11 Hemostasis, Wound Healing, & Wound Closure

What are the methods of hemostasis?

Clot formation or vessel spasm, or surgically by mechanical pressure, ligation, or application of hemostatic agents.

What is the correct order of the the phases of the clotting process?

• Platelet aggregate forms a thrombus

• Platelets adhere to sub-endothelium of vessel walls

• Permanent thrombus forms after clotting factor reaction

• Release of ADP causes further layers of platelets to adhere

• Platelets release ADP

• Platelets adhere to sub-endothelium of vessel walls

• Platelets release ADP

• Release of ADP causes further layers of platelets to adhere

• Platelet aggregate forms a thrombus

• Permanent thrombus forms after clotting factor reaction

The CST is responsible for knowing the amount of irrigation is used in a procedure.

a. True

b. False

a. True

Give an example of a congenital hemostatic defect.

Hemophilia

Give examples of acquired bleeding disorders.

• Liver disease

• Anticoagulant therapy with heparin or warfarin sodium??????

• Aplastic anemia

What are the four hemostatic methods?

• Biological

• Chemical

• Mechanical

• Thermal

What are pledgets?

Small squares of Teflon that are used as buttresses over the suture line, when bleeding occurs through needle holes in vessel anastomosis.

Stratafix and V-loc are types of ________ sutures.

barbed

Plain gut or chromic gut are types of _______ _________ ______ sutures.

absorbable natural monofilament

Monocryl, polyester, polyglyconate are types of __________ ________ ________ sutures.

absorbably synthetic monofilament

Biosyn and Caprosyn are types of ________ _________ ________ sutures.

absorbable synthetic monofilament

Polyglactin, vicryl, and polysorb are types of ________ _________ ________ sutures.

absorbable synthetic multifilament

Nylon, ethilon, polybutester, polypropylene, and stainless steel are types of ________ _________ ________ sutures.

Non-absorbable synthetic monofilaments

Surgical silk or natural fibers are types of ________ _________ ________ sutures.

nonabsorbable natural multifilament

What is the most common method that is used to obtain hemostasis?

Thermal hemostasis

Devices include electrosurgery and lasers. Lasers include argon plasma coagulation and the ultrasonic harmonic scalpel.

The following methods are what type of hemostatic methods

• Hemostatic instruments

• Ligatures

• Clamps and clips

• Sponges

• Pledgets

• Bone wax

• Pressure devices

Mechanical Methods

Pooled donor plasma or fibrin glue is what type of hemostatic method?

Biological Hemostasis

The following types of pharmacological agents are what type of hemostasis method?

• Absorbable gelatin (Gelfoam®)

• Collagen (Avitene®)

• Oxidized cellulose (Nu-Knit®; Surgi-Cel)

• Silver nitrate

• Epinephrine

• Thrombin

Chemical Hemostasis

What is used when blood loss is too great to be controlled by intraoperative hemostatic techniques alone?

Blood replacement

When blood is not properly matched including Rh factor prior to transfusion, what could occur? What are the symptoms?

Hemolytic transfusion reaction

The following symptoms are caused by what?

• Fatigue and lack of energy

• Rapid pulse, shortness of breath, etc.

• Jaundice and pallor may be exhibited

Hemolytic transfusion reaction

What are the three categories of wounds?

1. Intentional

   -Chemical

   -Occlusion banding (causes ischemia of the tissue, such as in a hemorrhoid ligation)

   -Surgical site incision/excision

2. Unintentional

   -Traumatic

   -Closed

   -Simple (Simple, complicated, clean, contaminated, and delayed)

3. Incidental and Chronic

   -Chronic wounds develop because of underlying physical conditions or infection (Pressure sores and decubitus ulcers)

What are the three phases of wound healing by first intention?

1: Lag phase or inflammatory response phase

2: Proliferation phase

3: Maturation or differentiation phase

Which intention occurs when two granulated surfaces are approximated?

Third intention

Which intention occurs when a wound fails to heal by primary union and the wound is left open and allowed to heal from the inner layer to the outside surface?

Second intention

Which intention of wound healing occurs with a primary union that is typical of an incision opened under ideal conditions and the most common?

First intention

What type of would healing is delayed primary closure?

Third Intention

Which phase of wound healing by first intention is this?

“Fibroblasts multiply and bridge the wound edges. The fibroblasts secrete collagen that forms into fibers that give the wound approximately 25 percent to 30 percent of its original tensile strength. New networks are formed from existing capillaries by the fifth to eighth day and lymphatic networks are reformed by the tenth day, many of which diminish during the final phase of wound healing.”

Proliferation Phase

Which stage begins within minutes of injury and lasts approximately 3 to 5 days and defined by the physiological changes associated with inflammation manifested as heat, redness, swelling, pain, and loss of function?

