Stages of primary surgical debridement
Adequate PSD requires quality pain control and strict adherence to the sequence of actions. The operation consists of three main stages:
- Tissue incision. Performed as widely as possible to explore all areas of the wound and eliminate "blind pockets". Exceptions are anatomical zones where an extensive incision threatens disability (hand, face).
- Tissue excision. The main goal is to remove necrotic masses. Skin, fascia, and muscles are removed sparingly, whereas subcutaneous adipose tissue is excised widely. At this stage, foreign bodies must be extracted, bleeding stopped, and the cavity sanitized (irrigation with antiseptics, vacuuming, ozonation).
- Reconstruction. The surgeon restores the integrity of bones, nerves, tendons, and muscles. If the patient is in a severe condition, this stage is postponed until vital functions stabilize.
PSD concludes with mandatory active "tiered" drainage.
> How to determine muscle necrosis during surgery? Non-viable muscle tissue has a dull dark color, tears easily with forceps, does not bleed when incised, and does not contract in response to mechanical stimulation.
Types of sutures by timing of placement
Wound closure during PSD depends on the nature of the injury and the time elapsed since the wounding.
- Primary sutures (on the day of surgery). Absolutely indicated for open traumatic brain injuries, chest, abdominal, joint, facial, genital, and hand wounds, as well as radiation injuries. In other cases, they are placed only if no more than 6–8 hours have passed, there is confidence in the radicality of PSD, the edges are approximated without tension, and the patient remains under observation.
- Provisional sutures. The threads are placed on the day of PSD, but tied only a few days later if the wound process proceeds favorably.
- Primary-delayed sutures. Applied after 2–7 days if there are no signs of suppuration in the wound.
- Secondary-early sutures (8–14 days). Used on a granulating wound that has already cleared of necrosis but has not yet begun to scar. The edges are approximated without additional incisions.
- Secondary-late sutures (from 3 weeks). By this time, the wound edges become rigid due to cicatricial changes. Simply pulling them together is impossible — excision of granulations, incision of scars, and mobilization of the edges are required.
Purulent wound infection
The most common complication, caused in 60–70% of cases by Staphylococcus (often as part of microbial associations). The infection can manifest as phlegmon, abscesses, purulent streaks, or osteomyelitis.
Clinically, it presents with local symptoms (throbbing pain, increasing edema, hyperemia, and hyperthermia) and general signs of intoxication (fever, weakness).
Surgical tactics:
- For superficial inflammation, the focus must be opened (sutures removed or an incision made) and drained.
- For deep suppuration (e.g., abscess of an intermuscular hematoma), a diagnostic puncture is performed first.
- After the inflammation subsides, the defect is closed with secondary sutures or skin grafting.
Treatment is always comprehensive: general (combating intoxication, correcting protein losses) and local (cleansing the wound with enzymes, antiseptics, physical methods, and modern sorbent dressings).
Anaerobic infection (Gas gangrene)
An extremely dangerous, highly contagious form of infection caused by clostridia (Cl. perfringens, Cl. oedematiens, etc.). Bacteria release exotoxins that cause rapid tissue necrosis, hemolysis, and vascular thrombosis with damage to internal organs. Pronounced edema and gas production predominate locally.
Clostridia require an anaerobic (oxygen-free) environment to develop. It is provoked by:
- Tightly closing the wound without indications.
- Prolonged tourniquet application or tight tamponade.
- Leaving blind pockets due to poor-quality PSD.
- Heavy soil contamination and poor transport immobilization.
The incubation period is usually 3–5 days, but can be shortened to a few hours. According to prevailing symptoms, the edematous form (clostridial cellulitis) and emphysematous form (clostridial myositis) are distinguished.
Briefly: answers to topical questions
What groups of drugs are used for general conservative treatment of purulent wound infection?
General treatment of purulent wound infection aims at the mandatory correction of:
- Intoxication — general supportive and detoxification therapy.
- Decreased immunity.
- Protein and water-electrolyte balance disorders — restoration and maintenance of protein-electrolyte balance.
Local treatment is carried out taking into account the stages of the wound process; among chemical and biological drugs, proteolytic enzymes, antiseptics, saline solutions, and antibiotics are used.
What antiseptic solutions are used for medical sanitation of the wound cavity during PSD?
For medical sanitation of wound surfaces after PSD, the sources indicate the following antiseptics:
- 3% hydrogen peroxide solution.
- Pink potassium permanganate solution.
- Methylene blue — for treating exposed bone.
- Brilliant green — for treating exposed bone.
The general PSD protocol also mentions wound irrigation with antiseptic solutions, without specifying their composition.
What are the clinical and morphological forms of gas gangrene?
Depending on the predominance of the clinical picture and the depth of tissue damage, two main forms of gas gangrene are distinguished.
- Clostridial cellulitis (edematous form) — the disease proceeds with predominant damage to the subcutaneous adipose tissue.
- Clostridial myositis (emphysematous form) — the pathological process is characterized by predominant damage to muscle tissue.
Class and exam questions
In which cases is the placement of primary sutures strictly mandatory?
In penetrating injuries of the joints, thoracic and abdominal cavities, open TBI, injuries of the face, hand, external genitalia, as well as in patients with radiation injury.
How does an early secondary suture differ from a late secondary suture?
Early sutures are applied on the 8–14th day by simple edge approximation. Late sutures are applied after the 3rd week, when the edges have already scarred, so before closure, edge separation and scar excision are required.
Why is it forbidden to treat a patient with gas gangrene in a general ward?
Anaerobic clostridial infection is highly contagious. At the slightest suspicion of it, the patient must be completely isolated and transferred to a strict anti-epidemic regime.
What else to study on this topic
- Modern wound dressings: collagen and alginate dressings.
- Physical methods of sanitation: ultrasound, laser, ozonation, and vacuuming of the wound.
- Method of early active surgical treatment of purulent wounds with primary closure and irrigation-suction drainage.
- Special forms of wound infection: tetanus and putrefactive infection.
- Pathogenesis of systemic disorders in purulent wounds: anemia and protein-electrolyte imbalance.
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