Wound Management

wound managementSome of the recent discussion on wound management caused me to jot down a few of my believes on the subject. There is too little science about this, or I fail to appreciate it.

I have twice been to the european wound management conferences. Everything that is marketed for wound management was on display. Also, there are many wound healing clinics around the world, in UK, US, and Australia just to mention the lead countries. I heard that wound dressing for chronic or failed wounds cost a billion pound sterling in UK only, per year ( it sounds like a lot of money and I may be wrong). Is it the wound that cost all this money, or is it the traditions to treat them that cost? How come we have hundreds of ways of treating open wounds and nobody has an answer to if one way is better than another. The wound management practices is probably the worst of all in surgery. It is remarkable how well wounds healed despite all things surgeons did to prevent it.

Was I too hard on that? Well. I was once sent an article to review for a journal. The authors had randomly compared open versus closed wound management after excision of a pilonidal cyst. There was no difference. What they had done was either packing wounds or suturing wounds. And the conclusion, which the authors did not make: Whether wound margins were held together (with suture) or kept apart (with gauze ) the healing rate was the same. So, what are we talking about in surgical wound management?

Today I saw a patient referred to me for a recurrent anal fistula. She had an abscess incised in January, but it turned out to be a high anal fistula which was operated in May. The wound never heald and she still has a fistula. I asked this lady how many times during this period she had been to dressing sessions at the doctor=B4s or the nurse. It was more than a hundred times, and twice in general anethesia. She was so deadly tired with it because all her routine life had to be adjusted to the dressing sessions. And dressing changes had been very painful at times. This is outright crazy, but it is common.

I see a number of anal fistula referred to me and for the last decade dressing sessions have been abolished. I don’t even schedule patients for return visits. They go home with at times big open wounds the day after the operation. I tell them there should be no pain at all (some tenderness is acceptable) and the wound will take from 6 to 12 weeks to heal during which time they take showers and wear a pad, the sort women use and buy in the nearest store. If there is pain they call, or if the wound has not healed after three months. There is no pain, there are no dressing sessions, and no intereference with patients regular life. Wounds do not do any better but the part that cost time, money and discomfort, i.e. the doctors and the nurses have been deleted.

Before me on the table is the recent book on Anal fistula by Robin Phillips and Peter Lunniss (editors): I just give you the kind of wound management for fistula that is done in two hospitals in London. London Free: The wound is lightly packed and this must be replaced under adequate analgesia. Antibiotic cover is continued for at least 5 days and the wound is inspected under general anaesthetic on at least one occasion after about ten days. Patients are discharged when there is sufficient fibrosis to prevent premature closure of the skin wound. And from St Mark’s : The patient is admitted to hospital one day before operation. …it allows the patient to become familiar with the surroundings where he or she might spend the next 3 weeks. It allows time for a detailed explanation of the postoperative course. The way the wound will be dressed is explained at length.

I believe in delayed primary closure of war wounds and some traumatic wounds. I leave wounds open that are under tension if closed. I close most other wounds with a loose running skin suture. Some blood and secretions may drain between sutures if it is loose enough. I reclose infected wounds that have been drained. I disbelieve almost all wound management. I cut down dressing sessions to a minimum and use only dry gauze layered on top. Never pack. Tap water and soap is unsurpassed. I believe in patients who manage wounds on their own because doctors are dangerous and expensive. I believe there are two types of wounds: those inflicted in normal potentially healing tissue, and those in abnormal non-healing tissue. Those former are most common and heal whatever we do, so do nothing. The management of the latter is a speciality in its own right. Refer to someone who knows what to do.

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