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Wound Healing and Suture Knowledge. ASR Certification Prep. Kim Bayer, SRS, BS, CVT, LATg. Tissue Handling / Technique. Goal is to minimize trauma Gentle use minimal tension with tissue Retractors should be placed to avoid excessive tension Proper use of instruments DO NOT CRUSH
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Wound Healing and Suture Knowledge ASR Certification Prep Kim Bayer, SRS, BS, CVT, LATg
Tissue Handling / Technique Goal isto minimize trauma • Gentle • use minimal tension with tissue • Retractors should be placed to avoid excessive tension • Proper use of instruments • DO NOT CRUSH • Use Proper Technique • Keep Tissue Moist • Dry tissue is dead tissue • Minimize Time
Incisions • Heal side-to-side, not end-to-end • There is little advantage to making an incision too small to easily view the surgical site
Tissue Handling / Technique • Different surgical techniques induce different levels of damage • cutting with sharp instrument • minimal traumatic • cuts / divides the cells • little adjacent cell damage • cutting with scissors • causes crush and tear trauma • relatively traumatic • adjacent cell damage
Tissue Handling / Technique • blunt dissection between / along tissue planes • minimal trauma
Tissue Handling / Technique • clamping tissue with hemostats / etc. • causes crushing of the cells • very traumatic • causes release of vasoconstrictors, clotting factors • proper for clamping vessels for ligation / hemostasis
Tissue Handling / Technique provide gentle retraction with proper instruments
Tissue Handling / Technique • Keep Tissue Moist “The solution to pollution is dilution” • Irrigate, rinse the incision surgery site • Lavage, irrigate body cavities
Hemostasis • Bleeding should be stopped whenever possible • Excessive bleeding may cause hematomas or increase dead space • Hematomas prevent wound apposition and retard healing • Blood is a natural food for micro-organisms and a large clot will help protect them from the body’s immune system • Bacteria inside the clot will be protected • Bleeding may be slowed or stopped by applying pressure, clamping, electro/thermocautery, and with various chemicals • Excessive pressure may lead to tissue necrosis
Dead Space and a Clean Wound • Remove all non-essential material • Wounds with excessive debris should be thoroughly lavaged with an appropriate sterile fluid (isotonic saline, LRS, Tis-U-Sol, etc.) to flush them away • Dead Space is an open area in closed tissue • Filled with room air, it prevents tissue apposition, provides a space for blood and other fluid influx, and may harbor micro-organisms
Classification of Wounds • Clean • Standard surgical wound • Clean-contaminated • Clean wounds that are contaminated by entry into a viscus resulting in minimal spillage of contents • Contaminated • Lacerations, fractures, gross spillage from the GI tract, resulting from a break in aseptic technique • Within 6 hours of initial colonization a wound can be infected
Classification of Wounds • Dirty-infected • Caused by perforated viscera, abscesses, or a prior clinical infection • Ongoing infection at time of surgery may lead to a 400% increase in infection rates
Problems • Infection • The source of infection should always be determined • Before closure of an infected wound the wound should be drained, debrided, and a small opening or drain left in • Dehiscence • Wound reopens • May result from too much tension on tissue, improper suturing technique, or improper suture materials
Wound Healing • Skin and fascia are the strongest but regain tensile strength quite slowly • Stomach and small intestine are weak, but heal quickly
Physiology of Wound Healing Phases of Wound Healing • Inflammatory Phase • Migration /Proliferation Phase • Maturation Phase Healed Incision Inflammatory Migration /Proliferation Maturation
Physiology of • Wound Healing • Inflammatory Phase • 0 - 5 Day • can be prolonged • inflammatory and “clean-up” process • plasma, cells, fibrin, blood components • neutrophils, monocytes • remove debris • “remove the trash” • epithelialization / migration (as early as 48 hours) • clinically characterized by swelling, redness, warmth • strength due to suture Incision Inflammatory
Physiology • Inflammatory Response • Clinical Signs • swelling • redness • warmth / heat • Course / Duration • peak within 24 hours, • subsiding by day 3 • Inflammation results in pain / discomfort
Wound Healing-Phases • Phase 1 • Inflammatory response causes an outpouring of tissue fluids, accumulation of cells and fibroblasts, and increased blood supply • Leukocytes produce enzymes to dissolve and remove damaged tissue debris
Wound Healing-Phases • Phase 1 (day 1 to 5) • Inflammatory response phase • Fluids flow into the wound and a scab forms • Localized edema, pain, fever, and erythema present • Basal cells migrate over the incision from the skin to cover the wound • Closure material is the primary source of tensile strength
Wound Healing-Phases • Phase 2 • Fibroblasts begin forming collagen fibers in the wound • Beginning of the return of tensile strength
Wound Healing-Phases • Phase 2 (day 5 to 14) • Fibroblasts migrate toward the wound site • Begin forming collagen fibers • Tensile strength rapidly increases • Lymphatics recanalize • Blood vessels bud • Granulation tissue forms • Capillaries develop
Physiology • Maturation Phase • begins ~ day 14 and continues for months • collagen fibers become oriented along the “stress” line of the incision and form crosslinks • increases tensile strength • contraction Healed Incision Maturation
Wound Healing-Phases • Phase 3 • Sufficient collagen is now laid down to withstand normal stress
Wound Healing-Phases • Phase 3 (day 14 until done) • Tensile strength continues to improve for as long as one year • Skin regains 70 to 90% of its original strength • Collagen content remains constant but cross-links with other fibers • Scar is formed which grows paler as new vessel construction tapers off • Wound contraction occurs over a period of weeks or months
Wound Healing Types • First Intention • Wound edges brought together during closure at the time of surgery • Second Intention • Wound is left open and heals from the bottom up • Slower than first intention and creates more granulation and scar tissue • Third Intention • Wound is initially not closed and remains open until a granulation bed formed, then the granulated tissue is closed using standard techniques • Useful in infected wounds • Infected tissue should not be closed or it will dehiss • Infection is resolved naturally, or with topical and systemic treatments
Closure / Suturing • Proper Apposition • Restore alignment of the tissues • close / decrease dead space • balance adequate closure with too much suture • suture is a foreign body and too much can effect healing
Closure / Suturing • Proper Suture • use minimal size suture that has sufficient strength • knot security • absorbable vs. non-absorbable
Sutures • Ideal suture material • All-purpose, composed of material which could be used in any surgical procedure (the only variables being size and tensile strength) • Sterile • Nonelectrolytic, noncapillary, nonallergenic, and noncarcinogenic • Nonferromagnetic, as is the case with stainless steel sutures • Easy to handle
Sutures • Ideal suture material • Minimally reactive in tissue and not predisposed to bacterial growth • Capable of holding securely when knotted without fraying or cutting • Resistant to shrinking in tissues • Absorbed with minimal tissue reaction after serving its purpose • Doesn’t exist!
