Pho and entry wounds. Primary surgical debridement - what is it, algorithm and principles

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a) Definition, steps
PRIMARY SURGICAL TREATMENT OF THE WOUND is the first surgical operation performed on a patient with a wound under aseptic conditions, under anesthesia, and consists in the sequential implementation of the following steps:

Dissection of the wound.
Revision of the wound channel.
Excision of the edges, walls and bottom of the wound.
Hemostasis.
Restoring the integrity of damaged organs and structures
Suturing the wound with drainage (according to indications).

Thus, thanks to PHO, an accidental infected wound becomes incised and aseptic, which creates the possibility of its rapid healing by primary intention.
Dissection of the wound is necessary for a complete revision of the zone of spread of the wound channel and the nature of the damage under the control of the eye.

Excision of the edges, walls and bottom of the wound is performed to remove necrotic tissues, foreign bodies, as well as the entire wound surface infected during the wound. After completing this stage, the wound becomes incised and sterile. Further manipulations should be carried out only after changing tools and processing or changing gloves.
It is usually recommended to excise the edges, walls and bottom of the wound in a single block by about 0.5-2.0 cm (Fig. 4.3). In this case, it is necessary to take into account the localization of the wound, its depth and the type of damaged tissues. With contaminated, crushed wounds, wounds on the lower extremities, the excision should be wide enough. With wounds on the face, only necrotic tissues are removed, and with an incised wound, excision of the edges is not performed at all. It is impossible to excise viable walls and bottom of the wound if they are represented by tissues of internal organs (brain, heart, intestines, etc.).
After excision, careful hemostasis is carried out to prevent hematoma and possible infectious complications.
The restorative stage (suture of nerves, tendons, blood vessels, connection of bones, etc.) is desirable to be performed immediately during PST, if the surgeon's qualifications allow it. If not, you can subsequently perform a second operation with a delayed suture of the tendon or nerve, to perform a delayed osteosynthesis. Restorative measures in full should not be carried out during PST in wartime.
Wound closure is the final stage of PST. The following options are available for completing this operation.

Layer-by-layer suturing of the wound tightly

It is performed for small wounds with a small area of damage (cut, stab, etc.), slightly contaminated wounds, with localization of wounds on the face, neck, torso or upper limbs with a short period from the moment of damage.

Wound closure leaving drainage(s)

Performed in cases where there is either a risk of infection,
but it is very small, or the wound is localized on the foot or lower leg, or the area of damage is large, or PST is performed 6-12 hours after the injury, or the patient has a concomitant pathology that adversely affects the wound process, etc.

The wound is not sutured

This is done at a high risk of infectious complications:

late PHO,
abundant contamination of the wound with earth,
massive tissue damage (crushed, bruised wound),
concomitant diseases (anemia, immunodeficiency, diabetes mellitus),
localization on the foot or lower leg,
advanced age of the patient.

Gunshot wounds should not be sutured, as well as any wounds in the provision of assistance in wartime.
Sewing the wound tightly in the presence of adverse factors is a completely unjustified risk and a clear tactical mistake of the surgeon!
b) Main types
The earlier PST of the wound is performed from the moment of injury, the lower the risk of infectious complications.
Depending on the prescription of the wound, three types of PST are used: early, delayed and late.
Early PST is performed within 24 hours from the moment of infliction of the wound, includes all the main stages and usually ends with the application of primary sutures. With extensive damage to the subcutaneous tissue, the inability to completely stop capillary bleeding in the wound, drainage is left for 1-2 days. In the future, treatment is carried out as with a "clean" postoperative wound.
Delayed PST is performed 24 to 48 hours after the wound is inflicted. During this period, the phenomena of inflammation develop, edema, exudate appear. The difference from early PXO is the operation performed against the background of the introduction of antibiotics and the completion of the intervention by leaving the wound open (not sutured) followed by the imposition of primary delayed sutures.
Late PHO is performed after 48 hours, when the inflammation is close to maximum and the development of the infectious process begins. Even after PHO, the likelihood of suppuration remains high. In this situation, it is necessary to leave the wound open (not sutured) and conduct a course of antibiotic therapy. It is possible to apply early secondary sutures on days 7-20, when the wound is completely covered with granulations and acquires relative resistance to the development of infection.

c) Indications
The indication for PST of a wound is the presence of any deep accidental wound within 48-72 hours from the moment of application.
PHO are not subject to the following types of wounds:

superficial wounds, scratches and abrasions,
small wounds with margins less than 1 cm,
multiple small wounds without damage to underlying tissues (shot wound, for example),
stab wounds without damage to internal organs, vessels and nerves,
in some cases through bullet wounds of soft tissues.

d) Contraindications
There are only two contraindications for PST of a wound:

Signs of development in the wound of a purulent process.
Critical condition of the patient (terminal condition, shock

degrees).

TYPES OF SEAMS

The long existence of the wound does not contribute to the fastest functionally beneficial healing. This is especially true for extensive injuries, when there are significant losses of fluid, proteins, electrolytes through the wound surface, and suppuration is large. In addition, the execution of the wound by granulations and its closure by the epithelium take a rather long time. Therefore, one should strive to reduce the edges of the wound as early as possible with the help of various types of sutures.
Benefits of suturing:

healing acceleration,
reduction of losses through the wound surface,
reducing the likelihood of re-suppuration of the wound,
increase in functional and cosmetic effect,
facilitating wound care.

Allocate primary and secondary seams.
a) Primary seams
Primary sutures are applied to the wound before the development of granulations, while the wound heals by primary intention.
Most often, primary sutures are applied immediately after the completion of the operation or PST of the wound in the absence of a high risk of developing purulent complications. Primary sutures are not advisable to use in late PST, PST in wartime, PST of a gunshot wound.
The removal of sutures is carried out after the formation of a dense connective tissue adhesion and epithelialization at a certain time.

