Basic techniques

1. Basic techniques That somehow everyone doesn’t know

2. Wound care priorities • Discover and treat injuries to critical deep structure • Cover critical structures with skin • Maintain function without contracture • Prevent infection • Cosmesis is a distant fifth priority

3. Basic techniques • Managing contaminated wounds • Wound eversion • Inverted dermal sutures as primary closure • Instrument tying

4. Managing contaminated wounds • Never close an infected wound • If wound merely contaminated, clean it up and then make a decision for primary, secondary or tertiary (delayed primary closure)

6. Timing of delayed closure in contaminated wound

7. Managing contaminated wounds • Debride all dead or marginal tissue (if unsure cut a little, does it bleed?) • Remove all foreign debris • When irrigation needed use either a hydrostatic irrigator or a 10 cc syringe with an 18 ga angicath or Zerowet

9. Klenzalac irrigation tray

10. Managing contaminated wounds • If wound is over 6 hours old and exudative, prep it, then gram stain it for white cells and/or bacteria • Frequently, where there are no important structures and skin is loose enough to avoid tension, better simply to excise a dirty wound, then close it

11. Wound excisionScore skin in ellipse

12. Excise wound with scissors or scalpel

13. Undermine excised wound to allow eversion on closure

14. Evert to allow flat scar after healing

18. Use dermal stitches as primary closure • allows natural eversion from technique • tissue 1/2 life of about a month allows for far longer support for healing than skin sutures • after dermal layer placed, often can close skin with rapid techniques (tapes, running suture, glue)

19. Wound is weakest when skin sutures are removed

20. Use dermal stitches as primary closure • Wound must be clean • Technically a little more difficult than skin sutures

26. Instrument tie • Surgeon’s knot • Follow with at least three square throws • Granny knots will lead to untieing

27. Driver in middle, two overhand throws

28. Grab loose tail

29. Cross hands to lay flat

30. Finish by • Placing needle driver between tails • single overhand throw, grasp loose tail • cross hands to lay flat • at least 3 more throws