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TISSUE HANDLING AND WOUND CLOSURE

SIU School of Medicine

OVERVIEW This module is designed to orient participants in the use of basic surgical instruments. Tissue techniques, tissue handling and tissue dissection will be covered. You will work on cadavers of the upper limbs to suture various wounds and to dissect various tissues in their respective planes. I. OBJECTIVES The residents should be able to understand and perform the following principles of wound management. a. Handling of the surgical instruments b. Basic surgical skills of tissue handling c. Debridement d. Irrigation e. Hemostasis f. Wound tension g. Obliterating dead space h. Skin Closure

The residents should be able to understand and perform the following tissue planes. a. Fascial dissection b. Nerve dissection c. Vessel dissection d. Tendon handling
II. ASSUMPTIONS

A basic knowledge of the anatomy of the major peripheral nerves and vessels in the upper extremities required. General anatomy of muscles and bones should be understood. III. SUGGESTED READINGS

Preuss, S, Breuing, KH, Eriksson E. Plastic Surgery Techniques, In Plastic Surgery, Indications, Operations & Outcomes. (Ed. Mosby) 2000 Chapter 13, 147-161. Singer A, Hollander J, Quinn J. Evaluation and Management of Traumatic Laceration Current Concepts New England Journal of Medicine 237;1142-1148 1997 IV. DESCRIPTION OF THE LABORATORY MODULE

The participants will be introduced to the various surgical instruments required in tissue handling and tissue dissection. Fresh forearm cadavers will be brought in for the procedures so that experience with tissue handling can be obtained. Wound debridement and skin closure will be carried out. Tissue planes will be dissected by one resident

specifically identifying and isolating the neurovascular bundles, tendons, and muscles while the other participant retracts to provide appropriate visualization. V. DESCRIPTION OF TECHNIQUE/PROCEDURE

1. PRINICPLES OF WOUND MANAGEMENT DEPBRIDEMENT There are three main objectives that need to be understood and practiced throughout this station. The first principle involves wound management, incisions made on the proximal dorsal aspect of the upper extremity. The wound edges are excised to develop smooth regular edges for primary closure. The participant will exercise the use of appropriate debridement back to good viable wound edges. The wound is then irrigated and closed in layers. A deep dermal suture is utilized to close the wound edges and the skin closed definitively with non-absorbable sutures. The participant will practice handling the wound edges in a delicate, nontraumatic fashion so that the remaining tissue does not become compromised. Forceps with fine teeth are utilized. IRRIGATION The wounds need to be copiously irrigated with saline prior to debridement and closure. All involved tissue planes are irrigated to mechanically decrease the bacterial load and decrease the chance of infection. This also further defines those tissues that are compromised, devitalized or otherwise traumatized by remaining clot and debris. HEMOSTASIS Hematomas increase wound tension, delay wound healing, and promote wound infection. Meticulous hemostasis is a necessary step in wound preparation and is facilitated by the use of cautery. This is difficult to perform in our workstation but large vessels may be tied off with 4-0 or 3-0 Vicryl suture. REDUCTION OF WOUND MARGIN TENSION Proper reduction of tension across the wound margins minimizes potential complications resulting from wound dehiscence. Scar hypertrophy or widening is minimized if tension is decreased. The participant will practice decreasing wound tension by undermining the edges of the wound using deep dermal absorbing sutures. OBLITERING DEAD SPACE Obliteration of the dead space between the skin and the underlying tissue prevents formation of seromas or hematomas. In small wounds, this is accomplished by deep suture fixation, whereas in moderate or larger size defects, this is optimally achieved by the use of deep tissue mobilization. Drains are often required. The participant will practice deep wound suturing. SKIN CLOSURE This goal is to produce an absolutely accurately coapted yet atraumatically closed wound. This is accomplished by ensuring that the insertion and pull through of the needles are in

