Wound Excision

Objectives

To provide guidance on the principles of surgical wound management in the deployed setting. This has previously been known as “debridement” but is now described as “wound excision”.

This CGO has been developed as a series of consensus statements agreed by Defence Plastic Surgery and Orthopaedic Surgery Consultants. These are listed below, along with explanatory notes. The objective of this guideline is to act as an aide memoire for the deployed clinician as to what the agreed “best practice” is. These guidelines are to be interpreted with reference to pre-deployment education and training. They are not designed to be an exhaustive manual of how to perform wound excision.

 

Context:

Contextual factors are fundamental to decision-making in the deployed setting. These guidelines have been written with the intention of providing helpful direction while, at all times, emphasising the importance of surgical judgement. Deviation from these consensus statements may be justified by a wide range of contextual factors that include, but are not limited to: tactical situation, timeliness and reliability of patient movement into and out of the facility, equipment and resource supply levels, and volume of cases.

Scope

This guideline applies to the management of combat injured patients within Role 2 and Role 3 settings only (deployed surgical care). Management of combat wounds prior to this is beyond the scope of this guideline. Management of these wounds at Role 4 should adhere to UK standards of practice.

Not all wounds encountered in the deployed setting require surgical care. This guidance applies only to those patients who require surgical management of their wounds as judged by the deployed team.

Audience

Members of deployed surgical teams

Initial Assessment & Management

Initial management of combat injured patients should proceed according to the CGO “Approach to the injured patient” (Link here when linked CGO is live).

Patients with burn injuries should be managed as per the “Burns” CGO (Link here when linked CGO is live).

Administration of Tetanus prophylaxis should be guided by the “Tetanus” CGO (Link here when linked CGO is live).

Clinicians must decide if wounds require formal surgical excision. Factors to include when making this decision include, but are not limited to:

  • Size and Depth: wounds that may be managed non-operatively include abrasions, superficial / extra-fascial wounds, uncomplicated narrow-channel wounds.
  • Complicating Factors: wounds involving underlying fractures, damage to important organs and structures, and infected wounds will require surgical management.
  • Physiological condition of the patient

Wounds that do not require surgical management can be treated under the direction of the Emergency Medicine Consultant with simple wound cleaning, pain relief, suture or steri-strip closure, and dressing as appropriate. Refer to the Deployed Antimicrobial Guidance regarding choice and need for antibiotics in these cases.

 

Record Keeping

At the initial assessment, the following information should be recorded for each wound:

  • Date / Time of injury
  • Mechanism of injury
  • Treatment so far
  • Antibiotic treatment given
  • Is there clinical suspicion of infection
  • Site / Size of the wound
  • General impression (e.g. “heavily contaminated”, “purulent discharge”, “significant necrosis”, “clean”, etc)

 

Photography: See consensus statement 4 below.

Advanced Assessment & Management

Kit and Equipment:

If wound excision is to be undertaken as part of Damage Control Surgery (DCS), the “DCS Set” contains all the required instruments.

If wound excision is to be undertaken in isolation, the “Debridement” set should be used in order to preserve stocks of DCS sets.

 

Additional Equipment:

  • Bowl and swabs for pre-operative decontamination
  • Appropriate fluid for irrigation
  • Suction
  • Diathermy
  • Dressings (see below)

 

Patients undergoing surgical management of combat wounds should receive pre-operative antibiotic prophylaxis, as directed by the Deployed Antimicrobial Guideline (Link here when linked CGO is live).

 

Consensus Statements:

 

1. Patients with combat wounds should undergo wound excision within the following timelines: As soon as possible for heavily contaminated wounds. Within 12 hours for high energy-transfer injuries. Within 24 hours for all other wounds requiring surgery.

Timing to surgical excision will be dictated by many factors. The detail of how each of these factors may affect the OPCP and subsequently timing and location of wound excision is outside the scope of these recommendations. NATO planning guidelines and JSP Health Service Support to Land Operations provide overarching doctrinal support. The OPCP should aim to deliver patients to surgical facilities within the timelines of 10.1.2(2)+2.

