Primary Surgical Toilet of the

Wound
Treatment of the Wounds of the
Head
 Types of Wounds
•Volume of injury depends on type
of weapon or injuring agent and
properties of the lacerated tissue.
•In civilian life the injuries are the
result of the accidents or violence
and are due to fists, teeth, bottles,
sticks, bullets and bombs and even 1
surgical interventions.
•Therefore are distinguished
incised wounds, crush lacerations,
in which the skin has burst, stab
wounds, contusion lacerations,
bites, surgical wounds.
• The severest wounds with large
volume of injured tissues result
from the gun shot (1) and blast (2)
wounds.
22
 Zones of the Wound
•Several zones are distinguished
in each wound, they are the
follow:
1 – zone of tissue loss
(or missile tract, or primary
wound canal - 5)
2 – zone of primary traumatic
necrosis (1,2, 3)
3 – zone of secondary necrosis .
1.Free fragments of the bone
•Most of wounds are 2.Cavity
3.Spread of debris
contaminated with 4.Bone fragments with
microorganisms and contain preserved periosteum
5.Missile tract
foreign bodies too. 6.Separated periosteum
 Primary Wound Canal (Missile Tract)
•Primary wound canal is a defect of
tissue along a pathway of an injuring
agent (bullet, knife etc.).
•In modern agencies this zone can be
absent because it is filled with debris or
blood.
•Later its size diminishes because of
swelling and deviation of tissue.
•Size of the missile tract depends on
the type of injuring agent and on the
anatomic structure of the organs and
tissue.
•Then more high is the energy of the
agent, then more severe is an injury.
 Zone of Primary Traumatic Necrosis
•Walls of the missile tract are
formed by unviable tissue,
where all cells are destroyed,
fibers are torn and tissue is
filled with blood.
•There are some foreign
bodies and microorganism
among lacerated tissue too.
• This tissues around the
missile tract are said the zone
of primary traumatic necrosis
(1, 2, 3, 4).
 Zone of Secondary Necrosis
•This zone starts to form near the zone of
primary necrosis in a few hours.
•Viability of tissue in this area is different,
and morphological changes are lesser and
depend on the type of injuring agent and
functional processes in the tissue.
Thrombosis of the vessel in a
•The necrotic changes of the muscles and blast wound
parenchimatous organs develop in 4-6
hours, and in the skin and subcutaneous fat
they can be found in 12-15 hours, in the
bones necrosis appears in 2-3 days.
• Commonly there are loculi of necrotic
tissue only, not total necrosis.

Rupture of muscular fibers

 Zone of Secondary Necrosis
•Local swelling, compression of
the muscles, damage to regional
nerves and blood supply together
with central nervous system
disturbances and hypovolemia
influence to the wound formation
and healing.
•Therefore these changes can be
reversible in correct treatment,
but sometimes there can be tissue
death with secondary necrosis
formation, pus inflammation and
other complications which Wound after motorcycle fall 3 days
later debridement. Presence of
develop in the cases of severe necrotic tissue in the wound.
injuries or incorrect therapy.
 Properties of the Wounds of the Limbs
•Limbs occupy 61% of the human
body.
•Almost 70% of all wounds are the
wounds of the extremities.
• Injuries of the muscles are the
main type of tissue laceration
•Muscles are totally destroyed at
a distance of 10-15 mm from
primary wound canal and have
their functional changes on 30-40
mm from the missile tract.
•But there can be injuries of the
vessels and hematomas at a
larger distance which can
complicate healing of the wound.
 Properties of the Wounds of the Head and Neck
•Head and neck are about 12% Coup Injury
of the surface of the body and
are injured in about 20% of
cases.
•But mortality from these
wounds is about 50%.
•Position of the brain within the
Countercoup Injury
skull results in special local
laceration because of bullets
and bone fragments together
with back strike at a distance
(countercoup injury).
 Properties of the Wounds of the Body
•25% of the body belongs to the
chest and abdomen, and these
regions have about 15% of the
wounds which results in
mortality in 40% of patients.
•Wounds of the abdomen are
characterized by multiple
injuries of the parenchimatous
and gastrointestinal organs
which can be too far from the
place of an injury and of high
severity. Injury of parietal pleura
or parietal peritoneum results in •Open penetrating blast
penetrating wounds formation. wound of the chest
 Surgical toilet of the wound
is a surgical operation devoted to removal of nonviable tissue
and prevention or treatment of pus complications to provide
good healing.

Modern Doctrine about Wound Treatment

• All wounds are primary contaminated with microorganisms
• Early surgical toilet of the wound is the best method to prevent
development of wound infection
• The most patients with wounds need in early surgical toilet of
the wound
• Prognosis and result of treatment are the best after early
surgical procedure
• Volume of surgery depends on indications and potencies of
hospital (amount of patients, their condition, amount of
surgeons etc.)
 Types of the Surgical Toilet of the Wound

They depend on the time between the injury and surgery.

Surgical toilet of the wound

↙ ↘
primary secondary
- early (12-24 hours) because of the various
- delayed (24-48 hours) complications of wound
- late (48 hours later) healing (pus collections)
Indications to the Surgical Toilet of the Wound
•In 30-40% of cases of soft tissue
injuries toileting of the wound
contains only washing of the
skin and wound canal with
antiseptics, local antibiotics
application, drainage of the
wound with plastic tube, aseptic
dress, immobilization of the
extremity in the case of large
soft tissue or nerves injuries.
•Primary surgical toilet is
indicated to those patients who
have wounds with large zones of
primary and secondary necrosis
and potency of follow
development of pus collections.
 General Requirements to the Surgical Toilet of the
Wound
• Convenient position of the surgeon,
. good light and aseptic
• Get a good access to the injured segment of a body, therefore take
off clothes together with dressings and splints after anesthesia
• Close the wound with sterile gauze to avoid any contact of the wound
with antiseptic solution
• Carefully prepare and shave the skin of the whole limb
• All adjacent regions have to be visible
• Establish normal anatomic relationships between the segments of
the broken bones, muscles, vessels and nerves in the cases with large
shortening of the limb
• Apply tourniquets in necessity only to avoid possible injury of tissue
• Treat tissue carefully, or they will be less able to resist infection
• Change or scrub the instruments, gloves and napkins after each step
of operation
 Surgical Toilet of the Wound (Debridement).
Steps of the Operation.
• Surgical toilet of the wound consists of several steps,
they are:
1) surgical access is an incision through the wound, its
exploration and exposure all injured anatomic
formations;
2) surgical method includes
 foreign bodies removal
 dissection of all unviable tissue,
 repair of bones, nerves and vessels,
 closure and drainage of the wound,
 dressing and immobilization of the extremity.
 1. Surgical Access
•Wounds of the limbs are extended
with incisions parallel to the long axis
of the extremity to expose the entire
deep zone of injury and to preserve
integrity of the neurovascular bundles.
•The incision have to be long to
provide a wide opening of all pouches
of the wound.
•If there are many small wounds at a
short distances from each other
connect them into one incision.
•But deep wounds at a large distance
should be treated separately.
 1. Surgical Access
•At the flexion side of the joints,
the incisions are made obliquely
to the long axis in order to S-fashioned Incision
prevent the development of through the Joint
flexion contractures.
•Application of longitudinal
incisions, rather than transverse
ones, allows for proximal and
distal extension, as needed, for
more thorough visualization and
debridement.
 1. Surgical Access
•The deep fascia should be opened parallel Z-shaped fascial incision
to the muscular fibers in both directions.
•To the fascias of the forearm and calf
apply Z-shaped or U-shaped incisions
which provide good exposure of all tissue
and decompression of the muscles. These
incisions remove swelling and improve
microcirculation of lacerated tissue too.
•Check the wound to find all dead pouches U-shaped incision of the fascia
and join up all cavities so that they drain
readily.
•To explore the wound carefully it must be
opened widely to look into the depth.
 2.Surgical Method
Foreign bodies (bullet, pieces of
food, gravel, or clothing) should be
removed, and debris and clots must
be flush out with any sterile solution.
In the case of too deep position of
the foreign body or is too danger to
remove it (very close to the deep
structures of the brain, to large
vessels of the chest or to the heart)
leave it in place. It can be removed
later in special department by
specialist.
Start from one side of the wound.
Step by step remove unviable skin,
subcutaneous fat, fascia, muscular
fibers.
Change the gloves, napkins and
instruments or scrub them after each
step of debridement.
 Surgical Method: Dissection of Unviable Tissue
•For skin, a conservative excision of 1 to 2 mm of
damaged skin edges is performed. Excessive skin
excision is avoided; questionable areas can be
assessed at the next debridement.
•For fat, damaged contaminated fat should be
generally excised.
•For fascia, one must bear in mind that the
damage to the fascia is often minimal relative to
the magnitude of destruction beneath it.
Shredded, torn portions of fascia must be excised.
Complete fasciotomy is often required.
• Removal of dead muscle is important to prevent
infection. Accurate initial assessment of muscular
viability is difficult. Sharply excise all nonviable,
severely damaged, avascular muscle.
Questionable areas can be assessed later.
The “4 Cs” rule for muscular assessment: colour, contraction,
consistency, circulation. Healthy muscle is a nice bright red,
and has a good capillary ooze.
 2. Surgical Method. Dissection of Unviable
Tissue

• Close clean edge of the

wound with sterile napkin,
wash or change the gloves and
instruments.
• Repeat debridement on the
opposite side. The shape of
the wound should be oval or
fusiform after skin dissection.
• Control of bleeding.
• Look at the depth of the
wound. Check the bones,
nerves, tendons and vessels.
Cut nonviable ends only.
 2. Surgical Method.
Dissection of Nonviable Bones, Nerves and Tendons.

Bone fixation with osteosynthesis or any

other method
 2. Surgical Method. Control of Bleeding.
•Bleeding should start after cutting of
dead tissue. If it doesn’t, the surgeon have
not yet reached viable tissue.
•Most of bleeding will probably stop after
compression of tissue with gauze balls or
napkins.
•In severe bleeding tying of preliminary
applied tourniquet is necessary.
•Tie the larger artery with non absorbable
threads and the smaller vessels with fine
monofilament. Avoid catgut because it
makes a good culture medium and slips
off the vessel too easy.
•Several arteries can be tied safely, they
are smaller arteries below the elbow and
the knee, a.profunda femoris, a. iliaca
interna.
•Try to preserve blood flow with temporal
grafting or
•Repair the larger arteries with
autovenous transplants.
 2. Surgical Method. Drainage of the Wound.
•Pay your attention that all exposed or
repaired bones, tendons, arteries and
joints should be covered with adjacent
soft tissue to prevent desiccation.
Provide good hemostasis.
•Drainage of a wound or body cavity is
indicated when there is risk of blood or
serous fluid collection or when there is
pus or gross wound contamination.
•Type of applied drain depends on both
indication and availability. There are
follow types of drainage:
Passive with rubber tubes, surgical
gloves, gauze strips etc.;
Active suction;
Lavage with inflow and outflow of
solutions
 Drains
•Drains are classified as open or closed
and active or passive:
1) Closed drains do not allow the entry of
atmospheric air and require either suction
or differential pressure to function
2) Open drains allow atmospheric air
access to the wound or body cavity
3) Continuous suction drains with air
vents are open but active drains.
•Drains are not a substitute for good
hemostasis or for good surgical technique
and should not be left in place too long.
• They are usually left in place only until
the situation which indicated insertion is
resolved, there is no longer any fluid
drainage or the drain is not functioning.
• Leaving a non-functioning drain in place
unnecessarily exposes the patient to an
increased risk of infection.
 2. Surgical method. Wound closure.
•Traditionally all traumatic wounds,
including those created by fasciotomies,
are left opened for 48 hours; and primary
delayed suture should be applied on 4-7
days after wound toilet. Early secondary
suture can be applied on 8 -15 day.
•After this operation is over good external
fixation of the limb with splints is
necessary even if the bone is not injured.
•Primary sutures can be applied
• to the face and the skull
• to the neck
• to the perineal region,
because unsutured wounds can result in
 severe inflammation and wide
spreading of pus;
 formation of rough skin scars and
deformations of these regions.
 Increased Compartment Pressure

•It is an elevation of interstitial

pressure in closed fascial
compartment that results in
microvascular compromise; as
duration and magnitude of
interstitial pressure increase,
myoneural function is impaired and
necrosis of soft tissue eventually
develops.
•This necrosis may begin at
interstitial pressure as low as 30
mm of mercury therefore this
pressure has been suggested as
threshold at which diagnosis of
compartment syndrome should be
considered.
 Compartment Syndrome Is Commonly Caused by:
1. Tight casts or dressings
2. External limb compression
3. Burn
4. Fractures
5. Soft tissue crush injuries
6. Arterial injury.
The most common areas involved are the anterior and deep posterior
compartment of the leg and the volar forearm compartment. Other
areas include the thigh, the dorsal forearm, the foot, the dorsal hand
and, rarely, the buttocks.
Diagnostic physical findings include:
Pain out of proportion to the injury
Tense muscle compartments to palpation
Pain with passive stretch of the involved muscle
Decreased sensation
Weakness of the involved muscle groups
Pallor and decreased capillary refill (late finding)
Elevated compartment pressure (if measurement is possible).
 Compartment Syndrome
•If signs and symptoms persist, treat the acute
compartment syndrome with immediate surgical
decompression.
•Even short delays will increase the extent of irreversible
muscle necrosis so, if you suspect a compartment
syndrome, proceed with the decompression
immediately.
•Techniques for the leg
1 Use two full length incisions to decompress the leg
compartments.
2 Place one incision on the anterior lateral aspect of
the leg just anterior to the fibula. Divide skin and the
fascia surrounding the anterior and lateral
compartments.
3 Place the second incision 1–2 cm posterior to the
medial border of the tibia to access the superficial and
deep posterior compartments
 Wounds of the Head
•Traumatic brain injury (TBI) continues to be an
enormous public health problem. Almost all
patients with sever brain injury and as many as
two thirds of those with moderate head injury
will be permanently disabled and will not return
to the normal level of function.
•The annual incidence of TBI in the US has been
estimated to be 180-220 cases per 100,000
people.
• Approximately 600,000 new TBI is occurring per
year in the US with population of almost 300
million.
• The commonest reasons of traumatic brain
injuries are motor vehicle accidents, falls,
assaults, sport-related injuries, shot gun and
blast wounds.
•Male-to-female ratio is nearly 2:1. More
common in persons younger than 35 years old.
 Penetrating Wounds of the Head
•There are open and closed wounds
of the skull, or penetrating and non
penetrating wounds.
•Injury of the dura mater is a sign of
penetrating wound.
•Penetrating injury from any missile
such as a bullet has a mortality rate
of 92%. Thus, firearms cause the
most head injury-related deaths.
Perforating injuries have an even
worse prognosis. A 57-year-old male who suffered a
•Penetrating head trauma can cause motorcycle accident. He was not
loss of abilities controlled by parts of wearing a helmet. He suffered a severe
the brain that are damaged. abrasion with tissue loss through skin,
temporalis muscle, temporal bone, and
•Up to 50% of patients with dura. Note brain tissue exposed through
penetrating brain injuries get late- his wound. He was taken urgently to