line with the curve of the needle and placed in such a matter that the wounds are appropriately everted when the knot is secured. WOUND CLOSURE A description of the various means of obtaining wound closure is described in the syllabus. Each participant will practice the art of skin coaptation with simple sutures, running sutures, vertical mattress, horizontal mattress, and subcuticular sutures. Various suture materials will be available to achieve these goals. Introduction of the surgical needle should be placed through the skin at a greater than 90 from the skin surface. The opposing edge of the tissue site is everted as the needle is brought out through this opposite side. Equal bites from each side of the wound will ensure adequate closure. The participant will practice in laying down the square knots and slip knots. TISSUE PLANES A separate incision on the volar aspect of the forearm will be made. The participant will dissect the muscle compartments of the forearm. Blunt and sharp dissection techniques will ensue to fully identify superficial veins, and nerves along the anti-brachial fascia. The dissection will be carried down from proximal to distal over the anti-brachial fascia. The fascia will then be incised to reveal the muscle bellys. Each of the flexor muscle bellys will be identified. The major peripheral nerves (ulnar, median and radial) will be identified in their appropriate planes. The dissection within these planes will be carried out with blunt and sharp dissection using the equipment supplied. Arterial and venous dissection will also be carried out along these tissue planes. The median nerve will be dissected in its entirety in the volar forearm down to the wrist and through the carpal tunnel. The carpal ligament will be transected to reveal the trifurcation of the median nerve in the palm. The cephalic vein will be dissected the dorsoradial aspect of the forearm. The dissection of this vein is made easier in a distal to proximal direction. In the distal forearm on the volar aspect, there are a number of flexor tendons that enter carpal tunnel. Dissection of these tendons will ensue so that the participant will fully understand the synovial sheaths that surround the tendons and note their relationship between each other and the surrounding structures. 2. ABOUT THE SURGICAL INSTRUMENTS Surgical Knife Blade and Handling No 10.*cutting edge is predominantly straight except for its distal end *used for sharp debridement *use to cut long linear incisions *if you hold this knife like a pencil it will be difficult to control the blade and a jagged incision will result No 15.*curved distal end is the major portion of its cutting edge *use to cut short, tortuous or angulated incisions *hold the knife like a pencil to have optimal control No 11.*sharp point is the major cutting end *used primarily for incision and drainage *hold this knife like a pencil Tissue Forceps

Non-Toothed. Toothed.

*can be more damaging to tissue *used to stabilize suture material

* hold so that one arm is an extension of your thumb and other arm an extension of your fingers *use the thumb extension arm to elevate tissue planes or wound edges *avoid compressing the tissue between the teeth. This will crush the tissue, damaging the tissues defenses and inviting infection.

Surgical Scissors Sharp dissection. *use the tips of the scissors for sharp dissection

Blunt dissection. *use the tips of the scissors *insert the tips of the scissors and spread them open *useful for dissecting vital structures such as neurovascular bundles 3. BASIC SURGICAL SKILLS Incision 1) 2) 3) 4) 5) 6) 7) 8) 9) Mark out important landmarks Add cross hatches with the marking pen for accurate wound closure later Apply gentle traction to the skin to avoid wrinkles Use the belly of the No. 10 blade holding it like a violin bow perpendicular to the skin Apply enough pressure to the scalpel to cut through to subcutaneous fat with one stroke Always cut toward you in one motion Do not use a sawing motion Focus your attention on the segment already cut in order to continue in a straight line and to adjust the required pressure Avoid numerous cuts in different planes

Dissection 1) 2) 3) 4) 5) Use the tips of the instruments Cut only 5 mm of tissue at a time (only cut what you can see!) Maintain traction on surrounding tissue Work between tissue planes Use blunt dissection to isolate neurovascular structures

Wound Healing and Wound Closure Surgical Needles 3 basic components: swage = attachment to suture body = can have difference radii or curvature point = can be tapered, cutting, reverse cutting, tapercut

The swage is more susceptible to bending or breaking by the needle holder jaws than the body, therefore, it is best to hold the needle well beyond the site of the swage. Taper:

Cutting:

spreads tissue rather than cutting it used for closing muscle or fascia 2 to 3 cutting edges designed to cut through tough tissue when the apical point is on the inner aspect of the needle curvature it is a conventional cutting when the apical point is on the opposing side it is a reverse cutting reverse cutting are used for skin and dermis and produce a hole that is very resistant to suture cut-through

Tapercut: cutting edges extend only a short distance recommended for closing oral mucosa Healing First intention: surgical re-approximation allows for minimal healing time and scarring. Second intention: used for infected wounds to allow for spontaneous formation of granulation tissue Third intention: delayed primary closure for infected wounds or dehiscence lessening the duration for packing or dressing changes Wound dehiscence is a serious complication associated with prolonged morbidity and increased mortality. 4. ELECTIVE INCISIONS Elective incisions should be well thought-out, as they provide the surgeon with considerable control over the final appearance and orientation of the resulting scar. In general, incisions should be placed parallel to the Relaxed Skin Tension Lines. Relaxed Skin Tension Lines are generally oriented perpendicular to the direction of the underlying muscle fibers. The specific location can be determined by examination of patients natural skin creases at rest and during animation. An example of the proper orientation in various portions of the face is shown below.

Orientation of the final scar parallel to or within a natural skin crease gives a superior cosmetic result. The use of triangular excisions in certain areas of the face prevents distortion of adjacent structures. Closure is achieved by medial advancement of flaps in an inverted T. Fusiform excision of skin lesions are therefore performed with the longitudinal axis running parallel to the Relaxed Skin Tension Lines. The length of the fusiform defect should be fourth times with width of the defect to produce an accurate coaptation of skin edges without dog ear formation.

