Pho transcript. Primary surgical treatment of wounds (PSW)
1. Wound healing by primary intention. Wound healing by secondary intention. Healing under the scab.
2. PHO. Surgical treatment of the wound. Primary surgical treatment of the wound. Secondary surgical treatment of the wound.
3. Vascular suture. Seam according to Carrel. Carrel's vascular suture modified by Morozova. Stages of performing a vascular suture.
4. Operations on the veins of the extremities. Venipuncture. Vein puncture. Venesection. Opening a vein. Technique of venipuncture, venesection.
5. Tendon suture. Indications for suturing the tendon. Tendon suturing technique.
6. Nerve suture. Indications for suturing nerves. Purpose of nerve suturing. Technique for suturing a nerve.
PHO. Surgical treatment of the wound. Primary surgical treatment of the wound. Secondary surgical treatment of the wound.
Under primary surgical treatment gunshot and traumatic wounds are understood as surgical intervention, which consists of excision of its edges, walls and bottom with the removal of all damaged, contaminated and blood-soaked tissues, as well as foreign bodies.
Purpose of debridement- prevention of wound infection and acute suppuration of the wound and, therefore, rapid and complete healing of the wound.
Primary surgical treatment of the wound performed in the first hours after injury. Even with indirect signs of necrosis (crushing, contamination, isolation of damaged tissue), the damaged tissue is excised.
Surgical treatment of the wound in the first days after injury, with direct signs of necrosis (decay, disintegration of necrotic tissue) and suppuration of the wound, it is called secondary.
Excision of wound edges during primary surgical treatment.For good skin access edges of the wound excised with two semi-oval incisions within healthy tissue, taking into account the topography of large anatomical formations in this region and the direction of the skin folds (Fig. 2.29).
When excision of skin its crushed, crushed, thinned and sharply bluish areas should be removed. Cyanosis or severe hyperemia of the skin usually indicates its subsequent necrosis. The criterion for the viability of the skin edges of a wound should be considered profuse capillary bleeding, easily determined when making an incision.
Viable muscle shiny, pink, bleeds profusely, contracts when cut. The dead muscle is often disintegrated, cyanotic, does not bleed when cut, and often has a characteristic “boiled” appearance.
These signs with some experience, they can almost always correctly determine the living-dead boundary and sufficiently completely excise non-viable tissue.
In case of combined injuries, when large vessels, nerves, bones are damaged, primary surgical treatment of the wound produced in a certain sequence.
After excision non-viable tissues stop bleeding: small vessels are ligated, large ones are temporarily captured with clamps.
If large vessels are damaged, the veins are ligated, and a vascular suture is placed on the arteries.
Primary nerve suture in the wound applied if it is possible to create a bed for the nerve from intact tissue.
Bone wound for open fractures of any etiology, it should be treated as radically as a soft tissue wound. The entire area of crushed, devoid of periosteum bone must be resected within healthy tissue (usually 2-3 cm away from the fracture line in both directions)
After primary surgical treatment of the wound sutured layer by layer, the limb is immobilized for the period necessary for bone consolidation, nerve regeneration or strong tendon fusion. In doubtful cases, the wound is not tightly sutured, but the edges of the wound are only tightened with ligatures. After 4-5 days, if the course of the wound process is favorable, the sutures can be tightened; in case of complications, the wound will heal by secondary intention. Drains are left in the corners of the wound, if necessary, using active drainage - introducing antiseptic solutions through the drainage tube and suctioning out the liquid along with purulent exudate.
Under primary surgical treatment understand the first intervention (for a given wounded person) performed according to primary indications, i.e. regarding tissue damage itself as such. Secondary debridement- this is an intervention undertaken for secondary indications, i.e. regarding subsequent (secondary) changes in the wound caused by the development of infection.
For some types of gunshot wounds, there are no indications for primary surgical treatment of wounds, so the wounded are not subject to this intervention. Subsequently, significant foci of secondary necrosis may form in such an untreated wound, and an infectious process breaks out. A similar picture is observed in cases where the indications for primary surgical treatment were obvious, but the wounded person arrived to the surgeon late and a wound infection had already developed. In such cases, there is a need for surgery for secondary indications - secondary surgical treatment of the wound. In such wounded patients, the first intervention is secondary surgical treatment.
Often, indications for secondary treatment arise if the primary surgical treatment did not prevent the development of a wound infection; such secondary treatment, carried out after the primary (i.e., the second in a row), is also called re-treatment of the wound. Repeated treatment sometimes has to be done before wound complications develop, i.e., according to primary indications. This happens when the first treatment could not be carried out fully, for example, due to the impossibility of X-ray examination of a wounded person with a gunshot fracture. In such cases, the primary surgical treatment is actually performed in two steps: during the first operation, the soft tissue wound is mainly treated, and during the second operation, the bone wound is treated, fragments are repositioned, etc. The technique of secondary surgical treatment is often the same as the primary one, but sometimes secondary treatment can be reduced only to ensuring the free outflow of discharge from the wound.
The main task of primary surgical treatment of a wound- create unfavorable conditions for the development of wound infection. Therefore, this operation is more effective the earlier it is performed.
Based on the timing of the operation, it is customary to distinguish between surgical treatment - early, delayed and late.
