Surgical Technology Lecture

Series 2000©

Power-Point®
Wound Healing

The Basics
 Production Notes

Primary Author - Kevin Frey CST, MA

Coauthor and Executive Editor - Bob

Caruthers CST, PhD

Series Editor - Teri Junge CST/CFA

 Table of Contents
• Types of Wounds
• Types of Wound Healing
• Factors Influencing Wound Healing
• Surgical Wound Classifications
• Complications of Wound Healing
• Classifications of Infection
• Infection - Clinical Factors
• Surgical Site Infection
Types of Wounds
 Surgical Wounds

• Surgeon cuts through intact skin

• Surgical wounds are either incisional or
excisional
– Incisional: Cut through intact tissue to expose
or excise underlying structures
– Excisional: Removal of tissue
 Traumatic Wounds
General Information
• With a traumatic injury preservation of life
is the first concern; “life over limb”
• Six types of traumatic wounds
Closed Open
Simple Complicated
Clean Contaminated
Note: A single wound may fall into more than
one category
 Closed Wound
• Skin remains intact
• Underlying tissues damaged
• Hematoma may develop
• Examples
– Contusion
– Torn ligament
– Closed fracture
– Lacerated liver
 Open Wound

• Integrity of the skin is destroyed

• Examples
– Abrasion
– Laceration
– Penetration
– Compound fracture
 Simple Wound
• Integrity of the skin is destroyed
• No loss or destruction of tissue
• No foreign body in wound

• Example
– Laceration
 Complicated Wound
• Tissue is lost or destroyed
• Foreign body remains in the wound

• Examples
– Crush injury
– Burn
– Sliver
 Clean Wound
• Wound edges can be approximated and
secured
• Wound is expected to heal by first intention

• Examples
– Surgical wound (Class I)
– Laceration
 Contaminated Wound
• Contaminated object penetrates skin
• Contamination can become infection within
4-6 hours
• Debridement is necessary
– Wound may be left open to heal by second
intention
– Delayed primary closure may be performed
– Skin graft may be necessary
Contaminated Wound (continued)

• Examples
– Compound fracture
– Gunshot wound
 Chronic Wound
• Wound persists for extended period of time
• Tissue necrosis and/or infection may be
present
• Causes
– Debilitating condition (diabetes)
– Radiation therapy
• Example
– Decubitus ulcer
Types of Wound Healing
 First Intention (Primary Union)
• Most desired method of healing
• No postoperative swelling
• No local present
• No separation of wound edges
• Minimal scar formation
• Wound heals from side to side
• Healing occurs in three phases
 Phase I of Healing by First
Intention

Lag Phase (Inflammatory Response Phase)

• Fibrin deposited; weakly holds wound

edges together for about 5 days
• Fibrin dries out; scab forms
 Phase I (continued)
• Fibroblasts and epithelial cells migrate to
area. These cells adhere to form a stronger
bond of the wound edges; this process of
migration is called fibroplasia
• WBCs (leukocytes) produce an enzyme to
dissolve and remove tissue debris
– Macrophages and neutrophils ingest cellular
debris and bacteria
 Phase II of Healing by First
Intention

Proliferation Phase (Healing Phase)

• Begins approximately the 5th postoperative

day
• Fibroblasts multiply rapidly, restoring
continuity of wound edges
 Phase II (continued)

• Collagen is secreted by fibroblasts and

formed into fibers resulting in a gain in
tensile strength of wound
• Healing phase begins rapidly and lasts 14 to
20 days
 Phase III of Healing by First
Intention
Maturation Phase (Differentiation Phase)
• Scar formation continues with deposits of
fibrous connective tissue
• Fiber pattern re-forms and meshes to
increase tensile strength
• As collagen density increases, vascularity
decreases, scar grows pale
• Phase begins on the14th postoperative day
and lasts anywhere from weeks to months
 Second Intention (Granulation)

Occurrence

• Wound fails to heal by primary union

– Infection causes breakdown of a sutured wound

• Large wounds that cannot be approximated

– Risk of infection is great
– Decubitus ulcer
 Second Intention (continued)

