Surgery L2 - Wound Healing and Closure

Inlammatory, Proliferative, Remodeling

What are the main 3 phases of wound healing?

Inflammatory Phase

Activation of macrophages

Which phase of wound healing has generalized or non-specific inflammation around the wound wedges and lasts about 3 days if there is little to no contamination.

What indicates the start of the next phase?

Epithelization (Proliferative)

Which phase of wound healing is characterized by fibroblasts and collage production, fibroblasts synthesize collagen and are active for 6 weeks?

Fibroplasia and Contraction (maturation)

Which phase of wound healing involves remodeling of collagen by formation of intermolecular cross links, lasts 6-12 mos and results in a paler, flatter scar?

Primary

Primary, Secondary or Tertiary intention?

Recent, clean wounds closed by sutures.

Typically irrigated and debrided

Tissues brought close for optimal healing

Secondary

Primary, Secondary or Tertiary intention?

Wounds are left open to heal without surgical intervention.

Prolonged inflammatory phase

Wounds heal from edges to central aspect and from bottom up. Heal about 1mm per day.

Indicated in severe infections and contaminated wounds.

Tertiary

Primary, Secondary or Tertiary intention?

Closure of wound that was initially left open or not repaired.

Indicated in wounds with high bacterial content (dog, human bites)

usually 3-5 days for closure

1. Decreasing bacterial load

2. Good preparation of wound edges

3. Debridement of foreign material

In tertiary intention, good results depend on what 3 things?

1. Inhibit inflammatory response

2. Inhibit wound healing

3. Stop granulation tissue formation

4. Increased inflammatory response

What are 4 local and system factors that affect healing?

Steroid use, Immunosuppressants, Chemotherapy

What are the 3 things that inhibit inflammatory response?

Vitamin A def, Zinc Def, Malnutrition (acute worse than chronic)

What are 3 things that inhibit wound healing?

Excessive inflammatory response (toxins, septic shock, gram neg infections)

What can stop granulation tissue formation?

Massive trauma (cytokine release, increase lactate production)

What can increase inflammatory response?

Cardiac failure, Hypoxia, poor tissue perfusion, vasoconstriction

What are post-op factors for wound healing?

failure to maintain proper temp

hypovolemia

fear

beta blockers

cigarette smoking (including nicotine patches)

hypoxemia

What are causes of vasoconstriction?

Chromic Gut

Which suture type?

absorbable

made from bovine intestines

used in OB/Gyn, Plastics, Oral Surg

Loses tensile strength in 14-21 days

Complete absorption 90-120 days

Outlawed due to concerns of Mad Cow Disease

Risk of inflammatory reaction d/t foreign protein nature

Vicryl

Which suture type?

absorbable

braided

used for subcuticular approximation and ligation of vessels

Tensile strength 14-21 days

absorption in 8-10 weeks

Risk of potentiating infections (draws moisture)

Made from polyglycolic acid

Dyed (purple) vs undyed (white)

PDS

Which suture type?

synthetic

absorbable

monofilament

poor knot security, difficulty to tie

tensile strength decreases 25% every 2 weeks

Used in "tissue under tension" and contaminated wounds

SILK suture

Which suture type?

Braided or entwined from silkworm larva

Non-absorbable

Treated with silicone to increase strength

High risk for suture abscess "spit stitches"

Cannot use for grafts or prosthetic cardiac valves

Used in ocular, neural, closure of oral mucosa and CV surgery

Monocryl

Which suture type?

synthetic

monofilament

high tensile strength that decreases within 1-2 weeks

absorbable within 12 days

Subcuticular closures - less scar risk

Used in face, eyes, ears, neck and abdomen

Prolene

Which suture type?

nonabsorbable

monofilament

typically dyed

wound closures - infected, contaminated

lack of tissue adherence

used in wounds with high tension

Nylon

Which suture type?

Monofilament

nonabsorbable

low skin reactivity

good tensile strength

lower risk of knot issues compared to PDS and Prolene

used in laceration repair, surgical incision closures

Simple Interrupted

Which suture technique?

Mostly used in lacerations and incision closures

Safer than running due to multiple separate sutures and knots

infection, scarring, ischemia and/or necrosis from excessively tight sutures

Potential complications of simple interrupted technique?

Vertical Mattress

Which suture technique?

used in incision or wounds that are under tension

greater closure strength and distribution of tension

allows skin edges to evert

good in areas with convex surfaces (posterior neck)

suture is thrown far to far then near to near, knot tied on side of incision when first throw is made

Scarring - railroad tracks

Complications of vertical mattress technique?

Horizontal Mattress

Which suture technique?

used in incision or wounds under tension

early removal limits scarring/railroad tracks

anchoring stitch for skin flap closure

promote skin eversion which limits scarring

Can use alternating horizontal mattress and simple sutures to prevent wound dehiscence with early removal of horizontal mattress sutures.

Deep Dermal

Which suture technique?

used when closing large or gaping wounds

helps reduce tension over course of wound

pass suture from deep to superficial, then superficial to deep (buries knot)

Good for deep wounds/incisions

usually require another layer of closure

use monofilament if laceration

use vicryl (braided) in surgical setting

Subcuticular

Which suture technique?

Placed into epidural layer

Running stitch most common

absorbable vs nonabsorbable

nylon vs monocryl

easy to bend needle and dull/break tip so be gentle and don't force needle where to go.

Running Stitch

Which suture technique?

Used in longer incisions/wounds with minimal tension

faster closure

can use to hold skin grafts in place

only requires failure of one knot to allow for dehiscence (use aberdeen to prevent this)

nylon most common

Staples

Type of wound closure?

Quick, secure with low risk of failure

can be an irritant - inflammation

quick removal but possibly painful

concern for skin overgrowth if not removed timely

avoid inversion to avoid wound breakdown/slower healing

possible allergic reaction

Basic surgical knot

Type of knot?

Square

Two throws make the knot

anywhere from 4-8 throws for complete tie

watch for airballs

Surgeon's Knot

Type of knot?

How you start tying every stitch

requires two loops in the first throw, then one loop thereafter

good for incisions/wounds under tension

prevents loosening and locks in stitch for second throw

prevent making initial knot too tight and prevents strangulation of tissue

One hand knot

Type of knot?

Faster

Tension difficult to control

potentially less secure

better for tight spaces

Two hand knot

Type of knot?

Better control of knot

more consistent tension

slower

6-0

Monofilament, non-absorbable

3-5 days

What is the suture size, material and removal time for face/lip?

3-0, 4-0

Monofilament, non-absorbable

7-10 days

What is the suture size, material and removal time for the scalp?

3-0, 4-0

Monofilament - may be absorbable or non-absorbable

10-14 days

What is the suture size, material and removal time for chest/abdomen/back?

3-0 to 5-0

Monofilament - may be absorbable or non-absorbable

10-14 days

What is the suture size, material and removal time for the limbs?

4-0 or 5-0

Monofilament - usually non-absorbable

10-14 days

What is the suture size, material and removal time for hands?

6-0

Braided, rapidly absorbable

Absorbable

What is the suture size, material and removal time for the nailbed?