Cath Lab Digest

Classical evaluation of a wound consists of descriptors of location, size (length, width, and depth), presence or absence of drainage, odor, and swelling. A description of the periwound is also important with regard to swelling, color, and warmth. Although probing wounds is useful to evaluate undermining, tracts, and foreign bodies, routinely ascertaining wound volume has been difficult. Most wounds can be evaluated using standard wound assessment techniques.

Additionally, physical examination of various parts of the body includes inspection, auscultation, percussion, and palpation. Although not all of these are applicable to wounds, inspection and palpation are routinely performed to evaluate for tenderness, temperature, swelling, induration, and to determine the presence of a foreign body. The deep inspection of wounds has been limited to surgical incision and exploration.

The authors describe the use of endoscopy to gain additional information about wounds that have not healed by standard therapies. They applied the term woundoscopy to this technique.

Procedure

Woundoscopy is performed using both Olympus (Olympus America, Inc., Melville, NY) and Pentax (Pentax, Englewood, Colo.) standard video upper gastrointestinal endoscopes and/or an Olympus video laryngoscope. The choice of instrument depends upon the size of the wound opening and the diameter of the tract. Before the procedure, all wounds are cleansed. Not infrequently, injecting the wound opening with 1% lidocaine with epinephrine followed by incision with a scalpel is necessary to permit entrance of the scope. The authors sterilize the endoscopes using the Steris System. Following the procedure, all wounds are again cleansed and dressed appropriately. Foreign bodies noted during the procedure are grasped with endoscopic rat-tooth forceps and removed with gentle traction.

Case Reports

Patient 1. One case involved a 47-year-old white female with morbid obesity, noninsulin dependent diabetes mellitus, and a nonhealing midline abdominal wound with chronic drainage due to a prior umbilical herniorrhaphy followed by an abdominal wall abscess. The wound had been surgically opened, excised, and left to heal secondarily. What resulted was a 15-cm tract that remained infected and drained continuously. Standard therapies had been unsuccessful and her surgeon referred her to the Wound Care Institute.

Woundscopy findings. When woundoscopy was performed, the tract was 12.9 cm in length and 1 cm in diameter. The tract was lined with a whitish-pink covering, suggesting a chronic fungal infection. No foreign body was seen. Biopsies showed nonspecific fibrinopurulent exudate. The wound was treated by cleansing with Techni-care (Care-Tech® Laboratories, St. Louis, Mo.), rinsing with normal saline, irrigating with gentamicin/clindamycin solution, and stenting the tract with Mesalt ribbon (Mölnlycke Health Care, Newtown. Pa.) sprinkled with nystatin powder. Initially, significant, albeit slow, healing was observed. When the wound appeared to stabilize, a second woundoscopy was performed. During the second procedure, the wound was found to be much smaller both in length and diameter; however, the tract appeared to have epithelialized in some areas, preventing further healing. A Pap smear brush was used to “rough up” the tract, along with the Regranex gel (Ortho-McNeil Pharmaceutical, Raritan, NJ) to make an acute wound. Further healing subsequently occurred.