Management of Surgical Wounds

Surgical wounds can be created anywhere on the body for any number of reasons. They can be closed at the skin level by sutures, staples, or liquid Band-Aid (glue), or they can be left open to drain the infection. Healing occurs differently on each of these wounds and dressing them is quite different. The length of time it takes to heal a surgical wound quite different as well. Many factors will affect wound healing.

Healing by Primary Intention

When a surgical wound is closed at the skin level after a procedure, the intended healing occurs from the skin level down to the base of the wound. This is called healing by primary intention. Staples, sutures, or surgical glue are used to approximate (close) the skin level. Initially, the incision is covered with dry gauze in case of oozing occurs. This is expected.

The skin approximates (closes) very quickly. If staples or sutures were used to close the skin, they can be removed in 10 to 14 days. The incision line will continue to heal and build scar tissue. It will be reddish in color and become firm. This firmness will soften with time. The incision line will regain a maximum strength of 80% of unwounded skin. This takes approximately 8 weeks.

Healing by Secondary Intention

Sometimes, an incision line that is closed can be disrupted and open. We see this most often in the obese population. This is called dehiscence. The wound cannot be re-closed with staples, sutures, or glue. The wound is expected to heal by secondary intention, from the bottom of the wound bed up to the surface. This can take a long time. Another cause of disruption is an infection

Factors that affect the time it takes to close a wound such as this depend on how big the wound is and how deep it is. For example, a patient that is obese may have a significant amount of adipose tissue (fat cells) in the abdomen. The wound can be quite deep and will take longer to fill in. Also, consider decreased blood flow to adipose tissue. This will delay healing as well. Those with diabetes have a slower rate of healing. Infection in the wound will increase blood sugar.

Management of blood sugar is vital for wound healing. Infection in the wound will slow healing in those who do not have diabetes. Poor nutrition will slow wound healing. Protein plays an important role in building tissue along with other vitamins and minerals. It’s helpful to take a multivitamin daily and be sure to include protein supplements to ensure you are taking enough in.

 

Dressing for Open Surgical Wounds

Types of dressing used to manage surgical wounds should be recommended by the physician. For deep surgical wounds, a wound Vac unit is often used. This creates a gentle suction (negative pressure) within the wound to increase blood flow, which speeds wound healing by almost 50%. It also pulls drainage from the wound. The dressings are made of sponge-like material to allow the pressure or suction to pull through the wound bed. This requires an order by the doctor and a nurse to do the dressing changes 3 times a week. The patient is connected to a battery-powered unit with a disposable canister for drainage. This travels with the patient everywhere. The unit should never be disconnected while in use.

If a wound Vac is not used, the wound can be managed with wet to dry dressings. This type of dressing is usually changed twice a day. Patients and their families will be taught how to do this. These dressing require gauze, sterile normal saline solution, and a covering dressing such as a combined dressing or an absorbent border gauze. The covering or secondary dressing is determined by how much drainage the wound creates.

Wounds that do not have significant depth are managed differently. The wound needs to have a moist environment to heal, but not too moist. If the wound has a moderate to a large amount of drainage, a primary dressing (dressing used in the base of the wound) should be absorbent. Examples are alginate dressings or hydro fiber dressings. These dressing help absorb fluid but maintain the proper amount of moisture to facilitate healing. The cover dressing, also known as the secondary dressing should be absorbent as well. Examples are Allevyn border dressing, combine dressing or foam dressing. These dressing can be left in place for 2 to 4 days before changing. When the outer dressing is stained one half to three-quarters full indicates the time for changing.

Wounds that are not deep and are dry need moisture added to heal properly. Hydrogel dressings or hydrocolloid dressing are appropriate. A hydrocolloid dressing contains a gel-forming agent that adds moisture to the wound and protects new granulation tissue. It is waterproof and does not need to be covered when showering. These can be left in place for 3 to 7 days. Hydrogels can be added to the wound bed and should not cover the surrounding skin. A secondary dressing should cover the entire wound. Gauze or transparent film can be used as a secondary dressing. Hydrogel dressings should be changed every 1 to 4 days depending on the type used. It is best to read the manufacturer's recommendations on the frequency of changing.

 

Surgical wounds on the upper (arms) and lower extremities (legs) can be treated as described above, based on the needs of the wound. Compression is often needed to manage to swell. A tertiary dressing will secure the primary and secondary dressings in place and can be used for compression as well. Examples are Kling wrap dressing, Ace wrap, Kerlex, and Koban

Management of surgical wounds varies and is based on the type of wound that needs to be healed. The goal is to close the skin and maintain the body’s first line of defense. Physicians should evaluate wounds and determine the proper treatment to maximize heal time and avoid or treat infection should it occur. Once healed, the strength of the scar tissue is maximized at 80% and care should be taken to avoid heavy lifting too early. Always use sunscreen on new scars to avoid permanent color changes that will be more noticeable.

 

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