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Toothed Dissecting Forceps 97
THE PRACTITIONER WITHEXTENDED SKILLS
The 2018 SFA position statement issued by the Perioperative Care Collaborative
identifies the fact that some practitioners may be required to further develop their sur-
gical skills and supports SFAs, after suitable education, undertaking limited surgical
intervention. Of the identified delegated skills, the sutured closure of layers of the
skin requires consideration in the context of the handling of surgical instruments.
When undertaking a wound closure, the practitioner should ensure that they are
standing on the appropriate side of the patient and that the table height is comfortable
for them– the American College of Surgeons (n.d.) in their ergonomic recommenda-
tions document considers that the operating table should be at elbow height with the
angle of the operator’s elbows held at 90°. They further advise that the practitioner
ensures that their upper arms and shoulders are held in a relaxed manner when
undertaking surgical activities. Traditionally it has been accepted that standing to the
right of the patient was the best position from which to undertake a wound closure /
closure of the layers of the skin; however, with the increasing use of minimal access
surgery in a wide range of surgical specialties, it may be necessary for the assistant to
adopt a different position for themselves depending on the placement of the incision
to be sutured.
TOOTHED DISSECTING FORCEPS
When suturing, the wound edges are picked up and subsequently held in toothed for-
ceps, this reduces the risk of crush injury to the skin being sutured with its resultant
impact on wound healing. The practitioner should ensure that the instrument is held,
usually in the non- dominant hand, as one would a pencil, while applying pressure
with both the thumb and fingers to control the grip of the instrument on the skin
edges (see Figure8.6).
FIGURE8.6 Toothed dissecting forceps held in a pencil grip. Source: Courtesy of Ruth Shroff.
98 Chapter 8 Instrument Handling forthe Surgical First Assistant
NEEDLE HOLDERS
Although there are many designs of needle holder in use across the range of surgical
specialties, the most commonly used in situations where an SFA undertakes the
sutured closure of layers of the skin is a Mayo- type instrument with ringed handles.
The most traditional method of holding this is the thumb and ring finger grip described
earlier in this chapter. This technique provides good control of the needle, enables
easy opening of the instrument’s ratchet and supports the pronation and supination
of the hand required during suturing.
Practitioners may find that their supervising surgeon has a preference for them to
use either the palmed grip, although this is more effective when closing dense tissue,
or the so-
called thenar grip which, whilst supporting rapid suturing, may result in a
less precise suturing technique.
REFERENCES
Crumplin, M.K.H. (2023). Hand- held surgical retractors. British Journal of Surgery 110 (9):
https://doi.org/10.1093/bjs/znac439.
Green, S.V., Morris, D.E., Naumann, D.N. etal. (2022). One size does not fit all: impact of
hand size on ease of use of instruments for minimally invasive surgery. The Surgeon
21 (5): https://doi.org/10.1016/j.surge.2022.11.001.
Linden, A.R., Susan Hallbeck, M., Morrow, M. etal. (2019). Ergonomic education and training
for surgical assistant trainees. Proceedings of the Human Factors and Ergonomics Society
Annual Meeting 63 (1): 688– 692. https://doi.org/10.1177/1071181319631421.
Myint, F. (2018). Kirk’s Basic Surgical Techniques. London: Elsevier Health Sciences.
Perioperative Care Collaborative (2018). Clinical Focus Supporting Policy into Practice
• ©Perioperative Care Collaborative Clinical Focus Supporting Policy into Practice.
https://www.afpp.org.uk/wp- content/uploads/sfa- position- statement-
final- april- 2018.pdf.
Rui, M., Lee, J.E., Vauthey, J.- N., and Conrad, C. (2018). Enhancing surgical performance
by adopting expert musicians’ practice and performance strategies. Surgery 163 (4):
894– 900. https://doi.org/10.1016/j.surg.2017.09.011.
Wicker, P. and Dalby, S. (2016). Surgical ergonomics recommendations prepared
by the American College of Surgeons Division of Education & Surgical
Ergonomics Committee Education American College of Surgeons 2. In:
Rapid Perioperative Care, 301– 303. Wiley https://www.facs.org/media/
tdeemrnw/23_ed_surgicalergonomicsrecommendations_pdf_v4.pdf.
Zihni, A.M., Cavallo, J.A., Ray, S. et al. (2016). Ergonomic analysis of primary and
assistant surgical roles. Journal of Surgical Research 203 (2): 301– 305. https://doi.
org/10.1016/j.jss.2016.03.058.
