Incision and Wound Closure Flashcards
Midline incision through linea alba
Easy incision to make, creates good access and easily extensible and relatively avascular.
Linea alba thins infraumbilically
Crosses Langer’s line, some vessel damage and can damage the bladder
Infra-umbilical incision
Paraumbilical hernia repair
Lap port insertion
Para-median incision
Rarely used, 1.5cm from linea alba and involves cutting through the rectus sheath.
- Less easy to create
- Poor cosmetic result
- Jenkins rule not applicable (Suture length=wound length x 4)
- Intercostal nerve damage
- Falciform ligament above umbilicus on right side of patient
Pararectal incision
Not used
Incisional hernias and nerve damage often result
Kocher’s incision
Open cholecystectomy (right) Splenectomy (Left) 3cm below and parallel to the costal margin, from the midline up to the rectus border Superiorly-sup epigastric vessels Laterally-intercostal nerves No caudal/posterior extension
Rooftop incision
Liver and spleen access
Pancreatic, gastric and adrenal procedures
Transverse muscle cutting incision
Intercostal nerves
McBurney’s/Gridiron incision
Classic appendicectomy scar
Perpendicular to McBurney’s line (ASIS-Umbilicus)
ilio-hypogastric, ilio-inguinal nerves
Deep circumflex artery
Rutherford Morrison incision
Good access to caecum, appendix and right colon
Good extensions possible
Lanz incision
1/3 distance from ASIS to umbilicus
better cosmesis
Splits ilioinguinal and iliohypogastric nerves causing denervation of the inguinal canal mechanism-increased risk of inguinal hernias
Pfannenstiel incision
2cm above pubis
Gynaecological, bladder and prostate access
Transverse incision
Neonate and children use
Less painful, better cosmesis than longitudinal incision but red muscle splitting=more bleeding
Loin scar
Nephrectomy
Wound closure principles (9)
Incise along tension lines Eliminate dead and infected tissue Gentle tissue handling Ensure good supply Eliminate potential spaces for haematoma Well appositioned tissue Low wound tension Appropriate closure technique Appropriate suture material
Mass closure of abdomen
Protect abdominal contents e.g. omentum
Non-absorbable suture nylon or slow absorbable e.g. PDS
Jenkins rule: suture length 4xwound length
Jenkins 1cm rule: suture bite 1cm, adjacent sutures 1 cm apart.
Include all layers of the abdomen except skin and subcut fat. Fascia provides wound strength
Choosing the right suture
Suture size
Characterisitics (Braided vs monofilament-handling vs knotting, absorbable/non-absorbable)
Needle
Absorbable suture for quick healing tissues e.g. bowel
Non-absorable for abdominal wall slower healing
Monofilament for running stitches e.g. vascular surgery
Braided for knotting (ligation)
Ideal suture
Monofilament strong easy handling Minimal tissue reaction Holds knot well Predictable reaction
Non-absorbable sutures pneumonic
Double ‘S’
Double “P” Double “P”
LC
Non-absorbable sutures Double S
Silk
- Natural
- Braided multifilament
- May be dyed and have wax coating
Steel
- Man made
- May be mono or multifilament
Non-absorbable sutures Double P (I)
Polyester
- Man made
- Multifilament
- Dyed/undyed
- Coated/Uncoated
Polyamide
- Man made
- Mono or multifilament
- Dyed/undyed
Non-absorbable sutures Double P (II)
Polypropylene (Prolene)
-Man made
-Monofilament
Dyed/Undyed
PVDF
- Man made
- Monofilament
- Dyed/Undyed
Non-absorbable sutures L
Linen
- Natural
- Twisted multifilament
- Dyed/undyed
Non-absorbable sutures C
Cotton
- Twisted multifilament
- Dyed/undyed
- Uncoated
Absorbable sutures PPPP
Polyglycolic acid
- Man made
- Braided multifilament
- Dyed/Undyed
- Coated/uncoated
Polygalactin 910 (Vicryl)
- Man made copolymer
- Coated
Polydioxanone sulfate (PDS)
- Man-made copolymer
- Monofilament
- Dyed/Undyed
Polyglyconate
-Man made copolymer
-Monofilament
Dyed/Undyed
Needle characteristics
Needle shape
- Straight
- Curved
- Circular
- J-shaped
Needle profile
- Blunt needle: abdominal closure
- Round bodied (Spreads rather than cutting tissue-organs)
- Cutting/Reverse cutting needle-triangular profile-tough fibrous tissue
Suture removal
Face 4-5 days
Scalp 6-7 days
Hands and Limbs 10 days
Abdominal wounds 10-20 days
Surgical drains use
- Drain a collection e.g. subphrenic abscess
Drains may be open or closed, suction and non suction
- Decompress e.g. pneumothorax
- Risk of leakage e.g. bowel anastamosis
- Divert fluid from an obstruction e.g. suprapubic catheter
-Minimise dead space and fluid collections e.g mastectomy
Surgical drain examples
Suction: Only closed system-Redivac and suction chest drain
Non-suction Open: Penrose and Corrugated drain
Non-suction Closed: Robinson drain, T tube, urinary catheter, chest drain
Scar minimisation
Langers lines Wrinkle lines (nasolabial folds, forehead wrinkles) Natural junctions (Nose and face) Hidden sites (Eye brow, hair line) Good appoition Low tension Small suture diameter Suture removal at earliest opportunity Avoid sun-pigmentation
Scar types
Hypertrophic scars
Keloid scars
Malignant change in scars
Hypertrophic
Proliferative phase of scar healing can remain if large area of skin damage e.g. abrasion/burns.
The scar appears red and hard
Keloid
Excessive scar tissue breaching beyond the wound
