2. COMPLICATIONS OF THE HEALING OF THE WOUND
Wound healing can be complicated by various
processes, the main of which are:
1. The development of infection
Perhaps the development of nonspecific purulent
infection, as well as anaerobic infection, tetanus,
rabies, diphtheria, etc.
4. 3. Divergence of wound edges (wound failure)
Considered as a serious complication of
healing. Special it is dangerous with a penetrating
wound of the abdominal cavity, as it can lead to the
exit of the internal organs (intestine, stomach,
ointment, etc.) to the outside - eventation. It occurs
in the early postoperative period (up to 7-10 days),
when the strength of the forming scar is small and
tissue tension is observed (intestinal obstruction,
flatulence, increased abdominal pressure).
The divergence of all layers of the surgical
wound requires urgent resurgery.
5.
6. SCARS AND THEIR COMPLICATIONS
Differences of scars in primary healing and
secondary tension. After healing by primary intention,
the scar is even, located on the same level with the
entire surface of the skin, linear, consistency
indistinguishable from surrounding tissues, mobile.
When healing by secondary intention, the scar has an
irregular star shape, dense, often pigmented, inactive.
Typically, such scars are retracted, located below the
surface of the skin, since the granulation tissue is
replaced by scar tissue that has a higher density and
lower volume, which leads to the retraction of the
surface layers and epithelium.
7. Hypertrophic scars and keloids
Hypertrophic scars consist of dense fibrous tissue
and are formed with excessive synthesis of collagen.
They are characterized by rough, tight, ugly scars, rise
above the surface of the skin, have a reddish tint,
sensitive and painful, often cause itching. Among them,
ordinary hypertrophic scars and keloids are
distinguished.
An ordinary hypertrophic scar never extends
beyond the area of damage, corresponds to the
boundaries of the previous wound. Two factors play a
leading role in the development of such a scar: large
sizes of the wound defect and permanent scar trauma.
8.
9. A keloid is a scar that invades surrounding normal
tissues that were not previously involved in the wound
process. Unlike ordinary hypertrophic scars, it is often
formed on functionally inactive areas of the body. Its
growth usually begins 1-3 months after epithelialization
of the wound. The scar continues to increase even after
6 months and usually does not decrease or soften. Keloid
scars occur after any, even minor trauma (needle prick,
insect bite), superficial burn. Scar stabilization occurs on
average 2 years after its appearance.
The morphological structure of the keloid is an
excessively growing immature connective tissue with a
large number of atypical giant fibroblasts.
10. The pathogenesis of keloid formation remains
unclear today. A certain role is played by autoaggression
mechanisms on one's own immature connective tissue.
Violation of the synthesis of collagen, possibly due to
genetic abnormalities.
In the development of keloids, electrophoresis
with enzymes (lidase), excision of the scar with the
application of a cosmetic intradermal suture and
exposure to the entire healing process by radiation
therapy, steroid hormones, enzymes, etc. are used.
However, it should be recognized that there are currently
adequate methods prevention and treatment of keloid
scars not found.
12. WOUND TREATMENT
Despite many features of various wounds, the main
stages of their healing are basically the same. You can
highlight the general tasks facing the surgeon in the
treatment of any wounds:
1. Fighting early complications.
2. Prevention and treatment of infection in the wound.
3. Achieve healing as soon as possible.
4. Complete restoration of the function of damaged
organs and tissues.
These tasks are already being carried out at the very first
stages of the first aid procedure.
13. SURGICAL TREATMENT OF THE WOUND -
surgical operation performed by a patient with a wound
in compliance with aseptic conditions, with anesthesia
and consisting in the sequential implementation of the
following steps:
■ Wound dissection.
■ Revision of the wound channel.
■ Excision of the edges, walls and bottom of the
wound.
■ Hemostasis.
■ Restoring the integrity of damaged organs and
structures
■ Suturing the wound with leaving drainage (as
indicated).
14. Dissection of the wound is necessary for a
complete, under the control of the eye, revision
of the zone of distribution of the wound channel
and the nature of the damage.
Excision of the edges, walls and bottom of
the wound is performed to remove necrotic
tissue, foreign bodies, as well as the entire wound
surface, infected by wound.
It is usually recommended to excise the
edges, walls and the bottom of the wound as a
single block by about 0.5-2.0 cm.
15. In this case, it is necessary to take into
account the localization of the wound, its depth
and the type of damaged tissue. With
contaminated, crushed wounds, wounds on the
lower extremities, the excision should be wide
enough. With wounds on the face, only necrotic
tissue is removed, and with a cut wound, the
excision of the edges is not performed at all. It is
impossible to excise viable walls and the bottom
of the wound if they are represented by tissues of
internal organs (brain, heart, intestines, etc.).
16. After excision, thorough hemostasis is
performed to prevent hematoma and possible
infectious complications.
The following options for completing this
operation are possible.
• Layer wound closure tightly
It is produced in case of small wounds with a
small damage zone (cut, punctured, etc.), slightly
contaminated wounds, with localization of
wounds on the face, neck, trunk or upper limbs at
a short time from the moment of damage.
17. • Wound closure with drainage (drainage)
Perform in cases where there is either a risk
of developing an infection, but it is very small, or
the wound is localized on the foot or lower leg, or
the zone of damage is large, or PEC is performed
after 6-12 hours from the moment of damage, or
the patient has a concomitant pathology that
adversely affects the wound process, etc.
18.
19. The wound is not sutured
This is done at a high risk of infectious
complications:
• late surgical treatment,
• profuse contamination of the wound with
earth,
• massive tissue damage (crushed, bruised
wound),
• concomitant diseases (anemia,
immunodeficiency, diabetes),
• localization on the foot or lower leg,
• elderly patient.
20.
21. Treatment of purulent wound
In the first phase of the wound healing process
(phase of inflammation), the surgeon has the
following main tasks:
■ Fighting microorganisms in a wound.
■ Ensuring adequate drainage of exudate.
■ Promoting the speedy cleansing of the wound
from necrotic tissue.
■ Reduced manifestations of the inflammatory
response
22.
23. In the local treatment of purulent
wounds, methods of mechanical, physical,
chemical, biological and mixed antiseptics
are used.
With suppuration of a postoperative
wound, it is usually enough to remove the
sutures and widely spread its edges. If these
measures are not enough, then it is
necessary to perform secondary surgical
treatment (SST) of the wound.
24. Indications for SST wounds are the presence
of a purulent focus, the absence of an adequate
outflow from the wound (pus retention), the
formation of extensive zones of necrosis and
purulent sagging. Contraindication is only the
extremely serious condition of the patient, while
being limited to opening and draining the
purulent focus.
Challenges for a surgeon performing SST wounds:
■ Opening of the purulent focus and sagging.
■ Excision of non-viable tissue.
■ Implementation of adequate drainage of the
wound.
25. It is performed by the SST in the operating
team of surgeons using anesthesia. Only adequate
anesthesia allows you to solve all the problems of
SST.
• Autopsy of the purulent focus and revision of the
wound with the presence of streaks
• Pus evacuation and excision of non-viable tissue -
necroectomy
Large vessels and nerves may be located near
or in the wound itself, which must be preserved.
Before the end of the operation, the wound cavity is
rinsed abundantly with antiseptic solutions, loosely
swabbed with gauze napkins with antiseptics and
drained.
26. GENERAL TREATMENT
General treatment of wound infection has several
directions:
■ Antibacterial therapy.
■ Detoxification.
■ Immunocorrective therapy.
■ Anti-inflammatory therapy.
■ Symptomatic therapy.
