Woundoscopy: A New Technique For Examining Deep, Nonhealing Wounds

   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.

   Patient 2. Another case involved a 74-year-old white male with a persistent, draining, right lower quadrant wound as a result of post ventral hernia repair. He had two prior hernia repairs that failed, requiring the third procedure during which the surgeon placed a Gortex graft to bolster the abdominal wall. Three weeks after the third surgery, the wound opened and began draining sanguinopurulent material. Standard treatment measures were unsuccessful; after 8 months of therapy, the patient was referred to the Wound Care Institute for further evaluation and treatment.

   Woundoscopy findings. Initial therapy with antibiotic irrigation of the wound helped reduce the drainage, but only temporarily. As a result, woundoscopy was performed. The graft was easily visualized and was not adherent to the abdominal wall on either side. However, the sutures were still intact, holding the graft in place (see Figure 1). The surgeon was contacted. The authors determined that the graft was acting as a foreign body for a nidus of infection. The surgeon agreed, and a week later a repeat woundoscopy was performed. The sutures were endoscopically cut and the graft grasped with rat-tooth forceps and pulled to the opening of the wound that was approximately 1 cm in diameter. The surgeon then grasped the graft with a clamp and pulled it out. Following the removal of the graft, the wound healed in 3 weeks and has remained healed.

   Patient 3. The third patient was a 46-year-old obese white female who recently had undergone two total hip replacements. She also had a history of 30 surgical procedure involving the left hip. The most recent surgery involved removal of the prosthesis. A large, open draining wound resulted.

   Woundoscopy findings. A woundoscopy was performed to see if any additional information could be obtained to help with healing. The end of the remaining femur could be seen, but no foreign body was present. The tissue was not very expansive despite air insufflation. Little helpful information was gained by the examination. Standard wound treatments were continued in conjunction with infectious disease consultation and management.

   Patient 4. A 49-year-old white female was post incisional hernia repair that had required placement of "mesh" to strengthen the abdominal wall. She had undergone standard wound care techniques that did not result in healing. Postoperatively, the wound opened and began draining.

   Woundoscopy findings. Woundoscopy showed a friable tract down to the level of the mesh; visible through the mesh was a deep open space. The findings were discussed with the surgeon who agreed that the mesh was most likely the cause of persisting infection. He surgically removed the mesh and the wound healed promptly.

   Patient 5. An 18-year-old white male with a long-standing draining wound from the area of the left iliac crest had a medical history indicating a bone graft had been taken from this area at age 4 for a leg-lengthening procedure due to Perthes Disease. Before referral to the Wound Care Institute, incision and drainage had been performed on two occasions without healing. Plain X-ray films and indium scan showed no evidence of osteomyelitis. Standard wound care techniques did not result in healing.

    Woundoscopy findings. Woundoscopy demonstrated a 7-cm tract extending to the bone. The bone could not be visualized well, but the area "felt" rough. No foreign body was in evidence. The fact that the tract extended to the bone, despite the negative indium scan, implied the possibility of chronic osteomyelitis. The patient was referred to an orthopedic surgeon who removed the "rough" area of the bone. The patient progressed to healing.

   Patient 6. This patient was a 35-year-old white male with a 6-year history of Crohn's disease. He had previously undergone a bowel resection with colostomy. The colostomy was reversed 4 months before he was referred to the Wound Care Institute. A ventral hernia also was repaired. Postoperatively, a wound infection developed. The initial large wound healed with the exception of a small central lower abdominal midline opening that continued to have large amounts of drainage. Despite antibiotics and standard wound care therapies, the wound did not heal. His Crohn's remained in complete remission on 6-mercaptopurine and mesalamine (Pentasa, Roberts Pharmaceutical Corp., Eatontown, NJ).

   Woundoscopy findings. Woundoscopy showed a 2-cm long tract that opened into an area where a large amount of mesh was seen. The mesh was adherent to the surrounding tissue but only about 40% circumferentially in the wound. The remainder seemed to be gathered into a heap. Non-reabsorbable sutures were visualized holding the mesh in place (see Figure 2). These findings were discussed with the surgeon. The mesh was acting as a nidus for infection. The surgeon performed a procedure to remove the mesh and primarily closed the wound. The patient suffered no further complications.

   Patient 7. A 48-year-old white female underwent a paniculectomy. Postoperatively, the wound opened and began to drain. She was hospitalized for 21/2 months and then referred to the Wound Care Institute. Her initial exam revealed a large, open transverse wound measuring 6.7 cm x 29.0 cm x 3.0 cm. The wound measured 6.2 cm at 3:00 in the right lower quadrant. Using standard technique, the wound healed satisfactorily. However, the patient continued to complain of pain in a deep sinus tract located in the right lower quadrant. Drainage and pain persisted, leading to a woundoscopy.

   Woundoscopy findings. Woundoscopy revealed a clean granulated tract. However, a foreign body was noted at the end of the tract (see Figure 3). This was grasped with rat-tooth forceps and withdrawn to the opening of the wound where it was grasped with a hemostat and removed with gentle traction. The foreign body was a 4-inch x 4-inch gauze that had inadvertently slipped deep into the tract sometime during the postoperative period (see Figure 4). The patient reported that the pain and drainage ceased immediately upon removal of the foreign body. The tract healed promptly.

   Patient 8. This patient was a 66-year-old obese white female with a history of diabetes who was diagnosed with ovarian cancer. A hysterectomy was performed but the wound dehisced while the patient was still in the hospital. She was referred to the Wound Care Institute 1 month later. On evaluation, the wound measured 3.5 cm x 1.8 cm x 8.0 cm. Radiation and chemotherapy further complicated her wound healing. The initial wound healed with the exception of a small midline opening that continued to drain.

   Woundoscopy findings. Woundoscopy revealed a large area of slough, probably due to necrotic tissue from the radiation therapy. The surgeon did not feel she was a surgical candidate. Therapy in the Wound Care Institute consisted of debriding the slough with a small Pap smear brush, irrigating with clindamycin/gentamicin antibiotic solution, and applying Regranex (Ortho-McNeil Pharmaceutical, Raritan, NJ) at the end of the tunnel. The wound healed over the next 2 months.

Discussion

   The technique of woundoscopy is not applicable or appropriate for the management of all wounds. However, for certain wounds with deep tracts that fail to heal with standard therapy, woundoscopy can be helpful. The most obvious benefit has been the identification and subsequent removal of previously undetected foreign bodies. Woundoscopy avoided further surgery in some patients and resulted in rapid healing of the wounds. This technique also has assisted in identifying the quality of tissue affected.

   Chronic deep tracts, especially in obese patients, are particularly problematic. Woundoscopy helps characterize the nature of the tracts, leading to innovative therapies that reactivate the chronic, nonhealing wound to heal.

   Woundoscopy appears most helpful in abdominal wounds surrounded by soft tissue, which expands with air insufflation necessary for visualization. The technique was not as useful in extremity wounds that occurred following orthopedic procedures due to the increased tissue resistance.

Conclusion

   Woundscopy is a new procedure for the endoscopic evaluation of chronic, deep, nonhealing wounds. It is useful for detecting and removing foreign bodies, as well as for gaining important information about the nature of long tracts in wounds that have been resistant to healing. The merits of woundoscopy indicate that further research into this exciting new technique is warranted.