Surgery Wound Management

1. MANAGEMENT OF SURGICAL
WOUND
Presenter: Dr Anand Ujjwal Singh, JR2
Moderator: Dr Abhijeet Kumar Sir

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
Sabiston textbook of Surgery 2016
Bailey and Love’s 27th Edition

5. Types of Surgical Wound:
• CLASS I  CLEAN:
• Respiratory , gastrointestinal, genital and urinary tracts not entered
• No break in aseptic technique
• No inflammation
• 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
• 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

9. Bailey and Love’s 27th Edition

10. Tidy vs Untidy Wounds:
Tidy:
• Incised
• Clean
• Healthy tissues
• Seldom tissue loss
Untidy:
• Crushed or avulsed
• Contaminated
• Devitalised tissue
• Other tissue loss
Bailey and Love’s 27th Edition

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

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

14. 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
Sabiston textbook of Surgery 2016
Bailey and Love’s 27th Edition

15. General principles of management of wound:
• Cleansing
• Exploration and diagnosis
• Debridement ( Devitalised tissue must be excised until bleeding occurs)
• Repair of structures
• Replacement of lost tissue when indication
• Skin cover if required
• Skin closure without tension
• Careful tissue handling and meticulous technique
Sabiston textbook of Surgery 2016
Bailey and Love’s 27th Edition

16. TYPES OF DRESSING:
1. Non adherent fabrics
2. Absorptive
3. Occlusive
4. Creams, Ointments and Solutions
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

17. European Journal of Pharmaceutics and
Biopharmaceutics 127 (2018) 130–141

18. 1. Non adherent fabrics:
• Fine mesh gauze
• Protection, moist environment
• Occlusive and non adherent properties
• Antibacterial characteristics
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

19. 2. Absorptive:
• Gauze :
• Wide mesh gauze
• Removes exudates, prevents maceration
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

20. • Foams:
• Hydrophobic polyurethane sheets
• Protection, absorption of exudates
• May provoke skin maceration
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

21. 3. Occlusive:
NON BIOLOGIC:
- Films
- Hydrocolloids
- Alginates
- Hydrogels
BIOLOGIC:
- Homograft
- Xenograft
- Amnion
- Skin substitues
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

22. 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
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23. 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
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION
Recent advances on antimicrobial wound
dressing: A review, Deborah et al, 2018

24. ALGINATES:
- Cellulose like polysaccharide fibres derived from calcium salt of
alginate ( sea weed )
- Soluble sodium salt in contact with wound exudate  hydrophilic gel
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

25. HYDROGELS:
- Polyethylene oxide or carboxymethylcellulose of water
- Rehydrating agents
- Weak mechanical properties  secondary dressing
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

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

27. Characteristics of ideal dressing:
• Creates a moist environment
• Removes excess exudate
• Prevents dessication
• Allows for gaseous exchange
• Imperpeable to microorganisms
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

28. • Thermally insulating
• Prevents particulate contamination
• Nontoxic to beneficial host
• Provides mechanical protection
• Nontraumatic
• Easy to use
• Cost-effective
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

29. Recent advances:
- Hyperbaric oxygen therapy
- NPWT (Negative pressure-assisted wound therapy)
- Tissue engineering
- Growth factors
- Nanoparticles

30. 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
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

31. Fig: Hyperbaric oxygen therapy chamber

32. NPWT:
• Negative Pressure- Assisted Wound Therapy
• Removal of chronic edema / Increase in local blood flow / stimulation
of granulation tissue  endothelial proliferation and angiogenesis
SABISTON TEXTBOOK OF SURGERY VOL 1
FIRST SOUTH ASIA EDITION

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

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

35. • 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

36. • Gene and Stem cell therapy:
• MAPCs – multipotent adult progenitor cells  self renewing
• MSCs- mesenchymal stem cells  improved granulation tissue formation and
neovascularization

37. Advantages/ Disadvantages and Indications of
graft and skin substitues:
Bello et al, JAMA, February 9, 2000, Vol 283

38. Bello et al, JAMA, February 9, 2000, Vol 283

39. Bello et al, JAMA, February 9, 2000, Vol 283

40. Yamakawa and Hayashida Burns & Trauma 2019
GROWTH FACTORS

41. Nanoparticles (NP) as potential antimicrobial agents (potential
alternative to conventional antibiotics):
Recent advances on antimicrobial wound
dressing: A review, Deborah et al, 2018