Slides 2 - Wounds,Ulcers

7/29/2019 Slides 2 - Wounds,Ulcers

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Dr.Ghazi Qasaimeh

Management

of Wound

Consultant Surgeon

K.A.U.HAssociate professor of surgery

J U S T


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J U S T

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Management of Wounds

Mechanism of injury Traumatic wounds

Sharp, penetrating Blunt

Bullet

Surgical wounds


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Types of wounds

Cut wounds incised

Lacerated wounds

Crushed wounds

Wounds with skin loss


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Examination of Wounds

Associated injuries:

Vessels Abdominal Cavity

Nerves Chest CavityTendons cranial Cavity

Museles

Bones, Joints


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Types of Suturing Primary suturing

Excision and primary suturing

Delayed primary suturing Secondary suturing

Skin grafting


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Elements of Wound Healing

1- Contraction

2- Connective tissue formation (granulationtissue)

3- Epithelization


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Phases of Healing1- Lag phase (preparation phase)

2- Proliferation phase

3- Maturation (differentiation)


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The organ of repairWound strengthWound histology:Neutrophils 1st day

Monocytes after 24 hrsFibroblasts 5-6 days

Capillaries 5-6 days

Collagen after 4th day


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Wound Biochemistrysynthesis

Collagen lyses (collagenase)Factors affecting healing:Age

Nutrition: Protein: Ascorbic acid: ZincVascularity

Sepsis

OxygenWound dressing


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Other measures: Fasciotomy

Types of healing

Healing by first intention

Healing by second intention

Bullet injuries: high velocity missileshock waves

temporary cavitation

Blast injuries: complex blast waves

mass air movement


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Surgical WoundsClean

Clean contaminated

Contaminated

Dirty


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Factors which affect wound healing General: Malnutrition, ureamia, malignancy,

radiothempy, cytotoxic drugs, duabetes, vitcdeficiency.

Local Factors:- Blood supply- Tension in wound

- presence of necrotic tissueand F.B

- presence of haematoma

- excessive cauterization, roughmanipulation

- infection


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Complieations of Wounds:

Wound infection

Wound dehisconce

Hyper trophied scar, keloid

Management of wound infection.

Role of antibiotics.


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Ulcers


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Definition

A Break in the skin continuity extending to all its

layers or break in the mucous membrane lining the

alimentary tract, that fails to heal and is often

accompanied by inflammation Or in other words, it isa macroscopic discontinuity of the normal epithelium

(microscopic discontinuity of epithelium is called

erosion)
http://en.wikipedia.org/wiki/Epitheliumhttp://en.wikipedia.org/w/index.php?title=Erosion_(medicine)&action=edithttp://en.wikipedia.org/w/index.php?title=Erosion_(medicine)&action=edithttp://en.wikipedia.org/wiki/Epithelium


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Cont Ulcers are non-healing wounds that develop on the

skin, mucous membranes or eye. Although theyhave many causes, they are marked by:

1.

Loss of integrity of the area2. Secondary infection of the site by bacteria, fungus

or virus

3. Generalized weakness of the patient

4. Delayed healing


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classification

Merck Manual classification

National Pressure Ulcer Advisory Panel

(NPUAP)

Wagner's classification
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NPUAP

Stage I - There is erythema of intact skinwhich does not blanch with pressure. It may bethe heralding lesion of skin ulceration.

Stage 2 - There is partial skin loss involvingthe epidermis, dermis, or both. The ulcer issuperficial and presents as an abrasion, orwound with a shallow center.


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Cont

Stage 3 - This is an entire thickness skin loss.

It may involve damage to or necrosis of

subcutaneous tissue that may extend down to,

but not through, the underlying fascia. Theulcer presents as a deep crater with or without

undermining of adjacent intact tissues.


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Cont

Stage 4 - Here there is entire thickness skinloss with extensive destruction, tissue necrosis,or damage to muscle, bone, or supporting

structures. tendons, and joints may also beexposed or involved. There may beundermining and/or sinus tracts associatedwith ulcers at this stage.


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Location

1. Lower limbs: most ulcers of the foot and leg

are caused by underlying vascular

insufficiency . The skin breaks down or fails

to heal because of repeated insult or trauma.

2. Sacrum and ischium

3. Mouth ulcer


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Cont

4. Peptic ulcer: This includes ulcers of the esophagus,

stomach, large and small intestine

5. Genitalia: May be penile, vulvar or labial. Most

often are due to sexually-transmitted disease.6. Eyes: corneal ulcers are the most common type.

Conjunctival ulcers also occur.


