Postoperative wounds explained

Postoperative wounds are those wounds acquired during surgical procedures. Postoperative wound healing occurs after surgery and normally follows distinct bodily reactions: the inflammatory response, the proliferation of cells and tissues that initiate healing, and the final remodeling. Postoperative wounds are different from other wounds in that they are anticipated and treatment is usually standardized depending on the type of surgery performed. Since the wounds are 'predicted' actions can be taken beforehand and after surgery that can reduce complications and promote healing.

Healing sequence

The body responds to postoperative wounds in the same manner as it does to tissue damage acquired in other circumstances. The inflammatory response is designed to create homeostasis. This first step is called the inflammatory stage.[1] The next stage and wound healing is the infiltration of leukocytes and release of cytokines into the tissue. The inflammatory response and the infiltration of leukocytes occur simultaneously. The final stage of postoperative wound healing is called remodeling. Remodeling restores the structure of the tissue and that tissues ability to regain its function.

Diagnosis

Surgical wounds can begin to open between three and five days after surgery. The wound usually appears red and can be accompanied by drainage. Clinicians delay re-opening the wound unless it is necessary due to the potential of other complications. If the surgical wound worsens, or if a rupture of the digestive system is suspected the decision may be to investigate the source of the drainage or infection.[2]

Complications

Wound dehiscence

The rates of a surgical wound opening after surgery has remained constant. When a wound opens after surgery, the hospital stay becomes longer and the medical care becomes more intensive if a surgical wound opens after surgery.[3]

Infection

Infection will complicate healing of surgical wounds and is commonly observed.[3] [4] Most infections are present within the first 30 days after surgery.[5] Surgical wounds can become infected by bacteria, regardless if the bacteria is already present on the patient's skin or if the bacteria is spread to the patient due to contact with infected individuals. Wound infections can be superficial (skin only), deep (muscle and tissue), or spread to the organ or space where the surgery occurred. Recent studies have established that infection after surgery can occur after several years post surgery, and these infection rates are not recorded due to loss in patient follow up, hard to access record of previous surgery, visiting a new surgeon, lack of requirement from national registries etc.[6] [7]

Fascia dehiscence

The surgical site or wound may allow the passage of air into the body. This most often occurs after abdominal and pelvic surgery. Treatment at this point becomes more complex depending upon the extent of the opening, where it occurs and if contents of the digestive system have entered the body.[3]

Risks

The risk of complications of the surgical wound is greater for those greater than 65-years-old, or who have pulmonary disease, nutritional deficiencies, overweight, other illnesses and high blood pressure.[3]

Prevention

Complications of postsurgical wounds can be reduced before, during and after surgery.

Some measures such as antibiotic prophylaxis before caesarean section and hernial repair are useful in reducing surgical site infection. Intravenous prophylactic antibiotics are recommended, to be administered within one hour from the beginning of the surgical procedure.[8] In addition to i.v. prophylaxis, oral antibiotic prophylaxis has been demonstrated to be beneficial in reducing surgical site infections after elective large bowel surgery.[9] [10] Adding a mechanical bowel cleansing in these patients might not be beneficial after colonic resection, but is still used and recommended by many before rectal resection (ideally in combination with oral antibiotics)[11] [12] However, some options include antibiotic coated sutures, antibiotic impregnated cement or locally administered paste or gel.[13] [14] [15] [16] Of note, a recent randomised controlled trial performed in low- and middle-income countries did not report any reduction in surgical site infection after abdominal surgery with antiseptic (triclosan-coated) sutures.[17] There is also evidence that adhesive tapes increase infection risks.[18]

Before surgery, clinicians can treat the patient to reduce hemoglobin A1c levels to less than 7%. Those anticipating surgery can reduce their risk of complications by stopping smoking thirty days prior to surgery. The patient's skin can be evaluated for the presence of Staphylococcus aureus prior to surgery since this bacterium causes wound infections in postoperative wounds. Treating any other infections prior to surgery also reduces the risks of a postoperative wound infection. Examples of these pre-existing infections are urinary tract infection or lower reproductive system infection. Removing the hair where the skin will be cut helps to reduce the risk of complications, though shaving is not considered to be appropriate and instead depilatories are used. Those who come in contact with the person who is receiving the surgery clean and disinfect their own skin surfaces. The patient's skin is also cleaned, scrubbed and treated with antiseptics. Patients undergoing surgery often receive antibiotics before surgery.

