General Surgery (Part-2)
PHASES OF ACUTE WOUND HEALING
Personal Notes
Early phase:
| Hemostasis
| Inflammation
Intermediate phase:
| Fibroblast migration
| Angiogenesis
| Epithelialization
Late phase:
| Collagen synthesis
| Wound contraction
| Scar formation and remodeling
Timeline of Wound Healing
Start End
Hemostasis Day 0 Day 0
Inflammation Day 0 Day 4
Fibroblast Day 2 Day 4
Migration
Collagen Synthesis Day 3 Scar: 2-3 weeks till 18-24 months
Peak: 4 weeks
Wound Contraction Day 4 Day 12-15 (2nd-3rd week)
Collagen synthesis:
| Requires proline and lysine → Undergoes hydroxylation with the help of
cofactors: vitamin C, iron, alpha-ketoglutaric acid.
| Hydroxyproline and hydroxylysine help in collagen formation.
| Granulation tissue: Type III collagen
| Early scar: Type III collagen
| Initial scar: Type III: I (1:1)
| Final scar: Type I: III (4:1)
Scar strength in comparison to normal skin:
Personal Notes
| 1 week: 3%
| 3 weeks: 20%
| 12 weeks: 80% (Maximum scar strength)
| Maximum: 90% (Theoretically maximum)
| 100% scar strength is not possible.
Causes of Post Operative Fever
| Wind: Day 1 (Atelectasis of lung)
To prevent chest physiotherapy
Adequate analgesia
Absolutely no smoking
Steam inhalation
| Water: Day 2-3 (UTI, Nosocomial infection)
Superficial thrombophlebitis
| Wound: Day 4-5 (Surgical site infection, wound infection)
| Walking: Day 5 (DVT)
| Day 6: Burst abdomen
Rectus sheath opened up
Bowel exposed out
Clinical features:
Salmon coloured fluid from wound site.
Large in quantity
Management:
Emergency: Urobag, bogota bag.
Definitive: Rectus resuturing.
| Day 7: Intra abdominal abscess.
Factors predisposing for burst abdomen:
| Patient:
Chronic cough
Post operative constipation
Immunocompromised patient
Obesity
Poor nutrition
2 Surgery
| Surgical:
Personal Notes
Incision: Midline > transverse
Emergency > elective
Continuous suture > interrupted suture
Poor choice of suture material
SSI (Surgical Site Infection):
| Any wound infection within 30 days of surgery.
| Post implant within 1 year of surgery.
Asepsis wound scale:
| A: Additional treatment is required for wound healing.
| S: Serous discharge present
| E: Erythema present
| P: Purulent exudate present
| S: Separation of deep tissue
| I: Isolation of organism (Most important)
| S: Stay in hospital greater or equal to 14 days due to surgical site
infection.
Southampton Wound Grading System
| Grade 0: Normal healing
| Grade I: Mild erythema
| Grade II: Erythema + signs and symptoms of inflammation.
| Class III: Clear or haemoserous discharge
| Class IV: Pyogenic discharge
| Class V: Severe wound infection without tissue loss or hematoma
requiring aspiration.
CLASSIFICATION OF SURGICAL WOUNDS
Class Description Examples % of SSI
Clean | Elective | Thyroid surgery 1-2 %
incised wound Breast surgery
| No role of
| Non-traumatic | Lipoma excision pro p hy l a ctic
No entry into antibiotics
|
| Uncomplicated
the natural inguinal hernia
cavity.
| Knee
replacement
| CABG
| Brain surgery
General Surgery (Part-2) 3
Clean | Nontraumatic | Elective <10 % Personal Notes
contaminated Elective cholecystectomy
| If given
surgery | Elective prophylactic
| Entry into appendectomy antibiotics: <
the natural | Elective bowel 3%
cavity in a surgery
controlled | Renal stone
environment. surgery (UTI
absent)
| Hysterectomy
| Duodenal
perforation
(chemical
peritonitis)
Contaminated | Traumatic | Emergency 20 %
wounds cholecystectomy
If given
| Emergency | Emergency prophylactic
bowel surgery appendectomy antibiotics:
| Entry into | Large 6%
natural instructional
cavity in an obstruction
emergency. | Open cardiac
massage
| Reexploration
| Bowel spillage
| Renal surgery
with UTI
| Hollow viscus
perforation
Dirty | Presence of | Abscess 30 - 70 %
pus Fetal peritonitis
| If given
| Infected prophylactic
traumatic wound antibiotics: <
(> 6 hours) 10%
| Enterocutaneous
fistula
| Delayed open
traumatic
wounds
4 Surgery
ULCERS
Personal Notes
| Breach in the continuity of the epithelial surface or mucous membranes
with microscopic death of the tissue due to an underlying cause.
Sloping edge: | Healing ulcers
| Venous ulcer
Undermined edge: | Tuberculosis ulcer
| Necrotizing fasciitis
Punched out edge: | Syphilitic ulcer
| Trophic/arterial ulcer
Raised and beaded edge: | Basal cell carcinoma
Raised and everted: | Squamous cell cancer
PRESSURE SORES
Criteria:
| Aka bedsore/decubitus ulcer.
| Pressure exerted over a part for sustained period > capillary occlusive
pressure (>30 mmHg).
| Tissue hypoxia over the pressure site.
Risk factors:
| Chronic bedridden status
| Prolonged immobilization
| Wheelchair bound
General Surgery (Part-2) 5
Sites:
Personal Notes
| Ischium > greater trochanter > sacrum > heel > lateral malleolus
Grade Description Management
I Presence of Conservative
non-blanching management:
erythema. | Water or
airbed
| Frequent
change in
position (2
Hourly for
bedridden
patients)
II Partial
thickness skin | Wheelchair
loss. patients: 10
minutes/10
seconds
III Full thickness Intervention:
skin loss. | Cleaning and
debridement
| Ulcer dressing:
VAC (Vacuum-
Assisted
Closure)/
NPWCS
(-125 mmHg,
IV Involvement intermittent
of underlying bases, change
structures. dressing once
in 3-5 days)
| Conservative
protocol
| Grafting/flap
Unstageable: Ulcer is covered with sluff or necrosis.
6 Surgery
