6a-The-Wounds

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The Wounds

- Loss of skin on the body as a result of trauma or injury is called “Wound‟.

Partial loss of skin is called “Abrasions‟

 Traumatic wounds are classified mainly in two categories which forms the basis of management.
They are:

1. Tidy wound, such as clean incised wounds.

2. Untidy wounds, such as lacerated wounds.

Another classification in four categories is based on the status of contamination of surgical sites.
Examples are:

1. Clean wounds - when no viscous is opened.

2. Clean contaminated wounds - when viscous is opened but with minimal spillage of its contents.

3. Contaminated wounds - when spillage is from inflamed viscous.

4. Dirty wounds - which are clearly infected.

Most surgical patients have wounds. Wounds require dressings. Clean wounds can be cleaned, dried,
closed and sealed by dressings.

 Clean contaminated and oozing wounds should not be closed or sealed. They should be allowed
to breathe and ventilate through porous dressings; they may require frequent dressings.
 Dirty wounds require cleaning, de-sloughing and debridement, till they become clean. Wounds
contaminated with dirt, dust and soil require tetanus prophylaxis.
 Healthy small wounds close by themselves slowly. Epithelium grows at an average rate of 1mm
per day; hence large wounds may take a long time to close. They may either be closed by
sutures or clips and staples; or may be covered by skin grafts.
 Healthy wounds are closed by primary suturing; unhealthy wounds are closed by secondary
suturing or delayed closure after they are rendered healthy. Sutures, clips in wounds along
stress lines and in vascular areas can be removed between 3-7 days. Those across the lines must
be left for 2-3 weeks. Supportive measures are essential for healing. Metabolic states like
diabetes must be controlled, infections must be eradicated, and nutritional status should be
restored to normal. Other than that, all wounds must be protected from further trauma and re-
infections. Clean wounds heal by primary intention; that is by regeneration of epithelium and
minimum repair by fibrous tissue. They leave minimum scar.
 Other wounds heal by secondary intention; plenty of repairs by fibrous tissue occur before they
are covered by regenerating epithelial tissue. Fibrous tissue contracts leaving ugly scars and
contractures.
 Repair of wounds require healthy granulation tissue which is composed of newly forming
capillaries and proliferating fibroblasts. It is therefore red, uniform and velvety in appearance
and bleeds on touch. Tissues rich in vascular supply heal better and faster. Infection, ischemia,
tension and foreign bodies, which include pus and necrotic dead tissue, are the worst enemies
of healing. Similarly wounds in diabetics, immuno-compromised and nutritionally deficient
patients take a long time to heal. Certain drugs like steroids and chemotherapeutic agents have
similar delaying effect.
 Wounds along stress lines in body [Langer‟s lines] heal faster with minimum scar. Those across
these lines take longer time to heal and leave ugly scars. Wounds start gaining strength from
third day onwards. They are strong enough to withstand normal stress within two weeks.
However, remodeling and further gaining of strength continues for up to six months.

Scars
All wounds, when they heal, leave scars. Scar is fibrous tissue, covered by epithelium. All scars
are deficient, devoid of nerves and vessels. Most of them are symptomless and fade away with time. In
some cases scar may become hypertrophied and give an unpleasant cosmetic appearance; however this
hypertrophy remains confined to the scar. Such scars may need revision.

Keloid, on the other hand is a complication of scar. Even a small scar of ear piercing can lead to
outgrowing keloids. These keloids mainly grow outwards, are only disfiguring, and have minimal
symptoms. Other type of keloids grows inwards and extends beyond the scar, deep into the tissues and
has symptoms like severe itching and burning pain. It has racial and genetic tendencies. Recurrence,
even after extensive excision is common.

Haemorrhages
Haemorrhage can be internal or external; and are of three types.

 Primary haemorrhage occurs due to trauma or during operations, and must be


stopped. Reactionary hemorrhage is the term used for early hemorrhage in post
trauma/operative period when collapsed small vessels open up following resuscitation,
and start to bleed.
 Secondary hemorrhage occurs in infected wounds when blood vessels are eroded by
inflammatory process. Similar measures will work in both these situations. As first aid,
in hemorrhages of extremities, elevation of the limb above the level of heart, direct
compression on the bleeding area can be effective. Temporary proximal compression by
bands or tourniquet can also be used; however it must be released intermittently so as
not to cause distal ischaemia. Finally the bleeding points may have to be ligated or
sutured.
 Spontaneous bleeding in skin and mucous membranes is called Ecchymosis.
 Bleeding and extravasations of blood in tissues due to injury or trauma is called Bruise or
Contusion. In these conditions, blood is diffusely spread and cannot be drained.
 Collection of blood in tissues is called Haematoma. Aspiration or drainage of blood collection is
possible as long as blood remains fluid. Eventually blood clots and cannot be drained; it may
need evacuation of clots.