Dog ears are areas of redundant skin and subcutaneous tissue resulting from a wound margin being longer on one side than the other. The dog ear is dealt with by one of two methods: 1) incremental oblique placement of sutures to redistribute the tension across the wound 2) fusiform excision of the dog ear with lengthens the scar considerably. Removal of a dog-ear. Following excision of the lesion, the skin defect is sutured until the dog-ear becomes apparent (A). The dog-ear is defined with a skin hook and is incised round the base (B). Excess skin is defined and removed and the skin is sutured(C).

VI.

EQUIPMENT NEEDED

Cadaver forearms No 10 blades No 15 blades No 11 blades 5-0 Nylon suture 4-0 Nylon suture cutting needles Army/Navy retractors Suture scissors Adson forceps Dissecting scissors Vascular forceps Rat tooth forceps Skin Hooks Weitlander retractors VII. REFERENCES Singer A, Hollander J, Quinn J. Evaluation and Management of Traumatic Lacerations Current Concepts New England Journal of Medicine 337:1142-1148 1997. http://content.nejm.org/cgi/reprint/337/16/1142.pdf? ijkey=8d8c4d06bcb72722ca81204fb5f259daeb22103c Preuss, S, Breuing, KH, Eriksson E. Plastic Surgery Techniques, In Plastic Surgery, Indications, Operations & Outcomes. (Ed. Mosby) 2000 Chapter 13, 147-161. Place, MJ, Herber SC, Hardesty, RA. Basic Techniques & Principles in Plastic Surgery In Grabb & Smith Plastic Surgery (Ed. Lippincott Raven) 4th Edition Chapter 2, 13-25. Francel, T Wound Closure Operative Plastic Surgery (Ed. McGraw Hill) Chapter 3, 18-25, 2000 Freedman J, Moser S. Closure and Material (Operative Plastic Surgery (Ed. McGraw Hill) Chapter 4, 26-32. 2000 Rohrich R. Wound Healing and Closure Selected Readings in Plastic Surgery, July 1990 Vol 6 No 1 Pages 1-38. www.synature.com www.residentnet.com

Absorbable Suture Profile Chart From www.syneture.com

Product CAPROSYN POLYSORB DEXON II DEXON S BIOSYN MAXON MAXON CV Chromic Gut Mild Chromic Gut Plain Gut

Material Monofilament Coated & Braided Coated , Braided Uncoated , Braided Monofilament Monofilament Monofilament Gut Fiber with Chromium Salt Gut Fiber with Chromium Salt Gut Fiber

Effective Wound Support 10 Days 3 Weeks 3 Weeks 3 Weeks 3 Weeks 6 Weeks 6 Weeks 10 - 14 Days 10 - 14 Days 7 - 10 Days

Absorption Time (Days) < 56 56 - 70 60 - 90 60 - 90 90 - 110 180 180 within 90 within 90 within 70

Non Absorbable Suture Profile Chart From www.syneture.com


Product Material Effective Wound Support Gradual Loss Gradual Loss Gradual Loss Permanent Permanent Permanent Permanent Permanent Permanent Gradual Loss Permanent Absorption Time (Days) Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent Permanent

DERMALON Monofilament Nylon MONOSOF Monofilament Nylon SURGILON Braided Nylon SURGIDAC Uncoated Braided Polyester TICRON Coated Braided Polyester SURGIPRO Monofilament Polypropylene SURGIPRO II Monofilament Polypropylene NOVAFIL Monofilament Polybutester Coated Monofilament VASCUFIL Polybutester FLEXON Multistrand Steel SOFSILK Silk - Coated STEEL Monofilament Steel

From wwww.Residentnet.com

Running or Continuous Stitch The "Running" stitch is made with one continuous length of suture material. Used to close tissue layers which require close approximation, such as the peritoneum. May also be used in skin or blood vessels. The advantages of the running stitch are speed of execution and accommodation of edema during the wound healing process. However, there is a greater potential for malapproximation of wound edges with the running stitch than with the interrupted stitch.

Interrupted Stitch Each stitch is tied separately. May be used in skin or underlying tissue layers. More exact approximation of wound edges can be achieved with this technique than with the running stitch.

Vertical Mattress Suture A double stitch that is made parallel (horizontal mattress) or perpendicular (vertical mattress) to the wound edge. Chief advantage of this technique is strength of closure; each stitch penetrates each side of the wound twice, and is inserted deep into the tissue.

Running Subcuticular Suture