Classification and Management of Surgical Wounds

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Management of Surgical Wounds

By the WoundSource Editors

Wounds resulting from surgical procedures have many commonalities with wounds of other etiologies. However, there are a few notable differences in their classification, as well as in the recommended care practices that promote the healing of these wounds. In understanding these differences, it is important to understand the classification of surgical wounds.

  • Clean wounds: These wounds show no sign of infection or inflammation, and their risk for infection is usually less than 2%. They often involve skin, eyes, or the vascular system and do not involve any internal organs.1
  • Clean-contaminated wounds: These wounds also show no outward sign of infection, although they occur during procedures that involve internal organs. The risk of developing a surgical site infection (SSI) with this type of wound is usually less than 10%.1
  • Contaminated wounds: These are fresh, open wounds that involve the repair or removal of an internal organ, meaning that blood or other fluids from the organ can spill into the wound. One example is any surgery that involves the gastrointestinal tract, which has a high risk of becoming infected. The risk of infection with this type of wound is approximately 13% to 30%.1
  • Dirty-contaminated wounds: These wounds have an infection that is already present during the time of surgery, and the risk of developing an SSI with this type of wound is high, at nearly 40%.1

It should also be noted that there is a difference between incisional wounds and excisional wounds. Incisional wounds are created when skin, muscle, and fat are incised to repair a body part. Excisional wounds occur when a cyst or other type of tissue is removed. Although these two types of wounds are very similar, there is a difference in their ability to handle tension. Minimal tension on incisional wounds will cause the elastin to stretch and the collagen to buckle, revealing mostly elastin. With excisional wounds under the same circumstances, the reverse occurs; the collagen stretches, and the elastin buckles.2 Although this does not impact the type of care a wound requires, it does have implications for the prominence of scarring for each type of wound.2

Caring for a Surgical Wound

Unlike many traumatic wounds, surgical wounds are made with precision in a clean area with techniques that minimize the risk of infection. Surgeons also strive to minimize the amount of trauma to surrounding skin, connective tissue, vessels, nerves, and internal organs. As a planned injury, there is more opportunity to minimize tissue damage, control for complications such as infection, and prevent dehiscence.3 This planning generally results in better healing outcomes for most patients; however, complications such as infection can still occur. Seventy-seven percent of deaths in surgical patients are related to infection, meaning that prevention of infection is essential in postsurgical wound care.3

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As with other wounds, surgical wounds should be cleansed as advised by the physician, and attention should be paid to special care techniques that may be necessary for different types of sutures or staples. The wounds should be dressed using proper techniques. The type of dressing selected is crucial for enhancing the healing environment after surgery. For instance, dressings with hydrogels are common in treating pressure ulcers, burns, abrasions, or skin tears, but they are used less frequently for surgical incision sites. Transparent films are frequently used for closed surgical incision sites, and silver-based dressings may be used on wounds with a high risk of becoming infected.1

Given the high risk of developing SSIs after an operation, clinicians often play an active role in patient care throughout the wound healing cycle; this may or may not be the case with other wound types. Clinician involvement often begins with preoperative assessments to identify and minimize any risk factors for the patient. Conditions such as obesity, hypertension, malnutrition, substance use, advanced age, diabetes, smoking, and excessive bioburden can impact skin integrity and wound healing. Recognizing these risk factors is essential for developing the most effective care plan possible.3

During the preoperative and postoperative stages, it is also important to recognize other factors that can impact healing status, such as the following3:

  • Patient-related factors: comorbidities, allergies, medications, pain, diseases
  • Wound-related factors: size, inflammation or infection, site, treatment responses, ischemia
  • Health care professional–related factors: skill, knowledge
  • Resource- and treatment-related factors: cost, availability, effectiveness, suitability of treatment

Conclusion

The prevention and management of surgical wound complications are different from those of other wound types. Because there is such high risk for negative patient outcomes, and even death, ensuring that patients receive comprehensive presurgical and postsurgical care and assessments is crucial. Best practice recommendations often serve as the most effective way to minimize the risk of complications.

References
1. American College of Surgeons. Wound Home Skills Kit: Surgical Wounds. Chicago, IL: American College of Surgeons; 2016. https://www.facs.org/~/media/files/education/patient%20ed/wound_surgical.... Accessed on August 26, 2019.
2. Paul SP Are incisional and excisional skin tension lines biomechanically different? Understanding the interplay between elastin and collagen during surgical procedures. Int J Biomed. 2017;7(2):111-114.
3. Harris CL, Kuhnke J, Haley J, et al. Best practice recommendations for the prevention and management of surgical wound complications. Wound Care Canada. 2017. https://www.woundscanada.ca/docman/public/health-care-professional/bpr-w.... Accessed August 26, 2019.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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