WOUND CLOSURE AND COMPLICATION

1. WOUND CLOSURE AND COMPLICATION
Facilitator- Dr Mahipendra Tiwari
Prepared By- Dr Lalit K Shah
Resident General Surgery

2. Wound
• Wound is a break in the integrity of the skin or tissues
often which may be associated with disruption of the
structure and function
• It is simply a disruption of any tissue

3. Wound Classification
• Classification of surgical wounds
1) Clean wound
2) Clean contaminated wound
3) Contaminated wound
4) Dirty Wound

4. • Classification based on involvement of structures
1) Simple wound
2) Complex wound

5. • Classifiaction based on time lapsed
1) Acute wound
2) Chronic wound

6. • Classification based on Rank and Wakefield
1) Tidy wound
2) Untidy wound

7. • Classification based on thickness of wound
1) Superficial wound
2) Partial thickness
3) Full thickness
4) Deep wound

8. • Classifiaction based on type of wound
1) Clean insiced wound
2) Lacerated wound
3) Bruise or contusion
4) Abraion
5) Puncture wounds and bites
6) Penetrating wounds

10. Phases of wound healing
1. Inflammatory phase
2. Proliferative phase
3. Remodelling phase

12. Wound closure
• Primary wound closure
• Secondary wound closure
• Delayed primary closure

13. Primary wound closure
• Also known as healing by primary intention
• In clean incised wound or surgical wound
• Occurs when there is
-apposition of wound edges
-minimal surrounding tissue trauma (least inflammation)
• Wound edges are approximated with suture

14. • Wound heals rapidly with complete closure and minimal
scar
• Primary suturing
suturing the wound immediately within 6 hours
done in clean incised wound
• CDC guidelines dictate that a sterile dressing should be
left in place during this susceptible period to prevent
bacterial contamination.

15. Secondary wound closure
• Also known as healing by secondary intention
• Wound is left open
• Heals slowly with granulation, contraction and
epithelialisation
• Wound with extensive soft tisue loss
• Poor scar

16. • Secondary Suturing
suturing the wound in 10-14 days or later
done in infected wound

17. Delayed primary closure
• Also known as healing by tertiary intention
• Wound initially left open
• The wound is first cleaned/debrided and observed for a
few days to ensure no infection is apparent before it is
surgically closed
• Edges later opposed when healing conditions favourable

18. • Delayed primary suturing
suturing the wound in 48 hours to 10 days
done in lacerated wound

19. Principles of wound suturing
• Primary suturing should not be done if there is
oedema/infection/devitalised tissue/hematoma
• Associated injuries to deeper structures like vessels/nerves
or tendons should be looked before closure of the wound
• Wound should be widened by extending the incision
whenever needed to have proper evaluation of the deeper
structures

20. • Proper cleaning, asepsis, wound excision/debridement
• Any foreign body in the wound should be removed
• Skin closure if it is possible without tension
• Untidy wound should be made tidy and clean before
suturing
• Proper aseptic precaution should be undertaken

21. Methods of wound closure
• Suture materials
• Stapler
• Adhesive

22. 1) Suture materials
• In primary wound closure, sutures are the standard of
care.
• There are two types of sutures
- absorbable and non-absorbable
• Non-absorbable sutures are used primarily to close
superficial wounds

23. • Whereas, absorbable sutures can be placed in a double
layer closure for deeper wounds
• The choice of suture and technique depends on the type
of wound, depth, degree of tension, and desired cosmetic
results

24. a) Interrupted suture
• The use of separate stitches allows for a
better approximation of the skin and
fascia.
• They provide greater tensile strength and
have less risk of injuring cutaneous
circulation.
• Also, in the case of an infection, the
entire length of sutures would not need
to come out.

25. b) Continous suture
• allows more rapid wound closure
• risk of complete wound opening if
suture breaks
• For rapid hemorrhage control or long
wounds with minimal tension, running
sutures are the best choice

26. c) Mattress suture
• For a wound that is deeper in nature, a
mattress stitch can be placed, providing
better strength.
• The deeper penetration into the skin layers
minimizes tension and allowing for better
closure at the wound edges
d) Subcuticular
• better cosmetic result

27. 2) Stapler
• Staples are cost-effective, easily
placed, require minimal training, and
have similar healing times and infection
rates as sutures
• Avoid in areas where cosmesis is
important
• They are also widely used to close
postoperative incised wounds

28. Fast, less painful than suture; glue contains n-butyl-2-
cyanoacrylate which polymerizes to form a firm adhesive
bond
3)Adhesives

29. Managing Acute Wound
• Examine the patient according to ATLS principles
• Cleaning
• Exploration and diagnosis
• Debridement
• Repair of stuctures
• Replacement of lost tissue where indicated

30. • Skin cover if required
• Skin closure without tension
• All of the above with careful tissue handling and
meticulous technique

31. Specific Treatment
Minor wounds:
• Wound is cleaned with saline thoroughly; then non-stick
dressing is placed.
• An incised wound is treated by primary suturing.
• In lacerated wound, wound edge is excised and then
apposed by primary suturing without tension.

