GOU VPO Izhevsk State Medical Academy of the Ministry of Health and Social Development of Russia

Department of Hospital Surgery

with a course of resuscitation and anesthesiology

wound treatment

Tutorial

UDC 616-001.4-089.81(075.8)

Compiled by: Candidate of Medical Sciences, Assistant of the Department of Hospital Surgery S.V. Sysoev; MD, Associate Professor, Head of the Department of Hospital Surgery B.B. Kapustin; Candidate of Medical Sciences, Associate Professor of the Department of Traumatology, Orthopedics and Military Field Surgery A.M. Romanov.

Reviewers: Head of the Department of General Surgery, Bashkir State Medical University of Roszdrav, Doctor of Medical Sciences, Professor M.A. Nartailakov; Head of the Department of Surgical Diseases with Courses of Urology, Endoscopy, Radiology of the FPC and PPS of the Tyumen State Medical Academy of Roszdrav, Doctor of Medical Sciences, Professor A.M. Mashkin.

The textbook deals with the issues of surgical treatment of wounds and injuries of soft tissues and cavities. Classifications of the wound process, primary surgical treatment of wounds in peacetime and wartime conditions are proposed. The issues of prevention of surgical infection were discussed. The textbook is intended for students of medical and pediatric faculty.

Wound treatment: Tutorial / Comp. S.V. Sysoev, B.B. Kapustin, A.M. Romanov. - Izhevsk, 2011. - p. 84.

UDC 616-001.4-089.81(075.8)

General characteristics and basic principles of surgical treatment of wounds

Wound- tissue damage, accompanied by a violation of the integrity of the skin and mucous membranes. Under wounded understand the process of tissue damage, the entire complex and multifaceted set of those pathological changes that inevitably occur both in the area of ​​the wound channel itself and throughout the body as a result of open damage.

The reaction of the body to injury: pain; blood loss (bleeding); shock; resorptive fever; wound infection; wound exhaustion.

Microbial contamination is inevitable with every injury: primary, secondary, hospital.

Wound infection is a pathological process caused by the development of microbes. The development of microbes is facilitated by: blood clots, dead tissue, association of bacteria, poor aeration, poor outflow; tissue hypoxia; BOV defeat; radiation sickness; blood loss, shock; exhaustion; hypovitaminosis.

According to the degree of infection, it is customary to distinguish aseptic, freshly infected (contaminated) and purulent wounds.

Infected (bacterially contaminated) wounds- wounds inflicted outside the operating room within 48-72 hours from the moment of injury. Microorganisms enter the wound with a wounding object or from the skin of the victim. There is a high probability of infection of gunshot wounds and wounds with soil contamination, as well as wounds with significant tissue multiplication. The number of microorganisms in a freshly infected wound does not exceed the "critical level", i.e. 10 5 -10 6 microbial cells, or rather colony-forming units (CFU) in 1 g of tissue, 1 ml of exudate or 1 cm 3 of the wound surface. This fabric has Clinical signs inflammation, a systemic inflammatory reaction of the body is often observed. In this case, the wound process can develop in two ways: either the inflammation stops and the wound heals by primary intention, or microbial cumulation occurs in the area of ​​the traumatic defect, the contamination reaches and often exceeds the “critical level”. Such a wound is called secondary purulent. O primary purulent the wound is said in those cases when it is formed after surgical treatment of a purulent focus in acute purulent diseases of soft tissues (abscess, phlegmon).

festering wounds differ from freshly infected ones by the presence of an infectious process in them with all the classic signs of inflammation (pain, swelling, hyperemia, fever and dysfunction of the damaged area).

The main method of treatment of wounds is their surgical treatment. This is understood as an operative intervention aimed at creating the most favorable conditions for wound healing and preventing a wound infection that may arise and develop. In practice, surgical treatment of wounds consists of dissecting the wound and excising non-viable and contaminated areas of damaged tissues, stopping bleeding with the removal of blood, blood clots and blood clots from the wound cavity. foreign bodies.

There are primary and secondary surgical treatment of wounds.

Primary debridement (PSW)- the first surgical intervention performed according to primary indications, i.e. about the damage itself. The main task is to create unfavorable conditions for the development of wound infection and ensure rapid wound healing.

