WOUND CLOSURE AND COMPLICATION

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 Clean wound Clean contaminated wound Contaminated wound Dirty Wound

4. Classification based on involvement of structures Simple wound Complex wound

5. Classifiaction based on time lapsed Acute wound Chronic wound

6. Classification based on Rank and Wakefield Tidy wound Untidy wound

7. Classification based on thickness of wound Superficial wound Partial thickness Full thickness Deep wound

8. Classifiaction based on type of wound Clean insiced wound Lacerated wound Bruise or contusion Abraion Puncture wounds and bites Penetrating wounds

9. Phases of wound healing Inflammatory phase Proliferative phase Remodelling phase

10. Wound closure Primary wound closure Secondary wound closure Delayed primary closure

11. 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

12. 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.

13. 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

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

15. 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

16. Delayed primary suturing suturing the wound in 48 hours to 10 days done in lacerated wound

17. 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

18. 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

19. Methods of wound closure Suture materials Stapler Adhesive

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

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

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

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

29. 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.

30. 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

31. 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.

32. 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).

33. 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.

34. 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

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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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.

42. 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

43. Hypertrophic scar or keloid

44. 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

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

46. THANK YOU