wound closure pearls daniel palmer, pa-c black hills orthopedic and spine center
TRANSCRIPT
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
Click icon to add picture
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
Click icon to add picture
Quick and effective for most wound typesMay be used in combination with a running pattern or a corner repair
Simple interrupted skin sutures
Click icon to add picture
Usually left in the skin for 7-14 days.
Simple running suture pattern
Click icon to add picture
Vertical mattress sutures
Click icon to add picture
Entry and exit points are stacked on same side of the woundExcellent for ensuring edges are inverted
Vertical Mattress
Click icon to add picture
Horizontal Mattress Sutures
Click icon to add picture
Excellent option for ensuring everted skin edgesGood tensile strengthMinimizes tissue trauma and circulation impairment
Horizontal Mattress
Click icon to add picture
Running subcutaneous sutures and Running intra dermal sutures
Click icon to add picture
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
Click icon to add picture
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
Click icon to add picture
Decreases trauma to fragile tip of an angled wound Use skin hook and avoid trauma to tip of woundProne to necrosis
Corner wound closure
Click icon to add picture
Variant of horizontal mattressAvoid trauma to tip of skin to avoid necrosis
Running locking stitch
Click icon to add picture
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