Sutures • Surgeon should select suture materials for • High uniform tensile strength (quality) • Permitting use of finer sizes • Suture should be the smallest diameter that will do the job • Consistent uniform diameter • Sterile • Pliable for ease of handling and knot security • Freedom from irritating substances or impurities for optimum tissue acceptance • Predictable performance
Sutures • Size • Generally stated in “oughts”; i.e., 3-0, 5-0, etc. • 2-0 is larger than 4-0, 0 is larger than 2-0, etc. • Some suture and wire is larger than 0, then numbered 1 and higher • 2 is larger than 1, 6 is larger than 1, etc. • From smallest to largest: • 7-0, 3-0, 0, 1, 3, 7, etc.
Sutures Monofilament Monofilament is a single strand • Passes through tissue easily, won’t harbor micro-organisms • Ties easily • May be weakened by crushing (clamping in forceps or needle holders) • Has more “memory” • Continues to hold the shape as it lay in the package • Good for percutaneous sutures • Knots may slip over time due to the slipperiness of the suture
Sutures Multifilament Multifilament is a bundle of strands, like rope • Affords greater tensile strength, pliability, flexibility, and knot security • May harbor micro-organisms and “wick” them down the suture • Should not be used for percutaneous sutures
Sutures Absorbable Absorbable suture holds temporarily but gradually loses tensile strength and is eventually mostly or completely absorbed
Absorbable Sutures Surgical Catgut: Plain or Chromic Absorbed by proleolytic enzymatic digestive process. Polyglactin 910 : Vicryl® Polyglycolic acid: Dexon® Poliglecaprone 25: Monocryl® Polydixanone: PDSII® Polyglyconate: Maxon® Absorbed by Hydrolysis
Sutures Nonabsorbable Nonabsorbable suture will retain tensile strength and not be absorbed • Many nonabsorbable sutures (silk) will lose some tensile strength over time • Useful for device fixation, areas of extreme tension, slow healing areas, or percutaneous skin sutures • Selected for procedures where the suture should be permanent
Non-Absorbable Sutures Monofilament Polypropylene: Polyester Fiber: Mersilene®, Dacron®, Ethibond®, Ti.cron® Monofilament Nylon: Ethilon®, Dermalon® Braided Nylon: Nurolon®, Surgilon® Silk Surgical Stainless Steel Wire
Conventional Cutting Needle needle body is triangular and has a sharpened cutting edge on the inside Primarily used for skin closure.
Reverse Cutting Needle cutting edge on outer curve For tough, difficult-to-penetrate tissues
Taper Point Needle needle body is round and tapers smoothly to a point Used for soft, easily penetrated tissues
Blunt Point Needle Taper body For blunt dissection and suturing friable tissue
Spatula Needle flat on top and bottom with a cutting edge along the front to one side Primarily used for eye surgery
Surgeon’s Knot • Extra throws do not add appreciable strength to the knot and may, in fact, weaken it while adding extra bulk • An initial double throw followed by one or two single throws is more than sufficient • The exception is nylon monofilament sutures, where two successive double throws are useful to prevent slippage
Suture Patterns • Simple Interrupted • Maintains strength and tissue position if one portion fails • Requires more time and suture material • Has minimal holding power against stress
Suture Patterns • Horizontal Mattress • Tension suture • Useful in skin of dog, cow, and horse • Rapid and involves less suture material • Difficult to apply without excessive eversion • Should pass just below the dermis
Suture Patterns • Horizontal Mattress • Tightness should be such that the skin edges just meet
Suture Patterns • Vertical Mattress • Tension suture • Stronger than the horizontal mattress • Time consuming and requires more suture material
Suture Patterns • Cross-mattress • Tension suture • Brings tissue into good apposition • Useful in suturing stumps (amputations) • Also useful for rib apposition and abdominal muscle closure
Suture Patterns • Gambee or Crushing • Useful in intestinal anastamoses • Permits minimal leakage • May reduce fluid passage through the lumen underneath • Crushing is similar to a vertical mattress pattern