Primary Closure

Primary closure

Primary closure is a wound closure method whereby the edges of a wound are immediately brought together with the use of sutures, staples, adhesive strips or surgical glue. It is carried out shortly after the injury or even following a surgical procedure to ensure that healing is rapid and is as good as possible.

When Primary Closure Is Used

Primary closure is selected in case of:

• The injury is not contaminated with a lot of dirt.
• Loss of tissues is low and edges are easily approximated.
• The risk of infection is low.
• Face, neck outcome is critical (cosmetic).
• The patient is stable medically to be closed.

Common Indications

• Surgical incisions
• Clean traumatic wounds (less than 6 to 8 hours old)
• Well-defined lacerations.
• Easy cuts that do not have foreign bodies.
• After excision wounds (e.g., removal of cyst, excision of a mole)

Contraindications

Primary closure might be contraindicated in the case of:

• There is contamination/infection of the wound.
• Tissue loss is widespread and it cannot be approximated.
• The wound is more than 12-24 hours (depending on location).
• Devitalized tissue is evident.
• Patient is uncontrolled diabetic or PVD (case-by-case determination)

Advantages

• Fastest healing time
• Infection risk (in case of wound is clean) is lower.
• Best cosmetic outcome
• Less tissue distortion and scarring.
• Premature normal functional recovery.

Primary closure wound healing

Healing by primary intention (also known as primary closure wound healing) is wound healing in which the wound edges are sewn together using sutures, staples, adhesive strips or tissue glue. The wound edges are approximated hence the quickness of healing with minimal scarring.

How Wounds are healed by Primary Intention

Hemostasis (Immediate -Minutes to hours)

• The narrowing of blood vessels to limit bleeding occurs.
• Platelets form a fibrin clot.
• Clot seals the wound edges.

Inflammatory phase (day 1–3) of wound healing

• White cells (neutrophils, macrophages) cleanse the bacteria and debris.
• A typical incision is slightly red, swollen and warm to the touch of playfully aged hands. 
• Growth factors that are emitted to stimulate tissue repair.

Proliferative Phase (Day 3─21)

• To add strength to the wound, fibroblasts produce collagen.
• Angiogenesis takes place, new blood vessels formed. 
• Wound edges bond firmly.
• The migration of epithelial cells occurs over the wound surface in order to bridge it up.

Maturation / Remodeling Period (3 weeks -1 year)

• There is reorganization and strengthening of collagen fibers.
• Scar tissue is made flatter, soft, and light.
• Tensile strength is raised (up to 80% original strength).

Primary Closure Healing Characteristics

• Fastest healing method
• Limited scar as opposed to other types of healing.
• Low risk of infection, wound clean.
• Little to no tissue loss
• Edges are estimated correctly.

Primary closure surgical procedure

Primary closure is a procedure whereby a wound or surgical incision is immediately closed by aligning its edges with sutures, staples, adhesive strips or tissue adhesive. It is the conventional procedure of sealing clean wounds with a minimum of contamination and loss of tissue.

Primary Closure Procedure Steps:

Patient Preparation

• Obtain informed consent
• Position patient in a proper manner.
• Clean surrounding skin
• Apply local anaesthesia (e.g. lignocaine 1-2%)

Evaluation of the wound 

• Examine wound depth, wound length, and tissue viability.
• Search foreign bodies, contamination, or devitalized tissue.
• Evaluate the engagement of deeper structures (tendons, vessels, nerves)

Wound Cleaning and Irrigation

• Wet down with normal saline at high pressure (18-20 gauge syringe)
• Remove debris, dust or dirt.
• Skin preparation with antiseptic. 

Debridement

• Debride the dead, necrotic, or infected tissue. 
• Shower off jagged ends where necessary.
• Have a clean and vascularized wound bed.

Hemostasis

• Apply direct pressure
• Apply electrocution where required.
• No active bleeding should be left after the operation.

Estimation of edges of the wound 

The method of closure requires depends on location, depth, and tension:

Sutures (most common)

• Deep layers (more than 1 centimetre) absorbable (e.g., Vicryl).
• Unabsorbable (e.g. Nylon, Prolene) against skin.

Techniques:

• Simple interrupted
• Running stitch
• Vertical/horizontal mattress
• Perfectly match the edges of the skin to prevent step-offs, and bad cosmetic results.

Staples

• Applied in long linear surgical cuts (abdomen, scalp)
• Quick application

Adhesive Strips

• Applied to low tension, superficial wounds.
• Often apply to the face or to children.

Tissue Adhesive (Dermabond) 

• Very superficial, clean, small wounds.
• An avoidance of high tension or damp places.

Dressing Application

• Use non-adherent sterile dressing.
• Give wound care instructions.

Postoperative Care

• Keep the area dry for 24–48 hours
• Change dressing according to recommendation.
• Follow-up whenever infection (pain, redness, pus) happens. 

Suture removal:

• Face: 5–7 days
• Scalp: 7–10 days
• Trunk & upper limb: 10–14 days
• Lower limb: 14–21 days

Primary closure for traumatic wounds

Primary closure for Traumatic wounds is the immediate approximation of wound edges by using sutures, staples, adhesive strips, or tissue glue. It should be carried out in case the wound involved is clean, fresh and has low chances of infection.

Indications

Primary closure should be used when the traumatic wound is:

• Clean and uncontaminated
• None of dirt, debris, or foreign body.
• Fresh (<6–8 hours old)
• Good vascularity may close facial wounds until 12-24 hours.
• Minimal tissue loss
• Well-vascularized area
• Smooth wound margins
• No signs of active infection
• Mechanism is low risk
• Injuries of sharp objects (knife, glass).
• Clean lacerations

Best hospital for primary closure India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Primary closure is a fairly common and efficient method of clean and fresh traumatic wound management. When used on the properly chosen wounds that are not contaminated much, have sufficient vascularity, and the tissue loss is minimal, it has the shortest healing time, lowest rate of infection, and the most cosmetic appearance. Primary closure requires careful wound evaluation, adequate wound irrigation, appropriate debridement, and tension free wound closure approximation. In conditions where contamination, late presentation, or necrotic tissue renders the patient prone to infection, the risk for delayed primary closure is reduced and it is the closure of choice. An optimal healing and minimal complication should be considered when choosing a closure method. 

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FAQ

1. In which cases primary closure is to be avoided?

• Primary closure is contraindicated in the presence of wound contamination, in wounds older than 12-24 hours, in animal or human bites, in severely crushed wounds, or when tissue is devitalized.

2. Why is wound irrigation important before closure? 

• Bacteria, debris and foreign material are eliminated through irrigation. It minimizes the risk of infection greatly and also is the most extremely important procedure before the closure.

3. Is antibiotic treatment necessary before all traumatic wounds are closed?

• No. Low-risk wounds are clean and may not need antibiotics. They are prescribed only in case of contaminated wounds, lower limb wounds, deep wounds or immunocompromised patients.

4. Is a dirty wound ever to be closed in the first place?

• No, dirty or contaminated wounds should be managed under delayed primary closure after 3-5 days when the risk of infection is decreased.