Ok , an MD graduate here. I am studying for the board exam in my country, though this lecture seems advanced for my level, it was helpful. Correct me if I am wrong, but I really want to learn this stuff. This is my conclusion after reading about this from multiple sources. Primary intention - For clean wounds, surgical wound, lacerations if wound edges can be approximated. Secondary intention - Same as above but patient presents too late - Contaminated wounds - Pressure sores - Diabetic ulcers - Full thickness burns - Bites most of the time unless you can get to them quickly. Delayed primary - It is a contaminated open wound that is really big, and it would take a long time to heal if we go with secondary intention.
Currently healing from a Secondary Intention closure due to perforated diverticulitis, finishing up on my first month. It is quite cumbersome but lucky me I work from home so it didn't upend my life.
I had surgery to my right armpit due to hidradenitis. It got infected and the surgeon prescribed ABT keflex x10 days. I finished the course of ABT, but I have tiny amounts of pus still. The incision is slowly closing. Any advice?
I’m a plastic surgeon and I’m watching this and saying , hmmm, hmmm, hmmm. As plastic surgeons we do delayed closure all the time. Understanding the vascularity of the tissue, and tension required to close. The wound are generally far more important variables than the number of hours or days. Paragraph gross contamination should be irrigated and non-viable tissues always removed before attempting to close. You can definitely partially open at closure that was repaired with a running suture. mark out the section you want to open and place a tide suture at the edges where the incision should be opened. Leave a long tail on each of those sutures. Next cut the running suture in the center and unwrap the suture material until you get to the knot you previously tied, then secure, the previously run suture to the stitch you just put in. Sorry to be nit picking. I don’t like dogmatic thinking in medicine. If there is one single thing to add is don’t close your incisions under tension. The tissue is going to swell and if your closure is tight your going to get tissue ischemia and this is what caused most wound post op wound infections. In contaminated wounds put even less tension on the incision so bacteria and fluid can find its way out. Considering putting drains or packing between each suture (to be removed in 1-2 days) and irrigate between the sutures after the closure if indicated. Instead of trying to remember the rule of not closing a would after so many hours or days use your brain to think about what makes sense. Iscemia from tight sutures is happens too often and is avoidable. Wound edges need blood supply to heal. Was this talk directed at medical students? I loved doing my pediatric surgery rotations. I got to be part of doing some fascinating surgery. I have nothing but respect for “pediatric surgeons” that specialty is a bit like special forces like Navy Seals in the military. Be well Mats H
Yeah it seems the wound after plastic surgery take long to heal. May I ask ..how to heal chronic wound then? What do you do with hypergranulation wound?
Could you elaborate on the way you do delayed primary closure with a contaminated abdominal incision sir? Do you close the fascia layer first and then put sutures through the skin layer, leave the skin sutures there, put the system, comeback after 48-72 hours, and tight the skin suture? Do I get it the right way? Anyway, interesting video sir, thank you.
When I do a delayed primary closure I close the fascial layer and leave the subcutaneous/adipose layer open, usually with a wound VAC or vacuum assisted closure divice. At the original operation I'll put the sutures in that I want to tie down 48-72 Horus later, usually a 3-0 nylon suture if it's the abdominal midline in an adult. You've got it right!
When a would is failing to close the first question should always be why? Failure of normal wounds to close can usually be explained. Reasons can include lack of arterial inflow. Venous hypertension, contamination, devitalized or necrotic tissue needing debridement, neoplastic growth or others. Number one in getting a would to heal is getting the would clean. This is most often accomplished with increased frequency of dressing changes and avoiding non stick dressing that do not aid in debridement. Almost all wounds should heal under normal circumstances. If they don’t then ask yourself what’s different and try to address the underlying cause of retardation in the healing process.
This was very interesting to me! In particular the part about delayed closure. Wondering how often or if you ever have a wound that is not closed at all? As a child I had an abscess in the muscle of my lower leg that required surgery. Due to the infection, the wound was never closed at all and it took a good long while to heal. I can relate to the comment about scarring. It left a horrid scar!
Thanks Nora! The body is fascinating for sure. There are some wounds that become chronic and do not close, for these wounds we need to consider all of the reasons they are not closing. Infected? Foreign body? Biofilm? We optimize the wound and if it won't close on it's own sometimes we need to place a skin graft or some other coverage.
