Basic surgical skills

SCRUBS

Overview
CDC wound classification  Types of wound healing  Instruments


Suture material Needle



Basic suturing technique

Simple interrupted suture Suture removal

CDC wound classification



Clean
Uninfected operative wound in which no inflammation is encountered and no systemic tracts are entered (respiratory, alimentary etc) Closed by primary intention and are usually not drained

Clean, contaminated
Operative wound in which systemic tract(s) are entered under controlled conditions and without contamination

Contaminated
Includes:
Open traumatic wounds (open fractures, penetrating wounds) Operative procedures involving:
Spillage from the GI, GU or biliary tracts A break in aseptic technique (open cardiac massage)

Microorganisms multiply so rapidly that a contaminated wound can become infected within 6 hours


Infected
Heavily contaminated/infected wound prior to operation Includes:
Perforated viscera Abscesses Wounds with undetected foreign body/necrotic tissue

Wound healing: Primary intention (I)

Optimum closure method since wound heals in minimum time with no separation of its edges and minimal scar formation  Takes place in 3 phases:


1. Inflammatory
Begins immediately and completed by Day 3-7 Initially, haemostasis occurs Then the wound is prepared for repair by:
Extravasation of tissue fluid, cells and fibroblasts Increasing blood supply to the wound Debridement of tissue debris by proteolytic enzymes

No increase in tensile strength of tissue and wound healing is dependent on approximation of edges by closure material

Wound healing: Primary intention (II)

2. Proliferative
Starts from Day 3 onwards Fibroblasts form a collagen matrix (granulation tissue) This matrix:
Determines the tensile strength and pliability of the healing wound Becomes vascular, supplying the nutrients and oxygen necessary for wound healing

Tensile strength increases until wound is able to withstand normal stress Wound contraction also occurs:
Wound edges pull together in order to close the wound If successful, it results in a smaller wound with less need for repair by scar formation Beneficial in areas such as the buttocks or trochanter Harmful in areas such as the hand, neck and face (can cause disfigurement and excessive scarring) Skin grafting reduces contraction in undesirable locations

Wound healing: Primary intention (III)

3. Remodelling
May continue for a year or longer Following completion of collagen deposition, vascularity decreases and any surface scar becomes paler Resulting scar size is dependent upon the initial volume of granulation tissue

The percentage recovery of the tensile strength of the wound is:

About 20% after 2 weeks About 50% after 5 weeks About 80% after 10 weeks

Wound healing: Secondary intention



Occurs when the wound fails to heal by primary intention due to:
Infection Excessive trauma Tissue loss Imprecise approximation of tissue (leaving dead space)

More complicated and prolonged than healing by primary intention  There may be excessive formation of granulation tissue which:


Contains myofibroblasts which lead to gradual but marked wound contraction May protrude above the wound surface, prevent epithelialisation and thus require treatment

Wound healing: Delayed primary closure



Used in management of contaminated and infected wounds with extensive tissue loss and a high risk of infection (eg. trauma following RTA, penetrating injury) Steps taken include:
Debridement of nonviable tissues, usually under sedation Leaving wound open with gauze packing inserted Wound approximation within 3-5 days if no infection is evident If infection is present, the wound is allowed to heal by secondary intention

Instruments: Forceps & needle-holder



Small toothed forceps (Addison forceps) grasp the skin edges during suturing Hold in the first three fingers in a similar way to a pen

Grasp the needle-holder by partially inserting the thumb and ring finger into the loops of the handle The free index finger provides additional control and stability

Instruments: Needle (I)



The main types of needle include:

Tapered
Gradually taper to the point and cross-section reveals a round, smooth shaft Used for tissue that is easy to penetrate, such as bowel or blood vessels

Cutting
Triangular tip with the apex forming a cutting surface Used for tough tissue, such as skin (use of a tapered needle with skin causes excess trauma because of difficulty in penetration)

Reverse cutting needle

Similar to a conventional cutting needle except the cutting edge faces down instead of up This may decrease the likelihood of sutures pulling through soft tissue

Instruments: Needle (II)

Most sutures with the suture material swaged onto the base of the needle  Shapes vary from a quarter circle to five-eighths of a circle, depending on how confined the operating field is  Choice of needle should alter the tissue to be sutured as little as possible and is dependent on:


The tissue being sutured (when in doubt about selection of a taper point or cutting needle, choose the taper for everything except skin sutures) Ease of access to the tissue Individual preference

Instruments: Properties of suture material



Handling of a suture
Memory
Tendency to stay in one position Leads to difficulty in tying sutures and knot unravelling

Elasticity
Ability to return to its original length after stretching High elasticity sutures should be used in oedematous tissue

Knot strength
Force required for a knot to slip Important to consider when ligating arteries

Tensile strength
Force necessary to break a suture Important to consider in areas of tension (linea alba)

Tissue reaction
Undesirable since inflammation worsens the scar Maximal between Day 3&7

Non-absorbable or absorbable  Monofilament or multifilament



Instruments: Monofilament or multifilament



Monofilament (Ethilon or Prolene)

Consists of a single smooth strand Less traumatic since they glide through tissues with less friction May be associated with lower rates of infection More likely to slip and should be secured with 5 or 6 throws (in contrast to 3 throws with multifilament) Preferred for skin closure because they provide a better cosmetic result

Multifilament (Mersilk or Mersilene)

Consists of multiple fibres woven together Easier to handle and tie and knots are less likely to slip

Instruments: Non-absorbable suture material



Composed of materials which can be:

Naturally occurring (Mersilk, cotton and steel) Synthetic (Prolene, Ethilon, Nurolon, etc)

Sutures may be:

