1887

Healing of elective surgical wounds

image of Healing of elective surgical wounds
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Abstract

The initial responses of a tissue to injury are highly predictable : there is bleeding and haemostasis, inflammation, swelling and oedema, heat and pain. This tissue response to injury then progresses to healing, and the process of normal tissue healing is also predictable: inflammation and debridement lead to regeneration to repair. Different tissues achieve these goals in different ways and timescales vary according to the injury and the tissue, and even with the species, but healing should progress with these basic processes. The chapter looks at the following: Phases of wound healing; Healing of surgical incisions; Clinical expectation of surgical wound healing; Factors affecting surgical wound healing; Complications of surgical wound healing; Techniques to avoid complications in surgical wound healing; and Healing of other tissues.

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Figures

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17.1 The interacting phases of wound healing with inflammation, followed by proliferation and finally repair, regeneration and remodelling of the scar tissue. (Reproduced from )
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17.2 A wound 24 hours after surgery. The skin edges have been accurately apposed and there is a thin clot between the edges. Inflammation is already receding and there is a seal on the wound, but the skin edges can still be easily peeled apart. (© DM Anderson)
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17.3 Healthy granulation tissue filling the defect of a dehisced surgical wound, prior to reconstruction. Granulation tissue is established in the proliferative phase of wound healing and consists of large amounts of extracellular matrix laid down by macrophages and fibroblasts. There are loops of immature capillaries that give it the very vascular and granular appearance. (© DM Anderson)
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17.4 Ventral abdomen of a Lurcher that had had sutures removed from a coeliotomy wound 5 days previously. The skin appears to have healed well and there is no sign of persistent inflammation or lack of healing. The owner had noticed that the ventral abdomen was sometimes bulging. Deep palpation of the midline revealed that the underlying linea alba had not healed and there was an incisional hernia. Despite the appearance of fully healed skin, this dog was at great risk of evisceration as the skin wound would still not have been strong enough to withstand the weight of the abdominal contents had the dog been very active or straining. (© DM Anderson)
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17.5 The surgical wound edges should be apposed with no tension on the sutures, which should be slightly loose at the time of placement to allow for postoperative swelling. This also makes them less irritating for the patient and easier to remove. (© DM Anderson)
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17.7 Granulating wound that had been sutured four times, but each time dehisced 10–14 days after repair. Underneath the granulation tissue was a sewing needle and thread. The wound healed uneventfully after foreign body removal. (© DM Anderson)
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17.8 Surgical wounds that have been sutured using braided nylon stored on a reel are much more likely to form suture sinuses. There is a low-grade infection associated with each pass of the suture material through the skin and a tract forms which epithelializes. This is more likely to cause irritation and self-trauma, but this will resolve once the sutures have been removed. (© DM Anderson)
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17.9 A Penrose drain is shown exiting the skin through a small stab incision and secured with a simple interrupted suture. (© DM Anderson)
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17.10 A substantial wound resulting from the removal of a very large subcutaneous tumour in the inguinal fold with an active drain placed in the dead space prior to closure. Wound following closure and skin sutures. Note there is a wound catheter placed dorsally to deliver local anaesthetic into the tissues as part of a balanced analgesia protocol. On the ventral aspect, the active drain is secured with a Chinese finger-strap suture and leads to a bottle, which is under negative pressure and applies continuous gentle suction to the drain. (© DM Anderson)
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17.11 Skin healing is inhibited in the presence of infection, tension or inflammation, or where the blood supply is compromised. In this case, the tip of an axial pattern skin flap has been sutured on a place of increased mobility (the elbow) and this may have contributed to the necrosis seen here. (© DM Anderson)
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17.12 Large acute avulsion injury in a young Staffordshire Bull Terrier repaired using several strategies to promote primary surgical healing: (i) poliglecaprone subcuticular sutures take the tension on the skin (this is a non-reactive absorbable monofilament suture material and so should generate little risk of infection secondary to the contaminated wound, as well as stabilizing the wound edges over a wide mobile area); (ii) the ‘at risk’ triangle where the three lines of sutures meet is sutured with monofilament nylon (which is easier to place accurately and loosely, as well as less likely to cause vascular necrosis of the skin tip); (iii) staples are used as a non-reactive suture material for the majority of the repair (this also speeds up the end of what had already been a long surgery); (iv) a suction drain is visible exiting on the ventral aspect of the abdomen to prevent seroma formation. (© DM Anderson)
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17.13 In this wound, the point at which the three edges come together is healing well, but there is too much tension on the lower part of the incision: there is prolonged swelling (as evidenced by the tight sutures) and the wound edges have separated. In this section, primary healing is not possible. (© DM Anderson)

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