Primary delayed sutures are also applied to the wound before the development of granulation tissue (the wound heals by the type of primary intention). They are used in cases where there is a certain risk of infection.
Technique: the wound after surgery (PHO) is not sutured, the inflammatory process is controlled, and when it subsides for 1-5 days, primary delayed sutures are applied.
A variety of primary delayed sutures are provisional: at the end of the operation, sutures are sutured, but the threads are not tied, the edges of the wound are not reduced in this way. The threads are tied for 1-5 days when the inflammatory process subsides. The difference from conventional primary delayed sutures is that there is no need for repeated anesthesia and stitching of the wound edges.
b) Secondary seams
Secondary sutures are applied to granulating wounds that heal by secondary intention. The meaning of the use of secondary sutures is to reduce (or eliminate) the wound cavity. A decrease in the volume of a wound defect leads to a decrease in the number of granulations required to fill it. As a result, the healing time is reduced, and the content of connective tissue in a healed wound, compared to open wounds, is much less. This favorably affects the appearance and functional features of the scar, its size, strength and elasticity. The convergence of the edges of the wound reduces the potential entry gate for infection.
An indication for the imposition of secondary sutures is a granulating wound after the elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. To objectify the subsidence of inflammation, you can use the sowing of the wound discharge - in the absence of growth of pathological microflora, secondary sutures can be applied.
There are early secondary sutures (they are applied on 6-21 days) and late secondary sutures (they are applied after 21 days). The fundamental difference between them is that by 3 weeks after the operation, scar tissue forms at the edges of the wound, preventing both the convergence of the edges and the process of their fusion. Therefore, when applying early secondary sutures (before scarring of the edges), it is enough to simply stitch the edges of the wound and bring them together by tying the threads. When applying late secondary sutures, it is necessary to excise the cicatricial edges of the wound under aseptic conditions (“refresh the edges”), and only then suture and tie the threads.
To accelerate the healing of a granulating wound, in addition to suturing, you can use the tightening of the edges of the wound with strips of adhesive tape. The method does not completely and reliably eliminate the wound cavity, but it can be used even before the inflammation subsides completely. The tightening of the edges of the wound with adhesive tape is widely used to accelerate the healing of purulent wounds.

Primary surgical treatment of facial wounds(PHO) is a set of measures aimed at creating optimal conditions for wound healing.

PHO prevents life-threatening complications (external bleeding, respiratory failure), preserves the ability to eat, speech functions, prevents facial disfigurement, and the development of infection.

Upon admission of the wounded in the face to a specialized hospital (specialized department), their treatment begins already in the emergency department. Provide emergency care if indicated. The wounded are registered, medical sorting and sanitization are carried out. First of all, they provide assistance according to vital indications (bleeding, asphyxia, shock). In the second place - the wounded with extensive destruction of the soft tissues and bones of the face. Then - the wounded, with light and moderate injuries.

N.I. Pirogov pointed out that the task of surgical treatment of wounds is "the transformation of a bruised wound into a cut wound."

Dental and maxillofacial surgeons are guided by the provisions of the military medical doctrine and the basic principles of surgical treatment of wounds in the maxillofacial region, which were widely used during the Great Patriotic War. According to them, surgical treatment of wounds should be early, simultaneous and exhaustive. The attitude to tissues should be extremely sparing.

Distinguish primary surgical debridement (SW) is the first debridement of a gunshot wound. Secondary surgical debridement is the second surgical intervention in a wound that has already undergone debridement. It is undertaken with complications of an inflammatory nature that have developed in the wound, despite the primary surgical treatment of it.

Depending on the timing of the surgical intervention, there are:

- early PST (conducted up to 24 hours from the moment of injury);

- delayed PHO (conducted up to 48 hours);

- late PHO (conducted 48 hours after injury).

PXO is a surgical intervention designed to create optimal conditions for the healing of a gunshot wound. In addition, its task is the primary restoration of tissues by carrying out therapeutic measures by influencing the mechanisms that ensure the cleansing of the wound from necrotic tissues in the postoperative period and the restoration of blood circulation in the tissues adjacent to it. (Lukyanenko A.V., 1996). Based on these tasks, the author formulated principles specialized surgical care for those wounded in the face, which are designed to bring the classical requirements of military medical doctrine into line with the achievements of military field surgery and the features of gunshot wounds to the face inflicted by modern weapons to a certain extent. These include:

1. One-stage comprehensive primary surgical treatment of the wound with fixation of bone fragments, restoration of soft tissue defects, inflow-outflow drainage of the wound and adjacent cellular spaces.

2. Intensive care of the wounded in the postoperative period, including not only the replacement of lost blood, but also the correction of water and electrolyte disorders, sympathetic blockade, controlled hemodilution and adequate analgesia.

3. Intensive therapy of a postoperative wound aimed at creating favorable conditions for its healing and including a targeted selective effect on the microcirculation in the wound and local proteolytic processes.

Before surgical treatment, each wounded person should be given an antiseptic (drug) treatment of the face and oral cavity. They usually start with the skin. Especially carefully treat the skin around the wounds. Use a 2-3% solution of hydrogen peroxide, 0.25% solution of ammonia, more often - iodine-gasoline (1 g of crystalline iodine is added to 1 liter of gasoline). The use of iodine-gasoline is preferable, as it dissolves caked blood, dirt, and grease well. Following this, the wound is irrigated with any antiseptic solution, which makes it possible to wash out dirt and small free-lying foreign bodies from it. After that, the skin is shaved, which requires skills and abilities, especially in the presence of hanging soft tissue flaps. After shaving, you can again rinse the wound and oral cavity with an antiseptic solution. It is rational to carry out such hygienic treatment by preliminarily administering an analgesic to the wounded, since the procedure is quite painful.

After the above treatment of the face and oral cavity, the skin is dried with gauze and treated with 1-2% tincture of iodine. After that, the wounded are taken to the operating room.

The volume and nature of the surgical intervention is determined by the results of the examination of the wounded. This takes into account not only the degree of destruction of tissues and organs of the face, but also the possibility of their combination with damage to the ENT organs, eyes, skull and other areas. The issue of the need to consult with other specialists, the possibility of an x-ray examination, taking into account the severity of the wounded person's condition, is being decided.

