Lecture 5 - Basic Suture Patterns, Hand Ties, & Electrocautery Flashcards
What are some reasons why you would use different suture patterns for different situations?
- Purpose of the procedure
- Strength of tissues
- Degree of tension
- Healing properties of the tissues
- Risk of complications
What are some classifications of suture patterns?
- Effect on wound margin (appositional vs. inverting vs. everting)
- Tension-relieving
- Placement (interrupted vs. continuous)
- Misc. patterns/techniques
- By tissue type (subcuticular/intradermal, SQ, skin, tendon)
_____ patterns are avoided in the skin.
Inverting
Inverting patterns are used to close _____.
hollow viscera
_____ patterns work nearly everywhere.
Appositional
Everting patterns can be used in _____.
the skin
In an interrupted pattern, every suture has a _____.
knot
Why are interrupted patterns more secure than continuous?
A single knot can fail while others are still in place
With interrupted patterns, it is easier to _____.
adjust tension
What are some disadvantages of interrupted suture patterns?
There is more foreign material in the wound;
They are slower to perform
Where are the knots located in continous suture patterns?
Single knot at beginning and end
What are some advantages of continuous patterns?
- Less foreign material
- Better seal
- Distributes tension evenly
- Quicker
What are some disadvantages of continuous patterns?
- Failure of knot or suture could lead to complete dehiscence
- Less able to adjust tension or apposition
- Bulkier knot at end (end + loop)
- Can create purse-string effect
What are the 7 appositional suture patterns?
- Simple interrupted
- Simple continuous
- Buried intradermal
- Continuous horizonal/intradermal
- Cruciate
- Ford interlocking
- Modified Gambee
What are the 7 inverting suture patterns?
- Lembert
- Cushing
- Connell
- Utrecht
- Halstead
- Parker-Kerr
- Purse-string
What are the 3 types of everting patterns?
- Horizontal mattress
- Vertical mattress
- Skin staples
What is the goal of appositional patterns?
To bring tissues into close approximation
What are some locations where a simple interrupted pattern can be used?
skin, linea, SQ, viscera
What are some advantages of a simple interrupted pattern?
- Secure
- Can adjust tension
- Disruption of one knot doesn’t compromise entirety
- Easy
What are some disadvantages of a simple interrupted pattern?
- Slow
- More foreign material
When would you use a modified Gambee pattern?
intestinal anastomosis
In a modified Gambee, why do we use additional submucosal purchase?
To minimize mucosal eversion
What is an advantage of a modified Gambee pattern?
Less wicking of GI contents
What are some disadvantages of using a modified Gambee pattern?
More tissue manipulation, slower
Where would you use a simple continuous pattern?
Intradermally, SQ, linea, fascia, viscera, vasculature
Where might you want to avoid using a simple continuous pattern?
in the skin (maybe)
What are some advantages to using a simple continuous pattern?
- Creates a seal
- Fast
- Easy
What are some disadvantages to using a simple continuous pattern?
- Excess tension leads to eversion/puckering
- Can cause strangulation
- Not as strong
Where would you use an interrupted intradermal/subcuticular pattern?
SQ, fascia, holding layer
An interrupted intradermal/subcuticular pattern is basically a _____ with the knot _____ or _____.
simple interrupted, deep, buried
Where would you use a continuous intradermal pattern?
Skin
A continuous intradermal pattern is basically a modified _____.
running horizontal mattress
What are some advantages of using a continuous intradermal pattern?
- Quick
- Easy
- Cosmetic
- No suture removal required
What are some disadvantages to using a continous intradermal pattern?
- Not as strong as skin sutures
- Expertise/practice required for proper knot burial
Where should you use a Ford interlocking pattern?
Thick skin
A Ford interlocking pattern is basically a modified _____ with each pass partially _____.
simple continuous, locked
What are some advantages to using a Ford interlocking pattern?
- Even tension distribution
- Fast
What are some disadvantages to using a Ford interlocking pattern?
- Microcirculatory compromise
- Nor very exact apposition
- Expertise/practice in ending the pattern is required
Where would you use a cruciate pattern?
Skin, muscle, fascia
How often is the wound crossed for each knot in a cruciate pattern?