99
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 9
Wound Management
Julie Quick
1
and Mark Owen
2
1
Birmingham City University, Birmingham, UK
2
University of Gloucestershire, Cheltenham, UK
INTRODUCTION
As a member of the extended surgical team, one of the responsibilities of the SFA is
the application of wound dressings (PCC2018). It is the responsibility of the surgeon
to select the appropriate dressing and the surgeon may apply it themselves or delegate
this task to the SFA or scrub practitioner. Regardless of whether the SFA applies the
wound dressing or only assists, they will need an understanding of the principles of
wound management. The aims of post- operative wound care are the same in all
patients, to promote fast, complication- free healing with the best possible functional
and aesthetic outcome (Singer and Dagum2008). Dealy (2008) suggests that a surgical
wound will usually heal without any problem, with only a small number of patients
going on to develop complications with wound healing. There are however many con-
founding factors that impact on wound management, and so this chapter identifies
the aetiology and classification of wounds as well as factors affecting wound healing
and common dressings to aid understanding regarding surgeon’s preference and
application.
This chapter should be read in conjunction with other chapters in this book,
namely, pre- operative assessment, assisting with wound closure, haemostasis and
pain management.
100 Chapter 9 Wound Management
ACUTE ANDCHRONIC WOUNDS
Acute wounds are generally the result of a surgical incision or traumatic injury
(Doughty and Sparks2016; White2016). Generally, acute wounds are newly formed
on healthy skin and proceed through the stages of the normal wound healing stages
resulting in closure of the wound and complete healing. Acute wounds typically heal
within 5–
10days or within 30days (White2016). A chronic wound develops when
there is a disruption of the normal wound healing process (Doughty and Sparks2016;
Baranoski etal.2020). A wound that is slow to heal or is not healing, generally within
six to eight weeks is considered a chronic wound (White2016).
WOUND HEALING
The processes involved in wound healing are dependent on the depth of the wound.
Superficial wounds involve the epidermis (Tortora and Derrickson2017) and may
include superficial layers of the dermis (Doughty and Sparks2016), while deep or
full- thickness wounds include the dermis subcutaneous tissue, muscles and bones
(White2016).
Superficial wounds may include abrasions to the skin and minor burns that only
affect the epidermis (Tortora and Derrickson2017). In response to this type of injury,
the inflammatory stage is short, and during this phase, a serous exudate containing
leukocytes is produced. If it is allowed to dry on the surface of the wound, a ‘’scab’ is
formed (Doughty and Sparks 2016). At the same time, basal cells in the epidermis
around the wound detach from the basement membrane and migrate across the
wound until the cells meet from opposite sides of the wound. The point at which they
meet is known as contact inhibition where no further migration occurs (Doughty and
Sparks 2016; Tortora and Derrickson 2017). During migration, a hormone called
‘epidermal growth factor’ stimulates basal cell division to replace those that migrated
into the wound (Tortora and Derrickson2017). The migrated basal cells divide to build
new strata that thicken the new epidermis. If there is only epidermal injury, the pro-
cess of wound healing produces no scars, and the skin retains its usual appearance
and the tissue involved has no loss of function (Doughty and Sparks 2016). Where
there is partial dermal loss, the wound healing processes described above occurs, with
dermal layer repair occurring concurrently. On day five following injury, the epidermis
is separated from the dermis by a layer of fluid and blood vessels begin to sprout with
fibroblasts proliferated by day seven. By the ninth day post- injury, collagen fibres are
visible in the wound bed. The synthesis of collagen produces new connective tissue
until approximately 10– 15days following injury, which grows upwards into the layer
of fluid between the dermis, while the flat epidermis falls onto the new vessels and
collagen fibres thus recreating ridges between the epidermal and dermal layers
(Doughty and Sparks2016). As the newly formed connective tissue contracts, it draws
the dermal and epidermal layers closer together (Doughty and Sparks2016).
Wound Healing 101
Deep or full- thickness wounds are part of a much more complex process than that
of epidermal wound healing (Doughty and Sparks2016; Tortora and Derrickson2017).
As Chapter5 identified (see Figure5.4), the complex process of wound healing occurs
through a number of overlapping phases which are included below (Holloway
etal.2020):
Phase 1
Haemostasis.
