Non-healing post-surgical wounds

Recommendations

Identify and Treat the Cause
1 Take a careful history and conduct an inspection of the surgical site. Level of Evidence
Not Assessed


Address Patient-Centered Concerns
2 Provide individualized patient education. Level of Evidence
5


Provide Local Wound Care
3 Ensure adequate nutrition to support healing of complicated surgical wounds. Level of Evidence
Not Assessed
4 Manage clean non-healing wounds by addressing the causative factors, if possible, and resuturing. Level of Evidence
Not Assessed
5 Non-healing surgical wounds that cannot be resutured should be allowed to heal by granulation, after addressing contributing factors, such as hematomas, dead space and infection. Level of Evidence
Not Assessed
6 Infection in nonhealing surgical wounds should be treated appropriately and the wound allowed to heal by second intention. Level of Evidence
Not Assessed
7 Consider negative-pressure wound therapy or hyperbaric oxygen therapy to speed granulation of nonhealing surgical wounds. Level of Evidence
Not Assessed


Provide Organizational Support
8 Establish and empower an interprofessional team to provide post-operative care. Level of Evidence
5


Background

Epithelialization occurs within a few days of surgery and, after approximately 5 days, fibroplasia and collagen production begin, at which time collagen deposition and remodeling begin strengthening the wound. A healing surgical wound regains 3–5% of its original strength by 2 weeks, 15% by 3 weeks, 35% at 1 month and a final 80% after several months. Lack of healing of post-surgical wounds may be related to dehiscence, necrosis and infection.

• Dehiscence (incisional separation): Failure of a surgical wound to heal in apposition is most often due to surgical error, but local or systemic factors may also cause dehiscence. Inadequate undermining or poor planning may produce excessive tension on the wound, causing sufficient mechanical force to separate the incision. Excessively tight sutures may cause tissue necrosis, decreasing wound strength. Electrocautery causes necrosis, increased inflammation and decreased wound strength. Premature removal of superficial sutures may cause dehiscence, especially if deeper tissue layers have not been sutured adequately. Ineffective hemostasis and dead space also increase the risk of dehiscence. Systemic factors associated with dehiscence include tobacco use, a variety of comorbid conditions, age greater than 65 years, and several medications, especially antiinflammatory and immunosuppressive agents.

Wounds that have dehisced due to premature suture removal or trauma may be resutured if no infection is present. Freshening of healthy wound edges should be avoided, to allow already active fibroblasts to continue the wound-healing process. Wounds dehisced due to hematoma formation may be resutured after complete removal of the hematoma. Dehiscence due to delayed hematoma formation or infection may be best managed with healing by secondary intention (granulation), with scar revision usually delayed until at least 8 weeks later.

• Necrosis: Tissue ischemia is the proximate cause of necrosis. The most common cause is tissue damage during surgery, possibly due to too much undermining, suturing or tension on wound edges. In addition, superficial undermining and some flaps or grafts may leave wound edges with barely adequate circulation for healing. An expanding hematoma may contribute to tissue necrosis by increasing suture line tension and compromising the circulation.

Cigarette smoking causes vasoconstriction and hypoxia and increases blood viscosity and platelet aggregation, which promote microvascular thrombosis. This process can substantially reduce the survival of reconstructive flaps and grafts, but benefits can be seen by having patients stop or decrease smoking for at least 2 days before and 7 days after surgery.

The necrotic area should be fully demarcated before debridement, to prevent loss of viable tissue, unless infection or a hematoma is present. Easy separation of the eschar from the wound bed indicates that careful sharp debridement may be performed. A high risk of infection is present, and systemic antibiotics may be required. The wound can be allowed to heal by secondary intention, and scar revision may be considered at a later date.

• Infection: Most often, infection results from a combination of a break in aseptic technique and impaired host defenses, through interference with blood flow or development of local inflammation. Signs and symptoms of wound infection usually develop and increase from approximately days 4–6 and may include early tenderness, erythema, warmth and swelling, followed by cellulitis, lymphangitis and fever. An early infection may be treated with oral antibiotics and the patient followed closely. Infection that has progressed further, to purulence, fluctuance, inflammatory edema or systemic symptoms, requires the incision to be opened, lavaged with sterile saline and packed with iodoform gauze. Empiric antibiotic therapy should be instituted when wound cultures are taken and adjusted as necessary. The infection should be cleared and the wound allowed to heal by secondary intention.

