wound closure pearls daniel palmer, pa-c black hills orthopedic and spine center

Wound Closure PearlsDaniel Palmer, PA-CBlack Hills Orthopedic and Spine Center

Objectives

Understand the Principles of wound healing and closure

Demonstrate closure of Deep fascia, subcutaneous and dermal tissue layers

Demonstrate horizontal and vertical mattress, simple interrupted and running intradermal suturing techniques.

Understand the differences between suture and needle types and selection.

Basic Anatomy review

The skin

EpidermisDermisHypodermis Subcutaneous FatFascia

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Principles of wound healing Wounds heal side to side not end to end three phases of wound healing are:

inflammation, tissue formation and tissue remodeling

No flow no grow – healthy tissues need adequate blood supply

Smoking, diabetes, immune compromise, metabolic disorders, and poor nutrition slow wound healing

Tissue moisture is essential for wound healing Dirty wounds are destined for failure

Pearls when closing a wound

Pearls When Closing a Wound Approximate, Don’t Strangulate A Clean Wound is a Happy Wound –

remove foreign material and necrotic tissues

Inverted Edges Do Not Heal Close the Dead Space Maintain Tissue Moisture

Dead spaceAvoidance of trapping of fluid or air within tissue layers promotes wound healingSeromas can promote growth of microorganisms and limit tissue profusion. Especiallly common in the fatty layers

Primary wound Closure

Sterile field Anesthetic Suture and

needle Tissue forceps Needle

driver/holder Suture scissors Maybe a tissue

scissors Dressings

Equipment

Suture

Any strand of material used to ligate vessels and approximate tissues togetherIs vastly a surgeons preferenceSuture types have inherent basic principles

Size denotes the diameter of the suture material look at the number of 0s ie. 2-0 is larger than 3-0 – 00 vs 000

The smaller the size the smaller the tensile strength of the suture

Size and Tensile strength

Choose the suture with the smallest diameter that will maintain adequate tensile strength to keep wound approximated thru the healing process

Suture Characteristics

Monofilament Pass smoother thru

tissues causing less tissue trauma – great for vascular procedures

Harbor less organisms due to simple structure

Weaker than multistranded suture

Multifilament strands

Higher tensile strength

some are coated to allow for smoother passing thru tissues.

Absorbable vs non absorbable

Absorbable Sutures that lose their

tensile strength and break down within 60 days

Made from the collagen of healthy mammals or from a synthetic polymer.

Ie. Vicryl, Polysorb, gut, Monocryl, chromic,

Non absorbable Sutures that maintain

their tensile strength and do not breakdown within 60 days

Ie. Silk, nylon, wire, Fiberwire, Prolene, Nurolon, Ethibond, PDS

Needles

Cutting Cutting and reverse

cutting Both have triangular

bodies Effective in cutting

thru tough tissues but may not be best choice in fragile tissues.

Tapered Sharp and tapered point Not as durable as the

cutting needle in general Less tissue trauma Not as effective in tough

tissues due to needle strength

Perfect for intra dermal repairs and fragile tissues

Basic suturing techniques1. Simple interrupted skin sutures2. Running skin sutures3. Mattress suturing : vertical and

horizontal4. Subcutaneous and facial closures:

locking and barried sutures5. Running intradermal sutures

Knot tying All suture use the principle of the square

knot with variations: over under, under over

May use a “surgeons knot” – a double throw on first throw – helps to lock in the knot

Loop tensioning technique – 2 square knots usually adequate to

secure a stitch

Simple interrupted sutures

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Quick and effective for most wound typesMay be used in combination with a running pattern or a corner repair

Simple interrupted skin sutures

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Usually left in the skin for 7-14 days.

Simple running suture pattern

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Vertical mattress sutures

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Entry and exit points are stacked on same side of the woundExcellent for ensuring edges are inverted

Vertical Mattress

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Horizontal Mattress Sutures

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Excellent option for ensuring everted skin edgesGood tensile strengthMinimizes tissue trauma and circulation impairment

Horizontal Mattress

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Running subcutaneous sutures and Running intra dermal sutures

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Good for decreasing tension on dermal layer and avoiding wound dehiscenceSimilar technique in the running dermis pattern – may be reinforced with steri -strips

Running intradermal closure

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No sutures protruding from skinMay seal this with Dermabond and/or Steri- stripsA variant of this is to put a pulling stitch at each end or one end of the wound to tensionUsually you use a monofilament suture with a taper needle

Corner or tip stitch

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Decreases trauma to fragile tip of an angled wound Use skin hook and avoid trauma to tip of woundProne to necrosis

Corner wound closure

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Variant of horizontal mattressAvoid trauma to tip of skin to avoid necrosis

Running locking stitch

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May be used for skin closure but caution due to vascular compromiseEffective suture for fascial closures

Keep wound clean May need to

immobilize wounds under tension ie. Flexor and extensor surfaces

Keeping wound moist ie. Vaseline

Keeping wound covered to avoid contamination

How long to keep sutures in?

How to minimize scaring?

Is it infected?

Pearls for mound management post closure

THANK YOU