Primary surgical treatment, depending on the duration of the operation, is divided into early, delayed and late. Under early PST understand an operation performed before the visible development of an infectious wound process, i.e. during the first day (24 hours) from the moment of injury. Surgical treatment performed during the second day (from 24 to 48 hours) is called delayed PHO wounds. In cases where the primary surgical treatment is performed in the presence of a developing wound infection (more often after 48 hours from the moment of injury), the operation is called late PHOR.

Secondary debridement- surgery performed according to secondary indications, i.e. due to changes in the wound caused by wound infection (infiltration, edema, suppuration, phlegmon).

40. Technique for suturing and removing sutures.Primary debridement (PSD) wounds - is the main component of surgical treatment for them. Its goal is to create conditions for rapid wound healing and prevent the development of wound infection.

Distinguish between early PST, carried out in the first 24 hours after injury, delayed - during the second day and late - after 48 hours.

The task during PST of a wound is to remove non-viable tissues and the microflora contained in them from the wound. PHO, depending on the type and nature of the wound, consists either in the complete excision of the wound, or in its dissection with excision.

Complete excision is possible provided that no more than 24 hours have passed since the moment of injury and if the wound has a simple configuration with a small area of ​​damage. In this case, PST of the wound consists in excision of the edges, walls and bottom of the wound within healthy tissues, with the restoration of anatomical relationships (Fig. 3).

Rice. 3. Primary surgical treatment of the wound (scheme):

a - excision of the edges, walls and bottom of the wound;

b - the imposition of the primary seam.

Dissection with excision is performed for wounds of complex configuration with a large area of ​​damage. In these cases, the primary treatment of the wound consists of the following points:

1) wide dissection of the wound;

2) excision of deprived and contaminated soft tissues in the wound;

3) stop bleeding;

4) removal of free-lying foreign bodies and bone fragments devoid of periosteum;

5) wound drainage;

6) immobilization of the injured limb.

PST of the wound begins with the treatment of the surgical field and its delimitation with sterile linen. If the wound is on the hairy part of the body, then the hair is first shaved 4-5 cm in circumference, trying to shave from the wound to the periphery. For small wounds, local anesthesia is usually used.

The treatment begins with the fact that in one corner of the wound with tweezers or a Kocher clamp, they capture the skin, slightly lift it, and from here a gradual excision of the skin is made around the entire circumference of the wound. After excision of the crushed edges of the skin and subcutaneous tissue, the wound is expanded with hooks, its cavity is examined and non-viable areas of the aponeurosis and muscles are removed. available pockets in soft tissues opened with additional incisions. During the primary surgical treatment of the wound, it is necessary to periodically change scalpels, tweezers and scissors during the operation. PHO is performed in the following order: first, the damaged edges of the wound are excised, then its walls and, finally, the bottom of the wound. If there are small bone fragments in the wound, it is necessary to remove those that have lost contact with the periosteum. In case of PXO of open bone fractures, sharp ends of fragments protruding into the wound, which can cause secondary injury to soft tissues, vessels and nerves, should be removed with bone forceps.

Depending on the timing of the PST, they are divided into early, delayed and late. early processing produced within a day after injury. Prophylactic use of antibiotics often allows you to increase the period up to 2 days. In this case, processing is called delayed primary. Despite the later terms of the intervention, the delayed primary processing is designed to solve the same problem as the early one, i.e. ensure the prevention of wound infection. Late debridement It is aimed not at prevention, but at the treatment of wound infection. It is performed after 2 days (48 hours) in those who received antibiotics or on the 2nd day (after 24 hours) in those who did not receive them. It is quite obvious that the possibilities of closing the wound with sutures after late surgical treatment are sharply limited.

Primary surgical treatment should not be performed when:

1 - small superficial wounds and abrasions;

2 - small stab wounds, including blind ones, without damage to blood vessels and nerves;

3 - with multiple blind wounds, when the tissues contain a large number of small metal fragments (shot, fragments of grenades);

4 - penetrating bullet wounds with even inlet and outlet holes in the absence of significant damage to tissues, blood vessels and nerves.

Along with the primary distinguish secondary surgical treatment wound, which is carried out according to secondary indications, due to complications and insufficient radicalness of the primary treatment in order to treat wound infection.

