UNRESOLVED QUESTIONS OF SURGICAL PROCESSING OF WOUNDS.WHETHER BURN WOUND REQUIRES SEPARATE TERMINOLOGY?
Kemerovo State Medical Academy,
Kemerovo, Russia
Wounds present the significant part of surgery. One should note that the wounds in the ancient people crated a stimulus for development of the surgery. At the present time thousands of patients receive assistance in view of surgical preparation for wounds. But despite of several-hundred-old history of improvement in the methods for surgical and conservative treatment of patients with wounds, the doctrine of wounds lacks the uniform understanding about designation of wound process periods, wound classification in dependence on periods of wound process, relationship between wounds and microorganisms and the surgical techniques for treatment of patients with wound injuries. In relation to the elements of wound surgical preparation the consistent tendency exists in view of granting the status of the independent method for treating wounds (for example, suturing and necrectomy), and introducing other definitions (wound cleansing, dissection of granulation, toilet etc.) instead of dressing or surgical preparation. One should believe that the system for surgical treatment of wounds which was developed during the Second World War [5] with primary and secondary wound processing (PWP and SWP) and secondary sutures is far from perfection.
In the following years the proper research of wound process has explained the essence of the changes in the tissues surrounding the wound cavity. It allowed presenting it in the corresponding classifications. The concept of wound treatment is based on understanding the course of wound process with addition of the new methods [1, 2, 3, 7]. So, in the classification by I.G. Rufanov (1954) the wound process is separated into two phases: hydration and dehydration. In 1956 S.S. Girgolav offered three phases of the wound process: 1) inflammation phase corresponding to hydration phase, 2) regeneration phase, 3) the phase of scar reconstruction and epithelialization. We should note that separation of inflammation phase was erroneous, because the following phases (regeneration, reconstruction) also relate to inflammation. There was an error in creation of the classifications with use of one criterion. The following classifications have maintained this inaccuracy [3].
In the end of the 20th century the final opinion appeared in relation to the fact that healing of fresh and purulent wounds happen according to the same biologic particularities. It was shown that primary suturing of the processed purulent wound resulted in healing by first intention in 80-90 % of the cases upon condition of draining and suppression of microflora. That fact removed the seeming vital difference between PWP and SWP. But the main positions of the doctrine of wound treatment with unsolved problems remained unbreakable and shifted to the surgical practice of XXI century.
According to our opinion the analysis of the existing position in the doctrine of wounds identified the existing disadvantages and the ways for their correction [9]. We based on the integrity of understanding the wound process, which is presented in view of periods of inflammatory response in relation with microorganisms and refusal from canonization in definitions of PWP and SWP [8]. Some issues were not discussed, for example, significance of dressing in process of wound treatment, classification and position of necrectomy, need for specific definitions of curative measures for injuries of non-mechanic nature. For discussing the designated topics with should reduplicate some elements and summarize the essence of the offered concept.
Which moments of wound theory attract attention?
Firstly, absence of the relationship between the classification of phases of wound process (inflammation, regeneration, scar reconstruction and epithelialization) and the classification of wounds in dependence on the relationship between the macroorganism and the microorganisms (aseptic, bacterial contamination, infected, purulent wounds). As seen, the classification does not include purulence phase corresponding to purulent wounds, and the classification of wounds does not include wound process to the full degree, particularly, regeneration and epithelialization phases have no the corresponding wound type. Besides, some terms in the wound classification are not correct. Instead of the word combination “microbial contaminated” (mud, the soil soaked with water) one should use the term “infected” (contaminated with germs), and the erroneous use of the definition “infected wounds” (with clinical signs of inflammation) can be replaced by the word combination “inflamed wounds” in concordance with clinical signs. Regeneration phase corresponds to granulating wounds which are removed from the classification.
Secondly, the classification of wound surgical processing includes the excessive number of the definitions with indication of time of the procedure (primary, delayed [early or delayed], secondary [although it is usually performed for the first time] processing). The same things relate to treatment for granulating wounds (secondary sutures [early or late sutures with indicated time of application]).
Thirdly, necrectomy and secondary sutures are positioned as the main procedure, despite the fact that previously necrectomy was the element of WSP, and suturing was the last stage of any surgery. Dissection of old granulations and suturing are nothing but WSP. Why do we call this procedure as secondary late suture?
