surgery Lec 2

7/29/2019 surgery Lec 2

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wound

Management of wounds; Everybody of us are responsible to get awound.

-we divided the Traumatic wounds to :-Sharp, penetrating: by knife, sharp thin wire.

-Blunt: stone

-Bullet:

Types of wound:

We have a division of wounds due to the cause of it, and if the

cause settles inside the body, or stroke the body without settling

inside:

Cut wounds: during shaving, cutting meat.

Learning points of

this lecture are

about:

Wound, ulcer,

fistula, cyst

The wound either be

traumatic surgicalhappens by

accidents

made by

surgeons

most ofour talk will be

about

traumatic

wounds which

cause by Car

accidents, by

Falling from

high places,,,

etc.


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Lacerated wounds: when someone strikes u by a stone or stick andu get a wound, and u can describe that wound that its Broken and

irregular.

Crushed wounds: when a stone fall into someone or car hit him.

Wounds with skin loss : by a drill, piece from skin loss in place ofaccident.

Examination of Wounds: its a very important step, u must care ofit.-By examine the wound I can know :-the extension of the wounds,

-how its deep, -if there is any associated injures.

Associated injuries:

In emergency room there is a lot of cases about people

come with a horrible look, their heads covers with blood, butwhen uput them on the table and remove the blood, cut the covering hair, may

found thats a very small wound, anyway, u must examine the wound

carefully, maybe inside that a small wound there is a stone, glass,

breakage of bone, so the examination of the wound is very important, to

know the extent of the wounds, and to know if we have associated

injures,

Always the people concern about the superficial wound, but often

there are things inside are more serious, so we must care about the

muscles, vessels, tendons, and bones that there location in, or near the

injured site.

Eg; A patient with an injured wrist by a knife, we haveunderneath that area artery and tendons that moven the fingers, there

is a nerve that moven the muscle, and the nerves that get us the

Examination

of Wounds

It's as

important as

history if the

patient was

unconscious.


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sensations, and any one of them may get associated injure, so we have

to examinecarefully.

Abdominal cavity: Eg; patient have an injury in the abdomen by athin sharp wire as example,,, so we must be aware about everything in

the place of injury, to impose the injury was near the spleen, we must

think about the stomach, the colon, the kidney, even if it looks

superficially not deep, but in deep may there is a server bleeding.

Chest cavity: we must be aware about the lung the heart, maybethere is a collection of air or blood in plural space.

cranial cavity: Eg; someone striking with stone, he come tohospital walking as normal, the wound was small, the Dr suture it, but

after six hours the patient come back in a coma, after a new

examination, the Dr found that the patient has a broken cranial bone,

there is sub- cranial bleeding, that compress the brain associatedinjury.

Types of Suturing:

- Primary suturing :if the wound was in the skin and clean we suture

it.

-Excision and primary suturing: we cutting from the wound and

then do suturing.

-Delayed primary suturing: I want to delay the suturing to next

day or like that.

-Secondary suturing: suturing after a week, I can't suture it today

or tomorrow.

-Skin grafting.

so u have

to ensure

there is no

associated

injuries


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: if we dont suture the wound ,,,The big questionwhat will happen??

-The wound will heal ,,, as simple as this >> the explanation is:Our Great Creator gives us all the mechanism of healing, so we asDoctors, we just accelerate this mechanism, because if we dont do

suturing the process of healing will delayed and inflammation will

occurs, and the final result will be a large scar.

How do we think to choice thetype of suturing????!! when the wound is clean "there edges very regular and there is no debrison it" we do primary suturing-after antiseptic for sure-

when the wound is polluted with debris like soil and glass, and thereedges not regular, so we need first of all to regulate the edges and clean

the wound then suture it so we do excision and primary suturing,

If the wound was" a crashed wound"; we have hematoma, swelling,broken bone underneath it, obstructing vessels >>> we can't do suturing to

it, how we deal with it: we clean it, and wait to second day third day until

the inflammation gone and the suturing become possible so we dodelay primary suturing.

if the suture delay more than that time- like a week- we name thesuturing a secondary suturing.