During the surgery, there are several precautions that can be taken to reduce the risk of postoperative wound complications. These are: minimizing traffic in the operating room, providing adequate ventilation, not closing wounds that are infected, minimize tissue handling, re-administer prophylactic antibiotics if large amounts of fluid are lost during surgery, and keeping the patient warm.[3] Lately, studies have highlighted new preventative measures of avoiding repeated reprocessing and intraoperatively guarding the implants in the sterile-field, for surgeries implanting single-use devices such as orthopedic and spine surgeries.[19] [20] [21] [22] [23] [24] [25]

The risk of complications after surgery can be reduced by: maintaining blood glucose levels in the normal range and constant evaluation of surgical site infection.[3] [26]

There is insufficient evidence to show that whether applying cyanoacrylate microbial sealants on the wound site before operation is effective in reducing surgical site infection post surgery.[27]

There is no evidence that one type of hand antisepsis is better than the other in preventing surgical site infection.[28]

There is no evidence that plastic adhesive tapes reduces surgical site infections.[29]

See also

Notes and References

  1. Stadelmann WK, Digenis AG, Tobin GR . Physiology and healing dynamics of chronic cutaneous wounds . American Journal of Surgery . 176 . 2A Suppl . 26S–38S . August 1998 . 9777970 . 10.1016/S0002-9610(98)00183-4 .
  2. Stanirowski PJ, Wnuk A, Cendrowski K, Sawicki W . Growth factors, silver dressings and negative pressure wound therapy in the management of hard-to-heal postoperative wounds in obstetrics and gynecology: a review . Archives of Gynecology and Obstetrics . 292 . 4 . 757–775 . October 2015 . 25864095 . 4560760 . 10.1007/s00404-015-3709-y .
  3. Book: Hoffman B . Williams gynecology . McGraw-Hill Medical . New York . 2012 . 9780071716727 . 972–975 .
  4. Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, Sweet FA, Lee DH, Riew KD . 6 . Methods to decrease postoperative infections following posterior cervical spine surgery . The Journal of Bone and Joint Surgery. American Volume . 95 . 6 . 549–554 . March 2013 . 23515990 . 10.2106/JBJS.K.00756 . 207283208 .
  5. Encyclopedia: Surgical wound infection - treatment . MedlinePlus Medical Encyclopedia. U.S. National Library of Medicine . 2017-02-07.
  6. Agarwal A, Kelkar A, Agarwal AG, Jayaswal D, Schultz C, Jayaswal A, Goel VK, Agarwal AK, Gidvani S . 6 . Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery . Global Spine Journal . 10 . 5 . 640–646 . August 2020 . 32677561 . 7359681 . 10.1177/2192568219869330 .
  7. Web site: The Hardest Decision Any Spine Surgeon Has to Make Orthopedics This Week. 2020-08-24. ryortho.com.
  8. Web site: World Health Organization WHO. WHO Surgical Site infection Prevention Guidelines Web Appendix 25. 27 December 2021 .
  9. Espin Basany E, Solís-Peña A, Pellino G, Kreisler E, Fraccalvieri D, Muinelo-Lorenzo M, Maseda-Díaz O, García-González JM, Santamaría-Olabarrieta M, Codina-Cazador A, Biondo S . 6 . Preoperative oral antibiotics and surgical-site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial . The Lancet. Gastroenterology & Hepatology . 5 . 8 . 729–738 . August 2020 . 32325012 . 10.1016/S2468-1253(20)30075-3 . 216109202 .
