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3SP: Surgery/Injections > Tissue Closure And Suturing > Flashcards

Tissue Closure And Suturing Flashcards

1
Q

First intention

A
  • Skin edges are in contact (sutures)
  • blood produces fibrin rich clotting in the small gap—mild acute inflammation-macrophages/minimal granulation tissue—removes debris (fibrin)-scar formation. Nearby squamous epithelium of overlying epidermis migrates and proliferates until healed
  • healing time takes weeks to months
  • tensile strength: 7-10 days=1-2%, 14 days=5%, 60 days=35% of unwounded skin
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2
Q

Second intention

A
  • skin wedges are open and not touching
  • higher chance of infection
  • blood produces fibrin-rich clotting over large area—moderate acute inflammation—mainly granulation tissue with little macrophage assistance—removes debris (fibrin)—scar formation
  • healing time takes many months
  • tensile strength: 7-10 days=10%, 90 days=80% of unwounded skin
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3
Q

Age and healing

A

Increased age-decreased muscle tone, elasticity, circulation

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4
Q

Weight and healing

A

Obses patients have excess fat=prevent good closure

-fat tissue=poor blood supply

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5
Q

Nutritional status and wound healing

A

Malnutrition is associatd with chronic disease, cancer, or appropriate vitamins and nutrients needed for the healing process

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6
Q

Dehydration and wound healing

A

A depletion of fluid causes changes to cardiac, kidney, cellular metabolism ,hormonal function, and oxygen ration of blood-delay healing process

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7
Q

Inadequate blood supply and wound healing

A

Blood carries oxygen, oxygen is needed for eval survival

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8
Q

Immune repsosne and wound healing

A

The patient’s immunity protects them from infection, without it there is deceased ability to
fight infection and heal properly
• A heightened immune response in the form of an allergic reaction will interfere with the healing
process

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9
Q

Chonric disease

A

Diabetes, thyroid, malignancies, debilitating injuries, infections cause increased healing times

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10
Q

Radiation therapy and wound healing

A

Kills healthy tissue and decreases ability for the cells to properly perform healing

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11
Q

Wound closure goals

A

– Preserve function
– Restore function
– Achieve a cosmetically appealing scar

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12
Q

How to successfully accomplish these goals of wound closure

A

– Maintaining proper tissue handling and the rules
– Matching each wound layer to its counterpart
– Slightly everting wound edges
– Minimizing tension across the wound

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13
Q

Tissue mishandling

A
  • Using the wrong instrument
  • Crushing wound margins or surrounding skin with forceps
  • Tying sutures too tight
  • Allowing tissue to dry out
  • Excessive cauterization
  • Pouring iodine, peroxide, chlorohexidine, or alcohol into the wound
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14
Q

Maintain

A
  • Asepsis

* Hemostasis → limits infection, improve control during procedure, and dead space

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15
Q

Minimize

A

• Tissue trauma
• Surgery time
– Knowing anatomy, technique, instruments, and material used

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16
Q

Use good surgical judgement

A
  • Eliminate dead space

* Adequate removal of foreign and devitalized material

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17
Q

Minimizing tissue trauam

A
  • Do NOT crush
  • Do NOT twist
  • Do NOT stretch
  • Do NOT tear
  • Do NOT burn
  • Do NOT strangulate
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18
Q

Instrumentation

A
  • Surgical drape
  • 4x4.gauze
  • Suture material
  • Antiseptic solution and saline
  • Syringe
  • Scalpel
  • Hemostat
  • Scissors
  • Skin hooks
  • Tissue forceps
  • Suture tying forceps
  • Needle drivers
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19
Q

Surgical drape

A

– Should completely surround the wound and a portion of the surrounding sterile field

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20
Q

4x4 gauze

A

Clean the wound area

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21
Q

Suture material

A

6.0

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22
Q

Antiseptic solution nand saline

A

– Antiseptic: around the wound

– Saline: within the wound

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23
Q

Syringe and splash cap

A

To irrigate the wound with sterile saline to remove debris and contaminants

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24
Q

Scalpel

A

To extent or debride wound edges

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25
Q

Hemostat

A

-Used for blunt dissection of tissue

– Curved or straight

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26
Q

Scissors

A

-Only intended to cut sutures

– No role in dissection or removal of tissue

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27
Q

Skin hoooks

A

– Used in place of forceps
– They do not crush the tissue
– Careful:
• Always anchor deeper within the tissue
• Avoid piercing the epidermis with the points of the hook
• Avoid twisting which can decrease blood flow

