Surgical wound debridement

Classification and triage of the wounded

The effectiveness of surgical treatment directly depends on the time elapsed since the moment of trauma. The earlier the intervention is performed, the higher the probability of successfully preventing infectious complications. The only valid reason for delaying surgery is the state of shock — the patient must first be resuscitated from it.

Depending on the timing, three types of PSD are distinguished:

• Early: performed within the first 24 hours (up to 24 hours).
• Delayed: performed during the second 24-hour period (from 24 to 48 hours).
• Late: carried out 48 hours after the trauma.

During a mass casualty intake, surgeons adhere to a strict sequence. First and foremost, patients with a hemostatic tourniquet applied, casualties with extensive shrapnel wounds, and patients with wounds heavily contaminated with soil are sent to the operating table (due to the critically high risk of developing anaerobic infection).

Indications for conservative treatment

Far from every injury requires aggressive surgical intervention. The experience of military field surgery and peacetime shows that PSD is not performed in the following cases:

• Minor superficial injuries (abrasions and scratches).
• Through-and-through wounds with small entry and exit openings (provided there is no damage to major vessels and vital organs).
• Multiple blind soft tissue wounds (a typical example is shotgun pellet wounds).
• Puncture non-penetrating wounds without signs of major vascular trunk injury.
• Incision wounds whose depth does not reach tissues below the subcutaneous adipose tissue.

Principles and technique of PSD

The operation must meet two fundamental requirements: single-stage performance (all actions are performed in a single step) and radicality (absolutely all necrotic tissues are excised).

The essence of the procedure boils down to the excision of the edges, walls, and bottom of the wound tract within healthy tissues, after which the surgeon restores the anatomical relationships of the structures.

Main stages of the surgery:

1. Revision and incision. Narrow, deep wounds or wounds with blind pockets are expanded beforehand. The skin incision is extended along the longitudinal axis of the limb, along the course of neurovascular bundles.
2. Working with fascia. Fasciae and aponeuroses are incised with a Z-shaped or arcuate incision. This provides a good view and prevents muscle compression due to increasing edema, which is especially critical in gunshot injuries.
3. Cleansing. Clothing fragments, blood clots, and freely lying foreign bodies are removed.
4. Excision. Skin and subcutaneous tissue around the wound are removed in a 0.5–1 cm layer, along with all crushed and contaminated tissues.

Surgical tactics regarding various tissues

When performing PSD, the surgeon takes a differentiated approach to various anatomical structures:

• Muscles. Excised strictly within healthy areas. Non-viable muscle is dark red in color, appears dull, does not bleed when cut, and does not contract when touched with forceps.
• Vessels, nerves, and tendons. Undamaged elements must be preserved. Contamination is removed from their surface with extreme care. If a structure is damaged, its integrity is restored.
• Bones. Freely lying small fragments are removed. If sharp ends of large bone fragments devoid of periosteum protrude into the wound, they are carefully clipped with bone rongeurs.

The procedure concludes with thorough hemostasis (stopping bleeding). If the wound is completely cleared of necrotic masses and foreign bodies, a primary suture is applied.

Delayed debridement and historical aspects of suture placement

Late surgical debridement is indicated when signs of purulent inflammation have already appeared in the wound. Its main goal is to ensure adequate outflow of purulent discharge. The surgeon cleans the cavity of dirt, extracts foreign bodies, removes obvious necrosis, and opens purulent streaks, pockets, or abscesses. Important: radical tissue excision at this stage is generally not performed, as this threatens generalization of the infectious process.

Approaches to wound closure have changed over time:

• Experience of the Great Patriotic War (1941–1945): Due to the extremely high risk of suppuration, PSD was often not performed in full, and primary sutures were almost never applied (provisional and primary-delayed sutures were used). Secondary sutures were applied to the granulating wound only after inflammation subsided.
• Peacetime: Thanks to the development of antibacterial therapy and the possibility of continuous patient monitoring, primary sutures are widely used, even in late-stage operations (12–24 hours). If signs of infection appear, sutures are partially or completely removed.

For gunshot wounds, primary sutures are still considered inappropriate due to the specific nature of the injuries. In such cases, when the danger of suppuration has completely passed, a secondary suture is applied to the granulating surfaces, which can be used anywhere from a few days to a few months after the injury.

Class and exam questions

What else to study on this topic

• Features of surgical tactics in gunshot wounds
• Types of sutures: primary-delayed, provisional, and secondary
• Principles of draining purulent wounds
• Antibacterial therapy in the complex treatment of infected wounds

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.