TEHNIK JAHITAN dan DRAINASE

Methods for Wound Closure

Types of Closure

Primary closure
Immediate

closure, rapid healing

Secondary closure
delayed

closure and healing

Delayed primary (tertiary)

left

open 4-5d then closed if no infection

Wound Closure Devices

Sutures Staples Tissue Adhesives Adhesive Tapes

Sutures

Non-absorbable
retain

tensile strength >60d Outer skin and tendon repair monofilament (nylon, prolene) - infection rate

Absorbable
lose

most of tensile strength within 60d deep structures (dermis, fascia) and ligation monofilament - tissue reactivity

Rapid absorbing (vicryl rapide)

superficial

skin to avoid suture removal

Absorbable Sutures
Suture Silk
Nylon

Structure braided

Reactivity ED Uses significant intraoral mucosal surfaces monofilament minimal soft tissue/ skin
soft tissue/ skin

Polypropylene monofilament least (prolene)

Polyester (ticron) Polybutester (novafil)

braided or minimal monofilament monofilament minimal

tendon repair
soft tissue, easy handling, knot security

Sutures

Choose suture size ...

Face: 5-6.0 Hands/ fingers: 5.0 Other: 4.0

Hemostasis ...

direct pressure with or without Epi (1:1000) Ligature tie electrocautery ( infection/ scarring)

Suturing Goals ...

approximate edges eversion minimize tension

PRINCIPLES OF WOUND CARE MANAGEMENT

Wound Care and the Pediatric Patient

Choice of closure materials

Continuous Percutaneous
Advantage rapid accommodates edema Disadvantage less meticulous than interrupted sutures if single knot unravels, wound may dehisce Frequent uses linear percutaneous closure

Simple Interrupted Percutaneous

Advantage excellent approximation Disadvantage time-consuming may strangulate tissues Frequent uses low-tension wounds used c deep sutures for high-tension

Interrupted Dermal
Advantage reduces tension on surface early percut suture removal may scar width Disadvantage may infection in contaminated wounds Frequent uses high-tension wounds closure of dead space

Continuous Dermal
Advantage Rapid reduces tension on surface early percut suture removal may scar width Disadvantage technically difficult less accurate approximation single knot unravelsdehisce Frequent uses dead space closure

Vertical Mattress
Advantage excellent eversion combines advantage of deep and superficial sutures Disadvantage may cause tissue strangulation Frequent uses high tension areas thin or lax skin with little dermal or fascial tissue

Horizontal Mattress
Advantage more rapid than simple interrupted excellent wound eversion Disadvantage may cause tissue strangulation Frequent uses Bleeding scalp wounds initial approximation of high-tension wounds

Half-buried Horizontal Mattress

Advantage less compromising to flap perfusion Disadvantage time consuming technically difficult Frequent uses corner stitches and flaps

Continuous Subcuticular
Advantage good approximation w/o more superficial closure Disadvantage complex technique Frequent uses linear, low-tension wounds

Staples
Advantage speed, ease of use, and cost effective less tissue reactivity Disadvantage least precision in wound approximation Frequent uses limited to linear non-facial lacs scalp lacs

Adhesive Tapes
Advantage inexpensive, does not require removal least reactive of all devices simple, painless, and rapid Disadvantage slough off with tension or moisture Frequent uses very low tension simple wounds fragile skin use mastisol or benzoin to improve adhesion

Cyanoacrylate Adhesives

Dermabond, Indermil strength = 5.0 suture sloughs off in 5d forms occlusive dressing High viscosity available

Procedure
1. apply 5-10mm either side of wound 2. let dry 30-45 sec 3. apply 2-3 more layers, allowing each to dry for 5-10 sec.

Surgical Drains:
Indications, Types, & Principals of Use

Goals

Decrease Infection Rate Decrease Healing Time

Indications
1.

To help eliminate dead space To evacuate existing accumulation of fluid or gas To prevent the potential accumulation of fluid or gas

2.

3.

Drain Types

Flat Dependent on gravity and capillary action Drainage related to surface area Penrose - latex

Drain Types

Flat drains - Penrose Advantages

Allow drainage Help obliterate dead space Soft / malleable less painful Very irritating Allow bacterial ingress Cannot be connected to suction Gravity dependent

Disadvantages

Drain Types

Tube Single lumen +/- side holes Silicone, polyvinyl chloride, red rubber

Drain Types
Tube drains Advantages

Drain from both within and outside of lumen Can be connected to suction Can be used with closed collection system

Disadvantage

Discomfort due to stiffness

Drain Types

Double lumen Sump drains open/open suction Drainage of fluid via large lumen Sump lumen smaller and allows ingress of air

AIR FLUID AIR

Drain Types
Double lumen Advantages

More efficient than single lumen Maintain patency longer than single lumen

Disadvantages

Risk of contamination of wound as environmental air drawn in reduced with filter

Drain Types

Passive Active

Continuous suction Intermittent suction

Passive Drains

Passive

Drain by means of pressure differentials, overflow, and gravity Provides a stent that keeps a draining tract / cloaca open Allow egress via a path of least resistance Flat or with a lumen Open or Closed Closed preferred

Passive Drains

Passive closed

Advantages

Allow evaluation of volume and nature of fluid Prevent bacterial ascension Eliminate dead space Help appose skin to wound bed quicker wound healing Gravity dependent affects location of drain Drain easily clogged

Disadvantages

Active Drains

Vacuum pulls fluid / gas from the wound Closed to atmosphere = Closed suction Vacuum applied to a single lumen tube Not gravity dependent

Active Drains

Active Drains

Advantages

Keep wound dry efficient fluid removal Can be placed anywhere Prevent bacterial ascension Help appose skin to wound bed quicker wound healing Allows evaluation of volume and nature of fluid
High negative pressure may injure tissue Drain clogged by tissue

Disadvantages

Principals of Ideal Use

Aseptic site preparation (clip, scrub, debride, lavage) Place to avoid anastomosis sites and major vessels Exit through separate stab incision, away from surgical incision Aseptic postoperative management (cover with sterile bandage, change before strike through, clean & dry cage)

Principals of Ideal Use

Protect from premature removal or loss E-collar Remove as soon as possible drainage decreases or fluid changes character (2 5 days) Bacterial culture on removal

Complications and Failure of Drains

Poor Drain Selection

Poor Drain Placement Poor Post-operative Management

Complications and Failure of Drains

Poor Drain Selection

Poor Drain Placement Poor Post-operative Management

Complications and Failure of Drains

Discomfort / Pain

Thoracic Tubes diameter too large Stiff tubing

Exiting in non-dependent locale (passive drains) Kinked tube Obstructed Poor drain selection diameter too small to remove viscous fluid

Inefficient Drainage

Complications and Failure of Drains

Breakdown of anastomotic sites Erosion into hollow organs (firm drains) Incisional dehiscence / hernia

Poor placement Accumulation of fluid

Premature Removal

Thoracic Cavity

Drain Selection

Diameter Intercostal Space (ICS) Tubular type

Questions?