Surgery Chapter 1 Wounds Sinus Fistula

Front 1

Wound

Back 1

discontinuity or break in the surface epithelium.
*simple- when only skin involved
*complex- when involves underlying nerves, vessels,tendons etc.

Front 2

Types Of Wounds

Back 2

Closed-contusion, abrasion, haematoma

Open- Incised, lacerated, penetrating, crushed

Front 3

Contusions

Back 3

Minor soft tissue injury w/t skin break.
Can be major due to run over by vehicle

Front 4

Abrasion

Back 4

Epidermis scraped off, dermis->exposed
Painful, Nerves in dermis-> exposed
need cleaning, antibiotics, proper dressing.

Front 5

Haematoma

Back 5

-Collection of blood
Incomplete hemostasis-
*Inadequate intraoperative hemostatis
*Anticoagulants/Anti-platelet agents(eg. Aspirin)
* Coagulation disorder
-local fluctuant swelling
-discolouration of wound site
-hypovolemic shock w/ very large haematomas.

Front 6

Haematoma
T/t and complications

Back 6

small hmt- Left alone/get absorbed
large hmt- Aspirated
complications of hmt-
*Pain
*Risk of infections(blood-good culture medium)

Front 7

Open wounds-
Incised

Back 7

Sharp objects-knife, glass, blade
-Sharp edges and less contamination
-pri. suturing for neat and clean scar.

Front 8

Lacerated

Back 8

blunt objects, fall on road, RTA(road traffic acci.)
-Jagged edges, involves epidermis,dermis or even deep structures.
-Crushing of tissues- haematoma, bruising, or necrosis of tissue.
Wound excision and Primary suturing- <6hrs

Front 9

Penetrating

Back 9

stab injuries
small few cms long cut from outside
Internal organ may be damaged inside
-admitted->observed for 24 hrs
Layer by layer exploration and repair

Front 10

Crushed/Contused

Back 10

Blunt trauma
-Severe haematoma, death of tissue, crushing of blood vessels.
-patient more prone to gas gangrene, tetanus.
T/t- Good debridement and removal of dead and necrotic tissue.

Front 11

Management of wound

Back 11

Admission+TPR(temp,pulse,respi)+Antibiotics(Abs)
Wound--->
-cleaning and bandage
-Arrest the bleeding
---->Splint if fractures
---->I.V line,transport---->Abs+tetanus toxoid

Front 12

STEPS OF WOUND HEALING

Back 12

Coagulation
Inflammation
Collagen synthesis
Angiogenesis
Epithelialization
Contraction

Front 13

STEPS OF WOUND HEALING(conti)

Back 13

-Collagen Synthesis
fibroblasts in the vicinity, in response to various growth factor peptides
Impaired by vitamin deficiency (especially C) and PEM
-Angiogenesis (Granulation)
Peptide growth factors such as VEGF.
>new vascular networks gives granulation tissue beefy-red appearance.
*presence of granulation
tissue--->evidence that the healing process is under way.

Front 14

Epithelialization

Back 14

Occur due to migration of epithelial cells over wound
-24-48hrs, basement memb restored by Type IV collagen, other matrix components deposited
-foreign bodies stay non attached to wound due to migration of epithelial cells
-Waterproofing to wound

Front 15

Contraction

Back 15

Surrounding uninjured skin is pulled over the wound to reduce scar.
Due to Myofibroblasts- have the ability to contract like muscles, takes months.

Front 16

Complications of Scar Formation

Back 16

Skin- Keloid, Skin Carcinoma
GI tract- small bowel obs, sec to constrictions
Liver-Intra/Extrahepatic cholestasis sec. to stricture formation.
Musculoskeletal-Pain/ Limited range of motion(ROM) sec to osteoarthritis/ankylosis
Heart: Pericardial tamponade secondary to rupture of ventricular
aneurysm, congestive heart failure (CHF) secondary to ruptured chordae
tendinea and resulting incompetent valve
Nerve: Paresis/paralysis/paresthesia/anesthesia secondary to failure of
nerve conduction

Front 17

wound suturing/closure

Back 17

Pri. suturing
wound excision and pri. suturing of skin
wound excision and delayed pri. suture
wound with skin loss
sec. suturing

Front 18

Factors affecting wound healing

Back 18

Wound infection (see next section)
Tissue perfusion
Oxygen
Malnutrition
Vitamin and trace element deficiency (vitamin C, vitamin A, zinc, cop-
per)
Smoking
Foreign body
Chronic disease

Front 19

Primary (First) Intention

Back 19

Type of healing seen following closure of clean surgical wounds, or trau-
matic lacerations in which there is minimal devitalized tissue, and min-
imal contamination.
Edges of the incisional defect are approximated with the use of sutures
or staples.
Since the defect is very small, reepithelialization occurs rapidly, and
overall healing time is short.
Wounds closed primarily may have their dressing changed after 24 to 48
hours. By this time, epithelialization should be complete, and a less
bulky dressing can be applied.
Wound strength reaches its maximum at about 3 months and is gener-
ally 70–80% that of normal skin.
*Generally, clean traumatic
lacerations are closed with
sutures or staples (primary
intention) if less than 6 to
8 hours old.

