The use of transposed rectus femoris muscle in the treatment of infected abdominal wounds

Summary A recent publication, where three experienced workers in the field of managing post-operative contaminated open wounds, especially of the abdominal wall, underscores the considerable number of different methods that are in vogue. Infected abdominal wounds are usually treated by debridement, the administration of appropriate antibiotics and wound closure on a delayed basis. In the presence of a surgical implant, the latter is often partially or completely removed depending on the circumstances that led to its insertion. While healing often results, there remain a hard core of recalcitrant cases where multiple operations are necessary to heal the wound. Over 30 years ago a method was introduced to treat a variety of non-healing and infected wounds, namely the use of transposed muscles. Experience shows that this approach is either unknown or rejected by physicians treating patients with recalcitrant wounds and, at times, major ablations are performed. Introduced originally by a general surgeon, the procedure is better known by those engaged in plastic surgery. At our wound center, patients who have been unsuccessfully treated by multiple operations are regularly seen, which indicates that physicians need to be reminded of this proven, but perhaps forgotten, method of management. For this reason an illustrative case report is presented of a patient whose abdominal wall hernia was treated and which resulted in an infected non-healing wound that was successfully managed using a transposed rectus femoris muscle.     

Delayed primary closure in colon operations.

Secondary closure of incisions by tape is a simple, safe procedure. In a retrospective series of 179 contaminated surgical wounds (incisions for colon operations) delayed wound closure resulted in a lower incidence of wound infection (5.8%) than did primary closure of similar wounds (11.8%). Although wounds left open do become infected, the acute swelling and systemic signs typical of an infection in a closed wound never develop. Delayed closure facilitated wound healing in hospital: only 3.8% of patients thus treated left hospital with open wounds, but 9.5% of patients whose wounds were closed primarily left hospital with wounds that were partially or completely open.     

Reduction of infection rates in abdominal incisions by delayed wound closure techniques.

A low incidence of infection in abdominal wounds after contaminated, infected, and selected clean-contaminated operations was achieved after delayed wound closure of the skin and subcutaneous tissue. An effective method of delayed primary closure is described. Four days of open wound management with Xeroform gauze between the skin and subcutaneous tissue is followed on the 5th day be removal of the Xerform and skin approximation with Steri-Strips. Proper use of this technique is based upon appropriate assessment of wound contamination and infection risk factors. All contaminated and infected wounds are best managed with delayed primary closure and, when not possible, with healing by secondary intention. Delayed primary closure should be applied to clean-contaminated wounds if the patients are older than 60 years or have associated diabetes mellitus, malnutrition, or obesity.     

Continuous aspiration in prevention of postoperative wound suppuration

The aspiration method of preventing suppurations (after Redon) was used in 948 patients. After "pure" operations suppurations were found to appear in 0,8%, after "conventionally pure" operations in 1,3% and after operations associated with a considerable postoperative risk of a wound infection--in 17% of cases. The aspiration--irrigation method of preventing suppurations was used in 69 patients operated under conditions of a developing purulent process. Suppuration of the wounds was found to develop in 1,3% of cases.     

烧伤外科深度创面修复手术的疗效分析

目的总结烧伤外科深度创面修复手术的临床经验。方法对2006年1月~2013年12月间我科行深度创面修复手术的210例患者(共312处创面)临床资料进行分析。按创面病损因素分为热力烧伤组142处创面、特殊烧伤组(包括电烧伤、化学烧伤、热压伤)94处创面和非烧伤组(包括外伤、手术后创面及各种非烧伤的慢性难愈性创面)76处创面。根据手术时间分为早期手术组36处和非早期手术组276处,根据手术方式分为一期修复组263处和延期修复组49处,根据不同创面分为非难愈性创面组129处和难愈性创面组183处。比较各组间再手术率和创面愈合效果的差异。结果本组64处创面行缝合术,300处行皮片移植术,42处采用各种皮瓣修复,31处行异种皮覆盖术、负压持续吸引及清创术。其中125处创面手术为再手术,包括71处创面计划再手术和54处创面非计划再手术。特殊烧伤组非计划再手术率明显低于热力烧伤组和非烧伤组(P0.01),难愈性创面组的计划再手术率和非计划再手术率均明显高于非难愈性创面组(P0.01)。除5处缝合伤口经再手术7次愈合,余缝合伤口均正常愈合。皮片愈合优、良、差者分别为191、66和43处。皮瓣愈合优、良、差者分别为33、5和4处。早期手术组皮片愈合效果明显优于非早期手术组(P0.05),延期修复组皮片愈合明显优于一期修复组(P0.05),非难愈性创面组皮片愈合效果明显优于难愈性创面组(P0.01)。组间皮瓣愈合效果比较均无统计学差异(P0.05)。按病因分组后,仅热力烧伤患者非难愈性创面组皮片愈合明显优于难愈性创面组(P0.01)。结论合理选择皮片或皮瓣修复深度创面是取得治疗成功的重要环节,早期皮片手术、延期皮片手术和非难愈性创面皮片手术的疗效较好。积极开展非早期手术和一期修复手术,重视难愈性创面手术,可促进创面早日愈合。     