Negative-pressure wound therapy (NPWT) reduces interstitial fluid and bacterial colonization and increases angiogenesis and perfusion, to assist in healing dehisced wounds. The benefits of this modality may relate to continuous removal of wound effluent, which may contain both bacteria and inhibitory cytokines. NPWT should ideally be continued until the wound is completely granulated and no longer undermined. Adequate nutrition is essential for healing, and advanced technologies, such as NPWT, are ineffective if the patient’s body cannot respond.

When the objective of NPWT is closure of an abdominal wound, the abdominal fascia must be intact to prevent evisceration. Implants and vascular grafts must not be infected to prevent ongoing wound drainage as granulation covers these ‘foreign bodies.’ Appropriate debridement to provide a clean wound bed allows maximal benefit from angiogenic stimulation.

Appropriate management of excessive bacterial burden or infection with systemic antibiotics or topical antimicrobial preparations is critical to prevent abscess formation. Similarly, regular monitoring for developing abscesses simplifies management during healing. Unroofing of tracts is beneficial, as thin skin bridges between two wounds in an incision are often poorly vascular. Beefy red granulation tissue is a sign of healing with NPWT, whereas pale and friable granulation tissue may be an important indicator of infection. Hypergranulation tissue may require control with silver nitrate to prevent problems with epithelialization.

Skin protection is important, as the airtight seal of the NPWT unit to the skin surrounding the wound may compromise skin barrier function. Skin protection can usually be provided with hydrocolloids, and antifungal preparations can manage candidal infections.

Hyperbaric oxygen therapy also increases tissue oxygen levels, angiogenesis and growth factor production, while reducing tissue edema.

