DR. dr. Hardisiswo, SpBP-RE (K)
Pit IDI Bogor, 31 Oktober 2015
Divisi Bedah Plastik, Dept BedahFK Unpad/ RS Hasan Sadikin
Bandung
Wound
disruption of the normal anatomical relationships of tissues as a result of injury.
surgical incision
trauma
Wound Type
Wound Problem
Infection
Delayed healing
Septic wound
Scar: hypertrophic scar,
keloid
Chronic wound
Delayed healing
Infection
Septic wound
Intractable wound/unhealing
wound
All Wound problems can
occur
Acute wound
Chronic wound
Non healing
wound
Luka
Akut Kronis
≥ 6 minggu
Wound Classification
Wound
Chronic
Acute
skin loss
vulnus
escoriatum
vulnus laceratum
vulnus punctum
vulnus scissum
skin avulsion/ deglovingeschar
slough
infection
granulation
Process of Wound Healing
Luka Akut
Bersih
Kontaminasi
Kotor
Infeksi
Daerah luka akut yang
berisiko terhadap fungsi
Mengenai pembuluh darah besar
Saraf-saraf penting: N.VII, plexus brachialis, dst.
Tendon-tendon
Organ-organ = mata, hati, jantung, dsb
Duktus/saluran kelenjar – Stenson
Luka akut berisiko infeksi
Luka ≥ 6 jam
Luka kontaminasi/kotor
Terjadi di tempat yang kotor
Luka dalam dan benda kontaminan/kotor (paku/bambu/besi)
Luka akut berisiko keloid/parut
hipertrofik
Luka laserasi dalam
Luka laserasi kotor
Luka compang-camping
Luka tegang (skin loss) – tension
Luka akut jadi kronis
Penanganan luka akut
Primary survey – life threatening
Secondary survey – manajemen luka
Manajemen luka akut
Membuat luka menjadi bersih
Mengurangi/mencegah risiko infeksi
Mencegah menjadi luka kronis
Mengurangi/mencegah parut buruk
(keloid/hypertrophic scar)
Tujuan
Good wound
management
Debridement
Wound toilet
Good surgery
technique
Good Healing
aesthetic&
functional
Simple
Laceration
Complex
wound
Wound toilet / Debridement
Wound toilet – luka kecil dan bersih
Debridement – membuang semua kotoran pada luka, jaringan mati dan membuat luka jadi bersih dan siap ditutup
Irrigation & Debridement
Debridement – excision of all devitalized, contaminated &
Foreign bodies
If Possible, Vital structures including nerves, blood vessels,
tendons and bones shouldn’t be debribed.
Irrigation with NaCL
Mechanical debridement (sharp& blunt)
Gauze debridement
Chemical debridement
Trusler AP. Surgical Techniques and Wound Management. In Brown DL. Michigan Manual of
Plastic Surgery. Lippincott Wiliams& Wilkins.Philadelphia. 2007
Defect Closure
Need Meticulous surgical technique
Good approximation SOLVE the puzzle
Suture material
Tissue handling
Subcutaneous suture
AVOID TENSION
Cutaneous suture — eversion
Langer Line
Penutupan luka
Dijahit
Primer
Tersier
Graft – STSG & FTSG
Tidak dijahit
Sekunder
Dirawat terbuka
Post Operative Care
Dressing
Clean, Moist, Pressure
Suture removal within 5 - 7 days (face)
Silicone sheet
Avoid sunlight
Cream / Ointment for scar
Wound dressing
Syarat
Bersih
Menyerap / hidrofil
Lembab
Efek pressure (menekan)
Antibiotik
Modern wound dressing
Acute Wound
Vulnus
Excoriatum
Vulnus
Laceratum
Acute Wound
Vulnus
Scissum
Acute Wound
Skin Avulsion Gun Shot wound
Acute Wound
Skin Degloving
Pre – Post Operative
Pre – Post Operative
Management of Skin Avulsion
Test vitality
Distal to
proximal
HarvestingSuture the
vital flap +
graft
Chronic wound
All chronic wounds begin as acute wounds but fail to progress
through the normal healing process and become locked in an
extended inflammatory phase.