Ultrasonic cavitation and ozonization in treatment of patients with pyo-necrotic complications of diabetic foot syndrome

The main group consisted of 130 patients with pyo-necrotic complications of diabetic foot syndrome, in who after operations within the foot limits, there were ultrasonic cavitation and ozonization of the wound surface. The control group consisted of 90 patients who underwent operative treatment as well as a standard local treatment using the preparations with reference to the phase of the wound process. The use of low-frequency ultrasound allows in short-terms ablation of necrotized tissues within the limits of healthy tissues, decrease of microbial contamination of the wounds and preparing to closing. Ozonization of the wounds facilitates growth of the granulating tissues and prolongs the effect of decontamination of the wound surface. The application of physical methods in treatment of patients with pyo-necrotic complications of diabetic foot syndrome decreases the number of disabling operations.     

Wound Infection: Experience with 12,000 Sutured Surgical Wounds in a General Hospital over a Period of 11 years

Wound infection rates in a general hospital over an 11-year period have been studied, the review embracing over 12,000 sutured surgical wounds. There is a remarkably constant downward trend in the wound infection rate. This is considered real, as there has been no change in the method of recording. Changes in operating theatre technique have not individually influenced the rates or the trend. In particular, the use or non-use of surgical masks made no difference to the incidence of wound infection. Changes in scrub-up-technique and the introduction of air-conditioning in the operating rooms had no appreciable effect. There is a difference between wound infection rates of acute operations and elective operations, of “clean” operations and “dirty” operations. The possible sources of surgical wound infection are discussed. The classification into “inherent” and “sporadic” groups is offered, and in “sporadic” infections the role of the patient as a source of infection is considered.     

Management of radiated reoperative wounds of the cervicothoracic spine: the role of the trapezius turnover flap

Reoperation for malignant disease of the cervicothoracic spine can lead to compromised wound healing secondary to poor tissue quality from previous operations, heavily irradiated beds, and concomitant steroid therapy. Other complicating factors include exposed dura and spinal implants. Introducing well-vascularized soft tissue to obliterate dead space is critical to reliable wound healing. The purpose of this study was to determine the efficacy of the trapezius turnover flap in the management of these complex wounds. This study is a retrospective review of all patients undergoing trapezius muscle turnover flaps for closure of complex cervicothoracic wounds after spinal operations for metastatic or primary tumors. Six patients (3 male/3 female) were operated over an 18-month period (mean patient age, 43 years). Primary pathologies included radiation-induced peripheral nerve sheath tumor (N = 2), chondrosarcoma (N = 1), nonsmall-cell lung cancer (N = 1), paraganglioma (N = 1), and spindle cell sarcoma (N = 1). Trapezius muscle turnover flaps were unilateral and based on the transverse cervical artery in every patient. Indication for flap closure included inability to perform primary layered closure (N = 3), open wound with infection (N = 2), and exposed hardware (N = 1). All patients had previous operations of the cervicothoracic spine (mean, 5.8 months; range 2-9 months) for malignant disease and prior radiation therapy. Exposed dura was present in all patients, and 2 patients had dural repairs with bovine pericardial patches. Spinal stabilization hardware was present in 4 patients. All patients underwent perioperative treatment with systemic corticosteroids. All flaps survived, and primary wound healing was achieved in each patient. The only wound complication was a malignant pleural effusion communicating with the back wound, which was controlled with a closed suction drain. All wounds remained healed during the follow-up period. Four patients died from progression of disease within 10 months of surgery. The trapezius turnover flap has been used successfully when local tissue conditions prevent primary closure, or in the setting of open, infected wounds with exposed dura and hardware. The ease of flap elevation and minimal donor site morbidity make it a useful, single-stage reconstructive option in these difficult wounds.     

Prophylactic closed suction drainage of femoral wounds in patients undergoing vascular reconstruction

Prophylactic closed suction drainage has been advocated in a variety of surgical wounds, but its use in wounds involving vascular anastomoses has not been studied. Fifty patients undergoing lower extremity revascularization that required bilateral groin incisions were randomly assigned to have either the right or left side of the groin drained with a closed suction catheter. The contralateral wound was closed without drainage. Statistically there was no difference between wound closed with drains and undrained wounds in the occurrence of hematomas, seromas, lymphoceles, superficial infections, subcutaneous infections, or graft infections; although serious complications were more frequent in the drained wounds. Prophylactic closed suction drainage appears to offer no advantage over closure without drainage in wounds of the groin resulting from elective vascular operations.     

