CAL 2: Practical choices for suturing, surgical staples and tissue glue Flashcards
What would you use to close the linea alba after a laparotomy in a 25kg labrador? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Slowly absorbed, synthetic monofilament EXAMPLE: Polydioxanone, polyglyconate, glycomer 631 SIZE: 3.5 metric NEEDLE: taper-cut PATTERN: simple continuous
What is a good general rule of suture material size?
3 metric for an average dog 2 metric for average cat/small dog Add 0.5-1 metric sizes where extra strength is needed Subtract 0.5-1.5 metric sizes wherer high tensile strength isn’t needed or tissue is delicate
How would you close the SC fate of a 15kg cocker spaniel? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: rapidly absorbable, synthetic monofilament EXAMPLE: polyglecaprone, polyglytone SIZE: 2 or 3 metric NEEDLE: taper-cut PATTERN: subcuticular (continuous)
When is a cutting needle not needed?
if tissue has little collagen
How would you place a subcuticular suture in a 4kg cat? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: rapidly absorbable, synthetic monofilament EXAMPLE: polyamide (nylon), polypropylene SIZE: 2 or 3 metric NEEDLE: taper-cut PATTERN: subcuticular (continuous)
How should the skin be closed following a ventral midline laparotomy in a 20kg Golden Retriever. You have placed a subcuticular pattern, but it hasn’t resulted in good apposition. MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: synthetic monofilament, non-absorbable EXAMPLE: nylon or polypropylene SIZE: 2 or 3 metric NEEDLE: cutting or reverse cutting PATTERN: simple interrupted
When is a cutting or reverse needle needed?
high collagen content
What pattern gives the most accurate approximation of skin edges?
simple interrupted
Closure of the skin following a ventral midline laparotomy in a 2.5 kg cat. The cat is hypotensive and you would like a rapid closure so that the cat can be recovered from anaesthesia as quickly as possible. MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAl: Synthetic monofilament non-absorbable EXAMPLE: Polyamide (nylon), polypropylene SIZE: 1.5 or 2 metric NEEDLE: Cutting or reverse cutting PATTERN: Ford interlocking
Which gives a better apposition of skin edges? ford interlocking, simple continuous, running suture
Ford interlocking
True/False: If a subcuticular suture has been placed and resulted in accurate apposition, then suture closure of the skin may be omitted
True
T/F: skin staples produce a more rapid closure (vs. sutures)
True
Closure of the stomach wall following gastrotomy to remove a foreign body in a 15kg border Collie MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Rapidly-absorbed synthetic monofilament absorbable EXAMPLE: Polyglecaprone SIZE: 2 metric NEEDLE: Taper-cut PATTERN: Simple continuous, either a 1-layer closure or a 2-layer closure
When is it best to use a taper-cut needle?
it is the best compromise between avoiding suture cut-through with a cutting needle and avoiding the trauma to the tissue that may occur if a more blunt needle, e.g. taperpoint, is used.
How would you close the jejunum following an enterotomy to remove a FB in a 1.5kg kitten? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Rapidly-absorbed synthetic monofilament absorbable EXAMPLE: Polyglecaprone SIZE: 2 metric NEEDLE: Taper-cut PATTERN: Simple interrupted, single layer (or simple continuous)
Why is an inverting pattern not used to close jejunum following enterotomy?
to avoid luminal compromise
How would you perform an anastomosis of the remaining proximal and distal colon following subtotal colectomy for acquired megacolon in a 4kg cat. MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Slowly-absorbed synthetic monofilament absorbable EXAMPLE: Polydioxanone, Polyglyconate, Glycomer 631 SIZE: 1.5 or 2 metric NEEDLE: Taper-cut PATTERN: Simple interrupted, single layer (or simple continuous)
How would you anchor a gastrostomy feeding tube to the stomach in a 15kg WHWT following removal of an oesophageal FB? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Slowly- or rapidly-absorbed synthetic monofilament material EXAMPLE: Polyglecaprone or Polydioxanone/Polyglyconate/Glycomer 631 SIZE: 2 metric NEEDLE: Taper-cut PATTERN: Purse-string (main use for this suture)
What happens if a purse string suture is tied too tightly?