Thus, the volume of surgical treatment is determined individually. However, if possible, it should be radical and carried out in full. The essence of radical primary surgical treatment involves the implementation of the maximum volume of surgical manipulations in a strict sequence of its stages: treatment of the bone wound, soft tissues adjacent to the bone wound, immobilization of jaw fragments, suturing the mucous membrane of the sublingual region, tongue, vestibule of the mouth, suturing (according to indications) on the skin with mandatory wound drainage.

Surgical intervention can be performed under general anesthesia (about 30% of the wounded with severe injuries) or local anesthesia (about 70% of the wounded). About 15% of the wounded admitted to a specialized hospital (department) will not need PST. It is enough for them to carry out the "toilet" of the wound. After anesthesia, loose foreign bodies (earth, dirt, scraps of clothing, etc.), small bone fragments, secondary wounding projectiles (teeth fragments), and blood clots are removed from the wound. The wound is additionally treated with a 3% hydrogen peroxide solution. An audit is carried out along the entire wound channel, if necessary, deep pockets are dissected. The edges of the wound are bred with blunt hooks. Foreign bodies are removed along the wound channel. Then proceed to the processing of bone tissue. Based on the generally accepted concept of gentle treatment of tissues, sharp bone edges are bitten and smoothed with a curettage spoon or cutter. The teeth are removed from the ends of the bone fragments when the roots are exposed. Remove small bone fragments from the wound. Fragments associated with soft tissues are stored and placed in their intended place. However, the experience of clinicians shows that it is also necessary to remove bone fragments, the rigid fixation of which is impossible. This element should be considered mandatory, since the mobile fragments eventually lose their blood supply, become necrotic and become the morphological substrate of osteomyelitis. Therefore, at this stage, "moderate radicalism" should be considered appropriate.

Taking into account the peculiarities of modern high-speed firearms, the provisions set forth in the military medical doctrine require revision

(M.B. Shvyrkov, 1987). Large fragments associated with soft tissues, as a rule, die, turning into sequesters. This is due to the destruction of the intraosseous tubular system in the bone fragment, which is accompanied by the outflow of plasma-like fluid from the bone and the death of osteocytes due to hypoxia and accumulated metabolites. On the other hand, microcirculation is disturbed in the feeding pedicle itself and in the bone fragment. Turning into sequesters, they support acute purulent inflammation in the wound, which can also be caused by bone necrosis at the ends of the mandible fragments.

Based on this, it seems appropriate not to bite and smooth the bone protrusions at the ends of the mandible fragments, but to saw off the ends of the fragments with a zone of supposed secondary necrosis before capillary bleeding. This makes it possible to expose viable tissues containing granules of proteins-regulators of reparative osteogenesis, viable osteoclasts, and pericytes. All this is intended to create the prerequisites for a full-fledged reparative osteogenesis. When shooting the alveolar part of the lower jaw, surgical treatment consists in removing the broken bone section, if it has retained its connection with soft tissues. The resulting bone protrusions are smoothed with a cutter. The bone wound is closed with a mucous membrane, moving it from neighboring areas. If this fails, then it is closed with a swab of iodoform gauze.

During surgical treatment of gunshot wounds of the upper jaw, if the wound channel passes through her body, in addition to the above measures, an audit of the maxillary sinus, nasal passages, and the ethmoid labyrinth is carried out.

The revision of the maxillary sinus is carried out by access through the wound channel (wound), if it is of considerable size. Blood clots, foreign bodies, bone fragments, and a wounding projectile are removed from the sinus. The altered mucous membrane of the sinus is excised. The viable mucous membrane is not removed, but placed on the bone skeleton and subsequently fixed with an iodoform swab. Be sure to impose an artificial anastomosis with a lower nasal passage, through which the end of the iodoform tampon is brought into the nose from the maxillary sinus. The external wound of soft tissues is treated according to the generally accepted method and sutured tightly, sometimes resorting to plastic techniques with “local tissues”. If this fails, plate sutures are applied.

When the inlet is small, an audit of the maxillary sinus is performed according to the type of classical maxillary sinusectomy according to Caldwell-Luke with access from the vestibule of the oral cavity. Sometimes it is advisable to introduce a perforated vascular catheter or tube into the maxillary sinus through the imposed rhinostomy to flush it with an antiseptic solution.

If the wound of the upper jaw is accompanied by the destruction of the external nose, middle and upper nasal passages, then it is possible to injure the ethmoid labyrinth and damage the ethmoid bone. During surgical treatment, bone fragments, blood clots, foreign bodies should be carefully removed, free outflow of wound discharge from the base of the skull should be ensured in order to prevent basal meningitis. It should be checked for the presence or absence of liquorrhea. Carry out an audit of the nasal passages according to the above principle. Non-viable tissues are removed. The bones of the nose, vomer and shells are set, check the patency of the nasal passages. In the latter, polyvinyl chloride or rubber tubes wrapped in 2-3 layers of gauze are inserted to the full depth (up to the choanae). They provide fixation of the preserved nasal mucosa, nasal breathing and, to a certain extent, prevent cicatricial narrowing of the nasal passages in the postoperative period. The soft tissues of the nose, if possible, are sutured. Bone fragments of the nose, after their reposition, are fixed in the correct position with the help of tight gauze rollers and strips of adhesive plaster.

If the wound of the upper jaw is accompanied by a fracture of the zygomatic bone and arch, then after processing the ends of the fragments, the fragments are repositioned and fixed with

bone suture or in another way to prevent the retraction of bone fragments. When indicated, an audit of the maxillary sinus is carried out.

In case of injury to the hard palate, which is most often combined with a gunshot fracture (shooting) of the alveolar process, a defect is formed that communicates the oral cavity with the nose, maxillary sinus. In this situation, the bone wound is treated according to the principle described above, and the bone wound defect should be tried to be closed (removed) using a soft tissue flap taken in the neighborhood (the remains of the mucous membrane of the hard palate, the mucous membrane of the cheek, upper lip). If this is not possible, the manufacture of a protective, separating plastic plate is shown.

