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Intro to Surgery > Lecture 8 - Advanced Suture and Knots > Flashcards

Lecture 8 - Advanced Suture and Knots Flashcards

1
Q

What are the properties of the skin?

A

tension, shear, and viscoelasticity

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2
Q

What is tension determined by?

A

the pull of collagen and elastin in dermal and hypodermal tissues

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3
Q

What is the shear skin property?

A

mobile areas of skin with forces on either wound edge opposing the other

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4
Q

How does viscoelasticity occur?

A

adaptation to prolonged stress

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5
Q

What are the tension relieving techniques?

A

undermining tissues, tension-relieving sutures, skin stretching, relaxing incisions

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6
Q

How do you undermine tissue?

A

You use metzenbaums to dissect superficial to the muscle

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7
Q

What does undermining take advantage of?

A

the skin’s elastic potential

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8
Q

What type of dissection does undermining use?

A

blunt and sharp dissection

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9
Q

When should you not use undermining?

A

when the patient has cancer

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10
Q

What are some tension-relieving sutures?

A

interrupted vertical mattress, interrupted or continuous horizontal mattress, quilled/stented/bolster, far-near-near-far, far-far-near-near, cruciate, and walking sutures

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11
Q

What tissues is the vertical mattress used for?

A

skin, gingiva, fascia, and tissues under tension

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12
Q

What bites are used for the vertical mattress suture?

A

far-far, near-near

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13
Q

Which bites in the vertical mattress suture should be deep?

A

the far bites

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14
Q

How far from the incision should the near bites in the vertical mattress suture be?

A

2 mm

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15
Q

If the vertical mattress is tight, what type of suture pattern is it?

A

everting

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16
Q

When does the vertical mattress appose best?

A

when the near bites are close

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17
Q

Is the vertical mattress or horizontal mattress stronger?

A

vertical

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18
Q

In what type of tissue should you use the quilled/stented pattern?

A

skin under tension

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19
Q

What is the quilled/stented suture a modified suture of?

A

the interrupted vertical mattress that loops over a stent

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20
Q

What type of pattern is the quilled/stended suture coupled with?

A

an appositional pattern at the skin edge

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21
Q

What is a potential complication associated with the quilled/stented suture pattern?

A

ischemia between sutures or under stents

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22
Q

When should the quilled/stented suture pattern be removed?

A

earlier than the remaining sutures

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23
Q

In what type of tissue should you use a far-near-near-far pattern?

A

skin and fascia under tension

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24
Q

What is the far-near-near-far pattern a modification of?

A

a vertical mattress pattern

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25
Q

The far-near-near-far suture pattern avoids excess ______ at the wound edge.

A

tension

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26
Q

What is the thickness of the bites in the far-near-near-far suture?

A

full thickness

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27
Q

In what type of tissue should you use a far-far-near-near pattern?

A

skin and fascia under tension

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28
Q

What is the far-far-near-near pattern a modification of?

A

modified vertical mattress

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29
Q

The far-far-near-near suture avoids excess ____ at the wound edge?

A

tension

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30
Q

What is the thickness of the bites in the far-far-near-near pattern?

A

full thickness

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31
Q

What is the purpose of the walking suture?

A

move skin across a defect, eliminate dead space, and distribute tension

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32
Q

In the walking suture, the suture bite in ____ is closer to the center of the _____.

A

fascia; wound

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33
Q

What effect does the walking suture cause?

A

cosmesis

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34
Q

What is cosmesis?

A

dimpling

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35
Q

When don’t you use the walking suture?

A

with flaps or grafts

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36
Q

What are some ways to facilitate skin stretching?

A

pretensioning sutures, posttensioning sutures, presuturing, acute intraoperative skin stretching, and chronic skin expansion

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37
Q

When do you do pretensioning sutures?

A

48-72 hours preop

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38
Q

Pretensioning sutures are continuous through ______ or _____ with lead _____ _____.

A

skin; intradermal; split shots

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39
Q

Pretensioning sutures are considered ____ ____ _____.

