wound healing

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