GENERAL SURGERY 1 Wound, Keloid and Hypertrophic Scar + Types of wound: Classieaton + General principles of management * Wound healing + Factors attecting wound nealing + Compartment syndromes + caastcaton of surgical wounds + Hypertophic soar and elid + Healing of specialise tesues + Whats new?iRecentaavances Introduction ‘Wound isa discontinuity o break in the surface epithelium. ‘A wound i simple wen only skin is involved. Is complex ‘when involves underying nerves, vessels and tendons ‘Types of wounds ‘+ A few classifications have been given below, 1A. Closed wounds: = Contusion + Abrasion “Contasion: Can be minor sof tissue injury without break in the skin or major such as when run over by a vebicl. {Generally it produces discolouration of skin due to collection of blood underneath Abrasion: In this wound, epidermis of the skin is seraped away exposing the dermis, They ate painful as dermal nerve ndings are exposed. These wounds need cleaning. antibiotics and proper dressings. Haematoma: This refers to collection of blood usually “allowing injury. Ieean occur spontancousy in patients who have bleeding tendencies such as haemophilia. Depending ‘pon the sit, it can be subcutaneous, intramuscolar o even subperiosteal. A knee joist haematoma may need to be spirsted followed by application of compression banda. ‘Shall haematmas gt absorbed. not they can get infected. + Hsematoma 'B. Open wounds Tncised Laceated Penetrating Crushed {Ineised wounds: They are caused by sharp objects such as Kenife, Blade, glass, et. This type of wound has a sharp edge fan i ess contaminated. Primary suturing is ideal for such ‘wounds asi gives a neat and clean sex Lacerated wounds: They are caused by blunt objects ik fall ‘onastone or duc to rad traffic accidents. Edges are jagged “The injury may involve only skin and subcutaneous tssve oF sometimes deeper stuctres also, Due tothe unt nature of he ‘object. there is crushing of the tissue which may result in haematoma, bruising of even necrosis ofthe tissue, These ‘wounds are tested by wound excision and primary suturing provided they are ested within ix hours of injury. Penetrating wounds: They are not uncommon. Stab injuries of abdomen ae very notorious, It may look lke an innocent {injury with asmal, oe or wom long cut but internal organs ‘Sich ay intestines, liver, spleen of mesenteric blood vessels may have been damaged. All penetrating wounds of the thdomea should be admitted aad observed for at least 24 hours. Layer by layer exploration and repair, though recommended, may not be posible a times due t oblique track of the wound Crushed or contused wounds: They are caused by blunt trauma due ton over by vehicle, wal collapse, earthquakes© eres tent ot surgery oor industrial accidents. These wounds are dangerous as they may cause severe haemorrhage, death of the tissues and crushing of blood vessels. These patients are more prone for ‘gas gangrene, tetanus, etc. Adequate treatment involves good. debridement and removal of all dead and necrotic tissues, Tidy and untidy wounds A. Tidy wounds: Incised, clean, healthy tissue and seldom associated with tissue loss. B. Untidy wounds: Crushed or avulsed, contaminated, devitalised tissues and often with tissue loss. Ill Acute wound and chronic wound ‘A. Acute wound: Stab wounds, following RTA and blast injuries B. Chronie wound: Leg ulcers, pressure sores General principles of management of wound (Fig. 1.1) + Admission or observation in the hospital + Monitoring of temperature pulse and respiration. + Systemic antibioties depending upon the contamination of wound. + Injection tetanus toxoid for prophylaxis against tetanus. + Treatment of the wound in the form of cleaning, dressing ‘or suturing Components of wound healing (Table 1.1) |. Inflammatory phase (lag phase) + Injury results in the release of mediators of inflamms mainly histamine from platelets, mast cells granulocytes, This results in increased capil permeability *+ Later kinins and prostaglandins act and they pl chemotactic role for white cells and fibroblasts. *+ Inthe first 48 hours, polymorphonuclear (PMN) leuko dominate. They play the role of scavengers by remc the dead and necrotic tissue (Figs 1.2 to 1.6). Intammatory phase ae \Vasoconstiction + Thrombus ‘act PMN + Macrophages (Cleaning and bandage ‘rest the Deeding ao harsis ochre Suturing Transport Fig. 1.1: Wound management Healing of the wound Healing by primary intention occurs in a clean incised ‘wound such as a surgical incision wherein there is only @ potential space between the