@@citizensurgeonWell thankfully mine eventually healed on its own. - ‘secondary intention’ It did take several weeks. Probably now they would do something to help it along once the infection was gone! All in the past thank goodness!
@@citizensurgeon Doctor, I am having a difficult case for contradictory opinions, a patient had a dehiscent LSCS from skin to fascia 16 weeks ago, it got infected 4 times with Pseudomonas aeruginosa, Staphylococcus aureus, so far, the wound is healing well by secondary intention after the infections were treated, from a 12cm incision, now there is only 3.8cm open wound, is shallow. There was a lot of tension in the wound at the beginning of the treatment. Is 16 weeks since admission, one doctor wants to discharge the patient home for ambulatory dressings and the other wants to close the wound with stitches? what would you recommend? 16 weeks is not a bad time, but the wound has healed slowly in the last two months ago. It is better to continue with healing by second intention? the stitches are going to make a difference or are going to complicate the wound? is this a case where a skin graft should be considered? Or can steri-strips be used along with dressing with Med honey or algisite? Thanks in advance.
Non infected nickel sized wound top of foot after TMA been using Santyl > daily change, tissue is healthy n pink , close to surface but edges not closing or taking long... Wound Vac?
While I can’t give medical advice I would think about the process…why the TMA? If because of poor vascular flow than blood supply is an issue in healing, a wound vac may help, may also need a flap or graft of some type, make sure to rule out any of the impediments
Wanted to give you heads up 10:16-10:35. You forgot to edit in the images your describing 😅 😊otherwise fabulous video and thank you for sharing what you have anyway
Thank you for engaging, check out this article on sacral decubitus ulcers and Medihoney gauze, I think you may find it helpful! www.nature.com/articles/sc201187
So I had a biliary drain the bulb time in my right rib cage for sn alledged gallstone that was never actually seen on radar but they said it was likely gallstones that was giving me the abdominal pain but that only happened one time never had a problem with anything concerning that ever again and that was a year ago... The last drain fell out in my sleep I must have snagged it when I rolled over or whatever and it was laying on the floor and the hole on my side 4 months later keeping it clean and religiously changing it twice a day this thing is still leaking out this clearest maybe a tinge of very light yellow slimy odorless liquid ... The VA has been sending me this gauze strips that you're supposed to stuff a wound with, boxes of wooden q-tips and gauze and miles of tape so I keep it clean change it twice a day and this s*** is driving me nuts. I mean, this thing should have healed by now I'm thinking but I had this drain in my side for almost 5 months and I think it was maybe too long and you know swinging around and hanging around and stuff like that maybe made that hole bigger than it normally would be but how do I get this thing to stop or turn off the faucet or what do I need to facilitate
While I can’t give medical advice on a channel like this the thing that comes to mind is a small fistula or communication between your gallbladder and skin. Sometimes when we have drains in for a long time a channel can form. If this tract forms it usually will not close on its own with dressing changes. Of course there are a lot of reasons a wound may not heal, I would definitely get this checked out by a surgeon.
@@citizensurgeon yeah I'm probably going to go to the ER over at Audie Murphy here in San Antonio that's the VA hospital here and have them take a look at it. I get red carpet treatment over there because the misdiagnosed me with congestive heart failure and put me on 11 different medications when I didn't need them and now I'm all screwed up.... smh... it is what it... thank you Doctor
Geared toward students and surgical residents but I think there is some value for everyone to understand the decision making process with wound closure. No?
Ok , an MD graduate here. I am studying for the board exam in my country, though this lecture seems advanced for my level, it was helpful. Correct me if I am wrong, but I really want to learn this stuff. This is my conclusion after reading about this from multiple sources.
Primary intention
- For clean wounds, surgical wound, lacerations if wound edges can be approximated.
Secondary intention
- Same as above but patient presents too late
- Contaminated wounds
- Pressure sores
- Diabetic ulcers
- Full thickness burns
- Bites most of the time unless you can get to them quickly.
Delayed primary
- It is a contaminated open wound that is really big, and it would take a long time to heal if we go with secondary intention.
Absolutely got it, nice work, now go crush those exams
Been waiting for this. Always delivering gems
Thank you Walter! More gems on the way!
Currently healing from a Secondary Intention closure due to perforated diverticulitis, finishing up on my first month. It is quite cumbersome but lucky me I work from home so it didn't upend my life.
