Ch 11 Test review

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approximated

Returned to proximity; brought together sides or edges

Nonsuture needles, such as ... are commonly utilized during surgical procedures.

Nonsuture needles, such as *hypodermic, arterial, intravenous, irrigation, biopsy, insufflation, and spinal needles*, are commonly utilized during surgical procedures.

hemostat

An instrument used to grasp tissue on vessels, or clamp onto a vessel.

autologous

From oneself

memory

The bytes of memory of a computer

Size indicates the diameter of the suture material. The suture diameter is referred to as the gauge of the suture. The surgeon will try to use the smallest-diameter suture that will support the tissue wound closure. This serves two purposes:

(1) minimizes tissue trauma as the suture passes through tissues; (2) contributes to minimizing the amount of foreign material implanted in the body.

__sutures are often the first choice for tissue that does not need continued support. __ sutures are used where continued strength is necessary—for instance, to close abnormal openings in the heart. They are typically used to close the dura over the brain or spinal cord and for fascia and skin closure; for example, silk sutures are commonly used for ligating vessels. Absorbable sutures may be used for fascia and nonabsorbable sutures used for the mucosal layer of the intestine and skin; however, as with many instances in surgery, surgeon's preference will always dictate the suture to be used during a procedure.

*Absorbable sutures* are often the first choice for tissue that does not need continued support. *Nonabsorbable sutures* are used where continued strength is necessary—for instance, to close abnormal openings in the heart. They are typically used to close the dura over the brain or spinal cord and for fascia and skin closure; for example, silk sutures are commonly used for ligating vessels. Absorbable sutures may be used for fascia and nonabsorbable sutures used for the mucosal layer of the intestine and skin; however, as with many instances in surgery, surgeon's preference will always dictate the suture to be used during a procedure.

__ involves the use of argon gas in combination with monopolar electrical energy in the form of a noncontact, white light beam. The argon beam coagulator provides rapid hemostasis that travels from a generator to a pencil-like handpiece. There is little to no tissue adherence since the handpiece does not come in direct contact with the tissue that is bleeding. There is less charring of the tissue compared to the ESU.

*Argon plasma coagulation* involves the use of argon gas in combination with monopolar electrical energy in the form of a noncontact, white light beam. The argon beam coagulator provides rapid hemostasis that travels from a generator to a pencil-like handpiece. There is little to no tissue adherence since the handpiece does not come in direct contact with the tissue that is bleeding. There is less charring of the tissue compared to the ESU.

__, such as the Potts-Cournand needle/cannula assembly, are used to introduce diagnostic or angioplasty guiding catheters over guiding wires into the arterial system. Venous needles with an aspirating syringe are used to puncture large veins for the introduction of monitoring catheters, such as the Swan-Ganz. __ attached to syringes are used during open cardiovascular procedures to irrigate open arteries with a saline-heparin solution.

*Arterial needles*, such as the Potts-Cournand needle/cannula assembly, are used to introduce diagnostic or angioplasty guiding catheters over guiding wires into the arterial system. Venous needles with an aspirating syringe are used to puncture large veins for the introduction of monitoring catheters, such as the Swan-Ganz. *Heparin needles* attached to syringes are used during open cardiovascular procedures to irrigate open arteries with a saline-heparin solution.

__ needle assemblies employ a needle to introduce a plastic indwelling catheter into a vessel (commonly called an IV in order to deliver IV fluids, blood, and/or blood products into the circulatory system). __ assemblies are used to obtain arterial blood gases or are attached to a line leading to a transducer to directly monitor arterial blood pressure. Intravenous cannula/needle assemblies, such as the Angio-Cath, are attached to IV lines for the introduction of fluids and/or medications into the patient's system.

*Arterial or venous/cannula* needle assemblies employ a needle to introduce a plastic indwelling catheter into a vessel (commonly called an IV in order to deliver IV fluids, blood, and/or blood products into the circulatory system). Arterial needle/cannula assemblies are used to obtain arterial blood gases or are attached to a line leading to a transducer to directly monitor arterial blood pressure. Intravenous cannula/needle assemblies, such as the Angio-Cath, are attached to IV lines for the introduction of fluids and/or medications into the patient's system.

Accessory devices for wound closure include ... Although vessel loops and umbilical tapes are not used for closure of a wound, they are described here.

Accessory devices for wound closure include *bolsters and bridges, buttons, lead shots, and adhesive skin closure tapes*. Although vessel loops and umbilical tapes are not used for closure of a wound, they are described here.

__ is the reinfusion of the patient's own blood, whether donated prior to surgery or collected and reinfused intraoperatively. This process is preferable to the use of homologous blood because it uses the patient's own blood, eliminating the danger of a compatibility mismatch or disease transmission. If blood is collected intraoperatively, it is suctioned directly from the wound into a cell saver or cell salvager machine that filters and anticoagulated the blood and reinfuses it intravenously with little or no damage to the red blood cells.

*Autotransfusion* is the reinfusion of the patient's own blood, whether donated prior to surgery or collected and reinfused intraoperatively. This process is preferable to the use of homologous blood because it uses the patient's own blood, eliminating the danger of a compatibility mismatch or disease transmission. If blood is collected intraoperatively, it is suctioned directly from the wound into a cell saver or cell salvager machine that filters and anticoagulated the blood and reinfuses it intravenously with little or no damage to the red blood cells.

__ migrate across the skin edges, closing the surface of the wound. __ in the deeper tissue begin the reconstruction of the nonepithelial tissue. The wound does not gain tensile strength during this phase.

*Basal cells* migrate across the skin edges, closing the surface of the wound. *Fibroblasts* in the deeper tissue begin the reconstruction of the nonepithelial tissue. The wound does not gain tensile strength during this phase.

__involves the administration of whole blood or blood components such as plasma, fresh-frozen plasma (FFP), packed red blood cells, or platelets via in intravenous (IV) line. This is used to increase the circulating blood volume, to increase the number of red blood cells, to increase the number of circulating platelets for clotting, and to provide plasma-clotting factors that have been depleted during surgery. Blood products may be __ (donated by another person) or __ (donated previously by the patient and stored, or obtained through __). __ is the use of the patient's own blood, which has been processed for reinfusion. When homologous banked blood is used, blood typing and cross-matching are essential to prevent transfusion reactions.

*Blood replacement* involves the administration of whole blood or blood components such as plasma, fresh-frozen plasma (FFP), packed red blood cells, or platelets via in intravenous (IV) line. This is used to increase the circulating blood volume, to increase the number of red blood cells, to increase the number of circulating platelets for clotting, and to provide plasma-clotting factors that have been depleted during surgery. Blood products may be *homologous* (donated by another person) or *autologous* (donated previously by the patient and stored, or obtained through autotransfusion). *Autotransfusion* is the use of the patient's own blood, which has been processed for reinfusion. When homologous banked blood is used, blood typing and cross-matching are essential to prevent transfusion reactions.

__ have a round shaft that ends in a blunt tip. These points are used primarily for the kidney or liver due to the tissue being so friable or weak.

*Blunt points* have a round shaft that ends in a blunt tip. These points are used primarily for the kidney or liver due to the tissue being so friable or weak.

__, made of refined and sterilized beeswax, is used on cut edges of bone as a mechanical barrier to seal off oozing blood

*Bone wax*, made of refined and sterilized beeswax, is used on cut edges of bone as a mechanical barrier to seal off oozing blood

__ wounds are the most uncommon form of intentional wounds where a chemical is placed to the skin or other tissue surface in an effort to denude and/or coagulate the area. This process causes inflammation and reepithelialization to the surface. This process is most often used in plastic surgery.

*Chemical wounds* are the most uncommon form of intentional wounds where a chemical is placed to the skin or other tissue surface in an effort to denude and/or coagulate the area. This process causes inflammation and reepithelialization to the surface. This process is most often used in plastic surgery.

__ wounds are those that persist for an extended period of time. A __ wound may develop because of an underlying physical condition that the patient suffers, for example, from pressure sores and decubitus ulcers. A __ wound may also be due to infection.

*Chronic wounds* are those that persist for an extended period of time. A chronic wound may develop because of an underlying physical condition that the patient suffers, for example, from pressure sores and decubitus ulcers. A chronic wound may also be due to infection.

__ are used to compress the walls of vessels and to grasp tissue. Most commonly used is the __ that is available with either straight or curved jaws. Special hemostatic clamps are available for different situations, such as vascular clamps designed to be atraumatic so they cause little damage to delicate vessels.

*Clamps* are used to compress the walls of vessels and to grasp tissue. Most commonly used is the *hemostat* that is available with either straight or curved jaws. Special hemostatic clamps are available for different situations, such as vascular clamps designed to be atraumatic so they cause little damage to delicate vessels.

__ needles may have round or square holes and are loaded by inserting the end of the suture material through the hole. The eyed needle allows the use of a wide variety of sutures with a wide variety of needles. Loading the eyed needle with the suture strand can be a cumbersome process when wearing gloves or if the needle is small. The eyed needle causes more tissue damage than the eyeless (swaged) needle because the suture strand is not continuous with the needle.

*Closed-eyed* needles may have round or square holes and are loaded by inserting the end of the suture material through the hole. The eyed needle allows the use of a wide variety of sutures with a wide variety of needles. Loading the eyed needle with the suture strand can be a cumbersome process when wearing gloves or if the needle is small. The eyed needle causes more tissue damage than the eyeless (swaged) needle because the suture strand is not continuous with the needle.

__ and acquired __ affect the ability of the patient's body to form blood clots naturally.

*Congenital hemostatic defects and acquired hemostatic disorders* affect the ability of the patient's body to form blood clots naturally.

