Chapter 23: Surgical Considerations in Wound Care

Introduction

The most effective modality for chronic wound care remains surgical débridement. The goal of any wound care, acute or chronic, is always the same: closure and reepithelialization of the wound. Thus, the wound care practitioner must be familiar with some surgical wound techniques and procedures. This chapter presents wound care management from a surgical perspective. The patterns of wound healing, the preparation of the wound care bed, and advanced débridement and closure techniques are discussed. Some remarks concerning plastic and vascular surgical considerations conclude the chapter.

Types of Wound Closure

Acute wounds are defined as wounds that are expected to close primarily, as in simple suturing of a laceration. The normal, orderly process of wound closure occurs after an injury and requires only basic wound care (ie, clean and close wounds). The physiology of wound closure, both acute and chronic, was previously discussed in Chapter 2. Before discussing complex wound closure techniques, a primer on wound closure and care is in order.

All wounds heal in three distinct patterns: primary, secondary, and tertiary intention. Primary intention refers to the direct closure or approximation of a wound, usually with sutures or closure devices, but it may also involve placement of grafts or flaps.¹ While up to 6 hours after injury has been previously thought to be the ideal time for closure for primary intention healing, current studies have challenged this period of time, and, provided gross contamination has not occurred, wounds may be cleaned, débrided, and closed after longer periods. There is growing evidence that wounds, especially well-vascularized wounds such as facial injuries, may be closed within 24 hours.²

Suturing involves a stitch or series of stitches working to appose the edges of a surgical or traumatic wound. The technique involves the use of needles of variable size and shape, for instance, a cutting needle, which has a razorlike triangle designed to be placed through tissue such as skin. A circular or noncutting needle is used to approximate delicate tissue such as bowel or blood vessels. Other types of needles may be used depending on the tissue traversed, including reverse cutting needles and blunt needles.³

The type of stitch used in closure of the wound is usually divided into categories: absorbable versus nonabsorbable, monofilament versus braided, natural versus synthetic. Advantages and disadvantages are noted in all suture materials, and there is no perfect material for all cases. For example, absorbable suture heals with a more pronounced inflammatory reaction but does not need to be removed. Monofilament is usually less strong than braided multifilament but has the advantage of not allowing bacteria to reside between the braids. Natural suture material, such as silk, is generally easier to work with, whereas synthetic material ...