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28
Q

Tissue forceps

A

– Allows you to create counter traction and control skin edge
• Also used to grasp needle when repositioning the needle holder
– Fine toothed
• Toothed are better for tissue gripping = less traumatizing
• 0.3mm for periocular skin
– Tying platform
• Some tissue forceps have a tying platform in order to grasp suture
– Careful:
• Use as a retractor and not as a claw
• Grasp the subcutaneous tissue instead of the epidermis at the margin

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29
Q

Suture tying forceps

A

– Straight or curved
– Have a tying platform for grasping the suture
– May be in combination with tissue forceps

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30
Q

Needle drivers

A

– Required to grasp and advance the curved needle
– Special textures within the jaws allowing for no slippage
– Will not damage the suture material itself
– Grip needle 2/3rds of the way back
– Types
• Conventional
• Micro- or Ophthalmic
– Held like a pencil between thumb and index finger
– Very little wrist action

31
Q

Absorbable sutures

A 
– Broken down by the body (enzymatic)
– Used for deep tissue and tissue that heals
rapidly
• Small bowl anastomosis
• Urinary/biliary tracs
• Tying off small vessels near the skin
• Entropion repair
32
Q

Non-absorbable sutures

A 
– Provide long-term tissue support
– Used for tissue that heals slowly
• Fascia or tendons 
• Closure of abdominal wall 
• Vascular anastomose 
• Skin
33
Q

Types of absorbable sutures

A 
Synthetic 
-monocryl
-vicryl
-PDS
Natural 
-collagens
34
Q

Non-absorbable sutures

A 
Synthetic 
-ethilon
-proline
Natural
 -surgical cotton
-surgical steel
-surgical silk
35
Q

How long before sterile field is no longer sterile

A

15-20m

36
Q

Sterile field and fluid

A

Pour away
If you get a couple drops thats ok
If you spill the whole bottle, not ok

37
Q

Types of needle drivers

A

Conventional

Micro- or Ophthalmic
– Held like a pencil between thumb and index finger
– Very little wrist action

38
Q

Synthetic suture

A

– Man-made
– More predictable
• dont lose tensile strength and absorption
– PDS or nylon

39
Q

Organic and natural sutures

A

– Natural fibers
– Provoke greater tissue reaction since
made with natural materials
– Silk or catgut

40
Q

Monofilament suture types

A

– Single strand
– Lower infection risk
– Poor knot security/ease of handling
– Nylon, PDS, prolene

41
Q

Multifilament suture

A

– Several filaments twisted together
– Higher infection risk
– Better knot security
– Braided silk or vicryl

42
Q

Suture diameter

A

• Affects tensile strength and handling properties
• Larger the size = smaller the diameter
– 7-0 suture is smaller than a 4-0 suture

Periorbital=6-0 to 7-0
conj=7-0

43
Q

Anatomy of needle

A 
Needle point 
Needle body 
Swaged end (eye)
44
Q

Eye (swaged)

A

Attached needle tp suture

45
Q

Blunt needle point

A

Abdominal wall closure/friable tissue

46
Q

Sharp needles

A

Pierce and spread tissue/minimal cutting

Prevents leakage

47
Q

Round needle point

A

Friable tissue: liver/kidney

48
Q

Cutting

A

• Triangle in shape with 3 cutting edges
• Cutting surface on concave (inside) edge
• Penetrates tough tissue
– Skin and sternum

49
Q

Reverse fitting

A

What we use

  • decreased risk o cutting through
  • cutting surface on the convex edge (outside curve)
  • penetrates tough tissue. Tendons and subcuticular suturing, periorbital
50
Q

Needle body

A 
• Measured by the amount
of circle the needle fills 
• Periorbital
– ¼ t, 3/8, or compound
curved
51
Q

Needle length

A

• Changes in needle radius
• Periorbital
– Smaller needle radius
• 26-23

52
Q

Process of suturing

A
  1. History and physical assessment & informed consent
  2. Non-sterile gloves
  3. Drawing and injecting local anesthetic
  4. Donning sterile gloves
  5. Cleaning and irrigating the wound
  6. Draping
  7. Simple interrupted suture
  8. Disposing of sharps
  9. Patient post-op instruction
  10. Suture removal
53
Q