Early surgical treatment refers to an operation performed before the visible development of infection in the wound. Experience shows that surgical treatments performed in the first 24 hours from the moment of injury, in most cases, “outpace” the development of infection, i.e., they belong to the early category. Therefore, in various calculations for planning and organizing surgical care in war, early surgical treatment is conditionally taken to include interventions performed on the first day after injury. However, the situation in which stage-by-stage treatment of the wounded is carried out often forces the operation to be postponed. In some cases, the prophylactic administration of antibiotics can reduce the risk of such delay - delay the development of wound infection and, thus, extend the period during which surgical treatment of the wound retains its preventive (precautionary) value. Such treatment, carried out albeit with delay, but before the appearance of clinical signs of wound infection (the development of which is delayed by antibiotics), is called delayed surgical treatment of the wound. When calculating and planning, delayed treatment is taken to include interventions performed during the second day from the moment of injury (provided that the wounded person is systematically administered antibiotics). Both early and delayed treatment of the wound can, in some cases, prevent suppuration of the wound and create conditions for its healing by primary intention.
If the wound, due to the nature of tissue damage, is subject to primary surgical treatment, then the appearance of clear signs of suppuration does not prevent surgical intervention. In such a case, the operation no longer prevents suppuration of the wound, but remains a powerful means of preventing more serious infectious complications and can stop them if they have already arisen. Such treatment, carried out during wound suppuration, is called late surgical treatment. With appropriate calculations, the late category includes treatments performed after 48 (and for wounded people who did not receive antibiotics, after 24) hours from the moment of injury.
Late surgical debridement carried out with the same tasks and technically in the same way as early or delayed. The exception is cases when intervention is undertaken only due to a developing infectious complication, and tissue damage by its nature does not require surgical treatment. In these cases, the operation is reduced primarily to ensuring the outflow of discharge (opening phlegmon, leakage, applying a counter-aperture, etc.). The classification of surgical treatment of wounds depending on the timing of their implementation is largely arbitrary. It is quite possible for cases of severe infection to develop in a wound 6-8 hours after injury and, conversely, cases of very long incubation of a wound infection (3-4 days); processing, which appears to be delayed in execution time, in some cases turns out to be late. Therefore, the surgeon must proceed primarily from the condition of the wound and from the clinical picture as a whole, and not just from the period that has passed since the injury.
Among the means to prevent the development of wound infection, antibiotics play an important, albeit auxiliary, role. Due to their bacteriostatic and bactericidal properties, they reduce the risk of outbreak of infection in wounds that have undergone surgical debridement or in those where debridement is considered unnecessary. Antibiotics play a particularly important role when this operation is forced to be postponed. They should be taken as soon as possible after injury, and repeated administrations before, during and after surgery should maintain effective concentrations of drugs in the blood for several days. For this purpose, injections of penicillin and streptomycin are used. However, in the conditions of [Stage-by-stage treatment, it is more convenient to administer for prophylactic purposes a drug with a prolonged effect, streptomycellin (900,000 units intramuscularly 1-2 times a day, depending on the severity of the wound and the timing of the primary surgical treatment of the wound). If streptomycellin injections cannot be carried out, biomycin is prescribed orally (200,000 units 4 times a day). In case of extensive muscle destruction and delay in the provision of surgical care, it is advisable to combine streptomycellin with biomycin. For significant bone damage, tetracycline is used (in the same dosages as biomycin).
There are no indications for primary surgical treatment of the wound for the following types of wounds: a) through bullet wounds of the extremities with pinpoint entry and exit holes, in the absence of tissue tension in the wound area, as well as hematoma and other signs of damage to a large blood vessel; b) bullet or small fragment wounds of the chest and back, if there is no hematoma of the chest wall, signs of bone fragmentation (for example, scapula), as well as open pneumothorax or significant intrapleural bleeding (in the latter case, thoracotomy becomes necessary); c) superficial (usually not penetrating deeper than the subcutaneous tissue), often multiple, wounds from small fragments.
In these cases, wounds usually do not contain a significant amount of dead tissue and their healing most often proceeds without complications. This, in particular, can be facilitated by the use of antibiotics. If suppuration subsequently develops in such a wound, then the indication for secondary surgical treatment will be mainly the retention of pus in the wound canal or in the surrounding tissues. With free outflow of discharge, the festering wound is usually treated conservatively.
Primary surgical treatment is contraindicated in the wounded, in a state of shock (temporary contraindication), and in those in agony. According to data obtained during the Great Patriotic War, the total number of those not subject to primary surgical treatment is about 20-25% of all those injured by firearms (S.S. Girgolav).
Military field surgery, A.A. Vishnevsky, M.I. Schreiber, 1968
Treatment of fresh wounds begins with the prevention of wound infection, i.e. with carrying out all measures to prevent the development of infection.
Any accidental wound is primarily infected, because microorganisms in it multiply quickly and cause suppuration.
An accidental wound should be subjected to surgical debridement. Currently, surgery is used to treat accidental wounds.
method of treatment, i.e. primary surgical treatment of wounds. Any wound must be subjected to PSO of the wound.
Through PST of wounds, one of the following 2 problems can be solved (case number 3):
1. Transformation of a bacterially contaminated accidental or combat wound into an almost aseptic surgical wound (“sterilization of the wound with a knife”).