Phase 2
Inflammation.
Phase 3
Proliferation.
Phase 4
Remodelling/maturation.
Haemostasis
An acute injury, for example, a surgical incision, that extends below the epidermis
will cause bleeding and is the starting point of the cascade of the overlapping phases
of wound healing (Doughty and Sparks2016). In the initial first 10– 15minutes, vaso-
constriction occurs to control haemorrhage from the damaged blood vessels (Hollo-
way etal. 2020) and platelet activation and aggregation (White 2016). The injured
cells release clotting factors that convert prothrombin to thrombin that is used to con-
vert fibrinogen to fibrin and clot formation occurs (Doughty and Sparks2016). During
this phase, an overlapping phase of fibrinolysis begins to break down the clot allowing
further cell migration into the wound (Holloway etal.2020).
Inflammation
The degradation of the fibrin clot and vasodilation increases capillary permeability
(Holloway etal.2020) that allows plasma and blood cells to leak into the wound
and is observed as oedema, erythema and exudate (Doughty and Sparks2016). The
vascular and cellular response includes the influx of leukocytes, including neutro-
phils and macrophages (Tortora and Derrickson2017; Baranoski et al.2020). As
part of the inflammatory response neutrophils and macrophages phagocytose
bacteria (Doughty and Sparks2016) and other debris at the site of injury (Baranoski
102 Chapter 9 Wound Management
etal.2020). Macrophages also release growth factors that aid angiogenesis (new
blood vessel growth) and attract fibroblasts to the wound (Doughty and Sparks2016;
Fuller2022).
Proliferation
This phase begins within hours of injury, where epithelial cells migrate to provide
a protective barrier to the wound and close the epithelial deficit (Bak2018). This
phase, described as epithelization, provides a protective barrier and ensures resto-
ration of the vascular integrity, and for a wound created by surgical incision, the
repair of the incisional wound [healing] with new connective tissue (Doughty and
Sparks2016). In the overlapping phases, granulation tissue is formed at around
three to five days post- injury in the latter stages of the inflammatory phase
(Doughy and Sparks2016; Fuller2022). Fibroblasts that have proliferated in the
wound synthesise collagen and other cell matrices, thus providing support and
strength to the wound (Bak2018, p.247; Fuller2022, p.474). The restoration of
vascular integrity (angiogenesis) occurs whereby new capillaries are formed and
join with the existing damaged capillaries, allowing the delivery of oxygen and
nutrients to the wound bed (Doughty and Sparks2016). Wound contraction begins
around five days post- injury or surgical incision and continues to shrink the
wound at around two weeks (Bak2018).
Remodelling/Maturation
This overlapping phase with proliferation begins from three weeks and continues up
to one year or more (Doughty and Sparks2016; Bak2018; Fuller2022). Once the epi-
dermis is restored, the scab sloughs off (Tortora and Derrickson2017) and the new
collagen that forms is more orderly and increases the tensile strength of the wound
(Doughy and Sparks 2016; Holloway et al. 2020). The scar formation lacks elastin,
thus scar tissue is rigid compared with the normal tissue it has replaced. The scar
tissue itself is only 70–
80% of the tensile strength of non- injured tissue (Doughty and
Sparks2016; Bak2018; Holloway etal.2020).
Keloids and hypertrophic scars are a late complication of this maturation stage.
They are raised, thickened scars that can be caused by several abnormal pathophysi-
cal responses to wound healing including an extreme tissue response to dermal injury
after surgery, with both scars overproducing collagen (Campiglio etal.2022). A hyper-
trophic scar is categorised by the scar remaining within the edges of the wound,
whereas keloid scars extend beyond the incision line.
Pre- operative assessment of patients can identify those at risk of hypertrophic
and keloid scarring which is common in patients of African and Asian decent, and
location of the wound such as the shoulders, anterior chest and upper arms (Campi-
glio etal.2022). Treatment available to treat both types of scars is inconclusive so the
potential risk of developing these scars after surgery must be discussed with the
patient during the informed consent process.
Wound Healing 103
As Chapter 5 identified, closure of surgical wounds is via primary, secondary or
tertiary intention. A summary is included below of factors that may affect wound healing.
Holloway etal. (2020) describe these factors as local, systemic or biopsychosocial factors.