__, also known as a blanket stitch, is a variation of the simple continuous where the suture is locked prior to placement of the next throw. First and last ties are the same as for simple continuous and suture placement in the tissue is the same; however, the suture is looped through the opening and pulled into place prior to the next throw. This results in increased wound edge eversion and reduces the skin tension more than the simple continuous.

*Continuous running/locking suturing,* also known as a blanket stitch, is a variation of the simple continuous where the suture is locked prior to placement of the next throw. First and last ties are the same as for simple continuous and suture placement in the tissue is the same; however, the suture is looped through the opening and pulled into place prior to the next throw. This results in increased wound edge eversion and reduces the skin tension more than the simple continuous.

__ consist of three cutting edges that are directed along the inner curve of the needle. These needles place a small cut in the direction of the pull of the suture.

*Conventional cutting needles* consist of three cutting edges that are directed along the inner curve of the needle. These needles place a small cut in the direction of the pull of the suture.

__ is a synthetic adhesive used for skin closure; two commercial names are Dermabond™ (Ethicon product) and Indermil™ (Syneture product). A pencil-like device is held and a button on the side is pushed to deliver the chemical liquid glue. A small brush on the end is used to apply the glue, which dries in approximately 2 minutes. The glue provides a strong, flexible wound closure and naturally wears off in 7 to 10 days. Uses include ob-gyn surgical procedures such as cesarean sections; general surgery procedures; peripheral vascular procedures that involve incisions in the arm or leg; plastic surgery; and facial surgery, as long as the incision is not too close to the eyes. It is contraindicated for use in the presence of infection and patients who are allergic to __ or formaldehyde.

*Cyanoacrylate* is a synthetic adhesive used for skin closure; two commercial names are Dermabond™ (Ethicon product) and Indermil™ (Syneture product). A pencil-like device is held and a button on the side is pushed to deliver the chemical liquid glue. A small brush on the end is used to apply the glue, which dries in approximately 2 minutes. The glue provides a strong, flexible wound closure and naturally wears off in 7 to 10 days. Uses include ob-gyn surgical procedures such as cesarean sections; general surgery procedures; peripheral vascular procedures that involve incisions in the arm or leg; plastic surgery; and facial surgery, as long as the incision is not too close to the eyes. It is contraindicated for use in the presence of infection and patients who are allergic to cyanoacrylate or formaldehyde.

__ are devices that have been designed to remove unwanted fluids or gases from the body. __ can occur preoperatively, intraoperatively, and postoperatively. Not every __ is necessarily a "wound" __. A patient may need more than one type of drainage system as part of the postoperative care.

*Drains* are devices that have been designed to remove unwanted fluids or gases from the body. Drainage can occur preoperatively, intraoperatively, and postoperatively. Not every drain is necessarily a "wound" drain. A patient may need more than one type of drainage system as part of the postoperative care.

__ is the most commonly used thermal hemostatic device. The components of __ are the active electrode or Bovie pencil, electrosurgical or generator unit (ESU), and inactive or dispersive electrode, also called the grounding pad

*Electrosurgery* is the most commonly used thermal hemostatic device. The components of electrosurgery are the active electrode or Bovie pencil, electrosurgical or generator unit (ESU), and inactive or dispersive electrode, also called the grounding pad

__ is a single-use suturing device for the placement of interrupted or running stitches in soft tissue. The device has two jaws; the needle is loaded from a single-use loading unit; the needle can be passed between the jaws by closing the handles. The device also serves as the knot pusher to tighten the knot.

*Endo Stitch™* is a single-use suturing device for the placement of interrupted or running stitches in soft tissue. The device has two jaws; the needle is loaded from a single-use loading unit; the needle can be passed between the jaws by closing the handles. The device also serves as the knot pusher to tighten the knot.

__ staplers are not much different from skin staplers. They are a disposable stapler shaped like a gun and discharge a single, wide stainless steel staple by squeezing the handle. The staple first penetrates the __ and then is formed to approximate the __. It is frequently used in abdominal, gynecological, and orthopedic surgery.

*Fascia staplers* are not much different from skin staplers. They are a disposable stapler shaped like a gun and discharge a single, wide stainless steel staple by squeezing the handle. The staple first penetrates the fascia and then is formed to approximate the fascia. It is frequently used in abdominal, gynecological, and orthopedic surgery.

__ is a biologic adhesive and hemostatic agent. __ consists of fibrinogen, cryoprecipitate derived from human plasma, calcium chloride, and thrombin. The surgical technologist mixes the calcium chloride and thrombin in a specimen cup on the back table and draws the solution into a syringe and attaches a 14-gauge IV catheter. The cryoprecipitate is drawn into the second syringe that also has a 14-gauge IV catheter. The surgeon is handed one syringe and discharges the solution onto the tissue at the same time the surgical technologist discharges the other syringe. The thrombin immediately converts fibrinogen to fibrin to produce a clot.

*Fibrin glue* is a biologic adhesive and hemostatic agent. Fibrin glue consists of fibrinogen, cryoprecipitate derived from human plasma, calcium chloride, and thrombin. The surgical technologist mixes the calcium chloride and thrombin in a specimen cup on the back table and draws the solution into a syringe and attaches a 14-gauge IV catheter. The cryoprecipitate is drawn into the second syringe that also has a 14-gauge IV catheter. The surgeon is handed one syringe and discharges the solution onto the tissue at the same time the surgical technologist discharges the other syringe. The thrombin immediately converts fibrinogen to fibrin to produce a clot.

__ healing occurs with a primary union that is typical of an incision opened under ideal conditions. Healing occurs from side to side in a sterile wound in which dead space has been eliminated and the wound edges have been accurately approximated. Wounds heal rapidly with no separation of the edges and minimal scarring. Wound tensile strength plateaus at the third month at 70 to 80 percent of original strength.

*First intention* healing occurs with a primary union that is typical of an incision opened under ideal conditions. Healing occurs from side to side in a sterile wound in which dead space has been eliminated and the wound edges have been accurately approximated. Wounds heal rapidly with no separation of the edges and minimal scarring. Wound tensile strength plateaus at the third month at 70 to 80 percent of original strength.

__ tissue that contains myofibroblasts forms in the wound, causing closure by contraction. As the wound heals, large gaps in tissue fill, from the bottom upward, with granulation tissue, leaving a weak union and a wide, irregular scar that may result in __. Excessive granulation tissue, sometimes referred to as proud flesh, may protrude above the defect margins and block re-epithelialization.

*Granulation* tissue that contains myofibroblasts forms in the wound, causing closure by contraction. As the wound heals, large gaps in tissue fill, from the bottom upward, with granulation tissue, leaving a weak union and a wide, irregular scar that may result in *herniation*. Excessive granulation tissue, sometimes referred to as proud flesh, may protrude above the defect margins and block re-epithelialization.

__ are used to inject medications into tissues or intravenous tubing. The surgical technologist uses them to withdraw medications into a syringe from a vial held by a circulator. __ may also be used to withdraw fluids from tissues. They are produced in varying sizes and lengths. Needle lengths range in size from 1/2 to 4 in., and gauge sizes range from 12 to 30, with smaller needles having the larger gauge number.

*Hypodermic needles* are used to inject medications into tissues or intravenous tubing. The surgical technologist uses them to withdraw medications into a syringe from a vial held by a circulator. Hypodermic needles may also be used to withdraw fluids from tissues. They are produced in varying sizes and lengths. Needle lengths range in size from 1/2 to 4 in., and gauge sizes range from 12 to 30, with smaller needles having the larger gauge number.

__ wounds, or iatrogenic wounds, are wounds that can happen as a result of therapy or treatment. __ injuries can occur from tissue being nicked with an instrument or trocar wounds on unattended tissues during a suture procedure.

*Incidental wounds*, or iatrogenic wounds, are wounds that can happen as a result of therapy or treatment. Incidental injuries can occur from tissue being nicked with an instrument or trocar wounds on unattended tissues during a suture procedure.

__ is the body's protective response to injury or tissue destruction. The __ process serves to destroy, dilute, or wall off the injured tissue.

*Inflammation* is the body's protective response to injury or tissue destruction. The inflammatory process serves to destroy, dilute, or wall off the injured tissue.

__ is a two-bite suture technique. The two stitches are placed parallel to each other on each side of the wound. The first bite is a simple suture; second bite is placed parallel to the first bite and travels back across the wound edge to end on the same side as the first bite. Each suture placement substitutes for two simple interrupted stitches.

*Interrupted horizontal mattress* is a two-bite suture technique. The two stitches are placed parallel to each other on each side of the wound. The first bite is a simple suture; second bite is placed parallel to the first bite and travels back across the wound edge to end on the same side as the first bite. Each suture placement substitutes for two simple interrupted stitches.

__ is also a two-bite suture technique. The first small bite is placed close to the wound edge; the second bite is placed slightly behind the first bite and deeper in the tissue; the needle comes out the side where the first bite was placed. This technique is used for deep wounds and provides excellent eversion and skin approximation.

*Interrupted vertical mattress* is also a two-bite suture technique. The first small bite is placed close to the wound edge; the second bite is placed slightly behind the first bite and deeper in the tissue; the needle comes out the side where the first bite was placed. This technique is used for deep wounds and provides excellent eversion and skin approximation.

__ are used to anastomose tubular structures within the gastrointestinal tract . This stapler fires a double row of circular staples and then trims the lumen with a knife located within the head of the stapler. These staplers are commonly used during resection and reanastomosis of the distal colon or rectum. Other types of intraluminal staplers are used to surgically repair severe cases of hemorrhoid prolapse and to correct obstructed defecation syndrome.

