27. Wound closure options (depending on the time of closure)

Question 1

27. Wound closure options (depending on the time of closure)

Answer 1

Wound closure
-decision whether or not to close the wound, when?
-primary closure
-delayed primary closure
-secondary closure
-drainage
-tension lines(incisions/closure
parallel to tension lines if possible)

Primary closure
-preferred for clean wounds,including surgical wounds and
contaminated wounds that have been debrided and are less than 6 hours old
-direct closure of the wound after lavage and debridement
-leads to a more rapid anatomical and functional recovery than delayed and secondary closure
-sutures can generally be removed in 1-2 weeks
-if the level of contamination,tissue viability,depth of tissue damage
or vascular supply is questionable,other options should be considered

Delayed primary closure
-wound managed as an open wound until it is clean and without formation of granulation tissue,then closed
-closure 3-5 days after the emergence of the wound
-allows for drainage of the wound,a decrease in contamination and
the development of a clear demarcation line between viable and necrotic tissue prior to surgery

Secondary closure
-closure of the wound after the formation of granulation tissue
-contaminated or infected wounds
-two methods:
>leaving the existing granulation tissue intact,only separating the edge of the
skin from the granulation tissue bed and advancing it over the wound
>excision of the granulation tissue bed followed by primary closure
-second method usually preferrable
>wound edges more mobile
>incidence of infection lower
>cosmetic reasons

Drainage
-necessary at times(moderate contamination or a large dead space)
-dead space resulting from suturing of large wounds promotes fluid accumulation,which is a good medium for growth of bacteria
-passive drains(Penrose drain)
>easier to insert, cost less
>draining under gravity
>risk of ascending infection
-active drains
>creation of a vacuum that removes fluid by suction
>can be placed anywhere on the body
>containers need to be emptied regularly
-removal as soon as possible(usually 2-4 days)

Wound dressings and bandages
-dressing–materials applied directly to the surface of a wound,
>most important function to allow moist healing
-no single dressing perfect for all wounds in all phases of wound healing–initial and follow-up assessments necessary
-bandage– wraps to hold plain and medicated dressings in place(immobilization,pressure to control hemorrhage,obliteration of dead
space,protection from external trauma and contamination)
>primary layer(contact dressing)
>secondary(absorptive)layer
>tertiary(protective)layer

Bandages
-appropriate materials of adequate width should be used
-as smoothly as possible to prevent irritation and skin necrosis
-each turn of the bandage should overlap the previous turn by 50%
-patients should be observed for discomfort,swelling,hypothermia,skin discoloration,dryness,or odor
-(absorbent,adherent,non-adherent,stabilizing,pressure bandages,pressure relief bandages etc.)

Advanced techniques(chronic wounds)
-used for chronic wounds
-topical negative pressure
-low-level laser therapy
-hyperbaric oxygen therapy
-ultrasound
-seldom used,research warranted

Surgical closure
-possibilities limited mostly by imagination
-tension (‘’dog ears“)
-skin stretching and expansion