Secondary seam
A distinction is made between early and late Sh. centuries. Early Sh. century. applied to a granulating wound with moving edges until scarring processes develop in it within 1 to 2 weeks after the initial surgical treatment. Late Sh. century. applied to a granulating wound in which scar has already developed (3-4 weeks after the wound and later). In this case, the scarred edges are first excised. Application of secondary sutures on purulent wound is possible only after careful excision of all necrotic and non-viable tissue and subsequent adequate drainage. Primary healing in this case is possible in the absence of pathogenic microflora or contamination of the wound below a critical level - 10 5 microbial per 1 G fabrics. For better adaptation, if necessary, resort to excision or mobilization of the wound edges. Closed cavities and pockets (non-drainable) should not be left in the wound, because this may contribute to secondary suppuration. It is undesirable to leave non-absorbable ligatures (silk, lavsan, etc.) in the wound. Regardless of the timing and suturing method used, it is recommended to use only removable sutures. If the edges of the wound are smooth and there are no cavities or pockets, you can bring its edges together using strips of adhesive plaster. The application of secondary sutures significantly reduces the healing time of wounds and provides better wound healing compared to secondary intention, functional and cosmetic outcomes.
1. Small medical encyclopedia. - M.: Medical encyclopedia. 1991-96 2. First health care. - M.: Great Russian Encyclopedia. 1994 3. encyclopedic Dictionary medical terms. - M.: Soviet Encyclopedia. - 1982-1984.
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At the end of the initial surgical treatment, you always have to decide whether to sew the wound tightly, partially, or leave it open. The desire to stitch a wound tightly is very understandable and is explained primarily by the fact that a sutured wound heals in a shorter time. This issue is especially important when treating gunshot wounds, which have their own characteristic pathomorphological features.
Deadlines for their application.
The suture applied to the wound at the completion of PSO is called primary. Such a suture is permissible to apply only in cases where there is complete confidence in the absolutely radical primary surgical treatment, i.e.:
Treatment was performed in the first 6-8 hours after damage;
Foreign bodies, necrotic tissue, hematomas and areas of microbial contamination are completely removed;
Reliable hemostasis is ensured;
No damage great vessels and nerve trunks;
The edges of the wound come together freely without tension;
The general condition of the wounded is satisfactory;
It is possible to continuously monitor the operated patient for 4-5 days.
Confidence in meeting these conditions can only be when treating shallow musculocutaneous wounds, which limits the scope of application of primary sutures. If there is no such confidence, the wound is loosely packed.
Packing the wound should be carried out in such a way that the gauze swab loosely fills the entire wound cavity. A large number of medications, proposed for wetting tampons, makes their final choice difficult. However, wound packing has three purposes:
Keep the wound open;
Ensure the outflow of wound fluid (for this, the tampon must be hygroscopic);
Create an antiseptic environment in the wound.
Hypertonic sodium chloride solution.
Primary provisional sutures can be applied when, upon completion of the primary surgical treatment, there is no complete confidence in its radicality, however, the nature of the wound and the degree of its contamination do not inspire any particular concern. In such cases, sutures are applied without tightening the threads. After 3-4 days, with a calm wound, the threads are pulled and tied.
Delayed primary suture applied in cases where on the 3-6th day after PSO it turns out that the swelling has decreased or subsided, the color of the wound walls has not changed, the walls are actively bleeding, there is no pus or necrotic tissue in the wound.
In the case of a gunshot wound, by this time the tissues caught in the zone of molecular shock either become necrotic or restore their viability. If inflammatory-necrotic changes are noted during dressing, the wound still cannot be sutured.
Secondary early suture applied when, after suppuration of the wound and subsequent cleansing of pus, its bottom and walls are filled with granulations.
This usually occurs on the 10-18th day after injury. At the same time, during this period, contraction of the wound edges usually occurs and they diverge somewhat. In some cases, special techniques must be used to bring together and hold the edges of such a wound.
When stitches have to be placed after more than long term after injury, the walls of the wound become rigid, the edges of the wound and partially granulations degenerate into scar tissue.