Phase 1 or the lag phase or inflammatory response phase

Fluid that contains both blood and serum is ____________.

Serosanguinous

Physical condition of the patient, external factors, and suturing techniques are factors that influence…

wound healing

Are drug therapy, fluids and electrolyte balance, hematology, and radiation exposure; internal factors or external factors that influence wound healing?

External factors

Evisceration is a medical emergency.

a. True

b. False

a. True

What is the protrusion of the viscera through the edges of a totally separated wound.

Evisceration

What is the term for a mass of inflamed granulation tissue, usually associated with ulcerated infections?

Granuloma

What is the term for fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually because of inflammation?

Exudate

If a patient reports a “popping” or tearing sensation associated with coughing, vomiting, or straining, resulting in retrograde infection, what most likely occured?

Dehiscence

What is the result of wound dehiscence and occurs most often in lower abdominal incisions?

Herniation

What is the term for when small blood vessels rupture, blood plasma can seep out and the localized accumulation of the serum causes a mass or swelling within a tissue or organ that can sometimes develop after surgery?

Seroma

What are the three ways that dead space is eliminated?

1. Proper suturing techniques

2. Wound drains

3. Pressure dressings.

Can wound drains remove unwanted gases from the body?

Yes, along with unwanted fluids.

Nylon, Braylon, Ti-Cron, and Teydek are types of ________ _________ ________ sutures.

nonabsorbable synthetic multifilament

Which type of tie is used to occlude vessels for hemorrhage control or organ or extremity removal?

Called ties

• Free-tie

• Ligature reels

• Instrument tie (tie-on-a-pass)

• Suture ligature (stick tie)

What type of ligature method are these?

Ligating

• Hypodermic

• Arterial

• Intravenous

• Irrigation

• Biopsy

• Insufflation

• Spinal

What type of needles are these?

Surgical specialty needles

What is the correct order of closing layers in abdominal wounds, from the innermost layer to the outermost layer?

1. Peritoneum

2. Fascia

3. Muscle

4. Subcutaneous

5. Subcuticular

6. Skin

Which suturing technique helps retract a structure that may not be easily retracted with a conventional retractor instrument?

Traction sutures

This accessory device has replaced umbilical tape as isolation and retraction devices for vessels, nerves, or ducts.

Silicone vessel loops

Tendon sutures may be pulled through _________ and tied over a button to prevent tissue damage

buttonholes

_______ _______ ______ may be clamped onto the ends of subcuticular sutures after skin closure.

Split lead shots

Vessel loops and umbilical tapes are accessory devices used to close a wound.

a. True

b. False

b. False

________ _________ are used in orthopedic surgery to fix tendons and ligaments to bone.

Suture anchors

_________ _________ is often used for infant and pediatric surgical procedures that prevent the child from pulling on and removing the dressing and possibly removing skin suture or closure tapes.

Skin adhesive

Precision, cost, and accelerated wound healing are advantages over suturing.

a. True

b. False

b. False

Cost and precision are disadvantages of stapling

Less tissue reaction, accelerated wound healing, less operating time, less anesthesia time, and efficiency are advantages to stapling over suturing?

a. True

b. False

a. True

What type of stapler is used to insert two straight, staggered, evenly spaced, parallel rows of staples into tissue?

Linear staplers

Which stapler is used to staple and transect the tissue to deliver two double staple lines, like the one produced by the linear stapler, and contain a knife blade that passes between the two staple lines, dividing the tissue?

Linear cutter

Which stapler is used to anastomose tubular structures within the GI tract?

Intraluminal or circular

How many strands of suture is contained in a running or continuous suture technique?

One single strand

How does the CST help the surgeon keep the proper amount of tension on the suture line during closure?

The CST should “follow” or “run” the suture by holding the lower quarter of the suture taut and away from the area of closure.

Which type of suture technique is used to close tissues that are under tension or to close infected tissues?

Interrupted suturing

Extracorporeal and intracorporeal are two methods of what type of suturing?

Endoscopic suturing

• Simple Interrupted

• Interrupted Horizontal Mattress

• Interrupted Vertical Mattress

• Figure-of-8 Stick Tie

• Buried

Which above type involves two stitches placed parallel to each other on each side of the wound. The first bite is a simple suture, and the second bite is placed parallel to the first bite and travels back across the wound edge to end on the same side as the first bite.

Interrupted Horizontal Mattress

• Simple Interrupted

• Interrupted Horizontal Mattress

• Interrupted Vertical Mattress

• Figure-of-8 Stick Tie

• Buried

Which above type involves the first small bite placed close to the wound edge and the second bite is placed slightly behind the first bite and deeper in the tissue. The needle comes out the side where the first bite was placed. This technique is used for deep wounds and provides excellent eversion and skin approximation.

