A 64-year-old woman undergoes elective inguinal hernia repair. The patient has had a left inguinal hernia for the past several years, but it recently increased in size, became more uncomfortable, and began affecting her daily activities. Medical history includes hypertension, hyperlipidemia, and a previous cesarean delivery. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits, and physical examination is unremarkable except for a reducible left inguinal hernia. After consideration of the surgical options, the patient undergoes a nonmesh open hernia repair with no intraoperative complications. At discharge, the patient is advised to limit strenuous physical activity to prevent wound disruption. Which of the following will provide the maximum tensile strength to this patient's wound?

Question

A 64-year-old woman undergoes elective inguinal hernia repair.  The patient has had a left inguinal hernia for the past several years, but it recently increased in size, became more uncomfortable, and began affecting her daily activities.  Medical history includes hypertension, hyperlipidemia, and a previous cesarean delivery.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits, and physical examination is unremarkable except for a reducible left inguinal hernia.  After consideration of the surgical options, the patient undergoes a nonmesh open hernia repair with no intraoperative complications.  At discharge, the patient is advised to limit strenuous physical activity to prevent wound disruption.  Which of the following will provide the maximum tensile strength to this patient's wound?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8bb_b607_bc81_c1188f2f7e30_MD0003_00 Acute wounds, such as those created during elective surgical procedures (eg, inguinal hernia repair), transition through an organized wound-healing process to restore tissue continuity and tensile strength. This occurs in 4 phases, which are sequential but have significant overlap, as follows: Hemostasis, which occurs immediately after tissue injury, involves small vessel constriction, platelet aggregation, and clotting cascade activation, leading to hemostatic plugging and cessation of bleeding. Clot formation provides a fibrin matrix scaffold for subsequent wound healing but little to no tensile strength for the wound (Choice C). Inflammation, which usually starts within hours of the injury and lasts approximately 5 days, results in increased vascular permeability and cellular recruitment (eg, neutrophils, macrophages). During this phase, there is often swelling, redness, and/or warmth of the wound and nearby soft tissues. Proliferation begins during the inflammatory phase and continues afterward. During this phase, a superficial epithelial layer forms to act as a barrier against bacteria. In addition, fibroblasts proliferate and synthesize type III collagen and ground substance, forming an amorphous gel into which new capillaries can grow. This initial collagen is disorganized and without covalent cross-links, so the wound has low tensile strength (Choice B). Maturation, the final phase of wound healing that occurs between approximately 3 weeks and 2 years, results in replacement of type III collagen with thicker type I collagen, reorganization of collagen fibers along tension lines, and covalent cross-linking of collagen subunits. These are the primary mechanisms by which the tensile strength of the wound increases. It typically takes at least 6 weeks for surgical wounds to regain most (~80%) of their original tensile strength; therefore, patients are often advised against strenuous activity during that period. (Choice D) During the proliferation phase, some fibroblasts differentiate into myofibroblasts. By contracting (via contractile proteins), myofibroblasts can help approximate wound edges and/or decrease wound size; however, they do not provide significant tensile strength to the wound. (Choice E) The superficial epithelial layer formed during reepithelialization restores the skin's protective barrier. However, it can be easily traumatized and has little tensile strength. Educational objective: Surgical wounds proceed through 4 phases of wound healing: hemostasis, inflammation, proliferation, and maturation. Collagen production begins during the proliferation phase. Collagen remodeling and cross-linking, which are most responsible for the wound's final tensile strength, occur during the maturation phase. References: The role of wound healing and its everyday application in plastic surgery: a practical perspective and systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25289204)

A 64-Year-Old Woman Undergoes Elective Inguinal Hernia Repair