Depending on the period from the moment of injury and the nature of the surgical treatment, a primary suture is distinguished, which is applied immediately to a fresh wound, and a suture is applied after treatment or after 24-48 hours, i.e. until granulation appears. In this case, it is called a delayed primary suture (Fig. 4).

Rice. 4. Imposition of primary delayed sutures.

When using a delayed primary suture, many surgeons suture the wound immediately after surgical debridement, leave it untied, and if there is no suppuration within a few days, they are tied, connecting the edges of the wound. In addition to the primary surgical practice a secondary suture is used, which is early and late. An early secondary suture is applied on the 2nd week (8-14 days) after treatment on a granulating wound that has cleared of necrotic tissues and does not have obvious signs of inflammation in its edges. A late secondary suture is applied at 3-4 weeks (20-30 days) after careful excision of granulations and scars.

For purulent wounds, conservative and surgical treatment is used, which is aimed at the fastest recovery of the patient and the full restoration of anatomical and functional relationships. However, in the vast majority of cases, only surgery can provide the necessary conditions for optimal wound healing due to the removal of non-viable purulent tissues, the creation of adequate outflow from the wound, and the reduction of intoxication. Complete surgery creates the best conditions for the success of conservative therapy.

Surgical treatment of a purulent wound is carried out in accordance with the principles that are used in the primary surgical treatment. It is advisable to perform the operation under general anesthesia. This allows you to painlessly expand the wound if necessary, remove damaged and dead tissues, perform effective hemostasis, and establish adequate drainage (Fig. 5).

Rice. 5. Vacuum drainage according to Redon: a significant vacuum is created in the bottle (a), due to which not only blood and wound fluid are removed, but also the edges of the wound are actively pressed against each other (b).

The volume of tissue excision depends on the extent of necrosis, the spread of the purulent process, and the presence of vital anatomical formations in this area that limit the actions of the surgeon. Intraoperative wound debridement is of great importance. For this, multiple washing of the wound with an antiseptic solution, treatment of the wound cavity with a pulsating jet of an antiseptic solution or ultrasound, evacuation of the wound, photocoagulation of the cavity of a purulent wound using a high-energy laser can be effectively used. Thanks to these measures, it is possible to reduce the bacterial contamination of the wound below a critical level, which in some cases makes it possible to suture the wound using through drainage for continuous flow-through washing (Fig. 6).

Rice. 6. Scheme of flow drainage.

With conservative treatment, the phase of the course of the wound process should be taken into account. AT Iphase- hydration phase - first of all, it is necessary to ensure the rest of the wounded area, the appointment of antibiotics and antiseptics, the manifestation of detoxification and activation defensive forces body, local application of dehydration drugs, hypertonic solutions, detoxification tampons, proteolytic enzymes with careful and gentle handling of tissues.

In II phase - phase of regeneration and epithelialization - to reduce the duration of treatment and obtain better functional results, one should more widely resort to the imposition of an early and late secondary suture, plasty with local tissues, autodermoplasty, and in the case of conservative treatment, use biostimulating ointments.

Technique for removing sutures from a postoperative wound.

All manipulations in the wound should be performed using a sterile instrument. Remove the bandage from the wound first. If the dressing material dries to it, it is necessary to moisten the dressing with a sterile antiseptic solution. The skin around the wound and the sutures themselves must be treated with an antiseptic solution (1% iodonate, 0.5% chlorhexidine solution, etc.). The suture is held with tweezers, closer to the knot, grabbing the ends of the ligature, which, when the suture is applied, are not cut short, but left about 1 cm long. The ligature is pulled up to show the area that was in the tissues. It is most often unpainted if the wound was treated with iodine solutions and is clearly visible. To reduce pain, you can hold the skin in the suture area using scissors. As soon as the seam has shifted, you need to stop its tension, because. this is accompanied by a pain reaction. With pointed scissors, the ligature in the intersection zone (uncolored zone) is cut and pulled out with tweezers. At the same time, the section of the seam that was on the skin does not pass through the wound, and thus the infection is prevented from entering the wound.

The basis of the treatment of wounds is their surgical treatment. Depending on the timing of the surgical treatment, it can be early (in the first 24 hours after injury), delayed (24-48 hours) and late (over 48 hours).