Surgical Infections
Infections are the commonest pathology dealt by surgeons. It is considered as a major
complication in surgery. In addition to primary infective conditions, these include:

1. Surgical site infections [SSI],


2. Nosocomial infections, and
3. Cross infections.

Staphylococci, streptococci, E. Coli, proteus, pseudomonas and anaerobes are the usual
organisms in surgical infections. Staphylococci produce localized necrotizing inflammations and may end
in collection of thick pus, due to their coagulase positive nature. Abscesses, boils, carbuncles, are
examples of such lesions. Boil or furuncle is an infected hair follicle and is self limiting condition. It may
spread and become an abscess, requiring drainage.

Carbuncle is infection of many hair follicles in a group at one place, and occurs usually on nape
of neck or on back. It is common in diabetics. Wide excision and drainage maybe required in addition to
control of diabetes and infection. Streptococci produce spreading lesions due the presence of enzyme
hyaluronidase. Examples are erysipalas, cellulitis, fasciitis and myositis.

However, most of the surgical infections have mixed organisms. Blue or green pus indicates
pseudomonas infection; foul smelling pus indicates presence of anaerobes. Cellulitis is spreading
inflammation of subcutaneous tissues. Antibiotics are required. Surgery is not necessary unless abscess
develops. In humans Lymphangitis presents as red streaks in white skinned people; difficult to see in
dark skin ones. Thrombophlebitis is inflammation of superficial veins and may follow as complication of
venipuncture. Treatment is conservative.

Abscess is localized collection of pus. Usually caused by staphylococcus, mixed organism may be
present. Fluctuation can be elicited in superficial abscesses. Deep ones require ultrasound to diagnose.
Pus is digestive product of dead and dying bacteria, blood cells and local tissue.

Pus, wherever it is, must be removed, by aspiration or drainage. All acute abscesses require
drainage. Dead tissue must be desloughed, and thick fibrotic edges must be debrided to promote
healing in chronic wounds and ulcers.

When the pus collection is in deep tissues covered by dense fascia, such as the palm of the hand
and parotid region, early decompression is essential to prevent necrosis. One should not wait for
classical signs to appear. Presence of throbbing pain is enough to warrant early intervention. Timely
interventions are essential. Treatment delayed is treatment denied.

All foreign bodies that delay healing must be removed. Pus, dead tissue, slough and sequestrum
act like foreign bodies. Thin watery pus discharge from ulcers and sinuses indicates chronic infections
Tumors
These are neoplastic growths that present as swellings or ulcers. In most cases, cause is
unknown; although recent research in molecular biology and genetics is trying to unravel this mystery.

Tumors are either:

a. Benign, which are usually capsulated and grow slowly; or


b. Malignant, where growth is very fast.

Most benign tumors have high potential for malignant change. Tumors are the result of
uncontrolled growth of tissues by cellular hyperplasia, dysplasia and anaplasia. These are either
epithelial in origin [Carcinomas], or mesothelial [Sarcomas].

Carcinomas have no capsule; they grow and spread by infiltration in surrounding tissues.
Once vessels are infiltrated, lymphatic or blood spread occurs. In the abdomen cancers can
spread all over the peritoneal surface by freely falling malignant cells, called trans-coelomic
spread.

Sarcomas usually grow by expansion, and spread by blood stream. Histologically carcinomas
may be well differentiated in their cellular structure and glandular pattern; moderately
differentiated, or completely undifferentiated when they are called „Anaplstic‟. This last group
has the poorest prognosis.

Tumors of endocrine glands may involve more than one gland of Neuro-Endocrine origin.
These are called „Multiple Endocrine Neoplasia‟ [MEN], and are divided into two main groups;
MEN-1 and MEN-2. Complete evaluation of the patient before surgery on endocrine tumors is
very important.

Surgical excision is the treatment of choice for Benign Tumors, if they are bulky, unsightly,
causing symptoms, changing their growth pattern, or are known to be premalignant. Radical
curative surgery is the treatment of choice for most Malignant Tumors in early stage.

Palliative surgery is required to relieve symptoms in advanced tumors which are not curably
resectable. Certain tumors respond to cancer chemotherapy, either completely as in
lymphomas; or partly, when tumor size and its stage can be reduced. This is called neo-adjuvant
therapy, and is followed by surgical excision.

In other instances chemotherapy is used as adjuvant therapy after surgery, to deal with any
remaining cancer cells. It can also be the only therapy in advanced tumors. Certain tumor cells
are sensitive to radiations. Radiotherapy is indicated in such radio-sensitive tumors; pre-
operative, post-operative, or as the sole treatment. At times both chemotherapy and
radiotherapy are combined to enhance the anti tumor effect; it is then called „Chemo-
radiation‟.
Cysts
Cysts are abnormal swellings containing air or fluid; clear thin or turbid & thick.