*Intraluminal (circular) staples* are used to anastomose tubular structures within the gastrointestinal tract. This stapler fires a double row of circular staples and then trims the lumen with a knife located within the head of the stapler. These staplers are commonly used during resection and reanastomosis of the distal colon or rectum. Other types of intraluminal staplers are used to surgically repair severe cases of hemorrhoid prolapse and to correct obstructed defecation syndrome.

__ are not actually needles but small-diameter cannulated tubes attached to a plastic needle hub for placement on a syringe. The __ are available straight and angled, disposable or nondisposable, and in various lengths. They are commonly used during eye and microsurgery procedures.

*Irrigation needles* are not actually needles but small-diameter cannulated tubes attached to a plastic needle hub for placement on a syringe. The irrigation needles are available straight and angled, disposable or nondisposable, and in various lengths. They are commonly used during eye and microsurgery procedures.

__ move to the endothelial lining of the small vessels within hours after the injury, eventually moving through the endothelial spaces outside of the vessels. Once in the extravascular space, they are drawn to the site of the injury. The neutrophils and macrophages begin to neutralize foreign particles by phagocytosis.

*Leukocytes* move to the endothelial lining of the small vessels within hours after the injury, eventually moving through the endothelial spaces outside of the vessels. Once in the extravascular space, they are drawn to the site of the injury. The neutrophils and macrophages begin to neutralize foreign particles by phagocytosis.

Ligating __ are often used in place of suture ligatures when many small vessels need to be ligated in a short period of time. These __ are made of a nonreactive metal, such as titanium or stainless steel, or plastic material and come in various sizes as well as absorbable or permanent varieties. They are applied either from a manually loaded applicator or from any of several preloaded disposable applicators.

*Ligating clips* are often used in place of suture ligatures when many small vessels need to be ligated in a short period of time. These clips are made of a nonreactive metal, such as titanium or stainless steel, or plastic material and come in various sizes as well as absorbable or permanent varieties. They are applied either from a manually loaded applicator or from any of several preloaded disposable applicators.

__ may be wound with absorbable or nonabsorbable sutures and are typically used to occlude superficial bleeders. Reels with absorbable suture material are frequently used on superficial bleeders of subcutaneous tissue just after the incision is made. The most commonly used ligature reels are chromic, plain, or polyglactin 910 sutures. Silk ligature reels are still available for use, as well.

*Ligature reels* may be wound with absorbable or nonabsorbable sutures and are typically used to occlude superficial bleeders. Reels with absorbable suture material are frequently used on superficial bleeders of subcutaneous tissue just after the incision is made. The most commonly used ligature reels are chromic, plain, or polyglactin 910 sutures. Silk ligature reels are still available for use, as well.

__, or ties (referred to as stick ties when a needle is attached), are strands of suture material used to tie off blood vessels. __ are made of either natural or synthetic material and are designed either to dissolve over a period of time or to remain in the body tissue permanently.

*Ligatures*, or ties (referred to as stick ties when a needle is attached), are strands of suture material used to tie off blood vessels. Ligatures are made of either natural or synthetic material and are designed either to dissolve over a period of time or to remain in the body tissue permanently.

__ staplers are used to insert two straight, staggered, evenly spaced, parallel rows of staples into tissue (Figure 11-28). __ staplers are typically used to staple tissue to be transected within the alimentary tract or thoracic cavity, although they have many other surgical applications as well. The __ stapler is available in various lengths. To operate the __ stapler, the tissue is placed within the jaws of the stapler at the level of transection. The stapler is closed, compressing the tissue. The safety mechanism is removed and the stapler is activated.

*Linear staplers* are used to insert two straight, staggered, evenly spaced, parallel rows of staples into tissue (Figure 11-28). Linear staplers are typically used to staple tissue to be transected within the alimentary tract or thoracic cavity, although they have many other surgical applications as well. The linear stapler is available in various lengths. To operate the linear stapler, the tissue is placed within the jaws of the stapler at the level of transection. The stapler is closed, compressing the tissue. The safety mechanism is removed and the stapler is activated.

__ sutures are relatively inert and do not readily harbor bacteria. They glide through tissues more easily than multifilament sutures, resulting in minimal tissue damage because they encounter little resistance within the tissue. __ sutures, however, do not hold knots as well as multifilament sutures and are relatively difficult to handle.

*Monofilament* sutures are relatively inert and do not readily harbor bacteria. They glide through tissues more easily than multifilament sutures, resulting in minimal tissue damage because they encounter little resistance within the tissue. Monofilament sutures, however, do not hold knots as well as multifilament sutures and are relatively difficult to handle.

__ are typically not closed with suture because they do not tolerate suture material well. __ are usually separated or retracted and therefore do not need to be closed (Figure 11-17). If they are incised, however, they should be loosely approximated with interrupted absorbable sutures.

*Muscles* are typically not closed with suture because they do not tolerate suture material well. Muscles are usually separated or retracted and therefore do not need to be closed (Figure 11-17). If they are incised, however, they should be loosely approximated with interrupted absorbable sutures.

__ is an intentional wound that results from ischemia of the tissue by means of banding, such as in a hemorrhiod ligation.

*Occlusion banding* is an intentional wound that results from ischemia of the tissue by means of banding, such as in a hemorrhiod ligation.

__ contain the surgeon's suture routine, suture sizes, needles, and product code numbers for specific procedures. The surgical technologist should consult with the surgeon to find out if any sutures from the preference card can be excluded or if any need to be added, or if the patient's size or condition requires modification of the suture routine.

*Preference cards* contain the surgeon's suture routine, suture sizes, needles, and product code numbers for specific procedures. The surgical technologist should consult with the surgeon to find out if any sutures from the preference card can be excluded or if any need to be added, or if the patient's size or condition requires modification of the suture routine.

__ have a round shaft without a cutting edge, so they penetrate tissue without cutting it. These points are used for delicate tissues, such as the tissue of the gastrointestinal tract. __ combine a sharp taper point with a cutting tip. This point is designed to penetrate tougher tissue while still making smaller holes in the tissue. It is generally the primary choice for use in vascular tissue.

*Regular tapered point needles* have a round shaft without a cutting edge, so they penetrate tissue without cutting it. These points are used for delicate tissues, such as the tissue of the gastrointestinal tract. *Tapercut needles* combine a sharp taper point with a cutting tip. This point is designed to penetrate tougher tissue while still making smaller holes in the tissue. It is generally the primary choice for use in vascular tissue.

__ are large-gauge, interrupted, nonabsorbable sutures placed lateral to a primary suture line for wound reinforcement. These sutures may be placed through all layers of the tissue. They are used when the surgeon suspects that the wound will not heal properly or will heal slowly due to immunosuppression, obesity, diabetes, or other compromising factors. __ sutures can also prevent wound disruption that may result from sudden increases in abdominal pressure created by postoperative vomiting or coughing.

*Retention sutures* are large-gauge, interrupted, nonabsorbable sutures placed lateral to a primary suture line for wound reinforcement. These sutures may be placed through all layers of the tissue. They are used when the surgeon suspects that the wound will not heal properly or will heal slowly due to immunosuppression, obesity, diabetes, or other compromising factors. Retention sutures can also prevent wound disruption that may result from sudden increases in abdominal pressure created by postoperative vomiting or coughing.

__ consist of opposing cutting edges in a triangular configuration that extend into the full length of the shaft. They are used for the skin because they have a flat edge in the direction of the pull. This results in less tearing of tissue.

*Reverse cutting needles* consist of opposing cutting edges in a triangular configuration that extend into the full length of the shaft. They are used for the skin because they have a flat edge in the direction of the pull. This results in less tearing of tissue.

__ healing occurs when a wound fails to heal by primary union. It generally occurs in large wounds that cannot be directly approximated or in which infection has caused breakdown of a sutured wound. It also occurs in a wound in which primary wound closure would result in infection. __ healing may be allowed following the removal of necrotic tissue or after a wide debridement. The wound is left open and allowed to heal from the inner layer to the outside surface.

*Second intention healing* occurs when a wound fails to heal by primary union. It generally occurs in large wounds that cannot be directly approximated or in which infection has caused breakdown of a sutured wound. It also occurs in a wound in which primary wound closure would result in infection. Second intention healing may be allowed following the removal of necrotic tissue or after a wide debridement. The wound is left open and allowed to heal from the inner layer to the outside surface.

__ are used primarily for ophthalmic procedures because they will not penetrate into deeper tissues and separate the tissue layers during placement.

*Side cutting needles* are used primarily for ophthalmic procedures because they will not penetrate into deeper tissues and separate the tissue layers during placement.

__ suturing is used for long, straight incisions when the wound edges easily evert. Simple suture is placed at one end and tied off; suture is placed at equal distances along the wound; final throw is not pulled all the way through since the tie is done with the loop end of the suture. The surgical technologist keeps gentle tension on the suture behind the next throw to keep the suture material out of the way of the surgeon, as well as to prevent the previous throws from loosening.

*Simple continuous* suturing is used for long, straight incisions when the wound edges easily evert. Simple suture is placed at one end and tied off; suture is placed at equal distances along the wound; final throw is not pulled all the way through since the tie is done with the loop end of the suture. The surgical technologist keeps gentle tension on the suture behind the next throw to keep the suture material out of the way of the surgeon, as well as to prevent the previous throws from loosening.