In the event of an injury to the eyeball, when the wounded person, by the nature of the prevailing injury, enters the maxillofacial department, one should be aware of the danger of loss of vision in the intact eye due to the spread of the inflammatory process through the optic chiasm to the opposite side. Prevention of this complication is enucleation of the destroyed eyeball. It is desirable to consult an ophthalmologist. However, the dental surgeon must be able to remove small foreign bodies from the surface of the eye, wash the eyes and eyelids. When treating a wound in the region of the upper jaw, it is necessary to maintain the integrity or restore the patency of the nasolacrimal canal.

After completing the surgical treatment of the bone wound, it is necessary to excise non-viable soft tissues along the edges of the wound until capillary bleeding occurs. More often, the skin is excised at a distance of 2-4 mm from the edge of the wound, fatty tissue - a little more. The sufficiency of excision of muscle tissue is determined not only by capillary bleeding, but also by the reduction of its individual fibers during mechanical irritation with a scalpel.

It is desirable to excise dead tissues on the walls and bottom of the wound, if this is technically possible and is not associated with the risk of injuring large vessels or branches of the facial nerve. Only after such tissue excision can any wound on the face be sutured with mandatory drainage. However, recommendations for gentle excision of soft tissues (only non-viable) remain in force. In the process of processing soft tissues, it is necessary to remove from the wound channel foreign bodies that secondarily injure projectiles, including fragments of broken teeth.

All wounds in the mouth should be carefully examined, regardless of their size. Foreign bodies present in them (fragments of teeth, bones) can cause severe inflammatory processes in soft tissues. Be sure to examine the tongue, examine the wound channels in order to detect foreign bodies in it.

Next, reposition and immobilization of bone fragments are performed. To do this, conservative and surgical methods (osteosynthesis) of immobilization are used, as in case of non-gunshot fractures: splints of various designs (including dental splints), bone plates with screws, extraoral devices with various functional orientations, including compression-distraction ones. The use of a bone suture and Kirschner wires is inappropriate.

In case of fractures of the upper jaw, they often resort to immobilization according to the Adams method. Reposition and rigid fixation of bone fragments of the jaws is an element of the reconstructive operation. It also helps to stop bleeding from a bone wound, prevents the formation of a hematoma and the development of a wound infection.

The use of splints and osteosynthesis involves fixing the fragments in the correct position (under bite control), which, in case of a gunshot defect of the lower jaw, contributes to its preservation. This further makes it necessary to carry out multi-stage osteoplastic operations. The use of a compression-distraction apparatus (CDA) makes it possible to bring the fragments closer together before their contact, creates optimal conditions for suturing the wound in the mouth due to its reduction in size and allows

start osteoplasty almost immediately after the end of PST. It is possible to use various options for osteoplasty, depending on the clinical situation.

Having immobilized the fragments of the jaws, they begin to suture the wound - first, rare sutures are applied to the wounds of the tongue, which can be localized on its lateral surfaces, tip, back, root, and lower surface. Sutures should be placed along the body of the tongue, not across it. Sutures are also applied to the wound of the sublingual region, which is made accessible through the external wound under the conditions of immobilization of fragments, especially with bimaxillary splints. After that, blind sutures are applied to the mucous membrane of the vestibule of the mouth. All this is designed to isolate the external wound from the oral cavity, which is essential for preventing the development of wound infection. Along with this, you should try to cover exposed areas of the bone with soft tissues. Next, sutures are placed on the red border, muscles, subcutaneous adipose tissue and skin. They can be deaf or lamellar.

Blind sutures, according to military medical doctrine, after PXO can be applied to the tissues of the upper and lower lips, eyelids, nasal openings, auricle (around the so-called natural openings), on the oral mucosa. In other areas of the face, lamellar sutures or others (mattress, nodal) are applied, with the aim of only bringing the edges of the wound closer together.

Depending on the timing of suturing the wound tightly distinguish:

- early suture(applied immediately after PST of a gunshot wound),

- delayed primary suture(imposed on 4-5 days after the PST in cases where either a contaminated wound was treated, or a wound with signs of incipient purulent inflammation in it, or it was not possible to completely excise necrotic tissues, when there is no certainty in the course of the postoperative period according to the optimal option: without complications, it is applied until active growth of granulation tissue appears in the wound),

- secondary seam early(impose on the 7th - 14th day on a granulating wound, which is completely cleared of necrotic tissues. Excision of the edges of the wound and mobilization of tissues are possible, but not necessary),

- secondary suture late(applied for 15-30 days on a scarring wound, the edges of which are epithelialized or already epithelialized and become inactive. It is necessary to excise the epithelialized edges of the wound and mobilize the tissues approaching to contact with a scalpel and scissors).

In some cases, to reduce the size of the wound, especially in the presence of large hanging soft tissue flaps, as well as signs of inflammatory tissue infiltration, a plate suture can be applied. By functional purpose plate seam divided into:

bringing together;

unloading;

guide;

Deaf (on a granulating wound).

As tissue edema decreases or the degree of their infiltration decreases, the edges of the wound can be gradually brought closer together with the help of a lamellar suture, in which case it is called “converging”. After complete cleansing of the wound from detritus, when it becomes possible to bring the edges of the granulating wound into close contact, that is, to suture the wound tightly, this can be done using a laminar suture, which in this case will serve as a “blind suture”. In the case when conventional interrupted sutures were applied to the wound, but with some tissue tension, it is additionally possible to apply a plate suture, which will reduce tissue tension in the area of interrupted sutures. In this situation, the plate seam performs the function of "unloading". For fixation of soft tissue flaps in a new location or in an optimal position, which

imitates the position of tissues before injury, you can also use a laminar suture, which will act as a "guide".