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But when we do suturing; we lower the distance between edgesof the skin, so the space that must filled with granulation tissue will

be very minimum, and that of course mean that the process of

healing become easier for the body, and the scar that forming will be

very minimum.

,contractionthe wound will??occursHow the healing-

the space between the walls of wound will filled with tissues that will

forms from the edges of the wound, with blood supply will form

granulation tissues, and after filled, it will convert to fibrous tissuethe skin will growth and form epithelium "epithelization".

Phases of healing:that-macrophagesneutrophil, and,phagocytesthe,:Lag phase

doing phagocytosis- will go to site of wound to remove the damaged

tissue and any sign of inflammation.

the phase that the granulation tissue:Proliferation phase

will form.

tissue form andfibrouswhen:(differentiation)Maturation

cover the skin(epithelization).

---------------------------------------------------------------------

is the granulation tissue which is forms and:The organ of repairfills the cavity, and form a new cavity instead of tissue which was lost

in the accident.

-------------------------------------------------------------------------------

Elements of

healing:

contractiongranulationtissue the

epithelization

.


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------------------------------------------------

from the wound, andbiopsyif we take a:Wound histologyexamine it in the lab, what are the cells that are proliferating

there???

amount, they goplenty"neutrophils" are there, byfirst dayat the-

out of the capillary and get into the tissue, and engulf the foreign

bodies by phagocytosis,

we find monocyte, the monocyte have the same:hrs.after 24-

function as phagocytes,

since thefibroblast; which working in building unit,:6 days-after 5-

fibroblast is the cells that form the connective tissue, this fibroblast

appears in the surrounding tissue,

6 day-will appear by the 5the capillary-

.dayth

after 4collagenthe-

thebuildingsstartit6 days-Once the wound in the 5

collagen that forms from fibroblast, , and in the same duration in the

wound, the microbes release an enzymes that lysing the collagen

"collagenase", but if the immunity of the person is good the collagen

synthesis will overcome the collagen lysis ..

Factor affecting healing

: does after suturing and healingwound strength

occur the strength of the skin will back to original one?

When I open the muscle and go to the abdomen and then

suture them,, does the strength of the muscle come back

as it was??

No,, it will never come back to normal, usually by six

month it will have maximum strength which is less than

the original one (come back to 60, 70 % of their original

strength )

neutrophils

represent

the firstline

defense.

the collagen

is the

connective

fibers which

gives

strength to

the tissue


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What are the factor delay healing?? Why w e findpeople with fast healing and others are not??-the age: healing in young and children is better than elderly.

-the nutrition: if the person have protein, ascorbic acid or zinc

deficiency, this will delay healing.

-vascularity: if the tissues have good blood supply, the healing will be

quick.

-sepsis: if the wound infected the healing will delay.

-oxygenation: its related to vascularity.

-Wound dressing: if the wound contaminated we have to repeat

dressing.

if the wound is clean, we dont repeat dressing,but clean wound that will interrupt with thebecause repeat dressing in a.healing process, and this will delay the healing

types of healingfirst intention: if I suture the wound, the spaces between twoedges become too minimum, so the healing is quick.

Second intention: if the wound is wide, and it remains open all thetime, it will need to fill this cavity-in a month maybe-, at the end we

get a scar which is very wide and thick.

bullet injures- it has many types: high velocity missile, shockwaves,

temporary cavitation.


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high velocity missile: the bullet inter the abdomen -as example,andinjures the liver or colon, then it may go out or remain inside. It can

also pass just through the skin.

Even if it pass just through the skin, the shock waves that Generated

by it, will damage the liver, even if it doesnt pass through it.

the temporary cavitation: if the bullet pass the liver from point toanother point, the damage will not only in the tract "that made by

passing the bullet", the damage will extend to the surroundings of

the tract, by the effect of cavitation.

:slast injursometime we will have complex blast waves: no only the explosion

will make a shock wave, but the shrapnels too, and even ifwe dont

hit directly by the blast, we may have injury by the" mass air

movement"because the air in this area if it has an explosion the air

will move to another side rapidly and can shattered.

