What are the next steps for a sutured wound that does not approximate?

Management of Sutured Wounds That Do Not Approximate

For a sutured wound that does not approximate, the wound should be reopened, thoroughly irrigated, debrided if necessary, and reclosed with appropriate tension-distributing suturing techniques to ensure proper wound healing and minimize complications. 1

Assessment of Non-Approximating Wound

When faced with a sutured wound that fails to approximate, consider the following:

• Causes of poor approximation:

  • Excessive wound tension
  • Inadequate suturing technique
  • Infection
  • Tissue necrosis
  • Hematoma formation
  • Inappropriate suture material

• Signs requiring immediate attention:

  • Wound dehiscence
  • Purulent drainage
  • Excessive erythema extending >5 cm
  • Systemic symptoms (fever >38.5°C, tachycardia >110 bpm) 1

Step-by-Step Management Approach

1. Remove Existing Sutures and Reassess the Wound

• Carefully remove all existing sutures
• Thoroughly examine the wound for:
  • Signs of infection
  • Necrotic tissue
  • Foreign bodies
  • Hematoma formation

2. Wound Preparation

• Irrigation: Perform copious irrigation with sterile saline (100-1000 mL) to remove debris and reduce bacterial load 1
• Debridement: Remove any necrotic tissue to create viable wound edges 1
• Dry the wound: Ensure the wound is dry before attempting reclosure

3. Reclosure Techniques

• For wounds with minimal tension:

  • Use mattress sutures with long scleral passes to increase vector forces in re-apposing wound edges 2
  • Consider non-locking continuous sutures which provide strong closure with low dehiscence rates 1

• For wounds with moderate tension:

  • Place deep buried sutures to reduce tension on superficial closure
  • Consider pulley or far-near-near-far sutures to distribute tension 3

• For wounds with significant tension:

  • Perform undermining of wound edges to increase mobility
  • Consider partial closure to reduce tension while allowing part of the wound to heal by secondary intention 3

4. Additional Closure Support

• For wounds at high risk of dehiscence:

  • Apply wound sealants such as fibrin glue to reinforce closure 2
  • Consider using adhesive strips (Steri-Strips™) as additional support

• For difficult-to-close wounds:

  • Consider intraoperative skin expansion techniques 3
  • Apply processed pericardium or donor graft material to reinforce closure in complex cases 2

5. Post-Closure Care

• Dressing: Apply a non-adherent dressing (Mepitel™ or Telfa™) directly to the wound surface 1
• Antibiotic prophylaxis: Consider for high-risk wounds (amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days) 1
• Tetanus prophylaxis: Administer tetanus toxoid if not received within 10 years (5 years for contaminated wounds) 2, 1
• Follow-up: Arrange for wound check within 24-48 hours to ensure proper healing 1

Special Considerations

For Facial Wounds

• Facial wounds may be reclosed with primary intention after thorough irrigation and cautious debridement 2
• Use finer suture material (5-0 or 6-0) and place sutures closer together for better cosmetic outcome

For Hand Wounds

• Hand wounds have higher infection rates and should be reclosed with caution 2
• Consider leaving hand wounds to heal by secondary intention if infection is suspected

For Infected Wounds

• Do not attempt primary closure of infected wounds
• Provide drainage, debridement, and appropriate antibiotic therapy
• Consider delayed primary closure after infection resolves 2

Monitoring for Complications

• Monitor for signs of infection: increasing pain, erythema, warmth, purulent drainage, or systemic symptoms 1
• Watch for wound dehiscence, which may require additional intervention
• If persistent problems with approximation occur despite proper technique, consider underlying factors such as poor nutrition, diabetes, or immunosuppression

By following this systematic approach to managing non-approximating sutured wounds, you can optimize healing outcomes and minimize complications that could lead to increased morbidity.