WOUND
COMPLICATIONS
Bernard M. Jaffe, MD
Professor of Surgery,
Emeritus
COMPLICATIONS
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Infection
Hematoma
Seroma
Dehiscence
Hernia
Evisceration
WOUND HEALING
• Wound Repair- Effort of Tissue to
Restore Normal Function and
Structural Integrity After Injury
• Involves Scarring
• Regeneration- Perfect Restoration of
Pre-Existing Tissue Architecture
• Occurs Only in Bone and Liver
WOUND CLOSURES
• Primary- Sealed Immediately
• Secondary Intention- No Active Intent
to Seal Wound
• Heals on Its Own
• Contaminated Wounds
• Tertiary (Delayed Primary)- After
Appropriate Maneuvers
PHASES OF HEALING
• Three Phases- Inflammatory
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Proliferative
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Maturation
• All Overlap in Time
• Wound Can Have Several Phases at
Once in Different Areas
INFLAMMATORY
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First Six Days
Also Called Reactive Phase
Primary Actions- Hemostasis
Inflammation
Wound Cleansing
Release of PGDF, TGFβ, IGF-1,
Cytokines
INFLAMMATORY (2)
• Platelet Aggregation and Adhesion
• Activation of Coagulation System
• Vasoconstriction → VasodilationIncreased Vascular Permeability
• Migration of Polys, Macrophages,
Lymphocytes Into Wound
PROLIFERATIVE
• Days 4-14
• Angiogenesis, Fibroplasia, Epithelialization
• Granulation Tissue- Capillary Bed,
Fibroblasts, Macrophages, Collagen
Hyaluronic Acid
• Requires Extracellular matrix
• Fibroblasts Derived From Resting Local
Mesenchymal Cells
• Delay in Collagen 3-5 Days- Lag Phase
MATURATION
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Days 8->16
Wound Contraction
Remodeling Toward Normal
Accumulation of Wound Breaking
Strength
INHIBITORS OF HEALING
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Infection
Deficiencies
Ischemia
Vitamins A,C
Diabetes Mellitus
Minerals Zn, Fe
Ionizing Radiation Medications
Advanced Age
Steroids, ChemoRx
Malnutrition
Immunosuppression
WOUND FAILURES
• Dehiscence- Failure of All Levels to
Heal
• Evisceration- Dehiscence Plus Escape
of Peritoneal Contents
• Hernia- Failure of Fascia to Heal But
Peritoneum Sealed
DEHISCENCE
• Usually days 7-10
• Presents With Sudden Gush of
Peritoneal Fluid
• Risk of Infection From Environment
Into Peritoneum
• If Wound NOT Infected- Treatment is
Reclosure of Wound
CAUSES OF DEHISCENCE
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Technical Error
Infection
Advanced Age
Seroma
Uremia
Steroids
Malnutrition
Radiation, Chemo
Diabetes
Hematoma
Obesity
COPD
WOUND VAC SYSTEM
• Immediate Coverage of WoundMinimizes Heat Loss
• Removes Interstitial Fluid
• Decreases Bowel Edema
• Decreases Wound Size
• Reduces Bacterial Contamination
• Increases Local Perfusion With Blood
WOUND VAC (2)
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Induces Healing Response
Can Heal 85% of Dehiscences
Closure Takes Very Long Time
Useful for Infected Wounds
Risks- Fistula Formation
Incisional Herniation
INCISIONAL HERNIA
• Result From Excessive Tension, Poor
Healing of Prior Operation, Often
Superficial Site Infection
• Cause Pain, Bowel
Obstruction/Incarceration,
Strangulation
• Frustrating and Difficult to Successfully
Treat
CAUSES
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Obesity (Increased Tension)
COPD
Malnutrition
Steroids
Chemotherapy
Diabetes
TREATMENT
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Primary Repair of Defect <4cm
Larger, Need Prosthetic Material
Recurrence Rates 10-50%
Less Frequent With Mesh
Mesh Can Be Placed Onlay
Underlay
At Fascial Edges
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MESH
Many Options
Polypropylene- Ingrowth of Fibroblasts
PTFE- Flexible, Smooth, No Ingrowth
Composite- PTFE Against Bowel
Polypropylene Incorporated
Non Synthetic- Porcine Intestinal
Submucosa
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Cadaver Acellular Matrix
• Less Likely to Be Infected
COMPONENT SEPARATION
• Separate Tissue Layers
• Individual Layers Advanced
• Relaxing Incisions Lateral External
Oblique
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Internal, Transversus
• Allows Fascial Closure
• Avoids Use of Mesh