I had surgery to my right armpit due to hidradenitis. It got infected and the surgeon prescribed ABT keflex x10 days. I finished the course of ABT, but I have tiny amounts of pus still. The incision is slowly closing. Any advice?
I’m a plastic surgeon and I’m watching this and saying , hmmm, hmmm, hmmm. As plastic surgeons we do delayed closure all the time. Understanding the vascularity of the tissue, and tension required to close. The wound are generally far more important variables than the number of hours or days. Paragraph gross contamination should be irrigated and non-viable tissues always removed before attempting to close.
You can definitely partially open at closure that was repaired with a running suture.
mark out the section you want to open and place a tide suture at the edges where the incision should be opened. Leave a long tail on each of those sutures.
Next cut the running suture in the center and unwrap the suture material until you get to the knot you previously tied, then secure, the previously run suture to the stitch you just put in. Sorry to be nit picking. I don’t like dogmatic thinking in medicine.
If there is one single thing to add is don’t close your incisions under tension. The tissue is going to swell and if your closure is tight your going to get tissue ischemia and this is what caused most wound post op wound infections. In contaminated wounds put even less tension on the incision so bacteria and fluid can find its way out. Considering putting drains or packing between each suture (to be removed in 1-2 days) and irrigate between the sutures after the closure if indicated.
Instead of trying to remember the rule of not closing a would after so many hours or days use your brain to think about what makes sense. Iscemia from tight sutures is happens too often and is avoidable. Wound edges need blood supply to heal.
Was this talk directed at medical students? I loved doing my pediatric surgery rotations. I got to be part of doing some fascinating surgery. I have nothing but respect for “pediatric surgeons” that specialty is a bit like special forces like Navy Seals in the military.
Be well
Mats H
Yeah it seems the wound after plastic surgery take long to heal. May I ask ..how to heal chronic wound then? What do you do with hypergranulation wound?
Sir. Oh my. This was brilliant. Thank you
Awesome! So pumped you enjoyed it!
Excellent video, explained very well !
Could you elaborate on the way you do delayed primary closure with a contaminated abdominal incision sir?
Do you close the fascia layer first and then put sutures through the skin layer, leave the skin sutures there, put the system, comeback after 48-72 hours, and tight the skin suture?
Do I get it the right way?
Anyway, interesting video sir, thank you.
When I do a delayed primary closure I close the fascial layer and leave the subcutaneous/adipose layer open, usually with a wound VAC or vacuum assisted closure divice. At the original operation I'll put the sutures in that I want to tie down 48-72 Horus later, usually a 3-0 nylon suture if it's the abdominal midline in an adult. You've got it right!
Should i remove mepitel one or swap it for another one, and is it necessary to keep puting the bandages the full 10 days duration?
When a would is failing to close the first question should always be why? Failure of normal wounds to close can usually be explained. Reasons can include lack of arterial inflow. Venous hypertension, contamination, devitalized or necrotic tissue needing debridement, neoplastic growth or others.
Number one in getting a would to heal is getting the would clean. This is most often accomplished with increased frequency of dressing changes and avoiding non stick dressing that do not aid in debridement.
Almost all wounds should heal under normal circumstances. If they don’t then ask yourself what’s different and try to address the underlying cause of retardation in the healing process.
I have a lower leg ulcer any help would be appreciated on which wound cover would be the best thank you
This was very interesting to me! In particular the part about delayed closure. Wondering how often or if you ever have a wound that is not closed at all? As a child I had an abscess in the muscle of my lower leg that required surgery. Due to the infection, the wound was never closed at all and it took a good long while to heal. I can relate to the comment about scarring. It left a horrid scar!
Thanks Nora! The body is fascinating for sure. There are some wounds that become chronic and do not close, for these wounds we need to consider all of the reasons they are not closing. Infected? Foreign body? Biofilm? We optimize the wound and if it won't close on it's own sometimes we need to place a skin graft or some other coverage.
@@citizensurgeonWell thankfully mine eventually healed on its own. - ‘secondary intention’ It did take several weeks. Probably now they would do something to help it along once the infection was gone! All in the past thank goodness!