References

Essential Publications
1 Antisepsis - Lavasept Quality Indicator
 Type: RCT
Fabry W, Trampenau C, Bettag C, Handschin AE, Lettgen B, Huber FX, Hillmeier J, Kock HJ. Bacterial decontamination of surgical wounds treated with Lavasept. Int J Hyg Environ Health 2006;209(6):567-573.
The purpose of this study was to determine if 0.2% Lavasept solution leads to a reduction in the bacterial count on the surgace of wounds and if it interferes with wound healing. There was no evidence that Lavasept was superior to the Ringer solution.
2 Dressings Quality Indicator
 Type: Systematic review
Vermeulen H, Ubbink D, Goossens A, de Vos R, Legemate D. Dressings and topical agents for surgical wounds healing by secondary intention. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003554. DOI: 10.1002/14651858.CD003554.pub2.
The purpose of this study was to evaluate different dressings and topical agents used to treat surgical wounds healing by secondary intention. Only small, poor quality randomised controlled trials that provided inadequate evidence were found. Quality research is required on this topic.
3 Dressings - Gauze Quality Indicator
 Type: RCT
Ubbink DT, Vermeulen H, van Hattem J. Comparison of homecare costs of local wound care in surgical patients randomized between occlusive and gauze dressings. Journal of Clinical Nursing 2008;17(5):593-601.
The purpose of this paper was to examine the cost and outcome of gauze compared to occlusive dressings in home-based wound care. The occlusive dressings were changed significantly less often than the gauze dressings, median 0.6/day versus 1.1/day (p = 0.008). The daily cost of the occlusive dressing was €5.31 compared to €0.71 for gauze, yielding a significant mean difference of €4.60 (95% CI €2.68 to €6.83). However, the mean difference between total daily costs, which includes material and nursing costs, was not significant (mean €2.86, 95% CI €-6.50 to €-10.25). Wound healing required a median of 48 days for occlusive compared to 30 days for gauze dressings (NS). Gauze dressings were found to reduce the length of time required for healing acute surgical wounds and were more cost-effective than occlusive dressings. Readers of this article are warned that the authors' conclusions are very controversial as a result of research methodology issues (e.g., small sample size, number of wound types, and 3 different dressing options per group).
4 Dressings – Hydrofiber with silver Quality Indicator
 Type: RCT
Jurczak F, Dugre T, Johnstone A, Offori T, Vujovic Z, Hollander D. Randomised clinical trial of Hydrofiber dressing with silver versus povidone-iodine gauze in the management of open surgical and traumatic wounds. Int Wound J 2007;4(1):66-76.
In this study, Hydrofiber Ag was found to be more effective than povidone-iodine in open wound treatment. Lack of blinding could have adverse effects on the results of the study as the primary outcome of pain severity is a subjective measurement.
5 Tissue adhesives Quality Indicator
 Type: Systematic review
Coulthard P, Worthington H, Esposito M, van der Elst M, van Waes OJF. Tissue adhesives for closure of surgical incisions. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD004287. DOI: 10.1002/14651858.CD004287.pub2.
In this review, various aspects of tissue adhesives for closure of surgical incisions are analyzed. It was unclear whether tissue adhesives were more effective than sutures or tapes. Further research is required.
6 Tissue adhesives Quality Indicator
 Type: Systematic review
Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T, Vandermeer B. Tissue adhesives for traumatic lacerations in children and adults. CochraneDatabase of Systematic Reviews 2001, Issue 4. Art.No.:CD003326.DOI: 10.1002/14651858.CD003326.
In this review, tissue adhesives are shown to be an acceptable alternative to standard wound closure techniques such as sutures, staples, and adhesive strips for simple traumatic lacerations.
7 Vacuum assisted closure Quality Indicator
 Type: RCT
Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005;366:1704-10.
The purpose of this paper is to determine the efficacy of vacuum assisted closure in wound healing compared with moist wound dressings in complex diabetic acute foot amputation site wounds. The researchers found that vacuum assisted therapy was superior to moist wound dressings in both wound healing and total healing time.
8 Vacuum assisted closure Quality Indicator
 Type: RCT
Armstrong DG, Lavery L A, Boulton AJ. Negative pressure wound therapy via vacuum-assisted closure following partial foot amputation: what is the role of wound chronicity? Int Wound J 2007;4(1):79-86.
In this study, evidence suggesting that negative pressure wound therapy treatment is superior to standard wound treatment is provided. It was found that negative pressure wound therapy had a faster healing time and is a viable option for treating chronic wounds. Further research is required to confirm these findings.
9 Vacuum assisted closure Quality Indicator
 Type: RCT
Braakenburg A, Obdeijn MC, Feitz R, van Rooij IA, van Griethuysen AJ, Klinkenbijl JH. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg 2006;118(2):390-397.
In this study, the use of vacuum assisted closure therapy in the treatment of wounds is examined, and some interesting preliminary evidence that it may be a better treatment for patients with cardiovascular disease and/or diabetes than modern dressings is uncovered. Small study groups prevent the results from being significant. More research is needed to verify these findings.
10 Vacuum assisted closure Quality Indicator
 Type: RCT
Huang WS, Hsieh SC, Hsieh CS, Schoung JY, Huang T. Use of vacuum-assisted wound closure to manage limb wounds in patients suffering from acute necrotizing fasciitis. Asian J Surg 2006;29(3):135-139.
In this paper, it was found that the vacuum assisted closure technique was effective in treating wounds. The population used in the study was very small, so the results are questionable.
11 Vacuum assisted closure Quality Indicator
 Type: RCT
Stannard JP, Robinson JT, Anderson ER, McGwin G Jr, Volgas DA, Alonso JE. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2006;60(6):1301-1306.
Two related studies concerning the positive effect of negative pressure wound therapy through vacuum assisted closure in treating both hematomas and fractures sustained from trauma were described in this study. While the results from this study appear convincing, the population was fairly small and, for the hematoma study, the group sizes were lopsided in favour of the VAC group (31 patients vs 13 in the control group).
12 Vacuum assisted closure Quality Indicator
 Type: RCT
Vuerstaek JDD, Vainas T, Wuite J, Nelemans P, Neumann, MHA, Veraart JCJM. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. Journal of Vascular Surgery 2006;44(5):1029-37.
The purpose of this study was to determine the efficacy of vacuum assisted closure in wound healing compared with standard wound dressings in hospitalized patients with chronic venous, combined venous and arterial, or micro angiopathic leg ulcers with durations greater than six months. Vacuum assisted closure significantly reduced the healing time compared to standard wound dressings, though recurrence rates, relapse rates, and complications were similar between the two groups.


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