 

2. Wound excision should be undertaken in a surgical facility.

A “surgical facility” is defined here as wherever the deployed surgical team have designated as their “operating theatre”. This may be in a tented structure, aboard ship, on a suitable vehicle, in a building of opportunity, or any other designated location. Formal surgical wound excision should not take place forward of R2.

 

3. Gross contamination should be removed preoperatively by irrigation. Potable water is acceptable for this purpose.

Use enough fluid to remove all loose contamination. Be as thorough as resources allow. Some contamination will inevitably remain embedded in tissues and will require surgical removal.

 

4. Pre- and Post-excision wound photography is strongly encouraged as part of the patient record.

Electro-Med and operational Personal Electronic Device (PED) policy may be limiting factors but medical photography of the injuries is best practice and allows for accurate surgical planning. Seek guidance from the chain of command regarding the mechanism for capturing, storing, and transmitting these images. Every effort should be made by the deployed command team to facilitate this process.

 

5. Wound excision should be performed to remove all non-viable tissue. Nerves and blood vessels should be preserved wherever possible.

A systematic and meticulous approach should be used when undertaking wound excision. The aim is to remove all contamination and non-viable tissue. This is not a quick procedure so theatre utilisation and physiological consequences to the patient and must be accounted for.

The surgeon should proceed from superficial to deep, ensuring that all contamination and non-viable tissue are excised at each level: skin, subcutaneous fat, fascia, etc. A “clockface” approach is recommended at each level, whereby the surgeon works from “12 o’clock” around the wound to ensure comprehensive assessment.

If part or all of a limb is clearly beyond salvage, given the contextual factors, it must be excised in the same manner as any other non-viable tissue. It is not considered an “amputation” in the same manner as those performed in firm base-practice. See Consensus Statement 11 below.

Surgeon judgement is required to assess what is and is not viable tissue. Where there is doubt about the viability of tissue there should be an assumption that excision is safer than retention. However, nerves and blood vessels are a special case and should be preserved unless they are clearly beyond salvage.

 

6. At the primary excision, non-viable skin at the margins of the wound should be carefully excised to leave edges that bleed from the dermis. If the skin edges remain healthy, this does not need to be repeated during subsequent wound excisions.

Military wounds are dynamic and can change over time as the effect of blast or ballistic trauma can take delayed effects on the tissues. This phenomenon is called Progressive Tissue Necrosis (PTN). Wound assessment should take place at each surgical stage. Further excision is only necessary if previously viable tissue has advanced to become non-viable. Over excision during subsequent surgery will result in unnecessary removal of tissue.

7. In a mature operational patient care pathway (OPCP), serial marginal wound excision may be an appropriate strategy to avoid excessive removal of viable tissue in evolving complex wounds.

This consensus statement reflects the fundamental importance of contextual factors in how combat wounds are managed and is a modification of Consensus Statement 5. In very specific deployed settings where resources are plentiful relative to patient volume, the surgical decision-making may permit the retention of tissue with intermediate viability on the assumption that the patient will be able to return to theatre for further review and removal of tissue that has declared itself as non-viable. Where early return to theatre for serial excisions cannot be guaranteed, excision is safer than retention.

 

8. If acute compartment syndrome is suspected, manage according to the Acute Compartment Syndrome & Fasciotomy CGO
9. Where necessary, wound extensions should be along fasciotomy lines if possible.

Wound extensions, and their length, are determined by the size and shape of the wound as well as the need to access deeper structures. The surgeon must access the full extent of the wound cavity and explore tissue planes along which contamination can spread. If the wound is complicated by a fracture, wound extensions are required to allow full delivery of both ends of the bone out of the wound for irrigation and removal of contamination.

 

10. Skin degloving should be avoided. Wound extension should be in the sub-fascial plane.

Do not undermine skin.

 

11. Do not fashion flaps during primary excision, keep all viable tissue.

Anatomical flaps such as those fashioned for closing amputation residua are not indicated in the deployed setting. All viable tissue, regardless of anatomical pattern, should be retained. This maximises the reconstructive options available upon evacuation to definitive care.

