Читать книгу Complications in Equine Surgery - Группа авторов - Страница 135

Treatment will vary depending on the identified cause of incisional dehiscence and whether it is a partial or completed dehiscence. Location, size, tissue viability, reason for the dehiscence, owner expectations and financial concerns will all play a critical role in how the dehisced sutured line is treated. Examination of the dehisced incision and determination of cause is the first step in determining a course of treatment. Early and meticulous evaluation of the dehisced incision along with appropriate management using a combination of timely surgical and medical treatments are used to promote the best healing outcome [6].

If there is no suspicion of infection then the dehisced sutures are removed, the wound cleansed, without the use of antiseptics, debrided, lavaged, and primary closure can be performed [5]. If excessive tension is suspected, additional steps are taken as needed, such as incorporating tension relieving suture patterns, walking sutures, or tension relieving techniques such as tissue undermining, relief incisions, or plasties can be performed [7]. If excessive motion is thought to be involved, increasing incisional support through bandaging, splinting, or casting is recommended. In addition, stricter confinement may be necessary, such as cross‐tying, smaller stall confinement, no hand‐walking, etc.

Partial dehiscence or intentional partial dehiscence, in the case when dependent sutures are removed to allow for adequate drainage, can be managed with appropriate wound care including cleansing, debridement, lavaging, and appropriate wound dressings.

Passive or active drains are incorporated to ensure adequate drainage and obliteration of dead space if discharge, fluid, or gas build‐up within the repair was suspected to have contributed to the dehiscence. Drains will function by channeling undesired discharge, fluid, gas, or debris and usually promotes faster healing and decreases the chance of dehiscence reoccurring [3]. Incorporation of a compression bandage when applicable will help with the elimination of dead space.

Common isolates from infected equine wounds include Streptococcus spp, Staphylococcus spp, Enterobacteriaceae, Pseudomonas spp, and anaerobes [6]. With the suspicion of infection of the suture line, a course of broad‐spectrum antibiotics and or regional limb perfusions are recommended and initiated until culture and sensitivity results have been obtained. Delayed primary closure, secondary closure, or second intention healing are recommended in cases where there is a presence of infection, necrotic or compromised tissue, or if additional debridement is needed [5]. The degree of bacterial contamination, determined by qualitative and quantitative culture, will help identify the most appropriate wound management [7]. Appropriate wound care and wound dressings are essential and are dictated by the wound characteristics and phase of wound healing.

Sequesta formation may not be evident on radiographs until 3–4 weeks after injury [6, 7, 14]. Similarly, healing is delayed in most horses with foreign bodies present and are prone to dehiscence of the suture line and development of a persistent draining tract [6, 14]. Prolonged medical treatments are usually unsuccessful in resolving the infection and the drainage returns once treatment is discontinued. Complete removal of the fistulous tract, sequestrum and debridement of the underlying bone or removal of the foreign body usually results in a positive outcome [6]. The dehisced incision may be managed by primary closure or second intention healing [6]. In dehisced cases not managed by closure, skin grafting can improve the cosmetic appearance [6, 7].

In the case of self‐mutilation, applying cayenne pepper or similar substances on the outside of the bandage may deter the behavior in some horses. Medicating with tranquilizers or other calming agents may also be indicated in horses not tolerant of stall confinement. Different bandaging techniques can be tried in certain cases, such as with head surgeries where the use of a stockinette or nothing in place of an Elastikon bandage may be more beneficial for the outcome of the incision healing.

Systemic diseases that could be playing a factor in delayed wound healing and dehiscence should be addressed, diagnosed, and treated accordingly.

Incisions over areas of motion should be immobilized appropriately, depending on the predicted amount of movement. This may be achieved with a bandage or a splint or cast in certain circumstances [7].