Skin Closure Techniques & Controlling Bleeding Flashcards
Intraoperative Procedures
4 Goals of Suturing
- Stop bleeding
- Close any dead space
- Approximate the wound edges
- Minimize Scar Formation
Peritoneum would need what type of suture material to close it?
3-0 monocryl (some don’t close this layer)
Fascia may need what type of suture material to close it?
large absorbable suture - 0- vicryl
Deep space (deep dermal) may need what type of suture material to close it?
smaller absorbable - 3-0 vicryl
Skin can be closed by what materials?
subcutaneous suture, staples, or glue
For superficial wounds and delicate tissues (e.g., facial lacerations, mucosal surfaces), use what type of suture?
absorbable sutures - polyglactin (e.g., Vicryl) or polyglycolic acid (e.g., Dexon).
For deeper tissues and those requiring prolonged support, what type of suture do you use?
non-absorbable sutures like nylon (e.g., Ethilon) or polypropylene (e.g., Prolene) are often used.
If the wound is expected to heal rapidly and not require long-term support, what type of suture may be preferred?
absorbable
_____ sutures are used when prolonged support is necessary, such as in cardiovascular or orthopedic surgeries.
Non-absorbable
the Selection of Suture Material and Size depends on what 7 factors?
1) Type of Tissue
2) Healing Characteristics
3) Location of the Wound
4) expected tension
5) size of suture
6) biocompatibility and allergy considerations
7) cost and availability
- If the wound is expected to heal rapidly and not require long-term support, _____ sutures may be preferred.
- _____ sutures are used when prolonged support is necessary, such as in cardiovascular or orthopedic surgeries.
- absorbable
- Non-absorbable
what sutures are preferred in contaminated areas because they are less likely to harbor bacteria?
monofilament sutures - nylon or polypropylene
what sutures may be used in areas where a more flexible suture is needed, such as the scalp?
multifilament
difference between the sutures used for high-tension areas vs lower-tension areas?
- High-tension - stronger; braided polyester (e.g., Ethibond)
- Lower-tension - finer material; polyglactin like Vicryl.
what is the correlation to the number to the diameter size of the suture?
smaller = larger diameter
types of suture allergies
- silk
- catgut
- chromic gut
- nickel
- other metal components - titanium, alloys
- adhesives
Chromic gut sutures are treated with ____ _____ to delay absorption and prolong their tensile strength.
chromium salts
Some sutures, particularly those made of ?, may contain traces of nickel.
stainless steel
Selecting the style of closure is based on:
- Wound size
- Location
- Amount of stress/tension the wound will undergo while healing
Most Common type and easiest to perform suturing technique
simple interrupted
characteristics of simple interrupted suturing
- individually placed and tied
- Allows for eversion of edges
- ONLY for in Low Tension
- ensure every stitch is of equal - helps healing; less scarring
Most commonly used material in simple interrupted?
Nonabsorbable - Nylon or Prolene
benefit of rule of halves for simple interrupted?
Ensures tension is evenly distributed along the wound edges
- better wound healing
- less risk of tissue ischemia or necrosis
- Aesthetically pleasing outcome
- Place sutures again and again without tying each individual suture.
- Easier of the wound is very clean
- Best to help stop bleeding from skin edge - Ex) scalp laceration
Simple Running/Continuous Stitch
indications for Mattress Suture
- good choice when the skin edges are difficult to evert.
- Provide relief of wound tension while still allowing skin edge approximation
types of mattress suture
- vertical
- horizontal
indications for vertical mattress
- for joints or areas with significant tension
- thick wounds that occur on a surface that is concave or posterior neck surfaces.
contraindications for vertical mattress
Face, Palms, Soles, Areas where blind, deep suture should not be performed
technique for vertical mattress
“Far, Far; Near, Near”
indications for horizontal mattress
- Excellent for wounds under tension and very fragile wounds
- Spreads the tension out over the length of wound edge
technique for horizontal mattress
box-like closure
- Can be Interrupted or Running
- interrupted sutures but with buried knots
- Requires a little more skill - must enter the skin on opposite side at a depth similar to where you exited
Subcuticular (Buried) Suture
indications for Subcuticular (Buried) Suture
- Wounds under little tension
- prone to keloids
interrupted subcuticular is MC used to close what type of incisions?
small laparoscopic
MC sutures used for interrupted subcuticular
vicryl or monocryl
Pro of interrupted subcuticular
No Suture removal required and better cosmetic result
- MC used in plastic surgery
- Best cosmetic result
- No suture removal required
Running Subcuticular
technique for running subcuticular
Starts with buried simple subcuticular suture with a short tail cut and rest of suture left long.
