Basic surgical skills Flashcards
Types of Wounds/Classifications
- clean
- clean, contaminated
- contaminated
- infected
- Uninfected operative wound in which no inflammation is encountered and no systemic tracts are entered (respiratory, alimentary, etc)
- Closed by primary intention and are usually not drained
type of wound?
clean
Operative wound in which systemic tracts(s) are entered under controlled conditions and without contamination - Lung surgery, appendix, vaginal procedures
what type of wound
clean, contaminated
- Open traumatic wounds (open fracture, penetrating trauma)
Operative procedures involving:
- Spillage from GI, GU, or Biliary tracts
- A break in aseptic technique (open cardiac massage) - Microorganisms multiply so rapidly that a contaminated wound can become infected within 6 hours
what type of wound
contaminated
- Heavily contaminated/infected wound prior to operation
- Includes: Perforated Viscera, Abscesses, Wounds with undetected foreign body/necrotic tissue
what type of wound
Infected
types of Wound Healing
- Primary Intention
- Secondary Intention
- Delayed Primary
Primary Intention - 3 Phases
- inflammatory
- proliferative
- remodeling
Optimum closure method since wound heals in minimum time with no separation of its edges and minimal scar formation
has 3 phases
what type of wound healing
primary intention
what happens during the inflammatory stage during primary intention
- Begins immediately and completes by Days 3-7
- Initially, hemostasis occurs
- Then the wound is prepared for repair by:
- Extravasation of tissue fluid, cell, and fibroblasts
- Increasing blood supply to wound
- Debridement of tissue debris by proteolytic enzymes - Increase in tensile strength of tissue and wound healing is dependent on approximation of edges by closure material
what happens during proliferative stage during primary intention
- Starts from Day 3 onwards
- Fibroblasts form a collagen matrix
( granulation tissue ) - This matrix:
- Determines the tensile strength and pliability of the healing wound
- Becomes vascular, supplying the nutrients and oxygen necessary for wound healing - Tensile strength increases until wound is able to withstand normal stress
- Wound contraction occurs
what happens during wound contraction in proliferative phase of primary intention
- Wound edges pull together in order to close the wound
- If successful, it results in a smaller wound with less need for repair by scar formation
- Beneficial in areas such as the buttocks or trochanter
- Harmful in areas such as the hand, neck, and face
- Can cause disfigurement and excessive scarring - Skin grafting reduces contraction in undesirable locations
what happens during remodeling phase of primary intention
- May continue for a year or longer
- Following completion of collagen deposition, vascularity decreases and any surface scar becomes paler
- Resulting scar size is dependent upon the initial volume of granulation tissue
The percentage recovery of the tensile strength of the wound is:
- About 20% after 2 weeks
- About 50% after 5 weeks
- About 80% after 10 weeks
Primary Intention wound closure is performed with:
- Sutures
- Staples
- Tape/glue
secondary intention - Occurs when the wound fails to heal by primary intention due to:
- Infection
- Excessive trauma
- Tissue loss
- Imprecise approximation of tissue (Leaving dead space)
T/F: secondary intention is more complicated and prolonged than primary intention
T
during secondary intention, there may be excessive formation of granulation tissue which:
- Contains myofibroblasts leading to gradual but marked wound contraction
- May protrude above the wound surface, prevent epithelialization and thus require treatment
Used in management of contaminated and infected wounds with extensive tissue loss and high risk of infection - Trauma, penetrating injury
Delayed Primary Closure
steps for Delayed Primary Closure
- Debridement of nonviable tissue, usually under sedation
- Leaving wound open with gauze packing/wound vac system
- Wound approximation within 3-5 days of no infection is evident
- If infection is present, the wound is allowed to heal by secondary intention
proper way to hold forceps
- Small toothed forceps (Addison forceps) grasp the skin edges during suturing
- Hold in the first three fingers in a similar way to a pen
proper way to hold for needle-holder/needle-driver
- Grasp the needle-holder by partially inserting the thumb and ring finger into the loops of the handle
- The free index finger provides additional control and stability
Most suture material is swaged onto the base of the needle, why?
- suture permanently attached to the needle
- consistently sharp with known shape and durability (not damaged by previous use)
- convenient as threading not required
- more efficient as suture doesn’t pull out while suturing
Shapes vary from ?, depending on how confined the operating field is
1/4 circle - 5/8 of a circle
Choice of needle should “alter the tissue to be sutured as little as possible” and should depend on:
The tissue being sutured
- When in doubt of taper point or cutting needle, choose taper for everything except skin sutures.