Fourthly, the drive to implementation of new definitions as independent surgical interventions. So, instead of WSP or dressing, combustiologists insistently implement such surgical definitions as wound cleansing, toilette, wound excision, granulation excision.
Fifthly, at the different historical stages of wound theory one of the objects of WSP was declared as its goal: incision, necrectomy, and in the last WSP definitions the aim is prevention of wound infection (for PWP) and correction of developed infection in the wound (for SWP). Admission of the fact of healing in fresh or purulent wounds according to the uniform biologic particularities virtually removed the difference between PWP and SWP. Therefore, there is a necessity for specification of the aim of WSP and definition for surgical processing and the place in the system for wound treatment. Dissection, necrectomy, granulation incision, hemostasis, wound debridement, draining and suturing are to be reviewed as possible elements of surgical preparation, which is aimed to promoting wound healing. All SWP elements are directed to achievement of this objective.
Sixthly, canonization of wound surgical processing, with presentation as surgery with 5 elements (incision, resection, hemostasis, elimination of foreign bodies, restoration of disordered relationships in tissues). The available clear definition of WSP would eliminate discussions about sense of primary surgical processing for the wound and, in case of absence of one of the elements, would preclude naming WSP as wound toilet, wound incision etc. [4, 6]. According to our opinion, from one hand, WSP corresponds to any surgical interventions in terms of possible volume, but, from other hand, it aligns with such manipulation as dressing.
Elimination of the above-mentioned contradictions and unsolved issues of WSP is possible only with development of wound classification in concordance with wound process course that will automatically remove multiple terminological misunderstandings.
In concordance with tissue changes [9] we offered four stages of the wound process. In comparison to the available classifications these stages present better reflection of dynamics of structural and metabolic changes in the wound and are well identified with use of the clinical signs: 1) the stage of metabolic and vascular disorders with reactive extravasation; 2) the stage of cellular infiltration and inflammatory serous extravasation; 3) the stage of inflammatory purulent extravasation; 4) the stage of regeneration and epithelialization.
In the presented classification each stage of the wound process relates to the clinical definition of wounds (aseptic and infected wounds – the first stage; inflamed wounds – the second stage; purulent [purulent necrotic] wounds – the third stage; granulating wounds – the fourth stage):
- Aseptic wounds – the wounds with very little amount of microorganisms without ability to cause inflammation; as a rule, these are fresh surgical wounds;
- Infected wounds – the fresh, accidental wounds; the changes in such wounds are at the stage of vasomotor and metabolic disorders with reactive edema, and microorganisms are at the period of incubation, without influence on the course of the wound process, and on the general state of the patient; classical clinical signs of inflammation are not identified at this stage;
- Inflamed wounds – the wounds with clinical signs of inflammation: edema, redness, hyperthermia. After completing the incubation period the period of contagion begins – microbial influence on the wound process is apparent, because inflammation goes to the stage of infiltration and inflammatory serous exudation;
- Purulent (purulent necrotic) wounds – the wounds with tissue necrosis, purulence and suppuration after the period of maximal expressiveness of inflammation;
- Granulating wounds – such wounds are characterized with regeneration processes, with secondary role of microorganisms in the wound process.
The admittance of the described classification of the wound process and wounds simplifies all terminological positions. There is no need for the definitions relating to the time of surgical preparation, subdivision to primary, delayed and secondary processing, and subdivision of sutures to primary, early secondary and late secondary.
From the perspective of this classification each surgeon defines WSP as the following: surgical processing for aseptic (infected, inflamed, purulent [purulent necrotic], granulating) wound (location). Then the description of surgery follows, particularly, incision, necrectomy, granulation dissection, the issues of draining, use of wound covering, autodermoplasty, suturing, isolating dressing, immobilization. It is naturally that the classification of accidental and surgical wounds must be uniform.
The offered classification does not violate the present concepts about changes in wounds and, at the same time, it greatly simplifies the terminology and problem perception by students, and, to a greater degree compared to the present classifications, directs the physician to the characteristics of preventive and curative measures for each type of the wound. The wound type is easily defined according to the clinical signs. Addition of granulating wounds to the classification prevents the physician from use of definitions “early suturing” or “late secondary suturing” as independent operations, because surgical preparation covers the whole wound process, and these procedures, as a rule, present one of the elements of late surgical preparation that relates to inflamed, purulent or granulating wounds. Early surgical preparation is carried out for aseptic and infected wounds. The classification means absence of necessity for using such definitions as “early” or “late” surgical preparation.
