Wound Closures Flashcards
What are wounds designated as?
Intentional or unintentional
Same wound healing process for both
What is an intentional wound?
Surgical wounds
An incision made into intact tissue
What are unintentional wounds?
Traumatic
Incidental
Chronic
Traumatic wounds?
Life threatening or less serious
- open or closed
- simple or complicated
- clean or contaminated
Incidental wounds?
Pressure related injury caused by compromised circulation as a direct result of inadequate or inappropriate surgical positioning
Chronic wounds?
Pressure injury as a result of tissue loss from arterial insufficiency or venous stasis
Suture vs ligate?
Suture - stitch together
Ligate - to tie off to prevent bleeding
Non absorbable sutures?
Resists enzyme activity
Not broken doen by inflammatory response
Provides mong term support
Ex. Abd wall
Composition of non absorbable sutures?
Synthetic, natural
Can be coated
Mono or multifilament
Non absorbable suture materials?
Natural:
- Silk
- Stainless steel
Synthetic:
- Nylon
- Polyester
What does coated sutures do?
Reduces friction when passing through tissues
Coating affects thickness but not tensile strength
Ex: antibacterial coating
Absorbable sutures?
Assimilated by tissues during healing process through digestion (enzymes) or hydrolysis from a chemical reaction with tissue fluids
Monofilament or braided
Examples: deep tissue, bowel anastomosis, vessel ligation
Composition of absorbable sutures?
Natural
- surgical gut: made drom collagen from animals
• plain or chromic
Synthetic
- made with polyglycolic acid and polyglactin
What can choosing wrong suture result in?
Tissue reaction
Dehiscence
Poor surgical outcomes
Suture material characteristics?
Physical configuration
Handling ability
Tissue reaction
Physical characteristics of a suture?
Configuration Coating Capillarity Diameter Tensile strength Knot strength Elasticity Plasticity Memory Knot tensile strength
What is suture configuration?
Monofilament- single strand
Multifilament- several strands braided or twisted
What is suture capillarity?
Fluid absorbed by the suture that is transfered along length of the suture
Diameter: gauge of suture?
Size described by zeros
Suture size decreases as the number increases
Ex 4-0 small than 2-0
Small sutures are easily handled and tied but has less tensile strength
What is suture tensile strength?
Measurement of the suture strands ability to resist breakage
What is suture knot strength?
Force required to allow knot to slip on itself
Related to pliability and the co efficient of knot tying and knot slippage
Suture elasticity?
Measurement of sutures ability to recover its primary form and length after being stretching or other deformation
What is suture plasticity?
Measure of the suture strands capability to be stretched, tied or misshapen from original form without breaking
Suture memory?
Capability of suture to keep or return to its original packaging shape after being stretched or tied
High memory leads to lower confidence in knot security
Suture knot tensile strength?
Breaking point of a knotted suture
Sutures are 10-40% weaker after being tied
Examples of absorbable sutures?
Monocryl (used closed to skin)
Vicryl
PDS (deep)
Handling characteristics of a suture?
Pliability
Tissue drag
Knot tying
Knot slippage
What is suture pliability?
How easily suture bends
Ex: chromic stitch bends and unbends with greater pliability than steel stitch
Suture tissue drag?
How easily a suture slips through tissue
Ex: monofilament lower drag than multifilament
Suture knot tying?
How easily a suture can be tied
Ex: braided more difficult to tie
Suture knot slippage?
Ability of knots to be slid down suture
Tissue reaction?
Inflammation
Absorption
Infection potential
Allergic reaction
Whats covered on suture packaging?
Color coding
Length of suture
Needly type
Needle size and shape
# of needles in package
3 sections of surgical needles?
- Swage - suture strand manufactured into needle end
- Body - can be round, triangular or flat
- Point - cutting or tapered or non cutting
Conventional vs reverse cutting points?
Conventional (triangular) needles have a cutting edge on the inside
Reverse needles have a cutting edge and a non cutting edge
Why have blunt needle tip?
Evolved due to bloodborne pathogen exposure due to needle sticks
Threaded needles?
Less common than swaged
Eyed - needle is threaded with suture strand
Or
Spring/french eyed - suture is snapped through
What is suture selection based on?
Procedure Tissue being sutured Type of re approxmation required General condition of patient Surgeon preference
What can suturing too tight cause?
Tissue strangulation
Poor surgical outcomes
Interrupted suture?
Single sutures, tied independently
Continuous running suture?
Uninterupted suture
Retention suture?
Heavy suture reinforcing the primary suture line
Subcuticular suture?
Suture under the epidermis
Purse string suture?
Suture around a circular wound
Advantages vs disadvantages of skin staples?
Used on many incision types Ease of use Uniform incisional tension Faster wound closure Staple removal in easier
Vs
Not absorbable - have to be removed
Skin adhesives?
Highly flammable
Option for surgical wound skin closures
Ex. Laparoscopic
Advantages vs disadvantages to skin adhesives?