2. Transformation of a wound with a larger area of damage to surrounding tissues into a wound with a small area of damage, simpler in shape and less bacterially contaminated.
Surgical treatment of wounds is a surgical intervention consisting of a wide dissection of the wound, stopping bleeding, excision of non-viable tissue, removal of foreign bodies, free bone fragments, blood clots in order to prevent wound infection and create favorable conditions for wound healing. There are two types of surgical treatment of wounds - primary and secondary.
Primary surgical treatment of the wound - the first surgical intervention for tissue damage. Primary surgical treatment of the wound should be immediate and comprehensive. Performed on the 1st day after injury, it is called early; on the 2nd day - delayed; after 48 h from the moment of injury - late.
There are the following types of surgical treatment of wounds (case No. 4):
· Toilet wound.
· complete excision of the wound within aseptic tissues, allowing, if successfully performed, healing of the wound under the sutures by primary intention.
· Dissection of the wound with excision of non-viable tissue, which creates conditions for uncomplicated wound healing by secondary intention.
Toilet wound It is performed for any wound, but as an independent measure it is carried out for minor superficial incised wounds, especially on the face and fingers, where other methods are usually not used. By cleaning the wound we mean cleaning the edges of the wound and its circumference from dirt using a gauze ball moistened with alcohol or another antiseptic, removing adhering foreign particles, lubricating the edges of the wound with iodonate and applying an aseptic dressing. It is necessary to take into account that when cleaning the wound circumference, movements should be made from the wound outward, and not vice versa, in order to avoid introducing a secondary infection into the wound. Complete excision of the wound with the application of a primary or initially delayed suture to the wound (i.e., an operation is performed - primary surgical treatment of wounds ). Wound excision is based on the doctrine of primary infection of an accidental wound.
Stage 1- excision and dissection of the edges and bottom of the wound within healthy tissue. It should be noted that we do not always dissect the wound, but almost always excise it. We dissect in cases where it is necessary to inspect the wound. If the wound is located in the area of large muscle masses, for example on the thigh, then all non-viable tissues are excised, especially the muscles within healthy tissues along with the bottom of the wound, up to 2 cm wide. This cannot always be done completely and strictly enough. This is sometimes hampered by the tortuous course of the wound or functionally important organs and tissues located along the wound channel. After excision, the wound is washed with antiseptic solutions, thorough hemostasis is carried out and should not be washed with antibiotics - allergization.
Stage 2- the wound is sutured in layers, leaving drainage. Sometimes PSO of a wound turns into a rather complex operation and you need to be prepared for this.
A few words about the features of PST of wounds localized on the face and hands. Wide surgical surgical treatment of wounds is not performed on the face and hands, because these areas have little tissue, and we are interested in cosmetic considerations after surgery. On the face and hands, it is enough to minimally refresh the edges of the wound, clean it and apply a primary suture. The peculiarities of the blood supply to these areas make it possible to do this. Indication for PSW of a wound: In principle, all fresh wounds should undergo PSW. But a lot depends on the general condition of the patient; if the patient is very severe and in a state of shock, then PCO is delayed. But if the patient has profuse bleeding from the wound, then, despite the severity of his condition, PSO is performed.
Where, due to anatomical difficulties, it is not possible to completely excise the edges and bottom of the wound, a wound dissection operation should be performed. Dissection with its modern technique is usually combined with excision of non-viable and clearly contaminated tissue. After dissection of the wound, it becomes possible to inspect it and mechanically clean it, ensure free outflow of discharge, and improve blood and lymph circulation; the wound becomes accessible to aeration and therapeutic effects of antibacterial agents, both introduced into the wound cavity and especially circulating in the blood. In principle, dissection of the wound should ensure its successful healing by secondary intention.
If the patient is in a state of traumatic shock, a set of anti-shock measures is carried out before surgical treatment of the wound. Only if bleeding continues is it permissible to perform immediate surgical treatment while simultaneously carrying out anti-shock therapy.
The extent of surgical intervention depends on the nature of the injury. Stab and cut wounds with minor tissue damage, but with the formation of hematomas or bleeding, should only be dissected in order to stop bleeding and decompress tissue. Large wounds that can be treated without additional tissue dissection (for example, extensive tangential wounds) are subject only to excision; through and blind wounds, especially with comminuted bone fractures, are subject to dissection and excision.
The most significant mistakes that are made when performing surgical treatment of wounds are excessive excision of unchanged skin in the wound area, insufficient dissection of the wound, which makes it impossible to carry out a reliable revision of the wound channel and complete excision of non-viable tissue, insufficient persistence in searching for the source of bleeding, tight tamponade of the wound with the aim of hemostasis, use of gauze swabs for drainage of wounds.
Timing of post-surgical treatment of wounds (case No. 5). The most optimal time for PCO is the first 6-12 hours after injury. The sooner the patient arrives and the sooner PSO of the wound is performed, the more favorable the outcome. This is early PST of wounds. Time factor. At present, they have somewhat moved away from the views of Friedrich, who limited the period of emergency treatment to 6 hours from the moment of injury. PSO, carried out after 12-14 hours, is usually forced
processing due to late admission of the patient. Thanks to the use of antibiotics, we can extend these periods, even up to several days. This is a late PST of wounds. In cases where PSC of a wound is performed late, or not all non-viable tissues are excised, then primary sutures can not be applied to such a wound, or such a wound cannot be sutured tightly, but the patient can be left under observation in the hospital for several days and if the condition further allows wounds, then sutured it tightly.
