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WOUND
Primary repair
Primary closure requires that clean tissue is approximated
without tension. Injudicious closure of a contaminated wound
will promote infection and delay healing.
Essential suturing techniques (see Unit 3) include:
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Interrupted
simple |
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Continuous
simple |
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Vertical
mattress |
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Horizontal
mattress |
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Intradermal. |
Staples
are an expensive, but rapid, alternative to sutures for skin
closure. The aim with all techniques is to approximate the
wound edges without gaps or tension. The size of the suture “bite” and
the interval between bites should be equal in length and
proportional to the thickness of tissue being approximated
(see pages 4–4
to 4–7):
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As
suture is a foreign body, use the minimal size and amount
of suture material required to close the wound |
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Leave
skin sutures in place for 5 days; leave the sutures in
longer if healing is expected to be slow due to the blood
supply of a particular location or the patient’s
condition |
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If
appearance is important and suture marks unacceptable,
as in the face, remove sutures as early as 3 days. In
this case, re-enforce the wound with skin tapes |
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Close
deep wounds in layers, using absorbable sutures for the
deep layers. Place a latex drain in deep oozing wounds
to prevent haematoma formation. |
Delayed
primary closure
Irrigate clean contaminated wounds; then pack them open with
damp saline gauze. Close the wounds with sutures at 2 days.
These sutures can be placed at the time of wound irrigation
or at the time of wound closure (see pages 4–4 to 4–7).
Secondary healing
To promote healing by secondary intention, perform wound toilet
and surgical debridement. Surgical wound toilet involves:
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Cleaning
the skin with antiseptics |
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Irrigation
of wounds with saline |
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Surgical
debridement of all dead tissue and foreign matter. Dead
tissue does not bleed when cut. |
During
wound debridement, gentle handling of tissues minimizes bleeding.
Control residual bleeding with compression, ligation or cautery.
Dead or devitalized muscle is dark in colour, soft, easily
damaged and does not contract when pinched. During debridement,
excise only a very thin margin of skin from the wound edge
(Figure 5.1).
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Systematically
perform wound toilet and surgical debridement, initially
to the superficial layers of tissues and subsequently
to the deeper layers (Figures 5.2,
5.3). After scrubbing
the skin with soap and irrigating the wound with saline,
prep the skin with antiseptic. Do not use antiseptics
within the wound. |
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Debride
the wound meticulously to remove any loose foreign material
such as dirt, grass, wood, glass or clothing. With a
scalpel or dissecting scissors, remove all adherent foreign
material along with a thin margin of underlying tissue
and then irrigate the wound again. Continue the cycle
of surgical debridement and saline irrigation until the
wound is completely clean. |
| :: |
Leave
the wound open after debridement to allow healing by
secondary intention. Pack it lightly with damp saline
gauze and cover the packed wound with a dry dressing.
Change the packing and dressing daily or more often if
the outer dressing becomes damp with blood or other body
fluids. Large defects will require closure with flaps
or skin grafts but may be initially managed with saline
packing. |
Drains
Drainage of a wound or body cavity is indicated when there
is risk of blood or serous fluid collection or when there is
pus or gross wound contamination. The type of drain used depends
on both indication and availability.
Drains are classified as open or closed and active or passive:
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Closed
drains do not allow the entry of atmospheric air and
require either suction or differential pressure to function |
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Open
drains allow atmospheric air access to the wound or body
cavity |
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Continuous
suction drains with air vents are open but active drains. |
Drains
are not a substitute for good haemostasis or for good surgical
technique and should not be left in place too long. They
are usually left in place only until the situation which
indicated insertion is resolved, there is no longer any fluid
drainage or the drain is not functioning. Leaving a non-functioning
drain in place unnecessarily exposes the patient to an increased
risk of infection.
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Suction
drains are active and closed
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Differential pressure drains are
closed and passive
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Latex drains, which function by
capillary action, are passive and open.
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