Plastic and reconstructive operations in purulent surgery and traumatology

The authors propose a complex surgical treatment of extensive purulent wounds and tissue defects based on radical debridement of the pyonecrotic focus, primary and early reconstructive operations. New views on operation "debridement of a purulent wound" were formulated: it is considered as an initial element of the reconstructive surgery. 597 patients with extensive purulent wounds and tissue defects underwent plastic and reconstructive operations with good and satisfactory results in 96.6% of the cases.     

后腹腔镜术后穿刺孔延迟愈合的处理（附25例报告）

目的：探讨后腹腔镜术后穿刺孔延迟愈合的处理措施。方法：回顾性分析2003年1月-2008年12月行后腹腔镜肾脏及肾上腺手术患者689例的临床资料：术后发生穿刺孔延迟愈合25例，占3．63％。其中单纯伤口闭合不良12例，腹壁窦道形成8例，后腹腔皮肤瘘形成5例。运用湿性愈合方法处理单纯伤口闭合不良；使用带侧孔探针注生理盐水冲洗腹壁窦道；采用生理盐水特制棉签擦洗后腹腔皮肤瘘。清创期窦道伤口使用条状美盐（mesalt），每天换药1次，连续使用1～5天，伤口分泌物减少，过渡到肉芽增生期，窦道深度小于3cm，根据渗出物的多少选择藻酸盐类或水胶体糊剂填塞伤口，换药间隔3～5天。1例后腹腔皮肤瘘伴脓肿患者采用封闭式负压引流（VAC）辅助伤口愈合，4～6天换药1次。结果：5～10天，单纯闭合不良伤口愈合；10～15天，腹壁窦道伤口愈合；20-32天，后腹腔皮肤瘘伤口愈合。结论：湿性愈合适用于后腹腔镜术后穿刺孔延迟愈合，尤其是深腔和窦道感染伤口，是需要填补缺损的延期愈合伤口的标准非手术愈合方式。正确地评估伤口，并根据评估结果准确选择伤口敷料可缩短炎症期，缩短伤口愈合时间。美盐有利于坏死组织溶解与吸收，促进伤口清创，缩短炎症期过程，加速伤口愈合。     

A method for covering the subcutaneous fat in the surgery of postoperative ventral hernias]

The authors suggested a method for covering the subcutaneous fat and tested it in 115 operations for postoperative ventral hernias. The method is based on vertical arrangement of gauze napkins covering one another in turn by one third. All of the operated on patients had no inflammatory complications of the postoperative wound. The authors claim this method to be among the elements preventing postoperative inflammatory complications of wounds.     

Cefamandole in gastroduodenal surgery: a controlled, prospective, randomized, double-blind study

Acceptance of the value of antibiotic prophylaxis in gastroduodenal surgery is growing, but only one controlled, double-blind study justifying this is available. In this second, controlled, randomized, double-blind study 60 patients underwent urgent and elective gastroduodenal operations. Among 32 patients receiving cefamandole perioperatively for prophylaxis, only 1 subsequently had a wound infection, but wound infections occurred in 8 of the 28 patients who received a placebo (P less than 0.01). Infection rates were higher in contaminated wounds and in urgent operations than in clean-contaminated wounds and elective surgery. The results confirm the value of antibiotic prophylaxis in this setting.     

Postoperative wound infection in pediatric surgical patients: a study of 676 infants and children

We conducted an epidemiologic study of postoperative wound infection in pediatric patients. Over a 14-month period, 676 patients who received an operative incision on the Pediatric Surgical service were entered. Demographic, nutritional, clinical, and laboratory data were collected. The patients were followed for development of postoperative wound infection. Cultures were taken from wounds to identify the offending organisms. Of the 676 patients, 137 were neonates, 197 infants, and 342 older children. Wound infection occurred in 17 patients (2.5%): 1 neonate (0.7%), 8 infants (4.1%), and 8 older children (2.3%). Infection rates according to wound classification were: clean 1.0%, clean-contaminated 2.9%, contaminated 7.9%, and dirty 6.3%. Heavily contaminated or dirty wounds were packed open in one third of cases, and allowed to heal by granulation. The largest group of wound infections followed operations on the gastrointestinal tract (10 patients, 267 operations, 3.7%). Staphylococcus aureus, Escherichia coli, and alpha hemolytic streptococcus were the most common wound pathogens. An increased rate of wound infection was associated with operative procedures longer than 1 hour, with the presence of an associated illness, and with emergency operations. Age, sex, nutritional status, and duration of preoperative hospital stay did not significantly alter the wound infection rate. It could be concluded that the incidence of wound infection was lower among pediatric surgical patients than the reported incidence in adult surgical patients. The greatest risk factors were those associated with local contamination of the surgical wound.     

