Postoperative wounds

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][3]

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.[2]

Infection

Infection will complicate healing of surgical wounds and is commonly observed.[2][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.[5] Wound infections can be superficial (skin only), deep (muscle and tissue), or spread to the organ or space where the surgery occurred.[5] 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.[2]

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.[2]

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 prophylacitc antibiotics are recommended, to be administrated within one hour from the beginning of the surgical procedure.[8] In addition to i.v. prophylaxis, oral antibiotic prophylaxis has been demostrated 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)[10][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.[2]

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.[2] 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.[2][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][17]

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

See also

  • List of surgeries by type

References

  1. ↑ Stadelmann WK, Digenis AG, Tobin GR (August 1998). "Physiology and healing dynamics of chronic cutaneous wounds". American Journal of Surgery. 176 (2A Suppl): 26S–38S. doi:10.1016/S0002-9610(98)00183-4. PMID 9777970.
  2. 1 2 3 4 5 6 7 8 Hoffman B (2012). Williams gynecology. New York: McGraw-Hill Medical. pp. 972–975. ISBN 9780071716727.
  3. ↑ Stanirowski PJ, Wnuk A, Cendrowski K, Sawicki W (October 2015). "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. doi:10.1007/s00404-015-3709-y. PMC 4560760. PMID 25864095.
  4. ↑ Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, et al. (March 2013). "Methods to decrease postoperative infections following posterior cervical spine surgery". The Journal of Bone and Joint Surgery. American Volume. 95 (6): 549–554. doi:10.2106/JBJS.K.00756. PMID 23515990. S2CID 207283208.
  5. 1 2 3 "Surgical wound infection - treatment". MedlinePlus Medical Encyclopedia. U.S. National Library of Medicine. Retrieved 2017-02-07.
  6. ↑ Agarwal A, Kelkar A, Agarwal AG, Jayaswal D, Schultz C, Jayaswal A, et al. (August 2020). "Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery". Global Spine Journal. 10 (5): 640–646. doi:10.1177/2192568219869330. PMC 7359681. PMID 32677561.
  7. ↑ "The Hardest Decision Any Spine Surgeon Has to Make | Orthopedics This Week". ryortho.com. Retrieved 2020-08-24.
  8. ↑ World Health Organization WHO. "WHO Surgical Site infection Prevention Guidelines Web Appendix 25" (PDF). Retrieved 27 December 2021.{{cite web}}: CS1 maint: url-status (link)
  9. ↑ Espin Basany E, Solís-Peña A, Pellino G, Kreisler E, Fraccalvieri D, Muinelo-Lorenzo M, et al. (August 2020). "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. doi:10.1016/S2468-1253(20)30075-3. PMID 32325012. S2CID 216109202.
  10. 1 2 Pellino G, Espín-Basany E (December 2021). "Bowel decontamination before colonic and rectal surgery". The British Journal of Surgery. 109 (1): 3–7. doi:10.1093/bjs/znab389. PMID 34849592.
  11. ↑ Nelson RL, Hassan M, Grant MD (December 2020). "Antibiotic prophylaxis in colorectal surgery: are oral, intravenous or both best and is mechanical bowel preparation necessary?". Techniques in Coloproctology. 24 (12): 1233–1246. doi:10.1007/s10151-020-02301-x. PMID 32734477. S2CID 220857409.
  12. ↑ Koskenvuo L, Lehtonen T, Koskensalo S, Rasilainen S, Klintrup K, Ehrlich A, et al. (September 2019). "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. doi:10.1016/S0140-6736(19)31269-3. hdl:10138/319567. PMID 31402112. S2CID 199540216.