Therefore, they distinguish (sl. No. 7):
· Primary suture , when a suture is applied immediately after a wound and PST of wounds.
· Primary – delayed suture, when the suture is applied 3-5-6 days after the injury. The suture is applied to the pre-treated wound until granulation appears, if the wound is good, without clinical signs of infection, and the patient is in general good condition.
· Secondary seams, which are applied not to prevent infection, but to speed up the healing of an infected wound.
Among the secondary seams there are (sl. No. 8):
A) Early secondary suture applied 8-15 days after injury. This suture is applied to a granulating wound with movable, non-fixed edges without scars. In this case, the granulations are not excised, and the edges of the wound are not mobilized.
B) Late secondary suture 20-30 days or later after injury. This suture is applied to a granulating wound with the development of scar tissue after excision of the scar edges, walls and bottom of the wound and mobilization of the wound edges.
PCS of wounds is not performed (
sl. No. 9 ):
a) for penetrating wounds (for example, bullet wounds)
b) for small, superficial wounds
c) for wounds on the hand, fingers, face, skull, the wound is not excised, but a toilet is performed and stitches are applied
d) in the presence of pus in the wound
e) in the event that complete excision is not feasible, when the wound walls include anatomical formations, the integrity of which must be spared (large vessels, nerve trunks, etc.)
f) if the victim is in shock.
Secondary surgical treatment of the wound carried out in cases where primary treatment has not given an effect. Indications for secondary surgical treatment of a wound are the development of wound infection (anaerobic, purulent, putrefactive), purulent-resorptive fever or sepsis caused by tissue retention, purulent leaks, peri-wound abscess or phlegmon (case number 10).
The volume of secondary surgical treatment of the wound may vary. Complete surgical treatment of a purulent wound involves excision within healthy tissue. Often, however, anatomical and surgical conditions (danger of damage to blood vessels, nerves, tendons, joint capsules) allow only partial surgical treatment of such a wound. When the inflammatory process is localized along the wound canal, the latter is widely opened (sometimes with additional dissection of the wound), the accumulation of pus is removed, and foci of necrosis are excised. For the purpose of additional sanitation of the wound, it is treated with a pulsating jet of antiseptic, laser beams, low-frequency ultrasound, as well as vacuuming. Subsequently, proteolytic enzymes and carbon sorbents are used in combination with parenteral administration of antibiotics. After complete cleansing of the wound, with good development of granulations, secondary sutures are permissible. When an anaerobic infection develops, secondary surgical treatment is carried out most radically, and the wound is not sutured. Treatment of the wound is completed by draining it with one or more silicone drainage tubes and suturing the wound.
The drainage system allows you to wash the wound cavity with antiseptics in the postoperative period and actively drain the wound when vacuum aspiration is connected. Active aspiration-washing drainage of the wound can significantly reduce the healing time.
Thus, primary and secondary surgical treatment of wounds has its own indications, timing and scope of surgical intervention (case No. 11).
Treatment of wounds after their primary and secondary surgical treatment is carried out using antibacterial agents, immunotherapy, restorative therapy, proteolytic enzymes, antioxidants, ultrasound, etc. Treatment of the wounded under conditions of gnotobiological isolation is effective (see and for anaerobic infection - with the use of hyperbaric oxygenation
Among the complications of wounds areearly: organ damage, primary bleeding, shock (traumatic or hemorrhagic) and late: seromas, hematomas, early and late secondary bleeding, wound infection (pyogenic, anaerobic, erysipelas, generalized - sepsis), wound dehiscence, scar complications (hypertrophic scars, keloids) (case No. 12)
To the early complications include primary bleeding, injuries to vital organs, traumatic or hemorrhagic shock.
By the later complications include early and late secondary bleeding; Seromas are accumulations of wound exudate in wound cavities, which are dangerous due to the possibility of suppuration. When a seroma forms, it is necessary to ensure the evacuation and drainage of fluid from the wound.
Wound hematomas are formed in wounds closed with a suture due to incomplete stopping of bleeding during surgery or as a result of early secondary bleeding. The causes of such bleeding may be increases in blood pressure or disturbances in the patient’s hemostatic system. Wound hematomas are also potential foci of infection; in addition, by squeezing tissue, they lead to ischemia. Hematomas are removed by puncture or open exploration of the wound.
Necrosis of surrounding tissues- develop when microcirculation in the corresponding area is disrupted due to surgical tissue trauma, improper suturing, etc. Wet skin necrosis must be removed due to the danger of their purulent melting. Superficial dry necroses of the skin are not removed, as they play a protective role.