Reduced risk of infection
Less scarring
No removal
Vs
Limited to superficial wounds
Allergic reaction risk
Not good for conditions causing slow wound healing
Adhesive tape strips?
Advantages vs disadvantages?
Used to approximate skin edges alone or on conjuntion with another closure
Less expensive
Vs
Tape can loosen and cause compromised healing
Zipper closure?
Advantages vs disadvantages?
Used when wounds require skin stretching over area of tissue loss
Distributes over a wide surface area
Fast application
Lower infection rate
More cosmetic outcome
Vs
High cost
Not used in obese population
Terninal end stapler?
Used to close the end of the colon after the SIDE TO END anatomosis
Internal anatomosis stapler?
Used for side to bowel anastomosis
End to end stapler?
Used in a multi step procedure with the end result of achieving an internal anastomosis of hollow organ space
Steps of wound healing process?
Hemostasis
Inflammation
Proliferation
Remodeling
Hemostasis stage of wound healing?
Vascular constricton Platelet aggregation - platelet adhesion Degranulation - mast cell acitivation Fibrin formation - thrombus
Inflammation stage of wound healing?
WBC infiltration
Edema
Phagocytosis
Hemostasis
Proliferation phase of wound healing?
Blood vessel creation
Numerous cell type formations
Contraction
Collagen synthesis
Neovascularization
Epithelialization
Types of Wound healing?
First intention/primary union
Second intention
Third intention/delayed primary closure
Primary intention?
Normal surgical incison
Closed with suture or other product for clean approximated incison
Common features of primary intention wound healing?
No tissue loss
Minimal or lack of post op swelling
No discharge or infection
Nominal scar formation
Secondary intention wound healing?
Heals by granulation leading to wound contracture
Left open
Common fratures of secondary intention?
Infection Tissue loss May occur due to necrotic tissue or patients compromised immune system Releated debridement may be necessary Scar formation and contracture
Heals from bottom up
Third intention/delayed primary closure?
Delayed due to gross infection or considerable tissue loss
Wound is not devascularized in order ro promote healing
Common features of third intention/delayed wound healing?
Wound is cleaned, debrided and packed
Abx used
Evebtual approximation of clean granulation surfaces
Wide, deep scar
Negative pressure therapy, packing
Gun shot wounds?
High velocity > 2000ft/sec
Low < 2000ft/sec
Management:
Debridement
Irrigation
Stabilization of fracture
Wound clouse if < 8hrs
If > 8hrs wound closure 3-10 days after primary debridement
Surgical factors affecting wound healing?
Wound classification SSI Patient health Surgical technique Post op considerations
Class 1 - Clean wounds?
Clean operative wounds
No inflammation or infection
The resp, alimentary and GU tracts werent enerted
Elective surgeries 
Ex. Hernia repairs, breast surgery, non traumatic
Class 2 - clean contaminated?
Operative wounds in which resp, alimentary or GU tract have been entered under controlled conditions without contamination
Chronic inflammation (not acute)
No infection or break in sterile technique
Ex. Abd hysterectomy, chole without spillage, elective appy
Class 3 - contaminated?
Operative wounds invoving
- open, fresh, traumatic wounds
- major break in sterile texhnique
- gross spillage from GI tract
- acute non purulent inflammation
Ex. Traumatic wounds, laparotomy with spillage
Class 4 - dirty infected
PUS/Purulent
Infection, abcess
Ruptured, perforated
Requires delayed primary closure
Ex. I&D, perforated viscera
3 categories of SSIs?
Superficial incisional
Deep incisional
Organ/space
Superficial incisional SSI?
Located in epidermis, dermis and subcu layers
Normally within 30 days post op
Deep incisional SSI?
Fascial and muscle layers
Between 30-90 days post op
Organ/space SSI?
Organ/space layer
Between 30-90 days post op
How does patient health factors affect healing?
Age - less muscle/skin turgor, weakened immunity Resp/circulatory status - smoking Pre existing conditions - diab, immune compromised Nutrional status - malnourished, obese Immune system - allergy, immunocompromised
What nutritional deficiencies affect wound healing?
Decifiency in:
- vitamin A, B, C, K
- protein, carbohydrates
- zinc
Surgical factors that lead to SSI?
Break in sterile technique
Poor tissue handling
- unnecessary pressure on tissue, blood vessel
Hemostasis methods
- cauterizing, lasers interupts circulation
Tissue approximation
- dead space = bacterial growth
Post op considerararions affecting wound healing?
Edema N/V Coughing Pneumonia Clot
Debridement methods?
Surgical - sharp dissection, laser, hydrosurgical
Mechanical - forceful irrigation
Chemical - enzymatic agent
Biological - maggots
Negative pressure wound therapy/VAC?
Constant, controlled pressure to wound
- reduces edema
- decreases the bacterial load
What do skin substitutes do?
Produce growth factors and stimulate wound healing
Temporary treatment until permanent closure achieved
What do drains do and what are two types?
Provide exit for serum, blood, air, etc from surgical site
Simple: penrose
Closed suction: JP, hemovac