__ is a sterile liquid that is applied topically. It is used on the surface of a wound that will not be under tension in place of adhesive skin closure tapes, staples, or suture. The adhesive is applied after the area has been cleaned and dried. The wound edges are approximated and the adhesive is applied in layers to seal the skin edges, creating a microbial barrier. Application of the adhesive is faster than suture insertion and may provide a better cosmetic result. The adhesive remains intact for 5 to 10 days and is sloughed off naturally, eliminating the need for removal.

*Skin adhesive* is a sterile liquid that is applied topically. It is used on the surface of a wound that will not be under tension in place of adhesive skin closure tapes, staples, or suture. The adhesive is applied after the area has been cleaned and dried. The wound edges are approximated and the adhesive is applied in layers to seal the skin edges, creating a microbial barrier. Application of the adhesive is faster than suture insertion and may provide a better cosmetic result. The adhesive remains intact for 5 to 10 days and is sloughed off naturally, eliminating the need for removal.

__ are adhesive-backed strips of nylon or polypropylene tapes used to reinforce a subcuticular skin closure or approximate wound edges of small incisions or superficial lacerations when sutures may not be necessary. They should be applied to dry skin or skin that has been prepared with tincture of benzoin so that they stick properly. __ are available in -1/8, -1/4, and -1/2in. widths.

*Skin closure tapes* are adhesive-backed strips of nylon or polypropylene tapes used to reinforce a subcuticular skin closure or approximate wound edges of small incisions or superficial lacerations when sutures may not be necessary. They should be applied to dry skin or skin that has been prepared with tincture of benzoin so that they stick properly. Skin closure tapes are available in -1/8, -1/4, and -1/2in. widths.

__ are used to approximate skin edges during skin closure (Figure 11-27). These disposable devices dispense a single staple with each activation and they are supplied in a variety of staple quantities and widths. For example, staplers loaded with 35 wide or regular-width staples are used to close most long incisions. Smaller staplers loaded with 5 to 10 staples are available to close small incisions.

*Skin staplers* are used to approximate skin edges during skin closure (Figure 11-27). These disposable devices dispense a single staple with each activation and they are supplied in a variety of staple quantities and widths. For example, staplers loaded with 35 wide or regular-width staples are used to close most long incisions. Smaller staplers loaded with 5 to 10 staples are available to close small incisions.

__ may be closed with interrupted or continuous monofilament, nonabsorbable sutures on a cutting needle, or with stainless steel staples (__). Polypropylene or nylon are the preferred suture materials; however, stainless steel staples result in less tissue reaction. The drawback to __ closure is that the wound scars more than with a subcuticular closure and sutures must eventually be removed. If subcuticular closure is performed, the __ will be approximated with __ closure tapes.

*Skin* may be closed with interrupted or continuous monofilament, nonabsorbable sutures on a cutting needle, or with stainless steel staples (skin stapler). Polypropylene or nylon are the preferred suture materials; however, stainless steel staples result in less tissue reaction. The drawback to skin closure is that the wound scars more than with a subcuticular closure and sutures must eventually be removed. If subcuticular closure is performed, the skin will be approximated with skin closure tapes.

__ assemblies are 3 to 4 in. long with a sharp, beveled stylet within the metal cannula. These needles are typically employed to introduce anesthetic agents into the epidural or subdural space or to obtain cerebral spinal fluid for diagnostic purposes.

*Spinal needle/cannula* assemblies are 3 to 4 in. long with a sharp, beveled stylet within the metal cannula. These needles are typically employed to introduce anesthetic agents into the epidural or subdural space or to obtain cerebral spinal fluid for diagnostic purposes.

__ are used in orthopedic surgery for fixing tendons and ligaments to bone. The device consists of the anchor, such as a screw made of metal or absorbable material, that is inserted into the bone and an eyelet through which the suture passes. The anchor inserts into the bone and this facilitates the suture attaching to the tendon and thus fixing the tendon to the bone.

*Suture anchors* are used in orthopedic surgery for fixing tendons and ligaments to bone. The device consists of the anchor, such as a screw made of metal or absorbable material, that is inserted into the bone and an eyelet through which the suture passes. The anchor inserts into the bone and this facilitates the suture attaching to the tendon and thus fixing the tendon to the bone.

__, whether intentional or accidental, leaves the patient vulnerable to infection and other complications. Meticulous application of sterile technique alone will not ensure that the patient will remain complication free.

*Tissue disruption*, whether intentional or accidental, leaves the patient vulnerable to infection and other complications. Meticulous application of sterile technique alone will not ensure that the patient will remain complication free.

__ are used to retract a structure that may not be easily retracted with a conventional retractor instrument. A nonabsorbable suture is placed into or around the structure and the suture ends are clamped with a hemostatic clamp. The structure is then pulled to the side of the operative site. Examples of __sutures are those placed into the sclera of the eye, the myocardium of the heart, or the tongue.

*Traction sutures* are used to retract a structure that may not be easily retracted with a conventional retractor instrument. A nonabsorbable suture is placed into or around the structure and the suture ends are clamped with a hemostatic clamp. The structure is then pulled to the side of the operative site. Examples of traction sutures are those placed into the sclera of the eye, the myocardium of the heart, or the tongue.

__ wounds include traumatic injuries, closed wounds, and open wounds. __ wounds are classified in several different ways, according to __. A single wound may fall into more than one category.

*Unintentional* wounds include traumatic injuries, closed wounds, and open wounds. Unintentional wounds are classified in several different ways, according to *severity*. A single wound may fall into more than one category.

The first consideration is the physical condition of the patient, which includes:

-Age: Pediatric and geriatric patients may have decreased vascularity or poor muscle tone. -Allergic response: Patients may have known or unknown allergies to different types of medications, metal, materials such as latex, or suture. Allergic reactions can delay or interrupt wound healing and could ultimately result in additional surgeries. -Nutritional status: Dietary deficiencies can alter the healing process. -Obesity: The weight and pressure of adipose tissue may make it difficult to achieve a secure wound closure and contribute to incisional hernia. Adipose tissue also has a poor blood supply contributing to slow healing. -Disease (chronic or acute): Metabolic disease, cardiovascular or respiratory insufficiency, malignancy, and infection all negatively impact wound healing. -Smoking: Smoking causes vasoconstriction, diminishes oxygenation, and causes coughing that can put stress on a healing wound. -Immunocompromised or immunosuppressed patients: The patient's immune system may be deficient due to congenital or acquired conditions.

The second consideration is external factors, which include:

-Drug therapy: Medications taken routinely have potential interactions with medications given during surgery. Depending on the medication, patients will be instructed to either continue the use of the medication up until the time of surgery or to discontinue. Certain medications may also interfere with wound healing after surgery. -Fluid and electrolyte balance: Fluids are needed for oxygen profusion, hydration to the wound, as the transport medium for nutrients, as a solvent for vitamins, minerals, glucose, amino acids, and to transport waste away from the cells. -Hematology: Patients' blood samples are tested for different types of blood conditions such as anemia, hemophilia, blood clots, and blood cancers. -Radiation exposure: Patients undergoing radiation treatment in large doses may experience a decrease in blood supply to the irradiated tissue.

Many factors influence wound healing: continued Edema: Evisceration:

-Edema: Condition of abnormally large fluid volume in tissues between the body's cells. Either too much fluid moves from the blood vessels into the tissues or not enough fluid moves from the tissues back into the blood vessels. This fluid imbalance can cause mild to severe swelling. -Evisceration: Protrusion of the viscera through the edges of a totally separated wound. Evisceration is an emergency situation that requires immediate surgical intervention to replace the viscera and close the wound.

Many factors influence wound healing: continued Exudate: Gangrene:

-Exudate: Fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation. -Gangrene: Decay or death of an organ or tissue caused by a lack of blood supply. It is a complication resulting from infectious or inflammatory processes. Gangrene may be caused by a variety of chronic diseases and post-traumatic, post-surgical, and spontaneous causes.

Many factors influence wound healing: continued Granuloma: Hemorrhage: Infection:

-Granuloma: Mass of inflamed granulation tissue, usually associated with ulcerated infections. -Hemorrhage: Hemorrhage may be concealed or evident and occurs most frequently in the first few postoperative hours. Hemorrhage can result in postoperative shock. Surgery is frequently required to achieve hemostasis. -Infection: Infection of a wound occurs when microbial contamination overrides the resistance of the host. It results in increased morbidity and mortality. In addition to antibiotic therapy, additional surgery may be required as part of the treatment regimen. Table 11-3 lists factors in preventing infection.

Many factors influence wound healing: -Hematoma -Dehiscence

-Hematoma: Localized swelling filled with blood resulting from a break in a blood vessel. -Dehiscence: Partial or total separation of a layer or layers of tissue after closure. Dehiscence frequently occurs between the fifth and tenth postoperative day and is seen most often in debilitated patients with friable (easily torn) tissue. However, dehiscence can also be caused by abdominal distention, too much tension on the wound, inappropriate type or strength of suture material, or improper suturing technique. The patient often reports a "popping" or tearing sensation associated with coughing, vomiting, or straining. Dehiscence can result in retrograde infection (infection that travels backwards or inwards into the abdominal cavity), peritonitis, or evisceration if an abdominal incision is involved. Surgery may be required to correct the defect, depending on the severity of the separation. Table 11-2 lists factors in preventing dehiscence.

Stapling offers the following advantages over suturing:

-Less tissue reaction: Stainless steel is the least reactive of all wound closure materials. -Accelerated wound healing: Tissues are not handled as much as they would be with suturing, increasing the odds that the wound will heal without incidence. The B shape of the staples allows nutrients to pass through the staple line to the tissue edges. -Less operating and anesthesia time: Stapling takes less time to perform than suturing, resulting in less blood loss during the procedure. -Efficiency: Staples create an airtight and leak-proof anastomosis or closure.

