Joshua Nowocin, PA-C
Providing surgical wound care is a very common outpatient practice. Almost every outpatient center has had to provide Surgical wound care. There is plenty of information regarding wounds, so to keep it simple, this discussion will focus on Surgical wounds with normal and abnormal healing. Likewise, wounds can be classified as acute, chronic, clean, or contaminated. Wounds can also be viewed as “intentional” or “accidental.” For example, intentional wounds are those that usually involve an incision or planned approach by a healthcare provider. Conversely, accidental wounds are wounds that are not “planned.” These wounds are the result of an unintentional injury.
Types of Healing
Regardless of the cause of the wound, healing occurs in a predictable fashion. In general, wounds heal internally and progress from deep to superficial. There are three types of planned healing – primary, secondary, and tertiary intention.
Primary healing (first intention) allows the wound to heal by intentional direct approximation of the epithelial wound edges. Think of an acute laceration coming into the ER, with either sutures, staples, steri-strips, or glue closure. Clean and contaminated wounds alike can also heal by primary intention. With primary closure, the provider also has the ability to create a suitable wound appearance that will heal.
Secondary intention involves allowing the natural course of wound healing to progress without manipulation by the provider. Irregular or deep wounds also commonly heal by secondary intention. Wounds that are unable to be approximated can also heal in this manner. It is also seen in wounds that have failed primary closure. This is often due to infection or dehisence. Likewise, secondary healing has greater tissue loss, higher healing times, and increased chances of infection. These wounds heal from deep to superficial direction, and also form granulation tissue as they heal. Secondary wounds also produce more scar tissue.
Perhaps the biggest benefit of primary closure is a lower risk of infection. Benefits of primary healing also include reduced tissue loss, reduced scaring, and faster wound contraction. Wounds that heal by secondary healing are left open and allowed to close spontaneously. These wounds close by contraction and granulation. Sometimes wound edges cannot be brought together. In these instances, granulation must occur prior to epithelialization and wound closure. Examples include pressure ulcers, venous ulcers, diabetic ulcers, and also abscesses.
Tertiary healing can be thought of as a wound that intentionally left to heal on it’s own. These also involve a planned cosmetic closure after healing has progressed to an anticipated point. Surgical or traumatic wounds left open to heal, remove bacteria, and contamination with surgical wound closure after a delay for days to weeks. This postponement also allows time for improved edema or infection to improve. Tertiary wounds are then closed surgically using sutures or staples.
Providing surgical wound care requires a basic understanding of the healing process. All wounds should be cleaned and debrided prior to closure. The mantra “the solution to pollution is dilution” also comes to mind. The goal of irrigation is to flush any remaining debris, bacteria, or toxic chemicals from the wound site in a sterile, controlled manner. Likewise, normal saline is a great choice for Irrigation. Epithelialization of the primarily closed wound occurs in 12-24 hours. This causes the formation of granulation tissue, which is a thin layer of protective healing skin. Within 2-3 days, epithelial cells migrate from wound edges in a linear fashion along cut edges of the dermis.
Healing with time
Acute wounds go through a process of normal healing. This cascade of events occurs in 3 different phases. The initial inflammatory phase occurs in the first 1-4 days and removes debris to prepare for new tissue. Therefore in this phase, one might see serous or serosanguinous drainage with characteristics of pain, erythema, or swelling. There are many physiological actions that work simultaneously for wounds to heal. These include immune responses of leukocytes and macrophages that prevent micro-bacterial colonization. Platelets aggregate and cause blood clotting. Vasoconstriction and/or vasodilation also directs blood to wounds that need healing.
Around day 4 of the healing process, the proliferative phase begins and there is deposition of connective tissue and collagen cross linking. This results in granulation tissue to fill the wound bed. Angiogenesis (new formation of blood vessels) occurs, and macrophages continue to kill bacteria. This phase can last up to 24 days and creates tensile strength and structure. Around day 21 from incident, the maturation phase begins. The maturation phase strengthens and also reorganizes collagen fibers. This process shrinks and thins the scar. This phase also causes new tissue to grow, develop, and scar contracture continues.
Basic Wound Care Tips
After injury, wash the wound thoroughly with clean water and mild soap. Apply a gentle
pressure to stop any bleeding. Keep your wound moist with a layer of petroleum jelly or Neosporin and cover with a bandage.
- Keep your wound and the surrounding skin clean and free of irritants
- Monitor surgical sites for signs of infection (See below)
- Good nutrition with increased protein intake
- Good Blood Sugar control for Diabetics
- Avoid Tobacco Products
Common signs of skin infection include:
- Swelling, Induration
- Pain, Tenderness
- Purulent or odorous drainage
The risk of skin infection increases if patients:
- Have poor circulation = poor oxygenation/hypoxia
- Are older
- Have diabetes
- Have a weakened immune system due to disease (e.g., AIDS) or medicine (e.g., chemotherapy),
- radiation, or steroids)
- Are malnourished
- Have difficulty ambulating (e.g., stay in bed a long time or are paralyzed)
- Are obese
Wound Dehiscence and Breakdown
When a surgical site fails to close, dehiscence also occurs. Dehiscence can be partial, and only involve superficial tissue layers. Dehiscence can also be complete, and involve all layers of an incision. Likewise, these wound disruptions can make providing surgical wound care challenging. In this case, open wounds are separated from the underlying tissue. Organs may be exposed. Think of “Snakes in the Bed” in complete dehiscence of midline abdominal wounds. To help prevent dehiscence from developing educate the patient on good hygiene and also avoiding unnecessary strain on the surgical site. Partial dehiscence should also be treated by secondary healing.
When to Consult the Surgeon
Complete dehiscence requires emergent surgical consultation. Surgical consultation is also advised when wounds have necrosis or worsening fibrinous exudate. These wounds may also require surgical debridement to create a healthy wound bed.
- Basic wound care. University Health Services of UW-Madison.
https://www.uhs.wisc.edu/medical/common-student-concerns/basic-wound-care/. Accessed April 30,
- Surgical wounds. WoundSource. https://www.woundsource.com/patientcondition/surgical-wounds.
Accessed April 30, 2019.
- Larence, Peter F. (2006) “Essentials of General Surgery” (4th ed. pp.147-158) Lippincott Williams &
- Brown, P. & Maloy, JP (2005) “Quick Reference to Wound Care” (2nd ed. pp 207-215) Jones and Barlett.
- Doughty DB and Spaks-DeFriese B. Wound Healing Physiology, In R.A. Bryant, and D.P. Nix (Eds),
Acute and Chronic Wounds, Current Management Concepts (4th Ed) Mosby, 2012.4:63-82