i dunno Flashcards
finger grip/ dinner knife scalpel grip used for
initial and longer incisions
pencil grip on scalpel used for
stab or short incisions
how to incise linea alba
-stab while tenting tissues - reverse press cut for stab incision through the linea alba
adson tissue forceps use
General tissue handling
* eg. Sub Q and linea alba during closure
adson brown forceps use
Stronger grasp of tissues
* e.g. to tent the linea alba during abdominal approach
DeBakey forceps use
Least traumatic forceps
* Handle tissues like vessels, bladder and GI wall
olsen hegar vs mayo hegar needle drivers
olsens have scissor under driver grip
metzenbaum scissor use
not for linea alba - only fat and soft tissues
mayo scissors use
strong scissor, perfect for linea alba
scissors to cut sutures with
sharp-blunt
carmalt tissue forceps used for:
§Used to clamp large pedicles of tissues (e.g. ovarian pedicle during OHE)
carmalt striation description
§Carmalts have
longitudinal striations along the entire length -
Perfect to prevent tissue slippage during ovariohysterectomy
kelly or crile forceps are used for
smaller vascular pedicles
mosquito forceps are used for
§Used to clamp single vessels
>Use the tip of the clamp
§Small vascular pedicles (cat ovarian pedicle)
>Use the body of the clamp
suture is considered absorbable if
it loses significant tensile strength within 60 (to 90) days of implantation
§ This does not mean it is completely gone…
non-absorbable suture maitnains:
100% of tensile strength for at least 60 days
natural vs synthetic suture mechanism of absorbtion
§Hydrolysis vs Enzymatic
§Natural fibers absorbed by enzymatic actions of cellular
proteases and collagenases
§Synthetic absorbable sutures are absorbed through hydrolysis
rate of suture absorption should be proportional to
returning of strength of the healing tissue
speed of healing for stomach
2 weeks
rate of healing for intestine
3 weeks
rate of healing for fascia
6-7 weeks
rate of healing for tendons
forever
what is knotless, barbed suture used for
mostly laparoscopic
why are some sutures coated?
§ Coated with a variety of compounds to improve pliability, improve knot formation, reduce drag or to reduce infection
§Antimicrobials such as Triclosan
§PDS Plus®
§Useful in contaminated or infected sites
what is suture elasticity?
The degree to which a suture will deform under stress or load and return to its original form when the load is removed
what is suture capillarity?
The degree to which a suture will absorb fluid following immersion
multifilament suture pros and cons vs mono
+Greater strength and pliability (vs stiffer mono)
+Good knot security (mono considered less but variable) -Greater tissue drag or friction (vs smooth mono)
-Greater capillarity and tendency for bacterial colonization (avoid for infected wounds)
big to small suture sizes
2>1>0>2-0>3-0>4-0, etc.
suture strength is related to what? should be considered in relation to what?
§Related to size
§Strength should be considered in relation to the tissue where the suture is being placed
LARGER SUTURE MEANS THESE 3 THINGS
Stronger suture, More foreign body reaction, Less knot security
5 common rapidly absorbable sutures
- catgut
- polyglactin 910 (vicryl)
- polyglycolic acid (dexon)
- poliglacaprone 25 (monocryl)
- polyglytone 6211 (caprosyn)
catgut suture characteristics - best for what? problems?
§Twisted suture material
§Sheep intestinal submucosa or cattle
intestinal serosa
§ Treatment to delay absorption and reduce tissue inflammation
§Still rapid and inconsistent absorption and lots of tissue reaction so not ideal for anything other than vessel ligations (never for body wall or hollow organs like stomach and bladder)
polyglactin 910 / vicryl suture characteristcs and use
§Multifilament braided suture
> Vicryl Plus (Triclosan coating)
> Vicryl Rapide (irradiated for very rapid absorption)
§Retains about 50% of its original tensile strength at 2 to 3 weeks
§Good option for intradermal
poliglecaprone 25 / monocryl characteristics and use
- Rapidly absorbable monofilament suture
§ Monocryl Plus (Triclosan)
§High initial breaking strength
§Will lose approximately 50% of its strength at 1 week
and 70% to 80% at 2 weeks
§Completely absorbed in 90 to 120 days with mild tissue inflammation during the absorption period
§Excellent option for subcutaneous tissues and intradermal, also used for urinary tract
common slowly absorbable sutures
polydioxanone (PDS II)
polyglyconate (Maxon)
glycomer 631 (biosyn)
polydioxanone / PDS II suture characteristics and uses
§ Uncoated, (2nd generation monofilament suture made from polydioxanone (PDS Plus (Triclosan))
§Approximately 50% of its initial tensile strength remains at 5 to 6 weeks
§Excellent handling
§Polydioxanone generally has intermediate knot security (less than Maxon®) but pretty good for a monofilament
§Excellent option for the linea alba
common non-absorbable sutures
polypropylene (prolene)
nylon (ethilon)
polypropylene (prolene) suture characterstics and uses
§Non absorbable monofilament polyolefin suture
§ Very strong, higher break strength than any suture but less knot
security
§Good handling characteristics
§ Very resistant to degradation because of a lack of hydrolyzable bonds
§Excellent option for skin closure but must be removed after healing
nylon suture characteristics and uses
§Non absorbable monofilament polyamide-based suture
§ Very strong suture (less than Polypropylene)
§Nylon is susceptible to degradation in specific environments so not ideal for permanent implantation
§Excellent option for skin closure but must be removed once healing has occurred
benefits of skin staples, and drawbacks. When to use?