Local Factors
Hypoxia provides a stimulus to angiogenesis at the proliferation phase; however, pro-
longed hypoxia affects the endothelial cell proliferation and the formation of new ves-
sels (Doughty and Sparks2016). Poor tissue perfusion will inhibit fibroblast migration
and collagen synthesis at the overlapping proliferation phase which will result in
decreased tensile strength for the wound (Bak2018). Local wound infection is a common
cause of delayed wound healing in surgical patients (Bak 2018). The NICE (2019)
classification of wounds system was identified in Chapter5 and wider reading of the
risks of post- operative infection is recommended. Data from the United States provides
a baseline for the increased risks of a surgical site infection (SSI) from clean wounds at
1– 5% through to dirty or infected wounds at greater than 27% (Phillips2021; Fuller2022).
Allergic reactions to foreign materials, such as a local anaesthetic and wound
dressing, will prolong the inflammation phase of wound healing and cause a local
response at the wound site or a systemic response that includes airway obstruction
and cardiac dysrhythmias (Phillips2021, p.564). Allergies or other side effects of any
prescribed dressing should be documented and reported through the National Yellow
Card Reporting System.
Systemic Factors
The aging process can lead to a loss of skin turgor, decreased muscle tone and reduced
elasticity (Phillips2021, p.563). As an individual age, the blood supply to the tissues
is reduced, although this can also be related to other factors such as smoking, which
leads to local ischaemia and reduced oxygenation to the cells required for wound
healing and prevent the wound from healing (Phillips2021; Fuller2022). Tissue per-
fusion can also be reduced by the suture tension on aged skin and the application of
wound- closure strips should be considered to support the wound (Phillips2021).
Chronic diseases such as diabetes, coronary artery disease, radiation therapy and
chemotherapy interrupt angiogenesis at the proliferation phase and, as a result, delay
the wound healing process (Doughty and Sparks2016)
An individual’s nutritional status can impact the wound healing process due to
the requirements of proteins needed for the generation of new tissues (Bak2018). In
addition, carbohydrates, zinc and vitamins A, B, C and K are required and any defi-
ciencies impair the wound healing process (Phillips2021).
Defined as a body mass index (BMI) of 30+ (NICE2014) obesity can significantly
increase the risk of wound healing delays. Wound closure is more difficult due to the
higher levels of adipose tissue and the operating surgeon may need to place drains
and sutures in the subcutaneous fat, thus increasing the risk of infection
104 Chapter 9 Wound Management
(Phillips2021). Adipose tissue is also less vascularised leading to insufficient oxygen-
ation and nutrition required for wound healing (Fuller 2022) and furthermore
increases the risk of trauma and infection (Phillips 2021). Obesity also leads to
respiratory and cardiovascular compromise that can lead to wound complications and
delays in wound healing (Phillips2021; Fuller2022).
Biopsychosocial Factors
As described by Holloway etal. (2020, p.177), these factors that affect wound healing
may include ‘pain, anxiety, depression, cognitive changes, sleep disturbances and
anorexia’ and as indicated below highlight the importance of a comprehensive pre-
operative assessment to ensure that the care provided minimises the risk of wound
healing complications.
WOUND CARE
It is important to note that while the PCC (2018) identifies that one of the responsibil-
ities of the SFA’s role extends to application of dressings, application of some dress-
ings may fall outside the SFA’s scope of practice: exceptions include but are not limited
to those that require additional specialist training, for example, application of splints
and plaster casts. Most dressings, including medicated ones such as those that contain
antibiotics, fall under the Medicines Act (1968, PARTVIII 5b) and will need to be pre-
scribed as per national and local formularies. Dressings should only be applied by
trained practitioners following local wound management policy and manufacturer
guidance to ensure appropriate selection and application. A multidisciplinary team
approach that may include, tissue viability nurse specialists and pharmacists, is bene-
ficial in deciding the best course of treatment in complex wound management and
medical photography may be useful to record wound changes.
A dressing is applied to most surgical wounds at the end of a procedure under strict
aseptic technique and before drapes are removed. Adjuvant unsterile dressings such as
bandages may be applied after the removal of drapes. As discussed in Chapter 5, the
decision to close the wound is made by the surgeon on a number of factors, including
wound classification. A clean wound will most likely undergo primary closure at the
time of surgery and will require a simple adhesive dressing. A contaminated or infected
wound is likely to be left open to allow healing by secondary intention and will be packed
by the surgeon and an absorbent pad applied to cover the wound and absorb exudate.
