Wound dehiscence - Prevention and management
1 - Prevention;
The best way to avoid a wound dehiscence (wound breakdown), is by utilising good surgical technique and by applying careful decision making around timing for closure of open wounds. Here are a few tips.
- Apply Halstead's principles (gentle tissue handling, meticulous hemostasis, preservation of blood supply, aseptic technique, minimising tension, accurate tissue apposition, obliteration of deadspace)
- Consider a drain to prevent a hematoma or seroma, (unless you suspect you are leaving neoplastic cells).
- Identify systemic disease and treat where appropriate
- Don’t repair prematurely i.e don’t repair unhealthy wounds that cannot be converted to healthy wounds prior to closure (most common mistake)
- Exercise restriction to prevent excessive motion
- Avoid early suture removal in cats (they are slower to heal - I generally aim to remove sutures at 14 days)
- Delay chemotherapy or radiation for at least 10 days after repair
- HEAD COLLAR
This was a picture taken just before I gave my talk on wound dehiscence at the VSS conference. For a residency training programme, you are required to give a minimum of 5 talks, but often with conferences, workshops, residents forum and seminars it ends up being a lot more than this.
2 - Treatment Step 1: ID your risk factors (what led to the breakdown?). These can be patient related (e.g. disease), external factors (e.g. medications, infection) or surgeon related. I will focus on surgeon related factors. Surgeon related risk factors are; - Poor technique – incorrect suture/needle selection or knot-tying, poor choice of suture placement, fat within the wound edges or poor closure of dead-space - Tension – increased tension will put more pressure on the sutures and may lead to poor blood supply to the wound edges and ischemic necrosis of tissues. Seromas increase the tension on a wound. - Poor timing or conditions for closure (common) Step 2: Classify type of dehiscence. 1 – A small breakdown that affects the superficial layer only and is non-infected. 2 – A small infected area but otherwise the wound is healthy 3 – A medium - large healthy wound with a complete breakdown 4 – A medium - large infected or unhealthy wound with complete breakdown Step 3: treat Treatment differs for each type of dehiscence above. I will cover type 4. - General anaesthesia - Sterile technique including drapes - Remove tissue for deep culture (aerobic and anaerobic) - Explore the extent of the wound and debride any obviously devitalised or necrotic tissue. Take care not to remove any healing tissue. If in doubt, leave for the bandages, topical wound therapies or autolytic debridement. - Start broad-spectrum antibiotics whilst awaiting culture results. - Consider histopathology if neoplasia is suspected at the wound margins - Irrigate with copious amounts of saline DO NOT ATTEMPT RE-CLOSURE. Consider one of the below options; a) manage as an open wound with bandaging techniques, then repair prior to the formation of granulation tissue = delayed primary closure b) manage as an open wound with bandaging techniques then repair post the formation of granulation tissue = secondary closure c) leave to heal via granulation, contraction and re-epithelialisation = second intention healing.
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