Wound Closure Flashcards
What are the main benefits to primary wound closure?
More straight forward wound care Decreased need for bandages Faster resolution of the wound Less pain and scarring Better cosmetics and protection of underlying anatomic structures
What are the goals of wound closure?
Minimal tension Full return to function (ROM, robust skin coverage) Pain free final outcome Cost effective Acceptable cosmetics Satisfied owner
What are Halsted’s principles?
Gentile tissue handling Control of hemorrhage Aseptic technique Preserve blood supply to tissues Eliminate dead space Apposition tissue accurately with minimal tension
What size and type of suture should you used of fascial/intramuscular layers?
1-3.0 USP
monofilament absorbable > polydioxanone (most common)
What is the minimum number of throws to start and finish a continue suture pattern with PDS in fascial/intramuscular layers?
Start 5
Finish 7
What size and type of suture would you use in SQ layers?
3-0 or 4-0
Poligecaprone 25 (monocryl) Glycomer 631 (Biosyn) PDS
Adding 2 extra throws increases knot volume and tissue activity by a factor of _______
1.5
What are the typical closure patterns for subcuticular to intradermal layers?
Continuous horizontal
Continuous vertical
What size and type of suture do you use in cutaneous layers?
3-0 or 4-0
Ethilon (nylon)
Polypropylene (prolene)
When would a tissue adhesive, like cyanoacrylate, would not be appropriate to close a cutaneous wound?
Wounds with tension (only 15% as strong as wounds closed with suture)
Too much tension when closing a wound can cause??
Ischemia from pressure exerted by sutures
“Biologic tourniquet”
Tension lines serve as a guideline for wound closure because tension is reduced when wounds are closed __________ to these lines
Parallel
How can you assess tension around a wound?
Place animal in natural standing position
Gently lift/tent skin surrounding wound
Manipulate in several directions
Desired direction is that which result s in the least amount of tension
What are methods of relieving tension?
Undermining tissue
Tension reliving suture patterns
Releasing incisions
Walking sutures
V-Y / Z / M plasty
Stretching techniques
What technique do you use to undermine tissue?
Metzenbaum scissors to undermine skin and SQ
- blunt (closed to open blade) -> loose areolar hypodermal tissues
- sharp (open to closed blade) -> snipping tissue with scissor
When undermining tissue, it is critical that the peri-wound is healthy and pliable with respect to blood supply, inflammation, and edema. How is this blood supply maintained?
The direct cutaneous vessel is elevated with the undermined skin
-> preserves blood supply to the deep subdermal plexus, which will arborize to perfuse the dermis through superficial plexi
What are the tension-relieving suture patterns?
Mattress sutures (or through rubber stents)
Far-far-near-near
Far-near-far-near
What is the main concern when using a horizontal mattress suture to relieve tension?
Horizontal component may compromise blood supply
How do releasing incisions relieve tension?
Make relaxing incisions near the defect to allow skin apposition
After undermining the skin -> unilateral or bilateral simple relaxing incisions made adjacent to the wound
After prefacing a continuous subcuticular suture pattern —> multiple punctate incisions are made parallel to wound
How is a walking suture placed?
Place suture through the fascia of the body wall at a distance closer to the center of the wound than the bite through the subdermal fascia or deep dermis
When is walking suture ideal?
Large open wounds with surrounding skin that is pliable
What method provides tension relief adjacent to an orifice or can be used in chronic defects surrounded by inelastic skin and closing wounds near structures that would be distorted by closure under tension?
V-Y plasty
What method can you use to close a wound when there is insufficient laxity parallel to the wound to permit skin stretch ?
Z-plasty
The central arm of the Z plasty is __________ to the long axis of the wound?
Perpendicular
What method is used in fusiform wounds where the skin at one/both ends is limited?
M-plasty
What is mechanical creep?
Tension applied to skin gradually over 2-4days
—> randomly oriented dermal collagen and elastic fibers straighten and elongate, becoming more parallel to tension lines which allows for lengthening of the skin
What is stress relaxation?
Over time, less force is required to maintain collagen fibers in their stretched position because the skin’s elastic fibers lose their natural recoil
What are methods of stretching skin to close wounds under tension?
Pre-suturing
Skin stretchers
Inflatable tissue expanders
Adjustable sutures
How should you close fusiform shaped defects?
1st suture across widest part
Continue to divide each segment in half with subsequent sutures
How should you close crescent shaped defects?
Begin at midpoint and divide each segment in half
Space sutures farther apart on the longer side of the wound
OR
Close end to end and remove redundant skin —> close in T
How can you close a triangular shaped defect?
Close defect as a “Y” by beginning at each point and suturing toward the center
Use a half-buried horizontal mattress stitch to close the central portion of the “Y”
How can you close a circular shaped defect?
Close by direct apposition —> results in excessive redundant tissue at both ends (dog ears)
Divide circle into 3 arcs and meet in the middle
-> will likely still result in dog ear on at least one arc
If adequate skin -> convert to fusiform shape
How can square/ rectangular wounds be closed?
Rectangle —> double “Y”
Square —> double “X”
How can “step defects” be corrected?
Manipulation of knot —> pull to low side
Placement of suture at same depth on both sides of wound
Half-buried horizontal mattress (intradermal portion on low side)
Stiff untied suture from superficial on high side to deep on low side
How can you correct a dog ear?
Small —> suture manipulation of skin
-apex cutaneous suture pulls ear down and away from wound
Large —> resect and close
What postop analgesia do you use for wounds?
NOCITA (bupivacaine liposome injectable suspension)
Labeled for single-dose infiltration into the surgical site to provide oral postop analgesia for cranial cruciate ligament surgery in dogs