2x
What are some advantages of using a cruciate pattern?
- Resists tension
- Stronger than simple interrupted
- Fast
What are some disadvantages to using a cruciate pattern?
- Less effective exact apposition
- Difficult to place evenly
Where would you use a lembert pattern?
Hollow viscera, joint capsule imbrication
A lembert pattern can be _____ or _____.
continuous, interrupted
How are bites of a lembert pattern taken?
perpendicular
T/F: A Lembert pattern does not penetrate the lumen
True
What is an advantage to using a Lembert pattern?
good seal
What is the pattern used in a Lembert (how is the suture placed)?
Inverting; Placed far-near, near-far
Where would you use a Halstead pattern?
hollow viscera
A Halstead pattern is basically 2 _____ together.
interrupted Lemberts
A Halstead pattern is basically a modified _____ and _____ together.
Lembert, horizontal mattress
T/F: Halstead pattern does not penetrate the lumen
True
How are bites in a Halstead pattern placed?
perpendicular
What is an advantage of using a Halstead pattern?
good seal
What is a disadvantage of using a Halstead pattern?
Could cause microcirculatory compromise
Where would you use a Cushing pattern?
hollow viscera
How are bites taken in a Cushing pattern?
parallel
T/F: A Cushing pattern penetrates the lumen
False
What is an advantage of using a Cushing pattern?
Good seal
What is the most common inverting pattern in small animals?
Cushing
Where should you use a Connell pattern?
Hollow viscera
How are bites taken in a Connell pattern?
parallel
T/F: Connell pattern penetrates the lumen
True
What is an advantage of using a Connell pattern?
good seal
What is a disadvantage of using a Connell pattern?
May wick GI contents
Where would you use a Utrecht pattern?
Hollow viscera (uterus in large animal)
How are bites taken in a Utrecht pattern?
Diagonal ~45°
T/F: A Utrecht pattern does not penetrate the lumen
True
What is an advantage of using a Utrecht pattern?
Good seal
Where would you use a Parker-Kerr pattern?
viceral stumps
A Parker-Kerr pattern is a _____ pattern sewn over a _____ and _____ as the _____ is removed.
Cushing, clamp, tightened, clamp
What is done in a Parker-Kerr pattern after the clamp is removed?
oversewn with a second layer
What is a purse-string pattern used for?
To secure -ostomy tubes, temporarily close anus or treat prolapse
A purse-string pattern is basically a continuous _____.
Lembert
How is a purse-string pattern placed?
In a circular fashion
What happens to the tissue in a purse-string pattern when the suture is pulled tight?
it inverts
What is a disadvantage of using a purse-string pattern?
Can cause microcirculatory damage
Where would you use a horizontal mattress pattern?
Areas of tension or friable tissue, muscle, fascia, tendon
What does a horizontal mattress pattern form when complete?
square
Horizontal mattress sutures can be _____ or _____.
interrupted, continuous
What is a disadvantage of using a horizontal mattress pattern?
Can cause local tissue ischemia
What would you use skin staples instead of?
nylon skin sutures
What is an advantage of using skin staples?
Fast
What are some disadvantages to using skin staples?
- More painful to remove
- Can flip and imbed into tissues
- Need special staple remover
Skin staples have a tendency to _____ in animals.
evert
Skin staples must _____ during placement.
appose tissues gently
How are skin staples placed?
Line up arrow on stapler with incision, use downward pressure while clamping handle
What are the 2 types of hand ties?
one-handed and two-handed
When should you use hand ties?
In hard to reach areas, deep in cavities
What are some advantages to using hand ties?
faster, more secure
What are some disadvantages to using hand ties?
Requires more suture, need PRACTICE!
Where are one-handed ties used and what is a disadvantage?
Used in confined areas;
Less tension control
What is an advantage of using a two-handed tie?
better control and accuracy
What are some advantages to using inatrument ties?
- Wastes less suture
- Fast
Generally speaking, what is electrosurgery/electrocautery?
Atraumatic use of electromagnetic energy to coagulate blood vessels, cut, dissect, and ablate tissues.
What is electrosurgery, specifically?
Passage of electrical current from instrument through tissues using alternating current.
What is electrocautery, specifically?