Surgical woundsMade by surgeon in a regular way , under anesthesia, under

complete aseptic condition, so there will be no contamination.

surgical wound

clean

contaminated

dirty

cleancontaminated

high velocity

missile: whichis the

automatic

weapons like "

Kalashnikov"

and the velocity

of them is very

high, more

than 16m/sec,

and we have

the low

velocities, and

blast waves


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patient: Dr u will do to me "a thyroid operation",

what's the possibility that my wound will get inflamed??

Dr :very minimal,, because the operation is clean.

Patient: Why clean??

Dr: the thyroid is sterile, it dont have any microbe, the wound will be

clean, the possibility of wound infection is very minimum.

-petiant2: Dr u will remove my Gallbladder, what's the possibility

that my wound will get inflamed??

Dr: HERE the possibility of wound infected is more, WHY??Because

while I cutting through the duct, I open the biliary system, and the

biliary system which have bile which have microbes, those microbe

which lives normally inside the body, can contaminate the wound, so

this wound is clean contaminated.

Petient3: Dr u will remove my appendix, what the possibility to

wound infection??

Dr: according to the appendix, if it is inflamed so,, its fill of

microorganism and pus cells, so whatever u do to isolate it going to

contaminate, so the % from 15-20 %,BUTifthe appendix was

gangrenous or the colon have gangrene and it has a lot of stool, sothis wound get infected in highly percent may reach to 40%, so this

wound we can classified it" dirty".

So if the operation was mastectomy >>> clean.

Hernia>>> clean

Gallbladder and it acutely inflamed>>> contaminated.

In first case

the

possibility of

wound

infection b/w

0-2%, the

second case

like 10%


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Now, why we classifying this like that???

Because we want to inspect how much inflammation we get, to try to

reduce this incidence, so; in clean operation we dont give the

patient antibiotics, like in thyroid operations, that considers a mistake

if we give the patient of thyroid operation an antibiotic.

While, clean contamination, like gallbladder operation in case it is

not inflamed but have a stone, we give the patient one dose antibiotic

which called prophylactic antibiotic- because while am removing

gallbladder and during explosior of contaminations, we have high

level of antibiotics in blood, so I reduce the possibility of infection, andsometime, we may give in the contaminatedcasesprophylactic and

wait to three days, In dirtycases we wait till five days or week maybe.

So this is to gauge how much the wound will affect by infections,

and to decide which patient we should give an antibiotic at which

time, and for how long.

:actors which affect healingMalnutrition, ureamia, malignancy, radiothempy,:General-

cytotoxic drugs, diabetes, "vit c" deficiency.

,and FBBlood supply, presence of necrotic tissue-Local Factors:-

presence of hematoma, excessive cauterization, rough manipulation,

" THE GOAL of suturing the wound is toinfection, Tension in wound

approximate the edges but not to strangulate the wound, if the

edges of wound dont meet together I should not put intension, if Iin wound where will be no blood supplying and themake intention

.healing will delay"

Now,, after we manage the wound, what's the problems

that may happen??

Prophylactic

antibiotics

gives in all

cases of

surgical

wound

except: the

clean one


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the sings of wound infections??what's,, but,,,wound infection

Redness, swelling, pain, fever, tachycardia..

When the wound get infected,,, what I should do??

-I dont give the patient antibiotic but I open the wound or part of it,,

so the collection of pus will go out, and give antibiotics if there is a

surrounding cellulitis.

if we open the wound in first few days of suturing, it will be very:Pseasy to open and maybe it opens by itself by the effect of collection

and pus, but with passaging of time the wound become harder and

harder.

while the surgeon work in abdomen, like:Wound dehiscence

bowel obstruction operation, in the end of it, he sutures the layers of

abdominal wall, and the most important layers is the aponeuroticlayer- muscular layer- and suture it by no absorbable suturing

filament, in the end of 7th

day after operation that there is a swelling

in wound and fluid coming out, and when we examine we may found

that the bowels coming out between the muscles and collecting below

the skin directly which we call it" Wound dehiscence". and that may

occur because of increase in the abdominal pressure, so after

operation we should for many days avoid occurring the intra-

abdominal pressure which may occurs by intension, sever cough,

sever constipation,

-Hyper trophied scar, keloid:

When the patient has thyroid swelling, asking for operation, after he

considers in his mind the cosmetic appearance for sure, and we do a

plastic cosmetic operation and after the 7th

day we look at it , we find

it very fine, very thin, difficulty to seen it, but after a month he come

back, and his wound is thick and red in color" hyper trophied scar"


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Why that happens??!!

