Basic Surgical Skills Flashcards
1
Q
What are types of wounds?
A
- Clean
- Clean, Contaminated
- Contaminated
- Infected
2
Q
What would be considered a clean wound?
A
- Uninfected operative wound with no inflammation encountered
- No systemic tracts entered (respiratory, alimentary, etc.)
- Closed by primary intention and usually not drained
3
Q
What would be considered a clean, contaminated wound?
A
- Operative wound in which systemic tracts are entered under controlled conditions without contamination
- ie lung surgery, appendix, vaginal procedures
systemic tracts entered on purpose
4
Q
What would be considered a contaminated wound?
A
- Open traumatic wounds (open fracture, penetrating trauma)
- Operative procedures involving: spillage from GI, GU, or biliary tracts
- Break in aseptic technique (open cardiac massage)
- Microorganisms multiply so rapidly that a contaminated wound can become infected within 6 hours
5
Q
What would be considered a infected wound?
A
- Heavily contaminated/infected wound prior to operation
- Includes: perforated viscera, abscesses, wounds with undetected foreign body/necrotic tissue
6
Q
What is primary intention?
A
- optimal closure method
- Wound has no sepatation of edges and minimal scar formation
7
Q
What are the 3 phases of primary intention?
A
- Inflammatory
- Proliferative
- Remodeling
8
Q
Describe the inflammatory phase of primary intention
A
- Begins immediately and complete by days 3-7
- Initially hemostasis occurs
- Wound prepared for repair by extravasation of tissue fluid, cell, and fibroblasts; increased 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
9
Q
What happens during the proliferative phase of primary intention?
A
- Day 3 onwards
- Fibroblasts form collagen matrix
- Matrix becomes vascular, supplying nutrients and oxygen for wound healing
- Matrix determines tensile strength, which increases until wound able to withstand normal stress
- Wound contraction occurs
10
Q
What happens during wound contraction?
A
- Wound edges pull together to close wound
- If successful, smaller wound with less need for scar
- Beneficial in areas such as buttocks or trochanter
- Harmful in areas such as hand, neck, face–> disfigurement and scarring
- Skin grafting reduces contraction in undesirable locations
11
Q
Describe the remodeling phase of primary intention
A
- May continue for a year or longer
- Following deposition of collagen, vascularity decreases and scar becomes paler
- Resulting scar depends on initial volume of granulation tissue
12
Q
What is the percentage recovery of the tensile strength of a wound closing by primary intention at 2 weeks, 5 weeks, and 10 weeks?
A
- 2 weeks: 20%
- 5 weeks: 50%
- 10 weeks: 80%
13
Q
How is primary intention closure performed?
A
- Sutures
- Staples
- Tape/glue
14
Q
Why would secondary intention occur?
A
- Wound fails to heal by primary intention due to infection, trauma, tissue loss, or imprecise approximation of tissue
15
Q
Why would you not want to have a wound close by secondary intention?
A
- More complicated and prolonged than primary intention
- May have excessive formation of granulation tissue which contains myofibroblasts leading to wound contraction
- May protrude above wound surface, prevent epithelialization and thus require treatment
16
Q
What is delayed primary closure?
A
- Wound left open
- Used in management of contaminated and infected wounds with extensive tissue loss and high risk of infection ie trauma or penetrating injury
17
Q
What are steps taken in delayed primary closure?
A
- Debridement of nonviable tissue, usually under sedation
- Leaving wound open with gauze packing/wound vac
- Wound approximation within 3-5 days if no infection evident
- If infection present, wound allowed to heal by secondary intention
18
Q
What is the purpose of forceps?
A
Small toothed forceps grasp skin edges when suturing
19
Q
How do suture needle shapes vary?
A
From quarter circle to five-eighths of a circle, depending on how confined the operating field is
20
Q
What does the design of the suture needle tip impact?
A
sharpness and how easily it penetrates tissue
21
Q
What should choice of needle depend on?