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causes

Bacterial , viral & fungal infection

Cancer both primary & secondary

Venous stasis Arterial insufficiency

Diabetes

Rheumatoid arthritis Loss of mobility


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Description

Site

Size

Shape

Base

Edge

Tenderness

Discharge

Surrounding tissue & lymphatics


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Types

Peptic ulcer

Mouth ulcer

Pressure ulcer (decubitus) Arterial insufficiency ulcer

Venous insufficiency ulcer

Diabetic foot ulcer


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Cont

Hunners ulcer (of the bladder caused by

Interstitial Cystitis)

Ulcerative colitis (of the colon)


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Ischaemic ulceration

By definition caused by inadequate blood supply large\ small artery obliteration

In elderly , who also have symptoms of coronaryvascular disease.

Men predominate

Risk factor

Very painful, causes rest pain

Do not bleed but discharge thin serous exudateswhich can become purulent


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Cont

May penetrate into joints making movement

painful.

Site,size,shape,tenderness,edge,TM,

depth,base,surrounding tissue

Pulses


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Neuropathic ulceration

Deep penetrating ulcer which occur over pressurepoint, but the surrounding tissue are healthy and havegood circulation.

Diagnostic features:-

1- painless

2- surrounding tissues are unable to appreciate pain

3- surrounding tissues have normal blood supply


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Cont

Causes:-

- peripheral nerve lesions diabetes ,nerve injuries

-

Spinal cord lesionsspina bifida,tabes dorsalis


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Venous ulceration

Follow many year of venous disease.

Women predominant

Risk factor Site, size,shape, tenderness, edge, discharge,

TM, surrounding tissues

pulses


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Fistulas


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definition

Fistulas is an abnormal communication

between tow epithelial or endothelial surfaces


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Types of fistulas Congenital ( e.g. oesophageal atresia with a fistulous

communication with the trachea) Acquired : - external fistulas involve the

skin (e.g. enterocutaneous)

- internal fistulas affect adjacent

organs contiguously or morethrough an intervening

abscess cavity (e.g. entro-

enteric,entrocolic,etc.)

Arteriovenous fistulas are an abnormal communication

between an artery and a vein it could be :- congenital

- acquired :

*trauma

*iatrogenic ( for hemodialyisis )


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Internal abdominal fistulas :Majority result

from an underlying gastro-

intestinal disease ( e.g. colonic diverticular

disease, crohns disease, colonic carcinoma,

radiation enteritis ,intestinal tuberculosis ,

chronic cholecystitis , etc )


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External abdominal fistulas arise as acomplication of surgery or to the trauma to theintra-abdominal organs such as anastomotic

leakage , accidental or unrecognized injuryduring operation

Other external fistulas are due to primaryabscess formation which involve bowel andskin and these are best exemplified by theperianal fistulas


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The effect of internal abdominal fistulas depend on

: - site

- pathology of the condition causing it

E.g. :- malabsorption and steatorrhoea may occurwith entero-enteric and enterocolic fistulas

- cholangitis may follow bilio-enteric fistula

- severe cystitis with pneumaturia may becaused by vesicocolic fistula etc.


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Constitutional effects are minimal with external

colonic fistulas

Malnutrition and fluid and electrolyte depletion

accompany high output bowel fistulas Skin excoriation and digestion of the abdominal wall

is a serious feature of pancreatic , duodenal and high

small bowel fistulas


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Internal abdominal , perianal and anorectal fistulas

seldom if ever close spontaneously

Healing of external abdominal fistulas can be

expected if there is no distal obstruction to theinvolved bowel , the healing depend on :

- adequate drainage of any abscess

- the maintenance of a good nutritional state

Management is complex and requires definition


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Management is complex and requires definitionof the exact underlying pathological anatomy byappropriate contrast radiology with a sinogram

and/or barium enema, barium meal follow-through

Surgical intervention is required for internalfistulas and for external abdominal fistulasassociated with

- distal obstruction or when discontinuity of thebowel

- underlying neoplastic intestinal disease- when conservative medical management with

parenteral nutrition has failed to produce healing


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Mammary duct fistula

Most commonly in patients with mammary

duct ectasia


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Biliary fistulas

External which are secondary to bile duct

trauma or leakage or accessory bile ducts and

gallbladder bed

internal which are classified into three types :

bilio-enteric, broncho-biliary and bilio-pleural,

bilio-biliary


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Pancreatic fistulas

May be internal or external and carry a substantialmorbidity from sepsis, hemorrhage and persistent

pancreatitis

An external fistula may be secondary to a pancreaticabscess complicating acute pancreatitis, but may alsofollow abdominal trauma and operative intervention

An internal pancreatic fistula is almost always due toa pancreatic abscess which complicates acute

pancreatitis in 1-5 % of patients


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Gastrocutaneous fistulas

These are usually iatrogenic following unrecognizedoperative injuries during splenectomy or vagotomy

Partial necrosis of the lesser curve to duodenumanastomosis after a billlroth 1 gastrectomy may also

result in a gastric leak and fistula Some apparently arise as a result of erosion by drains

