Surgical Wounds

Surgery is the main field of medicine that deal with wounds.

There are various classifications of wound, here I’ve mentioned the frequently used classifications of wounds.


Classification Of Wounds

According to the depth of the wound

  • Superficial wounds
    • Only involves the dermis and epidermis
    • Heals without granulation tissue formation and true scar formation 
    • Ex : Superficial buns, Split skin graft, Grazes
  • Deep wounds
    • Involves layers deep to the dermis
    • Heals with granulation tissue formation and true scar formation
    • Ex : Laceration 


According to the risk of contamination
  • Clean wound – Hernia repair
  • Clean contaminated wound – Cholecystectomy
  • Contaminated wounds – Colonic resection
  • Dirty wound – Laparotomy for peritonitis
 
Stages of wound healing

Pathophysiology Of Wound Healing

 
Wound healing occurs in four phases. These phases have a slight overlap with the immediately next phase. 
Wound healing is broadly similar in most cells, but can have slight variations depending on the tissues involved, depth of the wound, mechanism of injury, etc. 
  • Haemotasis
  • Inflammatory phase
  • Proliferative phase / Regeneration
  • Maturation phase / Remodeling

Stages of Wound Healing
Factors Affecting Wound Healing

  • Local risk factors 
    • Wound infection 
    • Haematoma 
    • Excessive mobility 
    • Foreign body 
    • Dead tissue 
    • Dirty wound 
    • Surgical technique
    • Ischaemia
  • General risk factors 
    • Elderly 
    • Presence of systemic diseases 
      • Cardiac disease 
      • Respiratory disease 
      • Renal diseases
      • Hepatic disaese
    • Anaemia 
    • Obesity
    • Diabetes mellitus 
    • Smoking 
    • Malnutrition 
    • Malignancy 
    • Irradiation 
    • Steroid or cytotoxic drugs 
    • Immunosuppressive disease or drugs



Ideal Environment For Wound Healing

  • No foreign bodies
  • No infection 
  • Proper closure of wound in layers
  • No excessive tension 
  • Good blood supply
  • Good haemostasis
 
 

Complications Of Wound Healing

  • Delayed healing
  • Wound dehiscence (Partial or total disruption of any or all layers of the surgical wound)
  • Evisceration (Rupture of all layers of the abdominal wall and extrusion of the abdominal viscera)
  • Incisional hernia
  • Contractures
    • Occurs due to shortening of the scar
    • Managed with Z-plasty 
    • Physiotherapy, massaging, splinting is helpful to prevent contracture formation 
  • Hypertrophic scar
  • Keloid



Hypertrophic Scar And Keloid

Hypertrophic Scar
Keloid
Excess fibrous tissues that is confined to the scar Excess fibrous tissue that extend beyond the original boundary of the scar
Not progressive

(Do not tend to advance after 6 months of growth)

Continuous growth
No such association Maybe tender, itchy and oozing
Can regress over time Do not regress
Do not recur after excision Can recur after excision
Seen in burns, following wound infection, wounds across Langer’s lines Seen in pigmented skin, family history of keloids, past history of keloids

Keloid, Hypertrophic scar

 Treatment Of Hypertrophic Scar And Keloid

  • Excision (usually leads to recurrence) 
  • Excision and radiotherapy 
  • Intralesional steroid injection
  • Pressure garments 
  • Silastic gel treatment 
  • CO2 laser



Promote Wound Healing And Minimize Wound Complications

  • Optimization of nutrition
    • Protein, Vitamin A, Zn, Cu plays a major role in wound healing
    • Consider – NG feeds, parenteral nutrition 
  • Good circulation and oxygenation 
    • Hydration 
    • Oxygenation if necessary
  • Surgical technique 
    • Debridement of the wound
    • Careful tissue handling 
    • Thorough cleaning of the wound
    • Sutures should not be too tight
  • Address co-existing disease
    • Respiratory, renal, CVS problems
  • Minimize scar formation 
    • Using lines of skin tension 
    • Hiding cares in naturally occurring lines (Wrinkling lines)
    • Use of hidden sites (Eyebrow, hairline)
      • Incisions should be made parallel to the hair follicle to avoid sectioning of the hair follicle 
    • Use the smallest length possible as the incision 
    • Clean wounds thoroughly (Infection can cause tattooing of skin)
    • Close the wound in layers to reduce the tension 
    • Remove sutures as soon as possible
    • Massaging to avoid adherence to underlying structures 
    • Avoid exposure to sunlight as new scars can become pigmented 
Langer's Lines

Fig : Langer’s Lines

These lines corresponds with the relaxed  skin
Incisions are made along these lines to reduce skin tension 

Principles Of Wound Management

  • Primary intention
    • Criteria includes….
      • Uncontaminated wound
      • Minimal tissue loss
      • Edges can be approximated easily without any gap
    • These wounds heal with rapid epithelialisation with minimal granulation tissue formation and minimal scarring
  • Secondary intention 
    • Criteria includes….
      • Extensive tissue loss
      • Contaminated wounds
      • Edges cannot be approximated 
    • These wounds are left open till granulation tissue appears and then the wound is closed
    • Scar formation is prominent | Cosmetic quality is poor
  • Tertiary intention /Delayed primary closure 
    • Wound is kept open for several days
    • Wound is allowed to heal by secondary intention for a longer period 
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