Examples of synthetic meshes include:

-Polypropylene mesh (Prolene® mesh): This is a relatively inert material that can be used in the presence of infection. It has excellent elasticity and high tensile strength. -Polyglactin 910 mesh (Vicryl® Mesh): This is an absorbable material that provides temporary support during healing. -Polytetrafluoroethylene (PTFE) mesh (Gore-Tex® soft tissue patch): This is a soft, flexible material that is not absorbable and should not be used in the presence of infection. -Stainless steel mesh: This material is rigid and hard to apply, resulting in discomfort for the patient. It is, however, the most inert of the mesh materials and can be used in the presence of infection or during second intention healing. -Polyester fiber mesh (Mersilene® mesh): The least inert of the synthetic meshes, it should never be used in the presence of infection because its multifilament fiber construction can harbor bacteria.

Sponges are used to apply pressure on bleeding areas or vessels and to absorb excess blood or body fluids. The various types of sponges include the following:

-Raytec, also called 4 × 4s (the size of the sponge) -Laparotomy sponges, also referred to as lap sponges or tape sponges due to the radiopaque strand or tape that hangs from the sponge -Tonsil sponges (round sponges) -Patties (cottonoids) are smaller compressed radiopaque sponges used for neurosurgical procedures -Kitners and peanuts, also referred to as dissecting sponges, which consist of small pieces of tightly rolled gauze

sub classifications under open wound

-Simple wound: The integrity of the skin is compromised. There is no loss or destruction of tissue and there is no foreign body in the wound. -Complicated wound: Tissue is lost or destroyed, or a foreign body remains in the wound. -Clean wound: Wound edges can be approximated and secured. A clean wound is expected to heal by first intention. -Contaminated wound: Contamination occurs when a dirty object damages the integrity of the skin. A contaminated wound can become infected within a short period of time. Debridement of infected and/or necrosed tissue may be necessary, followed by thorough irrigation of the wound to further clean and wash out the contaminants, a procedure commonly referred to as an irrigation and debridement (I and D). -Delayed full-thickness injury: The full extent of damage caused by industrial accidents including crash injuries and deep injection of substances into the tissues may not be apparent for several days after the initial injury.

Classifications of unintentional wounds

-Traumatic injury: Refers to physical injuries of sudden onset and severity that require immediate medical attention. Traumatic injuries are the result of a variety of blunt, penetrating, and burn injuries. -Closed wound: The skin remains intact, but underlying tissues suffer damage. -Open wound: The integrity of the skin is damaged.

The phases of the clotting process are as follows:

1. Platelets adhere to subendothelium of vessel walls. 2. Platelets release ADP. 3. Release of ADP causes further layers of platelets to adhere. 4. Platelet aggregate forms a thrombus. 5. Permanent thrombus forms after clotting factor reaction.

Suture is usually cut by the surgical technologist. The act of cutting suture may sound simple, but requires practice and developing a "feel" for the act of cutting. Suture is usually cut close to the knot unless directed by the surgeon to leave a longer "tail" than usual. The following serve as guides for cutting suture:

1. Using the dominant hand, the surgical technologist should place the index finger on the screw joint to stabilize the suture scissors (straight Mayo scissors). 2. The scissors should be slightly opened and blades angled; the tip of one blade is placed gently against the suture and slid downward to where the knot is felt and is then cut. The tips should be used to cut the suture. 3. Ideally, the surgical technologist should be able to visualize the suture strand and knot in order to avoid cutting other adjacent tissue. However, there may be times when the surgical technologist will need to slide the scissors into a wound in which visualization is not possible (surgeon and surgical assistant are busy and cannot move to allow visualization). The surgical technologist will need to get a feel for sliding the scissors downward, feeling the knot, and cutting the suture without cutting the knot.

A __ is used to occlude a single small structure, such as a blood vessel or a duct. A structure to be divided must have at least two individual clips placed (one or more proximally and one or more distally). The structure is then divided with a scissors or a scalpel. The stainless steel, titanium, tantalum, or absorbable clips are available in an automated disposable applier (Figure 11-31) or may be manually loaded onto a reusable device. A variation of the automated disposable applier is available for endoscopic procedures and is especially useful during cholecystectomy.

A *ligating clip* is used to occlude a single small structure, such as a blood vessel or a duct. A structure to be divided must have at least two individual clips placed (one or more proximally and one or more distally). The structure is then divided with a scissors or a scalpel. The stainless steel, titanium, tantalum, or absorbable clips are available in an automated disposable applier (Figure 11-31) or may be manually loaded onto a reusable device. A variation of the automated disposable applier is available for endoscopic procedures and is especially useful during cholecystectomy.

Chemical hemostasis The following is a list of pharmacological hemostatic agents

Absorbable gelatin (Gelfoam®) Absorbable collagen (Avitene®) Microfibrillar collagen Oxidized cellulose (Nu-Knit®; Surgi-Cel®) Silver nitrate Epinephrine Thrombin

A __ is useful for support of the primary suture line. It helps to ease tension on the primary suture line, thus reinforcing the wound closure and obliterating any dead spaces. Retention sutures are an example of a secondary suture line.

A *secondary suture line* is useful for support of the primary suture line. It helps to ease tension on the primary suture line, thus reinforcing the wound closure and obliterating any dead spaces. Retention sutures are an example of a secondary suture line.

dead space

A space that remains in the tissues as a result of failure of proper closure of a surgical wound

inert

A substance, such as the aiming beam of a laser, that is inactive and has no effect on tissue

PTFE

A synthetic coating used on certain types of nylon suture material to reduce the drag through tissue

A type of fibrin glue is __ or __ plasma. Plasma is collected from a patient (__ donor) or a single donor (__) and manufactured into a cryoprecipitate that contains clotting factor XIII to produce fibrinogen. The __ or __ fibrinogen must be warmed to right before use. Thrombin is reconstituted to 1000 units/mL. The solutions are drawn up separately in two syringes and applied simultaneously to the tissue.

A type of fibrin glue is *autologous or homologous plasma*. Plasma is collected from a patient (autologous donor) or a single donor (homologous) and manufactured into a cryoprecipitate that contains clotting factor XIII to produce fibrinogen. The autologous or homologous fibrinogen must be warmed to right before use. Thrombin is reconstituted to 1000 units/mL. The solutions are drawn up separately in two syringes and applied simultaneously to the tissue.

French-eyed needle

A type of needle in which the suture must be threaded by pulling the strand through a V-shaped area into the eye

Abdominal wounds are closed in layers. From inner to outer, these layers include the ...

Abdominal wounds are closed in layers. From inner to outer, these layers include the *peritoneum, fascia, muscle, subcutaneous, subcuticular, and skin layers*

adhesion

Abnormal attachment of two surfaces or structures that are normally separate

herniation

Abnormal protrusion of an organ or other body structure through an opening in a covering membrane or muscle

tissue reaction

Abnormal response of tissue to foreign substances such as suture material

Another method of classifying traumatic wounds is by the mechanism of injury. Some examples are:

Abrasion: Scrape Contusion: Bruise Laceration: Cut or tear Puncture: Penetration Thermal: Heat or cold (can be chemical)

Additionally, the circulator may __ sponges removed from the sterile field to provide an estimate of blood. The circulator may use a scale and predetermined sponge weight formula. Alternatively, health care facilities may have a bloody-sponge weight estimate that is used and multiplied by the number of sponges removed from the sterile field. The sponges must be weighed wet, as the formula is based on the dry and wet weights of the sponges. This is not an exact method, but it provides the surgeon and anesthesia care provider with a reliable estimate of blood loss.

Additionally, the circulator may *weigh sponges* removed from the sterile field to provide an estimate of blood. The circulator may use a scale and predetermined sponge weight formula. Alternatively, health care facilities may have a bloody-sponge weight estimate that is used and multiplied by the number of sponges removed from the sterile field. The sponges must be weighed wet, as the formula is based on the dry and wet weights of the sponges. This is not an exact method, but it provides the surgeon and anesthesia care provider with a reliable estimate of blood loss.

Adhesion:

Adhesion: An adhesion is an abnormal attachment of two surfaces or structures that are normally separate. Fibrous tissue can develop within the peritoneal cavity because of previous surgery, infection, improper tissue handling, or the presence of a foreign body (lint or glove powder granule). The fibrous tissue that develops can cause abnormal attachments of the abdominal viscera that may cause pain and/or bowel obstruction.

After the initial white cell thrombus formation, reaction between __ and __ from the connective tissue of the cells activates clotting factors that cause another set of reactions.

After the initial white cell thrombus formation, reaction between *plasma and fibrin* from the connective tissue of the cells activates clotting factors that cause another set of reactions.

After the suture packets have been opened onto the sterile field and counted, the surgical technologist can arrange the sutures in the order in which they will be used during the procedure. Ligature reels should be removed from their packets and placed onto the Mayo stand with the strand end extended slightly. Free-ties should be opened at the end of the packet and placed on the Mayo stand with the suture strands protruding for easy access. Longer free-ties can be removed from their packets completely and placed into a rolled or folded towel. If hemorrhage is anticipated, stick ties should be loaded onto needle holders in advance of need and placed within reach and ties-on-passes should also be loaded and ready.

After the vasoconstriction of the vessel, platelets begin to adhere to the sides of the injured vessel walls, clumping together to form a plug at the cut end of the injured vessel. Once the platelets adhere to the vessel walls, they begin to release their contents, including __, __, and, most important, __.

