Beyond Closure

There is a certain satisfaction that comes with placing that final suture to close your incision and complete the surgical procedure at hand. As the only visual evidence that a surgery has been performed, a surgeon takes great pride in the final appearance of their wound closure.

Postsurgical Wound Care

by Justin Ganjei, DVM, DACVS-SA

Picture1.jpgExample of a recovery shirt used to protect the surgical incisions in a patient that underwent a thoracoscopic thoracic duct ligation and pericardiectomy. This shirt was used instead of an E-collar.

The surgical incision doesn’t often reflect the complexity of the procedure performed. This is true whether it be a massive, 14-centimeter incision to remove a lipoma that has been present for six years, slowly growing to the size of a watermelon, or four 1-centimeter incisions used to complete a laparoscopic adrenalectomy for a pheochromocytoma.

Regardless, there is a certain satisfaction that comes with placing that final suture to close your incision and complete the surgical procedure at hand. As the only visual evidence that a surgery has been performed coupled with the potential for that incision to cause a permanent alteration in the patient’s appearance, it is reasonable to assume that a surgeon takes great pride in the final appearance of their wound closure.

It is also extremely upsetting when a postoperative patient returns for a recheck examination and you discover that there has been an incisional dehiscence or infection. Although owner compliance plays a large factor in the development of postoperative incisional complications, there are other factors that are more under the control of the surgeon and can be used to minimize these complications.

Wound healing is a complex process consisting of three different phases: inflammatory phase, proliferation phase, and maturation phase. These phases are overlapping and work together to provide hemostasis, a decontamination process and barrier against infection, and a robust vascular supply, all of which allow wounds to heal and return to some level of prewounding strength. These phases can be affected by various factors, such as the type of wound, infection, species differences, anatomic location, systemic disease processes, and many other factors. These phases can also be manipulated in both a positive and negative manner by proper or improper wound management.

Stick to Your Principles

The road to minimizing postoperative incisional complications begins with Halsted’s seven principles. The following tenets revolutionized surgery more than a century ago and continue to be vital to minimizing postoperative complications and maximizing successful outcomes in the present day.

  • Gentle handling of tissue
  • Meticulous hemostasis
  • Preservation of blood supply
  • Strict aseptic technique
  • Minimum tension on tissues
  • Accurate tissue apposition
  • Obliteration of dead space

Picture2.jpgUse of a non-adherent, breathable wound dressing to cover an abdominal incision postoperatively.

Gentle tissue handling minimizes postsurgical pain to the patient, decreases postoperative inflammation of the surgical site, and preserves the vascular supply of the skin edges. Closing incisions in multiple layers helps to eliminate dead space and minimize tension on the surgical incision. Maintaining aseptic technique and meticulous hemostasis decreases bacterial burden and media for bacterial colonization, thus decreasing the risk of infection. Accurate tissue apposition is also critical, not only for wound healing but also in minimizing scar formation.

The postoperative management of wounds depends highly on the type of wound that is present. Wounds that can be primarily closed require minimal direct wound manipulation. The most important and often most problematic aspect of managing primarily closed wounds is keeping the patient or other dogs and cats away from the wound. Most commonly this is achieved with the use of an Elizabethan collar.

As effective as these products are at keeping the patient away from the incision, they have been anecdotally associated with negative impacts on patient welfare. This has led to the development of alternative products—such as soft, inflatable donut collars, and recovery suits—that deter patients from traumatizing their incision while attempting to minimize negative impacts on patient welfare. Although these products appear to be effective, there have been no clinical studies performed to evaluate the efficacy or impact on patient welfare on one over another.

Different Wounds, Different Options

Primarily apposed surgical incisions require very minimal postoperative care. They may be left exposed or can be covered with a wound dressing. Wound dressings may provide physical support to the incision, offer protection of the incision, and allow for absorption of wound exudate. Additionally, the applications of topical ointments to provide a moist wound environment may be beneficial for wound epithelialization. Despite these theoretical benefits, there have been no clinical studies that demonstrate superior wound healing or decreased incidence of surgical site infections when using wound dressings compared with leaving primarily closed incisions exposed.

There will be situations where surgeons encounter wounds that are not amenable to primary closure. In these situations, open-wound management will be necessary until the wound either is amenable to closure or will necessitate healing by second intention. If at any point in the wound healing process there is an opportunity for closure, this should be pursued as it will greatly facilitate the healing process.

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Acellular fish skin graft used to enhance epithelialization following a failed skin flap.

In situations where it is not possible, the creation and maintenance of a moist wound environment are favored as this strategy is believed to have numerous advantages over a dry wound environment. Moist wound healing allows for a reduced inflammatory reaction in the wound bed, thus limiting the inflammatory phase of wound healing and injury progression. Numerous studies, including those dated back to the 1960s, have shown improved rates of epithelialization when using a moist wound environment compared with a dry wound environment.

Establishing a moist wound environment is easily accomplished using various topical agents and hydrophilic dressings that are readily available nowadays. There are a variety of products available that can accommodate the specific needs of each wound, which is usually dependent on the degree of wound exudate. Dry to minimally exudative wounds are best treated with water-based hydrogel dressings that serve to rehydrate wound tissue. Mild to moderately exudative wounds benefit from the application of a hydrocolloid dressing that is very effective at absorbing exudate and transforming it into a gelatinous layer.

More heavily exudative wounds benefit from colloidal dressings such as calcium alginate. These dressings, derived from seaweed, have excellent fluid absorption properties and have also been shown to enhance wound healing through increasing granulation tissue and altering collagen ratios. Many of these products are now impregnated with various concentrations of silver, honey, or other antimicrobial agents with the aim of decreasing inflammation and preventing or treating infection.

Advancements in Wound Management

We are fortunate to be alive during a time when new products and techniques are constantly being developed to facilitate wound healing. Some examples of more advanced techniques and products used in veterinary wound management include hyperbaric oxygen therapy, negative-pressure wound therapy, and acellular fish skin grafts.

Hyperbaric oxygen therapy is widely used in human medicine to treat complex wounds and in situations where wound healing is inhibited for some reason. It does not have any beneficial effects for healthy wounds but can be quite helpful for wounds where there is a concern about tissue hypoxia, such as crush injuries, infection, and swelling.

Negative-pressure wound therapy involves the local application of subatmospheric pressure across a wound. This is purported to improve wound perfusion, reduce edema, stimulate granulation tissue formation, decrease bacterial colonization, and remove wound exudate.

Acellular fish skin grafts have recently been used in veterinary medicine to facilitate wound healing. These products, most commonly obtained from North Atlantic cod, incorporate omega-3 fatty acids, collagen, elastin, laminin, fibrin, proteoglycans, and other components into the wound bed, resulting in enhanced granulation tissue formation and epithelialization.

The standards of wound care will likely continue to change over time, especially as veterinary medicine gains access to newer technology that is rapidly becoming available. Despite this, even ancient methods of wound management, such as maggots and hirudotherapy, will continue to traverse time as their proven benefits remain unmatched. 

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Justin Ganjei DVM, DACVS-SA, is a board-certified veterinary surgeon who practices in the Northern Virginia/ Maryland/ Washington, DC region. Ganjei performs a wide variety of both soft tissue and orthopedic surgery, but he has a special interest in minimally invasive surgery, interventional radiology, and pain management. Ganjei regularly lectures at numerous national and international veterinary conferences and is a consultant for the Veterinary Information Network. He enjoys teaching and is an adjunct assistant professor of small animal surgery and minimally invasive surgery at his alma mater, the Virginia-Maryland College of Veterinary Medicine.

 

Photo credits: Photos courtesy of Justin Ganjei

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