Care of Surgical Wounds in Children

Overview

When the skin barrier is disrupted during surgery, a surgical wound is created. Depending on the extent of the surgery, these wounds can be tiny, such as when a catheter or laparoscope is passed through the site, or large, such as when the sternum (breastbone) is opened for heart surgery. Wounds may be left to close “primarily” (on their own) or brought together using sutures (“stitches”), surgical glue, staples, and/or adhesives, such as butterfly bandages. Occasionally, wound drains or wound vacuums (“wound vacs”) are left in place temporarily during the healing process. All surgical wounds need time and care to heal properly, and they may appear pink-red with raised edges during the healing process. Stress on the wound site (such as bending or stretching) can make it harder to heal. Do not advise patients to use alcohol, hydrogen peroxide, or apply creams or ointments to the site unless advised to do so by the surgical team.

ICD-10 Coding

Managing Dressings

For larger wounds covered with bandages, the surgical team should provide instructions on how long to keep the area dry and when the bandage should be changed or removed. Due to the different types of bandages and wounds, it is not possible to provide uniform recommendations. Specialized wound care devices such as wound vacuums or drains require ongoing monitoring and care by skilled medical professionals.

Removing Butterfly Bandages

For wounds covered in butterfly bandages (often called Steri-Strips), the surgical team should provide directions about how long to keep the sites clean and dry, and when to resume showering versus bathing. The skin’s natural oils will loosen the adhesive over time, and then the strips will fall off or be easily removed, generally in about 7-14 days. If butterfly bandages do not come off as expected, adhesive removers may be used. They should not be removed by pulling quickly, as is common practice with Band-Aids, because the adhesive is stronger and can damage the underlying skin if this is done. If the strips fall off before the recommended duration, they can be replaced one at a time at home or in a medical setting.

Removing Tissue Adhesive or Wound Glue

For wounds previously closed with tissue adhesive glue (often called by the brand name “DermaBond”), a clinician may need to trouble-shoot complications in the medical home setting.
Infections under the glue should be treated with oral antibiotics. Typically, the infection under the adhesive forces it open, allowing for wound care and cleansing. If the adhesive needs to be removed, apply petroleum jelly or antibiotic ointment for a half-hour to loosen it (see Using Tissue Adhesive for Wound Repair: A Practical Guide to Dermabond (American Family Physician)).

Removing Sutures and Staples

Sutures and staples come in different varieties, so the surgeon will need to provide the family instructions for how long to keep the area dry and when to come back for removal. It may be helpful to let families know that frequently, the removal of staples or sutures is bundled as part of the procedure, so there is no charge for the visit to remove them unless done by a different professional. For example, if a child has sutures (stitches) placed in the Emergency Room after a fall, he typically can get the sutures removed there without another visit fee. But if the primary care provider sees the child for follow-up and removes sutures or staples there, the primary care provider would generate a bill for suture or staple removal.
Some parents opt to remove the sutures at home. How to Remove Stitches (DrER.TV) is a video that demonstrates the removal of simple-interrupted and continuous-interlocking sutures. How to Remove Surgical Staples Video (EmpoweRN) is a video about the removal of post-operative staples.

Showering and Bathing

Showers and baths are not used interchangeably to cleaning wounds during healing. Showers are generally preferable to baths for cleaning wounds because showering washes bacteria down the drain, whereas in baths, one continues to sit in the wastewater. Typically, showering can be resumed much sooner because it does not submerge the wound or soften it as much as would occur while bathing in a tub or swimming in a pool. Showers are a good way to rinse the site and reduce bacteria on the skin, often with only soap and water. If unsure about showering or bathing, a sponge bath is a temporary way to cleanse the body after surgery.

Wound Complications

Retained Sutures

Absorbable suture materials should naturally break down during the healing process. This can take days to months, but usually no longer than 6 months. Retained absorbable sutures (sutures that accidentally do not get fully removed or don’t fully re-absorb) can cause local inflammation and may require the primary care provider or another skilled clinician to evaluate. It may be necessary to remove shallow retained sutures in clinic. The removal of retained sutures may require local anesthesia. If an abscess has formed, this would require incision and drainage and consideration of systemic antibiotics.

Wound Dehiscence

While healing, surgical wounds gradually regain tissue strength and regain about 80% of their former strength after several months. Along the way, wound edges may dehisce (separate prematurely) due to trauma, inadequate nutrition, sutures placed too tightly or too loosely, sutures removed too early, hematomas, or medications such as anti-inflammatories and immune suppressants. Clean dehisced wounds may be re-sutured without re-opening or “freshening” the wound edges because the fibroblasts that are already at work should not be removed (see Surgical Wounds (Woundpedia)).

Wound Necrosis

In contrast, necrotic wounds need to be debrided, and systemic antibiotics should be considered. Once cleaned, necrotic wounds should close via secondary intention, and scar tissue can be addressed later for cosmetic reasons if needed.

