Principles of incision and wound closure

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Principles of incision and wound closure

  1. 1. Principles of Incision and Wound Closure Fuad Ridha Mahabot 1
  2. 2. Introduction • Pre-operative planning - important!  for optimal cosmetic and functional result  healing process  wound contraction and scarring - may compromise function and appearance • Goals  to re-establish functional soft tissue structural support  to give the most natural aesthetic appearance with minimal distortion 2
  3. 3. Principles of Wound Incision • First priority - maintain a sterile and aseptic technique to prevent infection. THE LENGTH AND DIRECTION OF INCISION - to afford sufficient operating space and optimum exposure  the direction of wound naturally heal is from side-to-side, not end-toend  the arrangement of tissue fibers in the area to be dissected will vary with tissue type  the best cosmetic results  when incision made to the direction of tissue fibers 3
  4. 4. Principles of Wound Incision • Relaxed Skin Tension Lines (Langer’s line)  Is the skin lines oriented perpendicular to the direction of the underlying muscle fibers  determined by examination of patient’s natural skin creases at rest  orientation of the final scar parallel to or within a natural skin crease gives a superior cosmetic result. 4
  5. 5. Principles of Wound Incision • Dissection technique  clean incision should be made with one stroke or evenly applied pressure on the scalpel  preserve integrity of as many of underlying structures as possible • Fusiform excision  performed with longitudinal axis running parallel to RSTL  the length should be 4 times with the width of the defect to produce an accurate coaptation of skin edges without dog ear formation. 5
  6. 6. Principles of Wound Incision • Dog ears  areas of redundant skin and subcutaneous tissue resulting from a wound margin being longer on one side than the other  dealt with either by  incremental oblique placement of sutures to redistribute the tension across the wound  fusiform excision of the dog ear with lengthens the scar considerably 6
  7. 7. Principles of Wound Incision  removal of a ‘dog ear’ • skin defect is sutured until the “dog ear” becomes apparent • the “dog ear” is defined with a skin hook and is incised round the base • excess skin is removed and the skin is sutured 7
  8. 8. Principles of Wound Incision • Tissue handling  minimum tissue trauma promotes faster healing  surgeon must handle all tissues very gently - and as little as possible  retractors should be placed with care to avoid excessive pressure, since tension can cause serious complications 8
  9. 9. Principles of Wound Incision HAEMOSTASIS - allows surgeon to work in as clear a field as possible with greater accuracy. Without adequate control, bleeding may interfere with the surgeon’s view of underlying structures. also to prevent formation of postoperative hematomas collection of blood (hematomas) or fluid (seromas) can prevent direct apposition of tissue these collections provide an ideal culture medium for microbial growth  serious infection 9
  10. 10. Principles of Wound Incision  avoid excessive tissue damage while clamping of ligating a vessel of tissue. Mass ligation  necrosis, tissue death and prolonged healing time • Maintaining moisture in tissues  during long procedures  irrigate wound with normal saline, or cover exposed surfaces with saline-moistened gauze to prevent tissue from drying out • Removal of necrotic tissue and foreign materials  adequate debridement of all devitalized tissue and removal foreign materials  presence of foreign materials - increases possibility of infection 10
  11. 11. Principles of Wound Incision • Basic Surgical Skills of Wound Incision i. ii. iii. iv. 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 apply enough pressure to the scalpel to cut through to subcutaneous fat with one stroke v. always cut toward you in one motion vi. do not use a sawing motion vii. focus your attention on the segment already cut in order to continue in a straight line and to adjust the required pressure viii. avoid numerous cuts in different planes 11
  12. 12. Principles of Wound Closure Goal: “approximate, not strangulate” CHOICE OF CLOSURE MATERIALS - proper closure material will allow surgeon to approximate tissue with a little trauma as possible, and with enough precision to eliminate dead space •Suture Materials - generally categorized by three characteristics:  Absorbable vs. non-absorbable  Natural vs. synthetic  Monofilament vs. multifilament 12
  13. 13. Principles of Wound Closure i. Absorbable suture - degraded and eventually eliminated (e.g. cat gut, vicryl, monocryl) ii. Non-absorbable suture - not degraded, permanent (e.g. prolene, nylon, stainless steel) iii. Natural suture - biological origin; may cause intense inflammatory reaction (e.g. cat gut, chromic, silk) iv. Synthetic suture - synthetic polymers; do not cause intense inflammatory reaction (e.g. vicryl, monocryl, nilon) 13
  14. 14. Principles of Wound Closure v. Monofilament suture - grossly appears as single strand of suture material; all fibers run parallel  ties smoothly  e.g. monocryl, prolene, nylon vi. Multifilament suture - fibers are twisted or braided together  greater resistance in tissue  e.g. vicryl (braided), chromic (twisted), silk (braided) 14
  15. 15. Principles of Wound Closure • Cellular response to foreign materials  whenever foreign materials such as sutures are implanted in tissue, the tissue reacts - depending on type of material implanted • more marked if complicated by infection, allergy, trauma  tissue will deflect passage of needle and suture  edema of the skin and subcutaneous tissue  discomfort during recovery, as well as scarring secondary to ischaemic necrosis 15
  16. 16. Principles of Wound Closure Some of the Suturing Techniques i. simple interrupted stitch - single stitches, individually knotted  used for uncomplicated laceration repair and wound closure i. continuous stitch - allows more rapid wound closure  carries the risk of complete wound opening if the suture breaks 16
  17. 17. Principles of Wound Closure iii. horizontal mattress stitch - provides added strength in fascial closure; also used in calloused skin (e.g. palms and soles) iv. vertical mattress stitch - affords precise approximation of skin edges with eversion 17
  18. 18. Principles of Wound Closure v. subcuticular stitch - intradermal horizontal bites  allow suture to remain for a longer period of time without development of crosshatch scarring  better cosmetic result 18
  19. 19. Principles of Wound Closure • Elimination of dead space in the wound dead space in wound  this is critical to healing!!  results from separation of wound edges which have not been closely approximated, or from air trapped between layers of tissue  if the needle is not placed perpendicular to the skin, it can create dead-space, while unequal bites will create poor apposition  collection of blood or serum  ideal medium for microbial growth  infection  drain insertion or pressure dressing application may help to eliminate dead space in wound 19
  20. 20. Principles of Wound Closure • Closing with sufficient tension - to prevent exaggerated patient’s discomfort, ischaemia, tissue necrosis during healing  sutures must be placed tight enough to seal the wounds, but loose enough as to not strangulate the wounds edges and create tissue necrosis and increased scarring  the deep layer is used to minimize tension on the superficial layer 20
  21. 21. Principles of Wound Closure • Stress placed upon the wound after surgery  to prevent suture disruption  e.g. abdominal fascia will be placed under excessive tension after surgery if patient strains to cough, vomit, void, defecate • Immobilization of wound  adequate immobilization of the approximated wound, but not mandatory for the entire anatomic part  for efficient healing and minimal scar formation 21
  22. 22. Principles of Wound Closure • Factors influencing surgical wound closure  local factors  tight suturing  effect vascularity  necrosis and wound breakdown  overuse electrocoagulation  excessive bleeding and hematoma formation  creating dead space  focus for infection  systemic factors  age (>65), nutritional status, male, long term steroid  may lead to wound dehiscence  smoking, diabetes, rheumatoid arthritis  impaired microcirculation • obesity  reduced tissue oxygenation, increased subcutaneous dead space  more susceptible to haematoma and seroma formation  infection
  23. 23. THANK YOU 23

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