- taper needles are usually preferred for delicate tissues
- reverse cutting needles are usually selected for skin and tougher tissues - Ease of access to the tissue
- Individual preference
- Have a round body with a sharp pointed tip
- Generally used for viscera, muscle and light fascia
- Penetrates tissue, without cutting, creating a round hole
which type of needle
Taper or non-cutting needles
Taper or non-cutting needles should NOT be used for ?
why?
dense tissue like skin because the extra force needed to penetrate the tissue causes extra trauma or bends the needle
- Triangular shaped point with 2-3 cutting edges to facilitate penetration of dense tissue
- Cutting edge is on the inside of the curve (concave surface)
- Cut edge is where the tension is on the tied suture so this type of needle predisposes the suture to cutting through the tissue
- Use has generally been replaced by the reverse cutting needle
Traditional cutting needle
which suture needle is preferred by most surgeons
Reverse cutting needle
- Cutting edge on outer surface of the curve (convex surface)
- More efficiently uses the cutting surface when curve wrist during insertion
- More resistant to suture cutting through tissue because the cut edge is opposite to the direction of tension on the tied suture
- Decreases likelihood of sutures pulling through soft tissue
which type of suture needle
Reverse cutting needle
3 types of Handling of a suture
- Memory (Nylon/PDS)
- Elasticity (Monofilament)
- Knot strength (Surgeon’s knot)
- Ability of suture to return to previous shape after deformation
- Leads to difficulty in tying sutures and knot unravelling
which type of handling of suture
Memory (Nylon/PDS)
- Ability to return to its original length after stretching
- High elasticity sutures should be used in edematous tissue
which type of handling of suture
Elasticity (Monofilament)
- Force required for a knot to slip
- Important to consider when ligating arteries
which type of handling of suture
Knot strength (Surgeon’s knot)
what is tensile strength
- Force necessary to break a suture
- Important to consider areas of tension
what is Tissue Reaction
- Undesirable since inflammation worsens the scar formation
- Maximal between Day 3&7
properties of suture material
- handling of a suture
- tensile strength
- tissue reaction
- non-absorbable vs absorbable
- nonfilaments vs multifilament
◦ Consists of a single smooth strand
◦ Less traumatic since they glide through tissues with less friction
◦ May be associated with lower rates of infection
◦ More slip and should be secured with 5 or 6 ‘throws
◦ Preferred for skin closure because they provide a better cosmetic
result
which type of filament
monofilamenet - PDS/monocryl/nylon
O Consist of multiple fibers braided together
O Easier to handle, tie and less likely to slip
Multifilament (Vicryl/Silk)
materials for non-absorbable suture
- Naturally occurring - (Silk (braided), cotton/steel
-
Synthetic
- Prolene(mono),
- Ethilon(nylon-mono)
when to remove/not to remove non-absorbable suture
- Left in place indefinitely (during closure of abdominal fascia)
- Removed following adequate healing (closure of superficial laceration)
Absorbable Suture Material
Composed of biodegradable materials which can be:
- Naturally occurring (degraded enzymatically)
- Synthetic (Vicryl)
types of Naturally occurring absorbable suture material
-
Catgut
- Consists of processed collagen from animal intestines
- Broken down after 7 days -
Chromic catgut
- Consists of intestinal collagen treated with chromium
- Loses tensile strength after 2-3 weeks and is broken down after 3 months
Absorbable Suture Material are subclassified according to ?
degradation time
- Consists of processed collagen from animal intestines
- Broken down after 7 days
what type of absorbable suture?
Catgut
- Consists of intestinal collagen treated with chromium
- Loses tensile strength after 2-3 weeks and is broken down after 3 months
what type of absorbable suture
Chromic catgut
- Degraded non-enzymatically by hydrolysis when water penetrates the suture filaments and attacks the polymer chain
- Tend to evoke less tissue reaction than those occurring naturally
which type of absorbable suture
Synthetic (Vicryl)
how is the sizing of suture material?
- Size originally scaled from 0-3
- As technology advanced and sutures became smaller, extra 0s were added
- Scale now ranges from 0 (largest) to 12/0 (smallest)
loading the needle driver
- Open the suture packet with one tear to reveal the needle
- Grasp the needle two-thirds the distance from its pointed end
- Avoid grasping the needle at its proximal or distal extremities since this will prevent damage to the suture
Sutures should be removed:
- Face: 3-4 days
- Scalp: 5 days
- Trunk: 7 days
- Limb: 7-10 days
- Foot: 10-14 days
Suture Removal - Procedure
- Reassure patient that the procedure is not painful (Subjective)
- Cleanse the incision site
- Grasp one of the suture ‘tails’ with forceps and elevate
- Slip the tip of the scissors under the suture knot and cut close to the skin edge (to minimise the length of contaminated suture that will be pulled through the wound)
- Gently pull the knot with the forceps to remove and reinforce the wound Steri-Strips if required