The above-mentioned facts have lead us to the necessity for the new definition of WSP, which states that this procedure has its own objective covering all manipulations and concurrent procedures, and the amount of surgical manipulations is not overemphasized. The absence of the uniform action (for example, dissection) for some cases, with canonical understanding of surgical preparation, instigates some traumatologists and surgeons to call it differently – wound toilet, wound cleansing etc.
Therefore, wound surgical processing is the operation for promoting wound healing and recovery of functions in injured organs and tissues, removal of foreign bodies, resection of pathologic issues and tissues with questionable vitality, restoration of anatomic structures, suturing and draining.
Such definition of wound surgical processing does not preclude the features of any surgery, and, at the same time, it removes distance with wound dressing. In medical application and especially in surgical practice the procedure of dressing means the complex of measures which became the independent conception with corresponding application. Dressing is the medical diagnostic measure for wounds and other pathologic processes with disordered integrity of skin that includes examination, debridement for surrounding tissues and wound cavity, bloodless manipulations, particularly necrectomy and draining, and dressing.
As seen, dressing presents more general concept in comparison with dressing application, and includes application of dressing as the component of the whole. It means that dressing includes change of dressing, wound cavity revision, recovery by means of mechanical or chemical impaction, removal of foreign bodies, necrotic tissues, exudate, clots, pus, and draining.
The definition “wound toilet” became wide spread in practical medicine. This definition substitutes the term “dressing”, possibly because of the narrow understanding of latter as only change of dressing. But, first of all, the definition is unsuccessful from the point of meaning and phonation. Toilet (from French toilette) – 1) clothes; 2) garment care; 3) the table with a mirror and drawers; 4) water closet in public places. Use of this definition meant cleanup for the wound. For designation of this definition one can use more acceptable Latin term and more corresponding to the notion of dressing – sanitation (From Latin sanatio – treatment, health promotion). It is this term that is becoming popular in many fields of surgery during the last years: sanitation relaparatomy, sanitation bronchoscopy, abdominal sanitation. Dressing and wound sanitation are combined in the general notion of dressing or operation. As result, the term “toilet” is not justified for use both as independent manipulation or the component of dressing, where the term “wound sanitation” is more acceptable.
As result, the question arises: do we need the special terminology and definitions for burn wounds? During incision for old granulations, while late secondary suturing and for necrotic tissues during WSP, the general surgeons did not name these actions as granulation resection or necrectomy as independent operations. There is a false impression that such actions are related only to surgical processing for burn wounds. There is a tendency to disintegration of the definitions in treatment of burn wounds. Combustiologists initiated development of the classification for necrectomy as result of implementation of “active surgical tactics” in treatment of deep burns, with positioning as independent operation, which supported by the offer to call it as primary necrectomy, delayed or secondary necrectomy.
It is to be recalled that burns are traumatic injuries and everybody acknowledges it. Like mechanic injuries, burns demonstrate the same periods of the wound process and types of injuries (contamination, maximal expressiveness of inflammation, purulence, regeneration). But the features of burn surface resulted in deviation from the terminology for surgical treatment of mechanical injuries (primary and secondary surgical processing of wounds). Other authors tried to adapt the old terminology to the new circumstances. The essence of the problem became even more complicated.
The regularities of changes in the body after accidental postsurgical wounds are typical, as for any stress response. However expressiveness and duration of this response depends on the degree of potential impaction. In case of burns this impaction is stronger and more longstanding. Therefore, at the stage of resistance the regenerative processes develop later – after 5-6 days after injury. But neither this factor nor stronger suppression of phagocytosis and immunocompetence in the burn patient are not the reason for disintegration in the terminology for burn wounds.
As far as necrectomy is the key procedure for processing of wounds, burns and freezing, it is reasonably to provide systematization according to different signs that will allow characterizing surgical intervention in each case. The analysis of the state concerning the classification of necrectomy identified its incompleteness for some criteria. We consider the corrected form of the classification as indicated below.
According to the square. Single-step (full) necrectomy means removal of necrotic tissues along the whole affected surface. Partial necrectomy – removal of necrotic tissues from the part of affected surface. Staged necrectomy – subsequent removal of remaining tissue after partial necrectomy.
