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Surgical Wounds

 

 

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Scar Management

 

Minor Wounds    

 

There are various types of surgical procedures that create surgical wounds:

  • Investigative or corrective
  • Minor or major
  • Open (traditional) or Minimal Access surgery
  • Elective or emergency
  • Incisions (simple cuts) or excision (removal of tissue)

In each case surgery exposes sub-cutaneous tissue; the resulting wound requires management to promote satisfactory healing and to avoid complications such as infection. In the majority of cases this will require the use of some form of wound dressing.


Under ideal conditions, a surgical wound, whether an incision or excision, will follow the normal wound healing pathway associated with acute wounds. Unfortunately, not all such wounds are ideal and complications may impede the healing process.

 

Modes of Healing

Primary intention healing involves bringing the edges of the wound together (in apposition) and securing them with sutures, clips or skin closure strips. These wounds usually seal within 24 to 48 hours and heal in 8 to 10 days. Healing takes place, throughout the depth, of the wound simultaneously and little new tissue has to be formed. There may be a little leakage from the wound for the first 2 days; the presence of bloody exudate or of odour beyond this, is a warning sign of a potential complication. Managing the risks associated with the open phase of healing is a prime consideration.

 

Secondary intention healing requires that a wound is left open to allow healing by contraction and replacement of missing tissue with granulation and epithelial tissue. It is common for surgical excisions or traumatic wounds with tissue loss to be healed this way. The healing duration will depend on the amount of tissue that must be replaced and the resulting scar may be quite extensive.

 

In tertiary intention healing , or delayed closure the wound is kept open to allow for drainage of exudate, control of contamination or for further surgical procedures to be completed. At a later date (usually within 7 days as bacterial contamination rises markedly from the 8th day onwards), the patient returns to the operating room for the wound to be surgically closed. If the wound has to be kept open for longer periods of time and there is significant bacterial contamination, this has to be reduced before the wound is closed.

 

Infection

Infection is of major concern to most clinicians, institutions and patients. Prior to the development of antiseptics (Lister ~1860) and aseptic technique, infection rates following surgery were between 70% and 90%. Between 30% to 50% of surgical patients died as a consequence of these wound infections. Fortunately this situation has improved, with typical infection rates of ~10% being quoted in clinical literature. However, even surgical units applying the most advanced and thorough aseptic protocols rarely produce infection rates below a 5% average.

 

Sources of Infection

 
The risk of infection is significantly higher in hospitals than in the home environment because the patient is in a state of reduced immunity and is encountering exposure to micro-organisms to which an immune response has not been prepared. The development of an infection adds a substantial cost to treatment. A two year retrospective case control study undertaken at the Alfred Hospital determined the incremental cost attributable to surgical site infection after undergoing Coronary Artery Bypass Graft Surgery (CABG) to be $12,419. This cost was primarily driven by an increased length of stay but also included antibiotic treatment 1. Thus, infection is potentially a considerable financial drain on valuable patient care resources.

 

A study in Sweden by Bengtsson et al. found that Staphylococcus aureus is the most common causative organism in surgical infection (28% of total infections), while the various gram-negative bacilli accounted for a further 31%. Staphylococcus aureus is a commensal bacterium, found as part of normal skin flora. Of the Staphylococcal infections, 42% were shown to be caused by bacteria from the patient's own skin, whilst 28% were associated with bacteria in the air or from the skin of medical staff involved in the operation. These figures indicate how important it is to protect the incision site during the operation with surgical drapes, OpSite* Incise for example, and to protect the wound from environmental bacteria post-surgery. An added complication is the emergence of resistant strains of bacteria. These have become immune to a proportion of the antibiotics available. Methicillin Resistant Staphylococcus Aureus (MRSA) is now thought to colonise about 10% of the population of the world.

 

The risk of surgical incision complication is increased in certain categories of patients:

  • The elderly or very young
  • Immuno-compromised or immuno-suppressed
  • Those with underlying debilitating disease
  • The nutritionally deprived
  • Those taking drugs and therapeutic treatments that reduce their ability to withstand infection

 

Treatment

Clinical literature recognises the essential criteria for an effective Post-Operative dressing as below:

  • High Moisture Vapour Permeability (MVP)
  • Low adherence to the wound surface
  • Absorbent
  • Waterproof, or washproof for minor surgery
  • Bacterial barrier
  • Conformable
  • Non-sensitising
  • Good adhesion to skin
  • Sterile
  • Low cost
  • Non-flammable and non-toxic

 

The following criteria might also be added for the 'ideal' surgical dressing:

  • No risk of maceration of intact tissue
  • Easy to use
  • Removable without disturbing the sutures or clips
  • Allow inspection of wound site without disturbance

 

Product Selection

Skin Closure 

Leukostrip* skin closure strips assist to bring the edges of the wound together and secure the wound in primary healing.


Non-Traumatic Alternative to Sutures

Leukosan# SkinLink# is a non-invasive topical wound closure product that requires no suturing or anaesthesia and can be used for many surgical procedures.

 

Post-Surgical Dressings:
Opsite* Post-Op and Cutifilm* Plus are transparent, waterproof dressings - with a low adherent, absorbent pad - that create a seal around the entire wound to limit the chance for environmental introduced organisms infiltrating the incision site.

 

Primapore* and Cutiplast* Steril are non-woven island dressings consisting of an absorbent pad with a low adherent wound contact surface and an adhesive coated non-woven fabric backing.

 

Protective Dressings
OpSite* Flexigrid* can be useful for certain surgical wounds as the suture line can be visualised through the dressing.


Spray Dressings

Spray film products such as OpSite* Spray are useful for sealing a surgical incision and for treating difficult to dress locations. They can also be used after the Post-Operative dressing is removed.

 

Alginate Dressings
Algisite* M is derived from seaweed and can be used in wounds with moderate to high exudate to absorb fluid and/or to help control minor bleeding.

 

Related Links

Treating Inflammation and Infection >

1. Jenney A, Harrington G, Russo P, Spelman D (2001). "Cost of surgical site infections following coronary artery bypass surgery". ANZ J Surg. 71,662-664.