Lecture 4: Surgical Skills

Question 1

What is a clean wound and how is it closed?

Answer 1

• Uninfected operative wound, no inflammation, no systemic tract is entered (resp/GI)
• Closed by primary intention and no drainage.

Question 2

What is a clean contaminated wound?

Answer 2

• Operative wound where systemic tracts are entered under controlled conditions without contamination
• Ex: lung surgery, appendix, vaginal

Question 3

What is a contaminated wound?

Answer 3

• Open traumatic wound
• Operations with spillage from GI/GU, or biliary tracts
• Break in aseptic technique (open cardiac massage)

Infection can occur within 6 hours of contamination

Question 4

What is an infected wound?

Answer 4

• Heavily contaminated/infected wound PRIOR to operation
• Ex: Perforated viscera, abscesses, necrotic tissue

Question 5

What is primary intention?

Answer 5

Optimal closure method with no edge separation and minimal scar formation.

Takes place in 3 phases

Question 6

What are the 3 phases of primary intention?

Answer 6

1. Inflammatory (hemostasis => extravasation) + increased tensile strength
2. Proliferative (day 3, collagen matrix + increasing tensile strength)
3. Remodeling (lasts for a year+, area turns paler and devascularization)

Question 7

Describe the inflammatory phase of primary intention healing

Answer 7

Begins immediately and completed by day 3-7
* hemostasis occurs
* extravasation of tissue fluid, cell, and fibroblasts
* increasing blood supply to wound
* debridement of tissue debris by proteolytic enzymes

inc. in tensile strength of tissue and wound healing is dependent on approximation of edges by closure material

Question 8

What determines tensile strength and wound healing in the inflammatory phase of primary intention?

Answer 8

How approximated edges are by suture material

Question 9

Describe the proliverative stage of primary intension healing?

Answer 9

Starts from day 3
* fibroblasts form a collagen matrix
* this matrix determines the tensile strength and plability of the healing wound
* Becomes vascular, supplying the nutrients and oxygen necessary for wound healing

Question 10

What is wound contraction?

Answer 10

• Wound edges pulling together. If successful, results in smaller wound with less need for repair by scar formation
• Good in buttocks/trochanter
• Bad in hand, neck, or face, which can be reduced via skin grafting.

Part of proliverative stage in primary intention

Question 11

Describe the remodeling part of primary intention

Answer 11

may continue for a year +
* following completion of collagen deposition vascularity decreases and any surface scar becomes paler.

resultant scar size is dependent on initial volme of granulation tissue

Question 12

When is tensile strength greatest in primary intention?

Answer 12

10 weeks, at which point it is around 80%

20% @ 2 weeks
50% @ 5 weeks
80% @ 10 weeks

Question 13

what is primary intention wound closure performed with?

Answer 13

sutures
staples
tape/glue

Question 14

When does secondary intention occur?

Answer 14

Wound fails to heal by primary intention

d/t infection, excessive trauma, tissue loss, imprecise approximation of tissue (dead space)

Question 15

What is the concern with secondary intention?

Answer 15

Excessive granulation tissue, which contains myofibroblasts leading to gradual but marked wound contraction
may protrude above wound surface, prevent epithelialization and require additional tx.

Question 16

When is delayed primary closure used?

Answer 16

Contaminated and infected wounds with high tissue loss and risk of infection

trauma, penetrating injury

Question 17

How is delayed primary closure achieved?

Answer 17

• Debridement of nonviable tissue
• Leave wound open with packing/vacuum system
• Wound approximation within 3-5d of no infection
• If infection present, leave to secondary intention

Question 18

Do you hold the forceps or the driver in your dominant hand? What fingers are used?

OK THIS WONT BE A QUESTION BUT I AM PARANOID

Answer 18

Forceps with non dominant, hold in the first 3 fingers (like a pen)
Needle-holder in dominant hand, partially insert the thumb and ring finger in the loops of the handle

just 5 this

Question 19

Needle shapes image

Answer 19

Question 20

Image of 5 needle points

Answer 20

Question 21

What is the goal when choosing a suture needle and what is generally the MC?

Answer 21

Alter tissue to be sutured with as little damage as possible, usually with tapered/reverse non-cutting needles.

Generally, taper for delicate, reverse for skin/tough

Question 22

When is the conventional cutting used?

Answer 22

skin, sternum

Question 23

When is the reverse cutting needle used?

Answer 23

fascia, ligament, nasal cavity, mucosa, pharnxy, skin, tendon sheath

preferred for skin and tougher tissues

Question 24

When is the taper needle used?

Answer 24

aponeurosis, biliary tract, dura, fascia, GI tract, laparoscopy, muslce, myocardium, nerve, peritoneum, pleura, subcutaneous fat, urogenital tract, vessels, valve…..pass

preferred for delicate tissues

when in doubt, choose taper for everythign except skin sutures

Question 25

When should taper needles NOT be used?

Answer 25

Skin, which is dense and may bend the needle. | Otherwise taper is good.

Question 26

What is the preferred cutting needle?

Answer 26

Reverse cutting | Good for skin, whereas taper is not. ## Footnote decreases likelihood of sutures pulling through soft tissue

Question 27

Where is the cutting edge for the traditional cutting needle? what about for the reverse cutting needle?

Answer 27

traditional cutting needle: inside of the curve (concave surface) reverse cutting needle: outter surface of the curve (convex surface)

Question 28

What are the pros/cons of a memory/nylon/PDS suture?

Answer 28

* Pros: Returns to previous shape when deformed. * Cons: Difficult to tie and unravel

Question 29

What are the pros of elasticity/monofilament sutures? what tissue should it be used on?

Answer 29

* Pros: **Returns to original length** after it's stretched * Mainly used for edematous tissue

Question 30

What is knot strength?

Answer 30

Force required for a knot to slip. | important to consider when ligating arteries

Question 31

What are the 3 monofilament sutures and their features?

Answer 31

* PDS, Monocryl, Nylon * Less traumatic due to less friction * Lower rates of infection * **More likely to slip**, requiring 5-6 throws vs 3 for multi * **Preferred for skin closure** d/t better cosmetic result

Question 32

What are the 2 multifilament sutures and their features?

Answer 32

* Vicryl and silk * Easier to handle and tie, less likely to slip.

Question 33

What are the non-absorbable suture materials? | natural and synthetic

Answer 33

* Natural: Silk (braided)/cotton/steel * Synthetic: Prolene (mono), Ethilon (nylon-mono) | Left in place indefinitely or removed once adequate healing occurs.

Question 34

What are the absorbable suture materials?

Answer 34

* Natural: catgut, collagen-based for 1 week. * Natural: chromic catgut: collagen + chromium, take 3 months to breaht down. * Synthetic: **Vicryl is degraded by water**, minimal reaction by tissue compared to catgut. | Catgut used on small kids face ## Footnote Monocryl and PDS are also broken down by hydrolysis.

Question 35

Summary of absorbable suture materials

Answer 35

Question 36

How is suture size scaled?

Answer 36

0 to 12/0 | 0 is largest, 12/0 is smallest. ## Footnote They had to add on numbers as we got better technology, so higher number = smaller suture

Question 37

Suture Removal Timings

Answer 37

* Face: 3-4d * Scalp: 5d * Trunk: 7d * Limb: 7-10d * Foot: 10-14d | You need more tensile strength in feet