Although some surgeons debate whether a dressing is always required after surgery,
NICE (2020) recommends that an interactive dressing, that promotes wound healing,
should be applied to an incision at the end of the operation. Sterile saline should be used
for wound cleansing. Surgical wounds should not be disturbed in the first 48 hours as
this can introduce contaminants to the wound and damage the new delicate layer of
epithelium that forms during this time and seals the wound (Dealy2008). If a change or
removal of dressing is required earlier than 48 hours, for example in the case of bleeding,
Wound Assessment 105
then the surgeon should be consulted in the first instance and an aseptic non- touch
technique must be used (NICE2020). After this time, unless indicated otherwise by the
surgeon, the patient may be advised to shower after 48 hours using tap water (NICE2020).
PATIENT EDUCATION
In order for patients to make an informed decision regarding their surgery, patients
and their carers or guardians should be provided with pre- operative information on
how to look after their wound after surgery (NICE2020). This is especially important
in the modern healthcare setting where patients are discharged home much earlier in
their recovery and wound care may be provided by the patient and family members
(Bak2018). NICE (2020) recommends that patients are given advice on how to recog-
nise a wound infection or other complications. They should also be given details of
who to contact if they are concerned about their wound.
WOUND ASSESSMENT
The location, type and potential complications provide the basis for surgical wound
assessment and management. The wound should be assessed prior to dressing and
during any wound inspection or change of dressing, postoperatively. There are several
wound assessment tools that can be used to assess a wound. Cox’s (2019) approach to
wound assessment is detailed below:
• Anatomic location
• Type of wound
• Degree of tissue damage
• Wound bed
• Wound size
• Wound edges and peri- wound skin
• Signs of infection
• Pain
Anatomic Location andType ofWound
For surgical wounds, the location and type of the wound will be clearly identified,
documented and confirmed in the sign- out stage of the NatSSIPS2 (CPOC 2023).
While this chapter only considers surgical wound management, it is worth noting
that the patient may have concomitant wounds, for example, lacerations following
trauma or a pressure ulcer, that may also need to be assessed and dressed at the end of
surgery. An assessment tool, using correct anatomical terms and numbering, ensures
106 Chapter 9 Wound Management
that if more than one wound is present, the correct one can be assessed and treated.
Any newly identified wounds such as pressure ulcers or skin tears should be docu-
mented and reported to the surgeon.
Degree ofTissue Damage
Identifying the type and extent of tissue damage of a surgical wound is not within the
responsibilities of the SFA; however, they have a role in assisting with haemostasis
prior to application of the dressing to reduce any wound complications. If the SFA
identifies any bleeding while applying the dressing or when evaluating the wound
after surgery then this should be reported to the surgeon immediately. The surgeon
can then review the wound management plan. For bleeding that does not cease, the
surgeon may take the patient back to the operating theatre for exploratory surgery to
find and control any sources of bleeding. Late bleeding up to 30days after surgery
indicates the presence of an SSI (Dealy2008). The infection will need to be managed
and the patient may need to return to the theatre for exploratory surgery to ligate
bleeding vessels (Quick etal.2014).
Wound Bed andEdges
Prior to applying the dressing, the SFA needs to confirm that where a wound is closed
by primary intention, the wound edges are well- approximated to allow migration of
epithelial cells. While some swelling is expected after skin closure due to the wound
healing response, the incision should be free from tension (Baker etal.2010).
When the surgeon packs a surgical wound to allow healing by secondary inten-
tion, then the cavity should be completely packed from the wound bed to the top of
the wound. Secondary dressings can be applied to secure the packing and absorb exu-
date (Bak2018).
Wound Size andPeri- wound
Assessment of the size of the wound allows for the selection of the correct size dressing.
Sterile rulers are available if a gauge is needed to confirm the size of a wound. The
dressing needs to be large enough to cover the whole of the surgical wound, but not too
long it extends beyond it. This is important to ensure excess moisture does not lead to
maceration of the peri- wound skin. For subsequent dressing changes, as the wound
heals and shrinks, a smaller dressing may be required. The tissue surrounding the wound
should also be assessed to identify its integrity and aid selection of an appropriate dressing.
Signs ofInfection
The patient’s normal flora, such as staphylococci bacteria, is the most common type of
microorganism that can lead to an SSI but other common sources of cross- contamination
during a surgical procedure are from the surgical team, environment and surgical