It's not caused by the surgery, its sometimes due to the patient, to

the area.

The story is the wound after it heal,, it continue growing, and become

red in color with an itching state, and this case is more in pregnant

woman, and in wound that in bony contours, so I try to overcome

doing insegen in the shoulder, over the sternum, which is the areas of

probability of trophied scar to occur.

Anyway, we said to patientdont worry, we will wait for six weeks,

and it will reduce by itself and sometime we inject in it a

corticosteroid and sometimes using laser to reduce it.

:loidkecalledin thingproblemThe more big

It's rare, I do the surgery, in appropriate manner, but after 2 to 3

month the wound gets growth, after 6 month it still growing, andinvade the surrounding areas and it may reach areas we dont wound

it,,, this is keloid, and its due to the body itself, growing a lot of cells

more than needed and even if we remove it , it will recur and need

many operations.

IS THERE A POSSIPLITY OF LATENCY OF THE

INFECTION TO INFECT THE WOUND?:?

USUALLYTHE infection of the wound occurs in the end of the week,

and if the wound completely healed after one or two weeks, it's

unlikely to get wound infections after month or two, except in some

cases, when there is a retained foreign bodied-stone, glasses-, deep


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in the wound,, or there is non-absorbable Internal stitch, it may get

infected.

the time rate of the injury to heal?

The healing in the skin and the appearance of epithelization ends in

the first week almost, However; the wound itself not mature enough,

it will continue maturing till 6 month, and that include the bone, since

when we have bone fracture, we use plaster to confirm the bone and

prevent the patient from walking if the fracture was in his leg till 3

month,, until his fracture healing become more strength.

can we associate more than one type of wound with

another, during surgery??

-if I was doing a hernia surgery and in the same time the patient was

having a mass in his inguinal region and we removed it normally

BUT, IF I WANT to remove perforated appendix, and I found a

hernia near of it, I can't do it in the same time, because the first one

is contaminated, and will infect the other.

What is the Difference between clean contaminated

and contaminated??

-clean contaminated means that there is a possibility of

contamination but not always, for example, if I open the stomach,

which have an acid, so usually the microorganisms in it very low, if I

open the common bile duct usually it's not having microorganism, if Iopen the pelvis of the kidney, its unlikely to have microorganisms but,


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if have some infection, it can contain, while if I open the colon, this is

absolutely contaminated,

how can we differentiate between contaminated and

dirty??

-this depends upon the degree of contaminations, like, sometimes I

go and remove the appendix, pus is coming out from appendix-its

contaminated- but sometimes I go to remove the appendix and I

found that the abdominal cavity is full of pus and feces, and the smell

of the theater is full of feces, so this is dirty, so when the

contaminated is very massive its dirty.

lcersU

Ulcer: is a break in continuity of the skin, or its any

discontinuity in any epithelial surface, orits a microscopic

discontinuity of normal epithelium, epithelium like skin and

mucous membrane, the mucosa of the mouth, mucosa of

the stomach, so ulcer may happen in skin, mouth, stomach,

intestine, , , and if the discontinuity are microscopic we call

it erosion.

Ulcers are non-healing wounds that develop on the skin,

mucous membranes or eye. Although they have many

causes, they are marked by:

1-Loss of integrity of the area


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2-Secondary infection of the site by bacteria, fungus or virus

3-Generalized weakness of the patient

4-Delayed healing

:ocation-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.

-Mouth ulcers: by fungal, or virus infections.

-Ulcers in sacrum: like diabetic patient which has ulcers in

their legs, and it's not healing, because he has delay in the

healing mechanism.

-Peptic ulcers: this kind of ulcer occur by digestion of the

entire acids and enzymes to the mucosa of the stomach or

duodenum, so it will ulcerate. This includes ulcers of the

esophagus, stomach, large and small intestine.

