Management of Wound

Dr.Ghazi Qasaimeh

Consultant Surgeon K.A.U.H

Associate professor of surgery

J.U.S.T

Management of Wounds

Mechanism of injury
Traumatic wounds
Sharp, penetrating Blunt Bullet

Surgical wounds

Types of wounds

Cut wounds Lacerated wounds

incised

Crushed wounds Wounds with skin loss

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Examination of Wounds

Associated injuries:
Abdominal Cavity Chest Cavity cranial Cavity

Vessels Nerves Tendons Museles Bones, Joints

Types of Suturing

Primary suturing Excision and primary suturing Delayed primary suturing Secondary suturing Skin grafting

Elements of Wound Healing

1- Contraction 2- Connective tissue formation (granulation tissue) 3- Epithelization

Phases of Healing
1- Lag phase (preparation phase) 2- Proliferation phase

3- Maturation (differentiation)

The organ of repair Wound strength Wound histology:

Neutrophils Monocytes Fibroblasts Capillaries Collagen
1st day after 24 hrs 5-6 days 5-6 days after 4th day

Wound Biochemistry
Collagen synthesis lyses (collagenase)

Factors affecting healing:

Age Nutrition: Protein: Ascorbic acid: Zinc Vascularity Sepsis Oxygen Wound dressing
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Other measures: Fasciotomy

Types of healing Healing by first intention Healing by second intention Bullet injuries: high velocity missile shock waves temporary cavitation Blast injuries: complex blast waves mass air movement
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Surgical Wounds
Clean Clean contaminated Contaminated Dirty

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Factors which affect wound healing

General: Malnutrition, ureamia, malignancy,

radiothempy, cytotoxic drugs, duabetes, vitc deficiency. Local Factors: - Blood supply - Tension in wound - presence of necrotic tissue and F.B - presence of haematoma - excessive cauterization, rough manipulation - infection
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Complieations of Wounds: Wound infection Wound dehisconce Hyper trophied scar, keloid Management of wound infection. Role of antibiotics.
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Ulcers
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Definition

A Break in the skin continuity extending to all its layers or break in the mucous membrane lining the alimentary tract, that fails to heal and is often accompanied by inflammation Or in other words, it is a macroscopic discontinuity of the normal epithelium (microscopic discontinuity of epithelium is called erosion)

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Cont

1. 2.

3. 4.

Ulcers are non-healing wounds that develop on the skin, mucous membranes or eye. Although they have many causes, they are marked by: Loss of integrity of the area Secondary infection of the site by bacteria, fungus or virus Generalized weakness of the patient Delayed healing

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classification

Merck Manual classification National Pressure Ulcer Advisory Panel (NPUAP) Wagner's classification

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NPUAP

Stage I - There is erythema of intact skin which does not blanch with pressure. It may be the heralding lesion of skin ulceration. Stage 2 - There is partial skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion, or wound with a shallow center.

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Cont

Stage 3 - This is an entire thickness skin loss. It may involve damage to or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent intact tissues.

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Cont

Stage 4 - Here there is entire thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. tendons, and joints may also be exposed or involved. There may be undermining and/or sinus tracts associated with ulcers at this stage.

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Location
1.

2. 3.

Lower limbs: most ulcers of the foot and leg are caused by underlying vascular insufficiency . The skin breaks down or fails to heal because of repeated insult or trauma. Sacrum and ischium Mouth ulcer

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Cont
4. Peptic ulcer: This includes ulcers of the esophagus, stomach, large and small intestine 5. Genitalia: May be penile, vulvar or labial. Most often are due to sexually-transmitted disease. 6. Eyes: corneal ulcers are the most common type. Conjunctival ulcers also occur.

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causes

Bacterial , viral & fungal infection Cancer both primary & secondary Venous stasis Arterial insufficiency Diabetes Rheumatoid arthritis Loss of mobility
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Description

Site Size Shape Base Edge Tenderness Discharge Surrounding tissue & lymphatics
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Types

Peptic ulcer Mouth ulcer Pressure ulcer (decubitus) Arterial insufficiency ulcer Venous insufficiency ulcer Diabetic foot ulcer

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Cont

Hunners ulcer (of the bladder caused by Interstitial Cystitis) Ulcerative colitis (of the colon)

