Factors affecting wound healing: • Site of wound and Structure involved • Mechanism : Incision / Crush / Crush avulsion • Contamination : foreign body / bacteria • Loss of tissue • Local factors : Vascular insufficiency / Previous radiation / pressure • Systemic factors: Malnutrition / Vitamin and mineral deficiencies / Immunosupression / Smoking.

1. MANAGEMENT OF
SURGICAL
WOUND
Dr Mohammed Mujtaba
Dept of Gen. Surgery

2. Sequence of flow
• Normal wound healing
• Types of surgical wound
• Classification of wound closure and healing
• Factors influencing healing of a wound
• General principles of management of wound
• Types of Dressing
• Recent advances

3. • Wound is defined as a break in normal continuity of a tissue/
endothelium due to exogenous cause.
• Ulcer is defined as a break in normal continuity of a tissue/
endothelium due to endogenous cause.

4. Normal Wound Healing:
Three phases:
1. Inflammatory phase
2. Proliferative phase
3. Maturational phase

5. Types of Surgical Wound:
• CLASS I  CLEAN:
• Respiratory , gastrointestinal, genital and urinary tracts not entered
• Uninfected Operative wound
• No break in aseptic technique
• No inflammation is encountered.
• Eg: Breast Surgery, Hernia repair, Joint arthroplasty, Excisions

6. • CLASS II  CLEAN CONTAMINATED:
• Respiratory, gastrointestinal, genital or urinary tract is entered under
controlled conditions
• No major break in aseptic technique
• No acute inflammation
• No spillage
• Eg: Cholecystectomy ( chronic inflammation), Gastrointestinal procedures,
Gynecological procedures

7. • CLASS III  CONTAMINATED:
• Acute, non purulent inflammation encountered
• Open, fresh, accidental wounds
• Visible spillage from intestinal tract
• Necrotic tissue without evidence of purulent drainage
• Operations with major break in sterile technique
• Eg: Bowel resection for infarcted and/ or necrotic bowel, Cholecystectomy
with actue inflammation or bile spillage

8. • CLASS IV  DIRTY:
• Presence of frank pus or abscess
• Perforated viscera
• Fecal contamination
• Old Traumatic wounds with retained devitalized tissue
• Wet gangrene
• Eg: Laparotomy for intraabdominal abscess, Incision and Drainage for infection/
abscess, Ruptured appendicitis, Hollow viscus perforation, Amputation in presence
of infection

10. Tidy vs Untidy Wounds:
Tidy:
• Incised
• Clean
• Healthy tissues
• Seldom tissue loss
Untidy:
• Crushed or avulsed
• Contaminated
• Devitalised tissue
• Other tissue loss

11. Classification of Wound closure and Healing:
• Primary Intention:
• Wound edges apposed with suture/ stapler
• Normal healing  Minimal scar

12. • Secondary Intention:
• Wound left open
• Healing  granulation, contraction and epithelialization
• Increased inflammation and proliferation  Poor scar

14. • Tertiary intention ( delayed primary intention ):
• Wound initially left open
• Edges later opposed when healing condition is favourable

15. Factors affecting wound healing:
• Site of wound and Structure involved
• Mechanism : Incision / Crush / Crush avulsion
• Contamination : foreign body / bacteria
• Loss of tissue
• Local factors : Vascular insufficiency / Previous radiation / pressure
• Systemic factors: Malnutrition / Vitamin and mineral deficiencies /
Immunosupression / Smoking

17. Wound Dressings
The two concepts that are
critical when selecting
appropriate dressings for
wounds are Occlusion and
Absorption.

18. TYPES OF DRESSING:
1. Non adherent fabrics
2. Absorptive
3. Occlusive
4. Creams, Ointments and Solutions

19. 1. Non adherent fabrics:
• Fine mesh gauze
• Function : Protection, moist
environment
• It has Occlusive and non adherent
properties
• Antibacterial characteristics
• Eg : Scarlet red, Vassiline gauze

20. 2. Absorptive:
• Gauze :
• Wide mesh gauze
• Removes exudates, prevents maceration

21. • Foams:
• Hydrophobic polyurethane sheets
• Protection, absorption of exudates
• May provoke skin maceration

22. 3. Occlusive:
NON BIOLOGIC:
- A. Films
- B. Hydrocolloids
- C. Alginates
- D. Hydrogels
BIOLOGIC:
- A. Homograft
- B. Xenograft
- C. Amnion
- D. Skin substitues

23. A. FILMS:
- Clear polyurethane membranes with acrylic adhesives
- Waterproof, permeable to oxygen, carbon dioxide and watervapour
- allows visualization of wound
- nonabsorptive/ leakage/ requires intact skin around wound area
- adhere to the wound bed  exudate accumulation
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

24. HYDROCOLLOIDS:
- Hydrocolloid matrix ( gelatin, pectin, carboxymethylcellulose)
- Absorbs water from wound exudates  swells  liquefies  moist
gel
- Bulky/ interference with function / cytotoxic / unpleasant odour /
acidic pH at wound site

25. ALGINATES:
- Cellulose like polysaccharide fibres derived from calcium salt of
alginate ( sea weed )
- Soluble sodium salt in contact with wound exudate  hydrophilic gel

26. HYDROGELS:
- Polyethylene oxide or carboxymethylcellulose of water
- Rehydrating agents
- Weak mechanical properties  secondary dressing

27. HOMOGRAFT:
- Derived from genetically unique humans
- Temporary dressing
- Rejected if on wound for prolonged periods
- From cadaver skin
XENOGRAFT:
- Interspecies graft ( eg. Pig skin)

28. Recent advances in Mx of Wound:
- Hyperbaric oxygen therapy
- NPWT (Negative pressure-assisted wound therapy)
- Tissue engineering
- Growth factors
- Nanoparticles

29. HYPERBARIC OXYGEN THERAPY :
• Principle : uses oxygen as a drug and the hyperbaric chamber as a delivery system
to increase pO2 at the target area.
• Inhalation of 100 % O2 at 1.9 to 2.5 atm  increases tissue pO2 by upto 10 times
• Higher PaO2  supplies metabolic requirements and Induces synthesis of
endothelia cell NO synthase  angiogenesis / enhance fibroblast and leukocyte
function

30. Fig: Hyperbaric oxygen therapy chamber

31. NPWT:
• Negative Pressure- Assisted Wound Therapy
• Removal of chronic edema / Increase in local
blood flow / stimulation of granulation tissue
 endothelial proliferation and angiogenesis

32. Fig: Schematic diagram NPWT ( Negative Pressure-Assisted Wound Therapy

33. TISSUE ENGINEERING:
• Bioengineered skin substitues :
• Expansion of patient derived keratinocytes
• Behaves similar to extracellular matrix (ECM)
• Improves wound microenvironment

34. • Epidermal substitutes:
• Gold standard: Autograft from split-thickness skin grafting / cell line
bioreactor expansion
• Not subject to rejection
• 2- 3 weeks delay to generate enough tissue to cover a defect
• Limitations: well vascularized dermal bed required / low expansion
capabilities / limit of ability to form new tissue

35. • Gene and Stem cell therapy:
• MAPCs – Multipotent Adult Progenitor cells  self renewing
• MSCs- Mesenchymal Stem Cells  Improved granulation tissue formation
and neovascularization

36. Advantages/ Disadvantages and Indications of
graft and skin substitues: