Lecture 4: Surgical Skills Flashcards
What is a clean wound and how is it closed?
- Uninfected operative wound, no inflammation, no systemic tract is entered (resp/GI)
- Closed by primary intention and no drainage.
What is a clean contaminated wound?
- Operative wound where systemic tracts are entered under controlled conditions without contamination
- Ex: lung surgery, appendix, vaginal
What is a contaminated wound?
- Open traumatic wound
- Operations with spillage from GI/GU, or biliary tracts
- Break in aseptic technique (open cardiac massage)
Infection can occur within 6 hours of contamination
What is an infected wound?
- Heavily contaminated/infected wound PRIOR to operation
- Ex: Perforated viscera, abscesses, necrotic tissue
What is primary intention?
Optimal closure method with no edge separation and minimal scar formation.
Takes place in 3 phases
What are the 3 phases of primary intention?
- Inflammatory (hemostasis => extravasation) + increased tensile strength
- Proliferative (day 3, collagen matrix + increasing tensile strength)
- Remodeling (lasts for a year+, area turns paler and devascularization)
Describe the inflammatory phase of primary intention healing
Begins immediately and completed by day 3-7
* hemostasis occurs
* extravasation of tissue fluid, cell, and fibroblasts
* increasing blood supply to wound
* debridement of tissue debris by proteolytic enzymes
inc. in tensile strength of tissue and wound healing is dependent on approximation of edges by closure material
What determines tensile strength and wound healing in the inflammatory phase of primary intention?
How approximated edges are by suture material
Describe the proliverative stage of primary intension healing?
Starts from day 3
* fibroblasts form a collagen matrix
* this matrix determines the tensile strength and plability of the healing wound
* Becomes vascular, supplying the nutrients and oxygen necessary for wound healing
What is wound contraction?
- Wound edges pulling together. If successful, results in smaller wound with less need for repair by scar formation
- Good in buttocks/trochanter
- Bad in hand, neck, or face, which can be reduced via skin grafting.
Part of proliverative stage in primary intention
Describe the remodeling part of primary intention
may continue for a year +
* following completion of collagen deposition vascularity decreases and any surface scar becomes paler.
resultant scar size is dependent on initial volme of granulation tissue
When is tensile strength greatest in primary intention?
10 weeks, at which point it is around 80%
20% @ 2 weeks
50% @ 5 weeks
80% @ 10 weeks
what is primary intention wound closure performed with?
sutures
staples
tape/glue
When does secondary intention occur?
Wound fails to heal by primary intention
d/t infection, excessive trauma, tissue loss, imprecise approximation of tissue (dead space)
What is the concern with secondary intention?
Excessive granulation tissue, which contains myofibroblasts leading to gradual but marked wound contraction
may protrude above wound surface, prevent epithelialization and require additional tx.
When is delayed primary closure used?
Contaminated and infected wounds with high tissue loss and risk of infection
trauma, penetrating injury
How is delayed primary closure achieved?
- Debridement of nonviable tissue
- Leave wound open with packing/vacuum system
- Wound approximation within 3-5d of no infection
- If infection present, leave to secondary intention
Do you hold the forceps or the driver in your dominant hand? What fingers are used?
OK THIS WONT BE A QUESTION BUT I AM PARANOID
Forceps with non dominant, hold in the first 3 fingers (like a pen)
Needle-holder in dominant hand, partially insert the thumb and ring finger in the loops of the handle
just 5 this
Needle shapes image
Image of 5 needle points
What is the goal when choosing a suture needle and what is generally the MC?
Alter tissue to be sutured with as little damage as possible, usually with tapered/reverse non-cutting needles.
Generally, taper for delicate, reverse for skin/tough
When is the conventional cutting used?
skin, sternum
When is the reverse cutting needle used?
fascia, ligament, nasal cavity, mucosa, pharnxy, skin, tendon sheath
preferred for skin and tougher tissues
When is the taper needle used?
aponeurosis, biliary tract, dura, fascia, GI tract, laparoscopy, muslce, myocardium, nerve, peritoneum, pleura, subcutaneous fat, urogenital tract, vessels, valve…..pass
preferred for delicate tissues
when in doubt, choose taper for everythign except skin sutures
When should taper needles NOT be used?
Skin, which is dense and may bend the needle.
Otherwise taper is good.
What is the preferred cutting needle?
Reverse cutting
Good for skin, whereas taper is not.
decreases likelihood of sutures pulling through soft tissue
Where is the cutting edge for the traditional cutting needle?
what about for the reverse cutting needle?
traditional cutting needle: inside of the curve (concave surface)
reverse cutting needle: outter surface of the curve (convex surface)
What are the pros/cons of a memory/nylon/PDS suture?
- Pros: Returns to previous shape when deformed.
- Cons: Difficult to tie and unravel
What are the pros of elasticity/monofilament sutures? what tissue should it be used on?
- Pros: Returns to original length after it’s stretched
- Mainly used for edematous tissue
What is knot strength?
Force required for a knot to slip.
important to consider when ligating arteries
What are the 3 monofilament sutures and their features?
- PDS, Monocryl, Nylon
- Less traumatic due to less friction
- Lower rates of infection
- More likely to slip, requiring 5-6 throws vs 3 for multi
- Preferred for skin closure d/t better cosmetic result
What are the 2 multifilament sutures and their features?
- Vicryl and silk
- Easier to handle and tie, less likely to slip.
What are the non-absorbable suture materials?
natural and synthetic
- Natural: Silk (braided)/cotton/steel
- Synthetic: Prolene (mono), Ethilon (nylon-mono)
Left in place indefinitely or removed once adequate healing occurs.
What are the absorbable suture materials?
- Natural: catgut, collagen-based for 1 week.
- Natural: chromic catgut: collagen + chromium, take 3 months to breaht down.
- Synthetic: Vicryl is degraded by water, minimal reaction by tissue compared to catgut.
Catgut used on small kids face
Monocryl and PDS are also broken down by hydrolysis.
Summary of absorbable suture materials
How is suture size scaled?
0 to 12/0
0 is largest, 12/0 is smallest.
They had to add on numbers as we got better technology, so higher number = smaller suture
Suture Removal Timings
- Face: 3-4d
- Scalp: 5d
- Trunk: 7d
- Limb: 7-10d
- Foot: 10-14d
You need more tensile strength in feet
