9. Wound treatment and primary surgical treatment

1. Indications

• Primary surgical treatment (PST, primary surgical debridement) → first operation on an accidental wound
• Purpose:
  • Convert a contaminated wound into a surgically clean wound
  • Remove dead tissue (primary necrosis), foreign bodies and bacteria
  • Stop bleeding
  • Restore damaged structures
  • Create conditions for primary healing
• Done in the first 6–8 h (early PST)
  • Delayed PST → 24–48 h, with antibiotics
  • Late PST → > 48 h, infected wound; drainage, no closure
• Every deep, contaminated, contused or gunshot wound

2. Contraindications

• Shock → resuscitate first
• Superficial abrasions and small clean incised wounds → simple cleaning and closure
• Small through-and-through bullet wounds with no organ, vessel or bone damage
• Established infection → open and drain, no excision with closure

3. Preparation and positioning

• Assess the patient first → Advanced Trauma Life Support (ATLS) priorities
• Check distal pulses, sensation, movement before anaesthesia
• Tetanus prophylaxis → toxoid and/or human tetanus immunoglobulin according to immunisation status
• Antibiotics → contaminated, bite and old wounds
• X-ray → foreign bodies, fractures
• Anaesthesia → local infiltration, regional block or general
• Clean the skin around the wound, shave if needed; antiseptic from the wound edge outwards

4. Steps

1. Irrigate the wound with large volumes of saline under pressure
2. Explore the whole depth of the wound; extend the incision if needed (dissection)
3. Excise non-viable skin edges, 1–2 mm (face: minimal or none)
4. Excise dead fat, fascia and muscle
5. Muscle viability → 4 C's: colour, consistency, contractility, capillary bleeding
6. Remove foreign bodies and clots
7. Achieve haemostasis
8. Repair vessels, nerves, tendons when the wound is clean (or tag for later repair)
9. Irrigate again; change gloves and instruments
10. Decide on closure: primary suture or leave open
11. Drain if dead space remains
12. Dressing, immobilisation, elevation

5. Closure of the wound

A. Primary suture

• Immediately after PST, within 6–8 h
• Face and scalp → up to 24 h
• Indications:
  • Fresh wound, < 6–8 h
  • Complete debridement possible
  • Good blood supply, no tension
  • Patient can be observed
• Contraindications:
  • Wound > 8–12 h old
  • Heavy contamination, soil
  • Gunshot wounds, war wounds
  • Bite wounds (except the face)
  • Crushed tissue, incomplete debridement
  • Signs of infection

B. Delayed primary suture

• 3–5 days after PST
• Wound clean, no granulation tissue yet, no signs of infection
• Contaminated, bite, gunshot wounds

C. Early secondary suture

• 8–15 days, on a granulating wound without scar
• Edges mobilised without excision

D. Late secondary suture

• After 2–3 weeks, scar tissue present
• Excise the scar and granulations, then close

E. Other methods

• Skin grafts → split-thickness, full-thickness
• Local flaps
• Negative pressure wound therapy

6. Suturing a treated wound

• Skin sutures:
  • Simple interrupted → most common
  • Vertical mattress (Donati) → everts edges
  • Horizontal mattress
  • Intradermal (subcuticular) → best cosmetic result
• Materials → non-absorbable monofilament for skin (nylon, polypropylene); absorbable for deep layers
• Alternatives → staples, adhesive strips, tissue adhesive
• Rules:
  • Close dead space in layers
  • No tension on the edges
  • Equal bites on both sides, edges slightly everted
• Suture removal:
  • Face → 3–5 days
  • Scalp → 7–10 days
  • Trunk → 7–10 days
  • Limbs → 10–14 days
  • Over joints, back, feet → 14 days

7. Complications

• Wound infection → remove sutures, open and drain
• Haematoma, seroma
• Wound dehiscence
• Tetanus, gas gangrene → in untreated, contaminated wounds
• Missed foreign body, missed nerve or tendon injury
• Hypertrophic scar, keloid