onset post-traumatic epilepsy. surgery for debridement and
reconstruction using a rotational flap.
 Penetrating Injuries: Complications
Early complications:
•Infection
•Cerebral contusion
•Intracranial hemorrhage,
hematomas and ischemia
•Trauma to delicate brain
tissue due to increased
intracranial pressure because
of swelling or bleeding
•Compression of the brain and
death of the patient
Late complications: A brain after an "encircling"
Disability because of gunshot wound, showing the
pattern of injury caused by the
paresis, paralysis, coma, etc.; bullet's path
Late-onset epilepsy (up to
50%).
 Unpenetrating Wounds of the Head
•Injury without perforation of
the dura mater encephali is
said a nonpenetrating injury,
or closed head injury.
•Non penetrating wounds can The patient presented to the emergency
damage the soft tissue only or department with a golf club in his head. His
X-ray film. The club was removed in the
include the soft tissue injuries operating room.
together with fractures of the
skull bones.
•Prognosis in these types of
trauma is better, and various
complications are more rare.
 Surgical Treatment of the Wounds of the Head
•One of the most common urgent
operations upon the skull is a primary
surgical toilet of the wound.
•Surgical method differs from toileting of
other wounds because of anatomo-
physiological peculiarities of the skull and
the brain.
b
•Surgical treatment of head injuries should
focus on the following goals:
• Debridement of necrotic scalp, muscle,
dura and brain tissue
• Removal of driven in bone and bullet
fragments if they are easily accessible and c
can be removed without causing any
further neurological damage
• Evacuation of space-occupying
intracranial hematomas: Surgical treatment of a compound skull
• Repair of injured vessels fracture in a 10-year-old boy. b
• Meticulous hemostasis Intraoperative view showing three major
• Meticulous closure of the dura and the bone fragments. c Intraoperative view
scalp after replacement of the bone fragments
 1. Surgical Access: Peculiarities of the
Neurovascular Bundles of the Head
•Skin incisions for surgical toilet of
the wound of the skull should be
radial toward the top of the skull
(vertex), because blood vessels
and nerves pass in radial
direction.
•Excise unviable skin at a distance
about 3-5 mm from the margin of
the wound together with fatty
tissue and galea aponeurotica.
Fashion the wound in oval or
fusiform shape.
•Provide hemostasis.
 For Temporarily Control of Bleeding Are Used
•Tunica adventitia of the superficial vessels
is adherent to the fibrous strands and the
galea aponeurotica therefore even a small
wound of the soft tissue of the skull bleeds
furiously.
•There are many anastomoses between
superficial vessels of the skull, and between
these vessels and the arteries of the neck,
so compression of single artery
(a.temporalis superficialis) against the bone
is ineffective for control of bleeding.
•Follow methods of hemostasis are used:
1)soft tissue compression with fingers
against the skull bones around the wound
or
2) some special sutures through the
superficial layers, they are continuous
suture by Heidenhein (a) and interrupt
suture by Heidenhein-Hacker (b);
3) application of clips to the soft tissue.
Intraoperative view of a middle-aged male with an open
depressed skull fracture. Control of bleeding with clips.
 Definitive Control of Bleeding

