**8. Guidance for reducing post-operative surgical site infection (SSI) [20]**

A. Dressings and wound cleaning

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

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

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

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

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

bleeding edges and gentle tissue handling to minimise iatrogenic tissue trauma.

sutures, tapes or staples is usually required until epithelisation takes place [19].

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

Regardless of the nature of the wound, healing mechanism or the type of closure, the aims of post-operative wound care remain the same. The main goal is to promote fast, complicationfree healing with the best possible functional and aesthetic outcome [18]. Special consideration is given to wound healing with primary intention. As there is minimal tensile strength at the wound edges due to lack of remodelling collagen fibres, additional support in the form of

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

thoracotomy where it is sprayed straight to the chest wall and pleura [17].

of contaminant, sutures can be applied after 48 hours.

**6.2. For healing with secondary intention**

**7. Post-operative wound care**

keeping suture material for up to 7–10 days.

350 Wound Healing - New insights into Ancient Challenges

approximated tissues.

For delayed primary closure:

a. Aim not to disturb the wound in the first 48 hours as this can damage the new delicate layer of epithelium. If necessary, use sterile saline for cleaning wound during this period and not to rub the surface.

b. Aseptic non-touch technique is mandatory for changing/removing dressings.

c. Advise patients that they can have a shower 48 hours post-operatively as by this time the top layer of epithelium has formed and the wound becomes water tight.

d. Early referral to tissue viability services is preferable in cases of wounds healing by secondary intention.

B. Anti-microbial treatment

a. Consider giving antibiotics whenever SSI (cellulites) is suspected.

b. Antibiotic choice should be broad spectrum initially then spectrum should be narrowed to target specific organisms once the culture and sensitivity report is available [21].

C. Further debridement

a. If debridement becomes necessary, surgical debridement in the theatre is always preferred in grossly contaminated wounds.

b. Avoid gauze dressings as when gauze is removed it damages granulation tissue which sticks to it. Though in certain superficial pussy wounds this method is still used and statistically no difference has been found in the healing time in comparison to more costly dressings.

c. Some non-healing wound with lot of dead tissue can be treated with sterile Green Bottle Larvae (*Lucilia sericata*) which destroy the necrotic tissue with enzyme and then ingest it. Larvae are applied directly to the wound and then held in place with an occlusive dressing. These can be applied to wound infected with MRSA (Methecillin Resistant Staphylococcus Aureus) as the larvae digest the bacteria as well and reduce the chance of continued infection. It is stipulated that the enzyme also produces growth of granulation tissue, however, some patients may find having larvae on their body unacceptable and if left too long the enzyme produced may destroy the keratinised epithelium [2].

d. Different types of special dressings can be applied to absorb the exudates and let the wound heal quicker and with less pain when changing the dressing. There are numerous dressings available for this kind of wounds and are described in the next section.

e. Cleaning the wound with hydrojets and by putting the patient in whirlpool has also been tried and found helpful in cleaning grossly contaminated wounds or quite large wounds. If wound is small and irrigation is required to remove exudates and debris that might interfere with wound healing, gentle irrigation with a syringe filled with saline or sterile water is preferred [3, 22].

f. Irrigation of wounds with antiseptic solution has been tried with hypochloride (*Eusol*) solution, Aserbane™ and hydrogen peroxide as caustic agents have been tried but there are no reliable data available to prove their efficacy [3].

D. Structured wound care approach

a. Using flowcharts and a structured approach with clear guidance is essential to ensure continuity within the team.

b. Continuous education about recent updates in wound care.

E. Methods to avoid

a. Topical antibiotics in wounds healing by primary intention.

b. Moist cotton gauze or mercury-based antiseptic solutions.

F. Post-operative wound complications: The most common and significant post-operative wound complications are wound infection and wound dehiscence. Once suspected, active management should start and this includes swabs for culture and sensitivities, followed by empirical antibiotics administration in the first instance [21]. Debridement in some cases might be necessary to promote wound healing.