tendency to evert (particularly if bites are placed far from edge and if care isn’t taken to invert wound edges)
Is polyamide/nylon or polyproylene easier to handle and cheaper?
polyamide (nylon)
How would you place stay sutures in the bladder wall following a cystotomy in a 4kg cat? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Synthetic monofilament, non-absorbable suture (actually any since sutures are being placed for atraumatic manipulation of tissue and will be removed at end of procedure) EXAMPLE Polypropylene, Polyamide SIZE: 1.5 or 2 metric NEEDLE: Taper-cut PATTERN: Simple interrupted loop (usually, left untied with ends clamped in jaws of haemostat) or cruciate mattress (when more traction is needed, e.g. stomach)
How would you close the bladder following cystotomy to remove several cystic calculi in a 30kg dalmation? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Rapidly-absorbed synthetic monofilament EXAMPLE: Polyglecaprone SIZE: 2 metric NEEDLE: Taper-cut PATTERN: Simple continuous, either 1-layer or 2-layerHo
Why might you use a Czerny pattern when closing bladder?
to avoid exposure of suture material to urine
When might you use a 1 and a 2-layer suture pattern for bladder wall?
1 layer: if bladder wall is a normal thickness 2 layers: if bladder wall is thickened (one layer = mucosa +submucosa; other layer = muscularis and serosa)
How would you close a pre-scrotal urethrotomy wound in a 15kg English bulldog? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Rapidly-absorbed synthetic monofilament EXAMPLE: Polyglecaprone SIZE: 1.5 or 2 metric NEEDLE: Taper-cut PATTERN: Simple interrupted or simple continuous
What is the advantage of a simple continuous over a simple appositional?
simple continuous: may provide better haemostasis and be better at preventing urine leakage (simple interrupted - may give better apposition)
Why might a closure of a pre-scrotal urethrotomy be left to heal by second intention?
to reduce the likelihood of a stricture (but longer wound healing, may have wound edge haemorrhage, no clinically relevant increased incidence of stricture when sutured)
How would you suture the urethral ucosa to skin in creation of a perineal urethrostomy in a 6kg cat? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Synthetic monofilament non-absorbable EXAMPLE: Polypropylene, Polyamide SIZE: 1 to 1.5 metric NEEDLE: Cutting, reverse cutting or taper-cut PATTERN: Simple interrupted
How would you close the uterus following a c-section in a 7kg yorkshire terrier? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: (Slowly-) or rapidly-absorbed synthetic monofilament material EXAMPLE: Polyglecaprone or Polydioxanone/Polyglyconate/Glycomer 631 SIZE: 2 metric NEEDLE: Taper-cut or taper-point PATTERN: Simple continuous
When is luminal compromsie not an issue?
gravid uterus has a wide diameter hence to close this some surgeons use a single layer closure with an inverting pattern, or oversew an appositional pattern with a second layer using an inverting pattern.
How would you close a uterine stump following OVH for pyometra in a 50kg Newfoundland? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Rapidly-absorbed synthetic absorbable EXAMPLE: Polyglecaprone SIZE: 2 metric NEEDLE: Taper-cut or taper-point PATTERN: Parker-Kerr oversew
When is a rapidly-absorbable suture material most useful?
in a dirty wound since a suture may potentiate infection and so is in the wound for the shortest period of time
How would you close the joint capsule following a stifle joint arthrotomy in a 30kg labrador with CCLR? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Slowly-absorbed synthetic monofilament EXAMPLE: Polydioxanone, Polyglyconate, Glycomer 631 SIZE: 2 or 3 metric NEEDLE: Taper-cut PATTERN: Simple interrupted (or simple continuous)
What suture material is often used in orthopaedic surgery and why?
prolonged support is needed MATERIAL: Slowly-absorbed synthetic monofilament EXAMPLE: Polydioxanone, Polyglyconate, Glycomer 631
How would you overlap the fascia lata following stifle arthrotomy for medial patellar luxation in a 7kg Yorkshire Terrier? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL : Slowly-absorbed synthetic monofilament EXAMPLE: Polydioxanone, Polyglyconate, Glycomer 631 SIZE: 2 or 3 metric (higher than expected for a dog of this size because the wound will be closed under some tension) NEEDLE: Taper-cut PATTERN: Mayo mattress (main use in SA surgery)
How would you approximate the muscles of the pelvic diaphragm in a 30kg Old English Sheepdog with perineal hernia? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Synthetic monofilament, non-absorbable EXAMPLE: Polypropylene, polyamide SIZE: 3 metric NEEDLE: Taper-point PATTERN: Simple interrupted or horizontal mattress
Will a taper-point needle easily cut through muscle?