Front 20

Second Intention

Back 20

Type of healing seen following closure of wounds that are not approxi-
mated with sutures.
Reason for not using sutures may be (1) that the wound edges cannot
be apposed because the defect is very large (e.g., donor site of skin
graft); or (2) that the surgeon chooses not to close the wound primarily
because of the high risk of infection.
Wounds healing by second intention should be packed loosely with
moist gauze and covered with a sterile dressing. The wound should be
assessed daily for the development of granulation tissue and the pres-
ence of infection.

Front 21

Third (Delayed Primary) Intention

Back 21

Type of healing seen following closure of wounds in which there is ob-
vious gross contamination at the incisional site (i.e., the wound is clas-
sified as contaminated or dirty).
An example of where delayed primary closure is often used is s/p re-
moval of a ruptured appendix in which there was leakage of pus into the peritoneal cavity. In such cases, the parietal peritoneum and fascial
layers are closed, and antibiotics are administered. The skin and subcu-
taneous tissue are not sutured until 3 to 5 days later after bacterial con-
tamination has decreased.
*Sutures are utilized in
primary and delayed
primary intention healing
only

Front 22

sinus

Back 22

blind track from the surface into the tissue, lined by granulation tissue.
1. congenital-preauricular
2. acquired- median mental, pilonidal sinus, osteomyelitis sinus

Front 23

fistula

Back 23

Abnormal communication b/w
- Internal-the lumen of one viscous and the lumen of another.e.g- tracheo-oesophageal fistula, colovesical fistula
- External- communication of one hollow viscus w/ the exterior i.e. body surface e.g- Orocutaneous fistula, branchial fistula, Thyroglossal fistula.

Front 24

Hypertrophic scar Vs Keloid

Back 24

-Never gets worse after 6mnths; it get worse even after 1year anf for few years.
-Itching not usually present; severe itching present
-Non-tendor; margin is tender
-Not vascular; vascular, red, erythematous (immature blood vessels)
-Don't Spread to normal tissue;Spread w/claw like process hence name keloid :)

Front 25

Hypertrophic scar Vs Keloid
Precipitating factors

Back 25

Hypertrophic scar-
1. Scar crossing over normal skin creases
2. Over sternum, over joints
3. Young persons
Keloid Scar
1. Negroid race
2. Tuberculosis pts
3. women
4. hereditory and familial
5. vaccination sites
6. over the sternum
3. Over the sternum

Front 26

Hypertrophic scar Vs Keloid
complications

Back 26

Hypertrophic scar
-Don't occur
Keloid
Ulceration ,infection

Front 27

Hypertrophic scar Vs Keloid
T/t

Back 27

Hypertrophic scar
-often not neccessary, stockings, armlets,bandage may help
-excision canbe done
Keloid-
-Difficult
-Inj. of steroid prep like Triamcinolone acetate(Kanacort) useful, it flattens the keloid.
-Interkeloidal excision and skin graft is to be tried in the last.
-Recurrence common
-Care should be taken not to extend the incision on to the normal surrounding tissues.

Front 28

Classification of surgical wounds

Back 28

1.Clean
-Wound created in a sterile and nontraumatic fashion, in an area that is
free of preexisting inflammation.
-The respiratory, alimentary, genital, or urinary tract was not entered
- All persons involved in the case maintained strict aseptic technique.
2. Clean-Contaminated
-The respiratory, alimentary, genital, or urinary tract was entered, but
there was no significant spillage of its contents (e.g., feces), and there
was no established local infection.
-There was only a minor break in aseptic technique.
3.Contaminated
-There was gross spillage from the gastrointestinal tract.
-The genitourinary and biliary tracts were entered in the presence of lo-
cal infection (e.g., cholangitis).
-The wound was the result of recent trauma.
-There was a major break in aseptic technique.
4. Dirty/infected
-The wound was the result of remote trauma and contains devitalized
tissue.
-There is established infection or perforated viscera prior to the proce-
dure.

Front 29

Risk of infection for
wounds:

Back 29

Clean—1.5%
Clean-contaminated—3%
Contaminated—10%
Dirty—30–35%

Front 30

Risk of infection by age:

Back 30

15–24 yrs—4–5%
> 65 yrs—10%