A

external skin stretchers

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40
Q

What is pretensioning suture for and what mechanism does it use?

A

stress relaxation, mechanical creep

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41
Q

How often are pretensioning sutures tightened?

A

every 8-24 hours based on your judgement

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42
Q

When are posttensioning sutures applied?

A

postop to minimize skin tension

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43
Q

Posttensioning sutures are considered ____ ______ _____.

A

external skin sutures

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44
Q

What can be used to aid in posttensioning sutures?

A

bolster bandages

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45
Q

What is presuturing?

A

when sutures are placed around an area of planned excisioinn

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46
Q

What type of suture pattern is used in presuturing?

A

lembert sutures through intact skin to plicate skin

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47
Q

How many days before surgery is presuturing done?

A

3 days

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48
Q

What is acute intraoperative skin stretching used for and what mechanism does it use?

A

stress relaxation and limited mechanical creep

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49
Q

What tools can be used for acute intraoperative skin stretching?

A

skin hooks, towel clamps, and stay sutures

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50
Q

Acute intraoperative skin stretching provides constant ______.

A

tension

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51
Q

How long preop do you want to do acute intraoperative skin stretching?

A

30-45 minutes

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52
Q

What is chronic skin expansion used for?

A

to produce a new epidermis

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53
Q

In what patients is chronic skin expansion used for?

A

used in patients that have excessive skin loss

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54
Q

What type of effect does chronic skin expansion have?

A

delayed effect, biological creep

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55
Q

What tools are used for chronic skin expansion?

A

inflatable or expandable silicone elastomer devices

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56
Q

How do you do chronic skin expansion?

A

implant surgically, expand 10-15% every 2-3 days

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57
Q

What are some types of relaxing incisions?

A

mesh expansion, simple relaxing incision, plasties

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58
Q

How is mesh expansion facilitated?

A

multiple relaxing incisions adjacent to the incision

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59
Q

How big are the incisions in mesh expansion?

A

1 cm in length

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60
Q

How far from the incision are mesh expansion incisions made?

A

1 cm from the edge

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61
Q

How far apart of are incisions for mesh expansion made?

A

staggered rows 1 cm apart

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62
Q

What is a potential risk associated with mesh expansion?

A

skin necrosis

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63
Q

What part of the body is mesh expansion useful for?

A

extremities

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64
Q

What is a single relaxing incision?

A

a bipedicle flap - an incision parallel to the long axis wound

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65
Q

How does a single relaxing incision heal?

A

it heals by second intention

66
Q

What is V-Y plasty?

A

a chevron incision with point away from the wound that closes in a y

67
Q

What is V-Y plasty useful for?

A

to advance skin to a defect or near orifice

68
Q

What is a Z plasty used for?

A

cicatrix or closure nearby a wound

69
Q

How is a Z-plasty performed?

A

the transposition of 2 triangular flaps from a central limb

70
Q

For a wound, the central arm of the Z plasty perpendicular to the long axis wound should be ____ cm away.

A

>3cm

71
Q

What is an M plasty?

A

one or both ends of fusiform incision is under tension

72
Q

When is an M plasty used?

A

orifice, pat, or bilateral mastectomy

73
Q

How is an M plasty closed?

A

as a Y

74
Q

What is a fingertrap suture pattern used for?

A

to secure -ostomy tubes and anchor them to the skin

75
Q

How is the fingertrap suture structured?

A

repeated loops crossed around tubes

76
Q

What is the fingertrap suture used to prevent?

A

accidental distraction or slippage

77
Q

When does friction increase in the fingertrap suture?

A

if distract/pull tube

78
Q

What type of pattern is the kessler locking loop suture?

A

superior apposition

79
Q

What is the Kessler locking loop suture used for?

A

smaller tendons and flat tendons

80
Q

What does the kessler locking loop suture maintain in tendons?

A

gliding function

81
Q

How is the three-loop pulley suture oriented?

