Appropriate surgical wound and incision management in the post-operative time period is imperative to prevent complications, including surgical site infection and wound dehiscence. The tenets of modern wound management are applicable to primarily closed incisions, as well as to subacute and chronic wounds. Preventing incisional infection by appropriate cleansing, skin care, and moisture management is a requisite part of the post-operative plan of care. A cursory knowledge of the phases of wound healing and healing by intention will assist with understanding the rationale and importance of post-operative surgical wound and incision management.

Wound Healing Phases

Regardless of etiology, all wounds will progress through the phases of hemostasis, inflammation, proliferation, and remodeling. Hemostasis follows the initial insult and can take seconds to minutes to hours; it includes platelet aggregation and leukocyte migration. Inflammation occurs over hours to days (in uncomplicated wounds) and includes phagocytosis for removal of foreign material and pathogens; it also produces tissue edema from platelet degranulation and mast cell or histamine responses. Proliferation lasts from days to weeks, where collagen is synthesized by fibroblasts to form granulation tissue along with angiogenesis. Remodeling can last from weeks to months, even years; extracellular matrix is remodeled, and wound tensile strength increases.

Healing by Intention

Primary Intention: Often referred to as “primary closure,” healing by primary intention involves closure and approximation of an incision with the goal of complete functional healing. Most surgically-created wounds are approximated and closed primarily using sutures, staples, adhesive tapes, or skin adhesives. As a result of the edema produced during the inflammatory phase of wound healing, it is during this stage when external methods of wound closure are needed to provide tissue support until adequate healing has taken place and tensile strength begins to develop.

Secondary Intention: Wounds may be left open to heal with potential plans for staged closure with grafts or other advanced therapies. Examples would include wounds with high bacterial burden such as infected chronic ulcerations or abdominal incisions made in procedures with contamination from gross fecal or purulent material. This sequence of events is intended to minimize complications with the wound and provide the most expeditious healing route for the given scenario.

Tertiary Intention: This includes staged closure of wounds of varying etiologies that are surgically created or otherwise, involving a period of debridement and surveillance to ensure the tissue is viable before final closure or other procedures such as muscle flaps.

Topical Management of Surgical Wounds

All surgical wounds require a moist environment to support healing. If a dressing change is required within the first 48 hours post-operatively, aseptic technique should be strictly followed. Cleansing of surgical incisions is performed for removal of debris, pathogens, and exudate; it should be done with appropriate pressure utilizing a safe agent to avoid cytotoxicity (e.g., normal saline) or mechanical trauma (do not exceed 15 psi). Typically, initial surgical dressings are to remain in place for 48–72 hours, and some stay in place for up to seven days. Around post-operation day three, the superficial epidermis of a primarily closed incision line may appear “sealed.” Although the tissue layers are not completely healed and are not able to withstand external forces at this time, the epidermis is the first to resurface, or restratify, to begin to form a barrier to pathogens and contaminants.

Dressings applied to primarily closed surgical incisions should demonstrate an ability to protect the wound from contaminants and trauma, manage exudate, and avoid excessive pressure to the incision line.¹ The timeframe for staple or suture removal is generally in the one- to two-week range and depends on a multitude of factors, including anatomic location, involvement of deeper tissue structures, or areas involving areas of joint flexion or extension. In areas where cosmetic concerns are important, such as near the face or eyes, sutures may require early removal to prevent scarring (three to five days). Patients should be counseled to avoid sun exposure in the area, and they may shower once the suture line is epithelialized and no exudate is appreciated.

Post-Operative Incisional Pain Management

Opioid narcotics continue to be the mainstays of post-operative pain management, and combining them with non-steroidal anti-inflammatory drugs (NSAIDs) can significantly reduce the required dosage of opioids for adequate pain relief. This can serve to reduce the deleterious side effects of opioids, including altered mental status, urinary retention, respiratory depression, and constipation, among others.² Complete initial post-operative pain assessment should be comprehensive and include any contraindications for specific methods of pain relief (NSAID allergy, aversion to smells, allergy to specific dressings, cleansers, tapes, etc.). Anxiety related to pain, post-operative mobilization and activities of daily living, and often limited recovery time before return to work can actually increase perceived pain. Tailoring interventions to patient-specific needs such as allowing the patient to assist with care when possible, utilizing non-adherent dressing when possible, warming the wound cleansing solution, and positioning the patient for comfort during dressing changes can decrease reported incision-related pain.³

The patient’s input regarding preferred or desired interventions is crucial for success, and such interventions should always be utilized when feasible. Distractive measures should not be discounted in the post-operative plan of care for pain management; music therapy can reduce anxiety, reported pain, and opioid use. Frequent reassessments to the pain management plan should be conducted, guided by the type of pain, the patient’s other comorbid conditions, and the care setting.³

Conclusion

Key considerations in post-operative wound management include the following: knowledge of wound healing phases; an understanding of whether a surgical wound is healing by primary, secondary, or tertiary intention; topical wound management; and post-operative management of incisional pain. Careful attention to these aspects of wound care will help to optimize clinical outcomes for post-surgical patients.

References

1. Bryant RA, Nix DP . Acute & Chronic Wounds: Current Management Concepts. 5th ed. St. Louis, MO: Elsevier; 2016.

2. Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal Surg. 2013;26(3):191–6.

3. National Institute for Health and Clinical Excellence (NICE). Surgical site infection: evidence update June 2013. www.nice.org.uk/guidance/cg74/evidence/ evidence-update-241969645. Accessed September 11, 2018.