Principles of Wound Closure

CHAPTER 2 Principles of Wound Closure



Suhail K. Kanchwala, Louis P. Bucky




Case Study


A 21-year-old male presents to the emergency room with right lower quadrant pain. He is taken to the operating room with the presumed diagnosis of appendicitis. Abdominal exploration through a right lower quadrant incision reveals perforated appendicitis. After appendectomy, the abdominal fascia is closed with interrupted absorbable sutures. The skin is left open and packed with moist gauze.




BACKGROUND


Normal wound healing progresses through three distinct but overlapping phases. The inflammatory phase of wound healing begins first and lasts between 3 and 7 days in the normal wound environment; the presence of significant devitalized tissue (e.g., in traumatic wounds) can prolong this phase. The inflammatory phase is characterized by the influx of neutrophils and macrophages. The proliferative phase of wound healing typically begins after 24 hours and may last for up to 3 weeks. The hallmark of the proliferative phase is the formation of granulation tissue, a dense network of fibroblasts, extracellular matrix, and newly formed blood vessels. The principal cell types involved in the proliferative phase are the keratinocyte and the fibroblast. The remodeling phase of wound healing begins after 2 weeks and may last as long as 1 year. In the remodeling phase, the wound begins to contract and the collagen present in the wound is reorganized. The principal cell type involved in wound contracture is the myofibroblast, whereas fibroblasts are responsible for depositing and reorganizing collagen (Fig. 2-1).


image

Figure 2-1 Phases of wound healing.


(Modified from Clark RAF: Wound repair. In Clark RAF [ed]: The Molecular and Cellular Biology of Wound Repair, 2nd ed. New York, Plenum Press, 1996, p 3.)


Wound management is an essential component of every surgical procedure. The majority of surgical wounds are closed primarily (i.e., tissues are reapproximated). Contaminated wounds, or those that cannot be closed without significant tension, are sometimes allowed to close by secondary intention (i.e., left open and allowed to fill with granulation tissue and contract over time). Alternatively, a wound may be left open initially and closed at a subsequent time, a procedure called delayed primary closure. The management of open wounds not amenable to immediate closure may include dressing changes or application of a vacuum-assisted closure (VAC) dressing. Large wounds that will not close on their own are sometimes covered with a skin graft or flap. These wound closure techniques are the focus of this chapter.



PREOPERATIVE EVALUATION


Generalized malnutrition as well as specific nutrient deficiencies (e.g., vitamin C, vitamin A, and zinc) significantly impair wound healing. If malnutrition is suspected preoperatively, albumin and prealbumin levels should be obtained and nutritional status should be optimized. This may involve delaying surgery to allow for nutritional support. Similarly, diabetes, prior local radiation therapy, and immunosuppression from other etiologies (e.g., steroid use) are associated with delayed wound healing and higher rates of infection. In diabetic patients, blood glucose levels should be tightly regulated in the perioperative period to lessen the risk of wound complications. Administration of vitamin A has been shown to improve wound healing in patients receiving steroids.




Is your patient immunosuppressed?



WOUND CLOSURE



Suture Materials




The following principles of wound closure should be adhered to when possible:


1. Skin closure without tension.

2. Closure of underlying dead space.

3. Close dermal approximation.


I. Suture Size: Suture material is available in a variety of sizes. Sutures were originally manufactured in sizes ranging from #6 to #1, with #6 being the largest. As manufacturing techniques improved, #0 suture was introduced. Subsequently, smaller sizes were introduced and named according to the number of zeros they contained (i.e., 00 = 2-0, 000 = 3-0, etc.). The size of suture should reflect the application and the amount of tension on the wound. In general, the finest suture material that will maintain the approximation of tissues should be used.

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May 26, 2018 | Posted by in GENERAL SURGERY | Comments Off on Principles of Wound Closure

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