The most important single factor causing com-plications and bad results where surgery, whether it be incision or flap transfer, has other-wise been soundly planned and adequately car-ried out is haematoma. It provides a culture medium for organisms which in its absence would merely be commensals, and is readily converted into a collection of pus. Even in the absence of infection its presence adds to the gen-eral tension of the wound.
It acts as a foreign body which, unless evacuated, becomes organ-ised, producing fibrosis and adding to scar tissue formation. It is generally true that in a wound with an adequate blood supply and no obvious source of contamination, the occurrence of infection can nearly always be traced to haematoma. Indeed it is remarkable just how much contamination a wound can tolerate without clinical sepsis where there is no haematoma.
The aspects of haematoma specific to its occur-rence in flap transfer are discussed in future article. Present discussion is concerned with the more general considerations of its prevention and management. Even with the greatest care it is not always possible to avoid haematoma, and the problem of treatment then arises.
One’s natural instinct is to evacuate the clot as soon as it is diagnosed, but while early evacuation is sometimes effective the bleeding which gave rise to the original haematoma is apt to begin again and cause recurrence. In addition the suture line has to be opened enough to allow extrusion of the haematoma and the handling, pressure, etc., needed to squeeze out the fairly solid clot has an unfortunate habit of causing further wound dehiscence.
An alternative method of managing the situa- tion is to await natural liquefaction of the clot, and aspirate it through a polythene intravenous cannula inserted obliquely at a distance from the suture line. At this stage there is no tendency to fresh bleeding and recurrence of the condition. The problem is that liquefaction can take up to 10 days, and in the interval it may become infected.
Where a potential dead space is unavoidable, the use of suction drainage is the most effective prophylactic. Apart from its effect-iveness, it has the virtue, in contrast to the use of pressure dressings which hide the situation until the haematoma is well established, of allowing the local state to be continuously monitored. It should be noted, in addition, that the use of antibiotics as prophylaxis against infection is of no value in the presence of a haematoma, management of which is surgical rather than medical.