When you try to bring the edges of such a wound closer together, they tuck under. To apply secondary late sutures, it is necessary to excise the edges and walls of the wound, and in some cases also to mobilize the tissue in its circumference. Sometimes such mobilization does not bring success. In these cases, it is necessary to resort to various types skin plastic surgery.
Thus, it becomes clear that, given the specific characteristics of gunshot wounds, only secondary sutures (early or late) can be applied to them.
The only exceptions are wounds of the face, scalp, hand, penis, i.e. those areas that, on the one hand, are well supplied with blood (which reduces the risk of developing infectious complications), and, on the other hand, the formation of scar tissue in these areas (which is inevitable when primary sutures are abandoned) is extremely undesirable. In addition, primary sutures are applied to the gunshot wound for combined radiation injuries.
In all other cases the application of primary sutures to a gunshot wound is strictly prohibited!
DetailsAdvantages of suturing: accelerated healing, reduced losses through the wound surface, reduced likelihood of re-suppuration, increased functional and cosmetic effect, easier wound treatment.
Primary. It is applied until granulations form, the wound heals by primary intention. Apply immediately after surgery or early postoperative surgery in the absence of a high risk of development purulent complications. Removing sutures after the formation of a dense connective tissue(scar) and epithelization.
Primary delayed. It is applied until granulations form, the wound heals by primary intention. Immediately after surgery and delayed PSO, when there is a certain risk development of infection. Apply for 1-5 days after inflammation subsides. A variation is provisional sutures, in which sutures are placed, but the threads are not tied, and the edges of the wound are not closed in this way.
Secondary. Apply to granulating wounds, which heal by secondary intention. The meaning is to reduce or eliminate the wound cavity (with all the consequences). Indications: granulating wound after elimination inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. A) Early secondary (6-21 days) and B) Late secondary (after 21 days). They are differentiated because by the 21st day, scar tissue forms, preventing rapprochement and fusion. Therefore, when applying late secondary sutures, the scarred edges of the wound are excised under aseptic conditions, only then a suture is applied and the threads are knitted. To speed things up, tightening the edges of the wound with an adhesive plaster is sometimes used.
Primary sutures applied to the wound before granulation begins to develop, and the wound heals by primary intention.
Most often, primary sutures are placed immediately after completion of the operation or PSO wounds in the absence of a high risk of developing purulent complications. It is not advisable to use primary sutures in cases of late PHO, PHO in war time, PCS of a gunshot wound.
Sutures are removed after the formation of a dense connective tissue adhesion and epithelization within a certain time frame.
Primary delayed sutures also applied to the wound until granulation tissue develops (the wound heals by primary intention). They are used in cases where there is a certain risk of developing an infection.
Technique: the wound after surgery (PSO) is not sutured, the inflammatory process is controlled and when it subsides, primary delayed sutures are applied on days 1-5.
A variety of primary delayed sutures are provisional stitches: at the end of the operation, stitches are applied, but the threads are not tied, so the edges of the wound are not brought together. The threads are tied for 1-5 days when the inflammatory process subsides. The difference from conventional primary delayed sutures is that there is no need for repeated anesthesia and suturing of the wound edges.
Secondary seams applied to granulating wounds that heal by secondary intention. The purpose of using secondary sutures is to reduce (or eliminate) the wound cavity. A decrease in the volume of a wound defect leads to a decrease in the number of granulations required to fill it. As a result, healing time is reduced, and the content of connective tissue in a healed wound, compared to wounds that were treated open method, far less. This has a beneficial effect on appearance And functional features scar, on its size, strength and elasticity. Bringing the edges of the wound closer together reduces the potential entry point for infection.
The indication for the application of secondary sutures is a granulating wound after the elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. To objectify the subsidence of inflammation, culture of wound discharge can be used - in the absence of growth pathological microflora secondary sutures can be applied.