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Ischaemic ulceration

By definition caused by inadequate blood supply large \ small artery obliteration In elderly , who also have symptoms of coronary vascular disease. Men predominate Risk factor Very painful, causes rest pain Do not bleed but discharge thin serous exudates which can become purulent
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Cont

May penetrate into joints making movement painful. Site,size,shape,tenderness,edge,TM, depth,base,surrounding tissue Pulses

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Neuropathic ulceration
Deep penetrating ulcer which occur over pressure point, but the surrounding tissue are healthy and have good circulation. Diagnostic features:1- painless 2- surrounding tissues are unable to appreciate pain 3- surrounding tissues have normal blood supply

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Cont

Causes:peripheral nerve lesions diabetes ,nerve injuries Spinal cord lesions spina bifida,tabes dorsalis

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Venous ulceration

Follow many year of venous disease. Women predominant Risk factor Site, size,shape, tenderness, edge, discharge, TM, surrounding tissues pulses

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Fistulas
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definition

Fistulas is an abnormal communication between tow epithelial or endothelial surfaces

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Types of fistulas

Congenital ( e.g. oesophageal atresia with a fistulous communication with the trachea) Acquired : - external fistulas involve the skin (e.g. enterocutaneous) - internal fistulas affect adjacent organs contiguously or more through an intervening abscess cavity (e.g. entroenteric,entrocolic,etc.) Arteriovenous fistulas are an abnormal communication between an artery and a vein it could be : - congenital - acquired : *trauma *iatrogenic ( for hemodialyisis )

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Internal abdominal fistulas :Majority result from an underlying gastrointestinal disease ( e.g. colonic diverticular disease, crohns disease, colonic carcinoma, radiation enteritis ,intestinal tuberculosis , chronic cholecystitis , etc )

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External abdominal fistulas arise as a complication of surgery or to the trauma to the intra-abdominal organs such as anastomotic leakage , accidental or unrecognized injury during operation Other external fistulas are due to primary abscess formation which involve bowel and skin and these are best exemplified by the perianal fistulas
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The effect of internal abdominal fistulas depend on : - site - pathology of the condition causing it E.g. :- malabsorption and steatorrhoea may occur with entero-enteric and enterocolic fistulas - cholangitis may follow bilio-enteric fistula - severe cystitis with pneumaturia may be caused by vesicocolic fistula etc.
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Constitutional effects are minimal with external colonic fistulas Malnutrition and fluid and electrolyte depletion accompany high output bowel fistulas Skin excoriation and digestion of the abdominal wall is a serious feature of pancreatic , duodenal and high small bowel fistulas

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Internal abdominal , perianal and anorectal fistulas seldom if ever close spontaneously Healing of external abdominal fistulas can be expected if there is no distal obstruction to the involved bowel , the healing depend on : - adequate drainage of any abscess - the maintenance of a good nutritional state

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Management is complex and requires definition of the exact underlying pathological anatomy by appropriate contrast radiology with a sinogram and/or barium enema, barium meal followthrough Surgical intervention is required for internal fistulas and for external abdominal fistulas associated with - distal obstruction or when discontinuity of the bowel - underlying neoplastic intestinal disease - when conservative medical management with parenteral nutrition has failed to produce healing
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Mammary duct fistula

Most commonly in patients with mammary duct ectasia

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Biliary fistulas

External which are secondary to bile duct trauma or leakage or accessory bile ducts and gallbladder bed internal which are classified into three types : bilio-enteric, broncho-biliary and bilio-pleural, bilio-biliary

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Pancreatic fistulas

May be internal or external and carry a substantial morbidity from sepsis, hemorrhage and persistent pancreatitis An external fistula may be secondary to a pancreatic abscess complicating acute pancreatitis, but may also follow abdominal trauma and operative intervention An internal pancreatic fistula is almost always due to a pancreatic abscess which complicates acute pancreatitis in 1-5 % of patients

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Gastrocutaneous fistulas

These are usually iatrogenic following unrecognized operative injuries during splenectomy or vagotomy Partial necrosis of the lesser curve to duodenum anastomosis after a billlroth 1 gastrectomy may also result in a gastric leak and fistula Some apparently arise as a result of erosion by drains A small percentage are caused by benign gastric ulcer, pancreatic abscess and pancreatic carcinoma