Yes
How would you close the defect left following a punch biopsy of a dermal mass in a 15kg English Bull Terrier? MATERIAL EXAMPLE SIZE NEEDLE PATTERN
MATERIAL: Synthetic monofilament, non-absorbable EXAMPLE: Polyamide, Polypropylene SIZE: 2 metric NEEDLE: Cutting or reverse cutting PATTERN: Simple interrupted Usually a skin closure alone with suffice. If deep, the SC tissues may be closed with a rapidly-absorbed synthetic monofilament, using an interrupted subdermal pattern (i.e. with a buried knot)
What needles are usually used for the skin?
a cutting needle of some type (i.e. cutting or reverse cutting)
T/F: whereever possible, a monofilament material is used in preference to a multifilament material.
True - because there is less tissue drag and less wicking of tissue fluid between tissue planes Multifilament recommended for: ligation (superior handling and knot security)
What is silk a good suture material for?
ligating large vessels - e.g. PDA
What is the risk when using too small a guage suture material? 2
suture line failure and wound dehisence
When do you use single staples?
skin and fascia
What types of staple row can there be?
staggered double row triple row 2 double rows and cut
What is this?
TA stapler/linear stapler
What is this?
GIA stapler/ linear cutter
What is this?
EEA (end-to-end) stapler/ intraluminal stapler
What are these?
Skin and fascia staplers
Staplers - advantages - 9
quick and easy closure use in poorly-accessible areas consistent and precise inert material more rapid healing security of haemostasis lower likelihood of contamination minimal tissue trauma instruments allow new techniques
Staplers - disadvantages - 7
Cost of staples and instruments lack of familiarity with instruments failure possible with improper use human instruments - too big? access difficult with large staplers ethylene oxide sterilisation of some need skin staple remover
What is this?
Ligature clip applicator
Advantages - vascular/ligature clips - 4
simple and quick access to deep tissues inert material strong and secure ligature
Disadvantgaes - vascular/ligature clips - 5
instability of clip in applicator permanence of clips only vessels <11mm absorbable clips are bulky expensive
Define EEA stapler
end to end anastomosis stapler - useful for LI, particularly the distal colon and rectum where access is difficult. Match stapler and SI size (not useful in SI), need intraluminal access, will evert edges (stenosis)
What is this?
Triangulating end to end anastomosis linear stapler (TA stapler) - not commonly used, GIA stapler is better option.
What are tissue glues made of?
cyanoacrylates
Advantages - current tissue glues
Good composition additional agents –> flexibility More liquid Coloured Presentation - easier to use
Chemical action - tissue glues
monomer is converted to insoluble polymer on surface contact/water contact (setting time is 2-60 seconds)
List some tissue glue monomers (cyanoacrylates)
Methyl/ethyl: household use, brittle, toxic Butyl: 1st gen, stronger, brittle, vets Octyl: 2nd gen, strongest (2-4x bond strength of butyl), flexible, vets and medics
What does setting time depend on? 4
thickness (glue film) moisture pH (tissue fluid) length of alkyl chain
Biological actions - tissue glue
edge apposition waterproof barrier-dressing haemostasis (small BVs) antibacterial As healing progresses: epithelialisation proceeds under glue and the glue sloughs off eventually
3 examples of butyl-based polymer glues
Nexaband liquid (abbott) Vetbond (3M) Vetseal (Histoacryl. Braun)
2 examples of octyl-based polymer glues
Nexaband S/C (Abbott) Dermabond (Ethicon)
Major uses - tissue glue - 4
Wound closure/protection Tissue adhesion Augmentation of primary repair Attachment of apparatus
How do you apply glue?
