Management of

Acute and Surgical Wounds

Aim
To provide an
overview of the
principles of
surgical wound
management
 Objectives
Classify surgical wounds
Examine general and local principles of acute
and surgical wound management
Identify the potential complications
Review some of the evidence on use of
contemporary dressings for different types of
surgical wound
 The
Healing
Process
Haemostasis
Inflammatory
stage
Destructive
stage
Proliferative
stage
Maturation
Classification of
Surgical Wounds
Clean
Clean -
Contaminated
Contaminated
Dirty

Cruse and Foord, 1980

 Management
Restoration of function and physical
integrity with the minimum deformity
and without infection
Westaby, 1985

Haemostasis and haemodynamics

Wound Closure
Wound Drainage
Dressings
Monitoring for complications
Types of Acute
Wound Closure
Primary closure
Delayed primary
closure
Healing by
secondary
intention
Wound Closure
Approximate edges for rapid healing and minimal
scarring
Foreign bodies - can set up an inflammatory
response
Removed as soon as wound strong enough to remain
intact without their support
Removal time often in accordance with individual
Surgeons instructions, but generally:-
5 days for facial/head wounds
7 10 days for abdominal
10 14 for major orthopaedic approaches
5 days for obstetric and gynaecology
Aseptic technique
Appropriate removal extractor for clips and staples
Methods of Primary
Wound Closure
Sutures Clips
Tightness Staples
Size of tissue bite Skin tapes
Distance between
sutures
Continuous versus
interrupted
Choice of suture
material
Wound Drainage
Provides a channel to the
surface for fluid which
would collect in the wound,
e.g. blood, pus, serous
exudate, bile or other body
fluids
Closed drains
Open drains
Active suction systems
Passive suction systems
Disadvantages
Retrograde conduits
Infection
Pressure necrosis to internal organs
Contemporary Dressings -
Benefits for Surgical Wounds
Do not adhere
Prevent trauma to wound bed (NICE)
Reduce pain at dressing changes/comfortable
(NICE)
Absorptive
Some are haemostatic
Able to sequester bacteria to reduce bioburden
and prevent infection
Provide optimal environment for healing
Help with cosmesis - reduce risk of severe
scarring
Cost-effective - reduce need to change frequently
Primary Closure
Vapour-Permeable
Vapour-
Film Dressings
Properties/ Type of Type of Author &
Findings Surgical Study Date
Wound

The Opsite group had Abdominal Prospective Briggs M (1996)

reduced incisional pain hysterectomies randomised control
intensity trial comparing
Opsite against
Primapore
Pionidal Sinus
Hydrofibre Dressings
Properties/ Type of Type of Author
Findings Surgical Study and
Wound Date
Reduction in pain on Acute surgical Randomised Moore PJ &
dressing removal; wounds healing prospective parallel Foster L
ease of removal; by secondary group comparing (2000)
cost savings - intention Aquacel with ribbon
reduction in nursing gauze and
time to apply Proflavine involving
dressing, less 40 patients
frequent dressing
changes, facilitated
earlier discharge
Skin Grafts & Donor Sites
Non-Adherent Petrolatum &
Non-
Hydrocolloid Impregnated Dressing
Properties/ Type of Type of Author &
Findings Surgical Study Date
Wound
Improved healing rates Lower limb Multicentred Meaume S,
compared to previous postoperative non-controlled Senet P,
wound management and traumatic, clinical trial Dumas H,
regime; conformability; although the Total 92 Pannier M &
ease of application and study included patients, but Bohbot S
removal; non-adherence; chronic 34 were acute (2002)
no pain at removal; no wounds and
bleeding on removal; no burns
smell; minimal
maceration
Dehisced wounds
Alginates
Properties/ Type of Type of Author &
Findings Surgical Study Date
Wound
The Sorbsan group had less Surgical cavities Comparison of Gupta R,
pain and required less including abscesses Proflavine Foster M E &
analgesia; reduced bacterial soaked gauze Miller E (1991)
count within the wounds and Sorbsan
involving 29
patients

Reduced pain on dressing Haemorrhoidectomy Prospective Ingram M,

removal randomised study Wright T &
compairing Ingoldby C
Sorbsan and (1998)
gauze involving
50 patients
Surgical Cavities
Topical Negative Pressure (VAC)
Properties/ Type of Type Author &
Findings Surgical of Date
Wound Study
Containment of effulent; Gastrointestinal Alvarez A, Maxwell
protection of perifistulous fistula L & Rodriguez G
tissue (2000)

Increased granulation and Lymphocutaneous

wound contraction fistulas of the groin
compared to saline-soaked Case Greer SE et al
gauze; control of reports (2000)
lymphorrhea

Accelerated wound healing Pilonidal disease Duxbury MS, Finlay

IG, Butcher M &
Lambert AW (2003)
Complications -
Haemorrhage & Haematoma
Primary
Secondary
Haematoma
Complications - Infection
Spreading erythema of the
skin around the incision line
Local pain
Local oedema
Heat
Pyrexia
Increased exudate /
suppuration
Abscess formation
Lymphangitis
Cellulitis
Loss of function of a limb
Septacaemia
Complications - Dehiscence
Complications - Evisceration
Complications - Sinus
A track to the body
surface from an
abscess or some
material which has
an irritant effect
and becomes a
focus for infection
e.g sutures, fibres
from gauze
dressings
Complications - Fistula
Abnormal track
connecting one
viscus with another
viscus, or
connecting a viscus
with a body surface
Conclusion
Surgical and acute wound management focuses
on restoration of function and physical integrity
with the minimum deformity and without infection
A holistic approach to assessment and
management of surgical and acute wounds is
essential
Modern wound dressings have a role to play, as
they appear to reduce pain, reduce patients
length of stay and can provide potential savings
for the NHS
Organisations such as NICE have made some
recommendations for evidence based practice
regarding wound care. However, they have
highlighted further research is required