edges. It produces a clean, neat, thin scar, Healing by secondary intention refers to a wound which is infected, discharging pus or wound with skin loss, Such wounds heal with an ugly scar Remove devitalsed tissues] Fig. 1.2: Inflammatory and proliferative phase IL. Proliferative phase (collagen phase) *+ Between 3rd and Sth day, polymorphonuclear leuko. diminish in number but monocytes increase. They a specialised scavengers. + By Sth or 6th day, fibroblasts appear, proliferate eventually give rise to a protocollagen which is conv into collagen in the presence of an enzyme, protocol hydroxylase, 0,, ferrous ions and ascorbie acid necessary for this step. + Fibroplasia along with capillary budding gives ri granulation tissue ea Seer prio Coagen+ Secretion of ground substance—mucopolysaccharides by fibroblasts takes place. These are called proteoglycans, They help in binding of collagen fibres. Thus, wound is Fibre + Gel + Fluid system (resembles iron Rods + Cement + Water used for concrete slab) + Epithelialisation occurs mainly from the edges of the wound by a process of cell migration and cell multi- plication. Ths is mainly brought about by marginal basal cells. Thus, within 48 hours, the entire wound is re-epithe- lialised. When there is a wound with skin loss, skin appendages also help in epithelialisation, Slowly, surface cells get keratinised. lil. Remodelling phase (maturation) It starts after 4 days and is usually completed by 14 days. It is brought about by specialised fibroblasts. Because of their contractile elements, they are called myofibroblasts. It is the nature's way of reducing the size of defect thereby helping the wound healing. Wound contraction readily occurs when there is loose skin as in back and gluteal region. Skin contraction is greatly reduced when it occurs over tibia (skin) or malleolar surface. Corticosteroids, irradiation, chemo- therapy delay wound contraction. Connective tissue formation: Formation of granulation tissue is the most important and fundamental step in wound healing. (It can be compared to concrete slab laying). IV. Phase of scar formation Following changes take place during scar formation. + Fibroplasia and laying of collagen is increased. Wound, Mee end Myperemprn Soar 4 fac + Vascularity becomes less (devascularisation). + Epithelialisation continues + Ingrowth of lymphatics and nerve fibres takes place. + Remodelling of collagen takes place with cicatrisat resulting in a scar. ‘Complications of wound healing 1. Infection: It is the most important complication whic responsible for delay in wound healing. Majority of bact are endogenous. Depending upon pus/culture sensiti report, appropriate antibiotics are given, 2. Ugly sears It is the result of infections 3. Keloid and hypertrophic scar (Page 6) 4, Incisional hernia and wound dehiscence 5. Pigmentation of the skin 6. Marjolin’s ulcer (Page 118). Wound closure or wound suturing Primary suturing: Suturing the wound within a few ho following an injury (six hours is ideal) is called primary sucut EECGREE “ound healing Day 0-1 02 days 48-96 hours ST days + Tissue losg resulting in + Polymorphonuclear cells (PMN) Macrophages Fibroblasts appear + Exposure of extracellular ‘matrix to platelets | + Platelet degregation + Remove dead and necrotic tissue + Tnflammatory mediators + Epithelilisation Fig. 1.3: Platelets Fig. 1.4: Polymorph | y ranulation tissue Bridge the transition of inflammatory proliferative phase Phagocytosis + Role of T-lymphocytes is not clear + Wound contraction takes place Fig. 1.6: LymphocytesOe e svoey Primary suturing can be done provided: + Itis an incised or cut wound with a sharp object like knife of razor blade, ‘+ Minimal injury to structures on either side. + There should not be any infection. If a wound is sutured in the presence of infection, the suture material is eaten away (digested) by organisms which results in gaping of the wound, Precautions to be taken while doing primary suturing: + Foreign body, if present in the deeper aspect of the wound, should be removed, *+ Associated injury to blood vessels, nerves or tendons should be recognised and repaired + Wound on the abdomen may have associated visceral injuries, * Prevention of tetanus by using tetanus toxoid 0.5 ml intramuscularly. Wound excision and primary suturing of ‘skin: This is, indicated when: + Wound edges are jagged. + Wound is contaminated with organisms or foreign body + Tissues are crushed and devitalised. + Insuch situations, wound is explored and devitalised tissues, and foreign body. if