Optimizing Wound Outcomes in Surgery: Top Ten Tips Editorial Summary Surgical wound complications can range from surgical wound dehiscence, hypergranulation, periwound maceration, scarring, medical adhesive related skin injury, seroma, and haematoma. Surgical wound complications cause significant morbidity and have significant cost implications.
Introduction
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· Scarring
“Dura est manus cirurgi, sed sans.”
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T
· Medical adhesive-related skin injury (MARSI)
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· Seroma and haematoma
ranslated to ‘the hand of the surgeon is hard but healing’, is a famous quote by Walter Map. Thought provoking in its nature, because often surgery can be hard, tough and intensive on the patient. But our role as surgeons is to try to minimise damage to the tissue whilst carrying out extensive dissections, moving tissue flaps and performing skin substitute surgery and skin grafting. In other specialties such as vascular surgery procedures, lengthy dissections in multiple tissue planes are performed. Obstetric surgery has its own challenges too, including restoration of tissue to their original anatomical positions.
Surgical wound complications remain one of the most common managed wound type in clinical care and a cause of significant morbidity2. The International Surgical Wound Complications Advisory Panel (ISWCAP) has been set up to optimise care for patients with a focus on early identification of complications. The consensus report they produced is a useful guide for clinicians in their wound practice1.
Surgical wound complication (SWC) can range from the following1: •
Surgical wound dehiscence (SWD)
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Hypergranulation
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Periwound maceration
Consultant Plastic and Reconstructive Surgeon (Locum) Editor of Wound Masterclass London, United Kingdom
Tip 1: Surgical Technique Although techniques in surgery are ever evolving, the basic tenets of good surgical technique remain unchanged over time. Essentially a surgeon should consider every step of his or her procedure in advance to optimise all the steps in the procedure. For most procedures we perform, we tend to write down each step of the procedure as a roadmap ahead of time. Within each of those steps of surgery it is important to optimise your technique.
Miss Negin Shamsian
At the basis of these types of surgery remains an underlying set of principles of good technique that minimise wound complications. Careful tissue handling involves: •
Minimal skin edge handing with toothed forceps thus avoiding crush and tissue damage at the edges of your surgical wounds
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Judicious use of cautery devices that can cause heat damage to localised tissues and impair wound healing
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Careful placement of sutures to avoid tension and strangulation and subsequent necrosis of subcutaneous tissues.
Mr Andrew Diver Consultant Plastic and Reconstructive Surgeon (Locum) London, United Kingdom
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Optimizing Wound Outcomes in Surgery
Tip 2: Identify the High Risk Patient
Contaminated:
Patient groups at high risk of infection include the following:
An incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12 to 24 hours old also fall into this category.
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Patients undergoing emergency procedure
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Diabetics
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Obese patients
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Smokers
Dirty or infected:
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Immunosuppressed patients
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Cancer patients
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Long procedure times ( in excess of 2 hours)
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Undernourished or massive weight loss patients
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Older age group3
It is vital to identify patients from these groups pre-operatively to ensure you have a proactive surveillance model applied.
An incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds if treatment is delayed, there is faecal contamination, or devitalised tissue is present Use the local antibiotic formulary and always take into account the potential adverse effects when choosing specific antibiotics for prophylaxis. Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.
Tip 3: Identify High Risk Surgery Antibiotic prophylaxis should be given in: The National Institute of Clinical Excellence provides useful classifications for surgery4.
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Clean surgery that involves a prosthesis or implant
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Contaminated surgery
Clean: An incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered. Those that involve implant or prosthesis should be given antibiotic prophylaxis. Clean-contaminated: An incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.
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Tip 4: Minimise Preoperative Infection Risk Managing patients before surgery Ask the patients to have a shower before surgery. Hair removal is no longer recommended prior to surgery. If the type of surgery indicates the need for hair removal, single use clippers are recommended in place of razors4. Tip 5: Optimise Intraoperative Care Ensure that there is appropriate theatre wear for patient and staff according to your local protocols. Sterile gowns should be worn for operations, and consider double gloving, and
Optimizing Wound Outcomes in Surgery
avoid using diathermy for surgical incisions. Tip 6: Choose the Appropriate Dressing For Coverage After Surgery The NICE guidelines recommend Leukomed Sorbact for vascular and Caesarean incisions4. Tip 7: Optimize the Post Operative Phase Consider digital wound imaging by medical photography as part of your hospitals protocol. Don’t use topical antimicrobials for surgical wounds healing by primary intention. Report SSIs up to 30 days after surgery and 90 days after implant surgery. Monitor closely for signs of dehiscence. Red flags for urgent intervention include haemorrhaging dehiscence, burst abdomen, systemic sepsis , spreading cellulitis, dehiscence over mesh/implants or prosthesis. Ensure that baseline blood tests and wound swabs are taken.
References 1. Optimising Prevention of Surgical Wound Complications: Detection, Diagnosis, Surveillance and Prediction. International Consensus Document 2022. Wounds International. 2. Guest J, Fuller GW, Vowden P, Vowden KR. Cohort study evaluating pressure ulcer management in clinical practice in the UK following initial presentation in the community: costs and outcomes. BMJ Open 8(7): e021769 3. Torpy J. Wound infections. JAMA. 2005;294(16):2122 4. NICE Surgical site infections: prevention and treatment. NICE guideline. Published: 11 April 2019. Available at: www.nice.org.uk/guidance/ng125 5. National Wound Care Strategy Programme 2021. 6. Guest J.F., Ayoub N., McIlwraith T., Uchegbu I., Gerrish A., Weidlich D., et al. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open. 2015;5(12). 7. Stryja J., Sandy-Hodgetts K., Collier M., Moser C., Ousey K., Probst S., et al. Surgical Site Infection: Prevention and Management across Health-Care Sectors. Journal of Wound Care. 2020;29(Sup 2b):S1-S72. Available at: https://ewma.conference2web.com/#resources/384542 8. Sandy-Hodgetts K., Carville K., Leslie G.D. Surgical wound dehiscence: a conceptual framework for patient assessment. Journal of Wound Care. 2018;27(3):119-26. 9. Gray T.A., Rhodes S., Atkinson R.A., Rothwell K., Wilson P., Dumville J.C., et al. Opportunities for better value wound care: a multiservice, cross-sectional survey of complex wounds and their care in a UK community population. BMJ Open. 2018;8(3). 10. World Health Organisation. Global Action Plan on Antimicrobial Resistance. 2015. 6. Lipsky B.A., Dryden M., Gottrup F., Nathwani D., Seaton R.A., Stryja J. Antimicrobial stewardship in wound care: a Position Paper from the British Society for Antimicrobial Chemotherapy and European Wound Management Association. Journal of Antimicrobial Chemotherapy. 2016;71(11):3026-35. 11. Sandy-Hodgetts, K. Best Practice Statement: Antimicrobial stewardship strategies for wound management. Wounds UK, 2020 London. Wounds International.
Tip 8: Consider the Role of Negative Pressure Wound Therapy (NPWT) NPWT has been well established in chronic wounds and there is trend towards considering it for surgical wounds in high risk patients. Particular groups that have been considered include patients with heavy exudating wounds, and wounds at high risk of infection. Tip 9: Consider the Use of Diagnostic Technology Fluorescent imaging provides a useful insight into bacterial activity in the wound. It is well established in the hard-to -heal/ chronic wound groups and is gaining popularity in surgical wounds. Tip 10: Proactive Wound Surveillance Along with data on surgical site infections (SSI) proactive surveillance provides information early on any surgical wound issues. This proactive approach enables the clinicians to entity problems early.
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