WOUND SUTURING WITH ILLUSTRATIONS 2023.pptx

interesting slides notes about wound suturing

1. WOUND SUTURING

2. O bjectives of wound closure To avoid infection in the wounds To stop bleeding To aid wound healing Cosmetic purpose

3. Steps of wound healing 1. Stage of haematosis Is the initial stage, Characterized by haemorragic arrest, Aided by vascular contraction and blood clotting

4. 2. Inflammatory phase Begins after injury Controls bleeding and prevents infection Allows healing and repair cells to move to the healing site VIZ: Fibroblasts for initiating angiogenesis and epithelialization, collagen formation, white blood cells to fight infection (Macrophages, Neutrophils) etc

5. 3. Proliferative phase Wound matrix formed during haemastosis is replaced by granulation tissues consisting of fibroblasts, granulation, microphages and collagen bundles. Consists of 3 processes: Epithelialization - is a stage of regeneration of epidermis made of epithelium Granulation formation for dermal repairs( for;protection,proliferation vasculirization ) Angiogenesis – is the revascularization of the granulation tissue

6. 4. Maturation phase in would healing Final stage of wound healing Occurs only when the wound is closed Involves remodeling of collagen Cells used to repair the wound but no longer required for healing any more are removed by apoptosis or programmed cells death.

7. TYPES OF WOUND HEALING 1. Healing by primary intension employed in wounds with minimum loss of tissue such as:- Surgical incision wound Clean laceration wound Are always closed immediately after surgery (Primary) or delayed primary wound lasting up to 24 hrs The wounds heal with a clean neat and thin scars within 6 – 8 days There is low risk of wound infection and is cosmetic

8. 2. Healing by secondary intention Wound is left open for some times Dressing must first be done to render the wounds aseptic Risk of wound infection is common Commonly occurs in chronic wound Heals by granulation and epithelialization Takes long to heal due to volume of tissue required to fill the defect Suturing not performed within the first 24 hrs May heal with a big scar

9. 3. Healing by tertiary intention Is a delayed primary wound healing after 4-6 days Closure is done when granulation has already occurred Done in case there is need to delay closing a wound as in: Wound with poor circulation Infected wound Contaminated wound NB: Healing by Secondary intension vs Tertiary intention Secondary intention – Edges cannot close, wounds heal from bottom Tertiary- Wound closure is delayed but closed after some times

10. Complications of suturing: Haematoma associated with massive swelling Wound infection- dressing required, antibiotics given Hypertrophic scaring/keloid Extensive un cosmetic scaring Wound necrosis as in tight wound closure

11. SURGICAL TIOLET & SUTURING (sterile procedure ) Definition : Surgical procedures for cleaning infected or contaminated large wounds and eventually closing them Social Toilet: Cleaning a contaminated wound with clean water

12. REQUIREMENTS Trolly : Upper shelf and lower shelf Drape the trolly with sterile drapes Upper shelf: Gallipot with swabs Pieces of swabs Needle holder Sutures – absorbable Non- absorbable Sponge holding forceps Toothed dissecting forceps Stitch scissors Surgical blade with its holder ( Scalpel Handle) Sterile Gloves Kidney dish Lower shelf: (Bottom Shelf) Receiver for used swabs Extra requirements

13. SUTURE MATERIALS Classified as – Absorbable & Non-absorbable Absorbable: Catgut Polydioxanone (PDS) Poliglecaprone ( Monocryl ) Poliglactin 910 ( vicryl ) Non-absorbable: Nylon- Natural monofilament Polypropylene ( prolene ) – Synthetic monofilament Silk- Natural braided suture material Polyester – Synthetic braided suture materials

14. CAT GUT Absorbable non monofilament natural suture materials Used for repairing internal soft tissue Not suitable for hearts, vessels and neurosurgery because it causes some reaction leading to scaring It is got from sheep, cattle, pig guts, there are two types of cut gut; Chromic, Plain. Plain gut suture , is natural, weaker than chromic and takes shorter time to dissolve. Used for ligating small blood vessels Strength retention is one weak

15. CONT……… Chromic gut - contains chromic salt- meant to strengthen it and to prolong it’s tensile Strength-up to 2 weeks It is always kept in alcohol to maintain it’s integrity Indications of cat gut: Ligation of blood vessels Closure of tissues that heals rapidly eg intestines, oral mucosa Where stitch removal is normally not required e.g children Others are: In ophthalmic surgery Obstetrics and genecology Wound repair But not that related to CNS and CVS !!! It is dissolved by phagocytosis associated with tissue reaction

16. POLYDIOXANONE (PDS ) Synthetic absorbable monofilament – used for soft tissue wound repair such as: Abdominal closure, pediatrics, CNS& CVS surgeries Advantages Long duration of absorbability High tensile strength (strong) Can withstand infection site Good for CNS, CVS surgery because it doesn’t evoke reaction

17. CONTINUATION POLIGLECAPRONE aka- MONOCRYL Synthetic absorbable monofilament from lactide and glycolide ( salts of glycolic + lactic acids) Used for soft tissue repair Not suitable for CVS, CNS surgeries Commonly used in skin closure in an invisible manner POLIGLACTIN 9 IO aka. VICRYL Is a synthetic absorbable braided suture materials made from glycolic and lactic acid ( glyccolide + lactide ) Good for repairs of hand, and facial laceration Also used in repair of abdomen, uterus, and muscles Not suitable for CNS, CVS surgery for fear of scaring Tensile strength: 73% 2 weeks, 50% 3 weeks

18. Advantages(VICRYL) Good tensile strength Good flexibility Less traumatic Disadvantages Not used in CNS, CVS surgeries