 

12. Suture tagging of divided nerve and tendons is not required.

 

13. The status of neurovascular structures encountered during wound excision should be carefully documented.

 

14. It is not necessary to locate neurovascular structures solely in order to document their status.

The factors that determine the extent of the surgical excision are discussed in Consensus Statement 9. Neurovascular structures that lie outside the required surgical field should not be exposed unnecessarily.

 

15. Primary repair / reconstruction of tendons and nerves must not be performed at the primary excision. Definitive repair should be considered when the wound is undergoing delayed primary closure at a subsequent episode.

Nerves and tendon injuries may be managed at a later date, if necessary. They are of secondary importance to achieving a healed wound, and should not dictate the manner and timing of wound closure. Note that the word “considered” does not indicate any degree of compulsion, but permits an attempt at repair if the resources, equipment, and skill-set are available.

 

16. Bone fragments with a tenuous or no soft tissue attachment should be excised.

There is no role for the retention of devitalised bone fragments, no matter how orthopaedically important, in the deployed setting.

 

17. Intraoperative irrigation of contaminated wounds should be performed using copious low-pressure sterile saline, where resources allow. If sterile saline is unavailable, potable water may be used as an alternative.

During the excision operation, the wound should be copiously washed to attempt to remove any remaining contamination and colonisation. Use enough irrigation to achieve a "surgically clean" wound. Where resources allow, a minimum of 3 litres is recommended. Significantly higher volumes may be required in complex wounds. Normal saline is held in Role 2 modules and therefore should be used if resources allow. Systematic reviews (including a Cochrane review) have shown no increased rate of infection or effect on wound healing using tap water versus normal saline, and therefore potable water may be used as an alternative in resource-limited settings.

18. Do not use high pressure or pulsed lavage in the management of combat wounds.

High pressure lavage has been demonstrated to drive bacteria deeper into tissues, strip periosteum and cause tissue injury. It also requires additional equipment not found in surgical modules.

 

19. Following initial wound excision, use a simple dressing as follows: Non-adherent base layer in direct contact with the wound bed and edge. Cover with either an adhesive outer dressing or gauze/wool/crepe depending on size and location. This must be well secured.

Where available, negative pressure dressing systems may be used to manage complex and/or high-exudate wounds. However, these systems are not mandatory in the deployed setting.

A Cochrane review showed no benefit for NPWT versus conventional dressings, therefore deployed surgeons can confidently utilise conventional dressings as described above. Use a non-adherent interface (e.g. Jelonet or Mepitel, both of which are held at R2) between the wound bed and secondary absorbent gauze to prevent adherence which can cause pain and further damage the wound bed at the next change of dressing.

Do not underestimate the tendency for dressings to become displaced during patient evacuation. This can have significant negative effects for the patient and transport assets. Secure all dressings to withstand robust handling.

 

20. Surgeons should perform delayed primary closure at 3-5 days, if the following conditions are met:
  • No evidence of infection.
  • Tissues are healthy, with bleeding edges.
  • No evidence of deterioration since last excision surgery (no new necrotic or infected tissue).
  • The wound can be closed without excessive tension

If these conditions are not met, the patient requires re-excision surgery.

Wounds should ideally be reassessed at 24-48 hours to assess for the above. At each stage the wound should be irrigated and new dressings applied.

Ensure that record-keeping and photography, as described above, are undertaken at each surgical event.

 

21. Some low energy-transfer, narrow channel, and superficial wounds do not require full surgical excision.

Refer to the CGO Gunshot Injuries to Extremities for further guidance.

Prolonged Casualty Care

This is covered in the Consensus Statements above.

Paediatric Considerations

This guidance applies equally to children as to adults.

Last reviewed: 18/12/2025

Next review date: 18/12/2026

Version: 1.0

Related resources

Red Cross: WAR WOUNDS: BASIC SURGICAL MANAGEMENT. International Committee of the Red Cross, 1994. Robin Gray. War wounds : basic surgical management

 

The Red Cross Wound Classification: Robin Coupland. The Red Cross Wound Classification | International Committee of the Red Cross

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Evidence method

The literature supporting the historic consensus statement paper was reviewed and new literature was discovered via literature review for each consensus statement.