Introduction
Chronic wounds are those wounds that take longer than usual to heal due to underlying health problems like diabetes, vascular disease (disease affecting blood vessels), or immune system disorders. Unlike acute wounds that heal within a predictable timeframe, chronic wounds fail to progress through the normal stages of wound healing, leading to prolonged suffering, decreased quality of life, and increased healthcare costs. The surgical management of such wounds involves various techniques that aim to promote wound healing and closure.
Effective management of chronic wounds requires a multidisciplinary (doctors from different specialties) approach, with surgical interventions playing a crucial role in promoting wound closure and tissue regeneration. This article further discusses surgical techniques commonly employed in the management of chronic wounds, ranging from debridement and skin grafting to advanced procedures like flap surgery and vacuum-assisted closure therapy.
When Is Surgical Management of Chronic Wounds Indicated?
In several cases, the surgical management of chronic wounds is indicated:
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Failure of conservative treatment for managing chronic wounds.
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In case of the presence of any foreign bodies in the wounds.
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In cases where malignancy is suspected, such as SCC (squamous cell carcinoma - skin cancer). In such cases, biopsy (collection of a sample of tissue surgically from the wound site and sending it to the laboratory for further investigations) is recommended first to rule out a definitive diagnosis.
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In cases of complications such as wound dehiscence (partial or complete separation of wound edges), chronic inflammation, or recurrent infections, it may necessitate surgical intervention to address underlying factors contributing to poor wound healing and prevent further progression of infection.
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Chronic wounds that cause significant pain and discomfort or are located in areas of functional significance may require surgical management to restore functional integrity and improve quality of life.
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Chronic wounds associated with sinus tracts or fistulas (an abnormal wound track opening in the outer environment that can lead to the spread of infection) may require surgical exploration and repair to eliminate sources of infection and promote wound closure.
What Are the Different Surgical Approaches for the Management of Chronic Wounds?
Several surgical techniques for the management of chronic wounds are:
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Wound Debridement: Surgical debridement is the process of removing dead tissue, bacteria, and debris from a wound to promote healing. This can be done using sharp instruments (sharp debridement), surgical tools such as scalpels or scissors, or enzymatic agents.
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Skin Grafting: This technique involves removing skin from a healthy area (donor site) and then transplanting or grafting it to the wound site (recipient site). Skin grafts can be split-thickness (only the top layers of skin) or full-thickness (all layers of skin), depending on the depth and severity of the wound.
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Flap Surgeries: This is mostly used in surgical procedures and involves the removal of the skin along with its vascular supply (pedicled flap) from one part of the body and placing it in the affected area (wound site). This technique is mostly used in cases of complex wounds with large affected areas and when more tissue coverage is required at the wound site. Different types of flaps used in flap surgeries are:
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Local Flaps: These flaps are harvested from the adjacent area of the wound.
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Regional Flaps: These flaps are harvested from the nearby region of the wound.
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Vacuum-Assisted Closure (VAC): This therapy is also called “negative pressure wound therapy. VAC therapy involves placing a vacuum-sealed dressing over the wound to create negative pressure, which helps remove excess fluid and, in turn, reduces swelling and promotes the formation of granulation tissue required for promoting wound healing. VAC therapy can be used as a primary treatment or as an adjunct to surgical interventions.
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HBO (Hyperbaric Oxygen) Therapy: Hyperbaric oxygen therapy (HBOT) involves exposing the patient to 100 percent oxygen in a pressurized chamber. This therapy increases the amount of oxygen delivered to tissues, thereby increasing vascular supply in the area and promoting wound healing. It works by stimulating the formation of new blood vessels and enhancing the antimicrobial activity of white blood cells. It also increases the concentration of antibiotics penetrating the wound and improves antimicrobial action. HBOT is often used for chronic wounds that have failed to respond to other treatments. It is particularly effective for wounds associated with conditions like diabetes or radiation therapy.
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Surgical Reconstruction: In cases where chronic wounds result in significant tissue loss or deformity, reconstructive surgery may be necessary to restore function and aesthetics. This can involve techniques such as tissue expansion (use of tissue expanders for filling the wound gap or defects), skin flaps, or microsurgical reconstruction (reconstruction of blood vessels).
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Amputation: In severe cases where the tissue damage is extensive or if there is a risk of systemic infection or limb ischemia (loss of blood supply and nutrients to the wound area resulting in necrosis of the limb), amputation (surgical removal) may be necessary to remove the affected limb and prevent further complications such as septicemia or sepsis (spread of infection to the bloodstream). However, amputation is typically considered as a last resort when all other treatment options have failed.
It is crucial to individualize the treatment approach based on the characteristics of the wound, the patient's overall health status, and underlying conditions contributing to the chronicity of the wound. A multidisciplinary team approach involving surgeons, wound care specialists, nurses, and other healthcare professionals is often necessary to achieve optimal outcomes in the management of chronic wounds.
Conclusion
Chronic wounds present a significant burden on healthcare systems globally, requiring comprehensive and effective management strategies. Surgical interventions play a vital role in the treatment of chronic wounds, offering avenues for wound debridement, tissue reconstruction, and promoting healing.
By employing these surgical interventions in conjunction with other aspects of wound care, such as infection control, offloading pressure, and optimizing underlying health conditions, healthcare professionals can significantly improve outcomes for patients with chronic wounds. Furthermore, advancements in surgical techniques, technologies, and interdisciplinary collaboration continue to expand the armamentarium available for managing chronic wounds, offering hope for better outcomes and enhanced quality of life for affected individuals.