According to sequence of necrectomy at the same surface. The first necrectomy is called as primary. If the surface is exposed to recurrent removal of necrotic tissues – one calls it as secondary (recurrent) necrectomy, in case of the third procedure – tertiary necrectomy. Such sequence is possible only with conscious, non-radical resection during primary necrectomy (wound processing) or as result of secondary necrosis.
According to the objective. If resection of necrotic tissues does not include the whole deepness, and it is performed for deintoxication – this is palliative necrectomy. In case of radical necrectomy necrotic tissues are resected completely.
According to the manner of realization. If resection is realized tangentially, this is tangential necrectomy. It is usually performed with the dermatome. It is possible to remove necrotic tissues by means of bordering incisions (scalpel) and incision with scalpel. Combination of these maneuvers is possible with physical techniques. This is combined necrectomy.
According to deepness. Skin (dermal) necrectomy is limited to the skin. Skin-adipoid necrectomy achieves subcutaneous fat. Subcutaneous fat necrectomy is limited to subcutaneous fat. Fascial necrectomy is limited to a vital fascia. Fascial muscular necrectomy is performed within muscular tissue, bone necrectomy (osteonecrectomy) – within bone tissue. The final type is amputation.
This classification is used in Kemerovo burn center. The eligibility of this classification for thermic and freezing injuries was tested by means of the analysis of case histories from 43 patients treated within 3 months. Necrectomy was full in 96 % of the patients (single-step) and partial only in two patients. Recurrent necrectomy (for the same surface) was made for one patient. Radical necrectomy was in 83 % of the cases, palliative – in 17 %. Scalpel type of necrectomy was used for 64 % of the patients, for others – tangential. According to the deepness necrectomy procedures were distributed as follows: dermal – 1, dermal fat – 9, subcutaneous fat – 6, fascial – 1, fascial muscular – 3, osteonecrectomy – 21 (all cases with freezing injuries). One amputation was carried out for the burn, another – for the freezing injury.
The above-mentioned classification of necrectomy is offered for surgeon (traumatologist, combustiologist) describing his/her own activities as the elements of surgical processing for wounds (infected, inflamed, purulent, granulating). It is naturally that amputation and necrectomy have the specific objectives and manner of realization which do not get under the notions of WSP and dressing and must be used as independent operations. Necrotomy (Greek Necros – dead, tome – incision, transection) is transection of tissues. It is used for necrosis with aim of transition from humid gangrene to dry gangrene, for circular burns with aim of tissue decompression, for anaerobic and putrid infection with aim of aeration and deintoxication.
As any surgical operation, depending on time of realization from admission, WSP can be emergent, i.e. realized after preparation of the patient to surgery, delayed – according to medical indications or non-consent of the patient, and planned.
CONCLUSION
The analysis of state of the wound theory has shown that different directions had developed independently and without coordination with others. Finally it resulted in excessive definitions, endless attempts of implementation of new definitions with different interpretation, disintegration of different surgical specialties in terms of this issue and complexity of problem perception by students.
With aim of regulating the terminology and simplification of its practical usage for treatment of any wounds it is reasonable:
- To separate four stages of wound process according to structural criteria of inflammation (the stage of metabolic and vascular disorders with reactive exudate, the stage of cellular infiltration and inflammatory serous exudate, the stage of inflammatory purulent exudate, the stage of regeneration and epithelialization);
- To give the clinical classification of wounds in concordance with the stages of the wound process (aseptic, infected, inflamed, purulent [purulent necrotic], granulating);
- To supplement the name of surgical processing with the clinical type of the wound, without use of the terms primary, secondary, early or late, because the type of the wound better defines the purpose of these terms (for example, surgical processing for purulent wound, surgical preparation for granulating wound);
- To review the following procedures as the main independent measures for wounds: surgical processing, dressing, amputation and necrotomy. The following procedures should be considered as the elements of the main measures: wound incision, resection of granulations, necrectomy, wound covering, autodermoplasty, suturing, draining, wound debridement. Autodermoplasty and necrectomy have the own classification, but as the elements of the main medical measures.
Such approaches are appropriate for use by physicians of all surgical specialties. The described point of view may be considered by the reader as too revolutionary, but, as we think, it is necessary and timely point for such important interdisciplinary problem, i.e. he wound theory. The author is far from the idea that the offered concept is final and without disadvantages. Therefore, he calls the colleagues for discussion, presentation of other points of view, correcting positions and criticism. All we should strife towards uniform understanding of ideology of this issue, with orientation to the new approaches.