Overview
Definition:
Groin wound breakdown after vascular surgery refers to the partial or complete dehiscence of the surgical incision in the groin region, often complicated by infection, leading to exposure of underlying vascular repairs or grafts
It is a serious complication that can compromise the integrity of the repair and lead to limb ischemia or hemorrhage
This breakdown can manifest as superficial skin edge separation or deeper disruption involving the fascial layer and prosthetic material.
Epidemiology:
The incidence of wound complications after groin vascular surgery ranges from 2% to 10%, with breakdown and infection being significant contributors
Risk factors include obesity, diabetes mellitus, prior surgery, smoking, emergency procedures, prolonged operative times, and the use of prosthetic grafts
Specific procedures like femoropopliteal bypass, iliac endarterectomy, and common femoral endarterectomy carry a higher risk due to the anatomical location and potential for contamination.
Clinical Significance:
Groin wound breakdown is a critical surgical complication demanding prompt recognition and management
It significantly increases morbidity, prolongs hospital stay, and raises healthcare costs
Inadequate management can lead to graft infection, pseudoaneurysm formation, limb ischemia, sepsis, and even mortality
Successful management hinges on early diagnosis, aggressive treatment of infection, and appropriate wound coverage strategies to preserve the vascular reconstruction and restore wound integrity.
Clinical Presentation
Symptoms:
Increasing or persistent groin pain
Serous or purulent discharge from the wound
Fever or chills
Calf pain or claudication suggestive of compromised distal perfusion
Swelling and erythema around the incision site
A palpable or visible defect in the wound closure.
Signs:
Superficial or deep wound dehiscence
Redness and tenderness of the surrounding skin
Palpable fluctuance indicating abscess formation
Exposed subcutaneous tissue, fascia, or prosthetic material
Systemic signs of infection like tachycardia and hypotension.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the presence of wound dehiscence, signs of infection (erythema, warmth, purulent discharge, fever), and in cases involving prosthetic material, evidence of graft-patency issues
Microbiological cultures from wound exudates or tissue are crucial for identifying causative organisms and guiding antibiotic therapy.
Diagnostic Approach
History Taking:
Detailed history of the index vascular procedure (type of surgery, graft material used, duration)
Onset and evolution of wound symptoms
Presence of systemic symptoms of infection
Risk factors: diabetes, obesity, smoking, immunosuppression, previous wound issues
Medications, especially anticoagulants or antiplatelets
Allergies.
Physical Examination:
Careful inspection of the groin wound for dehiscence, discharge, erythema, and induration
Palpation for tenderness, crepitus, or fluctuance
Assessment of the surrounding skin for cellulitis
Examination of distal pulses to assess limb perfusion
General systemic examination to assess for signs of sepsis
Inspection of the contralateral groin and lower extremities for any associated findings.
Investigations:
Complete blood count (CBC) with differential to assess for leukocytosis
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to monitor inflammation and response to treatment
Wound cultures (aerobic, anaerobic, fungal, AFB) from discharge or tissue biopsy to identify pathogens
Blood cultures if systemic infection is suspected
Imaging: Doppler ultrasound to assess graft patency and rule out pseudoaneurysm
CT angiography or MR angiography may be considered if distal ischemia is suspected or to delineate the extent of infection and involvement of vascular structures.
Differential Diagnosis:
Simple wound dehiscence without infection
Cellulitis
Surgical site infection without dehiscence
Pseudoaneurysm formation at the anastomosis
Graft thrombosis
Seroma
Hematoma
Lymphedema
Hernia.
Management
Initial Management:
Prompt wound exploration and debridement of all necrotic, devitalized, and infected tissue
Copious irrigation of the wound with sterile saline
Culture of wound exudates or tissue
Broad-spectrum intravenous antibiotics initiated empirically, tailored to local resistance patterns and suspected pathogens (e.g., vancomycin for Gram-positive coverage, a broad-spectrum cephalosporin or fluoroquinolone for Gram-negative coverage, and metronidazole for anaerobes).
Medical Management:
Systemic antibiotics are the cornerstone of treatment
The choice of antibiotics should be guided by wound culture and sensitivity results
Antibiotic therapy should be continued for a prolonged period, typically 4-6 weeks or longer, especially if prosthetic material is involved or if there is deep tissue or graft infection
Pain management with analgesics
Anticoagulation/antiplatelet therapy as per the vascular indication, carefully balancing the risk of bleeding with the need to maintain graft patency
Nutritional support to promote healing.