Wound infection- its development is facilitated by necrosis, foreign bodies in the wound, accumulation of fluid or blood, disruption of local blood supply and general factors influencing the course of the wound process, as well as the high virulence of wound microflora. There are pyogenic infections, which are caused by staphylococcus, Pseudomonas aeruginosa, Escherichia coli and other aerobes. Anaerobic infection, depending on the type of pathogen, is divided into non-clostridial and clostridial anaerobic infection (gas gangrene and tetanus). Erysipelas is a type of inflammation caused by streptococcus, etc. The rabies virus can enter the body through bite wounds. When a wound infection generalizes, sepsis may develop.
Dehiscence of wound edges occurs in the presence of local or general factors that impede healing, and when the sutures are removed too early. During laparotomy, the divergence of the wound can be complete (eventration - exit of internal organs to the outside), incomplete (the integrity of the peritoneum is preserved) and hidden (the skin suture is preserved). Dehiscence of the wound edges is eliminated surgically.
Complications of wound scarring can be in the form of the formation of hypertrophied scars, which appear with a tendency to excessive formation of scar tissue and more often when the wound is located perpendicular to the Langer line, and keloids, which, in contrast
from hypertrophied scars have a special structure and develop beyond the boundaries of the wound. Such complications lead not only to cosmetic, but also to functional defects. Surgical correction of keloids often leads to a deterioration of the local status.
To select an adequate treatment tactic when describing the condition of a wound, a comprehensive clinical and laboratory assessment of many factors is necessary, taking into account:
· localization, size, depth of the wound, capture of underlying structures, such as fascia, muscles, tendons, bones, etc.
· condition of the edges, walls and bottom of the wound, the presence and type of necrotic tissue.
· quantity and quality of exudate (serous, hemorrhagic, purulent).
· level of microbial contamination (contamination). The critical level is the value of 105 - 106 microbial bodies per 1 gram of tissue, at which the development of a wound infection is predicted.
· time elapsed since the injury.
47. Principles and rules of primary surgical treatment of wounds. Types of seams.
Primary surgical treatment (PSD) of wounds - the main component of surgical treatment for them. Its goal is to create conditions for rapid wound healing and prevent the development of wound infection.
Distinguish early PHO, carried out in the first 24 hours after injury, delayed - during the second day and late - after 48 hours.
The task when performing PST of a wound is to remove non-viable tissues and the microflora found in them from the wound. PSO, depending on the type and nature of the wound, consists of either complete excision of the wound or its dissection with excision.
Complete excision is possible provided that no more than 24 hours have passed since the injury and if the wound has a simple configuration with a small area of damage. In this case, PST of the wound consists of excision of the edges, walls and bottom of the wound within healthy tissues, with the restoration of anatomical relationships.
Dissection with excision is performed for wounds of complex configuration with a large area of damage. In these cases Primary wound treatment consists of the following points;
1) wide dissection of the wound;
2) excision of deprived and contaminated soft tissues in the wound;
4) removal of loose foreign bodies and bone fragments devoid of periosteum;
5) wound drainage;
6) immobilization of the injured limb.
PSO of wounds begins with treatment of the surgical field and delimiting it with sterile linen. If the wound is on the scalp of the body, then first shave the hair 4-5 cm in circumference. For small wounds, local anesthesia is usually used.
Treatment begins by grasping the skin in one corner of the wound with tweezers or Kocher clamps, lifting it slightly, and from there gradually excising the skin along the entire circumference of the wound. After excision of the crushed edges of the skin and subcutaneous tissue, the wound is widened with hooks, its cavity is examined and non-viable areas of the aponeurosis are removed. Existing pockets in the soft tissues are opened with additional incisions. During primary surgical treatment of a wound, it is necessary to periodically change scalpels, tweezers and scissors during the operation. PSO is performed in the following order: first, the damaged edges of the wound are excised, then its walls, and finally, the bottom of the wound. If there are small bone fragments in the wound, it is necessary to remove those that have lost contact with the periosteum. During PST of open bone fractures, the sharp ends of fragments protruding into the wound, which can cause secondary injury to soft tissues, blood vessels and nerves, should be removed with bone forceps.
The final stage of PST of wounds, depending on the time from the moment of injury and the nature of the wound, may be suturing its edges or draining it. Sutures restore anatomical continuity of tissues, prevent secondary infection and create conditions for healing by primary intention.
Along with the primary, there are secondary surgical wound treatment, which is undertaken for secondary indications due to complications and insufficient radicality of primary treatment for the purpose of treating wound infection.
The following types of seams are distinguished.
Primary seam - applied to the wound within 24 hours after injury. The primary suture is used to finish surgical interventions during aseptic operations, in some cases, after opening abscesses, phlegmons (purulent wounds), if good conditions for drainage of the wound are provided in the postoperative period (use of tubular drainages). If more than 24 hours have passed since the injury, then after PSO of the wound, no stitches are applied, the wound is drained (with tampons with a 10% sodium chloride solution, Levomi-kol ointment, etc., and after 4-7 days until granulation appears, provided that the wound has not become suppurated, primary delayed sutures are applied. Delayed sutures can be applied as provisional sutures - immediately after PSO - and tied after 3-5 days if there are no signs of wound infection.
Secondary seam applied to a granulating wound, provided that the danger of wound suppuration has passed. There is an early secondary suture, which is applied to granulating PCS.