A
- Tissue being sutured
- Ease of access to the tissue
- Individual preference
22
Q
When in doubt, what tip should be selected?
A
Taper for everything except skin sutures
* Taper for delicate tissues
* Reverse cutting usually for skin and tougher tissues
23
Q
Describe a taper or non-cutting needle
A
- Round body with sharp pointed tip
- Used for viscera, muscle, and light fascia
- Penetrates tissue, without cutting, creating round hole
- Should not be used for dense tissue like skin because of force needed to penetrate tissue
24
Q
What is a traditional cutting needle?
A
- Triangular shaped point with 2-3 cutting edges to facilitate penetration of dense tissue
- Cutting edge on inside of curve (concave surface)
- Cut edge is where tension is on tied suture, so predisposes suture to cutting through the tissue
- Use has been generally replaced with reverse cutting needle
25
Describe a reverse cutting needle
* Cutting edge on outer surface of the curve (convex surface)
* Most efficiently uses cutting surface when curve wrist during insertion
* More resistant to suture cutting through tissue because cut edge opposite to direction of tension on tied suture
* Decreases likelihood of sutures pulling through soft tissue
* Preferred by most surgeons
26
What are types of handling of a suture?
* Memory: able to return to previous shape after deformation, difficult to tie and knot unravels
* Elasticity: able to return to original length after stretching, high elasticity should be used in edematous tissues
* Knot strength: force required for knot to slip, important for ligating arteries
27
What is tensile strength?
* Force required to break a suture
* Important for areas of tension
28
Describe tissue reaction
* Undesirable to have reaction since inflammation worsens scar formation
* Maximal between day 3 & 7
29
What are properties of suture material?
* Monofilament vs multifilament
* Non-absorbable vs absorbable
* Tissue reaction
* Handling
* Tensile strength
30
What is the difference between a monofilament and a multifilament suture?
Monofilament:
* one smooth strand
* glides through tissues with less friction
* lower infection
* more likely to slip and should be secured with 5 or 6 throws
* preferred for skin closure due to cosmetic result
Multifilament
* Multiple fibers braided together
* Easier to handle, tie, and less likely to slip
31
What materials can be non-absorbable?
* Naturally occurring: silk, cotton/steel
* Synthetic: prolene, ethilon
32
What is done with non-absorbable sutures once they are in place?
* Left in place indefinitely (ie during closure of abdominal fascia)
* Removed following adequate healing (closure of superficial laceration)
33
What are absorbable suture materials?
Naturally occurring:
* Catgut: processed collagen from animal intestines, broken down after 7 days
* Chromic catgut: intestinal collagen with chromium, loses tensile strength after 2-3 weeks and broken down after 3 months
Synthetic:
* Vicryl: degraded non-enzymatically by hydrolysis, evoke less tissue reaction
34
As the number of the size of suture increases, what happens to the size?
It gets smaller
35
What would you use a size 7/0 and smaller suture for?
Opthalmology, microsurgery
36
What would you use a size 6/0 suture for? 5/0?
* Face, blood vessels
* Face, neck, blood vessels
37
What would you use a size 4/0 suture material for? 3/0?
* Mucosa, neck, hands, limbs, tendons, blood vessels
* Limbs, trunk, gut blood vessels
38
What would you use a size 2/0 for? Size 0 and larger?
* Trunk, fascia, viscera, blood vessels
* Abdominal wall, fascia, drain sites, arterial lines, orthopaedics
39
How soon should sutures of the face be removed?
3-4 days
40
How soon should sutures of the scalp be removed?
5 days
41
How soon should sutures of the trunk be removed?
7 days
42
How soon should sutures of limbs be removed?
7-10 days
43
How soon should sutures of the foot be removed?
10-14 days
44
What are steps in suture removal?
1. Reassure patient that shouldn't cause much pain
2. Cleanse incision site
3. Grasp one of the suture tails with forceps and elevate
4. 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)
5. Gently pull the knot with the forceps to remove and reinforce the wound with Steri-strips if required