present, are removed. The wound is ierigated with antiseptic agents. Thus, lacerated wound is converted into an incised wound and then sutured, Precautions 10 be taken are: ‘+ Itshould be done within 6 hours, + Tetanus and gas gangrene prophylaxis. ‘+ Repair of tendons and nerves can be done at a later date, if contamination is excessive. Wound excision and delayed primary suturing: This is, indicated in lacerated wounds with major crush injuries, Primary suturing within 6 hours is not done in these wounds because of: ‘+ Gross oedema of the part + Increased tissue tension + Haematoma + Contamination with bacteria + In such situations, excision of all dead tissue is done. PEARLS OF WISDOM + Wound is inrigated with saline and left open without suturing and dressing is applied. + Wound is re-examined 4-6 days later. If there is no infection, or no nonviable tissues, wound is sutured. This two-stage procedure is called delayed primary suturing. Fig. 1.7: Wound with skin loss Wound with skin loss (Fig. 1.7): It can follow sar Procedures or accidents, ete. Principles of debridement + Ideally done under general anaesthesia + Assess the extent of injury/oss of tissues + Control bleeding + Excision of devitalised tissue better done with seisso + Good saline wash/irrigation is better than betad hydrogen peroxide wash, PEARLS OF WISDOM Complications of skin loss + Secondary infection of the wound. + The underlying structures such as tendons and nerves in danger. ‘+ Diabetic patients can develop septicaemia, + Deformity and disability can occur at a later date. Hence, as soon as possible, skin grafting should be done ‘Secondary suturing: After operations, sutures may give because of severe infection with persistent discharge of In such cases 7-14 days later, after controlling infection, skin is freed from the edge of the wound and the granuls tissue and skin are approximated. This type of suturin called as secondary suturing. FACTORS AFFECTING WOUND HEALING General factors 1. Age: In children, wounds heal faster. Healing is dela in old age. 2. Debilitation results in malnutrition. Wound healing delayed probably because of vitamin C deficienlowing injury, vitamin C deficiency can occur after 3-4 weeks. Vitamin C is necessary for the synthesis and ‘maintenance of collagen. Zine deficiency is known to delay the healing of pilonidal sinus. “In diabetic patients, would healing is delayed because of several factors such 2s microangiopathy, atherosclerosis, decreased phagocytic activity, proliferation of bacteria due to high biood sugar, etc. aundiced and uraemic patients have poor wound healing because fibroblastic repair is delayed. '5, Cytotoxic drugs and malignancy delayed healing. (6. Generalised infection: Pus in some part of body delays ‘wound healing 7, Corticosteroids given carly may delay wound healing. because of their antiinflammatory activity. Once healing is established, they do not interfere. Local factors 1. Poor blood supply: Wound over the knee and shin of tibia heals very slowly but wound on the face heals fast 2. Local infection: Organisms eat away the suture material, destroy granulation tissue and cause slough and purulent discharge. Collagen synthesis is reduced and collagenolysis, js increased. Antibiotics should be given immediately or within 2 hours to prevent infection. 3, Haematoma precipitates infection. 4, Faulty technique of wound closure 5, Tension while suturing. 6, Hypoxia: Killing property of macrophages and production of fibroblasts can decrease due to hypoxia. If contamination ‘oceuts, oxygen level in tissue decreases. iu COG Tees ‘= Typically occur in closed lower limb injuries, + Following injuries, inflammatory reaction results in gross ‘oedema of the region. + These are the tight undividing compartments in the leg containing nerves and vessels. ‘Clinical features “+ Severe pain in the leg + Sensory disturbances (Fig. 1.8) "= Colour changes—absence of pulses is @ late sign K Wound, Keloid and Hypertrophic Scar_| Fig. 1.8: Paraesthosia between first and second toe Measuring compartmental pressure «Iris measured using a pressure monitor and catheter in the muscle compartment. + Compartmental pressure greater than 30 mmH indication for urgent fasciotomy. Treatment—Fasciotomy PEARLS OF WISDOM ‘Danger lies in the delay not in the simple fascioto + 8-10 em ineisions, each being lateral to subeut border of the tibia (Fig. 1.9). Fig. 1.9: Fasciotomy8 Fy, [ae = i “ey e ‘Manipal Manual of Surgery + Once deep fascia is incised, muscle bulges out, Soleus must be detached from