Late secondary suture applied more than 15 days from the date of surgery. Bringing the edges, walls and bottom of the wound closer together in such cases is not always possible; in addition, the growth of scar tissue along the edges of the wound prevents healing after their comparison. Therefore, before applying late secondary sutures, the edges of the wound are excised and mobilized and hypergranulations are removed.
Primary surgical treatment should not be performed if:
1) minor superficial wounds and abrasions;
2) small puncture wounds, including blind ones, without damage to the nerves;
3) with multiple blind wounds, when the tissues contain a large number of small metal fragments (shot, grenade fragments);
4) through bullet wounds with smooth entry and exit holes in the absence of significant damage to tissues, blood vessels and nerves.
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All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.
Primary surgical treatment of wounds, or PST, is carried out to ensure rapid healing by forming an even scar and preventing complications. It is indicated for lacerations, shrapnel wounds, gunshot wounds, infection, hemorrhages, and tissue necrosis at the edges of the damage. The earlier the surgical treatment is performed, the faster and more favorable the recovery will be.
Wounds are one of the most common types of injuries that a person receives not only at home, but also at work. The problem of treating wounds becomes especially urgent in conditions of military operations and armed conflicts, as well as natural disasters. In the latter cases, wounds can be multiple, of varying severity and require serious, painstaking work by surgeons and long-term rehabilitation.
The smoother the edges of the damage, the higher the chances of favorable healing. However, this is only possible with not too deep, incised wounds, the boundaries of which are well comparable. Infection is one of the main factors that disrupts the regenerative process and leads to severe purulent-septic complications, which PSO of the wound helps to avoid.
Almost all types of injuries are subjected to primary surgical treatment, except perhaps for abrasions and minor deep cuts with smooth edges, the distance between which is no more than a centimeter. Such defects can heal on their own, without additional surgical intervention. PSO can also be avoided in the case of puncture injuries that occur without complications, as well as through bullet wounds in which there is no serious injury to soft tissues.
Massive areas of wounds, the presence of foreign objects, deep defects of soft tissues, blood vessels and nerves almost always require the help of a surgeon. However, it will have to be postponed when the wounded person is in a state of shock, has suffered massive blood loss and requires life-saving surgery and intensive care.
Indications and contraindications for PSO
PSO is needed for any type of wound received no more than three days ago, with crushing, infection, hemorrhages, tissue diastasis of more than a centimeter, or even without obvious secondary inflammatory changes. The exceptions are minor abrasions, scratches, small wounds without injury to deeper structures, puncture injuries with internal organs not affected, intact neurovascular bundles, and sometimes through bullet wounds that can regenerate on their own.
Only the serious condition of the victim (shock, coma, agony) and the increase in phlegmonous inflammation in the wound itself can hinder the implementation of PCO. This means that the wound will still be treated, but a little later, after the patient’s condition has stabilized.
The main principles when carrying out primary surgical treatment of a wound are necrectomy within healthy tissue, the correct choice of the type of suture, measures to prevent infection, adequate drainage and stopping bleeding.
The most effective option is when the wound is treated as early as possible, in a surgical department and simultaneously. For this reason, damage to the tissues of the head, brain, gunshot wounds involving bones are not operated on at the initial stages of assistance in military field conditions, except in cases where there is a threat to life due to bleeding, contamination with soil, or toxic substances.
The edges of the skin are excised with neat semi-oval incisions, which lie within healthy tissue flaps. It is important to correctly assess tissue viability based on its appearance. The skin is considered viable if, when cut, significant bleeding from the capillaries is detected. On the contrary, cyanosis, thinning, severe swelling or plethora indicate impending necrosis.
Timing of PSS and its types
The timing of PHO is an extremely important factor influencing the speed of healing and its outcome. The sooner the patient sees a surgeon, the lower the risk of complications, however, urgent surgical care is not always available in the first hours after injury, so victims often see a doctor a day or even more later. The forecasts are assessed as quite serious.
At the same time, some potential patients themselves do not rush to see a doctor in the hope that everything will heal on its own. After a short time, they observe the addition of infection, suppuration, and the appearance of signs of intoxication, and then it is already clear that they cannot do without a specialist.
Depending on the time frame in which the PSS was carried out, the following are distinguished:
- Early PSO - is carried out within the 1st day after injury, includes all the main stages of treatment and ends with suturing with the application of a primary suture;
- Deferred- in the next two days, when inflammatory changes, swelling, and inflammatory exudation increase, requiring mandatory prescription of antibacterial agents and opening of the wound, a little later, primary delayed sutures are applied;
- Late- carried out after 48 hours or more, when there is phlegmonous inflammation, stitches are not applied, antibiotics and detoxification measures are required.
Primary wound treatment technique and equipment
Primary surgical treatment of a wound is a surgical manipulation that presupposes the presence of appropriate conditions (an operating room or a dressing room in a surgical department), compliance with the rules of asepsis and antiseptics, and the use of special instruments. Excision of wound edges, drainage, and elimination of ulcers is impossible without adequate anesthesia, which is usually carried out by infiltrating tissues with local anesthetics - lidocaine, novocaine and others.
The instruments necessary for PSO of a wound are available in any surgical department; they are owned by a surgeon of any specialty, who can provide emergency surgical assistance to a patient in need, even if he independently comes for it, as they say, from the street. All instruments are sterile, and the skin and incision area are carefully treated with antiseptic agents (iodine, chlorhexidine, hydrogen peroxide, ethanol) to avoid infection.