Interrupted Vertical Mattress

The surgical procedure is booked as I&D of a leg abscess, this procedure would have a wound classification of?
a. Class 3
b. Class 2
c. Class 4
d. Class 1

c. Class 4

Juan the CST on call has just completed a gastrostomy feeding tube insertion. During the procedure the stomach was entered without any spillage of contents, the wound classification assigned would be?
a. class 2
b. Class 4
c. class 3
d. Class 1

a. class 2

The surgeon is working on a patient with severe hand laceration, he requests a fine Neurolon suture to repair the nerve. The CST knows the gauge of the suture should be?
a. 6-0
b. 2-0
c. 0
d. #1

a. 6-0

The surgeon asks for bolsters for the secondary suture line for closure of the laparotomy. The CST knows that this procedure will require closure with?
a. Retention sutures
b. Traction sutures
c. Interrupted sutures
d. Continuous sutures

a. Retention sutures

While performing the excision of a sacral decubitis, the surgeon tells john the CST, "I want this wound to heal by granulation ". John knows this would be healing by?
a. 3rd intention
b. 1st intention
c. 2nd intention
d. 4th intention

c. 2nd intention

During an open appendectomy a purse string suturing technique is used to invert the stump of the appendix. During a laparoscopic appendectomy a__________ is used to cut and staple the base of the appendix.
a. EEA
b. Endoscopic GIA
c. TA
d. Ligating clip

b. Endoscopic GIA

A day after surgery a postoperative patient's wound has several separated layers. This would be a wound?
a. Evisceration
b. Separation
c. Adhesions
d. Dehiscence

d. Dehiscence

During an abdominal perineal resection procedure to ends of the intestines need to be anastomosed together. The stapler that would best facilitate this would be the?
a. GIA
b. TA
c. Linear cutter
d. EEA

d. EEA

Dave the CST setting up for a hernia procedure notices a 3-0 vicryl ligature reel on the back table. He informs the circulator to?
a. Add it to the count
b. Check if it is the right size
c. Verify preference card
d. Ask why and who opened it

a. Add it to the count

On a closure of an infected wound the surgeon request a monofilament non absorbable suture. The best choice for the CST would be?
a. Chromic
b. Prolene
c. Vicryl
d. Silk

b. Prolene

The proliferation phase of wound healing by first intention begins on about the third postoperative day.
a. True

b. False

a. True

Which of the following is NOT a monofilament absorbable suture?
a. PDS II
b. Prolene
c. Monocryl
d. Chromic gut

b. Prolene

Which of the following is a multifilament nonabsorbable suture?
a. Surgical silk
b. Polyglactin 910
c. Monocryl
d. None of these choices is correct.

a. Surgical silk

Age can affect wound healing.
a. True

b. False

a. True

Third-intention wound healing is delayed primary closure.
a. True
b. False

a. True

Phase 1 of wound healing by first intention is the lag phase.
a. True

b. False

a. True

Ligatures are also called:
a. Ligament covers
b. Ties
c. Ligament forceps
d. Hemostats

b. Ties

A keloid is a raised, thickened scar caused by excessive collagen formation.
a. True

b. False

a. True

Collagen is a key component in scar tissue.

An adhesion is an abnormal attachment of two surfaces that are normally separate.
a. True

b. False

a. True

In an abdominal wound closure, the first layer sutured closed is the:
a. Peritoneum
b. Muscle
c. Fascia
d. Skin

a. Peritoneum

Smoking can affect wound healing.
a. True
b. False

a. True

A bruise is a(n):
a. Abrasion
b. Laceration
c. Puncture
d. Contusion

d. Contusion

The end of the needle where the suture attaches is called the:
a. Body
b. Eye
c. None of these choices is correct.
d. Point

b. Eye

Polyglactin 910 is absorbable.
a. True

b. False

a. True

A(n) _____ is a tract between two epithelium-lined surfaces that is open at each end.
a. Hernia
b. Sinus tract
c. Adhesion
d. Fistula

d. Fistula

Nylon is nonabsorbable.
a. True
b. False

a. True

Of the following, which is considered the largest in diameter for suture materials?
a. 7-0
b. 2-0
c. 1
d. 4-0

c. 1

A fistula is a tract between two epithelium-lined surfaces that is open at both ends.
a. True
b. False

a. True

A scrape is a(n):
a. Puncture
b. Laceration
c. Contusion
d. Abrasion

d. Abrasion

One of the classic local signs of inflammation is pain.
a. True
b. False

a. True

Which of the following factors does NOT affect wound healing?
a. Nutritional status
b. Insurance status
c. Smoking
d. Age

b. Insurance status

Second-intention healing is:
a. Delayed primary closure
b. A keloid
c. A cicatrix
d. Granulation of the wound

d. Granulation of the wound