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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


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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


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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


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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


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Tissue Handling / Technique

  • blunt dissection between / along tissue planes

    • minimal trauma


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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


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Tissue Handling / Technique

provide gentle retraction with proper instruments


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Tissue Handling / Technique

  • Keep Tissue Moist

    “The solution to pollution is dilution”

    • Irrigate, rinse the incision surgery site

      • Lavage, irrigate body cavities


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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


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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



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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


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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


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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


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Wound Healing

  • Skin and fascia are the strongest but regain tensile strength quite slowly

  • Stomach and small intestine are weak, but heal quickly


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  • Physiology of Wound Healing

    Phases of Wound Healing

    • Inflammatory Phase

    • Migration /Proliferation Phase

    • Maturation Phase

Healed

Incision

Inflammatory

Migration /Proliferation

Maturation


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  • 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


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  • Physiology

  • Inflammatory Response

    • Clinical Signs

      • swelling

      • redness

      • warmth / heat

    • Course / Duration

      • peak within 24 hours,

      • subsiding by day 3

    • Inflammation results in pain / discomfort


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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


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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


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Wound Healing-Phases

  • Phase 2

    • Fibroblasts begin forming collagen fibers in the wound

      • Beginning of the return of tensile strength


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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


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  • 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


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Wound Healing-Phases

  • Phase 3

    • Sufficient collagen is now laid down to withstand normal stress


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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


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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


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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


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Closure / Suturing

  • Proper Suture

    • use minimal size suture that has sufficient strength

    • knot security

    • absorbable vs. non-absorbable


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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


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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!


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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


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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.


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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


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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


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Sutures

Absorbable

Absorbable suture holds temporarily but gradually loses tensile strength and is eventually mostly or completely absorbed


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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


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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


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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


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Conventional Cutting Needle

needle body is triangular and has a sharpened cutting edge on the inside

Primarily used for skin closure.


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Reverse Cutting Needle

cutting edge on outer curve

For tough, difficult-to-penetrate tissues


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Taper Point Needle

needle body is round and tapers smoothly to a point

Used for soft, easily penetrated tissues


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Blunt Point Needle

Taper body

For blunt dissection and suturing friable tissue


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Spatula Needle

flat on top and bottom with a cutting edge along the front to one side

Primarily used for eye surgery


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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


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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


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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


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Suture Patterns

  • Horizontal Mattress

    • Tightness should be such that the skin edges just meet


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Suture Patterns

  • Vertical Mattress

    • Tension suture

    • Stronger than the horizontal mattress

    • Time consuming and requires more suture material


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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


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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


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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

    • Creates a good seal

  • More prone to failure if any portion is broken


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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


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Suture Patterns

  • Ford Interlocking

    • More stable in the event of partial failure or breakage

    • Provides greater tissue stability

    • Uses more suture material


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Suture Patterns

  • Lembert

    • Closes hollow viscera

    • Provides inversion and creates a good fluid-tight seal


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Suture Patterns

  • Halsted

    • Combination mattress and Lembert pattern


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Suture Patterns

  • Connell

    • Begun with a single inverting vertical mattress suture

    • Continues for the length of the incision


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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


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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


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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


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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


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Suture Patterns

  • Continuing Everting Mattress

    • Provides increased strength

    • Rapid placement


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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


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Suture Patterns

  • Subcutaneous

    • May use simple interrupted, simple continuous, or horizontal mattress

    • Simple continuous is fast and eliminates dead space


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Suture Patterns

  • Quilted

    • Exteriorized skin suture through plastic tubing to resist excessive tension and stress

    • Useful for high-tension closures


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Suture Patterns

  • Far-far, Near-near

    • Tension pattern

    • Overlapping suture pattern provides extra strength but requires extra suture material


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Suture Patterns

  • Near-far, Far-near

    • Tension pattern

    • Overlapping suture pattern provides extra strength but requires extra suture material


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Suture Patterns

  • Mayo Mattress

    • Useful for midline abdominal closures, abdominal hernia repair, and secondary cleft palate repair


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Suture Patterns

  • Bunnell

    • Used for apposing tendons

      • Requires a high degree of closure strength

    • Uses non-absorbable suture

    • Uses a double-armed suture


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Suture Patterns

  • Modified Bunnell

    • Used for apposing tendons

      • Requires a high degree of closure strength

    • Uses non-absorbable suture

    • Uses a single-armed suture


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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


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Suture Patterns

  • Hemicerclage

    • Wire goes through holes drilled in the bone


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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


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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


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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/wound/

  • 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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