Surgical Management:
This is the primary modality for severe breakdown, especially with exposed grafts
Surgical options depend on the extent of breakdown, graft status, and surrounding tissue viability: 1
Primary closure (only for minimal superficial dehiscence without infection)
2
Secondary intention healing with frequent dressing changes
3
Local fasciocutaneous flaps: Rotational or advancement flaps from adjacent well-vascularized tissue can provide good coverage for exposed structures
Examples include gracilis flaps or sartorius muscle flaps
4
Free flaps: For larger or more complex defects with critical exposure, free tissue transfer (e.g., latissimus dorsi, anterolateral thigh flap) may be necessary to provide robust coverage
5
Muscle flaps with skin grafts: A vascularized muscle flap (e.g., rectus abdominis, latissimus dorsi) can be used to fill the defect and provide a bed for a split-thickness skin graft
6
Graft explantation and revascularization: In cases of graft infection or extensive breakdown with compromised graft viability, removal of the infected graft may be necessary, followed by revascularization with an extra-anatomic bypass or using an antibiotic-impregnated graft if infection is controlled
7
Adjunctive measures: Vacuum-assisted closure (VAC) therapy can be used to manage large defects and prepare the wound bed for definitive closure.
Supportive Care:
Aggressive wound care with regular dressing changes, often with antiseptic solutions like povidone-iodine or chlorhexidine
Negative pressure wound therapy (NPWT) can be highly effective in promoting granulation tissue formation and reducing bacterial load
Close monitoring for signs of systemic sepsis or graft occlusion
Regular assessment of distal perfusion
Physical therapy to maintain mobility and prevent complications like deep vein thrombosis.
Complications
Early Complications:
Infection spreading to deeper tissues or graft
Pseudoaneurysm formation at the anastomosis or suture line
Hemorrhage from the wound or graft
Graft occlusion or thrombosis
Deep vein thrombosis
Sepsis.
Late Complications:
Chronic wound dehiscence
Persistent seroma or lymphocele
Formation of granulation tissue
Adhesions leading to chronic pain or bowel obstruction
Incisional hernia
Lymphedema
Recurrent infection.
Prevention Strategies:
Meticulous surgical technique with careful handling of tissues and minimal tension on the closure
Use of appropriate suture materials and techniques for wound closure
Prophylactic antibiotics judiciously administered
Preoperative optimization of patient risk factors (smoking cessation, diabetes control)
Maintaining sterile technique throughout the procedure and postoperative care
Early recognition and aggressive management of superficial wound issues
Avoiding shaving hair in the operative field if possible, or using clippers instead of razors
Postoperative wound care education for patients.
Prognosis
Factors Affecting Prognosis:
The extent of wound breakdown and infection
The presence and involvement of prosthetic material
The patient's overall health status and comorbidities
The promptness and adequacy of management
The viability of surrounding tissues for reconstruction
The success of graft salvage or revascularization.
Outcomes:
With prompt and appropriate management, including aggressive debridement, antibiotics, and reconstructive surgery (flaps, grafts), limb salvage rates can be high
However, outcomes are poorer in cases of extensive graft infection requiring explantation, where revascularization may be challenging and limb salvage rates can be significantly reduced
Patients may require prolonged rehabilitation and may experience chronic pain or functional limitations.
Follow Up:
Close follow-up is essential, especially after reconstructive surgery
This includes regular wound assessments, Doppler ultrasound or angiography to monitor graft patency, and clinical evaluation for signs of recurrent infection or complications
Long-term follow-up may be necessary for patients with prosthetic grafts to detect late complications such as endoleak, pseudoaneurysm, or graft infection
Patients should be educated on wound care and signs of recurrence.
Key Points
Exam Focus:
DNB/NEET SS questions often focus on risk factors for groin wound breakdown, common pathogens, immediate management steps (debridement, antibiotics), and the various surgical coverage options (local flaps, free flaps, skin grafts) and their indications in the context of vascular graft integrity
Graft infection management is a high-yield area.
Clinical Pearls:
Always consider the vascular graft when assessing a groin wound breakdown
infection of the graft is a catastrophic complication requiring aggressive surgical intervention
The choice of coverage should aim to provide a well-vascularized, healthy bed for the graft and restore wound closure with minimal tension
Early recognition of even small wound edge separations is critical.
Common Mistakes:
Delaying surgical intervention for significant wound breakdown or suspected graft involvement
Inadequate debridement of infected or necrotic tissue
Choosing inadequate coverage techniques that do not adequately protect the vascular repair or graft
Premature discontinuation of antibiotics, especially in the presence of prosthetic material
Overlooking distal perfusion assessment, leading to delayed diagnosis of limb ischemia.