Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Wound Management
 


> WOUND
> SPLIT-SKIN GRAFTING


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:

:: Interrupted simple
:: Continuous simple
:: Vertical mattress
:: Horizontal mattress
:: 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):

:: As suture is a foreign body, use the minimal size and amount of suture material required to close the wound
:: 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
:: 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
:: 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:

:: Cleaning the skin with antiseptics
:: Irrigation of wounds with saline
:: 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).

Figure 5.1
Figure 5.1

:: 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.
:: 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.

Figure 5.2
Figure 5.2

Figure 5.3
Figure 5.3


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:

:: Closed drains do not allow the entry of atmospheric air and require either suction or differential pressure to function
:: Open drains allow atmospheric air access to the wound or body cavity
:: 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.


> WOUND
> SPLIT-SKIN GRAFTING


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  Kep Points  
Suction drains are active and closed


Differential pressure drains are closed and passive



 
Latex drains, which function by capillary action, are passive and open.