You are called in to care for a patient with a full thickness wound. Now what?
Your goal should be to heal the wound as soon as possible and to keep it healed. There are three types of wound closure techniques to consider, and they include:
- Primary Intention
- Secondary Intention
- Tertiary Intention
What to Consider About Wound Closures
When choosing which intention to utilize, consider the possibility of a post-procedural infection occurring. Your selection is related to how the wound presented. The four wound categories listed from the lowest risk to the highest risk for developing an infection with a wound closure are:
- Clean wounds
- Clean-contaminated wounds
- Contaminated wounds
- Dirty wounds
Primary Intention
With selecting Primary Intention, it is acceptable to proceed with closure at that time of a full thickness wound with sutures, staples, adhesive strips of tape, or maybe surgical glue. Closing the wound now, there is a low risk for infection as well as little concern for the wound’s edges separating (dehiscing) due to tension on the incision line.
The advantages of closing by Primary Intention are low risk for infection, minimal scarring, and faster wound healing.
In general, the wounds that will be acceptable candidates for primary closure are:
- Wounds that are classified as clean wounds
- Wounds that are classified as clean-contaminated wounds
- Wounds that are closed within four (maybe up to eight) hours from their development
- Wounds that sustained little tissue loss and can be closed without tension
A clean wound is one that did not enter any organ, and there was no break in sterile operative technique. These are often elective, non-traumatic surgical procedures.
A clean-contaminated wound is one where an organ has been entered but without any significant spillage of the organ’s contents. These surgical procedures might have been conducted as an urgent or emergent fashion.
Secondary Intention
Closure by Secondary Intention is when the wound is not surgically closed either completely or partially.
With time, the clinician will witness the wound bed filling in with more viable tissue, such as granulation tissue, and containing less non-viable tissue, such as slough or eschar. Ultimately, the clinician will witness the epithelial covering of the wound bed. This can be a very slow process.
Often the wound’s healing progress might be “stuck” in one of the phases of full thickness wound healing. These are the types of wounds that may be labeled “chronic” wounds, and the attending clinician may ask for a consultation by a wound care clinician.
Wounds that lend themselves to closure by Secondary Intention are:
- Wounds that present as contaminated wounds
- Wounds that present as dirty wounds
- Wounds where there was a delay in the clinical consultation
- Wounds that do not allow surgical closure without tension
- Wounds where there is a significant concern for a post-procedure infection
Examples of contaminated wounds are ones such as penetrating traumatic injuries, wounds with spillage from the gastrointestinal tract but are less than four (maybe six) hours old, and wounds in which there was a major break in the operative sterile technique.
Examples of dirty wounds are wounds that present with an abscess, wounds that present with perforated bowel with possibly pus and/or stool within the abdominal cavity, and “old” contaminated wounds (older than six hours or so).
If perforated bowel was encountered, repair under Secondary Intention, so the fascia would be closed to prevent evisceration and the rest of the abdominal wall layers are left open to allow them to heal without any further surgical closure.
Tertiary Intention
Tertiary Intention closure is often labeled as Delayed Primary Intention. With this type of closure, there was a planned period of time where the superficial layers of the wound were left open. If the situation allows, later these layers are closed in a similar fashion to what might have been performed initially in Primary Intention but now in a “delayed” fashion. Also, this delayed type of closure might include closing the wound bed using a skin graft, a skin flap, or a skin substitute.
Examples for selecting Tertiary Intention closure could include:
- Superficial portion of soft tissue wounds left open to allow time for an infection to clear
- Superficial portion of soft tissue wounds left open to allow time for edema to clear
- Abdominal or pelvic area wound where there was a perforated viscus found, only the abdominal wall’s fascia was closed initially to prevent evisceration, and the more superficial subcutaneous fat and skin were left open for a period of time to be closed later
Selecting from the three types of wound closure is the decision of the clinician based on their training, their experience, as well as their clinical assessment of the patient. To the best of my knowledge, there are no absolute rules governing which type of closer to utilize.
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Don Wollheim, MD, FAPWCA, WCC, DWC, is board certified in general surgery by the American Board of Surgery. He has 25+ years of experience in general/vascular surgery and wound care, as well as extensive experience in medical-legal consulting and teaching college advance science courses. He is the lead instructor for the Diabetic Wound Certified® (DWC®) course and is also on the Editorial Advisory Boards of Wound Care Advisor and Wound Central® electronic journals. He also is owner of Implexus Wound Care Service LLC.