1. Wound Closure Pearls Daniel Palmer, PA-C Black Hills Orthopedic and Spine Center

2. Objectives  Understand the Principles of wound healing and closure  Demonstrate closure of Deep fascia, subcutaneous and dermal tissue layers  Demonstrate horizontal and vertical mattress, simple interrupted and running intradermal suturing techniques.  Understand the differences between suture and needle types and selection.

3. Basic Anatomy review

4. The skin Epidermis Dermis Hypodermis Subcutaneous Fat Fascia

5. Principles of wound healing  Wounds heal side to side not end to end  three phases of wound healing are: inflammation, tissue formation and tissue remodeling  No flow no grow – healthy tissues need adequate blood supply  Smoking, diabetes, immune compromise, metabolic disorders, and poor nutrition slow wound healing  Tissue moisture is essential for wound healing  Dirty wounds are destined for failure

6. Pearls when closing a wound

7. Pearls When Closing a Wound  Approximate, Don’t Strangulate  A Clean Wound is a Happy Wound – remove foreign material and necrotic tissues  Inverted Edges Do Not Heal  Close the Dead Space  Maintain Tissue Moisture

8. Dead space Avoidance of trapping of fluid or air within tissue layers promotes wound healing Seromas can promote growth of microorganisms and limit tissue profusion. Especiallly common in the fatty layers

9. Primary wound Closure

10.  Sterile field  Anesthetic  Suture and needle  Tissue forceps  Needle driver/holder  Suture scissors  Maybe a tissue scissors  Dressings Equipment

11. Suture Any strand of material used to ligate vessels and approximate tissues together Is vastly a surgeons preference Suture types have inherent basic principles

12.  Size denotes the diameter of the suture material look at the number of 0s ie. 2-0 is larger than 3-0 – 00 vs 000  The smaller the size the smaller the tensile strength of the suture Size and Tensile strength Choose the suture with the smallest diameter that will maintain adequate tensile strength to keep wound approximated thru the healing process

13. Suture Characteristics Monofilament  Pass smoother thru tissues causing less tissue trauma – great for vascular procedures  Harbor less organisms due to simple structure  Weaker than multistranded suture Multifilament strands  Higher tensile strength  some are coated to allow for smoother passing thru tissues.

14. Absorbable vs non absorbable Absorbable  Sutures that lose their tensile strength and break down within 60 days  Made from the collagen of healthy mammals or from a synthetic polymer.  Ie. Vicryl, Polysorb, gut, Monocryl, chromic, Non absorbable  Sutures that maintain their tensile strength and do not breakdown within 60 days  Ie. Silk, nylon, wire, Fiberwire, Prolene, Nurolon, Ethibond, PDS

15. Needles Cutting  Cutting and reverse cutting  Both have triangular bodies  Effective in cutting thru tough tissues but may not be best choice in fragile tissues. Tapered  Sharp and tapered point  Not as durable as the cutting needle in general  Less tissue trauma  Not as effective in tough tissues due to needle strength  Perfect for intra dermal repairs and fragile tissues

16. Basic suturing techniques 1. Simple interrupted skin sutures 2. Running skin sutures 3. Mattress suturing : vertical and horizontal 4. Subcutaneous and facial closures: locking and barried sutures 5. Running intradermal sutures

17. Knot tying  All suture use the principle of the square knot with variations: over under, under over  May use a “surgeons knot” – a double throw on first throw – helps to lock in the knot  Loop tensioning technique –  2 square knots usually adequate to secure a stitch

18. Simple interrupted sutures Quick and effective for most wound types May be used in combination with a running pattern or a corner repair

19. Simple interrupted skin sutures Usually left in the skin for 7-14 days.

20. Simple running suture pattern

21. Vertical mattress sutures Entry and exit points are stacked on same side of the wound Excellent for ensuring edges are inverted

22. Vertical Mattress

23. Horizontal Mattress Sutures Excellent option for ensuring everted skin edges Good tensile strength Minimizes tissue trauma and circulation impairment

24. Horizontal Mattress

25. Running subcutaneous sutures and Running intra dermal sutures Good for decreasing tension on dermal layer and avoiding wound dehiscence Similar technique in the running dermis pattern – may be reinforced with steri -strips

26. Running intradermal closure No sutures protruding from skin May seal this with Dermabond and/or Steri- strips A variant of this is to put a pulling stitch at each end or one end of the wound to tension Usually you use a monofilament suture with a taper needle

27. Corner or tip stitch Decreases trauma to fragile tip of an angled wound Use skin hook and avoid trauma to tip of wound Prone to necrosis

28. Corner wound closure Variant of horizontal mattress Avoid trauma to tip of skin to avoid necrosis

29. Running locking stitch May be used for skin closure but caution due to vascular compromise Effective suture for fascial closures

30.  Keep wound clean  May need to immobilize wounds under tension ie. Flexor and extensor surfaces  Keeping wound moist ie. Vaseline  Keeping wound covered to avoid contamination  How long to keep sutures in?  How to minimize scaring?  Is it infected? Pearls for mound management post closure

31. THANK YOU