tibia to decompress deep flexor ‘compartment. + All compartments of the leg can be approached by these incisions. ‘+ Most important motto should be to preserve blood supply by releasing compression on posterior tibial and peroneal arteries. ‘+ Infection and amputation are frequent outcomes. HYPERTROPHIC SCAR AND KELOID «As the name suggests, there is hypertrophy of mature fibroblasts in hypertrophic scar. Blood vessels are minimal in this condition. However, in keloid, proliferation of immature fibroblasts with immature blood vessels are found. These two conditions represent variations in the normal process of wound healing (Table 1.2). + Keloid is very common in blacks and least common in Caucasians (Key Box 1.2). ERTRPIEE comparison ot hyperrophic scar and Kelis Hypertrophic sear Goneral features ‘+ Teoccurs from a prolonged inflammatory phase of wound healing. Ie never gets worse after 6 months + ching isnot usually present, If present, itis not severe + Nontender + Not vascular “+ Does not extend beyond the boundary of the original incision or ‘wound. Irises above skin Precipitating factors ‘Scar erossing normal skin ereases Over stemum, over joints + Young persons Natural history ‘+ May become small Complications + Donot occur ‘Treatment + Iris often not necessary ' Stocking, armies, gloves + Blastic bandage may help + Excision cam be done + Silicone application + Topical etinoids + Keloid is not a true tumour but has a ma {or local recurrence after excision. ‘+ Keloid takes the shape of a butterfly over th the commonest site for a keloid. It is extr to treat the Keloid over the sternum. We who underwent wide excision and grafting sternal keloid (Fig. 1.10). Keloid ‘+ Ttcontinues to get worse even after 1 year and up + Severe itching is present + Margin is tender ‘+ Stascular, red, erythematous (immature blood ve ‘+ Extends to normal tissues, has elawake process + Black race ‘Tuberculosis patients ‘= Incision over the sternum. ear lobe ‘+ Equal in both sexes Hereditary and familial ‘Vaccination sites, injection sites, incision sites, + Does not become small ‘Ulceration, infection + tis difficult. Injection of steroid preparation Jone acetate (Kanacort) has been found t0 be & flattens the keloid. Intrakeloidal excision snd be ted last. Recurrence is common. Care shou extend the incision on to the normal surround + Silicone application ‘+ Topical retinoidsVous, Kel ene Hyparoone Sear @ 4.10: Keloid over the Fig. 1.11: Keloid over the jaw RISE e + Surgical wounds may be classified depending upon tt KELOID SITES High chances Least chances "Skin of ear lobe Eyelid nature of the wound, whether clean or contaminated (Tab Presternal Genitalia 13), Dettoid Palm, sole Upper back Across joint RLS OF WISDOM Collagen bundles are virtually absent in keloid. It is extremely difficult to treat a keloid. i me Fig. 1.14; Excision of neck swelling—clean Fig. 1.12: Recurrent keloid over the stemum. Excision attempted a Fig. 1.18: Cholecystectomy—ciean contaminateso= Manual of Sutgen ‘Classification of surgical wounds es ‘Wounds class Definition TExamplesoftypical procedures Wound infexion rate (%) Usual orga Clean + Nontraumatic + Mastectomy 2 Staphylococe (Fig 14) + Elective surgery ‘vascular procedures ‘aureus + Gastrointestinal, respiratory oF genitourinary tract not entered. Clean + Respiratory + Gastrectomy <10 Related tov contaminated genitourinary or + Hysterectomy entered 115) sstrointestinal tracts entered * Cholecystectomy but minimal contamination Contaminated = Open. fresh, traumatic wounds > ‘Ruptured appendix Depends on fae 116) + Uncontrolled spillage from an + Resetion of snderlying ‘unprepared viscus unprepared bowel + Minor breakin sterile technique Dirty + Open, traumatic diy wounds + Resection of gangrene 30-70 Depends (ig 17) + Traumatic perforated vseus underlying Pus in the operative field + Nerve cells of brain ‘and spinal cord + Peripheral nerves ‘= Stomach and intestines “= Colon and oesophagus + Wounds on the face + Muscles + Bone HEALING OF SPECIALISED TISSUES (Key Bo? HEALING OF SPECIALISED TISSUES ‘ONCE DESTROYED Cannot be replaced proliferation of other cells Regenerative capac present Healing is good afte ‘anastomosis, rely Healing is precariou chances of leakage high. Healing is excellent ‘good vascularity Can heal complete! ‘be replaced by fibr Rapid proliferation osteoblasts (reter orthopaedic books} SESS SS WHAT IS NEW IN THIS CHAPTER? / RECENT ADVA Caner acres wed vi 2 | Sareea arose «_ Debidenet ree ava + Prnerononber uageatH0, Estas |* Bots may case ie tone saree