The set of tools for chemical and chemical treatment includes:
- Forceps and tacks for linen;
- Tweezers;
- Cutting instruments - scalpels and scissors;
- Syringes;
- Clamps to stop bleeding;
- Needles and material for stitching;
- Probes and hooks;
- Drainage tubes, sterile gloves, bandages, cotton balls and swabs.
In addition to surgical instruments, during the primary surgical treatment of a wound, medications are used - disinfectants (hydrogen peroxide, iodine, ethanol), local anesthetics (lidocaine, novocaine), as well as alcohol and other means for treating instruments.
Primary surgical treatment of wounds consists of a number of successive stages:
- Incisions of wound edges.
- Inspection of the wound tract, palpation of existing cavities, opening them.
- Excision of the boundaries of the wound defect, walls and bottom.
- Stop bleeding by coagulation or ligation of blood vessels.
- Restoring the integrity of injured tissues, blood vessels, muscles, etc.
- Suturing and, if necessary, drainage.
Thanks to PST, an accidentally wound with torn, contaminated borders acquires smooth outlines, gets rid of infection, and regenerates faster with the formation of a scar and without suppuration. Naturally, the cosmetic result will also be much better than after complicated festering wounds.
The PST algorithm for combined wounds involving heterogeneous structures includes successive stages: elimination of necrotic tissue, stopping bleeding, suturing nerves, muscles, tendons, resection of non-viable bone tissue fragments. After these manipulations, stitches are applied, but the wound continues to drain. If the injury occurs on a limb, it is temporarily immobilized.
At the first stage of PHO In the wound, the surgeon uses a scalpel to make smooth, neat incisions, allowing the nature of the wound canal and its contents, the involvement of surrounding structures, the presence of additional pockets and cavities to be examined as fully as possible. The tissues are dissected layer by layer, the cutting instrument moves along the muscle fibers, along the neurovascular trunks.
In a complex wound, foreign objects are found - fragments, splinters, splinters, fragments of clothing, as well as coagulated blood, dead tissue, and bone fragments. They are removed by washing the space with antiseptic solutions under pressure.
After revision of the wound, it is necessary to excise the marginal zones, walls and bottom, remove dead areas and tissues with signs of infection, and remove foreign bodies. The skin is excised sparingly, fat can be removed with scissors more widely, to clearly “living” areas, fascia is excised where it has lost its relationship with the surrounding structures, and muscles - only in the zone of undoubted non-viability.
When everything unnecessary and pathological is removed, the wound can be called incised, and this is an important condition for the correct comparison of its edges, and sterile. To carry out the subsequent stages of primary surgical treatment, the surgeon will definitely change the set of instruments to clean ones, change his gloves or treat them with antiseptics.
It is recommended to remove the internal borders of the wound in one solid block, retreating a maximum of 2 cm to the periphery. It is important to consider where the wound is located, what its depth is, what tissues have been injured and lie in its bottom or walls. The most extensive removal of surrounding tissue is indicated for infected, contaminated wounds on the legs, crushing and necrosis.
PHO on the face should be as gentle as possible, because the result of healing will be one way or another a cosmetic defect. During the primary surgical treatment of facial wounds, the doctor acts as sparingly as possible, excising only those areas that have undergone necrosis. If the wound is an incision, then its edges are not excised at all.
When internal organs are located in the viable bottom of the wound or its walls, for example, the intestine, heart, lung, brain, then there can be no talk of any excision of the wound components. Areas of internal organs and tissue that can be preserved remain in their original place.
The most important stage of PSO is stopping bleeding, which occurs by coagulation of blood vessels or their ligation. This avoids bleeding into the wound and secondary infection.
With severe, deep wounds, tendons, muscles, and bone tissue can be injured. If the surgeon has the appropriate skills to restore the integrity of these structures, then it is advisable to do this during wound treatment, however, in conditions of military operations, it is recommended to postpone reconstructive operations.
If the surgeon does not know the technique of reconstruction of nerves, bones, soft tissues, or there are no technical capabilities for these manipulations, the victim will need another operation with the application of delayed tendon and muscle sutures, and osteosynthesis.
Wound suturing and drainage are considered the final stage of emergency treatment, and several options are possible:
- stitching layer by layer without drainage;
- suturing and leaving a drainage tube in the wound;
- temporary opening of the wound without sutures or drainage.
A tightly sutured wound can be left for puncture injuries, incisions with a small area of soft tissue injury, without signs of contamination or infection, when the injury is located on visible areas of the body, and for a short period of time that has passed from the moment the wound was received. Under such conditions, the likelihood of complications will be negligible, so there is no need for drainage.
If the surgeon cannot eliminate the risk of infection, even when such chances are relatively small, if the wound is located on the legs, the scale and depth of the damage is significant, PSO is performed after 6 or more hours, or there is a concomitant background that negatively affects the regenerative potential of tissues, suturing is indicated with the obligatory leaving of drainages.