Also to be taken into consideration in blood matching is the __, which is an antigenic substance found in the erythrocytes in most people. Individuals with the factor are termed Rh positive, whereas individuals lacking the factor are termed Rh negative. If blood given to an Rh-negative individual is Rh positive, __ occurs, leading to anemia. Due to these factors, blood is carefully typed and cross-matched prior to being administered.

Also to be taken into consideration in blood matching is the *Rh (Rhesus factor)*, which is an antigenic substance found in the erythrocytes in most people. Individuals with the factor are termed Rh positive, whereas individuals lacking the factor are termed Rh negative. If blood given to an Rh-negative individual is Rh positive, *hemolysis* occurs, leading to anemia. Due to these factors, blood is carefully typed and cross-matched prior to being administered.

tensile strength

Amount of pull or tension that a suture strand will withstand before breaking; expressed in pounds

An __ is an intentional cut through intact tissue for the purpose of exposing underlying structures. Once an __ is made the surgeon may perform an __. An __ is the removal of tissue—such as a splenectomy (removal of the spleen) or hemicolectomy (removal of a portion of the colon).

An *incision* is an intentional cut through intact tissue for the purpose of exposing underlying structures. Once an incision is made the surgeon may perform an excision. An *excision* is the removal of tissue—such as a splenectomy (removal of the spleen) or hemicolectomy (removal of a portion of the colon).

An inflammatory reaction occurs when injured tissues release __ from the damaged cells. The __ causes the small blood vessels in the area to dilate, increasing the blood flow to the area, resulting in heat, redness, and swelling.

An inflammatory reaction occurs when injured tissues release *histamine* from the damaged cells. The *histamine* causes the small blood vessels in the area to dilate, increasing the blood flow to the area, resulting in heat, redness, and swelling.

Another type of fibrin glue is __ plasma. It is manufactured from multiple donors, but the fibrinogen must undergo cleansing and destruction of viruses to prevent the transmission of bloodborne pathogens to the patient. It is used in Europe but has not been approved by the U.S. Food and Drug Administration (FDA) for use in the United States.

Another type of fibrin glue is *pooled-donor plasma*. It is manufactured from multiple donors, but the fibrinogen must undergo cleansing and destruction of viruses to prevent the transmission of bloodborne pathogens to the patient. It is used in Europe but has not been approved by the U.S. Food and Drug Administration (FDA) for use in the United States.

As soon as a vessel is injured, a period of __ begins, in which the muscular walls of the vessel constrict to help slow the flow of blood. This constriction of the vessel only lasts for a short time and slows but does not stop the bleeding.

As soon as a vessel is injured, a period of *vasoconstriction* begins, in which the muscular walls of the vessel constrict to help slow the flow of blood. This constriction of the vessel only lasts for a short time and slows but does not stop the bleeding.

Because surgery is invasive, it is almost a given that some blood and fluid loss is expected. In most surgical procedures, blood loss is negligible; however, ____ must be anticipated.

Because surgery is invasive, it is almost a given that some blood and fluid loss is expected. In most surgical procedures, blood loss is negligible; however, *major blood loss* must be anticipated.

Biological materials for tissue repair include fascia lata from the muscle of cattle or from the patient's own thigh. One of the more recently developed biomaterials is __ (Surgisis™). __ is harvested from porcine small intestine submucosa and the manufacturing process leaves the collagen fibrous matrix in place, so that it is porous to allow for new tissue in-growth. The mesh facilitates complete tissue remodeling, allowing new tissue to grow across and incorporate into the mesh. The mesh is replaced by the body's own tissue, creating a permanent repair without the long-term presence of a foreign body. During the repair and tissue growth process the mesh maintains its tensile strength. The mesh is used for a variety of general soft tissue reconstruction procedures.

Biological materials for tissue repair include fascia lata from the muscle of cattle or from the patient's own thigh. One of the more recently developed biomaterials is *in-growth mesh (Surgisis™)*. *In-growth mesh* is harvested from porcine small intestine submucosa and the manufacturing process leaves the collagen fibrous matrix in place, so that it is porous to allow for new tissue in-growth. The mesh facilitates complete tissue remodeling, allowing new tissue to grow across and incorporate into the mesh. The mesh is replaced by the body's own tissue, creating a permanent repair without the long-term presence of a foreign body. During the repair and tissue growth process the mesh maintains its tensile strength. The mesh is used for a variety of general soft tissue reconstruction procedures.

A variety of stapling devices are available to perform the following applications:

Biopsy Ligation Resection Skin closure Anastomosis Facial closure Division of tissue Closure of organs

Biopsy needles attached to syringes may be used to __ fluid from a cyst or abscess. Very small biopsy needles can obtain cells from breast lesions, lymph nodes, or other shallow tissues.

Biopsy needles attached to syringes may be used to *aspirate fluid* from a cyst or abscess. Very small biopsy needles can obtain cells from breast lesions, lymph nodes, or other shallow tissues.

Blood loss is charted by the __ and reported to the surgeon, particularly in instances of extreme blood loss. __ are used between the suction tubing and vacuum source to collect and monitor the amount of blood and body fluids suctioned from the field.

Blood loss is charted by the *circulator* and reported to the surgeon, particularly in instances of extreme blood loss. *Calibrated suction devices (canisters)* are used between the suction tubing and vacuum source to collect and monitor the amount of blood and body fluids suctioned from the field.

Blood products are usually obtained from the blood bank by a responsible individual, signed for, and brought to the OR. If the products are not to be used immediately, they should be stored in a refrigerator at a temperature of to ( to ).

Blood that has been exposed to __ hemostatic agents and certain __ cannot be used with these devices, as blood may coagulate the system. If the procedure involves blood exposed to gastric or enteric contents or amniotic fluid, it may not be salvaged, and blood may not be used when the patient has a known local or systemic infection. Additionally, if cancer cells are suspected or known to be present, the blood will not be used as the cell saver cannot wash or remove cancer cells.

Blood that has been exposed to *collagen hemostatic agents and certain antibiotics* cannot be used with these devices, as blood may coagulate the system. If the procedure involves blood exposed to gastric or enteric contents or amniotic fluid, it may not be salvaged, and blood may not be used when the patient has a known local or systemic infection. Additionally, if cancer cells are suspected or known to be present, the blood will not be used as the cell saver cannot wash or remove cancer cells.

capillarity

Capability of multifilament suture to harbor bacteria and retain tissue fluid that can travel down the length of the suture strand

Class I: Clean

Class I: Clean Primary closure No inflammation is encountered Closed wound drainage device if necessary Incision made under ideal surgical conditions No break in sterile technique during procedure No entry to aerodigestive or genitourinary tract

Class II: Clean Contaminated

Class II: Clean Contaminated Primary closure Open/mechanical drainage Minor break in sterile technique occurred Controlled entry to aerodigestive (includes biliary tract) or genitourinary tract

Class III: Contaminated

Class III: Contaminated Acute inflammation present Major break in sterile technique occurred Open traumatic wound (less than 4 hours old) with retained necrotic tissue Entry to aerodigestive (includes biliary tract) or genitourinary tract with spillage

Class IV: Dirty/Infected

Class IV: Dirty/Infected Perforated viscus Microbial contamination prior to procedure Open traumatic wound (more than 4 hours old) Surgical wound classification is subject to change during the procedure, according to the situation. The final wound classification is assigned at the end of the procedure and is included in the intraoperative documentation.

Surgical wounds are classified into four categories according to the degree of microbial contamination and are referred to in the patient record by Roman numeral (Table 11-4). The Centers for Disease Control and Prevention (CDC) wound classification categories are as follows:

Clean (Class I) Uninfected, uninflamed operative wound in which the respiratory, alimentary, genital, or uninfected urinary tracts are not entered Coronary artery bypass graft, total hip, breast biopsy, craniotomy Clean contaminated (Class II) Uninfected operative wound; respiratory, alimentary, genital, or urinary tract is entered under controlled circumstances without unusual contamination Appendectomy, cholecystectomy, tonsillectomy Contaminated (Class III) Acute, nonpurulent, inflamed operative wound or open, fresh wound, or any surgical procedure with major breaks in sterile technique or gross spillage from the gastrointestinal (GI) tract Open fracture, colon resection with gross spillage of GI contents, penetrating trauma Dirty (Class IV) Clinically infected operative wound or perforated viscera or old, traumatic wounds with retained necrotic tissue Resection of ruptured appendix

keloid

Complication of wound healing resulting in hypertrophic scar formation

The disadvantages of stapling use include:

Cost: Staples are more expensive. Precision: Staples must be precisely placed. Errors in technique for linear or circular stapling are much more difficult to correct than suturing errors.

Fistula:

Fistula: A fistula is an abnormal tract between two epithelium-lined surfaces that is open at both ends. It occurs most often after bladder, bowel, and pelvic procedures. Abnormal drainage is a prevalent sign. Surgery is required for correction.

Cotton __ was once used to ligate the severed ends of the umbilical cord after childbirth. It is used in the OR as a retraction and isolation device for bowel, nerves, vessels, or ducts. __ is usually packaged with two strands in a pink packet and is best used moistened with saline and loaded onto a hemostat.

Cotton *umbilical tape* was once used to ligate the severed ends of the umbilical cord after childbirth. It is used in the OR as a retraction and isolation device for bowel, nerves, vessels, or ducts. Umbilical tape is usually packaged with two strands in a pink packet and is best used moistened with saline and loaded onto a hemostat.

laceration

Cut or tear

Dead space:

Dead space: Separation of wound layers that have not been closely approximated or air that has become trapped between tissue layers (Figure 11-2). The space may allow for serum or blood to collect and provide a medium for microbial growth, resulting in a wound infection. Dead space is eliminated by use of proper suturing techniques, wound drains, and/or pressure dressings.