@@citizensurgeon Doctor, I am having a difficult case for contradictory opinions, a patient had a dehiscent LSCS from skin to fascia 16 weeks ago, it got infected 4 times with Pseudomonas aeruginosa, Staphylococcus aureus, so far, the wound is healing well by secondary intention after the infections were treated, from a 12cm incision, now there is only 3.8cm open wound, is shallow. There was a lot of tension in the wound at the beginning of the treatment. Is 16 weeks since admission, one doctor wants to discharge the patient home for ambulatory dressings and the other wants to close the wound with stitches? what would you recommend? 16 weeks is not a bad time, but the wound has healed slowly in the last two months ago. It is better to continue with healing by second intention? the stitches are going to make a difference or are going to complicate the wound? is this a case where a skin graft should be considered? Or can steri-strips be used along with dressing with Med honey or algisite? Thanks in advance.
How can we heal the laceration wound if coin sized on a groin area or balls area?
How do you treat hypergranulated wound?
Which ointment is best for leg ulcer
Non infected nickel sized wound top of foot after TMA been using Santyl > daily change, tissue is healthy n pink , close to surface but edges not closing or taking long...
Wound Vac?
While I can’t give medical advice I would think about the process…why the TMA? If because of poor vascular flow than blood supply is an issue in healing, a wound vac may help, may also need a flap or graft of some type, make sure to rule out any of the impediments
How to dresses an open sickle cells wound.please help
Thanks Doc
Absolutwly
thanks man !
❤Brilliant thank you
You are welcome!!!
Good work thx
Thanks so much I appreciate your support!
Wanted to give you heads up 10:16-10:35. You forgot to edit in the images your describing 😅
😊otherwise fabulous video and thank you for sharing what you have anyway
Dang I know! I’ve learned so much from the parts I’ve messed up! Thank you!
How do i use Medihoney gauze on type 4 bedsores?
Thank you for engaging, check out this article on sacral decubitus ulcers and Medihoney gauze, I think you may find it helpful!
www.nature.com/articles/sc201187
@@citizensurgeon thank you.
Is there any information on honey effects on toes instead of have a toe amputation?
So I had a biliary drain the bulb time in my right rib cage for sn alledged gallstone that was never actually seen on radar but they said it was likely gallstones that was giving me the abdominal pain but that only happened one time never had a problem with anything concerning that ever again and that was a year ago... The last drain fell out in my sleep I must have snagged it when I rolled over or whatever and it was laying on the floor and the hole on my side 4 months later keeping it clean and religiously changing it twice a day this thing is still leaking out this clearest maybe a tinge of very light yellow slimy odorless liquid ... The VA has been sending me this gauze strips that you're supposed to stuff a wound with, boxes of wooden q-tips and gauze and miles of tape so I keep it clean change it twice a day and this s*** is driving me nuts. I mean, this thing should have healed by now I'm thinking but I had this drain in my side for almost 5 months and I think it was maybe too long and you know swinging around and hanging around and stuff like that maybe made that hole bigger than it normally would be but how do I get this thing to stop or turn off the faucet or what do I need to facilitate
Thank you very much for your time and reading my dissertation I wrote lol .. sorry for being long winded
While I can’t give medical advice on a channel like this the thing that comes to mind is a small fistula or communication between your gallbladder and skin. Sometimes when we have drains in for a long time a channel can form. If this tract forms it usually will not close on its own with dressing changes. Of course there are a lot of reasons a wound may not heal, I would definitely get this checked out by a surgeon.
@@citizensurgeon yeah I'm probably going to go to the ER over at Audie Murphy here in San Antonio that's the VA hospital here and have them take a look at it. I get red carpet treatment over there because the misdiagnosed me with congestive heart failure and put me on 11 different medications when I didn't need them and now I'm all screwed up.... smh... it is what it... thank you Doctor
Large ulcers and bedsore
How anal fistula heal ? How long does it take ?
This might hurt😢
Ha, healing can hurt someone’s…if you’re talking about delayed primary closure yes it can be painful
@@citizensurgeon I'm really mad, he could have taken care of this property before it got this bad. Morton Neuroma surgery in Oct and hasn't heal
I’m sorry to hear that and I hope you heal up and recover soon
Remember: this is not medical advice! 0:23
Yes indeed. Not medical advice but education and knowledge is important :)
This video is not for a laymen
Geared toward students and surgical residents but I think there is some value for everyone to understand the decision making process with wound closure. No?
@@citizensurgeon I want to join your telegram channel to get book
👏👏👏👍👍👍👊👊👊
Glad you enjoyed!🙏