To apply a plate suture, a long surgical needle is used, with which a thin wire (or polyamide, silk thread) is passed through the entire depth of the wound (to the bottom), retreating 2 cm from the edges of the wound. A special metal plate is strung on both ends of the wire until it comes into contact with the skin (you can use a large button or a rubber stopper from a penicillin bottle), then 3 lead pellets each. The latter are used to fix the ends of the wire after bringing the lumen of the wound to the optimal position (the upper pellets located further from the metal plate are first flattened). Free pellets located between the already flattened pellet and the plate are used to regulate the tension of the suture, bring the edges of the wound closer together and reduce its lumen as the inflammatory edema in the wound stops.

Lavsan or polyamide (or silk) thread can be tied in a knot in the form of a "bow" over the cork, which can be untied if necessary.

Principle radicalism According to modern views, primary surgical treatment of a wound involves excision of tissues not only in the area of primary necrosis, but also in the area of supposed secondary necrosis that develops as a result of a “side impact” (not earlier than 72 hours after injury). The sparing principle of PHO, although it declares the requirement of radicalism, involves an economical excision of tissues. In case of early and delayed PST of a gunshot wound, in this case, tissues will be excised only in the area of primary necrosis.

Radical primary surgical treatment of gunshot wounds of the face can reduce the number of complications in the form of suppuration of the wound and divergence of sutures by 10 times compared to PST of the wound using the principle of sparing treatment of excised tissues.

It should be noted once again that when suturing a wound on the face, first sutures are placed on the mucous membrane, then the muscles, subcutaneous fat and skin. In case of injury to the upper or lower lip, the muscles are first sutured, then a suture is placed at the border of the skin and the red border, the skin is sutured, and then the mucous membrane of the lip. In the presence of an extensive soft tissue defect, when the wound penetrates the mouth, the skin is sutured to the oral mucosa, which creates more favorable conditions for the subsequent plastic closure of this defect, significantly reducing the area of scar tissue.

An important point in the primary surgical treatment of facial wounds is their drainage. Two methods of drainage are used:

1. supply-and-flow method, when a leading tube with a diameter of 3-4 mm with holes is brought to the upper section of the wound through a puncture in the tissues. A discharge tube with an inner diameter of 5–6 mm is also brought to the lower section of the wound through a separate puncture. With the help of a solution of antiseptics or antibiotics, long-term lavage of the gunshot wound is carried out.

2. Preventive drainage cellular spaces of the submandibular region and neck adjacent to the gunshot wound with a double-lumen tube according to the method of N.I. Kanshin (through an additional puncture). The tube approaches the wound but does not communicate with it. A washing solution (antiseptic) is injected through a capillary (a narrow lumen of the tube), and a washing liquid is aspirated through its wide lumen.

Based on modern views on the treatment of wounded in the face in the postoperative period, intensive therapy is indicated. And it must be ahead of the curve. Intensive care includes several fundamental components (A.V. Lukyanenko):

1. Elimination of hypovolemia and anemia, microcirculation disorders. This is achieved by conducting infusion-transfusion therapy. In the first 3 days, up to 3 liters of media are transfused (blood products, whole blood, saline crystalloid

solutions, albumin, etc.). In the future, the leading link in infusion therapy will be hemodilution, which is extremely important for restoring microcirculation in injured tissues.

2. Postoperative analgesia.

A good effect is the introduction of fentanyl (50-100 mg every 4-6 hours) or tramal (50 mg every 6 hours - intravenously).

3. Prevention of adult respiratory distress syndrome and pneumonia. Achieved by effective anesthesia, rational infusion-transfusion

ion therapy, improvement of the rheological properties of blood and artificial ventilation of the lungs. Leading in the prevention of adult respiratory distress syndrome is mechanical artificial lung ventilation (ALV). It is aimed at reducing the volume of pulmonary extravascular fluid, normalizing the ventilation-perfusion ratio, and eliminating microatelectasis.

4. Prevention and treatment of disorders of water-salt metabolism.

It consists of calculating the volume and composition of daily infusion therapy, taking into account the initial water-salt status and fluid loss by the extrarenal route. More often in the first three days of the postoperative period, the dose of liquid is 30 ml / kg of body weight. With a wound infection, it is increased to 70 - 80 ml / kg of body weight of the wounded.

5. Elimination of excess catabolism and providing the body with energy substrates.

Energy supply is achieved through parenteral nutrition. Nutrient media should include glucose solution, amino acids, vitamins (group B and C), albumin, electrolytes.

Intensive therapy of a postoperative wound is essential, aimed at creating optimal conditions for its healing by influencing microcirculation and local proteolytic processes. To do this, use reopoliglyukin, 0.25% novocaine solution, Ringer-Lock solution, trental, contrycal, proteolytic enzymes (solution of trypsin, chemotripsin, etc.).

Wound - damage of any depth and area, in which the integrity of the mechanical and biological barriers of the human body, delimiting it from the environment, is violated. Patients come to medical institutions with injuries that can be caused by factors of various nature. In response to their impact, local (changes directly in the wounded area), regional (reflex, vascular) and general reactions develop in the body.

Classification

Depending on the mechanism, localization, nature of damage, several types of wounds are distinguished.

In clinical practice, wounds are classified according to a number of signs:

origin (, operational, combat);
localization of damage (wounds of the neck, head, chest, abdomen, limbs);
the number of injuries (single, multiple);
morphological features (cut, chopped, chipped, bruised, scalped, bitten, mixed);
length and relation to body cavities (penetrating and non-penetrating, blind, tangential);
type of injured tissues (soft tissues, bone, with damage to blood vessels and nerve trunks, internal organs).

In a separate group, gunshot wounds are distinguished, which are distinguished by the particular severity of the course of the wound process as a result of exposure to tissues of significant kinetic energy and a shock wave. They are characterized by:

the presence of a wound channel (tissue defect of various lengths and directions with or without penetration into the body cavity, with the possible formation of blind "pockets");
formation of a zone of primary traumatic necrosis (an area of non-viable tissues that are a favorable environment for the development of a wound infection);
the formation of a zone of secondary necrosis (the tissues in this zone are damaged, but their vital activity can be restored).