Uses heat generated bu direct electric current into a metal wire or probe
What are 3 characteristics of an electrical current?
- Takes path of least resistance
- Seeks ground
- Requires a complete circuit
What is the circuit used in electrocautery?
Generator –> active electrode –> patient –> inactive electrode (grounding pad)
What is an electrical current?
Waveforms transmitted by the generator
What type of electrical current does cutting use?
continuous
What type of electrical current does coagulation use?
intermittent
What does tissue effects by electrocautery depend on?
- Surgical unit power (watts)
- Length of exposure
- Volume of tissue treated
- Contact type of electrode
- Density
- Tissue impedance
What are the high resistance tissues?
bone, scar tissue, adipose
What are the low resistance tissues?
muscle, vasculature
What is the tissue effect at 250°C?
Tissue carbonization from dehydration
What is the tissue effect at 100°C?
Cell wall rupture
What is the tissue effect at 90°C?
Tissue dessication
What is the tissue effect at 70°C?
Protein denaturing
What is the tissue effect at 50°C?
Enzymatic activity inactivated
What is the tissue effect at 40°C?
Inflammation and edema
What is fulguration coagulation?
Holding electrode away from tissue using coagulation mode with gap from electrode to tissue
What is dessication coagulation?
Direct contact electrode and tissue in coagulation mode
What is coaptive coagulation?
Lumen of vessel is occluded by metal instrument and wall is coagulated
In monopolar electrocautery, where does the current pass through?
Via hand-held electrode, through patient to grounding pad
In monopolar electrocautery, the field must be _____.
dry
In monopolar electrocautery, an _____ is created on tissue.
eschar/coagulum
In monopolar electrocautery, there is direct contact or indirect via _____.
instrument arc
In monopolar electrocautery, what size ground plate should be used?
Largest plate with good contact
In monopolar electrocautery, vessels _____ in size are coagulated.
>2mm
In monopolar electrocautery, you can cut for _____ or other tissues.
skin incision
In monopolar electrocautery, caution should be used inside ____, in patients with _____, and with _____ surgery.
chest, arrhythmias, minimally invasive
Where does the current pass in bipolar electrocautery?
From one tip of the forceps to the other
In bipolar electrocautery, what tissues are included in the circuit?
Only those between the electrodes
What is an advantage of bipolar electrocautery over monopolar?
More precise, prevents adjacent tissue damage
In bipolar electrocautery, the field can be relatively _____.
wet
What are some disadvantages to using bipolar electrocautery?
- Lower power setting, needs more time
- Limited to dissection and coagulation, NO cutting
- Can cause charring and adherence to instrument
What are the two electrodes called in bipolar electrocautery?
Active electrode and dispersive electrode
What is battery powered cautery used for?
Quick, brief application
In battery-powered cautery, current doesn’t _____.
transfer through the patient
In battery-powered cautery, where is the heat transfer?
Direct from the tip of the instrument
In battery-powered cautery, what is the instrument called?
bovie pen
What 3 things do vessel sealing devices do?
- Apply pressure and bipolar energy to the tissues
- Denature collagen and elastin from vessel wall and c.t.
- Limit blood loss
What is an advantage to using a vessel sealing device?
No foreign material used
What is the seal cycle of LigaSure and what size vessels can it be used on?
2-4 seconds; vessels up to 7 mm
What does EnSeal do?
Limits thermal spread to 2 mm
What do ultrasonic energy systems do?
Deliver electrical energy in the form of mechanical energy
In an ultrasonic energy system, the current delivers ultrasonic waves at _____ to cut and coagulate tissue _____.
55,000 vibrations/sec, simultaneously
In ultrasonic energy systems, _____ produce vibration-induced heat and coagulation.
oscillations
What type of coagulationdo ultrasonic energy systems use?
coaptive
What is an advantage of using ultrasonic energy systems?
Less collateral tissue damage
What is a disadvantage to using ultrasonic energy systems?
Not reliable >3mm
What are some precautions that should be taken when using electrocautery?
- Do not use with explosive gas or liquid (fire hazard)
- Avoid grounding pad burns (use largest possible with good contact, avoid ECG leads nearby)
- Arrhythmias
- Smoke plume - use suction