Highlight early secondary sutures(they are applied on 6-21 days) and late secondary sutures(application is carried out after 21 days). The fundamental difference between them is that by three weeks after the operation, scar tissue forms at the edges of the wound, preventing both the rapprochement of the edges and the process of their fusion. Therefore, when applying early secondary sutures (before the edges become scarred), it is enough to simply stitch the edges of the wound and bring them together by tying the threads. When applying late secondary sutures, it is necessary to excise the scarred edges of the wound under aseptic conditions (“refresh the edges”), and after that apply sutures and tie the threads.
To speed up the healing of a granulating wound, in addition to suturing, you can use tightening the edges of the wound with strips of adhesive tape. The method does not completely and reliably eliminate the wound cavity, but it can be used even before the inflammation has completely subsided.
Tightening the edges of a wound with an adhesive plaster is widely used to speed up the healing of purulent wounds.
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a) Definition, stages
PRIMARY SURGICAL TREATMENT OF A WOUND is the first surgery performed on a patient with a wound under aseptic conditions, with anesthesia and consisting of the sequential implementation of the following steps:
- Dissection of the wound.
- Revision of the wound channel.
- Excision of the edges, walls and bottom of the wound.
- Hemostasis.
- Restoring the integrity of damaged organs and structures
- Applying sutures to the wound, leaving drainage (if indicated).
Dissection of the wound is necessary for a complete inspection, under eye control, of the area of the wound channel and the nature of the damage.
Excision of the edges, walls and bottom of the wound is carried out to remove necrotic tissue, foreign bodies, as well as the entire wound surface infected during injury. After completing this stage, the wound becomes cut and sterile. Further manipulations should be carried out only after changing tools and processing or changing gloves. It is usually recommended to excise the edges, walls and bottom of the wound en bloc for approximately 0.5-2.0 cm (Fig. 4.3). In this case, it is necessary to take into account the location of the wound, its depth and the type of damaged tissue. For contaminated, crushed wounds, wounds on lower limbs the excision should be wide enough. For wounds on the face, only necrotic tissue is removed, and for an incised wound, excision of the edges is not performed at all. It is impossible to excise the viable walls and bottom of the wound if they are represented by tissues internal organs(brain, heart, intestines, etc.).
After excision, careful hemostasis is carried out to prevent hematoma and possible infectious complications.
It is advisable to perform the restorative stage (suturing nerves, tendons, blood vessels, connecting bones, etc.) immediately during PSO, if the surgeon’s qualifications allow it. If not, you can subsequently perform a repeat operation with a delayed suture of the tendon or nerve, or perform delayed osteosynthesis. Restoration measures should not be carried out in full during PHO in wartime.
Suturing the wound is the final stage of PSO. The following options are available for completing this operation.
- Layer-by-layer suturing of the wound tightly
- Suturing the wound leaving drainage(s)
but it is very small, or the wound is localized on the foot or lower leg, or the damage area is large, or PSO is performed 6-12 hours from the moment of injury, or the patient has concomitant pathology, adversely affecting wound process, etc.
- The wound is not stitched up
- late PHO,
- excessive soil contamination of the wound,
- massive tissue damage (crushed, bruised wound),
- accompanying illnesses(anemia, immunodeficiency, diabetes),
- localization on the foot or lower leg,
- elderly age patient.
Suturing the wound tightly in the presence of unfavorable factors is completely unjustified risk and an obvious tactical mistake by the surgeon!
b) Main types
The sooner PSO of the wound is performed from the moment of injury, the lower the risk of infectious complications.
Depending on the age of the wound, three types of PST are used: early, delayed and late.
Early PST is performed within 24 hours from the moment of wound infliction, includes all the main stages and usually ends with the application of primary sutures. If there is extensive damage to the subcutaneous tissue and it is impossible to completely stop capillary bleeding, drainage is left in the wound for 1-2 days. Subsequently, treatment is carried out as for a “clean” postoperative wound.
Delayed PST is performed from 24 to 48 hours after the wound is inflicted. During this period, inflammation develops, swelling and exudate appear. The difference from early PSO is that the operation is performed while antibiotics are administered and the intervention is completed by leaving the wound open (not sutured) followed by the application of primary delayed sutures.