lavage wound (bicarbonate wash or sterile isotonic crystalloid fluid. This is to enhance polymerisation in an alkaline environment) blot dry appose edges run glue along top of edges maintain apposition until full strength (1-2 min)
What should you avoid when applying glue? 3
AVOID: excess quantities burying glue deep in tissues applying over a pool of blood/fluid
Advantages - glue
Surgeon benefit: rapid closure, easy, no suture removal Patient benefit: not painful, reduced self-trauma, effective haemostasis, AM effect Client benefit: reduced cost (25% sutures)
Disadvantages - glue
WOUND: introduce FB, healing impaired if glue in edges, poor closure if cracking or peeling, dehisence more likely if tension, tissue toxicity (especially earlier cyanoacrylates), granuloma formation, potentiation of wound infection, poor adherence to moist surfaces, interference with cortical bone healing if used near bone TECHNIQUE: difficult to close irregular wounds, augment with sutures? PRODUCT: adhesion to gloves/instruments/patient, new technique to be learned
What do human studies suggest about the use of glue?
rapid closure no healing delay similar cosmetic effect similar wound infection rates high patient satisfaction
What gives nexaband (Octyl product) greater flexibility and strength?
plasticisers and stabilisers intended for closure of skin wounds 5-5 second setting time
When have tissue adhesives been used effectively?
- oral surgery - intestinal anastomosis - management of corneal ulceration - control of haemorrhage from cut surface of parenchymatous organs - microvascular incisions - skin incisions - skin grafts
T/F: tissue adhesives are more likely to be used in traumatic than surgical wounds
False - should be used when skin isn’t under tension and when wound isn’t infected/contaminated which are more likely with traumatic than surgical wounds
Outline how tissue adhesives have been used for corneal ulcers
- protect both superficial and deep corneal ulcers - attach contact lenses for emergency treatment of deep corneal ulcers which are near to perforation. Glue and contact lens are sloughed by desquamation of corneal epithelium over time. - attache conjunctival pedicle flaps to the cornea to avoid need for sutures
What would incorporation of glue into deeper structures do?
impede normal wound healing
How may the glue be used?
using the applicator device supplied dispensed with a small gauge syringe, with or without an IV catheter
How can tissue glue be removed from skin other than wound or an inanimate object?
it can be removed once polymerised by soaking in acetone
How do staples work?
C-shaped (in device) –> B-shape (on firing) which provides some haemostasis without completely occluding the microcirculation at the cut edges of the tissue, because they allow some flow in small vessels through the openings in the staple
What does a staggered, double row of staples allow?
Blood flow between the individual staples, which allows blood flow between the individual staples, to assure viability of the 2 or 3 mm of tissue beyond the staple line.
How are clips presented?
V or U-shaped metal clips
Name 4 types of stapling device.
TA/linear stapler (thoracoabdominal) GIA/linear cutter EEA Skin and fascia staplers
How many sizes of TA staplers are there?
3 (30mm, 5mm or 90mm staple lines)
How many sizes of staples are there for a TA stapler?
2 (leg lengths of 3.5mm or 4.8mm)
List some uses of TA/linear surgical staplers
Pulmonary lobectomy Right atrial appendage excision Closure of enterotomy and gastrotomy wounds Performance of GIT resection and anastomosis Typhlectomy Hepatic lobectomy Spelectomy Prostatectomy Ligation and division of vascular pedicles
What pattern does a GIT anastomosis stapler/linear cutter stapler produce?
a pair of double, staggered rows of staples (the instruments also contain a blade which cuts between the two double rows)
How many instrument sizes are available for GIT anastomosis stapler/linear cutter stapler
Two (create staple lines measuring 50mm and 90mm)
How many sizes of staple are available for GIT anastomosis staplers/linear cutter staplers?