The nature of the disease process is also important to consider in suture choice because disease affects the patient's metabolic processes, which, in turn, modify the condition of the tissues. Wound healing and suture selection are affected by these factors. Some individual disease processes affecting suture choice that the surgical technologist should be aware of are:

Diabetes mellitus. Systemic infection. Localized infection. Immune system diseases. Pituitary gland dysfunction.

After loading the suture onto the needle holder, depending on the type of suture, the surgical technologist should straighten the suture with a gentle pull. Other handling tips include:

Do not attempt to pull or stretch plain or chromic gut. Excessive handling with rubber gloves can weaken and fray these sutures. Nylon sutures should be drawn between gloved fingers to remove memory. Care should be taken when straightening controlled-release (pop-off) suture so as not to remove the needle and waste the suture. Do not place any tension on the needle suture attachment (swage). Avoid crushing or crimping sutures with instruments. Keep surgical gut away from heat. Never soak plain or chromic gut in saline or water, which will cause it to deteriorate. Do not wet rapidly absorbing sutures. Keep silk dry. Do not bend stainless steel wire.

Prevention of wound infection: Microbial contamination of the wound could lead to an infection, causing an increase in morbidity or mortality.

Dressings Wound drains Tissue perfusion Bowel technique Wound irrigation Antibiotic therapy Standard precautions Control endogenous infection Reduce sources of contamination

serosanguinous

Fluid that contains both blood and serum

exudate

Fluids or other substances that are discharged from cells or blood vessels; examples are perspiration and pus

Dressings are applied using sterile technique in the OR as the final step of the procedure. The purpose of the dressing is to provide an optimal __ to promote wound healing. If a dressing must be changed within 48 hours of initial application, or if the wound is open, sterile technique and Standard Precautions must be employed. Dressings are removed or changed if they become wet or soiled or if the patient shows signs of infection. They are generally removed after 48 hours for closed nonchronic wounds. Stomas or areas affected by incontinence may require the use of special products to provide safe drainage, such as a stoma bag.

Dressings are applied using sterile technique in the OR as the final step of the procedure. The purpose of the dressing is to provide an *optimal physiological environment* to promote wound healing. If a dressing must be changed within 48 hours of initial application, or if the wound is open, sterile technique and Standard Precautions must be employed. Dressings are removed or changed if they become wet or soiled or if the patient shows signs of infection. They are generally removed after 48 hours for closed nonchronic wounds. Stomas or areas affected by incontinence may require the use of special products to provide safe drainage, such as a stoma bag.

friable

Easily torn or crumbled

Factors that must be considered when choosing suture material are the...

Factors that must be considered when choosing suture material are the biological characteristics of the suture material, healing characteristics of tissue, type of procedure, the condition of the patient's tissue, the nature of the disease process, and the surgeon's preference.

Surgical site infections (3)

Incisional infections Nosocomial infections Deep wound infections

For a contaminated wound the skin and subcutaneous tissues are generally left open and packed loosely with fine mesh gauze, such as __. __ is removed after 4 to 5 days and, if no infection is present, the wound may be closed at that time. If the wound is still infected, it is allowed to heal by second intention. For this type of healing the wound should be repacked twice daily with wet-to-dry dressings

For a contaminated wound the skin and subcutaneous tissues are generally left open and packed loosely with fine mesh gauze, such as *Iodoform. Packing* is removed after 4 to 5 days and, if no infection is present, the wound may be closed at that time. If the wound is still infected, it is allowed to heal by second intention. For this type of healing the wound should be repacked twice daily with wet-to-dry dressings

For routine procedures, such as __, sutures can be loaded onto needle holders and arranged in the order in which they will be used. Otherwise, the suture packets are left unopened on the sterile field until they are needed, with the exception of packets that contain multiple needles. In order to avoid having to count the needles intraoperatively, the surgical technologist will often open the packet and count the needles during the preoperative count with the circulator.

For routine procedures, such as *coronary bypass*, sutures can be loaded onto needle holders and arranged in the order in which they will be used. Otherwise, the suture packets are left unopened on the sterile field until they are needed, with the exception of packets that contain multiple needles. In order to avoid having to count the needles intraoperatively, the surgical technologist will often open the packet and count the needles during the preoperative count with the circulator.

Fresh-frozen plasma (FFP)

Fresh-frozen plasma (FFP) The fluid component of blood containing clotting factors removed from 1 unit of whole blood Restores clotting factors; usually 1 unit of FFP is given for every 4 units of PRBCs

homologous

From the same species

wound disruption

General term for the various types of abnormal separation of a surgical wound such as dehiscence and evisceration

Rh (Rhesus) factor

Genetically determined blood group antigen that is present on the surface of erythrocytes of some individuals; if the antigen is present the individual is Rh1 (positive) and if absent Rh- (negative)

second intention

Healing that occurs when a wound fails to heal by primary union, or the wound is left open and allowed to heal from the inside to the outside by filling with granulation tissue

third intention

Healing that occurs when two granulated surfaces are approximated; also referred to as delayed primary closure

Hemostasis is stopping the loss of blood (hemorrhage). This may be accomplished by ___ or __, or surgically by ___, ___, or the application of ___.

Hemostasis is stopping the loss of blood (hemorrhage). This may be accomplished by *clot formation or vessel spasm*, or surgically by *mechanical pressure, ligation*, or the application of *hemostatic agents*.

Herniation:

Herniation: Herniation is a result of wound dehiscence and occurs most often in lower abdominal incisions. A hernia is usually discovered two to three months postoperatively and could result in bowel incarceration. Surgery may be required to correct this condition.

However, an important factor that determines suture choice is __. __ is measured by the force in pounds that the suture strand can withstand before it breaks. The tensile strength of tissue is what determines the size and tensile strength of the suture the surgeon chooses. The rule of thumb is the suture should be as strong as the tissue on which it is being used; in other words, the suture tensile strength should equal the tissue tensile strength.

However, an important factor that determines suture choice is *knot tensile strength*. Knot tensile strength is measured by the force in pounds that the suture strand can withstand before it breaks. The tensile strength of tissue is what determines the size and tensile strength of the suture the surgeon chooses. The rule of thumb is the suture should be as strong as the tissue on which it is being used; in other words, the suture tensile strength should equal the tissue tensile strength.

Ideal wound healing involves __, __, __, and __.

Ideal wound healing involves *restoration of continuity, strength, function, and appearance to the tissue*.

If a hemolytic transfusion reaction is suspected, the transfusion should be immediately stopped and a blood sample sent to the blood bank to rule out the mismatch. Appropriate drug therapies, usually including __, should be begun as quickly as possible. __ is monitored closely in these patients, as hypovolemia may hinder kidney function. In some cases, the patient will need to undergo dialysis, which will aid in the systemic removal of the mismatched blood.

If a hemolytic transfusion reaction is suspected, the transfusion should be immediately stopped and a blood sample sent to the blood bank to rule out the mismatch. Appropriate drug therapies, usually including *steroid therapy*, should be begun as quickly as possible. *Urine output* is monitored closely in these patients, as hypovolemia may hinder kidney function. In some cases, the patient will need to undergo dialysis, which will aid in the systemic removal of the mismatched blood.

If blood is not properly matched, including Rh factor, prior to transfusion, a __ reaction may develop. This may result from Rh incompatibility from mismatched blood transfusions. Severe hemolytic transfusions can be fatal and must be treated immediately.

If blood is not properly matched, including Rh factor, prior to transfusion, a *hemolytic transfusion* reaction may develop. This may result from Rh incompatibility from mismatched blood transfusions. Severe hemolytic transfusions can be fatal and must be treated immediately.

Instrument Tie (Tie-on-a-Pass) Deep bleeding vessels that have been occluded with a hemostat clamp may be inaccessible for a free-hand ligature. Therefore, a suture is loaded onto an __, usually a Crile hemostat, Schnidt tonsil clamp, Mixter clamp, Adson clamp, or Sarot clamp, for easier placement around the tip of the occluding hemostatic clamp.

Instrument Tie (Tie-on-a-Pass) Deep bleeding vessels that have been occluded with a hemostat clamp may be inaccessible for a free-hand ligature. Therefore, a suture is loaded onto an *instrument*, usually a Crile hemostat, Schnidt tonsil clamp, Mixter clamp, Adson clamp, or Sarot clamp, for easier placement around the tip of the occluding hemostatic clamp.

Intentional wounds include __, __, and surgical site __ or __. Surgical site incisions can be incisional or excisional.

Intentional wounds include *chemical wounds, occlusion banding, and surgical site incision or excision*. Surgical site incisions can be incisional or excisional.

evisceration

Interruption of a closed wound or traumatic injury that exposes the viscera

Intraoperative hemostasis may also be achieved __. Some patients in need of surgery have congenital or acquired clotting disorders, making the maintenance of hemostasis more difficult.

Intraoperative hemostasis may also be achieved *thermally*. Some patients in need of surgery have congenital or acquired clotting disorders, making the maintenance of hemostasis more difficult.

Ischemia:

Ischemia: Decreased supply of oxygenated blood to a body part. Signs of acute limb ischemia (which can be summarized as the "six Ps") include pain, pallor, pulseless, paresthesia, paralysis, and poikilothermia (inability to regulate core body temperature). Some causes of ischemia are arterial embolism, atherosclerosis, thrombosis, and vasoconstriction.