True cysts are lined by epithelium. False cysts, on the other hand, have no epithelial lining.
[Pseudo-pancreatic cyst]. True cysts can be classified as follows.

a. Developmental cysts: Examples are Branchial cyst, Thyroglossal cyst, Duplication cyst,
Mesenteric cyst, Polycystic disease of liver, kidneys, pancreas, lungs, etc.
b. Malformation cysts: Example, Cystic Hygroma. Sequestration cysts: Sequestration
Dermoids. Germinal cysts: These arise from germinal layers and are common in testes
and ovaries in the form of Dermoids and Teratomas.
c. Retention cysts: When ducts of small glands are blocked, secretions are retained
forming a cystic swelling. Examples are epidermal cysts and ranula.
d. Distention cysts: When secretions in the acini of a ductless gland accumulate, they
distend the acini forming cysts. Example is colloid cyst of thyroid gland.
e. Pulmonary cysts are also due to distension of alveoli with air.
f. Degeneration cysts: Solid masses may undergo ischaemic necrosis and degeneration in
their center leading to cyst formation. Example is chocolate cysts of ovary.
g. Implantation cysts: A penetrating foreign body may implant a tiny piece of dermis in
subcutaneous tissue causing sub-minimal aseptic inflammatory reaction and cyst
formation called implantation dermoid cyst.
h. Parasitic cysts: Classical example is hydatid cyst. Parasite causes lesions where germinal
layer secretes fluid leading to formation of cyst and floating daughter cysts which look
Common Lesions of Skin and Subcutaneous Tissue Simple Benign Lesions Epidermal
cysts, earlier called sebaceous cysts, are the commonest. They arise from sebaceous
glands and occur in hairy areas such as scalp, scrotum, chest, etc. They are attached to
the skin as a black spot from where the hair fell. They contain thick cheesy sebum.
Complications include infection, ulceration, and rarely the sebaceous horn. Small ones
can be left alone. Large, unsightly or infected ones require excision. Recurrence is
common like grapes.

Peri-Operative Care
An operation is merely a part of the holistic management of a patient. Success of operation
depends on at least three factors.

 First factor is the art and technique of operation; appropriate choice of the procedure, and its
execution with minimum collateral damage to the healthy tissues. A technically successful
operation is meaningless for the patients if the final outcome is not as per their expectations.
This also emphasizes the importance of informed consent and continued meaningful dialogue
between patient and the managing team.
 Second factor is related to the patient in the form of pre-operative assessment and preparation
for surgery, in order to achieve the most satisfactory outcome.
 Third factor is environment related; and includes sterility standards of the theater suit,
antiseptic precautions, availability of appropriate instruments, optimally working equipment
without any possible hazards, and trained support staff.

Peri-operative care includes pre-operative preparation, intra-operative care and post-operative


complications and their management.

Preoperative Preparation

This starts with obtaining “Informed consent‟ of the client and by evaluating the risk status of the
patient like coexisting medical conditions, medications if any, and current haemo-dynamic and cardio-
respiratory status.

Elective surgical procedure is postponed till near normal physiological state is achieved. Special
preparations may be required before surgery, depending on the procedure, such as bowel preparation,
exchange transfusion, etc.

In emergency surgery, high risk consent is taken and critical care monitoring is initiated.

Intra-Operative Care

This includes guaranteeing a near normal physiological status of the patient while asleep, as well as
after coming out of the effects of anaesthesia. It is important to keep a constant surveillance on
monitoring screens, checking vital signs; pulse, respiration, blood pressures and body temperature.

Digital oxymetry for oxygen saturation and checking hourly urine output to regulate IV fluids are
equally important. Alert monitoring avoids situations such as hypoxia, dehydration, and temperature
fluctuations. Everyone should remain prepared for any sudden unwanted developments.

Postoperative care recognizes developing complications, if any, in time and takes steps to deal with
them. In many situations surgeon has to use drains. Their function is to remove undesirable collections.
Once drainage stops, drains can be removed.

Postoperative Complications and Management

In immediate postoperative period [first 24 hrs] bleeding from operative site and pulmonary
complications are likely events. Main causes for the „Post-operative pulmonary complications‟ are pre-
existing pulmonary conditions, intubation trauma, effect of anesthetic gases, and inability to sit, move or
cough due to pain. This leads to excessive trachea-bronchial secretions and their retention leading to
atelactasis, bronchitis, and aspiration pneumonias.
Early mobilization of patient and chest physiotherapy, are preventive measures. During first
postoperative week, infections, at surgical site, chest or urinary tract if catheter has been used, are
likely.

Wound dehiscence, partial or complete can occur, requiring supportive or surgical approach.
Infection is the most common cause of wound dehiscence in surgical wound. It can be suspected by thin
serous discharge from fresh post-operative wounds. Few common causes include poor nutrition, poor
closure and excessive intra-abdominal pressure. By the end of first week, deep vein thrombosis [DVT]
can manifest by pain in the calf muscles, tenderness on squeezing, oedema of leg and unexplained fever.

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