Mechanism of healing

• Wound contraction, rather than primary

union
• Granulation tissue containing fibroblasts
forms in defect and closes by contraction
with secondary growth of epithelium
 Second Intention (continued)
• Features
– Heals from bottom up
– Healing is delayed
– Packing may be placed in wound many times
– May produce weak union conducive to
herniation later
– Excessive scar formation
– Grafting may be necessary during healing or
after healing process to fill in a defect or revise
a scar
Third Intention (Delayed Primary
Closure)

• Occurs when two granulated surfaces are

approximated
– Suturing delayed (4-6 days)
• Deep, wide scar can occur
Factors Influencing Wound
Healing
 Physical Condition of Patient
• General (overall) health
– Preexisting conditions
– Presence of chronic disease
• CV and/or respiratory conditions
– Coughing places strain on abdominal wounds
• Infection
– Smoking
• causes vasoconstriction
• carbon monoxide smoke binds with hemoglobin
 Physical Condition of Patient
(continued)

• Advanced Age
– Thickened connective tissue
– Decreased subcutaneous fat
– Diminished capillary flow
– Reduced vascularity
 Physical Condition of Patient
(continued)
• Nutritional Status
– Deficiencies in protein, carbohydrates, zinc,
vitamins A, B, C, K affect wound healing
• Protein provides amino acids for new tissue
construction
• Carbohydrates provide an energy source for cells
• Vitamin A and Zinc are necessary for collagen
formation; mechanism in wound healing not
understood
 Physical Condition of Patient
(continued)
• Nutritional status (continued)
• Vit. B: necessary for metabolism of carbohydrates,
protein and fat
• Vit. C: permits collagen formation
• Vit. K: involved in synthesis of prothrombin and
blood-clotting factors; found in liver
• Malnutrition has major effect on wound healing
 Physical Condition of Patient
(continued)

• Obesity
– Adipose tissue makes good closure difficult
– Adipose most vulnerable to trauma and
infection due to poor blood supply
– Drains placed to minimize dead space
 Physical Condition of Patient
(continued)

• Hematology
– Anemia: low RBC, result in tissue hypoxia,
which affects synthesis of collagen; low
hematocrit
– Sickle cell disease
– Hemophilia
 Physical Condition of Patient
(continued)

• Drug Therapy
– Steroids: inhibit fibroplasia and collagen
formation
– Chemotherapy delays wound healing
• Radiation Therapy
– Large doses decrease blood supply
 Physical Condition of Patient
(continued)

• Key factor in wound healing

– Early ambulation after surgery
– One of the most important factors in overall
recovery of the patient
Surgical Wound Classifications
 Surgical Wound Classification
Four Classifications
• Class I - Clean
• Class II - Clean Contaminated
• Class III - Contaminated
• Class IV - Dirty and Infected

Note: Wound classification is subject to

change during the procedure
 Class I - Clean

• Wound created under ideal conditions

• No break in sterile technique
• Wound is primarily closed
• No drain necessary
• Infection rate less than 5%
 Class II - Clean Contaminated

• Wound is primarily closed

• Wound drain may be placed
• Minor break in sterile technique
• Controlled entry into aerodigestive or GU
tract
• Infection rate 5% - 15%
 Class III - Contaminated
• Open traumatic wound (less than 4 hours
old)
• Major break in sterile technique
• Inflammation present
• Entry into aerodigestive or GU tract with
spillage
• Infection rate 15% - 27%
 Class IV - Dirty and Infected
• Open traumatic wound (greater than 4 hours
old
• Infection present prior to procedure
• Perforated viscus
• Infection rate 25% - 40%
Complications of Wound Healing
 Scar/Cicatrix
General Information
• Cicatrix is the term used to describe the normal
surgical scar
• Incision made within natural skin folds or along
hairlines if possible
• Location and direction of incision affect scarring
• Patient bases the outcome of the surgery on the
appearance of the scar
 Scar/Cicatrix (continued)