Depending on the indications, there are primary (performed for the direct and immediate consequences of injuries) and secondary surgical treatment (performed for complications, usually infectious, which are an indirect consequence of the injury).

Primary surgical treatment (PHO).

For its proper implementation, full anesthesia (regional anesthesia or anesthesia; only when treating small superficial wounds is it possible to use local anesthesia) and the participation of at least two doctors (surgeon and assistant) in the operation.

The main tasks of the PHO are:

Dissection of the wound and opening of all its blind cavities with the creation of the possibility of visual revision of all parts of the wound and good access to them, as well as providing full aeration;

Removal of all non-viable tissues, free-lying bone fragments and foreign bodies, as well as intermuscular, interstitial and subfascial hematomas;

Performing complete hemostasis;

Creation of optimal conditions for drainage of all sections of the wound channel.

The PST operation of wounds is divided into 3 consecutive steps: dissection of tissues, their excision and reconstruction.

1. Dissection of tissues. As a rule, the dissection is made through the wall of the wound.

The incision is made along the course of the muscle fibers, taking into account the topography of the neurovascular formations. If there are several wounds located close to each other on the segment, they can be connected by one incision. They begin with a dissection of the skin and subcutaneous tissue so that all the blind pockets of the wound can be well examined. The fascia is dissected more often Z-shaped. Such a dissection of the fascia allows not only a good revision of the underlying sections, but also to provide the necessary decompression of the muscles in order to prevent their compression by increasing edema. The bleeding that occurs along the incisions is stopped by the imposition of hemostatic clamps. In the depths of the wound, all blind pockets are opened. The wound is abundantly washed with antiseptic solutions, after which it is evacuated (the contents of the wound cavity are removed with an electric suction).

P. Excision of tissues. The skin, as a rule, is excised sparingly, until a characteristic whitish color appears on the incision and capillary bleeding. An exception is the area of ​​the face and the palmar surface of the hand, when only obviously non-viable skin areas are excised. When treating uncontaminated incised wounds with even, non-sedimented edges, in some cases it is permissible to refuse to excise the skin if there is no doubt about the viability of its edges.

Subcutaneous adipose tissue is excised widely, not only within the visible contamination, but also including areas of hemorrhage, detachment. This is because the subcutaneous adipose tissue the least resistant to hypoxia, and when damaged, it is very prone to necrosis.

Loose, contaminated areas of the fascia are also subject to economical excision.

Surgical treatment of muscles is one of the critical stages of the operation.

First, blood clots, small foreign bodies located on the surface and in the thickness of the muscles are removed. Then the wound is additionally washed with antiseptic solutions. It is necessary to excise the muscles within healthy tissues, before the appearance of fibrillar twitching, the appearance of their normal color and luster, and capillary bleeding. A non-viable muscle loses its characteristic luster, its color changes to dark brown; it does not bleed, does not contract in response to irritation. In most cases, especially in bruised and gunshot wounds, imbibition of the muscles with blood over a considerable extent is noted. Perform meticulous hemostasis as needed.

The edges of damaged tendons are sparingly excised within the limits of visible contamination and marginal defibration.

III. Wound reconstruction. In case of damage to the main vessels, a vascular suture is performed or shunting is performed.

Damaged nerve trunks, in the absence of a defect, are sutured end-to-end behind the perineurium.

Damaged tendons, especially in the distal parts of the forearm and lower leg, should be sutured, otherwise their ends will subsequently be far apart from each other, and it will not be possible to restore them. In the presence of defects, the central ends of the tendons can be sewn into the preserved tendons of other muscles.

The muscles are sutured, restoring their anatomical integrity. However, in case of PST of crushed and gunshot wounds, when there is no absolute confidence in the usefulness of the treatment performed, and the viability of the muscles is doubtful, only rare sutures are applied to them in order to cover bone fragments, exposed vessels and nerves.

The operation is completed by infiltration of the tissues around the treated wound with antibiotic solutions and the installation of drains.

Drainage is mandatory when performing the primary surgical treatment of any wound.

For drainage, one- and two-lumen tubes with a diameter of 5 to 10 mm with multiple perforations at the end are used. Drainages are removed through separately made counter-openings. Through the drains, solutions of antibiotics or (preferably) antiseptics begin to be injected into the wound.

