Anesthesiology). 15-ARID-4409 DVM, 6th, 1 Morning, Section B. Goals! • To get General idea about Wound Wound Types Wound Healing (Major focus) Factors Affecting Healing Wound Management Wound Closure And why a surgeon must have the idea about wound healing. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 2 Morning, Section B. Content • General Definitions • Introduction to Wound Healing • Phases of Wound Healing • Factors affecting Healing • Wound Management • Wound Closure • Conclusion • References. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 3 Morning, Section B. General Definitions • Wounds are cuts, tears, burns, breaks, or other damage to living tissue or Disruption of normal anatomic continuity and metabolic functions of body structures, including organs, tissues, and cells. • Clean or Aseptic wound which does not carry any infection as surgical wounds or by sterilized instrument • Septic wound which is produced on roads and it carry some infection or invasion of microorganisms. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 4 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 5 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 6 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 7 Morning, Section B. Cont. • Open wounds Incised wound caused by sharp sterile object like scalpel. Laceration are irregular tear like wounds caused by blunt force. Abrasion wounds are superficial caused due to friction. Avulsion wound is in which a part of tissue is removed. Penetration wound caused by a knife like object. Gun shot Wound, also referred as through and through wound, as there may be 2 wounds, one of entering and one of exiting of bullet. Puncture Wound, wound caused by needle like substances.
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 8 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 9 Morning, Section B. Cont. • Closed wounds Heamatoma are accumulated blood under skin due to damage to blood vessels. Petechiae <3 mm Purpura > 3 <10 mm Ecchymosis> 10 mm
Contusion is heamatoma caused by external trauma.
Crush injury occurred under trauma force applied over longer period of time. Thermal wounds Chemical Wounds Electrical wounds
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 10 Morning, Section B. Introduction • Wound Healing is the complex biological process through which damaged organ or tissues regains its biological integrity i-e maintains its structure and function.
• Integral cellular components of wound healing include;
Platelets, neutrophils, monocytes, macrophages,
endothelial cells, fibroblasts, myofibroblasts, and keratinocytes.
In addition to these cellular components, important
cellular mediators include growth factors, cytokines, and chemokines. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 11 Morning, Section B. Phases Of Wound Healing • For our understanding, some divide this process in 4 and some in 3 phases; • A) Hemostasis • B) Inflammation and Debridement • C) Proliferation • D) Maturation/ Remodeling
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 12 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 13 Morning, Section B. If we put it simply!
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 14 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 15 Morning, Section B. But it actually happens like this! a) Hemostasis • Disrupted vascular endothelial cell produce endothelin, which (in combination with epinephrine, norepinephrine, and prostaglandins) initiates contraction of smooth muscle resulting in vasoconstriction.
• The coagulation cascade is initiated, and thrombin is
formed.
• Thrombin serves as a catalyst for fibrinogen conversion to
fibrin and contributes to platelet activation .
• Activated Platelets aggregate and adhere to exposed
collagen and degranulate (release GF). SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 16 Morning, Section B. b) Inflammation • Vasodilatation and increased vascular permeability occur in response to the presence of leukotrienes, prostaglandins, histamine, and kinins.
• Which result in increased blood flow to the
wound bed and extravasation of fluid.
• Creating the classic signs of inflammation—heat,
redness, swelling and maybe loss of function.
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 17 Morning, Section B. b) Debridement • Neutrophils and macrophages, through phagocytosis and their degradative enzymes, breakdown and remove (“clean-up”) the cell debris resulting from tissue injury.
• Macrophages secrete a variety of chemotactic
and growth factors that establish the microenvironment for the proliferation (granulation) phase. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 18 Morning, Section B. c) Proliferation(Granulation) • Day 4 through day 12 • The proliferation phase can last up to 3 to 4 weeks or longer depending on the size of the wound.
• This phase is characterized by the generation of new
endothelium (angiogenesis), epithelium (epithelialization), and connective tissue stroma (fibroplasia/desmoplasia) to restore normal structure and function to the injured tissue.
• The healing of skin after third-degree burns or severe
ulcerations is an example of this process. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 19 Morning, Section B. d) The Remodeling (Maturation, Contraction) phase • This phase begins approximately 3 to 4 weeks after injury, but only after the inflammation and proliferation phases have been successfully completed.