32. Haematoma:
• Ice packs wrapped in cloth is applied and kept for 15
minutes in every 2 hours for 24 hours
• compression bandage; elevation of the part; ultrasound of
the part and guided aspiration
• if persists; occasionally haematoma is evacuated

33. In a crushed or devitalised wound:
• there will be oedema and tension; all devitalised tissue is
removed (wound excision/debridement); oedema is
allowed to subside for 2-6 days; then delayed primary
suturing is done.
• If it is a deep devitalised wound, after wound debridement
it is allowed to granulate completely.

34. • Later if wound edges are closer, secondary suturing is
done usually after 1 0 days using monofilament non-
absorbable suture.
• If the wound is wider, wound is covered with split skin
grafting (SSG).

35. Major wound
• They need proper management in operation theatre under
general anaesthesia after initial assessment of the patient
and wound
• In a wound with tension, fasciotomy is done to prevent
development of compartment syndrome.

36. • Major vessels are sutured using 6-0 nonabsorbable
polypropylene sutures (round body, usually continuous
sutures).
• Nerve with clean cut ends is sutured primarily using fine
(6-0 or 7-0) polypropylene suture

37. Internal Injuries
• are managed accordingly laparotomy/ craniotomy/
intercostal tube drainage, etc.
• Fracture bones are identified and managed accordingly.

38. Burn wound
• Firstly initial pre-hospital care and fluid resustication
• Full thickness and deep dermal burns need antibacterial
dressing(silver sulphadiazine 1%, silver nitrate 0.5%,
mafenide acetate 5%)
• Superficial burn will heal and need simple dressing
• If eschar is present then escharotomy must be done to
prevent compartment syndrome
• Deep dermal burn need split skin grafting

39. Complication of wound
 Wound Infection
• It is common in devitalized deep difficult wounds
• Risk- diabetes, immunosuppression, cytotoxic drugs,
malnutrition, anemia, etc increases the chances of wound
infection
• Dx by cinical examination and wound culture
• Treatment is draining the infection by opening incision
and antibiotics

40.  Hematoma
• inadequate intraoperative hemostasis and in patient who are
anticoagulated in periopeartive period
• Dx by clinical examination
• Treatment- ice packs, compression bandage, elevation of the
part, ultrasound guided aspiration, if persists occasionally
haematoma is evacuated

41. Seroma
• pocket of clear serous fluid that develops after extensive
surgical dissection
• Dx made clinically and if neede confirmed by USG
• 90% of seroma will resorb within 6 weeks
• Symptomatic, persistent or infected seroma will require
aspiration and drainage
• Antibiotics only required in infected seroma

42. Wound dehiscence
 It is disruption of any or all of the layers in a wound
 occurs in upto 3% of abdominal wounds
 Most commonly occurs from 5th to 8th postoperative day
when strength of the wound is at its weakest
 usually all layers of abdomen give away causing
discharge, occasionally bowel will extrude out

43. • wound suddenly gives away with pain causing copious
serosanguineous discharge
• Patient may feel popping sensation during straining and
coughing
• It needs emergency closure of the abdominal wound
using specialized sutures or retention sutures.

44.  Factors
-Local: Hematoma, Seroma
-Regional: Intraabdominal infections, hemorrhage, trauma,
bowel edema, abdominal distension
-General: advance age, malnutrition, obesity, sepsis
comorbidites
-Surgical: emergency procedure, imperfect techniques of
wound closure, excessive tension, prolonged ot time, poor
knotting and suturing

45.  Hypertrophic scar or keloid

47. Contracture
• where scar cross joints or flexion creases, a tight web
may form restricting the range of movement at joint
• can cause hyperextension or hyperflexion deformity

48. Refernces
• Bailey & Love 26th edition
• Sabiston Textbook of surgery 21st edition
• SRB’s manual of surgery 5th edition