A wound is mechanical damage to tissues in the presence of violations of the integrity of the skin. The presence of a wound, rather than a bruise or hematoma, can be determined by signs such as pain, gaping, bleeding, impaired function and integrity. PST of the wound is carried out in the first 72 hours after the injury, if there are no contraindications.

Varieties of wounds

Each wound has a cavity, walls and bottom. Depending on the nature of the damage, all wounds are divided into stab, cut, chopped, bruised, bitten and poisoned. During the PST of the wound, this must be taken into account. After all, the nature of the injury depends on the features of first aid.

• Stab wounds are always caused by a piercing object, such as a needle. hallmark damage is great depth, but small integument damage. In view of this, it is necessary to make sure that there is no damage to blood vessels, organs or nerves. Stab wounds are dangerous due to mild symptoms. So if there is a wound on the abdomen, there is a possibility of liver damage. This is not always easy to see during PST.
• An incised wound is applied with a sharp object, so tissue damage is small. At the same time, the gaping cavity is easy to inspect and perform PST. Such wounds are well treated, and healing is carried out quickly, without complications.
• Chopped wounds are caused by cutting with a sharp but heavy object, such as an axe. In this case, the damage differs in depth, the presence of a wide gaping and bruising of neighboring tissues is characteristic. Because of this, the ability to regenerate is reduced.
• Bruised Wounds appear on use blunt object. These injuries are characterized by the presence of many damaged tissues heavily saturated with blood. When conducting PST of a wound, it should be borne in mind that there is a possibility of suppuration.
• Bite wounds are dangerous for infection with the saliva of an animal, and sometimes a person. There is a risk of developing acute infection and the emergence of the rabies virus.
• Poison wounds usually result from a snake or spider bite.
• differ in the type of weapon used, the characteristics of the damage and the trajectories of penetration. There is a high chance of infection.

When conducting PST of a wound, the presence of suppuration plays an important role. Such injuries are purulent, freshly infected and aseptic.

The purpose of the PST

Primary surgical treatment is necessary to remove harmful microorganisms that have entered the wound. For this, all damaged dead tissues, as well as blood clots, are cut off. After that, sutures are applied and drainage is performed, if necessary.

The procedure is needed in the presence of tissue damage with uneven edges. Deep and contaminated wounds require the same. The presence of major damage blood vessels and sometimes bones and nerves also require surgical work. PHO is carried out simultaneously and exhaustively. The assistance of a surgeon is necessary for the patient for up to 72 hours after the wound has been inflicted. Early PST is carried out during the first day, the second day is a delayed surgical intervention.

Pho tools

A minimum of two copies of the kit is required for the initial wound treatment procedure. They are changed during the operation, and after the dirty stage they are disposed of:

• clamp "Korntsang" straight, which is used to process the surgical field;
• scalpel pointed, belly;
• linen hoes are used to hold dressings and other materials;
• clamps Kocher, Billroth and "mosquito", are used to stop bleeding, when conducting PST of a wound, they are used in large quantities;
• scissors, they are straight, as well as curved along a plane or edge in several copies;
• Kocher's probes, grooved and bellied;
• a set of needles;
• needle holder;
• tweezers;
• hooks (several pairs).

The surgical kit for this procedure also includes injection needles, syringes, bandages, gauze balls, rubber gloves, all kinds of tubes and napkins. All items that will be needed for PST - suture and dressing kits, tools and medications, intended for the treatment of wounds - are laid out on the surgical table.

Necessary medicines

Primary surgical treatment of the wound is not complete without special medications. The most commonly used are:

Stages of PHO

Primary surgical treatment is carried out in several stages:

How is PHO done?

For surgery, the patient is placed on the table. Its position depends on the location of the wound. The surgeon must be comfortable. The wound is toileted, the operating field is processed, which is delimited by sterile disposable underwear. Next, the primary intention is performed, aimed at healing existing wounds, and anesthesia is administered. In most cases, surgeons use the Vishnevsky method - they inject a 0.5% solution of novocaine at a distance of two centimeters from the edge of the cut. The same amount of solution is injected from the other side. With the correct reaction of the patient, a "lemon peel" is observed on the skin around the wound. Gunshot wounds often require the patient to be given general anesthesia.

