Comprehensive Study Guide for Surgical Wounds and Wound Management

Classification and Definition of Surgical Wounds

A wound is defined as a breach in the integrity of tissues, which can be caused by various external or internal factors, including physical, mechanical, and chemical influences. Surgical and traumatic wounds are categorized through several classification systems to guide treatment strategies. According to the damage to the external covering, wounds are divided into open and closed types. Based on their relationship to body cavities, they are classified as non-penetrating or penetrating. A critical clinical classification involves the presence of infection and the environment from which the wound originated. Clean wounds are non-traumatic, demonstrate no signs of inflammation, and do not involve entry into the gastrointestinal (GIT), tracheobronchial, or urinary tracts. Clean-contaminated wounds are non-traumatic but involve limited contamination from these systems. Contaminated or dirty wounds involve traumatic origins, open systems, or pre-existing infection.

Etiological classification further divides wounds based on the mechanism of injury. Mechanical wounds include incised (rezná), slashed (secná), stabbed (bodná), gunshot (strelná), bite (kousnutím), torn (trzná), bruised (zhmoždina), and complex torn-bruised (trzně-zhmožděná) wounds. Thermal wounds encompass burns (popáleniny) and frostbite (omrzliny). Chemical wounds are distinguished by the substance involved: acids lead to coagulation necrosis, while alkalis (bases) cause liquefactive necrosis. Other categories include wounds caused by radiation or electrical current.

Pathophysiology and Stages of Wound Healing

Wound healing is the process of tissue repair where damaged tissue is replaced by non-functional tissue, known as a scar. The healing process occurs in three distinct stages. The first stage is the Exudative or Cleansing Phase, characterized by a local inflammatory reaction. A blood clot forms to adhere the wound edges together. During this phase, necrotic or devitalized tissue is eliminated through phagocytosis. The second stage is the Proliferative Phase, which focuses on the formation of granulation tissue. The final stage is the Differentiation Phase, which involves maturation, scar formation, and epithelialization.

Clinically, wounds heal via two primary pathways: primary healing (per primam) and secondary healing (per secundum). Primary healing is characterized by manual closure of the wound edges, while secondary healing occurs in infected or open wounds where the tissue must fill in from the base upward. Factors that influence healing are divided into general and local categories. General factors include hypovolemia and hypoperfusion (leading to inadequate tissue nutrition), age, use of corticoids (which suppress the inflammatory response), immunosuppression, chemotherapy, diabetes, malnutrition, vitamin C deficiency, and radiotherapy. Local factors include the quality of blood supply, the specific character of the wound (incised and slashed wounds heal better than torn-bruised ones), localization (wounds in the groin or on the back heal poorly due to lack of rest or friction), the presence of infection or foreign bodies, and surgical technique, such as placing a suture under tension or choosing the wrong suture material.

Initial Surgical Management and Assessment

The immediate treatment of a wound begins with hemorrhage control using compression or electrocoagulation during surgery. This is followed by a thorough toilet of the surrounding area using $H_2O$ and the application of antisepsis using agents like Jod (iodine) or Chlorhexidine. Proper anesthesia is administered before a wound revision and toilet. This includes a physical examination to exclude injuries to nerves, tendons, and vessels, the removal of necrotic tissue and foreign bodies, and wound irrigation.

Documentation of the wound is essential and must include the precise localization, size (measured with a ruler), depth, and the type of exudate present. Clinical assessment must also account for the condition of the surrounding area, levels of pain, and any distinct odors. The overall appearance should be noted, specifically looking for fibrin coatings, granulation, epithelialization, signs of infection, or necrosis. Healthcare providers must also check the patient's tetanus vaccination status. In the case of animal bites, a consultation with an infectious disease specialist is necessary to assess the risk of rabies.

Anatomical Specific Injuries and Chemical Burns

Specific diagnostic protocols are required for wounds in certain anatomical regions. For chest wall injuries, clinicians must exclude pneumothorax and hemothorax using RTG (X-ray) and ultrasound (sono). For abdominal wall injuries, it is vital to exclude penetrating injuries and conditions like pneumoperitoneum or hemoperitoneum via RTG or ultrasound. Head injuries require immediate consideration of possible brain or skeletal (skull) fractures.

Chemical injuries present unique pathological challenges. Acid injuries occur when acids coagulate proteins, leading to coagulation necrosis. Exposure to hydrochloric, sulfuric, or nitric acid can cause severe mucosal burns and intense pain. Treatment focuses on analgesia, stabilization of vital functions (VF), monitoring, establishing i.v. access, rinsing, and neutralization. Alkali (lye) injuries are often more severe as they dissolve proteins and penetrate deep into tissues, causing liquefactive necrosis. These wounds are typically wet and toxic (jedovatá), requiring strong analgesics and similar stabilization measures.

General Principles of Wound Therapy and Debridement

The hierarchy of treatment prioritizes the management of significant bleeding through compression, tourniquets, pressure bandages, or pressure points. Asepsis is the foundational principle for all further care. Infection prevention involves disinfection using agents such as peroxide, boric water, povidone-iodine, or chlorhexidine. Prontoderm may be used for decolonization, and the area may be shaved if necessary.

Debridement, the removal of necrotic tissue that cannot participate in healing, is a cornerstone of wound care. Enzymatic debridement utilizes ointments and hydrogels containing enzymes like hydrolases. Autolytic debridement involves keeping the wound moist to allow the body's own enzymes to break down devitalized tissue. Surgical debridement (necrectomy) is the mechanical removal of tissue using surgical spoons, scalpels, forceps, or scissors. For decolonization and disinfection within the wound itself, products like Prontosan, Aqvitox, Braunovidon, or Braunol are used. Hydrogen peroxide is specifically utilized for removing coarse impurities. Selection of appropriate dressings is vital to maintain moisture and protect the wound based on the phase of healing and levels of exudate.

Advanced Wound Healing Modalities

Modern wound care utilizes several specialized therapies. Hydrotherapy involves hydroactive dressings, such as HydroClean, and is suitable for complicated, non-healing wounds to remove necrosis, clean the area, and support hydration and granulation. This can include compresses, wraps, and baths. Wet therapy is currently the most utilized modern approach; it creates an optimally moist environment to support granulation and epithelialization. Specialized dressings like polyurethanes and hydrocolloids maintain temperature and moisture while absorbing excess exudate. This method allows for less frequent dressing changes and reduces the risk of maceration or drying out. Conversely, Dry therapy is now primarily reserved for already healed or sutured wounds and is becoming less common.

Compression therapy is essential for preventing and treating venous leg ulcers by supporting blood flow and improving circulation. This involves using bandages or stockings alongside wet healing and exercise. Negative Pressure Wound Therapy (NPWT), such as the Vivano system, uses a vacuum to remove infectious material and facilitate active wound closure. It is particularly effective for non-healing or complicated wounds where conservative treatments have failed. Required supplies for these procedures include disinfectants, rinsing solutions, indicated medications, sterile dressings, bandages, sterile drapes, syringes, swabs, sterile instruments (forceps, scissors), and personal protective equipment.