• Hypertrophic Scar
– Result of excessive fibrin formation within
border of scar
– Develop from too much tension on wound,
poor approximation of wound edges, infection
– Can be revised at later date
 Scar/Cicatrix (continued)
• Keloid Scar
– Extends beyond the border of the cicatrix
– Continues to grow
– Can be painful, itchy, prone to bleeding, easily
injured
– Develops due to an inflammatory response;
fibroblast proliferation is overactive during
healing
 Scar/Cicatrix (continued)
• Keloid (continued)
– Inherited trait; common among African-
Americans
– Scar revision with good approximation of skin
edges with skin staples or monofilament,
nonabsorbable suture shows improved results
– Antiinflammatory agent injected into tissue
prior closure
– Pressure dressing may help to prevent keloid
 Adhesion
• Unites two structures that normally are separate
• Band of tissue; can hold a loop of bowel together
causing bowel obstruction and bowel necrosis
(dead bowel)
• Previous abdominal surgery is a common cause
• Peritonitis or ruptured appendectomy can be cause
• Powder granuloma from glove lubricant
 Wound Disruption
• Failure of wound to heal or closure material
to secure wound edges; leads to separation
of wound edges
• Usually occurs between 5th and 10th
postoperative day during the lag phase
when the healing wound is not yet strong
• influenced by several factors, not just one
 Wound Disruption (continued)
• Usually occurs following major abdominal
procedures
• Small opening in peritoneal layer; omentum
starts to slip through
• Omentum swells (edema) and extends
opening along incision line and pushes
upward through other layers of abdomen
 Wound Disruption (continued)
• Disruption usually occurs when sudden
strain is placed on incisional area, such as
vomiting, coughing, sneezing and patient
does not brace area with pillow or hands
– Dehiscence: Partial or total separation of wound
layers
– Evisceration: Viscera is exposed through
incision. This is an emergency situation,
requiring immediate surgery to replace viscera
and close the wound
 Wound Infection
• Wound healing can be interrupted by an infection
during any phase of wound healing
• Bacterial infection most common cause of
infection in surgical patients
• Wound infection usually begins between 4th and
8th postoperative day
• Cellulitis occurs: inflammatory process indicating
infection; pain, redness, swelling, heat
• This body’s first initial defense to localize and
contain invading microbes
 Wound Infection (continued)

• RBC’s, WBC’s, and macrophages infiltrate

the area; abscess is formed (suppuration)
• Abscess is result of tissue breakdown
(liquefaction) and spread of infection
• Body attempts to wall off infection/abscess
with a membrane that produces surrounding
induration and heat
• Attempt should be made to drain abscess
 Wound Infection (continued)

• If infection is not localized it may become

regional
• Microbes are carried from main site of
infection into the lymphatic system
• If lymph system can’t control infection, it
becomes systemic
• Systemic infection may be characterized
with chills, fever, and signs of toxicity
 Wound Infection (continued)
• Sepsis (wound infection that has become
systemic) accelerates the patient’s metabolic
rate 30-40%, placing stress on vital body
systems
• The ability of the body’s defense system
and external factors determine if the
condition will progress to septic shock;
possibly leading to death
 Wound Infection (continued)

The “D’s” of Wound Infection

• Delayed healing • Deformity

• Discomfort • Disaster
• Distress • Dollars
• Dependency • Disability
Classification of Infections
 General Information
• Surgical infections classified by source or
clinical factors such as pathophysiology,
anatomic location of infection, microbial
etiology
• Sources include preexisting infection,
communicable disease, and nosocomial
infection
 Community Acquired Infection