All wounds, regardless of origin, are considered to be contaminated with microorganisms. At the same time, it is necessary to distinguish between primary microbial contamination at the time of injury and secondary, occurring during treatment. The following factors contribute to wound infection:

the presence in it of blood clots, foreign bodies, necrotic tissues;
tissue trauma during immobilization;
violation of microcirculation;
weakening of the immune system;
multiple damage;
severe somatic diseases;

If the body's immune defenses are weakened and unable to cope with pathogenic microbes, then the wound becomes infected.

Phases of the wound process

During the wound process, 3 phases are distinguished, systematically replacing one another.

The first phase is based on the inflammatory process. Immediately after the injury, tissue damage and vascular rupture occurs, which is accompanied by:

platelet activation;
their degranulation;
aggregation and formation of a full-fledged thrombus.

First, the vessels react to damage with an instant spasm, which is quickly replaced by their paralytic expansion in the area of damage. At the same time, the permeability of the vascular wall increases and tissue edema increases, reaching a maximum at 3-4 days. Thanks to this, the primary cleansing of the wound occurs, the essence of which is to remove dead tissues and blood clots.

Already in the first hours after exposure to a damaging factor, leukocytes penetrate the wound through the vessel wall, a little later macrophages and lymphocytes join them. They phagocytose microbes and dead tissues. Thus, the process of wound cleansing continues and the so-called demarcation line is formed, which delimits viable tissues from damaged ones.

A few days after the injury, the regeneration phase begins. During this period, granulation tissue is formed. Of particular importance are plasma cells and fibroblasts, which are involved in the synthesis of protein molecules and mucopolysaccharides. They are involved in the formation of connective tissue that ensures wound healing. The latter can be done in two ways.

Healing by primary intention leads to the formation of a soft connective tissue scar. But it is possible only with a slight microbial contamination of the wound and the absence of foci of necrosis.
Infected wounds heal by secondary intention, which becomes possible after the wound defect is cleansed of purulent-necrotic masses and filled with granulations. The process is often complicated by the formation.

The identified phases are typical for all types of wounds, despite their significant differences.

Primary surgical treatment of wounds

First of all, you should stop the bleeding, then disinfect the wound, excise non-viable tissues and apply a bandage that will prevent infection.

Timely and radical surgical treatment is considered the key to successful wound treatment. To eliminate the immediate consequences of damage, primary surgical treatment is carried out. It pursues the following goals:

prevention of complications of a purulent nature;
creation of optimal conditions for healing processes.

The main stages of primary surgical treatment are:

visual revision of the wound;
adequate anesthesia;
opening of all its departments (should be performed widely enough to obtain full access to the wound);
removal of foreign bodies and non-viable tissues (skin, muscles, fascia are excised sparingly, and subcutaneous fatty tissue - widely);
stop bleeding;
adequate drainage;
restoration of the integrity of damaged tissues (bones, muscles, tendons, neurovascular bundles).

In a serious condition of the patient, reconstructive operations can be performed delayed after the stabilization of the vital functions of the body.

The final stage of surgical treatment is the suturing of the skin. Moreover, this is not always possible immediately during the operation.

Primary sutures are necessarily applied for penetrating abdominal wounds, injuries to the face, genitals, and hands. Also, the wound can be sutured on the day of surgery in the absence of microbial contamination, the surgeon's confidence in the radicalness of the intervention and the free convergence of the edges of the wound.
On the day of the operation, provisional sutures can be applied, which are not tightened immediately, but after a certain time, provided that the course of the wound process is not complicated.
Often the wound is sutured a few days after the operation (primarily delayed sutures) in the absence of suppuration.
Secondary early sutures are applied to the granulating wound after it has been cleansed (after 1-2 weeks). If the wound has to be sutured later and its edges are cicatricially changed and rigid, then the granulations are first excised and the scars are dissected, and then the actual suturing (secondary-late sutures) is started.

It should be noted that the scar is not as durable as intact skin. It acquires these properties gradually. Therefore, it is advisable to use slowly absorbable suture materials or tighten the edges of the wound with adhesive tape, which helps to prevent the divergence of the edges of the wound and changes in the structure of the scar.

Which doctor to contact

For any wound, even at first glance, a small one, you need to go to the emergency room. The doctor must assess the degree of tissue contamination, prescribe antibiotics, and treat the wound.

Conclusion

Despite the different types of wounds in origin, depth, localization, the principles of their treatment are similar. At the same time, it is important to carry out the primary surgical treatment of the damaged area on time and in full, which will help to avoid complications in the future.

Pediatrician E. O. Komarovsky tells how to properly treat a wound to a child.

Under primary surgical treatment they understand the first intervention (in a given wounded man) performed according to primary indications, i.e., regarding the tissue damage itself as such. Secondary debridement- this is an intervention undertaken according to secondary indications, i.e., regarding subsequent (secondary) changes in the wound caused by the development of infection.

In some types of gunshot wounds, there are no indications for primary surgical treatment of wounds, so that the wounded are not subjected to this intervention. In the future, in such an untreated wound, significant foci of secondary necrosis may form, an infectious process flares up. A similar picture is observed in cases where the indications for primary surgical treatment were evident, but the wounded man came to the surgeon late and the wound infection had already developed. In such cases, there is a need for an operation according to secondary indications - in the secondary surgical treatment of the wound. In such wounded, the first intervention is secondary surgical treatment.

Often, indications for secondary treatment occur if the primary surgical treatment did not prevent the development of a wound infection; such secondary treatment, carried out after the primary (i.e., the second in a row), is also called re-treatment of the wound. Re-treatment sometimes has to be done before the development of wound complications, that is, according to primary indications. This happens when the first treatment could not be fully carried out, for example, due to the impossibility of X-ray examination of a wounded person with a gunshot fracture. In such cases, in fact, the primary surgical treatment is performed in two steps: during the first operation, the soft tissue wound is mainly treated, and during the second operation, the bone wound is treated, fragments are repositioned, etc. The technique of secondary surgical treatment is often the same as the primary one, but sometimes secondary treatment can be reduced only to ensuring the free outflow of discharge from the wound.