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Gastrojejunocolic fistula

Severe complication is usually found in association with inoperable carcinoma of the stomach or transverse colon Less frequently encountered as a result of recurrent ulcer at gastrojejunal anastomosis largely due to overall improvement in the results of ulcer management and surgical treatment
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Small-bowel fistulas

The majority (80-90 %) of small bowel fistulas follow operations on the intestinal tract either from anastomotic leakage or iatrogenic injury Often the anastomotic dehiscence is attributed to the presence of underlying small bowel disorder, crohns disease being the most common, but radiation enteritis and intestinal tuberculosis featuring often in several published series

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External colonic fistula

These most commonly follow colonic surgery, including colostomy closure Trauma accounts for some cases as does perforated colonic diverticular disease and cancer

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Colovesical and colovaginal fistulas

The former is one of the commonest forms of internal abdominal fistulas Both are usually encountered in association with diverticular disease and a pericolic abscess which perforates into the bladder or vagina, especially in females after hysterectomy as this allows the diseased bowel to lie directly onto the bladder or vaginal vault Less commonly these fistulas may be due to cervical or rectal carcinoma Crohns disease of the large and small bowel may be complicated by the development of entero/colovesical fistula Radiotherapy for malignant disease of the pelvis accounts for the majority of rectovaginal/vesical 55 fistulas

Treatment

Conservative : * the mainstays of medical management are: - nutritional support - meticulous collection of fistulous discharge - skin-stoma care - control of sepsis

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Surgical : * the absolute indications for operative intervention are : - intestinal distal obstruction - peritonitis - abscess formation - bowel discontinuity - presence of malignant disease - persistent inflammatory bowel disease
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Cysts
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What is a cyst?
a cyst is : any closed epithelium-lined cavity or sac, normal or abnormal, usually containing liquid or semisolid material" (Dorland's, 1995, pp.209). It is common can occur anywhere any age. Cysts vary in size Its wall called the cyst capsule
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What are the causes of a cyst?

Cysts are usually formed through one of these mechanisms:

1"Wear and tear" or simple obstructions to the flow of fluid . Infections and chronic inflammations Tumors Genetic (inherited) conditions Defects in developing organs in the embryo
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1.

2.
3. 4. 5.

Types of cysts

1.
2. 3. 4.

cysts in the neck :

Branchial cleft cysts. Thyroglossal duct cysts. Dermoid cysts. Sebaceous cysts

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Branchial cyst
Embryology : congenital abnormality that is presented in adult life . -incomplete involution of the branchial clefts -lined with epithelium derived from the branchial ectoderm.

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Branchial cyst continued

Clinical feature: presenting complaint. Age Location complication

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Branchial cyst continued

Diagnosis By location C.T. scan ultrasound can help. Treatment: A small incision is made in the neck and the cyst is removed. Sinuses may occasionally need two incisions for complete repair. Cysts are removed to prevent infection.This is a day surgery operation

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Thyroglossal cyst
Embryology and pathogenesis: The thyroglossal tract arises form foramen caecum Arises at junction of anterior 2/3 and posterior 1/3 of the tongue Any part of the tract can persist causing a sinus, fistulae or cyst Most fistulae are acquired following rupture or incision of infected thyroglossal cyst

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Thyroglossal cyst cont..

Clinical features: -Usual location midline -Painless surrounded by lymphoid tissue -age 40% present < 10 years of age 65% present < 35 years of age Protrude the tongue in its examination

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Thyroglossal cyst cont..

Treatment -The treatment is by surgical excision .the cyst along with the centre of the hyoid bone along with the thyroglossal duct up to the base of the tongue should be excised to ensure complete removal. It must be differentiated from the lymphoid tissue through us before incision .

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dermoid cysts

it occurs when skin and skin structures become trapped during fetal development. Along the line of embryonic closure.the mid line . It can be a true hamartoma. Two types intra and extra abdominal Dermis like capsule with all skin layer Surgically remove dermoid cysts. The spread of these
contents can cause foreign body reactions and severe complications
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-A mid line structure -A symptomatic -Soft on palpation -Good prognosis

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sebaceous cysts

it is caused by obstruction of the sebaceous gland duct leads to accumulation of secretions which may get infected specially by staph. Bacteria with secondary enlargement .they are common in the head and neck skin it is presence may point to DM and should not be confused with Kaposi sarcoma in aids patients. a drainage sinus may form and may be multible treatment : wide surgical excision may be needed without opening them to prevent complication
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