- Suture is ran along the incision in the subq tissue parallel to incision line.
- tied with knot buried
- Needle pulled through skin and suture is cut at skin surface.
- Skin is covered with glue or steri-strips
The most commonly used method of securing sutures in cutaneous surgery.
Instrument Tie
An absolute minimum of ? throws are needed for knot security, but some sutures require more to remain tied. When in doubt, ? throws will hold almost all sutures securely.
- three
- five
which type of tie is helpful when tying a knot deep in the abdomen
Free Hand Tie
free hand tie is MC performed with which hand?
non-dominate
a right handed surgeon is holding the needle driver in right hand while tying with the left
indications for staples
- main pro: quick; if you need close a bleeding wound ASAP
- Used often to close laparotomy incisions
con of stapling
more scarring
technique for stapling?
how far should staples be?
- evert edges
- place the center of stapler at point where skin edges come together
- gently touch stapler to skin, grasp handle to compress
- release handle, move stapler few mm back to separate staple from device
staples should be 1 cm apart
how to remove staples
- staple remover device - Put the jaws under the staple, and close the device.
- No staple remover - use a clamp
- open clamp to bend the staple; can be painful
- Can be applied as a primary closure or in conjunction with buried suture
- Used for closure of low tension, easily approximated wounds
- CI: active infection or on mucosal surfaces, and areas of high moisture
Skin Glue (DermaBond)
Often are placed after sutures are removed to help keep the skin closure from separating.
Can be used as a means of closure for relatively small wounds whose edges easily come together.
steri strips
technique for steri strips
- Cut strips so that 2–3 cm are on each side
- Place strips one at a time, several mm apart.
- placed across (perpendicular) the long axis of wound
- Stays for several days and should be allowed to fall off on their own.
- can wash the area but gently
ways to control Bleeding from Skin Edges
- applying pressure
- electrocautery - bovie
- tie off vessel
things to make sure with using a bovie
- Make sure pt is grounded
- Ensure your gloves are intact
Surgeon can ask for setting of “____” to enhance the ability of cutting currents to coagulate small bleeders during dissection and coagulation currents to dissect tissue during hemostasis.
Bovie
Blend
T/F: Bovies can remove/vaporize all types of lesions
F
NOT to be used when removing suspicious lesions that could be cancerous or pre-cancerous
technique for applying pressure when controlling bleeding
- Application of pressure is always a good first choice.
- It prevents further blood loss and may allow the vessel to clot
- Try this technique for at least 5–7 minutes.
what size vessel can be used by electrocautery to stop its bleeding?
small - 1-2 mm
when to tie off a bleeding vessel?
- If you do not have access to an electrocautery unit or
- large vein/artery (>3–4 mm)
2 options of tying a bleeding vessel
- regular
- stick tie
which tie is best for a small bleeding vessel?
technique?
regular tie
- Grasp end of vessel with a small clamp, hold it away from surrounding tissues.
- Pass a piece of 3-0 or 4-0 silk or Vicryl suture material (needle not needed) around vessel and under the clamp.
- Tie the suture securely, placing at least 3 or 4 knots.
most secure tie to control bleeding vessel?
stick tie
why is it best to use a stick tie on arteries?
thicker wall and increased interior pressure of an artery
Tips for Assisting During Bleeding
- If you can’t see, it is likely that the surgeon can’t see
- Help retract
- Suction blood
- Use tapes/sponges to blot blood away from surgical site
- Suction surgical smoke/plume away from surgical site
- Use care not to wipe or remove the eschar from site that has been cauterized
