Skin and Fascial wound closure - LA (Morton)

Question 1

Layers incised to perform a celiotomy

Answer 1

1. skin
2. subcutaneous tissues
3. linea alba (rectus….)
4. retroperitoneal fat
5. peritoneum

Question 2

Incision is as important as

Answer 2

closure

scalpel blade is better than electro

Question 3

when incising avoid

Answer 3

tangential incisions

incisional trauma

Question 4

Fascial closure

Answer 4

• most commonly involves celiotomy closure
• holding layers
  
  • linea alba
  • external rectus abdominus fascia
• proper technique associated with low incidence herniation (1–2%)

Question 5

Linea alba thickness

Answer 5

• thick towards the belly button
• thinner by the sternum

Question 6

Fascial closure and aponeuroses

Answer 6

• Cranially
  
  • take full thickness bites of linea
• Caudally
  
  • Small animal: take wide bites of external rectus fascia
  • Large animal: full thickness

Question 7

In fascial closure avoid

Answer 7

• avoid taking large bites of muscle and causing muscle necrosis
  
  • loosens closure
  • increases inflammation and associated risks

Question 8

Fascial closure and Peritoneum

Answer 8

• do not suture
• doesn’t contribute to wound strength, increases risk of adhesions
• defects are covered by mesothelial cells in 3 days

Question 9

Fascial closure

Simple continuous

Pro

Answer 9

• Pros
  
  • decreased time
  • decreased suture material
  • similar strength (higher bursting strength) compared to interrupted

Question 10

Fascial closure

Simple continuous

Con

Answer 10

• One break may result in herniation
  
  • springs
  • Proper size suture
  • knots
    
    • 5+ throws at beg
    • 7 throws at completions
  • proper handling of suture

Question 11

Suture material usually fails

Answer 11

at knots

Question 12

Closure usually fails

Answer 12

at body wall

Question 13

Interrupted suture patterns

Answer 13

• simple, cruciate
• slower
• inc suture material
• 4+ throws per knot
• plys = knot ends

Question 14

Suture material recommendation

Answer 14

• Monofilament (braided ok if no infected tissues) absorbable
  
  • polydioxanone (PDS) or Polyglyconate (Maxon)
  • Vicryl (polyglactin 910) #3 in horses
• Long retentio of tensile strength
  
  • PDS preferred over chromic gut
• Slow healing use non absorbable
  
  • cushings or infection
  • stainless steal, nylon
• Bite size (consider animals size)
  
  • 0.5-1 cm from incision
  • 0.4 - 1.0 cm apart

Question 15

Fascial closure

suture size

Answer 15

• < 5 kg: 3-0
• 5-15 kg: 2-0
• 20-40 kg: 0
• > 40kg: 1
• Horse (550 kg): 3

Question 16

Answer 16

Question 17

Skin incision guide

Answer 17

incise parallel to lines of tension (Langer’s lines)

Question 18

Tissue care during procedure

Answer 18

• keep tissue hydrated
  
  • saline moistened sponges
  • saline lavage

Question 19

undermining

Answer 19

• avoid
  
  • devitalizes (devascularization)
  • increases dead space
    
    • hematoma
    • seroma

Question 20

manipulation

Answer 20

• avoid excessive manipulation
  
  • minimal manipulation with instruments and fingers
  • skin hook, fingers, needles, fine toothed forceps acceptable

Question 21

Skin closure

Answer 21

• 2 layers (ddep to superficial
  
  • subcutaneous
  • intradermal
  • skin

*subcutaneous + Intradermal = subcuticular

Question 22

Subcutaneous

Answer 22

• closed to minimize dead space and appose skin
• Interrupted or continuous
• not a holding layer (minimal strenth)

Question 23

Subcutaneous technique

Answer 23

• interrupted or continuous
• bites placed close to skin/SQ juncture, perpendicular to incision
• avoid adipose tissue
• may tack down to external rectus fascia if excessive dead space and undermined tissue
• advance 5-10 mm between bites

Question 24

subcutaneous suture material

Answer 24

• non reactive (monofilament or braided) absorbable
• doesn’t require long retention of tensile strength
• PDS, Vicryl, Maxon, or monocryl
• small diameter
  
  • 0 to 4-0
  • 1-2 sizes smaller than used in linea

Question 25

Cutaneous patterns

interrupted

Answer 25

• cruciate
• simple interrupted
• 3-8 mm from edge of incision
• 5-10 mm apart

Question 26

cruciate

Answer 26

• increased speed (fewer knots)
• tension relief (similar to mattress)

Question 27

Simple interrupted

Answer 27

• Decreased speed
• Adjust tension more precisely

Question 28

Continuous cutaneous patterns

Answer 28

• Simple or Ford interlocking
  
  • rarely used in SA (self-trauma)
  • Farm pattern

Question 29

Cutaneous suture

Answer 29

• Monofilament, non-absorbable or absorbable
• Reverse cutting needle
• Nylon, Prolene, Fluorofil
• Cut ends 8-10 mm

Question 30

Intradermal pattern

Answer 30

• Pros
  
  • no suture removal
  • cosmesis
• Cons
  
  • technically difficult
  • time consuming
  • doesn’t eliminate dead space
  • dec resistance to tension
    
    • make sure lower levels opposed before

Question 31

Intradermal pattern

Indications (for use alone)

Answer 31

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

Question 32

Intradermal patter

Suture material

Answer 32

• absorbable monofilament or braided
• Vicryl, PDS, Monocryl
• Small diameter (3-0 to 4-0)
• Reversed cutting needle

Question 33

Indradermal pattern

Technique

Answer 33

• Burying know at beginning
  
  • Deep to Sup, Sup to Deep
  • 4 throws
• Dont advance between bites
• Bury knot at end
  
  • tighten parallel to incision
  • 4 throws

Question 34

Skin closure

Staples

Answer 34

• increased cost
  
  • 1 stapler (35 staples) = 10-20$
  • 1 pack suture = 2.00
• decreased operative time
  
  • patient benefits
  • surgeon benefits
  • cost saving (less anesth time)
• Not suited for wounds under tension or thin skin

Question 35

Summary

Answer 35

• Proper closure begins with proper approach
• To minimize incisional complications
  
  • minimal skin handling
  • use appropriate instruments
  • appropriate closure technique