The main task of the primary surgical treatment of the wound- create unfavorable conditions for the development of wound infection. Therefore, this operation is the more effective the earlier it is performed.

According to the timing of the operation, it is customary to distinguish between surgical treatment - early, delayed and late.

Early debridement call the operation performed before the visible development of infection in the wound. Experience shows that surgical treatments performed in the first 24 hours from the moment of injury, in most cases, “ahead” of the development of infection, that is, they are classified as early. Therefore, in various calculations for the planning and organization of surgical care in the war, interventions performed on the first day after the injury are conditionally taken as early surgical treatment. However, the situation in which staged treatment of the wounded is carried out often makes it necessary to postpone the operation. The prophylactic administration of antibiotics can in some cases reduce the risk of such a delay - to delay the development of a wound infection and, thus, extend the period during which surgical treatment of the wound retains its preventive (precautionary) value. Such debridement, albeit with delay, but before the appearance of clinical signs of wound infection (the development of which is delayed by antibiotics), is called delayed debridement. When calculating and planning, interventions performed during the second day from the moment of injury are taken as delayed treatment (provided that antibiotics are systematically administered to the wounded). Both early and delayed wound treatment can, in some cases, prevent wound suppuration and create conditions for its healing by primary intention.

If the wound, by the nature of tissue damage, is subject to primary surgical treatment, then the appearance of clear signs of suppuration does not prevent surgical intervention. In such a case, the operation no longer prevents wound suppuration, but remains a powerful means of preventing more formidable infectious complications and can stop them if they have time to arise. Such treatment, performed with the phenomena of suppuration of the wound, is called late surgical treatment. With appropriate calculations, the category of late includes treatments performed after 48 (and for the wounded who did not receive antibiotics, after 24) hours from the moment of injury.

Late debridement carried out with the same tasks and technically in the same way as early or delayed. The exception is cases when the intervention is undertaken only as a result of a developing infectious complication, and tissue damage by its nature does not require surgical treatment. In these cases, the operation is reduced mainly to ensuring the outflow of the discharge (opening the phlegmon, leakage, imposing counter-opening, etc.). The classification of surgical treatment of wounds depending on the timing of their implementation is largely arbitrary. It is quite possible to develop a severe infection in the wound 6-8 hours after the injury and, conversely, cases of very long incubation of the wound infection (3-4 days); processing, which in terms of execution time seems to be delayed, in some cases turns out to be late. Therefore, the surgeon must proceed primarily from the state of the wound and from the clinical picture as a whole, and not only from the period that has elapsed since the moment of injury.

Among the means preventing the development of wound infection, an important, albeit auxiliary, role is played by antibiotics. Due to their bacteriostatic and bactericidal properties, they reduce the risk of outbreaks in wounds that have undergone surgical debridement or where debridement is considered unnecessary. Antibiotics play a particularly important role when this operation is forced to be postponed. They should be taken as soon as possible after injury, and by repeated administrations before, during and after surgery, the effective concentration of drugs in the blood should be maintained for several days. For this purpose, injections of penicillin and streptomycin are used. However, under the conditions of [staged treatment, it is more convenient for the affected to administer a prophylactic drug with a prolonged action, streptomycellin (900,000 IU intramuscularly 1-2 times a day, depending on the severity of the injury and the timing of the primary surgical treatment of the wound). If injections of streptomycellin cannot be carried out, biomycin is prescribed orally (200,000 IU 4 times a day.). With extensive muscle destruction and delay in the provision of surgical care, it is desirable to combine streptomycellin with biomycin. With significant damage to the bones, tetracycline is used (in the same dosages as biomycin).

There are no indications for primary surgical treatment of the wound with the following types of injuries: a) penetrating bullet wounds of the extremities with pinpoint inlet and outlet holes, in the absence of tissue tension in the wound area, as well as hematoma and other signs of damage to a large blood vessel; b) bullet or small fragment wounds of the chest and back, if there is no hematoma of the chest wall, signs of crushing of the bone (for example, scapula), as well as open pneumothorax or significant intrapleural bleeding (in the latter case, a thoracotomy becomes necessary); c) superficial (usually not penetrating deeper than the subcutaneous tissue), often multiple, wounds with small fragments.

In these cases, the wounds usually do not contain a significant amount of dead tissue and their healing most often proceeds without complications. This, in particular, can be facilitated by the use of antibiotics. If, in the future, suppuration develops in such a wound, then the indication for secondary surgical treatment will be mainly the retention of pus in the wound channel or in the surrounding tissues. With a free outflow of discharge, a festering wound is usually treated conservatively.

Primary surgical treatment is contraindicated in the wounded, who are in a state of shock (temporary contraindication), and in those who are agonizing. According to data obtained during the Great Patriotic War, the total number of those not subject to primary surgical treatment is about 20-25% of all those affected by firearms (S. S. Girgolav).

Military field surgery, A.A. Vishnevsky, M.I. Schreiber, 1968

Surgical treatment of wounds- surgical intervention, which consists in a wide dissection of the wound, stopping bleeding, excising non-viable tissues, removing foreign bodies, free bone fragments, blood clots in order to prevent wound infection and create favorable conditions for wound healing. There are two types surgical treatment of wounds primary and secondary.

Primary surgical treatment of the wound- the first surgical intervention for tissue damage. Primary surgical treatment of wounds must be comprehensive and comprehensive. Produced on the 1st day after the injury, it is called early, on the 2nd day - delayed, after 48 h from the moment of injury - late. delayed and late surgical treatment of wounds are a necessary measure in case of mass admission of the wounded, when it is impossible to perform surgical treatment in the early stages for all those in need. Proper organization is essential medical triage, in which the wounded are isolated with ongoing bleeding, tourniquets, detachments and extensive destruction of the limbs, signs of purulent and anaerobic infection, requiring immediate surgical treatment of wounds. For the rest of the wounded, debridement may be delayed. When transferring primary H. o. r at a later date, they will take measures that reduce the risk of infectious complications, prescribe antibacterial agents. With the help of antibiotics, only a temporary suppression of the vital activity of the wound microflora is possible, which makes it possible to delay, rather than prevent, the development of infectious complications. Injured in condition traumatic shock before surgical treatment of wounds carry out a set of anti-shock measures. Only with continued bleeding is it permissible to perform surgical debridement without delay while conducting anti-shock therapy.