• This phase includes remodeling of granulating(healing)
tissue by immature connective tissue and the conversion of immature connective tissue to mature connective tissue through extracellular collagen formation.
• Remodeling can last for 2 or more years. It essentially
provides the time some tissues and organs, such as bone, need to return to the near-normal tensile strength required for normal axial and appendicular skeletal function. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 20 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 21 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 22 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 23 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 24 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 25 Morning, Section B. Factors Affecting Healing
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 26 Morning, Section B. Management of Wound • Following are some rules for successful surgical treatment of wounds Thorough debridement Meticulous Hemostasis Elimination of dead space Judicious Insertion of drains Proper placement of sutures
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 27 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 28 Morning, Section B. Cont. • Large volume of clean non-sterile fluid (e.g. mains water) is more valuable than small volume of sterile physiological saline. • Judicious use of 3% hydrogen peroxide, or 1% chlorhexidine solution speeds removal of pus and tissue debris. • Single or interrupted mattress sutures of sheathed polyamide polymer multifilamentous material (e.g. Vetafil®, Supramid® [Braun]), monofilament nylon or polypropylene. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 29 Morning, Section B. Cont. • Drains-Sialastic, Penrose. Polypropylene, flexible and thin-walled with multiple openings in deeper • 3 layers of Bandages
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 30 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 31 Morning, Section B. Wound Closure • Primary wound Closure or healing by primary intention includes healing of clean wounds without tissue loss, in this wound tissues are set appositionally either with use of bandage or suture.
• Secondary Wound Closure or healing by
Secondary intention includes filling with granular tissue and skin continuity is established through epithelization and contraction. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 32 Morning, Section B. Cont. • Delayed Primary intention or Tertiary Intention Healing includes initial healing by secondary healing and then extra granular tissue is excised and edge of wound are sutured.
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 33 Morning, Section B. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 34 Morning, Section B. Conclusion • The cornerstone of surgery is the restoration of function and healing, so surgery should be about that, plus a surgeon must understand these events so he/she could manipulate the factors affecting early wound healing to reduce the physical trauma to the animal and economical trauma to the owner.
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 35 Morning, Section B. JAZAK ALLAH • Questions?
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 36 Morning, Section B. References 1) Karen M. Tobias & Spencer A. Johnsten(2012) Veterinary Surgery: Small animal pp.125-135, www.veterinarysurgerysmallanimal.com
2) Kirby, R., & wilkins, P. (2018). Wound
Management - Special Pet Topics - Veterinary Manual. Retrieved from https://www.merckvetmanual.com/special-pet- topics/emergencies/wound-management#v3231987
3) Zachary, J. F., & Gavin, M. M. (2012). Pathologic
Basis of Veterinay Disease(Fifth ed.). Penny Rudolph. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 37 Morning, Section B. Cont. • 4) Alison shepherd(June,2009). The Role of The Surgical Technologist in Wound Management, Pp (255-261), https://r.search.yahoo.com/_ylt=A0geKWYtFgFbCMIA_vAPxQt.;_ylu=X3oDMTByOHZyb21tBG NvbG8DYmYxBHBvcwMxBHZ0aWQDBHNlYwNzcg-- /RV=2/RE=1526826669/RO=10/RU=http%3a%2f%2fwww.ast.org%2fpdf%2f306.pdf/RK=2/RS =bmtMOCX2HftVPnk7JaUu1KAWqjo-
• 5) Kumar, V., Abbas, A. K., Aster, J. C., &
Robbins, S. L. (2013). Robbins basic pathology(9th ed.). Philadelphia, PA: Elsevier/Saunders. SURG-302 (General Veterinary Surgery and Anesthesiology). 15-ARID-4409 DVM, 6th, 38 Morning, Section B. Cont. • 6) Turner, S. A., & McIlWraith, W. C. (2007). Techniques in Large Animal Surgery(Second ed.). Lippincott Williams and Wilkins.
SURG-302 (General Veterinary Surgery and
Anesthesiology). 15-ARID-4409 DVM, 6th, 39 Morning, Section B.