  10. Pellino G, Espín-Basany E . Bowel decontamination before colonic and rectal surgery . The British Journal of Surgery . 109 . 1 . 3–7 . December 2021 . 34849592 . 10.1093/bjs/znab389 . free .
  11. Nelson RL, Hassan M, Grant MD . Antibiotic prophylaxis in colorectal surgery: are oral, intravenous or both best and is mechanical bowel preparation necessary? . Techniques in Coloproctology . 24 . 12 . 1233–1246 . December 2020 . 32734477 . 10.1007/s10151-020-02301-x . 220857409 .
  12. Koskenvuo L, Lehtonen T, Koskensalo S, Rasilainen S, Klintrup K, Ehrlich A, Pinta T, Scheinin T, Sallinen V . 6 . Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial . Lancet . 394 . 10201 . 840–848 . September 2019 . 31402112 . 10.1016/S0140-6736(19)31269-3 . 199540216 . 10138/319567 . free .
  13. Edmiston CE, Seabrook GR, Goheen MP, Krepel CJ, Johnson CP, Lewis BD, Brown KR, Towne JB . 6 . Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? . Journal of the American College of Surgeons . 203 . 4 . 481–489 . October 2006 . 17000391 . 10.1016/j.jamcollsurg.2006.06.026 .
  14. Shahpari O, Mousavian A, Elahpour N, Malahias MA, Ebrahimzadeh MH, Moradi A . The Use of Antibiotic Impregnated Cement Spacers in the Treatment of Infected Total Joint Replacement: Challenges and Achievements . The Archives of Bone and Joint Surgery . 8 . 1 . 11–20 . January 2020 . 32090140 . 7007713 . 10.22038/abjs.2019.42018.2141 .
  15. McHugh SM, Collins CJ, Corrigan MA, Hill AD, Humphreys H . The role of topical antibiotics used as prophylaxis in surgical site infection prevention . The Journal of Antimicrobial Chemotherapy . 66 . 4 . 693–701 . April 2011 . 21393223 . 10.1093/jac/dkr009 . free .
  16. Kachel E, Moshkovitz Y, Sternik L, Sahar G, Grosman-Rimon L, Belotserkovsky O, Reichart M, Stark Y, Emanuel N . 6 . Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology . Journal of Cardiac Surgery . 35 . 10 . 2695–2703 . October 2020 . 32743813 . 10.1111/jocs.14890 . 220940129 . free .
  17. Reducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trial . Lancet . 398 . 10312 . 1687–1699 . November 2021 . 34710362 . 8586736 . 10.1016/S0140-6736(21)01548-8 . Ademuyiwa . Adesoji O. . Hardy . Pollyanna . Runigamugabo . Emmy . Sodonougbo . Pierre . Behanzin . Hulrich . Kangni . Sosthène . Agboton . Gérard . Adagrah . Luke Aniakwo . Adjei-Acquah . Esther . Acquah . Ato Oppong . Ankomah . James . Armah . Ralph . Acquah . Regina . Addo . Kwame Gyambibi . Acheampong . Dorcas Otuo . Adu-Aryee . Nii Armah . Abubakari . Fatao . Titigah . Abraham . Owusu . Frank . Adu-Brobbey . Raphael . Adobea . Vivian . Abantanga . Francis Atindaana . Gautham . Arun . Bhatti . Dimple . Jesudason . Esther Daniel Mark . Aggarwal . Manisha . Alexander . Philip . Dasari . Amos . Alpheus . Rahul . Kumar . Hemanth . 1 .
  18. Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O'Connor L, Cawthorne J, George RP, Crosbie EJ, Rithalia AD, Cheng HY . Jane Blazeby. 6 . Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews . The Cochrane Database of Systematic Reviews . 2018 . 2 . CD012653 . February 2018 . 29406579 . 6491077 . 10.1002/14651858.CD012653.pub2 . Cochrane Wounds Group .