Mechanism of injury

A

Blunt vs sharp

Potential adjacent injury

54
Q

Time elapse from injury to repair

A

> 8 hours=high risk of infection

-animal bites/farm injuries=best to leave open

55
Q

Patient factors

A

Healing factors

56
Q

Functional assessment

A

Evaluate nerves, blood vessels, tendons before local injections

57
Q

Non sterile gloves

A

Used during inital physical exam and injection of local

58
Q

Drawing and injecting local anesthetic

A

Injected into wound wall

-if you didnt make the cut yourself, never use epinephrine

59
Q

Donning sterile gloves

A

Scrub in and don sterile gloves to prevent spread of bacterial

60
Q

Cleaning and irrigating the wound

A
  • prep the area with betadine or providence iodine from sterile bowl. Non overlapping circular pattern
  • use sterile saline and splash cup to forcefully (but not violently) irrigate wound to dislodge bacterial and foreign material
61
Q

Draping

A

– Place fenestrated sterile drape over wound in order to isolate lesion
– Provides location for suture to rest

62
Q

Patient post op instructions

A

– Pain should subside significantly after 24-

63
Q

Suture removal (scrub in)

A

– Clean area with betadine
– Gently grab knot and lift, snipping underneath the knot close to the skin
– Gently pull strand towards the knot (over the wound) as to not decrease pull wound
apart
• Do not pull any part that was OUTSIDE the skin back THROUGH the skin!!
– Time frame
• Face: 4-5 days
• Scalp and trunk: 7-10 days
• Arms and legs: 10-14 days
• Joints: 14 days

64
Q

Surgeons knot

A

– Basics of suturing
– Must be mastered before attempting to suture
– variation of a square knot
– When properly tied it will not slip

65
Q

Hand tie

A

One- or two-handed tie

– Not for the face

66
Q

Instrument tie

A 
• Faster than hand ties
• More accurate/precision
• Use:
– Eyelid 
– Periorbital skin
 – Skin of the face
67
Q

Suturing methods

A 
– Interrupted percutaneous (simple interrupted suture)
– Continuous percutaneous
– Interrupted dermal
– Continuous dermal
– Special cases
• Vertical mattress 
• Horizontal mattress 
• Half-buried, horizontal mattress
68
Q

Simple interrupted suture advantages

A

• Most commonly used technique • Individual stitches which are not connected
– Easily removed without damaging closure
• High tensile strength
• Excellent approximation
• Used for low-tension wounds
– Used in combo with deep sutures for high-tension wounds

69
Q

Disadvantages of simple interrupted suture

A
  • Take a long time to place
  • Higher risk for infection
  • Possible strangulation of tissue
70
Q

Procedure for simple interrupted suture

A

– First suture is placed at center of wound
• Bisect the remaining section
– Subsequent sutures are placed midway between center of wound and
corners
– Gently grasp and evert skin edge (non-dominant hand)
– Pronate dominant hand so needle will pierce perpendicular
to skin (90*) and drive needle through skin by supinating the
hand before picking up the needle with the needle holders
(do not touch the needle tip) pulling through following the
natural curve of the needle and then repeating the process on
the opposite side of the wound edge
– Carefully gather thread to create long thread (with needle)
and short thread fore instrument tie

71
Q

Advancing the needle for simple interrupted technique

A

• The needle will be protruding from the
subcutaneous tissue
• MAINTAIN the position of the skin with the forceps
– Most people let go of the skin since the needle is through → this could cause skin retraction and needle
movement under the skin edge
• Release the needle from the needle holder and then
re-grasp the needle → complete the bite

72
Q

Edge eversion in simple interrupted suture

A
  • Swelling subsides→ everted edges flatten → scar becomes flush
  • If inverted → large depression/divot scar
  • Take larger and deeper bites with each suture
73
Q

Knot placement/tightness of simple interrupted suture

A

• The knots should be tied tight enough to close edges but NOT strangulating the tissue
– Must have space for swelling!
• All knots must be over to one side
– If left in the middle, the knot will push on the tissue and inhibit healing

3SP: Surgery/Injections (10 decks)

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