age, primary surgery, surgical indication, number of DDs performed, co-morbidities, wound status, wound culture and sensitivity results (qualitative), antibiotics used, and relevant clinical history. Perioperative assessment variables included preoperative and postoperative wound size (cm), blood loss measured by drain output (mL), and duration of hospital stay (days) before and after radical excision. Descriptive statistics were analysed using SPSS version 22 software. Continuous variables such as age, weight, before and after radical wound excision, and hospital stay.
Preoperative/postoperative scar size and healing days after excision were presented as mean ± SD, while categorical variables such as prior surgery, comorbid status, follow-up status and complications were expressed as frequencies and percentages. A paired t-test was used to compare the mean difference between preoperative and postoperative scar sizes, with statistical significance set at p < 0.005. Results were presented in tables. Follow-up assessments were conducted at 1 week, 2 weeks, 21 days, and 3 months to evaluate wound status, healing time, and any complications.
Following informed written consent from the patients, the procedure was performed under spinal anaesthesia by a consultant plastic surgeon who is well versed with this procedure. Preoperative wound measurements were taken, and photographs were captured. After cleaning and draping, tumescence (10 mg bupivacaine, 10 mL xylocaine, and 1 mL epinephrine in 500 mL Ringer's lactate) was injected around the wound site. Following marking, an incision was made with approximately 1-2 cm margins. Radical excision using monopolar cautery was performed, excising infected tissue down to the rectus fascia in its entirety. Any defects in the rectus sheath were closed with interrupted Prolene 2/0 sutures after achieving haemostasis. The dead space was closed with Vicryl 3/0, and a Vaccuderm drain was inserted. Dermal sutures were placed using Vicryl 4/0, followed by skin closure with skin staplers. The length of the scar was documented, and photographs were taken. A dressing with Bactigras and packs was applied. Patients were discharged the following day if stable, and the drain was removed if there was less than 30 mL of fluid collection. Regular follow-up appointments were scheduled.
RESULTS
The demographic details, such as mean recorded age, weight, type of prior surgery, comorbidities, average hospital stay before and after radical excision, and number of previous debridements performed, are mentioned in Table I and II. The mean difference between the duration of stay before and after radical excision was statistically significant, with a mean of 8.1 days (p <0.001, 95% CI: -5.55 to -11.97). The mean difference between preoperative and postoperative scar size was 10. 367, with statistical significance (p <0.001, 95% CI: 9.124-11.609).
Partial wound dehiscence was observed in three patients, and one patient had delayed wound healing that was more than 21days. Approximately 13.3% of patients developed wound dehiscence; however, the wounds subsequently healed by secondary intention within 2 weeks.
Table I: Demographic and effect of treatment.
|
Variables |
Mean ± SD |
|
Age |
38.70 ± 15.027 |
|
Weight |
67.43 ± 10.685 |
|
No. of prior wound debridements performed |
2.70 ± 1.601 |
|
Prior hospital stay in days |
11.47 ± 8.46 |
|
Duration of stay after wound excision (days) |
2.70 ± 0.837 |
|
Preoperative size of scar (cm) |
18.40 ± 3.578 |
|
Postoperative size of scar (cm) |
25 ± 4.690 |
|
Total time of healing after radical wound excision (days) |
13.20 ± 3.044 |
Table II: Baseline characteristics and follow-up.
|
Variables |
Frequency (%) n (%) |
|
Type of prior surgery Emergency C-section |
- 9 (30) |
|
Elective C-section |
7 (23) |
|
Elective gynaecological surgery |
14 (46.7) |
|
Comorbid status |
- |
|
Diabetes |
6 (20) |
|
Hypertension plus diabetes |
8 (26.7) |
|
Other medical disorders |
12 (42) |
|
Nil |
4 (13) |
|
Follow-up at 2 weeks |
- |
|
Healed |
26 (86.7) |
|
Dehiscence |
4 (13.3) |
|
Complications |
- |
|
Delayed wound healing (21 days) |
1 |
|
Partial dehiscence |
1 |
DISCUSSION
In this study, the overall SSI rate was 6.3%. The prevalence of SSI globally in elective clean and clean-contaminated surgeries was estimated to be 6%.9 The overall prevalence of SSI in Africa/Middle East, Latin America, Asia, and China was 10%, 7%, 4%, and 4%, respectively. In Pakistan, the SSI rate is 9.29%, according to a study conducted in Peshawar.9
The prolonged hospital stay of these patients for repeated debridements further strains an already resource-limited healthcare system.10,11 In this study, the patients' hospital stay for multiple debridements and re-admission was 11.47 days and after radical excision was 2.7 days. A study by Kaye et al. reported a mean duration of hospitalisation of 15.7 days for patients undergoing SSI wound debridement.12 In a study by Mahjoubi et al., which corresponds to this study of radical excision, the average hospital stay was 1.1 ± 0.4 days,13 with extremes of 1 and 4 days in radical wound excision of pilonidal abscess.
There were significantly higher SSI rates with a combined morbidity of 88.7% in this study. Another study also concluded significantly higher SSI rates among patients with a combined comorbidity scale score of 1–6 than those with no comorbidities.14
The average healing time of SSI on conservative treatment was 63.4 ± 32.2 days, with extremes of 10 and 150 days.15 In this study, the healing time was 13.2 days, with one patient having delayed wound healing up to 21 days.
Radical excision is a one-stage treatment that offers the advantage of requiring only a single anaesthetic exposure and procedure to definitively resolve the condition, albeit at the expense of a longer operation and greater tissue loss. In this study, the average wound scar size was 25 cm. A similar study presented 2 cases way back in 1992,16 with a patient who presented after C-section with necrotising fasciitis and had wound radicle excision with extension of wound size of up to 20-24 cm long, but the wound eventually healed.
This study was conducted as a descriptive case series without a control group, which limits the ability to draw causal inferences or compare outcomes with standard treatments. The assessment of surgical site infection was subjective; therefore, a more objective scoring method should be used in future studies. This study focuses more on immediate wound closure rather than long-term functional or aesthetic outcomes. Therefore, a long-term study for one year needs to be carried out.
The study addresses a common and challenging postope-rative complication in obstetric and gynaecological practice, making the findings highly applicable to routine clinical care. The inclusion of patients with confirmed infected Pfannenstiel wounds and multiple failed debridements ensured that the study focused on a well-defined and clinically challenging population. The use of a paired t-test to analyse changes in the duration of hospital stay strengthened the statistical validity of the findings.
CONCLUSION
With traditional wound dressings and appropriate antibiotic regimens, wounds typically heal by secondary intention. However, complications associated with Pfannenstiel incisions, such as deep incisional SSIs and multiple failed debridements, can be treated with radical excision exten-ding to the rectus sheath, followed by primary closure, which was performed in all cases in this study.
ETHICAL APPROVAL:
Ethical approval was obtained from the Institutional Review Board of Lady Reading Hospital, Peshawar, Pakistan (Ref. No. 40/LRH/MTI; dated 14 February 2024).
PATIENTS’ CONSENT:
Informed consent was obtained from all participants.
COMPETING INTEREST:
The authors declared no conflict of interest.
AUTHORS’ CONTRIBUTIONS:
RAA: Conception of the study and critical review.
FZ: Drafting of the manuscript and data collection.
ZT: Study design, drafting the manuscript, data analysis, and interpretation.
All authors approved the final version of the manuscript to be published.
REFERENCES