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Content:
Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing
containing hair, sweat glands, nerve endings, and capillaries Subcutaneous tissue: a layer of loose connective tissue, containing larger blood vessels and fat Fascia and muscle: composed of muscle and muscle aponeuroses, which form the fascia, covering deeper structures
Epidermis
Dermis
Subcutaneous tissue (fat)
Fascia/Muscle
Skin anatomy
Skin has 2 layers: The outer epidermis and the underlying dermis Epidermis: Provides waterproofing and serves as a barrier to infection, there are no blood vessels Dermis: Layer which contains the appendages of skin Connective tissue Basement membrane (anchors dermis) Nerve endings (touch/heat) Sweat glands Sebaceous glands Apocrine glands Hair follicles Lymphatic vessels Blood vessels
Skin anatomy:
Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing
Wound healing
Classification of wounds
Types of wound healing
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Punctures Incisions
Surgical
lacerations, and punctures. There is usually a delay between the time of injury and presentation to a medical facility for treatment. Infection is a significant concern with these injuries. Surgical wounds include puncture and incisions. There is no time delay between wound occurrence and presentation, and the controlled setting of a medical facility is designed to minimize infection risk.
medical costs
US >26 million/year = $35 billion1,2 EU >42 million/year = 15 billion3
Foreign bodies
Classification of wounds
Bacterial presence: Contamination: Bacteria are present, but not proliferating Colonization: Bacteria proliferating without host reaction Infected tissue: Deposition and proliferation of microorganisms in the tissue with consequent host reaction
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completely epithelialized by regeneration that has returned to its normal anatomic structure and function without the need for continued drainage or dressing
Some wounds fail to heal properly resulting in
chronic, non-healing wounds that need continued management2 Aberrations in certain phases of healing can result in excessive healing example: hypertrophic scars, keloids2
1. Enoch SE and Leaper DJ. Surgery. 2008;26:31-37. 2. Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.
0-5 days suture material is the sole factor in holding together the wound Suture high tensile strength needed
5- 14 Days stabilization of the wound closure is gradually taken over by collagen Suture- highest tensile strength needed
7-14 days to a year suture material becomes irrelevant Presence of suture material is a Foreign material with side effects
hours
- Fibroblasts produce collagen, a fibrous, insoluble protein that generates connective tissue.
- Collagen grows in and increases the stability of the wound
4-6 days
weeks
Maximum response
I Hemostasis
0.1
0.3
30
100
300
V Scar maturation
Alterations in one or more of these phases could result in chronic wounds Abnormalities in these phases result in hypertrophic scars and keloids Macrophages Cytokines and growth factors
However, the duration for each phase is longer and there is granulation tissue filling the wound. The scar formed is also not as good as compared to primary wound healing
Exudative (inflammatory) phase Proliferative phase Remodeling Phase
Days
Weeks
Months
Tenets of Halsted
Halsted delineated his tenets over a century ago, but they continue to guide surgeons in the optimal care of patients today. His principles are based on asepsis, and minimal physical trauma of tissue. His tenets were: Gentle handling of tissue Aseptic technique Sharp anatomic dissection of tissue Careful hemostasis, using fine, nonirritating suture material in minimal amounts Obliteration of dead space in the wound Avoidance of tension
Foy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention and Management. Saunders; 2009:11-22.
Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing
Wound Healing
Tissue Factors Patient Factors
contamination, tissue destruction, etc Patient factors: immunosuppression, nutritional status, etc Operative/surgeon factors: prolonged operative times, hypothermia, etc
Local
Presence of foreign body and
persisting disease
Deficiency syndromes Shock of any cause Infection
foreign body reactions Increased skin tension Blood supply Continued presence of microorganisms Infection
Leaper. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed. Edward Arnold Ltd; 2008.
Smoking
Poor glucose control or hyperglycemia
A patient with even ONE of these risk factors is at greater risk of developing a surgical site infection (SSI)
of potential contamination, from clean to dirty. Not surprisingly, contaminated and dirty cases are more likely to develop a surgical site infection (SSI).
Several scoring systems have been developed to
Classification of wounds:
Wounds are generally classified into 4 categories1: Class 1 = Clean Class 2 = Clean contaminated Class 3 = Contaminated Class 4 = Dirty infected Contaminated or dirty/infected wound classifications
II Cleancontaminated
III Contaminated
Opening of the lower GI tract Traumatic wounds Opening of the collecting system with infected urine Opening of bile ducts with infected bile Breach of sterility Bacterial infection in OP area Draining of abscesses Traumatic wounds with necrosis, foreign bodies and exit of faeces Old wounds Bite wounds or similar
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IV Dirty Infected
itself. All sutures are foreign bodies and represent a possible nidus of infection and biofilm development.
Biofilms: every suture acts as a medical implant,
1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277. 2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.
against the potential to further harm the patient with surgical intervention. As is shown here, staple placement and the use of tissue adhesives can result in trauma and tension on the wound.
Tissue trauma can result from:
Devices used for closure
Handling of tissue
suturing technique is a critical component of wound healing. When the suture is tightened, the wound edges should evert slightly (the best conditions for primary healing).
- If the suture enters and exits from the skin at an acute angle, the wound may become inverted with poor healing, producing a poor cosmetic result needing revision.
As the suture is tightened, the knot should be drawn to
one side to facilitate suture removal. When a nonabsorbable suture is later removed, it needs to be cut immediately beneath the knot and pulled out by the knot.
swelling Edges should be everted The knot should be placed to one side of the wound Knots must be secure, with the ends long enough to grasp if the suture is to be removed Use no touch technique whenever possible
- Use appropriate needle holders
Leaper D. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed. Edward Arnold Ltd; 2008.
Tissue Specific Healing Time Guides the Choice of Tissue Repair Material
Wound closure is about more than just skin. As seen here, different tissue types require different lengths of time to achieve complete healing. This is an important factor to consider when selecting a closure method or material.
5-7 days 7-14 days 5-7 days 7-14 days 7-14 days 14-28 days 7-14 days 8-12 weeks 14-28 days 8-12 weeks
Weeks
*Minimum
healing times shown here are for healthy individuals without medical complications.
Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing
Scarring
Dehiscence
Infection
Harahap (ed). Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.
close after surgical re-approximation. This is typically at skin layers, although dehiscence of facial closure results in ventral hernia, as shown in top image. A major risk factor is surgical site infection (SSI), which can delay re-epithelialization and collagen formation as well as cause further tissue damage and disruption. Mechanism may be an underlying wound healing problem or surgical technique
Images courtesy of David Leaper, MD Lammers. Principles of Wound Management. In Roberts Clinical Procedures in Emergency Medicine. Saunders Press. 2010.
events
Optimal wound healing by primary intention; not possible
in all cases
Many factors delay or impede wound healing: long-term
Finding the Best Abdominal Closure: An Evidencebased Review of the Literature Authors: Adil Ceydeli, MD, James Rucinski, MD, & Leslie Wise, MD
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