Left in place indefinitely (during closure of abdominal fascia) Removed following adequate healing (closure of superficial laceration)

Instruments: Absorbable suture material



Composed of biodegradable materials which can be:

Naturally occurring (degraded enzymatically)
Catgut
Consists of processed collagen from animal intestines Broken down after 7 days

Chromic catgut
Consists of intestinal collagen treated with chromium Loses tensile strength after 2-3 weeks and is broken down after 3 months

Synthetic
Degraded non-enzymatically by hydrolysis when water penetrates the suture filaments and attacks the polymer chain Tend to evoke less tissue reaction than those occurring naturally

Subclassified according to degradation time

Instruments: Size of suture material

Size originally scaled from 0-3  As technology advanced and sutures became smaller, extra 0s were added  Scale now ranges from 3 (largest) to 12/0 (smallest)


Size
7/0 and smaller 6/0 5/0 4/0 3/0 2/0 0 and larger

Uses
Ophthalmology, microsurgery Face, blood vessels Face, neck, blood vessels Mucosa, neck, hands, limbs, tendons, blood vessels Limbs, trunk, gut blood vessels Trunk, fascia, viscera, blood vessels Abdominal wall, fascia, drain sites, arterial lines, orthopaedics

Instruments: Suture material summary

Non-absorbable

Natural

Synthetic

Mersilk

Braided

Monofilament

Nurolon Ethibond

Ethilon Prolene

Absorbable

Short term

Medium term

Long term

Natural

Synthetic

Braided

Monofilament

Braided

Monofilament

Catgut

Vicryl rapide

Braided vicryl

Monocryl

Panacryl

PDS II

Arming the needle-holder



Open the suture packet with one tear to reveal the needle

Grasp the needle two-thirds the distance from its pointed end Avoid grasping the needle at its proximal or distal extremities since this will prevent damage to the suture

Simple interrupted stitch: Steps 1&2



Grasp the skin edge with the forceps and slightly evert the skin edge Then pronate the needleholder so that the needle will pierce the skin at 90o Ensure the trailing suture material is out of the way to avoid tangling Drive the needle through the full thickness of the skin by supinating the needle-holder Keeping the shaft of the needle perpendicular to the skin allows the curvature of the needle to traverse the skin as atraumatically as possible

Images courtesy of BUMC

Simple interrupted stitch: Steps 3&4

  

Release the needle and pronate the needle-holder Regrasp the needle proximal to its pointed end Maintain tension with the forceps to prevent the needle from retracting

Again, supinate the needleholder to rotate the needle upwards and through the tissue

Simple interrupted stitch: Steps 5&6



Regrasp the needle in order to rearm the needle-holder (due to HIV risks it is better to use the forceps to do this)

Grasp and slightly evert the opposing skin edge with the forceps Pronate the needle-holder

Simple interrupted stitch: Steps 7&8



Again, supinate the needleholder to rotate the needle through the skin, keeping the shaft 90 to the skin surface

After releasing the needle, pronate the needle-holder before regrasping the needle

Simple interrupted stitch: Steps 9&10

and again supinate the needleholder to rotate the needle through the skin

Pull the suture material through the skin until 2-3 cm is left protruding Discard the forceps and use your free hand to grasp the long end in preparation for an instrument tie Place the needle-holder between the strands

Simple interrupted stitch: Steps 11&12

Wrap the long strand around the needle-holder to form the loop for the first throw of a square knot

Rotate the needle-holder away yourself and grasp the short end of the suture

Simple interrupted stitch: Steps 13&14

Now draw the short end back through the loop towards yourself

Now tighten the first throw

Simple interrupted stitch: Steps 15&16

The throw should be tightened just enough to approximate the skin edges but not enough to strangulate the tissue

To begin the second throw of the square knot, wrap the long strand around the needle-holder by bringing the long strand towards yourself

Simple interrupted stitch: Steps 17&18

Rotate the needle-holder towards yourself to retrieve the short end

Grasp the short end and draw it through the loop by pulling it away from yourself

Simple interrupted stitch: Step 19&20

 

Finally, tighten the second throw securely against the first Ensure the knot is to one side of the wound to avoid involvement in the clot

  

In one hand hold the scissors as shown With the other hand maintain tension on the suture material Slide the tips of the scissors down the strands to the point where they will be cut Cut the suture material leaving 45mm tails (important for removal of external non-absorbable sutures)

Suture removal


Sutures should be removed:

Face: Scalp: Trunk: Limb: Foot: 3-4 days 5 days 7 days 7-10 days 10-14 days

Steps involved in removal:

Reassure patient that the procedure is not painful Cleanse the skin with hydrogen peroxide Grasp one of the suture tails with forceps and elevate Slip the tip of the scissors under the suture and cut close to the skin edge (to minimise the length of contaminated suture that will be pulled through the wound) Gently pull the knot with the forceps and reinforce the wound Proxi-Strips if required

Summary


Wound classification
Clean Clean, contaminated Contaminated Infected

Types of wound healing

Primary intention Secondary intention Delayed primary closure

Suture material
Properties
Natural or synthetic Non-absorbable or absorbable Monofilament or multifilament

Size
Ranges from 3 12/0

References


Ethicon
Knot Manual http://www.jnjgateway.com/public/useng/5256 ethicon_encyclopedia_of_knots.pdf Wound Closure Manual http://www.jnjgateway.com/public/useng/ethic on_wcm_feb2004.pdf

Student BMJ
Taylor B and Bayat A, (May 2003, June 2003 & July 2003), Basic plastic surgery techniques and principles.

Boston University School of Medicine

http://www.bumc.bu.edu/departments/pagemai n.asp?page=5734&departmentid=69