1 Wounds, ulcers, fistulae & cysts

wounds 2

3  Mechanism of injury  Traumatic wounds Sharp, penetrating Sharp, penetrating Blunt Blunt Bullet Bullet  Surgical wounds

4 Types of wounds Cut wounds incised Cut wounds incised Lacerated wounds Lacerated wounds Crushed wounds Crushed wounds Wounds with skin loss Wounds with skin loss

5 Types of Suturing Primary suturing Primary suturing Excision and primary suturing Excision and primary suturing Delayed primary suturing Delayed primary suturing Secondary suturing Secondary suturing Skin grafting Skin grafting

6 Elements of Wound Healing 1- Contraction 2- Connective tissue formation (granulation tissue) 3- Epithelization

Surgical Wounds Clean Clean contaminated ContaminatedDirty 7

Factors which affect wound healing General: Malnutrition, ureamia, malignancy, radiothempy, cytotoxic drugs, duabetes, vitc deficiency. General: Malnutrition, ureamia, malignancy, radiothempy, cytotoxic drugs, duabetes, vitc deficiency. Local Factors: Local Factors: - Blood supply - Tension in wound - presence of necrotic tissue and F.B - presence of haematoma - excessive cauterization, rough manipulation - infection - infection 8

 Complications of Wounds:  Wound infection  Wound dehiscence  Hyper trophied scar, keloid 9

Principles of wound management Correct all local and systemic factors that might impair wound healing Wound toilet Wound dressing Antibiotics if infected 10

Ulcers 11

Ulcers are non-healing wounds that develop on the skin, mucous membranes or eye. Although they have many causes, they are marked by: Ulcers are non-healing wounds that develop on the skin, mucous membranes or eye. Although they have many causes, they are marked by: 1. Loss of integrity of the area 2. Secondary infection of the site by bacteria, fungus or virus 3. Generalized weakness of the patient 4. Delayed healing 12

Location 1. Lower limbs: most ulcers of the foot and leg are caused by underlying vascular insufficiency. The skin breaks down or fails to heal because of repeated insult or trauma. 2. Sacrum and ischium 3. Mouth ulcer 13

Cont… 4. Peptic ulcer: This includes ulcers of the esophagus, stomach, large and small intestine 5. Genitalia: May be penile, vulvar or labial. Most often are due to sexually- transmitted disease. 6. Eyes: corneal ulcers are the most common type. Conjunctival ulcers also occur. 14

causes Bacterial, viral & fungal infection Bacterial, viral & fungal infection Cancer both primary & secondary Cancer both primary & secondary Venous stasis Venous stasis Arterial insufficiency Arterial insufficiency Diabetes Diabetes Rheumatoid arthritis Rheumatoid arthritis Loss of mobility Loss of mobility 15

Description Site Site Size Size Shape Shape Base Base Edge Edge Tenderness Tenderness Discharge Discharge Surrounding tissue & lymphatics Surrounding tissue & lymphatics 16

Types Peptic ulcer Peptic ulcer Mouth ulcer Mouth ulcer Pressure ulcer (decubitus) Pressure ulcer (decubitus) Arterial insufficiency ulcer Arterial insufficiency ulcer Venous insufficiency ulcer Venous insufficiency ulcer Diabetic foot ulcer Diabetic foot ulcer 17

Ischaemic ulceration By definition caused by inadequate blood supply “ large \ small artery obliteration ” By definition caused by inadequate blood supply “ large \ small artery obliteration ” In elderly, who also have symptoms of coronary vascular disease. In elderly, who also have symptoms of coronary vascular disease. Men predominate Men predominate Risk factor – Smoking, atherosclerosis Risk factor – Smoking, atherosclerosis Very painful, causes rest pain Very painful, causes rest pain Do not bleed but discharge thin serous exudates which can become purulent Do not bleed but discharge thin serous exudates which can become purulent Distal pulses are impalpable Distal pulses are impalpable 18

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Neuropathic ulceration Deep penetrating ulcer which occur over pressure point, but the surrounding tissue are healthy and have good circulation. Deep penetrating ulcer which occur over pressure point, but the surrounding tissue are healthy and have good circulation. Diagnostic features:- Diagnostic features:- 1- painless 2- surrounding tissues are unable to appreciate pain 3- surrounding tissues have normal blood supply 21

Cont … Causes:- Causes:- - peripheral nerve lesions “ diabetes,nerve injuries ” - Spinal cord lesions “ spina bifida,tabes dorsalis ” 22

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Venous ulceration Follow many year of venous disease. Follow many year of venous disease. Commonly occur on the medial side of the leg above the ankle Commonly occur on the medial side of the leg above the ankle Predominantly in women Predominantly in women Risk factor – Varicose veins Risk factor – Varicose veins Pulses are normal Pulses are normal 25

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Fistulas 28

Definition Fistulas is an abnormal communication between two epithelial or endothelial surfaces Fistulas is an abnormal communication between two epithelial or endothelial surfaces 29

Types of fistula NameConnection Tracheo-oesophageal fistulaTrachea - oeasophagus EnterocutaneousColon - Skin Rectovaginal fistulaRectum - Vagina Arterivenous fistulaArtery - Vein 30

Why do they occur? Some are congenital e.g. Tracheooesophageal fistula Some are congenital e.g. Tracheooesophageal fistula Internal abdominal fistulas :Majority result from an underlying gastro- Internal abdominal fistulas :Majority result from an underlying gastro- intestinal disease ( e.g. colonic diverticular disease, crohn ’ s disease, colonic carcinoma, etc ) intestinal disease ( e.g. colonic diverticular disease, crohn ’ s disease, colonic carcinoma, etc ) 31

External abdominal fistulas arise as a complication of surgery or to the trauma. External abdominal fistulas arise as a complication of surgery or to the trauma. Other external fistulas are due to primary abscess formation and rupture on to skin. E.g. perianal fistula Other external fistulas are due to primary abscess formation and rupture on to skin. E.g. perianal fistula 32

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Management Difficult to treat Is complex and usually surgical Depend on the site of the fistula 34

Treatment Conservative : Conservative : The mainstays of medical management are: The mainstays of medical management are: - nutritional support - nutritional support - meticulous collection of fistulous discharge - meticulous collection of fistulous discharge - skin-stoma care - skin-stoma care - control of sepsis - control of sepsis 35

Surgical : Surgical : The absolute indications for operative intervention are : The absolute indications for operative intervention are : - intestinal distal obstruction - intestinal distal obstruction - peritonitis - peritonitis - abscess formation - abscess formation - bowel discontinuity - bowel discontinuity - presence of malignant disease - presence of malignant disease - persistent inflammatory bowel disease - persistent inflammatory bowel disease 36

Cysts 37

What is a cyst? a cyst is : any closed epithelium-lined cavity or sac, normal or abnormal, usually containing liquid or semisolid material" (Dorland's, 1995, pp.209). It is common can occur anywhere any age. It is common can occur anywhere any age. Cysts vary in size Cysts vary in size Its wall called the cyst capsule Its wall called the cyst capsule 38

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What are the causes of a cyst? Cysts are usually formed through one of these mechanisms: Cysts are usually formed through one of these mechanisms: 1. Obstructions to the flow of fluid 2. Infections and chronic inflammations 3. Tumors 4. Genetic (inherited) conditions Genetic 5. Defects in developing organs in the embryo embryo 40

Examples of cysts Thyroglossal cyst Thyroglossal cyst Ovarian cyst Ovarian cyst Sebaceous cyst Sebaceous cyst 41

Treatment Usually surgical - Cystectomy 42