1)Application of artery
forceps: pick up bleeding
vessel together with the
galea aponeurotica with
artery forceps and pack
them with thread.
2)For a smaller vessels a
diathermy can be applied.
 Primary Surgical Toilet of the Wound of the Head

Unviable parts of the pericranium

should be carefully incised.
Exploration of the bone:
if bone injury is absent, skin
incision must be closed with
sutures;
In the case of bone fracture small
bone fragments which are not
attached to the pericranium should
be removed.
 Nibble away all dead or sharp
bony edges and extend the wound
(bone resection, craniotomy).
 Primary Surgical Toilet of the Wound of the Head
Leave larger bone in
place, because it will act like
a graft.
Remove extradural
hematoma and check the
dura mater. Intraoperative view of a middle-aged male
with an open depressed skull fracture and
If the dura mater is intact surgical reconstruction repair of a complex
(presence of its pulsations), skull fracture
finish this procedure with
skin sutures.
Commonly this operation
is used in emergency (in
primary toilet of the
wound).
 Craniotomy (Trepanation of the Bone)

•If necessary (presence

symptoms of compression of
the brain or foreign bodies)
carry out craniotomy .
•Resection of the skull bone is
carried out through one or
more burr holes with its
follow enlargement with
nibblers.
•Opening of the bones of the
skull is said trepanation, or
craniotomy.
 Control of Bleeding from the Vv. Diploicae
• Bones of the skull have 3 layers:
lamina externa, diploë, lamina
interna in various correlations.
•Vv.diploicae run through the middle
layer of the bones. Adventitia of
these veins is attached to the bone,
so to stop bleeding from the
vv.diploicae apply a bone wax or close
the vein with some shifts at first and
apply a wax after that.
•Other methods of control of
bleeding are biological tampons from
the m.temoralis, application of
tampons with warm physiologic
solution or mixture of bone dusts
with blood clots.
• Or diathermy can be applied for
small vessels.
 Treatment of the Wounds of the Head
Remove intracranial hematoma
and provide hemostasis from its
vessels with diathermy or clips.
Check the dura mater
encephali.
In the case of the penetrating
wound (absence of pulsations,
presence of injury) open the
dura mater with crest or radial a- clips to
the vessel
incisions. of the dura
Excise unviable edges of the mater
б-
dura mater and provide careful diathermy
control of bleeding.
 Treatment of the Wounds of the Head

Open the brain.

Use physiologic solution to
flush small superficial foreign
bodies out of the brain.
Remove large pieces of the
bone from the brain with
forceps.
Provide control of bleeding
from the vessels with diathermy
or tampons.
 Removal of Superficial (a) and Deep (b) Foreign
Bodies and Debris from the Wound
Do not excise margins of the
brain, do not use probes and
fingers to find foreign bodies.
 Instead of this raise intracranial
pressure with compression of the
veins of the neck or ask your
patient to cough.
Swelling of the brain helps to
remove any debris or foreign
bodies by suction or warm saline
application.
If the toilet is complete close
the dura mater with sutures. They
are counterindicated in the shot
gun wounds because of edema
and swelling of the brain.
 Control of Bleeding from the Sinus Duralis

•Walls of the sinus are very thick,

rigid, have a large tone, but have not
any valves.
•Blood can flow into the sinus from
the veins of the brain together with
blood from the soft tissue of the
skull and diploic veins. So their
injuries result in severe venous
hemorrhage and air emboli.
•Injuries of the sinus duralis should
be addressed with adequate
exposure, allowing proximal and
distal control of the vessel.
 Control of Bleeding from the Sinus Duralis

To stop bleeding from the sinus 2. Plasty by Burdenko –

linear vascular suture (1) or Brunning.
application of patch (2) can be Divide the dura mater into two
used. planes and use flap from
1. Suture to the linear
wound superficial plane or fascia lata
or artificial material to the hole
of the in the sinus.
 Control of Bleeding from the Sinus Duralis
•Ligation of the anterior third
of the superior sagittal or a
non-dominant transverse
sinus is usually safe. Before
this tying it is necessary to
tie all veins which bring
blood to the sinus from the
depth and superficial tissues.
•Ligation of other sinuses can
result in edema of the brain,
encephalopathy and death.
•So extensive and highly
demanding microsurgical
repair may be necessary in
these cases.
 Control of Bleeding from the Sinuses Durales:
Compression with Tampon (a, b) or with Piece of
Muscle

a b
 Dress by Mickulich – Demmer to Finish Procedure
Severe edema of the brain with
postoperative leakage and
necessity to dry the wound many
times per day results in application
of special dressing.
Circumpherential dress by
Mickulich-Demmer is indicated to
protect the brain in postoperative
period. Put cotton napkin to the
wound of the brain. It will stay in
place till the end of leakage. Close
craniotomic opening with
numerous gauze balls and second
napkin. Change these balls with
superficial napkin when they
become wet.