Late PST is performed after 48 hours, when inflammation is close to maximum and the development of the infectious process begins. Even after PSO, the likelihood of suppuration remains high. In this situation, it is necessary to leave the wound open (not sutured) and administer a course of antibiotic therapy. It is possible to apply early secondary sutures on days 7-20, when the wound is completely covered with granulations and becomes relatively resistant to the development of infection.
c) Indications
The indication for performing PST of a wound is the presence of any deep accidental wound within 48-72 hours from the moment of application.
The following types of wounds are not subject to PST:
- superficial wounds, scratches and abrasions,
- small wounds with edge separation of less than 1 cm,
- multiple small wounds without damage to deeper tissues (shot wound, for example),
- puncture wounds without damage to internal organs, blood vessels and nerves,
- in some cases end-to-end bullet wounds soft tissues.
There are only two contraindications to performing PSO of a wound:
- Signs of development of a purulent process in the wound.
- Patient's critical condition ( terminal state, shock
- degrees).
- TYPES OF SEAMS
Advantages of suturing:
- acceleration of healing,
- reduction of losses through the wound surface,
- reducing the likelihood of repeated wound suppuration,
- increasing functional and cosmetic effect,
- facilitating wound treatment.
a) Primary sutures
Primary sutures are placed on the wound before granulation begins to develop, and the wound heals by primary intention.
Most often, primary sutures are applied immediately after completion of the operation or postsurgical surgical treatment of the wound in the absence of a high risk of developing purulent complications. Primary sutures are not advisable to use in late post-surgical treatment, post-surgical treatment in wartime, or post-surgical treatment of a gunshot wound.
Sutures are removed after the formation of a dense connective tissue adhesion and epithelization within a certain time frame.
Primary delayed sutures are also placed on the wound before granulation tissue develops (the wound heals by primary intention). They are used in cases where there is a certain risk of developing an infection.
Technique: the wound after surgery (PSO) is not sutured, the inflammatory process is controlled and, when it subsides, primary delayed sutures are applied on days 1-5.
A type of primary delayed sutures are provisional: at the end of the operation, sutures are placed, but the threads are not tied, thus the edges of the wound are not brought together. The threads are tied for 1-5 days when the inflammatory process subsides. The difference from conventional primary delayed sutures is that there is no need for repeated anesthesia and suturing of the wound edges.
b) Secondary seams
Secondary sutures are applied to granulating wounds that heal by secondary intention. The purpose of using secondary sutures is to reduce (or eliminate) the wound cavity. A decrease in the volume of a wound defect leads to a decrease in the number of granulations required to fill it. As a result, healing time is reduced, and the content of connective tissue in a healed wound, compared to wounds treated openly, is much less. This has a beneficial effect on the appearance and functional characteristics of the scar, its size, strength and elasticity. Bringing the edges of the wound closer together reduces the potential entry point for infection.
The indication for the application of secondary sutures is a granulating wound after the elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. To objectify the subsidence of inflammation, seeding of wound discharge can be used - if there is no growth of pathological microflora, secondary sutures can be applied.
There are early secondary sutures (they are applied on days 6-21) and late secondary sutures (they are applied after 21 days). The fundamental difference between them is that by 3 weeks after surgery, scar tissue forms at the edges of the wound, preventing both the rapprochement of the edges and the process of their fusion. Therefore, when applying early secondary sutures (before the edges become scarred), it is enough to simply stitch the edges of the wound and bring them together by tying the threads. When applying late secondary sutures, it is necessary to excise the scarred edges of the wound under aseptic conditions (“refresh the edges”), and after that apply sutures and tie the threads.
To speed up the healing of a granulating wound, in addition to suturing, you can use tightening the edges of the wound with strips of adhesive tape. The method does not completely and reliably eliminate the wound cavity, but it can be used even before the inflammation has completely subsided. Tightening the edges of a wound with an adhesive plaster is widely used to speed up the healing of purulent wounds.