The amount of surgery depends on the nature of the injury. Stab and cut wounds with minor tissue damage, but with the formation of hematomas or bleeding, are only subject to dissection in order to stop bleeding and decompress tissues. Large wounds, which can be processed without additional tissue dissection (for example, extensive tangential wounds), are subject only to excision, through and blind wounds, especially with multi-comminuted bone fractures, to dissection and excision. Wounds with complex architectonics of the wound channel, extensive damage to soft tissues and bones are dissected and excised; additional incisions and counter-openings are also made to provide better access to the wound channel and drainage of the wound.

Surgical treatment is carried out, strictly observing the rules of asepsis and antisepsis. The method of anesthesia is chosen taking into account the severity and localization of the wound, the duration and trauma of the operation, the severity of the general condition of the wounded.

Excision of the skin edges of the wound should be performed very sparingly; remove only non-viable, crushed areas of the skin. Then the aponeurosis is widely dissected, an additional incision is made in the region of the corners of the wound in the transverse direction so that the incision of the aponeurosis has a Z-shape. This is necessary so that the aponeurotic case does not compress the edematous muscles after injury and surgery. Next, the edges of the wound are bred with hooks and damaged non-viable muscles are excised, which are determined by the absence of bleeding, contractility and characteristic resistance (elasticity) of muscle tissue in them. When carrying out primary processing in the early stages after injury, it is often difficult to establish the boundaries of non-viable tissues; in addition, late tissue necrosis is possible, which may subsequently require re-treatment of the wound.

With forced delayed or late surgical treatment of wounds the boundaries of non-viable tissues are determined more precisely, which makes it possible to excise tissues within the outlined demarcations. As the tissues are excised, foreign bodies and loose small bone fragments are removed from the wound. If at surgical treatment of wounds large vessels or nerve trunks are found, they are carefully pushed aside with blunt hooks. Fragments of damaged bone, as a rule, are not processed, with the exception of sharp ends that can cause secondary trauma to soft tissues. Rare sutures are applied to the adjacent layer of intact muscles to cover the exposed bone in order to prevent acute traumatic osteomyelitis. Muscles also cover exposed major vessels and nerves to avoid vascular thrombosis and nerve death. In case of injuries of the hand, foot, face, genitals, distal parts of the forearm and lower leg, the tissues are excised especially sparingly, because. wide excision in these areas can lead to permanent dysfunction or to the formation of contractures and deformities. In combat conditions surgical treatment of wounds supplement with reconstructive and restorative operations: suturing of blood vessels and nerves, fixation of bone fractures with metal structures, etc. In peacetime conditions, reconstructive and restorative operations are usually an integral part of the primary surgical treatment of wounds. The operation is completed by infiltration of the wound walls with antibiotic solutions, drainage. It is advisable to actively aspirate the wound discharge using silicone perforated tubes connected to vacuum devices. Active aspiration can be supplemented by irrigating the wound with an antiseptic solution and applying a primary suture to the wound, which is possible only with constant monitoring and treatment in a hospital.

The most significant errors in surgical treatment of wounds: excessive excision of unchanged skin in the wound area, insufficient wound dissection, making it impossible to make a reliable revision of the wound channel and complete excision of non-viable tissues, insufficient perseverance in search of the source of bleeding, tight tamponade of the wound for the purpose of hemostasis, the use of gauze tampons for draining wounds.

Secondary debridement carried out in cases where the primary treatment did not work. Indications for secondary surgical treatment of wounds are the development of a wound infection (anaerobic, purulent, putrefactive), purulent-resorptive fever or sepsis caused by delayed tissue discharge, purulent streaks, near-wound abscess or phlegmon. The volume of secondary surgical treatment of the wound may be different. Complete surgical treatment of a purulent wound involves its excision within healthy tissues. Often, however, anatomical and operational conditions (danger of damage to blood vessels, nerves, tendons, articular capsules) allow only partial surgical treatment of such a wound. When the inflammatory process is localized along the wound channel, the latter is widely (sometimes with an additional dissection of the wound) opened, the accumulation of pus is removed, and the foci of necrosis are excised. For the purpose of additional rehabilitation of the wound, it is treated with a pulsating jet of an antiseptic, laser beams, low-frequency ultrasound, as well as vacuuming. Subsequently, proteolytic enzymes, carbon sorbents are used in combination with parenteral administration of antibiotics. After complete cleansing of the wound, with good development of granulations, it is permissible to apply secondary seams. With the development of anaerobic infection, secondary surgical treatment is carried out most radically, and the wound is not sutured. The treatment of the wound is completed by draining it with one or more silicone drainage tubes and suturing the wound.

The drainage system allows in the postoperative period to wash the wound cavity with antiseptics and actively drain the wound when vacuum aspiration is connected (see Fig. Drainage). Active aspiration-washing drainage of the wound can significantly reduce the time of its healing.

Treatment of wounds after their primary and secondary surgical treatment is carried out using antibacterial agents, immunotherapy, restorative therapy, proteolytic enzymes, antioxidants, ultrasound, etc. Effective treatment of the wounded in conditions of gnotobiological isolation (see. Antibacterial managed environment), and in case of anaerobic infection - with the use of hyperbaric oxygen therapy.

Bibliography: Davydovsky I.V. Gunshot wound of a person, vol. 1-2, M., 1950-1954; Deryabin I.I. and Alekseev A.V. Surgical treatment of wounds, BME, v. 26, p. 522; Dolinin V.A. and Bisenkov N.P. Operations for wounds and injuries, L., 1982; Kuzin M.I. etc. Wounds and wound infection, M., 1989.