  19. Agarwal A, Lin B, Agarwal AG, Elgafy H, Schultz C, Agarwal AK, Goel VK, Sigler V, Karas C, Gidvani S, Wang JC, Anand N, Garfin SR . 6 . A Multicenter Trial Demonstrating Presence or Absence of Bacterial Contamination at the Screw-Bone Interface Owing to Absence or Presence of Pedicle Screw Guard, Respectively, During Spinal Fusion . Clinical Spine Surgery . 33 . 8 . E364–E368 . October 2020 . 32168115 . 10.1097/BSD.0000000000000976 . 212707844 .
  20. Agarwal A, MacMillan A, Goel V, Agarwal AK, Karas C . A Paradigm Shift Toward Terminally Sterilized Devices . Clinical Spine Surgery . 31 . 7 . 308–311 . August 2018 . 29912733 . 10.1097/BSD.0000000000000675 . 49303554 .
  21. Agarwal A, Schultz C, Agarwal AK, Wang JC, Garfin SR, Anand N . Harboring Contaminants in Repeatedly Reprocessed Pedicle Screws . Global Spine Journal . 9 . 2 . 173–178 . April 2019 . 30984497 . 6448207 . 10.1177/2192568218784298 .
  22. Agarwal A, Schultz C, Goel VK, Agarwal A, Anand N, Garfin SR, Wang JC . Implant Prophylaxis: The Next Best Practice Toward Asepsis in Spine Surgery . Global Spine Journal . 8 . 7 . 761–765 . October 2018 . 30443488 . 6232723 . 10.1177/2192568218762380 .
  23. Agarwal A, Lin B, Elgafy H, Goel V, Karas C, Schultz C, Anand N, Garfin S, Wang J, Agarwal A . 6 . Updates on Evidence-Based Practices to Reduce Preoperative and Intraoperative Contamination of Implants in Spine Surgery: A Narrative Review . Spine Surgery and Related Research . 4 . 2 . 111–116 . 2020 . 32405555 . 7217678 . 10.22603/ssrr.2019-0038 .
  24. Agarwal A, Lin B, Wang JC, Schultz C, Garfin SR, Goel VK, Anand N, Agarwal AK . 6 . Efficacy of Intraoperative Implant Prophylaxis in Reducing Intraoperative Microbial Contamination . Global Spine Journal . 9 . 1 . 62–66 . February 2019 . 30775210 . 6362554 . 10.1177/2192568218780676 . free .
  25. Web site: Ban 'Reprocessing' of Spinal Surgery Screws, Experts Say. 2020-08-24. Medscape.
  26. Xiong. Ze. Achavananthadith. Sippanat. Lian. Sophie. Madden. Leigh Edward. Ong. Zi Xin. Chua. Wisely. Kalidasan. Viveka. Li. Zhipeng. Liu. Zhu. Singh. Priti. Yang. Haitao. November 2021. A wireless and battery-free wound infection sensor based on DNA hydrogel. Science Advances. 7 . 47 . eabj1617 . EN. 10.1126/sciadv.abj1617. 8604401. 34797719.
  27. Wood C, Phillips C . Cyanoacrylate microbial sealants for skin preparation prior to surgery . The Cochrane Database of Systematic Reviews . 5 . CD008062 . May 2016 . 2016 . 27191948 . 10.1002/14651858.CD008062.pub4 . 9308063 . Cochrane Wounds Group .
  28. Tanner J, Dumville JC, Norman G, Fortnam M . Surgical hand antisepsis to reduce surgical site infection . The Cochrane Database of Systematic Reviews . 2016 . 1 . CD004288 . January 2016 . 26799160 . 8647968 . 10.1002/14651858.CD004288.pub3 . Cochrane Wounds Group .
  29. Webster J, Alghamdi A . Use of plastic adhesive drapes during surgery for preventing surgical site infection . The Cochrane Database of Systematic Reviews . 4 . CD006353 . April 2015 . 2015 . 25901509 . 6575154 . 10.1002/14651858.CD006353.pub4 . Cochrane Wounds Group .

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