Manejo Quirurgico Conservativo de Heridas

Complex wound management can be a very long and arduous venture and with persistence the reward is ultimately there. Most owners and a lot of us tend to underestimate the time and cost involved in caring for challenging wounds. Whether you are a general practitioner or a specialized surgeon, a solid foundation in wound management is essential in helping you manage challenging cases and make the right surgical decisions. A basic understanding of the phases of wound healing is critical to managing complex wounds. Wounds could be managed in multiple ways and in most circumstances all methods will lead to the same end goal of healing; however, without a proper understanding of wound healing, the patient, and the available products, the veterinarian may impair the healing process. Many complex wounds will require initial management followed by surgical repair.

When the veterinarian encounters a wound, he or she must decide if the wound can heal without intervention, if it should be left open, or if it should be surgically closed. Depending on the cause of the wound, empirical antibiotic therapy may be indicated. Wounds should be carefully examined to ensure there is no penetration into deeper cavities or organs that may result in a life-threatening scenario.

Wounds are generally managed open when there is gross contamination, foreign material that cannot be removed readily, there is severely damaged tissue, or a significant loss of soft tissues. If there is questionable viability to the edges of a wound or there is concern for ongoing necrosis, then wound closure should be delayed until lines of demarcation are evident, or in other words, declared themselves. Typical wounds will benefit from irrigation. Isotonic solutions are generally recommended as they are least likely to be cytotoxic. Irrigation solutions that will definitely cause cytotoxicity that you might still see in use include hydrogen peroxide, Dakin's solution, acetic acid, and tap water. The pressure at which tissues are irrigated may matter and some will recommend using a 35-ml syringe with an 18-gauge needle, which will generate approximately 7–8 PSI. The advantage to doing this is that you still remove debris, but you are less likely to embed bacteria deeper into the tissues. The use of sponges to scrub wounds is not recommended as that may more readily cause damage. Some wounds are excessively contaminated and/or damaged such that surgical debridement is a more logical approach. This has the added advantage of allowing the surgeon to readily evaluate the viability of the tissues. It should be noted that the extent of necrosis may not be immediately present and multiple debridements may be necessary.

The primary layer of the bandage is determined by what you are trying to achieve (debriding/adherent vs. non-adherent). The ideal bandage will maintain a moist wound environment to allow for a selective autolytic environment. It will also allow for effective gas exchange, be comfortable to patients, and require infrequent bandage changes. Below are tables of commonly used dressings and ointments.

Table of commonly used non-adherent dressings

Table of commonly used wound care products

Wet-to-dry bandages are increasingly discouraged, and some consider these contraindicated as they also result in debridement of cells you want to remain in the wound. Tie-over bandages may be very beneficial when stretching of skin is desired for ultimate closure. The exudative nature and the stage of wound healing will ultimately dictate the appropriate layer that should be placed to maximize wound healing and minimize any delays or onset of infection. Vacuum-assisted closure (VAC) has been shown to be highly beneficial in helping chronic wounds heal or large wounds get to a state that allow for surgical closure. The main disadvantages of VACs include the cost and equipment necessary to use these devices. That said, it is recommended that any high-volume practice with a regular caseload of complex wounds consider the integration of VAC into their wound care regimen.