• Infection developed or incubating prior

patient admission to health care facility
– Communicable disease: Systemic bacterial,
viral, or fungal infection
– Existing infection: Localized infection
requiring surgery (appendicitis) and/or therapy
(antibiotics)
 Nosocomial Infection
• Infection acquired within a healthcare
setting
– Exogenous: Acquired from sources outside of
body - cross contamination
• Fomite (door knob)
• Another individual
• Cross contamination
Nosocomial Infection (continued)
– Endogenous: Develops from sources within the
body.
• Majority of postoperative wound infections result
from endogenous source.
• Surgery disrupts the body’s microbial balance
– 35% of all nosocomial infections develop in surgical
patients
– Majority related to urinary and respiratory tracts
– Wound infection second most common nosocomial
infection
Nosocomial Infection (continued)
Examples of Nosocomial Infections

• Urinary tract infection (UTI)

• Upper respiratory infection (URI)
• Cellulitis/surgical abscess
• Peritonitis
• Ruptured viscous (spontaneous or due to
penetrating injury)
Infection - Clinical Factors
 General Information

• Infection results from interaction of 3

elements: microbes, tissues, body’s defenses
• Infection = (# of microbes x virulence)
divided by host defenses
• Surgery, of course, lowers body’s resistance
 Pathogenic Microbes

• Must be introduced or already present

– Must survive and multiply in wound
– Severity of infection depends on number of
microbes and virulence of microbe
 Local Factors
• Location of surgical site and condition of
tissues in surgical site
• Necrotic, avascular tissue, presence of a FB,
or accumulated blood and body fluids
contribute to growth of microbes by
providing excellent internal media
• Body tissues have varying powers of
resistance
– Low resistance: abdomen, thigh, calf, buttocks
– Greater resistance: face, scalp, chest
 Surgical Factors
• Surgical wounds are initially
– Uninfected
– Possibly infected: inflamed without discharge
(culture may be negative)
– Infected: suppuration with pus/drainage
 Surgical Factors (continued)
• Surgical procedures of the GI, GU, and
biliary tracts
– Some contamination occurs when these tracts
are opened
– Control of extent of contamination is important
• Length of surgical procedure
– Longer the person is open, the greater the
chance of contamination and infection
 Surgical Factors (continued)

• Constant implementation of Standard

Precautions
• Strict adherence to sterile technique
• Tissue handling technique
– Gentle tissue handling
– Gentle tissue retraction
 Other Factors
• Length of hospitalization
– Some organisms can maintain virulence by
passing from person to person
– Health care facility is concentrated reservoir of
microbes that can be easily transferred between
people and fomites
• Traumatic injuries
– Microbes can quickly grow and colonize in
open traumatic wounds
Surgical Site Infection
 Incisional Wound Infection
• Infection occurs at site of incision within 30
days following the procedure
• Skin, subcutaneous tissue, and muscle may
be involved
• Inflammation present
• Pus present (invading microbe identified by
culture)
• I&D may be necessary
 Deep Wound Infection
• Infection occurs in the tissue at or beneath
the fascia, at the surgical site
– Within 30 days following the procedure (no
prosthesis present)
– Within 1 year of procedure (implanted
prosthesis)
• Pus may be present
• Dehiscence could occur
• I&D may be necessary
 Postoperative Wound Infection
• Gram-negative bacteria are primary
contaminants in nosocomial infections
• Staphylococci species of gram positive
cocci are common pathogens
– Staph infections acquired in OR are
characterized by pus deep beneath the wound
site, redness, fever
– Symptoms within 7 days after surgery, indicates
infection acquired in OR
 Postoperative Wound Infection
(continued)
• Peritoneal contamination and infection can
result from manipulation of the viscera
(intestines) without actually opening or
entering the small or large bowel in patients
with malignant tumors/lesions
– Bowel wall can erode, permitting intestinal
microbes to escape into the peritoneal cavity
 Postoperative Wound Infection
(continued)
• Anaerobic microbes thrive in oxygen
deficient tissues
– They outnumber aerobic microbes in the GI
tract
– Less susceptible to antibiotics
– Often present in lower genital tract of females
and can cause severe pelvic inflammatory
disease (PID)
The Surgical Technologist’s Role
in Prevention of Surgical Site
Infection
• Frequent handwashing to prevent cross
contamination

• Strict adherence to sterile technique

• Follow all policies and procedures related to

Standard Precautions