-Genitalia: May be penile, vulvar or labial. Most often are

due to sexually-transmitted disease.

:ausesin form of wound,sforms, it startitUsually the ulcers when

, and otherbacteriathecalculatesand it does not heal, so it

.which inflame the wound and delay the healmicrobes


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And some time there is no infection, there is a cancer, likepatient comes to Dr and said he has a mass in his face and

then it ulcerated, from 6 month and it does not heal,, so this

not ulcerthis is cancer.

another patient came with Venous stasis, in her lowerlimps, for the last five years, but recently, her leg gets

ulcerated "that does not heal", this is venous ulcer.

Arterial insufficiency:patient with ischemia in lower limps,

the blood supply to his lower limps is occluded, the wound is

very painful.

-Diabetes: the diabetic patient with wound for 6 month or

more and not heal, if the diabetic patient has wound

infection, and ulcer in his leg it's like to be as a fire in the

forest, the ulcer will spread, why??,,,, because all the factor

that needed in the healing process is defective.And the

blood supply in diabetic patient; he has arteries sclerosis, the

sensation is absent" neuropathy", he does not feeling in any

kind of pain" loss of sensation", he has retinopathy, he has

impaired immunity, so the wound dont heal quickly, in

contrast it spread quickly.

-Loss of mobility: in Patient which is incapable of movement,

large ages, which need someone to change his position, hewill get ulcer, as a result of pressure with no blood supply.

:escriptionyou have to describe the features of the ulcer; Site, Size,

shape, base, edges, tenderness, discharge and surrounding

tissue and lymphatic's.

Those should be

describe

because it will

give usimpression if

the ulcer will

heal or not


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I

:lcerationschemic- those patient with lower limp arteries sclerosis are more

acceptable to get ulcer, because there is no blood supply,

- In elderly , who also have symptoms of coronary vascular

disease.

this patient has problem in the -blood supply and has ulcer in

the dorsum of the index.

this is an ulcer in the tip of

pecto, and this ulcer may is ischemic ulcer, or diabetic patient.

Practices:

Ifthe patient has ulcer in the upper half of the face, and its

shape is circular, the edges is rolled, so I said these is :basal cell carcinoma"

Ifthe ulcer found in the foot and its very painful to patient,

so I said this is "ischemic ulcer"

Ifthe ulcer in the foot and their smell awful, and it give out

a pus, and the patient dont feel anything,, so I said this

patient is "diabetic".


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-When we see this picture, we can

notice that the base of ulcer is red,

andthats a good sign of healing,

because when we find the floorblack, and have pus, this is infected

ulcer.

-Look to the edges we call it sloped edges, and also is a sign

of healing.

ents havei; loss of sensation, occur in patulcerNeuropathic

diabetic, paraplegia.

:Causes

-peripheral nerve lesions diabetes ,nerve injuries

-Spinal cord lesions

This is pic of ulcer in diabetic patient, the ulcer

occurs in the pressure areas.

,femalesoccurs usually in:The venous ulcers:

This is a venous ulcer, you will seevaricosities,_"varicosities is venous

veins which is congested and dilated".

It's found everywhere, and we found pigmentation on it, in the


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middle aspect of the lower third of the leg, this area called:"

gatal area".,,,,,,,,,,,,,,,,,,,,,,,,,, MAY ALLAH PROTECT US .

what's the cause of gastric ulcer??

-the stomach HCL main function is to digest the protein, BUT,

sometimes due to excessive production of IT, it will digest the

mucosa of the gastric, new thing is explorer recently that thereis a bacteria called "helocapterpylori " may exist in the

stomach and react with the HCl and cause ulceration, so we

can stop this bacteria by reducing HCL production.

estulasDefinition: Fistulas is an abnormal communication

between tow epithelial -or endothelial- surfaces.

The

medications

given;

lansoprazole

, and

antibiotics.


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,edthe feces collectin itwe see the anal canal which:picIn

then it will go out by auns canal, thats the normal scenario.

But,,, there is some people have another opening for feces,

this opening is end of a canal, which having another opening

inside to anus canal, so its abnormal communication between

the skin and the lining of anal canal, so the feces and secretion

will discharge to go out from the extra abnormal canal.