A

3 loops oriented 120 degrees to each other

82
Q

What is the three-loop pulley suture resistant to?

A

gap formation

83
Q

What is the three-loop pulley suture good for?

A

circular tendons and larger tendons

84
Q

What is the Bunnell-meyer suture used for?

A

circular tendons

85
Q

What is a potential risk of the Burnell-Mayer suture?

A

it may damage the tendons microcirculation

86
Q

What type of pattern is the Krackow pattern?

A

a locking-loop pattern

87
Q

What type of tendons is the krackow suture good for?

A

larger tendons and circular or flat tendons

88
Q

What is a potential risk of the Krackow suture?

A

may damage tendon circulation

89
Q

Where is the knot located in the Krackow suture?

A

it is within the tendon center

90
Q

What is the weakest point of a suture?

A

the knot

91
Q

What are the most reliable knots?

A

superimposing square knots

92
Q

How many throws should be done with an interrupted pattern?

A

4

93
Q

How many throws should be done with a continuous pattern?

A

6-8

94
Q

What are some types of knots?

A

square, granny, slipped, surgeons, and simple

95
Q

What is knot strength?

A

force required to cause a knot to slip

96
Q

What is knot security?

A

related to the coefficient of friction of suture and knot strength

97
Q

What factors affect knot security?

A
  1. material coefficient and memory 2. length of the cut suture ends and # of throws 3. structural configuration of the knot 4. body fluids/wound
98
Q

What affects the net tensile strength of the suture line?

A

initial tensile strength of the suture and knot security

99
Q

What are the principles of knot tying?

A
  1. use the simplest secure knot for the suture material and the situation 2. avoid friction between the strands as it may weaken the suture 3. use appropriate tension 4. approximate tissues don’t strangulate tissues 5. pull the 2 strands in opposite directions with uniform rate and parallel tension 6.avoid damage to the suture material that remains with the patient 7. knots should be secure and flat
100
Q

How are knots buried?

A

take bites deep to superficial and then superficial to deep; in SQ or intradermal sutures

101
Q

How do you bury a continuous pattern end knot?

A

superficial to deep, deep to superficial, then superficial to deep

102
Q

What is the aberdeen method?

A

a method to end a continuous suture pattern

103
Q

What are the benefits of the aberdeen method?

A

increased strength, increased security, decreased number of throws, and decreased size

104
Q

What are self-locking sutures?

A

sutures that contain a loop at the end

105
Q

What are self-locking sutures designed for?

A

laparoscopic procedures and can be used for intradermal

106
Q

What is hemostasis used for?

A

visability of the surgical field, decrease potential for infection, minimize blood loss, reduce hematoma and seroma formation, and decrease surgical times

107
Q

What are some methods of hemostasis?

A

electrocautery, bipolar vessel sealing device, harmonic scalpel, stapler devices, hemoclips, ligation, pressure/tamponade, torniquet/clamps/bandages, hemostatic agents, hypotension/hypothermia/reduced perfusion

108
Q

What hemostatic agents are used for topical vasoconstriction?

A

epinephrine/adrenaline/ephedrine

109
Q

What hemostatic agents are used for antifibrinolytics?

A

serine protease inhibitors, lysine analogues

110
Q

What hemostatic agents are used as sealants?

A

fibrin (tisseel, evicel, vitagel) and synthetic (coseal, and duraseal)

111
Q

What are some mechanical hemostatic agents?

A

gelatin (gelfoam, surgifoam), bovine collagen (avitene, helistat, instat, sanostat), oxidized cellulose (surgicel), bone wax, and ostene

112
Q

What are some active hemostatic agents?

A

thrombin (floseal, surgiflo) and alginate (kaltostat, sorbsan)

113
Q

What is the goal of ligation?

A

vascular strangulation

114
Q

Where does transfication occur in ligation?

A

distal to encircling

115
Q

What techniques are used for ligation?

A

simple encircling, transfixation, advanced circumferential friction knots

116
Q

What is the three clamp technique used for?

