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Medical Resident Research Case Reports

09 POST-OPERATIVE ESCHAR FORMATION FOLLOWING EXPLORATORY LAPAROTOMY

Mark Anderson, MD, PGY3; Amber Stephens, DO Corresponding author: mark.anderson@lpnt.net

Sovah Health - Danville, Danville, Virginia

targeted literature review was conducted using PubMed and Google Scholar with the search terms "eschar", "eschar debridement", and "post-operative necrotic eschar formation". Most eschar cases described in the current literature involve infectious etiology, presenting commonly as a result of scrub typhus. This patient case is somewhat unique in that there is a noticeable lack of cases described in the literature involving postoperative eschar formation. Diagnosis: Post-operative eschar formation following exploratory laparotomy. This patient developed an 11 X 15 cm area of full-thickness lower abdominal necrosis s/p surgical repair of a small bowel obstruction with incarcerated ventral hernia. The initial approach was to manage conservatively with Silvadene, however the patient later required surgical debridement due to increasing erythema and ulceration of the necrotic area.

was initially managed with Silvadene. At a follow-up appointment, patient was noted to have an ulceration along abdominal wall with full -thickness necrosis, and the decision was made to proceed with debridement. She was initiated on antibiotics, and underwent excisional debridement of full-thickness necrosis of abdominal wall. Comments: The term eschar refers to necrotic tissue developing on wounds. It is typically dry, black, firm and adheres to the wound bed and edges. It can occur on full-thickness wounds, extending below the epidermis/dermis. They commonly form on third degree burns, stage 3 and 4 pressure ulcers, as well as rashes associated with infection. An eschar differs from a scab, which forms when platelets/ fibrinogen form a fibrin mesh, trapping red blood cells on surface wounds, and forming a clot that dries into a scab. In contrast, an eschar forms when dead tissue debris from a wound dries out and hardens. The decision for eschar debridement should be made on a case-by case basis. There is some evidence that preservation of the eschar prevents excessive wound healing by reducing M2 macrophage polarization. Methods: A

Context: A 77-year-old female required surgical repair via exploratory laparotomy of an incarcerated, possibly strangulated, incisional ventral hernia with small bowel obstruction, s/p laparoscopic cholecystectomy three days earlier. She subsequently developed an 11x15cm eschar adjacent to the incision site, requiring excisional debridement of the abdominal wall, with vacuum-assisted closure. Report of Case: A nursing home resident originally presented with recurrent biliary colic/ dyskinesia. Laparoscopic cholecystectomy was performed under general anesthesia. Patient later returned to the ED for severe abdominal pain with repeated emesis. CBC demonstrated WBC 17,500. She had abdominal tenderness on PE, and a mass was noted inferior to umbilical trocar insertion site. Abdominal CT showed a small bowel obstruction and incarcerated incisional ventral hernia. Patient underwent emergent abdominal exploratory laparotomy, and reduction/ repair of small-bowel obstruction/hernia. Small bowel was released from incarceration, and resection deemed unnecessary. In the ensuing days, patient developed 11 X 15 cm area of skin sloughing with eschar. This

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140 Edward Via College of Osteopathic Medicine (VCOM)