**6. Surgical approaches to wound management [14]**

There are certain golden surgical principles that must be followed in order to achieve adequate wound management.

### **6.1. For primary repair**

A. Primary closure requires clean, well approximated and tension free suturing technique.

B. Infection and delayed healing are almost inevitable when primary closure of contaminated wound takes place without proper debridement or washout.

C. Various suturing techniques mean each technique is ideal for certain types of wounds. For example, while a subcuticular skin suture is considered to be an excellent option of good alignment for the wound edges, it is not the best haemostatic technique and in wounds with oozing edges or expected oozing a continuous mattress suture might be a better option in those cases where oozing is expected.

D. Choosing the correct suture material is vital in ensuring a desirable outcome. In general, a monofilament stitch carries less risk of infection in comparison to braided (multifilament) stitches [15]. Correct tensile strength of the material used is essential in maintaining the integrity of the wound until the healing is complete [15].

E. Size of sutures and interval between stitches should be proportional to the thickness of approximated tissues.

F. Deep wounds should be closed in layers whenever possible.

G. Timing of suture removal is determined by site and vascularity. For example, while skin stitches on the face can be removed as early as in 3 days, abdominal closure, usually, necessitate keeping suture material for up to 7–10 days.

H. Some operations that leave quite a large raw area may require drains as the chances of haematoma formation are high. The most common example is mastectomy. In these cases use of human fibrin glue spray reduces the drainage and also Seroma formation is reduced to a significant degree [16]. The product ARTISS is produced by Baxter Ltd. It contains 5% fibrin and 95% prothrombin and comes loaded in syringe. The product must be connected to a pressurised air source and before using the temperature of fluid must be at 25°C. This solution is good where one may need adjusting the flaps as it takes roughly 3 minutes for it to work [16]. If immediate fixation of the surfaces is required, Tessil (Baxter) is a good product [17]. This contains 95% fibrin and 5% prothrombin and adheres immediately. This is very useful in thoracotomy where it is sprayed straight to the chest wall and pleura [17].

For delayed primary closure:

A. Delayed primary closure is a good alternative in clean contaminated wounds and whenever washout is required. Wounds can be left open with saline-soaked sterile gauze and then patient should be taken back to the theatre, the gauze is removed and if wound looks clean and free of contaminant, sutures can be applied after 48 hours.

### **6.2. For healing with secondary intention**

A. Promote healing with secondary intention after performing surgical debridement.

B. Surgical debridement includes washout of wound edges with antiseptic solutions, thorough washout with copious amounts of saline, excising dead and necrotic tissue down to healthy bleeding edges and gentle tissue handling to minimise iatrogenic tissue trauma.