§Reduction in surgical time and cost with cosmetic outcomes equivalent to a sutured wound
§Greater resistance to infection
§Difficult to remove – twist within tissues (inert in the tissues)
§Used when time is of the essence
§ Don’t use in difficult patients that will require sedation to remove staples…
what material do we use at OVC to close the linea alba and for spay/neuter ligations?
§Polydioxanone (PDS®), absorbable
What material do we use at OVC for subcutaneous and intradermal skin closure
§Polyglecaprone 25 (Monocryl®), absorbable
what material do we use to suture the skin at OVC
§Polypropylene (Prolene®)
what type of suture material should we use for Hollow viscera (intestine, stomach)?
§Monofilament synthetic absorbable material such as PDS® (polydioxanone) or Biosyn® (glycomer 631)
§ For urinary bladder consider Monocryl® (PDS is calculogenic)
for bladder, what suture material should we use and why? what should we not use?
§ For urinary bladder consider Monocryl® (PDS is calculogenic)
for fascia such as the linea alba, what suture material should we use
§ Synthetic absorbable, typically monofilament such as PDS® or Biosyn® (long tensile strength)
§ Monocryl is not acceptable except to close short cat spay incisions
what suture material should we use for ligation?
§ Synthetic absorbable such as Monocryl®, Biosyn® or PDS® - Vicryl® (braided) is also an option
what type of suture material should we use for subcuticular or subcutaneous applications?
§Braided or monofilament synthetic absorbable
> Vicryl® (polyglactin 910)
> Monocryl® (polyglecaprone 25)
> Caprosyn® (polyglytone 6211)
what type of suture material should we use for skin?
§Monofilament synthetic non-absorbable such as Prolene® (polypropylene), nylon or staples
what should we do when we open new suture to reduce memory
stretch slightly by holding suture, not the needle
when do we use apposing suture patterns?
for eg. skin, intestine
when do we use inverting suture patterns?
for eg. stomach bladder
advantages of interuppted suture patterns, and disadvantages
§More precise wound margin apposition
§More selective adjustments to the wound edges (apposition)
§Improved closure security vs continuous*
§More time required for closure
§More suture and knots so more tissue reaction
types of interrupted suture patterns
§ Simple interrupted (linea alba, GI)
§ Mattress patterns
§ Cruciate (skin)
§ Horizontal mattress § Verticalmattress
what suture pattern should we use on the linea alba?
simple interrupted, or continuous
advantages of continuous suture patterns
§ Faster to insert
§ More even distribution of tension
§ More water and air-tight closure (seal)
when do we use continuous suture patterns?
§ *Not often used for the skin in small animals
§ Viscera (bladder, stomach, intestine)
§ Linea alba
§ Subcutaneous
§ Intradermal (subcuticular)
is interrupted safer than continouous suture pattern?
§Interrupted is considered ‘safer’ than continuous (relies heavily on the start and end knots) especially in the hands of a novice surgeon but interrupted is not actually safer if a continuous is performed correctly on the linea alba …
is it better to use interrupted or continuous suture patterns for abdominal wall closure?
§‘Use of a single-layer, simple continuous suture pattern to close abdominal body wall incisions has been shown to be comparable with use of a simple interrupted pattern in strength and complication rate and is quicker and easier to perform’
advantages of continuous suture patterns
-fast
-uses less material
>less foreign body rxn, cost
-more even distrbution of forces
advantages of interrupted suture patterns
-more secure, better apposition of tissue edges
6 types of continuous suture patterns
§Simple continuous
§Ford Interlocking (continuous lock)
§Cushing
§Lembert
§Connell
§Purse string
§A simple interrupted suture requires a minimum of ___* throws to form a secure knot (*depends on the suture material)
4 to 5
why and when to use a surgeons knot
§Provides friction and maintains position until second throw is placed = surgeon’s throw
§Use when there is tension on the tissues to appose**
>Closing linea alba
>Placing a ligature on fatty ovarian pedicle
>Not good for small vessels without fat since the extra suture results in a larger loop (isn’t as tight)
§Not actually safer once the knot is completed
how many throws should our knots have in a continuous suture line? does this rule always apply?
the starting knot should have one extra throw (5-6 throws total) and the final knot should have two extra throws (6-7 throws total) for added security (because of tying a loop to a single strand)
§ This rule is important for the linea alba but is typically not observed for a buried SQ knot due to lack of space!
how long should suture tags be
2-4mm
how many knots in suture for PDS II?
5 throws for an interrupted suture and
6 at start and 7 at end of continuous
with 2 to 4 mm suture tags
how do we hold the needle with needle holders?
Hold the suture needle with the tip of the needle holder and at about 1/3 of the needle
how long should we cut suture ends with synthetic suture? for skin closure?
§3 mm tags for synthetic suture
§I leave them a bit longer (4-5 mm) on the linea alba when doing a continuous closure
§6-10mm tags for skin sutures (have to remove them!)
advtangae of a muller knot/ clove hitch knot for ligature
§’locked double loop’
§More likely to prevent slippage
off of the pedicle cut end compared to simple circumferential
