Most surgical wounds go on to heal in the normal pathway of:
- Proliferation (a very small process in a healing sutured wound)
Most surgery can be categorised into two groups: elective clean, and emergency (this is often referred to as ‘dirty’). A surgical wound of the latter category has a higher incidence of dehiscence or complications.
Dehiscence is defined as ‘separation of the layers of a surgical wound, it may be partial or only superficial, or complete with separation of all layers and total disruption’ (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health 2003). There are a number of well identified risk factors that can lead to wound dehiscence, including being overweight, increasing/advanced age, poor nutrition, diabetes, smoking and having had radiation therapy previously in the area. The elective case has the opportunity to correct some of these risk factors, however the emergency case may not have such an opportunity.
The simple, straightforward suture line is generally treated with a dressing that will manage a small amount of anticipated early inflammatory exudate and provide a waterproof covering. All surgical wounds do require support and this is an important factor both for reducing oedema and ensuring patient comfort. This type of dressing is generally left intact for five to seven days and then removed for inspection of the suture line, with the view to remove the staples or sutures as prescribed.
Suggested dressings to achieve the aims for simple suture lines include: Opsite™ and Mepore Pro™ . Care of this simple suture line then involves continued support and hydration. For this, some surgeons prefer supportive adhesive flexible tape for ongoing scar hydration, such as Fixomull™ and Mefix™.
The dehisced surgical wound requires a thorough assessment of cavities or structures involved, as well as presence of foreign bodies, infection and/or necrotic tissue. Once these parameters have been considered, an aim can be set. Removal of necrotic tissue and management of infection is paramount to move the wound into a healing phase once again. Surgical debridement may leave large cavities or areas of raw tissue which can ideally be managed with a Topical Negative Pressure device. This ‘vacuum cleaner’ for wounds will remove excess exudate and contain it in a canister, away from the wound surface. Due to the negative pressure, the wound edges are drawn in, helping to promptly reduce wound surface. This also reduces oedema, an important aspect to consider in all wounds.
These wounds are generally acute and in most circumstances go on to heal almost regardless of what is done. Simple abrasions in particular, if not managed by a health professional, form a scab which eventually will drop off, revealing a healed area beneath. The issue here however, is that this type of healing can be slow and can result in an unacceptable scar. The best management of an abrasion is to stop the bleeding, give the area a good clean with an antiseptic, and then apply a mesh dressing that will protect the superficial raw area and allow new tissue to form quickly without being damaged when the first dressing is attended. Mesh dressings for this purpose include: Mepitel™, Urgotul™, or Hydrotul™. The secondary dressing on this mesh is generally a light absorbent adhesive pad, such as Cutipast Sterile™ or Primapore™. A secondary waterproof dressing is generally not recommended for this first dressing due to the risk of infection – the excessive heat and moisture will create an environment conducive to bacterial growth. At the next dressing change, if there are no signs of infection, then a waterproof dressing can be used as the secondary dressing.
After a thorough assessment, a small, simple laceration is generally managed with antiseptic cleansing and Steristrips™, and either a waterproof, light, absorbent dressing or a non-waterproof, light, absorbent, adhesive dressing, using the principles mentioned earlier about risk of infection. More complex lacerations may be referred to an acute care facility or surgeon after initial assessment.
Foreign bodies and penetrating, deep lacerations may involve tendons and nerves, which will require specific specialised care.
The post-surgical wound will then need to be well managed to avoid infection. An antimicrobial dressing that is also absorbent and protective would be ideal. Dressing examples include: Aquacel Ag™ and Aquacel Foam™ non adhesive, Actiflex™ and Mesorb™, Atraumann Ag™, and Zetuvit™. The dressings should be fixed in place with a firm crepe bandage and appropriately-sized tubigrip.
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- Dowsett, C, Protz, K, Drouard-Segard, M & Harding, K 2015, ‘Triangle of Wound Assessment Made Easy’, Wounds International, London, UK, viewed 3 August 2016, www.woundsinternational.com
- European Wound Management Association 2016, ‘EMWA Position Documents (2002-2008)’, EWMA, Denmark, viewed 3 August 2016, ewma.org
- Leaper, DJ, Schultz, G, Carville, K, Fletcher, J, Swanson, T & Drake, R 2012, ‘Extending the TIME concept: what have we learned in the past 10 years?’, International Wound Journal, vol. 9, no. 2, pp. 1-19, viewed 3 August 2016, www.woundinfection-institute.com
- Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health 2003, Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, 7th edn, Saunders, viewed 10 August 2016, http://medical-dictionary.thefreedictionary.com/wound+dehiscence
- Vowden, K & Vowden, P 2002, ‘Wound Bed Preparation’, World Wide Wounds, UK, viewed 3 August 2016, www.worldwidewounds.com
- Wounds International 2016, Best Practice, London, UK, viewed 3 August 2016, www.woundsinternational.com
Jan Rice is a Registered Nurse with many years experience in surgical nursing. Jan is a member of the Venous Leg Ulcer Guideline Implementation sub-committee and the Pressure Injury Guidelines Development sub-committee. Jan obtained a Masters in Wound Care in 2009 and runs a wound clinic in a large Metropolitan General Practice — Ashwood Medical.Through her own business, Jan has been acting as a consultant to over 80 aged care facilities and a resource for Divisions of General Practice and surgeons within Victoria. Jan is an author of a book chapter on wound healing and has been a volunteer with Interplast since 1983. In 2006, she was awarded Fellowship to the Australian Wound Management Association.