Why that happens??

-before the canal form, an abscess form with pain sensation,

this abscess is open in and out, but the patient dontaware only

to the out one, and at the way of the abscess we found a track,

which is not closed and this is the fistula. This is acquired fistula.

-May all of us hear about new baby born with difficulty in

breathing, when his family fed it the food go to the lung,

Types of

fistula:

Congenital

Ac uiredexternal

Arteriovenous fistulas

Internal abdominal fistulas

External abdominal fistulas

Congenital and acquired(traumatic or

iatrogenic)


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because of abnormal communication between the trachea and

,fistulacongenital, this is athe esophagus

-Sometimes the fistula may happen between vain and artery"".fistulasArteriovenous

-A patientwith mammal fistula," abscess in the breast",

happen in pregnant woman or after delivery, after the abscess

opened, at the site of drainage of the abscess the milk eject,"

the milk come out not from the nipple but from nearby" this is a

fistula between the ducts of milk and the skin.

-A patientget operation, he remove the gallbladder, the biliary

canal-common bile duct- tied, but after a while I found that the

"bile isfistulabiliary,,, this is abile come out of the wound

coming from the wound", there is abnormal communication

between the biliary tree and skin.

-A patientwith bullet inside his body, the bullet get inside the

pancreas "the pancreas produced pancreatic juice",

The pancreatic juice will go to the bowel but since the wound

reach the pancreas, so the pancreatic juices coming out through

the wounds, and after 2-3 month the pancreatic juice will

apancreatic fistula"the,,,,, this iscoming on skin by the woundcommunication between the skin and the pancreas".

get a hit with knife, the: a patientfistulaGastrocutaneous

knife go inside the stomach , in operation the stab wound in the

stomach closed, but it was a big stab, in the next day he have a

wound infection, in the 7ht-8th

day when he start eating, the

food go out from the wound, the stomach opens in the skin thisis Gastrocutaneous fistula.


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.jejunumandstomachbetween:Gastrojejunocolic fistula-

do operation to him, we cuta patient we:mall bowel fistulaS-part of his bowel that is gangrenous as example then we suture

the bowel with each other -that called" anastomosis"

After week -10 days the wound secret pus and intestinal

contents. Because there is opening between small bowel and

stomach.

had operation in his colon,patienta:fistulaExternal colonic-

suture the colon after trauma and suture the skin overlaying,

after few days the feces go out from the wound, and have a

complications between the colon and skin.

ladies,that happens with:and colovaginal fistulasColovesical

in cases of obstructed labor, so the head of the baby get

necrotic in the neck of uterus, and it will open on the bladder,

and the urea go up from the bladder to the uterus and the anus,

".covaginal fistulavesi"That called

.

The colon can also open in the vagina and the feces go:PSout from the vagina.

:yst, normal orlined cavity or sac-closed epitheliumany

abnormal, usually containing liquid or semisolid material.


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:cysts in the neck

Branchial cleft cysts: In imperiology phase there is arches,

and it will disappear and some of

it may remain, so may a baby born

with a cyst in his neck, and that

because one of this clefts did not

obliterated, this is a brainchial

cyst.

Thyroglossal duct cysts: When the thyroid gland formed, its

formed by Thyroglossal duct, this

duct will extend from the

posterior of the tongue to the

neck region, once the thyroid

gland form and the duct

disappear, sometimes some ofthe remnants' form a cyst " Thyroglossal cyst".Dermoid cysts: after 1-2years of

born of baby, we notice a swelling inthe outer border of the eyebrow, its

congenital because there is a part of

skin cells implanted under the skin

and make the dermoid cyst,, we

remove it by excision.


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Sebaceous cysts: its a small cyst

in the scalp, highly prevalence, and

its mobile attach to skin, contain

sebaceous materials.

a child with a swelling in the:in pic

midline under the chin directly,

when he swallow saliva it moves

and when he rise his tongue it will

go up.

Thats it

All extra info in slides are not included.

Malaysian brothers and sisters,,, for u, I did best what I can do

,,,:D

For my wonderful batch:

( , )

DONE BY: Asmaa Almawas


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Documents

surgery Lec 2