A

ligation of large vessels and vascular pedicles

117
Q

How do you perform the three clamp technique?

A
  1. 3 parallel forceps placed ~ 0.5cm from one another, transect between 2 most distal 2. release most proximal forceps partially while trying ligature in ‘crush’ 3. release completely as ligature is tightened
118
Q

When is encircling used?

A

for ligation of vessels, and small vascular pedicles

119
Q

What can be done with encircling do prevent loosening?

A

a surgeons knot

120
Q

How is halsted transfixing performed?

A

a bite is taken around the vessel but not tied, the ends are passed around the opposite side of the vessel to create the knot

121
Q

How is modified transfixing performed?

A

a bite is taken in the vessel with a simple knot performed on one side. The suture ends are passed around the opposite side for a surgeons throw, then completion of the knot

122
Q

How is figure-of-eight transfixing performed?

A

the suture needle is passed in figure-of-eight pattern through the vascular pedicle two times, the two loops are tied with a single knot

123
Q

When is double transfixing used?

A

for large dog spays

124
Q

How is double transfixing performed?

A

it is a modified technique with the use of two simple encircling around either uterine artery

125
Q

What is the Miller’s knot used for?

A

large vessels and pedicles; friction

126
Q

How is the Miller’s knot performed?

A

place a secure half hitch around the pedicle, one suture end passed around and looped through a space preserved by your finger

127
Q

What is the modified miller’s used for?

A

large vessels and pedicles

128
Q

How does the Modified Miller’s work?

A

it is a clove-hitch that binds itself when tightened, the 2 loops are parallel

129
Q

What is the constrictor knot used for?

A

large vessels and pedicles

130
Q

How does the constrictor knot work?

A

it is a clove-hitch that binds itself when tightened, 2 loops cross, and suture end over first loop and under both

131
Q

What is the strangle knot useful for?

A

large vessels and pedicles

132
Q

What is the strangle knot a modification of?

A

the constrictor with suture end going under and between the cross

133
Q

What are self-locking loops designed for?

A

laproscopic surgery

134
Q

What is a surgitie self-locking loop?

A

a loop suture in a carrier, loop over vessel/pedicle, and tied with a slip knot

135
Q

What is a ligatie self-locking loop?

A

an absorbable device that closes like a zipper

136
Q

What suture pattern is shown here?

A

a vertical mattress

137
Q

What suture pattern is shown here?

A

quilled/stented

138
Q

What suture pattern is shown here?

A

quilled/stented

139
Q

What suture pattern is shown here?

A

far-near-near-far

140
Q

What suture pattern is shown here?

A

far-far-near-near

141
Q

What suture patten is shown here?

A

walking suture

142
Q

What suture pattern is shown here?

A

pretensioning sutures

143
Q

What suture pattern is shown here?

A

posttensioning sutures

144
Q

What technique is shown here?

A

presuturing

145
Q

What technique is shown here?

A

acute intraoperative skin stretching

146
Q

What technique is shown here?

A

mesh expansion

147
Q

What technique is shown here?

A

single relaxing incision

148
Q

What technique is shown here?

A

V-Y plasty

149
Q

What technique is shown here?

A

Z plasty

150
Q

What technique is shown here?

A

M plasty

151
Q

What technique is shown here?

A

fingertrap

152
Q

What suture is shown here?

A

Kessler locking loop

153
Q

What suture is shown here?

A

three-loop pulley

154
Q

What suture is shown here?

A

Bunnell-mayer

155
Q

What suture is shown here?

A

Krackow

156
Q

What technique is shown here?

A

halsted transfixing

157
Q

What technique is shown here?

A

modified transfixing

158
Q

What technique is shown here?

A

figure-of-eight transfixing

159
Q

What technique is shown here?

A

double transfixing

160
Q

What knot is shown here?

A

a Miller’s knot

161
Q

What knot is shown here?

A

a modified Miller’s knot

162
Q

What knot is shown here?

A

a constrictor knot

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