The most complex and dangerous wounds cannot be sutured. They are left open due to the high risk of infection, which is facilitated by soil contamination, the presence of crushes and bruises, a long period of time between injury and surgery, background anemia, diabetes, immunity problems, the advanced age of the victim, and the location of the wound cavity on the lower extremities. Wounds received in military conditions or due to gunshot injuries also do not need to be stitched.
If the surgeon underestimates the degree of risk, concomitant pathology, the condition of the wound itself and provides a blind suture, then such actions can be considered a serious medical error, because the risk of severe complications cannot be justified by anything.
Early PST of a wound is carried out in accordance with the listed algorithm of actions and ends with a blind seam. For the first two days, drainage can be left in the wound resulting from massive damage to the subcutaneous layer, since it is quite difficult to eliminate the risk of bleeding. After removing the drainage, the wound is treated as uninfected.
The surgeon can leave an open wound after delayed PSO; it is mandatory to prescribe broad-spectrum antibiotics. Subsequently, primary delayed sutures are applied. If the doctor is faced with damage that lasts longer than two days, then the risk of purulent inflammation is too great even after surgical treatment and antibiotic therapy, so late PSO always leaves behind an open wound. After at least a week, the question of applying a secondary suture can be raised, but an important condition for this is the presence of granulation tissue in the wound.
Drainage is the final stage of PST. The easiest way to remove discharge from a wound is to install a hollow tube into it, through which blood, pus, and interstitial fluid will flow passively. A more difficult way is to use double-lumen drainages.
In a surgical hospital, the most complex, but also the most effective drainage can be established, the essence of which is the introduction of washing fluid through one drainage, and the removal of discharge through others. It is even better if an aspirator is connected to the excretory drainage to actively remove wound contents.
Video: example of PSO for an incised wound of the thigh
Specifics of suturing during PHO and their types
Tissue stitching and the correct choice of not only technique, but also timing play an important role in the outcome of the regenerative process and the cosmetic result. Wounds that exist for a long time without stitches are not capable of rapid healing. In addition, the presence of an open defect contributes to the evaporation of fluid, loss of protein and important microelements, as well as the addition of purulent inflammation.
An open wound is filled with granulation tissue and epithelializes very slowly, so the surgeon’s task is to bring its ends together as early as possible and fasten them with one of the types of sutures. Undoubtedly advantages of suturing wound edges are considered:
- Shortening the regeneration period;
- Reducing loss of moisture and electrolytes through the wound;
- Reducing the risk of secondary suppuration;
- Improved subsequent function and more favorable cosmetic results;
- Facilitation of care and treatment of wound elements.
Depending on the timing of application, there are:
- Primary sutures - actually primary and delayed;
- Secondary.
Primary suture indicated until granulation tissue begins to develop in the wound, and the damage itself will heal by primary intention. This type of suture is possible immediately after PSO, the end of the surgical intervention. The condition that must be met is the minimum probability of suppuration. After a scar has formed and the wound has been covered with epithelium, the suture is removed. Primary sutures are not recommended for use in cases of late treatment of wounds, in war conditions, or in cases of gunshot injuries.
Primary delayed sutures are also applied before granulation tissue appears in the wound, but only when there is a possibility of infection. The surgeon first leaves the wound open, monitors the inflammation, and after it reduces, stitching is possible (in the first 5 days).
A variant of the primary delayed suture is considered provisional: The surgeon stitches the edges of the wound, but does not tie any knots, so the wound remains partially open. You can also tie the threads in the next 5 days. This suture holds the edges of the wound, preventing them from moving too far away from each other, but, at the same time, provides access to the wound surface for inspection and monitoring the progress of inflammation.
types of surgical sutures
Secondary seams are indicated if the process of formation of granulation tissue has begun in the wound. Healing will occur by secondary intention with the formation of rough fibrous tissue. Secondary sutures make it possible, if not eliminate, then at least reduce the volume of wound cavities.
Open wounds with an abundance of granulations leave behind rough scars, and healing takes quite a long time. By reducing the size of the wound cavity, both the volume of granulation tissue and the healing period are reduced, and the cosmetic result becomes more beneficial for the patient. In addition, it is more difficult for infectious agents to penetrate through closely spaced edges of the damage.
Secondary sutures are indicated for wounds with granulations, without suppuration and necrosis. To determine the time when you can start applying a suture, it is advisable to culture the discharge: if there are no pathogenic microbes, then it is time to apply secondary sutures.
The secondary suture can be early or late. Early applied within the next three weeks from the moment of damage, late- after 21 or more days. The main difference between these types of sutures is the condition of the wound. Up to three weeks there is still no obvious scarring, so the edges come closer together and the threads are tied. When using a late suture, the surgeon will have to remove scar changes, only after which the wound can be sutured. For purulent wounds, additional approximation of the edges with a plaster is used.
In parallel with surgical treatment of wound defects, patients with complex injuries are prescribed antibacterial, detoxification therapy, adequate pain relief is required, and corticosteroids are prescribed to combat the inflammatory process.
Thus, PSO is a complex surgical procedure that may require the surgeon to have special skills in applying complex sutures (on nerves, tendons, etc.), the availability of specialized instruments, and operating room conditions, so it is not always possible outside of specialized surgical clinics . Its success depends not only on the qualifications of the doctor and the equipment of the hospital, but also on the time that has passed since the injury and its characteristics.
Video: carrying out PHO
