L07: Skin and Fascial Wound Closure (Morton) Flashcards
layers encised in celiotomy (ventral midline incision)
skin
SC tissues
linea alba (aponeurosis of rectus abdominis muscles)
retroperitoneal fat
peritoneum
linea alba and external rectus abdominis fascia are the holding layers to prevent herniation/peritonitis
General guidelines
incise with scalpel to minimize trauma
avoid tangental incisions
avoid incisional trauma
fascial closure cranial to umbilicus
take full thickness bites of linea
fascial closure caudal to umbilicus
SA: take wide bites of external rectus fascia
LA: full thickness bites
avoid large bites of muscle to reduce inflammation and associated risks
suturing of peritoneum
- does not contribute to wound strength
- INCREASES risk of adhesions
- healed by mesothelial cells in 3 days
- do not suture!
Pros of CONTINUOUS fascial closure pattern
dec. time, suture material
similar strength as interrupted
higher bursting strength than interrupted
Cons of CONTINUOUS fascial closure pattern
- one break can –> herniation
- suture material usually fails at knots
- closure usually fails at body wall
how many throws needed at start and end of continuous pattern?
5 at start, 7 at end due to loop, which has decreased knot security
Cons of INTERRUPTED fascial closure pattern
- slower
- increased suture material
- 4+ throws/knot
General recommendations for suture materials for fascial closure
- non-reactive monofilament
- absorbable
- PDS, Maxon, Vicryl in horses, all good choices
- long retention of tensile strength
- non-absorbable when slow healing anticipated (stainless steel, nylon)
- bites 0.5-1cm from incision, 0.4-1cm apart
suture size for fascial closure of body wall vs. body weight***
40kg: 1
Horse: 3
“subcuticular” skin closure includes:
dermis and subcutis
“intradermal” skin closure includes:
dermis only
“subcutaneous” skin closure includes:
subcutis only
-NOT a holding layer; must also close another layer more superficially
subdermal plexis includes:**
subcutis, fascia, muscle
layers of skin
epidermis dermis subcutis fascia muscle
general guidelines for skin closure
- incise parallel to lines of tension (Langer’s lines)
- keep tissue hydrated
- avoid undermining (creates dead space)
- avoid excessive manipulation (fingers, skin hook or needle, fine toothed forceps acceptable)
what determines scar width?
subcutaneous closure
what suture patterns used for SC closure
interrupted or continuous
“tacking down” SC sutures
take a bite every 4-5 sutures down to external rectus fascia
-only use if excessive dead space because potential to seed any infection deeper down
ideal suture material for SC closure
- non-reactive (monofilament or braided)
- absorbable
- doesn’t need prolonged tensile strength
- PDS, Vicryl, Maxon, Monocryl good
- smaller diameter than used in linea
what suture patterns are used for cutaneous?
Cruciate (increased speed, tension relief) Simple interrupted (dec. speed, can adjust tension more precisely, gets more perfect closure) Continuous (simple or Ford interlocking; rarely used because of increased irritation)
spacing of cutaneous sutures
3-8mm from incision
5-10mm apart
ideal suture material for cutaneous closure
- MONOFILAMENT
- non-absorbable or absorbable
- reverse cutting needle
- Nylon, Prolene, Fluorofil good
