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WOUND HEALING
DR. PRASAD DESHMUKH
Living tissues are best antiseptics and skin is the best dressing.
-Lister.
TYPES OF WOUND Lacerated Incised Abrasion Puncture Degloving
Definition: Loss of continuity in skin or mucous membrane due to injury , bone and soft tissues may or may not be damaged.
Regeneration -- Form -- Function Scarring – Laying down of collagen by
Fibroblasts.
PHYSIOLOGY OF WOUND HEALINGInflammation.Epithelialisatio
n.Fibroplasia.Wound
contraction.Scar
maturation.
INFLAMMATION VASCULAR Transient
vasoconstriction
Persistent
progressive vasodilatation
CELLULAR
Neutrophilic infiltration
Monocyte macrophage system
EPITHELIALISATIONMigration and subsequent
maturation of immature epithelial cells from basal layers.
Epithelial cells move beneath the scab ,
sealing the wound.
FIBROPLASIAProcess by which wounds regain
strength.Fibroblasts proliferate and
manufacture GP and MPS Ground substance formationCollagen—Tropocollagen
synthesis by 4-5 days
WOUND CONTRACTIONSurgical incisionAvulsion injuryContraction Contracture
SCAR MATURATIONMore orderly arrangement of collagen fibres so as to give denser and stronger scar
New scar softer and less bulky
HYPERTROPHIC SCAR-non familial-non racial-M=F-children -remain within
wound-subsides with time-along flexor aspect
KELOID
-may be familial-black > white-M < F-10-30 years-outgrows wound area-rarely subsides-along sternum,
shoulder, face
SURGICAL WOUND HEALINGPrimary intentionSecondary intentionTertiary intention(delayed primary
closure)
PRIMARY INTENTIONSurgically incised woundReapproximated by layersMinimum scar formationMinimum time for healing
SECONDARY INTENTIONContaminated infected surgical
woundsLeft open for formation of
granulation tissueAllowed to heal spontaneously -Contraction -Granulation tissue
formation
TERTIARY INTENTIONDelayed primary closureFor –post op wound breakdown
-grossly infected wounds
WOUND CLOSURE INCIDENCE 0.5 – 5 % in Gen surg 0.1-0.7 % in Gynaecology-Elective surgeries -Healthy patients-Less chance of infections-Decreased rate of enterotomies
WOUND CLASSIFICATION(SURGICAL CLASSIFICATION)
CLEAN 5 %
CLEAN CONTAMINATED 10 %
CONTAMINATED 20%
SEPTIC / DIRTY >30%
CLASS CATEGORY DEFINATION INFECTION RATE
I Clean Ideal operating room conditions; elective
<5%
II Clean contaminated
Entry into GIT, GUT and RS
2-10%
III Contaminated Open fresh traumatic wounds; incisions wid acute non purulent inflammations
15- 20 %
IV Dirty / Septic >4 hrs traumatic; perforated viscera, devitalised tissue or FB
> 30 %
FACTORS AFFECTING WOUND HEALINGLOCAL-Infection -Blood supply -Foreign body -Movements -UV lightSYSTEMIC-Age -Nutrition -Infection -Steroid therapy -Diabetes Mellitus -Haematological changes
COMPLETE WOUND DEHISCENCESeparation of skin and tissue
layers posterior to skin upto the fascia
With peritoneum – Complete dehiscence
With intestines protruding - Evisceration
PREDISPOSING FACTORS
CLINICAL FEATURES -usually on 5 -14 days -seepage of serosanguinous pink
discharge from apparently intact wound -examine integrity of fascial closure -sensation of something tearing or popping out
TREATMENTReplace bowel with saline soaked
pads Abdominal binderCBC , Ser. Electrolytes ,C/SBroad spectrum antibioticsUnder GA, debridement ,replace
bowel ,warm saline wash, Smead-Jones closure
REFERENCES Te Linde’s Operative Gynaecology Robbins’ Pathological basis of diseases Pye’s Surgical Handicraft Schwartz’ Principles of Surgery Baily & Love’s SPS Greenhills Surgical Gynaecology
A wise physician skilled our wounds to heal is more than armies for a common weal
-Homer
THANK YOU