External
Inflamation
Inducer
wounding
Acute
inflammatio
n
Chronic
inflammatio
n
Proliferatio
n
Remodelin
g
Chronic wound
growth factors,
cytokines, and
proteases all play
important roles in
wound healing process
alterations in one or more
components of these
factors may account for
the impaired healing in
chronic wounds.
Sucessful wound healing requires a
balance between protease and
inhibitor levels in order to bring
controled synthesis and
degradation of extracelular matrix
component
In Chronic Wounds Inflamatory phase
Management
Asses the WoundAcute wound — The problem is easy to resolve
Cronic Wound
?Nonhealing wound
Wound by Its Colour
Chronicwound
Venous Ulcer
Venous
ulcer
Blood Stasis
Chronic
Inflamation
Chronicwound
Diabetic Foot
Gangrene DM
Diabetic
Ulcer
Chronicwound
Management Chronic Wound
Management
Chronic Wound
Bed Preparation
Antibiotic
Status nutrition
Local
care
Systemic care
1. Broad spectrum
empiric
2. Kultur & resistency
Albumin > 2.5 g/dl1. Elastic verband
(celulitis, venous ulcer)
2. Mobilisastion
(pressure sores)
1. Glucose control
2. stop smoking
3. Cancer Therapy
Debridement
Dressing
Wound-bed preparation
Paradigm
TIME Principles of wound bed
preparation
Tissue non-viable or deficient
Infection or Inflammation
Moisture imbalance
Edge of wound —non-advancing or
undermining
TIME Principles of wound bed
preparation
Tissue non-viable or deficient
Patofisiologi
• Matriks yang
dipenuhi debris
menghambat
penyembuhan
luka
Sikap
• Debridement
(berkala atau
kontinyu)
Hasil yang
diharapkan
• restorasi luka
(fungsi ECM
baik)
• luka lebih
sehat
TIME Principles of wound bed
preparation
Patofisiologi
• Jumlah
baketeri
banyak
• Fase inflamasi
memanjang
Sikap
• Menghilangkan
fokus infeksi
dengan
antibiotik
topikal/sistemik
Hasil yang
diharapkan
• berkurangnya
bakteri dan
proses
inflamasi
Infection or Inflammation
Infected Ulcer
Infected
Ulcer
Chronicwound
TIME Principles of wound bed
preparation
Patofisiologi
• luka yang kering
memperlambat
epitelisasi
• Luka yang basah
menyebabkan
maserasi pada tepi
luka
Sikap
• dressing yang
melembabkan luka
• menggunakan
NPWT atau vakum
Hasil yang
diharapkan
• keseimbangan
kelembaban luka
tercapai
Moisture imbalance
TIME Principles of wound bed
preparation
Patofisiologi
• tidak ada migrasi
sel-sel keratinosit
• gangguan pada
ECM
• aktifitas protease
tinggi
Sikap
• menilai ulang
penyebab
(assessment)
• debridement
• skin graft
Hasil yang
diharapkan
• tepi luka yang
mengecil
(mendekat)
Edge of wound —non-advancing or
undermining
Banyak penawaran produk wound dressing
AI KARTIKAPressure sores grade IV
Pre Operation
Chronicwound
AI KARTIKAPost Operation
Debridement &
Wound care
Chronicwound
Post close defek
Chronicwound
2. ♂,32 TH, Chronic Ulcer + Anemia Gravis,
Post Debridement I
AFTER DEBRIDEMENT
Week 3 post op, edema
Pre – Post Operative
Pre – Post Operative
Pre – Post Operative
Conclusion
Penilaian luka
jenis
bentuk
lokasi
Penyakit komorbid
Pengetahuan anatomi
Luka akut atau kronis membutuhkan wound toilet atau
debridement
Goal: menghasilkan jaringan parut yang baik secara estetik dan
fungsi
LUKA KRONIK
LUKA AKUT
SEMBUH
•SLOUGH•BAKTERI•BIOFILM•ESCHAR
•PUS
DebridementAntibiotikdressing
DebridementAntibiotikdressing
•Bersih• granulasi sehat•Vaskularisasi ↑