19. NON-ABSORBABLE SUTURES NYLON : Naturally obtained from nylon materials consists of single strand(monofilament) Advantages Easily passes through tissues Doesn’t allow capillarity Discourages bacterial infection Strong tensile for hard tissue (Fascia, tendons… )

20. Disadvantages Poorly held knots, knots can easily disengage Non-absorbable Indications Cardiovascular surgery General surgery Skin closure Plastic surgery Micro-surgery Thoracic surgery Ophthalmology Orthopedics

21. SILK SUTURE MATERIAL Natural braided suture materials Is easy to handle Most used in ophthalmology and neuron surgery & CVS surgery It is strong Good retention time Disadvantages Can trigger inflammatory reaction (Not inert) Non Absorbable Encourages wound infection

22. SUTURE MATERIALS VS STITCHES Suture- thread used in surgery especially for repairing wounds Stitches: Suture materials already in the wound GRADING OF SUTURE MATERIALS Done according to the diameters of the suture strand Grading system begins from “o” Denomination below Zero is written with a back slash eg 2/0, 3/0, 4/0,5/0 Here the bigger the number, the smaller the size of the thread Denomination above zero is bigger as the number goes above zero and written as 1,2,3 Three has the biggest diameter in surgical suture 10/0 is the smallest diameter requiring a microscopic use These threads can be attached to a needle- a traumatic thread or without needle- traumatic .

23. Needle can be: Straight cutting or round body Curved cutting or round body Trochar pointed- only cutting at the tip Cutting used in hard tissue Round-on soft tissue

24. SUTURING TECHNIQUES 1. CONTINOUS SUTURE Suture materials is put continuously in the wound without any interruption The knot is finally made at the end. Advantages Simple, Easy to apply is rather economical Disadvantages Wound gaping can easily happen if there is suture break at any point May constrict blood vessels at the wound margin discouraging fast wound healing

25. 2. INTERRUPTED SUTURES TECHNIQUE Once any stitch is put, it is cut and this is repeated until all wound edges are closed Leads to well secured wound If one stitch breaks, the rest can still hold the wound But can consume a lot of stitches and time

26. CONTINUATION 3. DEEP SUTRE TECHNIQUES Stitch is placed deep to the skin Can be interrupted or continuous Used for closing deep wound Able to reduce surgical dead space Arrests deep bleeders 4. BURRIED SUTURES Knot is buried under the sutured margins, usually not removed Useful in the sutures inserted deep in the wound

27. 5. SUBCUTANOUS SUTURES Placed in second skin layer (dermis) and subcutaneous tissue Usually is continuous Stitches are anchored at either side of the wound 6. VERTICAL MATRESS SUTURE Used for closing wound edges Provides closure for both deep and superficial wounds Provides excellent wound support Decreases dead space Gives superior wound eversion

28. 7. HORIZONTAL MATRESS SUTURE Best in an area with minimum substances tissue to avoid wound eversion Stitches go horizontal to the wound not over the wound Doesn’t cause constriction to deeper tissue But can cause strangulation of blood supply to the wound edges

29. TYPES OF WOUND CLOSURE AND HEALING 1. PRIMARY WOUND CLOSER Aims: To avoid wound infection To stop bleeding Provide faster healing For cosmetic purpose Done immediately after the wound is open (immediate primary closure) Or at most before 24 hrs (delayed primary suture) Wound is appose by suture Wound heals due to epithelialization and connective tissue deposition Reduces infection rate Heals faster within 10-14days

30. 2. SECONDARY SUTURING/ CLOSURE Wound sutured when wound has lasted more than 24 hrs Wound is left open until it is ready for closure Sometimes this wound is allowed to heal by granulation then finally by epithelialization (common in chronic wound) Takes long to heal because of volume of the tissue required to fill the defect Is at high risk of getting infected

31. Healing by tertiary intention Also known as delayed primary wound healing Wound is kept open for 4-6 days Done in grossly infected or contaminated wounds Wound is left open till it is ready for closure when granulation is already formed In most cases there is no extensive tissue damage. Allows easy closure later

32. ANAESTHESA FOR WOUND CLOSURE Local anaesthesia usually used. Common drugs are: Lignocaine 2% ( Lidocaine ) Bupivacaine0.75%,0.5%,:O.25 %,0.125% Adrenaline can be added in order to: Reduce bleeding as a result of its vaso -constriction effect Reduce systemic absorption allowing higher dose of LA Prolong LA effect in the surgical site Route: is by direct infiltration in the surgical sites

33. DOSES Lignocaine with adrenaline – 7 mg / kgm Lignocaine plain – 4.5 mg/km Bupivacaine with adrenaline and without adrenaline – Adult 175 mgs,( 2-3 mg/ kgm ) NB: Avoid adrenaline in fingers, Toes, Penis, Ear Lobes,due to functional end arteries.

34. TYPES OF WOUND EXUDATES Serous fluid- watery yellow fluid normal when small amount much in infection Serosanguineous - A thin watery fluid, pink colour due to RBC (Red blood cells) indicates normal healing of wound. Purulent- White , yellow or brown fluid Slightly thick in texture- sign of infection Composition of pus: White blood cells trying to fight the infection (Dead/Alive) Dead and alive bacteria Dead tissues Exudate from blood vessels & cells

35. Terminologies related to pus : 1 . Purulent – pertaining to pus/Abscess 2. Purulence : state of forming of PUS at a site in the body(pus) 3. Suppuration : formation of Abscess and its discharge/ oozing (purulent discharge ) Abscess : pus

36. Bactria vs pus colors: Yellow ; staphylococcus aureus Green ; pseudomonas aeruginosa Brown yellow pus; red blood, dead muscle tissue +…… END OF PRESENTATION