A small percentage are caused by benign gastriculcer, pancreatic abscess and pancreatic carcinoma


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Gastrojejunocolic fistula

Severe complication is usually found in

association with inoperable carcinoma of the

stomach or transverse colon

Less frequently encountered as a result of

recurrent ulcer at gastrojejunal anastomosis

largely due to overall improvement in the

results of ulcer management and surgicaltreatment


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Small-bowel fistulas

The majority (80-90 %) of small bowel fistulas

follow operations on the intestinal tract either from

anastomotic leakage or iatrogenic injury

Often the anastomotic dehiscence is attributed to thepresence of underlying small bowel disorder, crohns

disease being the most common, but radiation

enteritis and intestinal tuberculosis featuring often in

several published series


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External colonic fistula

These most commonly follow colonic surgery,

including colostomy closure

Trauma accounts for some cases as does

perforated colonic diverticular disease and

cancer


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Colovesical and colovaginal fistulas The former is one of the commonest forms of internal

abdominal fistulas Both are usually encountered in association with

diverticular disease and a pericolic abscess whichperforates into the bladder or vagina, especially in

females after hysterectomy as this allows the diseasedbowel to lie directly onto the bladder or vaginal vault

Less commonly these fistulas may be due to cervicalor rectal carcinoma

Crohns disease of the large and small bowel may becomplicated by the development of entero/colovesicalfistula

Radiotherapy for malignant disease of the pelvisaccounts for the majority of rectovaginal/vesical

fistulas


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Treatment

Conservative :

* the mainstays of medical management are:

- nutritional support

- meticulous collection of fistulous discharge

- skin-stoma care

- control of sepsis


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Surgical :

* the absolute indications for operative intervention are:

- intestinal distal obstruction- peritonitis

- abscess formation

- bowel discontinuity

- presence of malignant disease

- persistent inflammatory bowel disease


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Cysts


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What is a cyst?

a cyst is : any closed epithelium-lined cavity or

sac, normal or abnormal, usually containing

liquid or semisolid material" (Dorland's, 1995,

pp.209).

It is common can occur anywhere any age.

Cysts vary in size

Its wall called the cyst capsule


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What are the causes of a cyst?

Cysts are usually formed through one of these

mechanisms:

1. 1"Wear and tear" or simple obstructions to the flow

of fluid .

2. Infections and chronic inflammations

3. Tumors

4. Genetic (inherited) conditions5. Defects in developing organs in the embryo
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Types of cysts

cysts in the neck :

1. Branchial cleft cysts.

2. Thyroglossal duct cysts.

3. Dermoid cysts.

4. Sebaceous cysts


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Branchial cyst

Embryology :

congenital abnormality that is presented in adult

life .

-incomplete involution of the branchial clefts

-lined with epithelium derived from the branchial

ectoderm.


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Branchial cyst continued

Clinical feature:

presenting complaint.

Age

Location

complication


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Branchial cyst continued

Diagnosis

By location C.T. scan ultrasound can help.

Treatment:

A small incision is made in the neck and the cystis removed. Sinuses may occasionally needtwo incisions for complete repair. Cysts are

removed to prevent infection.This is a daysurgery operation


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Thyroglossal cyst

Embryology and pathogenesis:

The thyroglossal tract arises form foramen caecum

Arises at junction of anterior 2/3 and posterior 1/3 of

the tongue Any part of the tract can persist causing a sinus,

fistulae or cyst

Most fistulae are acquired following rupture orincision of infected thyroglossal cyst


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Thyroglossal cyst cont..

Clinical features:

-Usual location midline

-Painless surrounded by lymphoid tissue

-age 40% present < 10 years of age

65% present < 35 years of age

Protrude the tongue in its examination


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Thyroglossal cyst cont..

Treatment

-The treatment is by surgical excision .the cyst

along with the centre of the hyoid bone along

with the thyroglossal duct up to the base of thetongue should be excised to ensure complete

removal.

It must be differentiated from the lymphoidtissue through us before incision .


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dermoid cysts

it occurs when skin and skin structures become

trapped during fetal development. Along the

line of embryonic closure.the mid line . It

can be a true hamartoma. Two types intra and extra abdominal

Dermis like capsule with all skin layer

Surgically remove dermoid cysts. The spread of thesecontents can cause foreign body reactions and severe complications


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-A mid line structure

-A symptomatic

-Soft on palpation

-Good prognosis


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sebaceous cysts

it is caused by obstruction of the sebaceous glandduct leads to accumulation of secretions which mayget infected specially by staph. Bacteria withsecondary enlargement .they are common in thehead and neck skin it is presence may point to DMand should not be confused with Kaposi sarcoma inaids patients.

a drainage sinus may form and may be multible

treatment :

wide surgical excision may be needed withoutopening them to prevent complication


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Slides 2 - Wounds,Ulcers

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