Surgical management of wounds

1. Wound Management.
Presented By:
Dr. Umair Ahmed
(PG-R1, SU-IV)

2.  Objectives
 Definition
 Classification
 Wound healing
 Management
 Complication
 References
Outline

3. At the end of this session are expected to:
 Define wound
 Classify wound
 Explain steps of wound healing
 Explain genral management of wound
 Identify the complication of wound
Objective

4.  It is a circumscribed injury which is caused by an external force
and it can involve any tissue or organ.
 surgical, traumatic
 It can be mild, severe, or even lethal.
 Simple wound
 Compound wound
 Acute
 Chronic
 Tidy and Untidy
Definition

6. Wound Shape

7. Classification of Wounds

8. (1) Mechanical
Abraded wound
Punctured wound
Incised wound
Crush wound
Bite wound
Shot wound
(2) Chemical
Acid
Base
(3) Wound caused by radiation
(4) Wound caused by thermal forces
Burning
Freezing
Based on the origin

9. Incised Wound

10. Abrasions

11. Punctured Wound

12. Lacerated Wounds.

13. Crushed wounds

14. Bite Wounds.

15. Gunshot Wounds.

16. Burn Wounds.

17. Acid Burn Wounds.

18. Frost Bite.

19. Radiation Wounds

20.  Clean wound:
Operative incisional wounds that follow nonpenetrating (blunt) trauma.
 Clean-contaminated wound:
Uninfected wounds in which no inflammation is encountered but the
respiratory, gastrointestinal, genital, and urinary tract have been entered.
 Contaminated wound
Open, traumatic wounds or surgical wounds involving a major break in
sterile technique that show evidence of inflammation.
 Infected wound
Old, traumatic wounds containing dead tissue and wound with evidence of
a clinical infection (e.g., purulent drainge).
According to the bacterial
contamination

21. Factors affecting wound healing
 Local
 Ischemia
 Infection
 Foreign body
 Edema, elevated tissue
pressure
 Systemic
 Age and gender
 Stress
 Ischemia
 Diseases (diabetes,
vascular diseases)
 Obesity
 Medication
 Alcoholism and smoking
 Immuno-compromised
conditions
 Nutrition

22. Hemostasis-inflammation
Granulation-proliferation
Remodeling.
Stages of wound healing

23. The main steps of the wound healing
 1. Hemostasis-inflammation
 vasoconstriction
 fibrin clot formation
 Pro-inflammatory cytokines and
 growth factors releasing
 vasodilatation
 infiltration PMNs, macrophages
 cytokines releasing
 → angiogenesis
 → fibroblast activation
 → B- and T-cells activation
 → keratinocytes activation
 → wound contraction
 2. Granulation-proliferation
 fibroblast migration
 collagen deposition
 angiogenesis
 granulation tissue formation
 epithelisation
 contraction
 3. Remodeling
 regression of many capillaries
 physical contraction myo-
fibroblasts
 collagen degeneration and
synthetisation
 new epithelium
 tensile strength – max. 80%

24. Wound Closure.

25.  Assessment of Wound.
 Wound Irrigation.
 Local Anesthesia.
 Debridement.
 Methods of Closure.
 Dressings and Splints.
 Anti-septics & antibiotics.
 Removal of Sutures.
Management of Laceration

26.  requires information in the following areas:
 force of injury,
 type of force (e.g. penetrating, hot oil burn)
 extent and depth of injury
 amount of blood loss
 level of contamination of the wound
 time from injury to presentation for treatment
 involvement of deeper structures damaged (e.g. nerves,
tendons)
 Direct communication from the outside to a fracture of the
bone (a compound fracture).
Assessment of the degree of damage

27.  All wounds should be cleaned. Irrigation rids the
wound of contaminants, debris and bacteria and is
considered the most important means of reducing
the incidence of wound infection.
 Cleaning with Anti-septic solutions like betadine is
standard method.
 Local Anesthesia may be topical or infiltrated.
 Debridement: Once the wound is adequately
anaesthetized and irrigated, devitalized wound edges
should be debrided using sharp scissors and/or a
scalpel blade. Irrigate the wound again after
debridement to remove tissue debris.
Wound Irrigation & Anesthesia

28.  is also known as healing by primary intention. Wounds
that heal by primary closure have a small, clean defect
that minimizes the risk of infection and requires new
blood vessels and keratinocytes to migrate only a
small distance. Surgical incisions, paper cuts, and
small cutaneous wounds usually heal by primary
closure.
Primary wound closure

29.  also known as healing by secondary intention,
describes the healing of a wound in which the wound
edges cannot be approximated. Secondary closure
requires a granulation tissue matrix to be built to fill
the wound defect. This type of closure requires more
time and energy than primary wound closure, and
creates more scar tissue.
Secondary wound closure

30.  also known as healing by tertiary intention. Delayed
primary closure is a combination of healing by primary
and secondary intention, and is usually instigated by
the wound care specialist to reduce the risk of
infection. In delayed primary closure, the wound is
first cleaned and observed for a few days to ensure
no infection is apparent before it is surgically closed.
Examples of wounds that are closed in this way
include traumatic injuries such as dog bites or
lacerations involving foreign bodies.
Delayed primary closure