Therapy of the pilonidal sinus--Primary wound closure or open wound after excision

The postoperative follow up of 177 operations in 162 patients with pilonidal sinus was investigated. After excision of the sinus a primary wound closure was performed in 80 cases; in 83 cases the wound was left open. After primary wound closure 40 % of the patients showed a primary healing of the wound. Although the remaining 60 % of the wounds healed secondarily the patients were not disabled longer and did not demonstrate more frequently recurrences than those with open wound management. As a consequence we recommend a primary wound closure after excision of a pilonidal sinus.     

Surgical wound infections. A 5-year prospective study of 20,193 wounds at the Minneapolis VA Medical Center.

This report describes a 5-year prospective study of postoperative wound sepsis utilizing a careful program of wound surveillance. Surgical wounds following 20,193 operations on all surgical services were surveyed by a trained nurse epidemiologist. Daily examination of wounds, culture of all suspicious wounds, and 30-day outpatient clinic follow-up were performed. Results were disseminated at monthly intervals to all involved surgeons and operating room personnel. Prospective and ongoing analysis of results facilitated identification and rectification of specific problem areas. Wound infection rates demonstrated a steady decline over the course of the study, overall rates dropping from 4.2% to 1.9% (p less than 0.05). This reduction in incidence of postoperative wound sepsis of 55% is estimated to have saved 2740 inhospital days and nearly $750,000.     

Risk of wound infections in trauma patients

Surgical incisions used to treat trauma wounds can be classified by risk of wound infection according to a modified system based on the NRC classification for surgical incisions. The wounds are classified by the amount of bacterial contamination and the time from injury to operative therapy as clean, clean-contaminated, and contaminated. The records of a total of 1,436 patients who had surgical therapy for traumatic wounds were reviewed. The infection rate for 331 clean wounds was 3.3 percent; for 855 clean-contaminated wounds, 10.5 percent; and for 250 contaminated wounds, 24.8 percent. These rates are similar to those seen with equivalent classes of elective operations.     

Experimental-clinical grounds for the treatment of granulating soft tissue wounds by the wound edge approximating stapler

Factors of risk of the appearance of wound complications were studied in experiment on a model of granulating wounds in 18 mongrel dogs. A traditional method (control group) and an apparatus method (main group) were used for suturing the wounds. In the main group of animals suturing the wounds was performed after bringing together the wound edges by specially designed devices. Morphological and microbiological investigations have shown that the leading role in the appearance of complications belongs to the morphological substrate of the wound with the main component including the degree of traumatizing the paravulnerable tissue with a suture thread when connecting the wound edges by a traditional method, ischemia of the paravulnerable tissues under conditions of microbial dissemination. The introduction of the developed method of closing the soft tissue granulating wounds into clinical practice resulted in a statistically significant reduction of pyo-inflammatory complications in the main group of patients. A conclusion is made on a more favorable course of the wound process when using the apparatus method of closing the wounds.     

Intraoperative antibiotic wound lavage: an attempt to eliminate postoperative infection in arterial and clean general surgical procedures.

Intraoperative antibiotic wound lavage has been used in all arterial reconstructive procedures for the past 7 years and reduced the incidence of early and late postoperative infections from 1.5% in 400 operations prior to 1969 to 0.23% (one post-hospital) in 434 patients operated since that date. In 226 consecutive clean major general surgical procedures since June 1971 there has been no early or late wound infections following intraoperative antibiotic wound lavage in contrast to an infection rate of 1.5% in 185 operations prior to that date. A double blind study of 200 patients undergoing operations for varicose veins was carried out as follows: The wounds of alternate patients were irrigated either with normal saline or with antibiotic solution. There were no gross (grade II) postoperative wound infections. Minor skin changes were noted in 93 of 632 incisions in the saline group and only 49 of 608 incisions irrigated with antibiotic solution (P less than 0.001). In clean operations without antibiotic wound lavage there was a 0.73% rate of in-hospital wound infections in 685 patients in contrast to a zero rate in 760 patients wherein intraoperative wound lavage was carried out throughout the operative procedure.     

Use of ultrasonics and antibiotics in the treatment of wounds in patients with high risk of infection of vascular transplants

The level of bacterial colonization of the operative wounds in performance of the reconstructive operations on the vessels equal to 10(3) bacteria in 1 g of tissue is critical for the development of suppuration. The use for treating the wounds of the low-frequency ultrasound and gentamycin solution in 17 patients permitted to reduce the critical level of bacterial wound colonization, and due to this, to decrease the incidence of the purulent-septic complications from 35.7 to 5.9%. In 14 patients after the operations for late reocclusion performed in presence of cicatrices of the tissues, there was no wound suppuration.