Two (with leg lengths of 3mm or 4mm which compress to a thickness of 1.25mm and 1.75mm respectively)
List some uses of GIT anastomosis staplers/linear cutter staplers
partial gastrectomy functional end to end anastomosis side to side anastomosis cholecytoenterostomy janeway tube gastrostomy resection of oesophageal diverticulum resection of prostatic cysts
Define cholecystoenterostomy
surgical anastomosis of the gallbladder and intestinal tract, usually indicated if the common bile duct has been disrupted by injury or neoplasia and, as is the case in dogs and cats, repair or choledochoenterostomy is technically impractical.
Define choledochoenterostomy
anastomosis of the bile duct to the intestines
What is the main advantage of a GIT anastomosis stapler/linear cutter stapler?
it will cut and seal both sides of an incision into a hollow organ
Describe how an end-to-end anastomosis stapler works
it places a circumferential double row of staples to connect the lumina of 2 hollow organs, creating an inverting anastomosis. An integral circular knife removes the redundant cuff of tissue from each luminal end
What are ovoid sizers for?
allow the surgeon to gauge the luminal diameter to identify the appropriate size of instrument to use (end to end anastomosis stapler/intraluminal stapler)
List some uses of an end-to-end anastomosis/intraluminal stapler
colorectal anastomosis end to side GIT anastomoses gastro-oesophageal anastomosis and subtotal gastrectomy oesophageal anastomosis
How is stapled anastomosis of the SI usually performed in small animals?
using TA or GIA staplers
How do the staples in skin and fascia staples differ?
Fascial staples –> B shape Skin staplers –> square shape
How frequently are skin and fascial staples used?
Skin: frequently in SA surgery Fascia: because of the size and cost of fascial staples, hand-sewn continuous suture lines remain the norm for fascial closure
What are the advantages of staplers?
speed inert material minimal tissue trauma easy even in poorly accessible areas consistency of application precision of application security of haemostasis reduced likelihood of contamination from GIT secure, air-tight closure of respiratory tract
What are the disadvantages of staplers?
cost (staples and instruments) lack of availability of equipment lack of familiarity with equipment potential for failure if used improperly necessity to re-sterilise applicators between patients requirement for staple removing instruments (skin)
How and when do stapled suture lines heal?
by first intention, with minimal or negligible lag period, perhaps because of the reduced inflammatory response.
What are the 2 main types of ligature clip?
Metallic (stell, titanium and tantlum. most common) Absorbable (polyglactin 910, polydioxanone) - absorption is by hydrolysis and is minimal until 90 days, complete by 210 days
List 3 types of ligature clip.
Single clip appliers - Ligaclip Multiple Clip appliers - Surgiclip, Ligaclip 20/20 Ligating-dividing stapler (LDS)
Describe Single clip appliers - Ligaclip - 4
metal forceps in to whose jaws a single clip is placed forceps apply the clip directly to the vessel forceps are re-usable forceps have to be loaded with clips each time
Describe Multiple Clip appliers - Surgiclip, Ligaclip 20/20
sterile, disposable can deliver up to 20 clips preloaded with clips which advance after firing reloaded with additional cartridges
Describe Ligating-diving stapler (LDS)
uses metallic, U-shaped crushing clips produces double ligation of a BV cutting blade divides between the two clips pistol grip, long thin shaft, j-shaped jaw
Are automated staplers suitable for many vessels to be ligated?
Yes
List some uses for ligature clips
splenectomy (especially where tumour neovascularisation has resulted in vascular omental attachments) dividing segemental branches of gastric and gastroepiploic vessels during partial gastrectomy
Outline some tips for using ligature clips
- dissect surrounding tissue from vessel to be ligated - 2-3mm of BV should extend beyond clip to prevent slippage - vessel diameter should be a third to two thirds of the length of the clip - stablise the stapler to avoid recoil - hand is moved slightly downwards and backwards to disengage the vessel from the jaws of the instrument
Advantages - ligating clips
improved efficiency ease of application in poorly accessible areas high strength of implanted material structural stability of implanted material improved security of ligature
Disadvantages - ligating clips
- instability of clip in applicator before use - permanence of metal clips in tissue - limitation on vessel diameter (11mm) - increased bulk of absorbable clips created by necessity for a locking mechanism
What might be the benefit of stapling equipment in a critically ill patient?
reduced surgical time
