Wound Healing and Suture Knowledge

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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
   UseProper 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
Dead Space
            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
Incision                                                      Healed


       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
Incision                                                  Healed


                                             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
                  Suture Patterns
   Simple Continuous
    – Usually used for lines no
      longer than 5”
    – Involves one diagonal pass
      and one perpendicular
      pass
    – Provide minimal tension-
      holding but hold tissue
      together in good apposition
                                    •More prone to failure if
    – Creates a good seal           any portion is broken
                   Suture Patterns
   Running
    – Both deep and shallow
      passes advance
    – Regularity more difficult
    – Slightly faster than a
      simple continuous pattern
    – Weaker than a simple
      continuous pattern
                  Suture Patterns

   Ford Interlocking
    – More stable in the
      event of partial failure
      or breakage
    – Provides greater
      tissue stability
    – Uses more suture
      material
                Suture Patterns

   Lembert
    – Closes hollow
      viscera
    – Provides inversion
      and creates a good
      fluid-tight seal
               Suture Patterns

   Halsted
    – Combination mattress
      and Lembert pattern
                Suture Patterns

   Connell
    – Begun with a single
      inverting vertical
      mattress suture
    – Continues for the
      length of the
      incision
                   Suture Patterns
   Cushing
    – Modified Connell
      where the needle and
      suture do not enter the
      lumen
    – Provides a better fluid-
      tight seal than the
      Connell pattern
                  Suture Patterns
   Parker-Kerr
    – A single layer of
      Cushing covered by a
      single layer of Lembert
    – Used for infected
      uterine stumps and
      some bowel closures
    – Provides complete
      clamping to prevent
      leakage during suturing
            Suture Patterns
– Rochester-Carmalt
  forceps are used to
  clamp the lumen
  shut and then
  slowly withdrawn
  while placed suture
  is tightened to
  prevent spillage of
  contents
                   Suture Patterns
   Guard
    – Modified Cushing
    – Closes incisions of the
      rumen, intestine, and
      uterus
    – Needle does not enter
      the lumen
    – Starts slightly higher
      than start of incision
                Suture Patterns

   Continuing
    Everting Mattress
    – Provides increased
      strength
    – Rapid placement
                  Suture Patterns
   Subcuticular
    – Does not penetrate the
      surface of the skin
    – Rapid and uses little
      suture material
    – Used to close the upper-
      most layer of the skin
      incision
    – Requires no suture
      removal
                Suture Patterns

   Subcutaneous
    – May use simple
      interrupted, simple
      continuous, or
      horizontal mattress
    – Simple continuous is
      fast and eliminates
      dead space
                 Suture Patterns

   Quilted
    – Exteriorized skin
      suture through plastic
      tubing to resist
      excessive tension and
      stress
    – Useful for high-tension
      closures
                Suture Patterns

   Far-far, Near-near
    – Tension pattern
    – Overlapping suture
      pattern provides
      extra strength but
      requires extra
      suture material
                Suture Patterns

   Near-far, Far-near
    – Tension pattern
    – Overlapping suture
      pattern provides
      extra strength but
      requires extra
      suture material
                Suture Patterns

   Mayo Mattress
    – Useful for midline
      abdominal closures,
      abdominal hernia
      repair, and
      secondary cleft
      palate repair
                Suture Patterns
   Bunnell
    – Used for apposing
      tendons
      »Requires a high degree
       of closure strength

    – Uses non-absorbable
      suture

    – Uses a double-armed
      suture
                  Suture Patterns
   Modified Bunnell
    – Used for apposing
      tendons
      » Requires a high degree
        of closure strength

    – Uses non-
      absorbable suture
    – Uses a single-armed
      suture
                 Suture Patterns
   Cerclage Wiring
    – Used for fracture repair
    – Wire/pin placed in the
      bone center to hold it
      together
    – Wire winds about the
      bone under the
      periosteum
                 Suture Patterns

   Hemicerclage
    – Wire goes through
      holes drilled in the
      bone
        Suture Patterns for Specific
                 Tissues
   Skin- simple interrupted, horizontal mattress,
    vertical mattress, continuous apposing or everting
   Subcutaneous tissue- simple continuous
   Fascia- simple continuous (primary), simple
    interrupted, vertical mattress, far-near, near-far,
    Mayo mattress
   Peritoneum- simple continuous (two-layer), and
    simple interrupted
    – Very thin and fragile in horse, close muscle instead
                 Suture Patterns
   Vessels- simple interrupted and simple continuous
   Viscera- direct appositional Cushing suture
   Muscle- simple continuous, simple interrupted, and
            horizontal mattress
   Tendons- Bunnell
   Bone- hemicerclage and cerclage
                         References
   Clinical Textbook for Veterinary Technicians; McCurnin, D.M.;
    W.B. Saunders Co., Philadelphia, 1994

 Ethicon Wound Closure Manual; Available at
  http://www.ethiconinc.com/wound_management/procedure/w
  ound/
    Fundamental techniques in Veterinary Surgery;
    Knecht, C.D.; Allen, A.R.; Williams, D.J.: Johnson, J.H.; W.B.
     Saunders Philadelphia, 1981
 Davis + Geck Veterinary Suture Manual, 1991

				
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