  13. ↑ Edmiston CE, Seabrook GR, Goheen MP, Krepel CJ, Johnson CP, Lewis BD, et al. (October 2006). "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. doi:10.1016/j.jamcollsurg.2006.06.026. PMID 17000391.
  14. ↑ Shahpari O, Mousavian A, Elahpour N, Malahias MA, Ebrahimzadeh MH, Moradi A (January 2020). "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. doi:10.22038/abjs.2019.42018.2141. PMC 7007713. PMID 32090140.
  15. ↑ McHugh SM, Collins CJ, Corrigan MA, Hill AD, Humphreys H (April 2011). "The role of topical antibiotics used as prophylaxis in surgical site infection prevention". The Journal of Antimicrobial Chemotherapy. 66 (4): 693–701. doi:10.1093/jac/dkr009. PMID 21393223.
  16. ↑ Kachel E, Moshkovitz Y, Sternik L, Sahar G, Grosman-Rimon L, Belotserkovsky O, et al. (October 2020). "Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology". Journal of Cardiac Surgery. 35 (10): 2695–2703. doi:10.1111/jocs.14890. PMID 32743813. S2CID 220940129.
  17. 1 2 "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. doi:10.1016/S0140-6736(21)01548-8. PMC 8586736. PMID 34710362.
  18. ↑ Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, et al. (Cochrane Wounds Group) (February 2018). "Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews". The Cochrane Database of Systematic Reviews. 2 (2): CD012653. doi:10.1002/14651858.CD012653.pub2. PMC 6491077. PMID 29406579.
  19. ↑ Agarwal A, Lin B, Agarwal AG, Elgafy H, Schultz C, Agarwal AK, et al. (October 2020). "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. doi:10.1097/BSD.0000000000000976. PMID 32168115. S2CID 212707844.
  20. ↑ Agarwal A, MacMillan A, Goel V, Agarwal AK, Karas C (August 2018). "A Paradigm Shift Toward Terminally Sterilized Devices". Clinical Spine Surgery. 31 (7): 308–311. doi:10.1097/BSD.0000000000000675. PMID 29912733. S2CID 49303554.
  21. ↑ Agarwal A, Schultz C, Agarwal AK, Wang JC, Garfin SR, Anand N (April 2019). "Harboring Contaminants in Repeatedly Reprocessed Pedicle Screws". Global Spine Journal. 9 (2): 173–178. doi:10.1177/2192568218784298. PMC 6448207. PMID 30984497.
  22. ↑ Agarwal A, Schultz C, Goel VK, Agarwal A, Anand N, Garfin SR, Wang JC (October 2018). "Implant Prophylaxis: The Next Best Practice Toward Asepsis in Spine Surgery". Global Spine Journal. 8 (7): 761–765. doi:10.1177/2192568218762380. PMC 6232723. PMID 30443488.
  23. ↑ Agarwal A, Lin B, Elgafy H, Goel V, Karas C, Schultz C, et al. (2020). "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. doi:10.22603/ssrr.2019-0038. PMC 7217678. PMID 32405555.
  24. ↑ Agarwal A, Lin B, Wang JC, Schultz C, Garfin SR, Goel VK, et al. (February 2019). "Efficacy of Intraoperative Implant Prophylaxis in Reducing Intraoperative Microbial Contamination". Global Spine Journal. 9 (1): 62–66. doi:10.1177/2192568218780676. PMC 6362554. PMID 30775210.
  25. ↑ "Ban 'Reprocessing' of Spinal Surgery Screws, Experts Say". Medscape. Retrieved 2020-08-24.
  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. doi:10.1126/sciadv.abj1617. PMC 8604401. PMID 34797719.
  27. ↑ Wood C, Phillips C, et al. (Cochrane Wounds Group) (May 2016). "Cyanoacrylate microbial sealants for skin preparation prior to surgery". The Cochrane Database of Systematic Reviews (5): CD008062. doi:10.1002/14651858.CD008062.pub4. PMID 27191948.
  28. ↑ Tanner J, Dumville JC, Norman G, Fortnam M, et al. (Cochrane Wounds Group) (January 2016). "Surgical hand antisepsis to reduce surgical site infection". The Cochrane Database of Systematic Reviews. 2016 (1): CD004288. doi:10.1002/14651858.CD004288.pub3. PMC 8647968. PMID 26799160.
  29. ↑ Webster J, Alghamdi A, et al. (Cochrane Wounds Group) (April 2015). "Use of plastic adhesive drapes during surgery for preventing surgical site infection". The Cochrane Database of Systematic Reviews (4): CD006353. doi:10.1002/14651858.CD006353.pub4. PMC 6575154. PMID 25901509.
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