Infections

Infections are a major concern of healing surgical wounds. Certain kinds of wounds may ooze or drain naturally and may be painful or itch while healing. Infected wounds may have increasing redness, drainage, swelling, induration, foul odor, increasing pain, lymphadenopathy (swollen lymph nodes), systemic illness, and/or new fevers. It is important for the surgical team to talk with families about recognizing complications such as an infection. The following care algorithm of the Infectious Diseases Society of America helps the clinician to manage suspected post-operative surgical wounds:
Algorithm for the management and treatment of surgical site infections (click image to see larger algorithm) [Stevens: 2014]
Wound Infection Algorithm
To summarize this algorithm, the Infectious Diseases Society of America 2014 guidelines advise: [Stevens: 2014]
  1. Suture removal plus incision and drainage should be performed for surgical site infections.
  2. Adjunctive systemic antimicrobial therapy is not routinely indicated, but in conjunction with incision and drainage, it may be beneficial for surgical site infections associated with a significant systemic response…, such as erythema (redness) and induration (firmness) extending >5 cm from the wound edge, temperature >38.5°C, heart rate >110 beats/minute, or white blood cell (WBC) count >12 000/µL.
  3. A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities with systemic signs of infection.
  4. A first-generation cephalosporin or an antistaphylococcal penicillin for MSSA, or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics), is recommended.
  5. Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract.

Granulation Tissue

While normal wound healing presents with a leading-edge, a raised and firmer border around the area that is gradually filling in with healing tissue, granulation tissue is an overgrowth of the small blood vessels supplying the healing tissue and impairs the wound from closing normally. Silver nitrate sticks are commonly used to reduce granulation tissue and may need to be reapplied multiple times before the wound fully closes, usually at 5-7 day intervals. Between cauterization, place dry gauze over the area, change the dressing 1-2 times per day, and advise showering daily to clean the area and rinse bacteria away. Granulation Tissue Treatment is a video demonstrating the use of silver nitrate to cauterize granulation tissue around a removed pilonidal cyst.

Scars

Scars will form where the skin has healed over a surgical wound. Over time the body typically transforms the pink, raised scar into a flat white line. Scars gradually decrease in size over the first year. Scars do not continue to get smaller after a year. Some people’s skin forms thicker scars called keloids. Using sunblock is a good idea to protect scars and healed skin. Some people use Vitamin E oil or other scar softening oils to rub into the site and promote faster repair. One’s health, age, weight, hydration, nutritional status, genetic factors, and lifestyle choices (such as smoking) all play a role in tissue healing and scar repair.

Resources

Information & Support

For Professionals

How to Remove Surgical Staples Video (EmpoweRN)
A 5 1/2-minute YouTube video demonstrating removal of surgical staples.

How to Remove Stitches (DrER.TV)
A 3-minute YouTube video by Dr. ER on suture removal.

Surgical Wounds (Woundpedia)
Recommendations on care of surgical wounds, based on systematic evidence review of surgical wound care guidelines.

For Parents and Patients

Frequently Asked Questions About Surgical Site Infections (CDC)
Concise answers to several common questions about infections after surgery; US Centers for Disease Control.

Practice Guidelines

Practice Guidelines (IDSA)
Searchable database of guidelines on various types of infections including skin infections and MRSA; Infectious Diseases Society of America.

Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC.
Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2014;59(2):e10-52. PubMed abstract
Diagnosis and appropriate treatment of diverse skin and soft tissue infections, ranging from minor superficial infections to life-threatening infections, such as necrotizing fasciitis. Contains algorithms for treatment of SSTIs and post-surgical wound care, plus Q & A on many related topics. Includes a dosing guide for antibiotics.

Patient Education

Let's Talk About... Steri-Strips: Wound Closure Tape (Spanish & English)
Patient education handout on home care for Steri-Strips; Intermountain Healthcare.

Let’s Talk About… Surgery, After Care (Spanish & English) (PDF Document 1.6 MB)
Intermountain Healthcare's patient education on taking care of a child after surgery. Answers common questions about eating and drinking, pain control, constipation, and care of wound dressings, etc; Intermountain Healthcare.

Helpful Articles

Bruns TB, Worthington JM.
Using tissue adhesive for wound repair: a practical guide to dermabond.
Am Fam Physician. 2000;61(5):1383-8. PubMed abstract

Authors & Reviewers

Initial publication: March 2021
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer: Sheryll Vanderhooft, MD

Page Bibliography

Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC.
Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2014;59(2):e10-52. PubMed abstract
Diagnosis and appropriate treatment of diverse skin and soft tissue infections, ranging from minor superficial infections to life-threatening infections, such as necrotizing fasciitis. Contains algorithms for treatment of SSTIs and post-surgical wound care, plus Q & A on many related topics. Includes a dosing guide for antibiotics.