L07: Skin and Fascial Wound Closure (Morton)

Question 1

layers encised in celiotomy (ventral midline incision)

Answer 1

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

Question 2

General guidelines

Answer 2

incise with scalpel to minimize trauma
avoid tangental incisions
avoid incisional trauma

Question 3

fascial closure cranial to umbilicus

Answer 3

take full thickness bites of linea

Question 4

fascial closure caudal to umbilicus

Answer 4

SA: take wide bites of external rectus fascia
LA: full thickness bites
avoid large bites of muscle to reduce inflammation and associated risks

Question 5

suturing of peritoneum

Answer 5

• does not contribute to wound strength
• INCREASES risk of adhesions
• healed by mesothelial cells in 3 days
• do not suture!

Question 6

Pros of CONTINUOUS fascial closure pattern

Answer 6

dec. time, suture material
similar strength as interrupted
higher bursting strength than interrupted

Question 7

Cons of CONTINUOUS fascial closure pattern

Answer 7

• one break can –> herniation
• suture material usually fails at knots
• closure usually fails at body wall

Question 8

how many throws needed at start and end of continuous pattern?

Answer 8

5 at start, 7 at end due to loop, which has decreased knot security

Question 9

Cons of INTERRUPTED fascial closure pattern

Answer 9

• slower
• increased suture material
• 4+ throws/knot

Question 10

General recommendations for suture materials for fascial closure

Answer 10

• 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

Question 11

suture size for fascial closure of body wall vs. body weight***

Answer 11

40kg: 1
Horse: 3

Question 12

“subcuticular” skin closure includes:

Answer 12

dermis and subcutis

Question 13

“intradermal” skin closure includes:

Answer 13

dermis only

Question 14

“subcutaneous” skin closure includes:

Answer 14

subcutis only

-NOT a holding layer; must also close another layer more superficially

Question 15

subdermal plexis includes:**

Answer 15

subcutis, fascia, muscle

Question 16

layers of skin

Answer 16

epidermis
dermis
subcutis
fascia
muscle

Question 17

general guidelines for skin closure

Answer 17

• 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)

Question 18

what determines scar width?

Answer 18

subcutaneous closure

Question 19

what suture patterns used for SC closure

Answer 19

interrupted or continuous

Question 20

“tacking down” SC sutures

Answer 20

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

Question 21

ideal suture material for SC closure

Answer 21

• non-reactive (monofilament or braided)
• absorbable
• doesn’t need prolonged tensile strength
• PDS, Vicryl, Maxon, Monocryl good
• smaller diameter than used in linea

Question 22

what suture patterns are used for cutaneous?

Answer 22

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)

Question 23

spacing of cutaneous sutures

Answer 23

3-8mm from incision

5-10mm apart

Question 24

ideal suture material for cutaneous closure

Answer 24

• MONOFILAMENT
• non-absorbable or absorbable
• reverse cutting needle
• Nylon, Prolene, Fluorofil good

Question 25

Pros of intradermal skin closure

Answer 25

no suture removal

cosmesis

Question 26

Cons of intradermal skin closure

Answer 26

technically difficult
time consuming
doesn’t eliminate dead space
dec. resistance to tension

Question 27

indications for intradermal skin closure

Answer 27

clean wound
healthy patient
minimal to no tension
mass removal or elective spay/neuter

Question 28

ideal suture material for intradermal skin closure

Answer 28

• absorbable monofilament or braided
• vicryl, PDS, monocryl
• small diameter
• reversed cutting needle

Question 29

intradermal skin closure pattern technique

Answer 29

• 4 throws “Deep to Sup, Sup to Deep”
• bury knot at beginning and end
• start on near side of incision
• bites at even depth
• don’t advance b/w bites

Question 30

Staples: pros and cons

Answer 30

cons: inc. cost, not suited for wounds under tension or thin skin
pros: dec. operative time which ultimately does save money