The edges of the damage up to 1 cm are held with a Kochcher clamp and cut off in a single block. When performing the procedure, non-viable tissue is cut off on the face or fingers, after which a tight suture is applied. Gloves and tools used are replaced.

The wound is washed with chlorhexidine and examined. Stab wounds with small but deep incisions are dissected. If the edges of the muscles are damaged, they are removed. Do the same with bone fragments. Next, hemostasis is performed. The inside of the wound is treated first with a solution, and then with antiseptic preparations.

The treated wound without signs of sepsis is sutured tightly with primary and covered with an aseptic bandage. Seams are performed, evenly capturing all layers in width and depth. It is necessary that they touch each other, but do not pull together. When doing work you need to get cosmetic healing.

In some cases, primary sutures are not applied. A cut wound can be more serious than it seems at first glance. If the surgeon is in doubt, a primary delayed suture is used. This method is used if the wound has been infected. Suturing is carried out to fatty tissue, and the seams do not tighten. A few days after observation, until the end.

bite wounds

PST of a wound, bitten or poisoned, has its own differences. When bitten by non-venomous animals, there is a high risk of contracting rabies. At an early stage, the disease is suppressed by anti-rabies serum. Such wounds in most cases become purulent, so they try to delay the PHO. During the procedure, a primary delayed suture is applied and antiseptic drugs are applied.

A snake bite wound requires a tight tourniquet or bandage. In addition, the wound is frozen with novocaine or cold is applied. Anti-snake serum is injected to neutralize the venom. Spider bites are blocked by potassium permanganate. Before that, poison is squeezed out, and the wound is treated with an antiseptic.

Complications

Careless treatment of the wound with antiseptics leads to suppuration of the wound. Incorrect anesthetic, as well as causing additional injuries, causes anxiety in the patient due to the presence of pain.

Rough attitude to tissues, poor knowledge of anatomy lead to damage to large vessels, internal organs and nerve endings. Insufficient hemostasis causes the appearance of inflammatory processes.

It is very important that the primary surgical treatment of the wound is carried out by a specialist in accordance with all the rules.

Primary surgical treatment of wounds (PHO). The main in the treatment of infected wounds is their primary surgical treatment. Its goal is to remove non-viable tissues, the microflora in them, and thereby prevent the development of a wound infection.

Distinguish between early primary surgical treatment, carried out on the first day after injury, delayed - during the second day and late - 48 hours after injury. The earlier the primary surgical treatment is performed, the more likely it is to prevent the development of infectious complications in the wound.

During the Great Patriotic War, 30% of wounds were not subjected to surgical treatment: small superficial wounds, penetrating wounds with small inlet and outlet holes without signs of damage to vital organs, blood vessels, multiple blind wounds. In peaceful conditions, stab non-penetrating wounds are not treated without damaging large vessels and incised wounds that do not penetrate deeper than the subcutaneous fatty tissue.

Primary surgical treatment must be simultaneous and radical, i.e. it must be performed in one stage and in the process of it non-viable tissues must be completely removed. First of all, the wounded are operated on with a hemostatic tourniquet and extensive shrapnel wounds, with soil contamination of the wounds, in which there is a significant risk of anaerobic infection.

Primary surgical treatment of the wound consists in excision of its edges, walls and bottom within healthy tissues with the restoration of anatomical relationships.

Primary surgical treatment begins with the dissection of the wound. The skin is excised with a bordering incision 0.5-1 cm wide and subcutaneous tissue around the wound and the skin incision is extended along the axis of the limb along the neurovascular bundle for a length sufficient to allow all blind pockets of the wound to be examined and non-viable tissues to be excised. Next, along the skin incision, the fascia and aponeurosis are dissected with a /-shaped or arcuate incision. This provides a good view of the wound and reduces compression of the muscles due to their swelling, which is especially important for gunshot wounds.

After dissection of the wound, scraps of clothing, blood clots, freely lying foreign bodies are removed and the excision of crushed and contaminated tissues is started.

Muscles are excised within healthy tissues. Non-viable muscles are dark red in color, dull, do not bleed on the incision and do not contract when touched with tweezers.