31. Types of Sutures.
 Absorbable Sutures:
1. Catgut:
 for soft tissue closure
2. Polyglycolic Acid:
 for deep tissue closure
 provides good tensile strength
3. Monocryl:
 for Subcutaneous closure
 Excellent cosmetic outcomes
 Non-Absorbable Sutures:
1. Silk:
 for skin closure
 Excellent handling characteristics
2. Nylon:
 for skin and soft tissue closure
 provides good tensile strength
3. Polypropylene:
 High tensile strength
 Commonly used in General Surgery, CVS
and hernia repairs
4. Stainless Steel:
 Used in orthopedic / plastic surgery
 For wounds that require long-term tissue
support

32.  Vicryl
 Chromic
 Prolene
 Silk
 Staples
 Glue
 Adhesive taps
Sutures Material

33. Running, or continuous stitch
 made with one continuous
length of suture material
 close tissue layers which
require close approximation
 speed of execution, and
accommodation of edema
during the wound healing
process
 greater potential for mal-
approximation of wound
edges with the running stitch
than with the interrupted
stitch

34. Interrupted Sutures.
 needle at a 90° angle to the
skin within 1-2 mm of the
wound edge and in the
superficial layer
 exit through the opposite side
equidistant to the wound edge
and directly opposite the initial
insertion
 stitch is tied separately
 used in skin or underlying
tissue layers
 more exact approximation of
wound edges can be achieved
with this technique than with
the running stitch

35. Mattress suture
 a double stitch that is made
parallel (horizontal
mattress) or perpendicular
(vertical mattress) to the
wound edge
 advantage of this technique
is
 strength of closure
 each stitch penetrates each
side of the wound twice
 inserted deep into the tissue

36. Purse string Suture.
 continuous stitch
paralleling the edges of a
circular wound
 wound edges are
inverted when tied
 used to close circular
wounds, such as hernia or
an appendiceal stump

37. Smead-Jones/Far-and-Near
 a double loop technique
alternating far and near
stitches
 greater mechanical
strength than continuous
or simple interrupted
sutures
 used for approximating
fascial edges, especially
for patients at risk for
fascial disruption or
infection

38. Continuous Locking, or Blanket Stitch
 a self-locking running
stitch used primarily for
approximating skin edges

39.  good approximation edges is paramount to proper
wound closure technique
 deep sutures serve to eliminate the dead space and
relieve tension from the wound surface
 deep sutures also ensure proper alignment of the
wound edges and contribute to their final eversion
 wound closure may require sharp undermining of the
tissues to minimize tension on the wound
 achieve hemostasis
 eversion of all skin edges avoids unnecessary
depression of the resultant scar
Features of Good Closure

40.  The main purpose of wound dressing is to provide the
ideal environment for wound healing.
 The dressing should facilitate the major changes
taking place during healing to produce an optimally
healed wound.
 Covering a wound with a dressing mimics the barrier
role of epithelium and prevents further damage.
 In addition, application of compression provides
hemostasis and limits edema.
Dressings

41.  Promote wound healing
 Pain control
 Odor control
 Non allergenic and nonirritating
 Permeability to gas
 Safety
 Non traumatic removal
 Cost-effectiveness
Desired characteristics of wound
dressing

42.  Occlusion of a wound with dressing material helps:
 Healing by controlling the level of hydration and oxygen tension
within the wound.
 It also allows transfer of gases and water vapor from the wound
surface to the atmosphere.
 Occlusion affects both the dermis and epiderms, and
it has been shown that exposed wounds are more
inflamed and develop more necrosis than covered
wounds.

43.  As it may enhance bacterial growth, occlusion is
contraindicated in infected and highly exudative wounds.
 Many types of dressings exist and are designed to achieve
certain clinically desired endpoints.
 These includes.
 Absorbent dressings
 Non adherent dressings
 Medicated dressings
 Occlusive and semi occlusive dressings.

44.  Antibiotics should be used only when there is an
obvious wound infection.
 Most wound are contaminated or colonized with
bacteria.
 Sign of infection to look for include:
 Erythema,
 Cellulitis,
 Swelling, and
 Purulent discharge.
Antibiotics

45.  Antibiotics can also be delivered topically as part of
irrigation or dressing, although their efficacy is
questionable.
 Indiscriminate use of antibiotics should be avoided to
prevent emergence of multidrug-resistant bacteria.

46. face: 3-4 days
scalp: 5 days
trunk: 7 days
arm or leg: 7-10 days
foot: 10-14 days
Suture removal

47.  Immediate and delayed complications may occur with
wound closure
 formation of hematoma
 wound infection.
 reduced by prophylactic antibiotics
 Late complications
 scar formation
 excess tension
 lack of eversion of the edges
 hypertrophic scarring and keloid formation.
 stitch marks
 wound necrosis
Wound Complications.

48. Keloid & Hypertrophic Scars.

49.  Bailey and loves, short practice of surgery.
 Schwartz's, principles of surgery.
 Surgery lecture note for health officers.
 Sabiston, textbook of surgery.
Reffrences

50. Thank You