Wound Closure Workshop Stanford University Division of Emergency Medicine

Overview Good Wound Care Practices Wound Closure Techniques - Basic suturing techniques Tissue adhesive application Staple placement Adhesive Tapes

Good Wound Care Practices History Mechanism - foreign body? - crush mechanism? - degree of contamination? - site and timing of the injury?

History Patient Factors factors predisposing to poor wound healing; immunosuppression, diabetes, collagen disorders tetanus status allergies; antibiotics, anesthetics, latex

CDC Tetanus Guidelines

Good Wound Care Practices Physical Exam Before anesthesia a detailed neurovascular and functional exam - may reveal a significant injury needing consultation and/or operative repair before exploration. After anesthesia a repeat functional exam with exploration for foreign bodies and partial injuries.

Local Anesthetics

Local Anesthetics True Allergic reactions to amides impossible (usually due to preservative) Buffering, warming and slow injection decreases pain Topical agents can provide adequate anesthesia in certain areas and can decrease the pain of infiltration Theoretically they are histotoxic, but clinically this is not significant

Wound Preparation Disinfecting solutions are bactericidal and cytotoxic and in general should not be used directly in wounds. Best way to decrease infection is by pressure irrigation which will lower colonization. no benefit to expensive antibiotic irrigants, saline and tap water are just as effective.

Selection of Wound Closure Devices

Suturing Techniques Simple Suture Dermal or Deep Suture Mattress Sutures Suture techniques for flaps

Simple Percutaneous Suture Time honored Can be used to close any wound with excellent cosmesis Divide the wound in halves to avoid dog ears

Simple Suture Placement The needle enters at 900 and is rolled in an arc resulting in equidistant entry and exit points. Taking more depth than width gives desired edge eversion.

The Use of Dermal or Deep Sutures Advantages - remove tension off the wound to prevent scar widening over time - close potential dead space Disadvantages - foreign bodies which potentiate infection

When Should Dermal Sutures Be Used? Site Age of Laceration Degree of Contamination Wound Tension: Dynamic vs. Static

Dynamic Wound Tension > 5 mm dermal sutures < 5 mm recommended not required

Placement of Dermal Sutures Note that the knot is buried in the depth of the wound and the suture is in the dermis not fat

Vertical Mattress Sutures Useful to take tension of wound edges without using dermal sutures Everts wound edges Use in combination with simple sutures Remove on time to avoid track marks

Suturing Flaps Traumatizing tips and flaps can cause vascular compromise Flaps with less than 1/3 of the pedicle remaining should be removed and attached as a skin graft Avoid Proper Technique

Timing For Suture Removal *Secure wounds with adhesive tapes or tissue adhesive after removal

Wound Aftercare for Sutures Keep clean and dry Ointments for 24-48 hours only Wounds prone to surface contamination for 24-48 hours Avoid sun exposure

Tensile Strength of a Wound Over Time

Pearls for Adjunctive Closures Staples With the stapler centered over the wound, press it gently but firmly against the wound and depressed the trigger This is a common mistake. People often apply no pressure and end up with partially applied “floating staples”. Properly applied staples naturally evert the wound edges.

Pearls for Adjunctive Closures Tapes and Steri strips Hemostatsis is necessary Benzoin can improve adherence but must be kept out of the wound Apply the tapes individually apply securely on one side then pulling the tape across, everting the edges

Pearls for Adjunctive Closures: Tissue Adhesives Use proper good wound care practices Achieve hemostasis - Topical anesthetics with epinephrine (LET, TAC etc.) are helpful and allow for proper wound cleansing Appose wound edges tightly DO NOT GET ADHESIVE IN THE WOUND!!!

Pearls for Adjunctive Closures: Tissue Adhesives Wound approximation is key to optimal use Steri strips can be used to achieve wound approximation Cut them short and narrow Leave in place to further re-enforce the wound

Well apposed wound edges with proper topical application Laceration at 3 months

Wound Aftercare For Tissue Adhesives Keep Dry Do Not Use Ointments Avoid Trauma Sloughs on own