Intact large vessels, nerves, tendons during the treatment of the wound should be preserved, contaminated tissues are carefully removed from their surface. (1 Small bone fragments lying freely in the wound are removed, sharp, devoid of periosteum, protruding into the wound, the ends of bone fragments are bitten off with wire cutters. If damage to blood vessels, nerves, tendons is detected, their integrity is restored. non-viable tissues and foreign bodies are completely removed, the wound is sutured (primary suture).

Late debridement is performed according to the same rules as the early one, but with signs of purulent inflammation, it comes down to removing foreign bodies, cleaning the wound from dirt, removing necrotic tissues, opening streaks, pockets, hematomas, abscesses, to ensure good conditions for the outflow of wound discharge.

Excision of tissues, as a rule, is not performed due to the risk of generalization of infection.

The final stage of the primary surgical treatment of wounds is the primary suture, which restores the anatomical continuity of tissues. Its purpose is to prevent secondary infection of the wound and create conditions for wound healing by primary intention.

The primary suture is applied to the wound within a day after the injury. The primary suture, as a rule, also ends with surgical interventions during aseptic operations. Under certain conditions, purulent wounds are closed with a primary suture after opening subcutaneous abscesses, phlegmons and excision of necrotic tissues, providing good conditions for drainage and prolonged washing of wounds with solutions of antiseptics and proteolytic enzymes in the postoperative period (see Chapter XI).

A primary delayed suture is applied up to 5-7 days after the primary surgical treatment of wounds until granulations appear, provided that the wound does not fester. Delayed sutures can be applied in the form of provisional sutures: the operation is completed by suturing the edges of the wound and tightening them after a few days, if the wound has not suppurated.

In wounds sutured with a primary suture, the inflammatory process is weakly expressed and healing occurs by primary intention.

To the Great Patriotic war due to the risk of infection, primary surgical treatment of wounds was not performed in full - without the imposition of a primary suture; primary-deferred, pharmacist-aphid sutures were used. When acute inflammatory phenomena subsided and granulations appeared, a secondary suture was applied. The widespread use of the primary suture in peacetime, even when treating wounds at a later time (12-24 hours), is possible due to targeted antibiotic therapy and systematic monitoring of the patient. At the first signs of infection in the wound, it is necessary to partially or completely remove the sutures. The experience of World War II and subsequent local wars showed the inexpediency of using a primary suture for gunshot wounds, not only due to the characteristics of the latter, but also due to the lack of the possibility of systematic monitoring of the wounded in military field conditions and at the stages of medical evacuation.

The final stage of the primary surgical treatment of wounds, delayed for some time, is the secondary suture. It is applied to a granulating wound in conditions where the danger of wound suppuration has passed. Terms of application of the secondary suture - from several days to several months. It is used to speed up wound healing.

An early secondary suture is applied to granulating wounds within 8 to 15 days. The edges of the wound are usually mobile, they are not excised.

A late secondary suture is applied at a later time (after 2 weeks) when cicatricial changes have occurred in the edges and walls of the wound. The convergence of the edges, walls and bottom of the wound in such cases is impossible, therefore, the edges are mobilized and the scar tissue is excised. In cases where there is a large defect in the skin, a skin graft is performed.

Indications for the use of a secondary suture are: normalization of body temperature, blood composition, satisfactory general condition of the patient, and on the part of the wound, the disappearance of edema and hyperemia of the skin around it, complete cleansing of pus and necrotic tissues, the presence of healthy, bright, juicy granulations.

Various types of sutures are used, but regardless of the type of suture, the basic principles must be observed: there should be no closed cavities, pockets in the wound, adaptation of the edges and walls of the wound should be maximum. The sutures should be removable, and ligatures should not remain in the sutured wound, not only from non-absorbable material, but also from catgut, since the presence of foreign bodies in the future can create conditions for suppuration of the wound. With early secondary sutures, the granulation tissue must be preserved, which simplifies the surgical technique and preserves the barrier function of the granulation tissue, which prevents the spread of infection to the surrounding tissues.

The healing of wounds sutured with a secondary suture and healed without suppuration is usually called healing by the type of primary intention, in contrast to true primary intention, since, although the wound heals with a linear scar, processes of scar tissue formation occur in it through the maturation of granulations.