Incision and Wound Closure

Question 1

Midline incision through linea alba

Answer 1

Easy incision to make, creates good access and easily extensible and relatively avascular.
Linea alba thins infraumbilically

Crosses Langer’s line, some vessel damage and can damage the bladder

Question 2

Infra-umbilical incision

Answer 2

Paraumbilical hernia repair

Lap port insertion

Question 3

Para-median incision

Answer 3

Rarely used, 1.5cm from linea alba and involves cutting through the rectus sheath.

• Less easy to create
• Poor cosmetic result
• Jenkins rule not applicable (Suture length=wound length x 4)
• Intercostal nerve damage
• Falciform ligament above umbilicus on right side of patient

Question 4

Pararectal incision

Answer 4

Not used

Incisional hernias and nerve damage often result

Question 5

Kocher’s incision

Answer 5

Open cholecystectomy (right)
Splenectomy (Left)
3cm below and parallel to the costal margin, from the midline up to the rectus border
Superiorly-sup epigastric vessels
Laterally-intercostal nerves
No caudal/posterior extension

Question 6

Rooftop incision

Answer 6

Liver and spleen access

Pancreatic, gastric and adrenal procedures

Question 7

Transverse muscle cutting incision

Answer 7

Intercostal nerves

Question 8

McBurney’s/Gridiron incision

Answer 8

Classic appendicectomy scar
Perpendicular to McBurney’s line (ASIS-Umbilicus)
ilio-hypogastric, ilio-inguinal nerves
Deep circumflex artery

Question 9

Rutherford Morrison incision

Answer 9

Good access to caecum, appendix and right colon

Good extensions possible

Question 10

Lanz incision

Answer 10

1/3 distance from ASIS to umbilicus
better cosmesis
Splits ilioinguinal and iliohypogastric nerves causing denervation of the inguinal canal mechanism-increased risk of inguinal hernias

Question 11

Pfannenstiel incision

Answer 11

2cm above pubis

Gynaecological, bladder and prostate access

Question 12

Transverse incision

Answer 12

Neonate and children use

Less painful, better cosmesis than longitudinal incision but red muscle splitting=more bleeding

Question 13

Loin scar

Answer 13

Nephrectomy

Question 14

Wound closure principles (9)

Answer 14

Incise along tension lines
Eliminate dead and infected tissue
Gentle tissue handling
Ensure good supply
Eliminate potential spaces for haematoma
Well appositioned tissue
Low wound tension
Appropriate closure technique
Appropriate suture material

Question 15

Mass closure of abdomen

Answer 15

Protect abdominal contents e.g. omentum
Non-absorbable suture nylon or slow absorbable e.g. PDS
Jenkins rule: suture length 4xwound length
Jenkins 1cm rule: suture bite 1cm, adjacent sutures 1 cm apart.
Include all layers of the abdomen except skin and subcut fat. Fascia provides wound strength

Question 16

Choosing the right suture

Answer 16

Suture size
Characterisitics (Braided vs monofilament-handling vs knotting, absorbable/non-absorbable)
Needle

Absorbable suture for quick healing tissues e.g. bowel
Non-absorable for abdominal wall slower healing
Monofilament for running stitches e.g. vascular surgery
Braided for knotting (ligation)

Question 17

Ideal suture

Answer 17

Monofilament
strong
easy handling
Minimal tissue reaction
Holds knot well
Predictable reaction

Question 18

Non-absorbable sutures pneumonic

Answer 18

Double ‘S’
Double “P” Double “P”
LC

Question 19

Non-absorbable sutures Double S

Answer 19

Silk

• Natural
• Braided multifilament
• May be dyed and have wax coating

Steel

• Man made
• May be mono or multifilament

Question 20

Non-absorbable sutures Double P (I)

Answer 20

Polyester

• Man made
• Multifilament
• Dyed/undyed
• Coated/Uncoated

Polyamide

• Man made
• Mono or multifilament
• Dyed/undyed

Question 21

Non-absorbable sutures Double P (II)

Answer 21

Polypropylene (Prolene)
-Man made
-Monofilament
Dyed/Undyed

PVDF

• Man made
• Monofilament
• Dyed/Undyed

Question 22

Non-absorbable sutures L

Answer 22

Linen

• Natural
• Twisted multifilament
• Dyed/undyed

Question 23

Non-absorbable sutures C

Answer 23

Cotton

• Twisted multifilament
• Dyed/undyed
• Uncoated

Question 24

Absorbable sutures PPPP

Answer 24

Polyglycolic acid

• Man made
• Braided multifilament
• Dyed/Undyed
• Coated/uncoated

Polygalactin 910 (Vicryl)

• Man made copolymer
• Coated

Polydioxanone sulfate (PDS)

• Man-made copolymer
• Monofilament
• Dyed/Undyed

Polyglyconate
-Man made copolymer
-Monofilament
Dyed/Undyed

Question 25

Needle characteristics

Answer 25

Needle shape - Straight - Curved - Circular - J-shaped Needle profile - Blunt needle: abdominal closure - Round bodied (Spreads rather than cutting tissue-organs) - Cutting/Reverse cutting needle-triangular profile-tough fibrous tissue

Question 26

Suture removal

Answer 26

Face 4-5 days Scalp 6-7 days Hands and Limbs 10 days Abdominal wounds 10-20 days

Question 27

Surgical drains use

Answer 27

- Drain a collection e.g. subphrenic abscess Drains may be open or closed, suction and non suction - Decompress e.g. pneumothorax - Risk of leakage e.g. bowel anastamosis - Divert fluid from an obstruction e.g. suprapubic catheter -Minimise dead space and fluid collections e.g mastectomy

Question 28

Surgical drain examples

Answer 28

Suction: Only closed system-Redivac and suction chest drain Non-suction Open: Penrose and Corrugated drain Non-suction Closed: Robinson drain, T tube, urinary catheter, chest drain

Question 29

Scar minimisation

Answer 29

``` Langers lines Wrinkle lines (nasolabial folds, forehead wrinkles) Natural junctions (Nose and face) Hidden sites (Eye brow, hair line) Good appoition Low tension Small suture diameter Suture removal at earliest opportunity Avoid sun-pigmentation ```

Question 30

Scar types

Answer 30

Hypertrophic scars Keloid scars Malignant change in scars

Question 31

Hypertrophic

Answer 31

Proliferative phase of scar healing can remain if large area of skin damage e.g. abrasion/burns. The scar appears red and hard

Question 32

Keloid

Answer 32

Excessive scar tissue breaching beyond the wound