Keloid scar:

Keloid scar: Keloid formation is a hypertrophic scar formation and occurs most frequently in dark-skinned individuals. Corticoid injections and use of pressure dressings can help reduce the size of the scar, but plastic surgery may be required for correction.

ischemia

Lack of oxygenated blood supply to an area or organ of the body

Large percutaneous __ needles are used to obtain tissue samples from within the body for biopsy. This type of biopsy is sometimes guided with the aid of CT scan or fluoroscopy. Examples of this type of needle include the Dorsey cannulated needle for biopsy of cerebral tissue through a burr hole, the Chiba biopsy needle for biopsy of lung tissue through the chest wall, the Franklin-Silverman cannulated biopsy needle with a "trap door" tip for biopsy of the liver and other internal organs, and the Tru-cut biopsy needle. The Tru-cut biopsy needle has a sharp cutting cannula to facilitate insertion into the tissue and cutting the tissue; a removable stylet allows for multiple biopsies to be taken. Some brands of the Tru-cut allow a luer slip syringe to be placed on the end for aspiration when the stylet has been removed. The Tru-cut needle is usually either 14 or 18 gauge and ranges in length from 3 to 6 in. Bone marrow trocars introduced through cortical bone may be used to obtain bone marrow.

Large percutaneous *biopsy* needles are used to obtain tissue samples from within the body for biopsy. This type of biopsy is sometimes guided with the aid of CT scan or fluoroscopy. Examples of this type of needle include the Dorsey cannulated needle for biopsy of cerebral tissue through a burr hole, the Chiba biopsy needle for biopsy of lung tissue through the chest wall, the Franklin-Silverman cannulated biopsy needle with a "trap door" tip for biopsy of the liver and other internal organs, and the Tru-cut biopsy needle. The Tru-cut biopsy needle has a sharp cutting cannula to facilitate insertion into the tissue and cutting the tissue; a removable stylet allows for multiple biopsies to be taken. Some brands of the Tru-cut allow a luer slip syringe to be placed on the end for aspiration when the stylet has been removed. The Tru-cut needle is usually either 14 or 18 gauge and ranges in length from 3 to 6 in. Bone marrow trocars introduced through cortical bone may be used to obtain bone marrow.

Large vessels are typically occluded with __, or __, to prevent suture slippage that can lead to uncontrolled hemorrhage. Stick ties are sutures with a swaged atraumatic needle loaded onto a needle holder for placement through the center of a large vessel after a hemostat clamp has been applied. The ends of the suture are brought around the clamp so that the vessel is doubly ligated (Figure 11-4). For superficial bleeders, 18-in. stick ties are used and 27-in. stick ties are used for deeper vessels. Sizes 2-0 and 3-0 are the most commonly used stick-tie sizes and silk is the preferred suture material. In theory, however, any suture material can be used as a stick-tie ligature; it depends on the tissue to be sutured.

Large vessels are typically occluded with *suture ligatures, or stick ties*, to prevent suture slippage that can lead to uncontrolled hemorrhage. Stick ties are sutures with a swaged atraumatic needle loaded onto a needle holder for placement through the center of a large vessel after a hemostat clamp has been applied. The ends of the suture are brought around the clamp so that the vessel is doubly ligated (Figure 11-4). For superficial bleeders, 18-in. stick ties are used and 27-in. stick ties are used for deeper vessels. Sizes 2-0 and 3-0 are the most commonly used stick-tie sizes and silk is the preferred suture material. In theory, however, any suture material can be used as a stick-tie ligature; it depends on the tissue to be sutured.

Ligating material may be used as either single-strand ties or as continuous ties from a reel or other device (see Figure 11-3). Precut ties that are removed as single strands from the package or were cut to length by the surgical technologist and placed into the opened hand of the surgeon for use as ligatures are referred to as __. This type of tie is not on a reel and is not loaded onto an instrument. The ligatures may be placed around a hemostatic clamp that has been affixed to a bleeding vessel. After the first knot is thrown, the surgical assistant removes the clamp and the ligature is secured with a surgeon's knot. The assistant then cuts the excess suture. Monofilament sutures, because the knots can slide, are typically cut leaving 1/4-in. ends. Multifilament sutures can be cut closer to the knot (1/8-in.) because they do not slide as readily as monofilament sutures.

Ligating material may be used as either single-strand ties or as continuous ties from a reel or other device (see Figure 11-3). Precut ties that are removed as single strands from the package or were cut to length by the surgical technologist and placed into the opened hand of the surgeon for use as ligatures are referred to as *free-ties*. This type of tie is not on a reel and is not loaded onto an instrument. The ligatures may be placed around a hemostatic clamp that has been affixed to a bleeding vessel. After the first knot is thrown, the surgical assistant removes the clamp and the ligature is secured with a surgeon's knot. The assistant then cuts the excess suture. Monofilament sutures, because the knots can slide, are typically cut leaving 1/4-in. ends. Multifilament sutures can be cut closer to the knot (1/8-in.) because they do not slide as readily as monofilament sutures.

Ligature reels are __ and are included in the count in many institutions because they can easily be lost within a wound. The most commonly used sizes are 2-0, 3-0, and 4-0. The size of the material is indicated by the number of holes visible on the side of the reel. The surgical technologist should prepare the reel by unhooking the end of the suture strand and pulling it 2 to 3 in. away from the reel so that the surgeon can grasp the suture without struggling to find the end.

Ligature reels are *radiopaque* and are included in the count in many institutions because they can easily be lost within a wound. The most commonly used sizes are 2-0, 3-0, and 4-0. The size of the material is indicated by the number of holes visible on the side of the reel. The surgical technologist should prepare the reel by unhooking the end of the suture strand and pulling it 2 to 3 in. away from the reel so that the surgeon can grasp the suture without struggling to find the end.

Ligatures, also referred to as __, are used to occlude vessels for hemorrhage control or for organ or extremity removal. For example, the occlusion of the femoral artery is necessary to prevent hemorrhage when amputating the leg. Typically, vessels that are not coagulated or occluded with stainless steel clips are ligated with suture. Ties are available as full-length or precut suture strands in a package, or wound onto radiopaque reels for superficial bleeders.

Ligatures, also referred to as *ties*, are used to occlude vessels for hemorrhage control or for organ or extremity removal. For example, the occlusion of the femoral artery is necessary to prevent hemorrhage when amputating the leg. Typically, vessels that are not coagulated or occluded with stainless steel clips are ligated with suture. Ties are available as full-length or precut suture strands in a package, or wound onto radiopaque reels for superficial bleeders.

Like muscle, __ tissue does not tolerate sutures well. Many surgeons prefer to place a few interrupted sutures into this layer to prevent dead space, especially for obese patients (Figure 11-18). Plain gut is often the preferred suture material for __ closure.

Like muscle, *subcutaneous tissue* does not tolerate sutures well. Many surgeons prefer to place a few interrupted sutures into this layer to prevent dead space, especially for obese patients (Figure 11-18). Plain gut is often the preferred suture material for subcutaneous closure.

hematoma

Localized collection of extravasated blood that is often clotted

Suture dispenser boxes contain one to three dozen suture packets and provide clear product identification through color coding, bold graphics, and descriptive symbols. The most important information that the surgical technologist should learn to look for on the box is suture size and material and the type and size of needle. Other important information displayed on the suture box includes:

Lot number. Surgical application. Product code number. Needle point geometry. Suture length and color. Expiration date, if necessary. Shape and quantity of needles (shown in silhouette). Metric diameter equivalent of suture size and length.

primary suture line

Main suture that approximates the wound edges for first intention healing to occur

synthetic

Material that is man-made such as synthetic sutures

More commonly seen in the operating room (OR) are bleeding disorders caused by an outside source, called __. Among these are liver disease, anticoagulant therapy with heparin or warfarin sodium, and aplastic anemia. Drug-therapy-induced platelet dysfunctions also affect hemostasis in the OR. Patients may be requested not to take aspirin for one week prior to surgery because of its anticoagulant properties.

More commonly seen in the operating room (OR) are bleeding disorders caused by an outside source, called *acquired bleeding disorders*. Among these are liver disease, anticoagulant therapy with heparin or warfarin sodium, and aplastic anemia. Drug-therapy-induced platelet dysfunctions also affect hemostasis in the OR. Patients may be requested not to take aspirin for one week prior to surgery because of its anticoagulant properties.

Multifilament sutures exhibit a characteristic called __, which is the capability to harbor bacteria and retain tissue fluids that can be communicated along the length of the strand. For this reason, multifilament sutures should not be used in the presence of infection. Multifilament sutures handle well and hold knots securely. Their multistrand configuration affords them greater tensile strength, pliability, and flexibility. Many brands are coated for enhanced handling capability and easier passage through tissues.

Multifilament sutures exhibit a characteristic called *capillarity*, which is the capability to harbor bacteria and retain tissue fluids that can be communicated along the length of the strand. For this reason, multifilament sutures should not be used in the presence of infection. Multifilament sutures handle well and hold knots securely. Their multistrand configuration affords them greater tensile strength, pliability, and flexibility. Many brands are coated for enhanced handling capability and easier passage through tissues.

gangrene

Necrosis of tissue usually due to ischemia and subsequent bacterial infection

Needle points may be __, __, or __, and the needle itself straight or curved. __ needles are used for tough tissue that is difficult to penetrate. The sharp edges of this type of point actually cut the tissue as they penetrate it. __ needles are typically used for the sclera of the eye, tendons, or skin.

Needle points may be *cutting, tapered, or blunt*, and the needle itself straight or curved. *Cutting needles* are used for tough tissue that is difficult to penetrate. The sharp edges of this type of point actually cut the tissue as they penetrate it. Cutting needles are typically used for the sclera of the eye, tendons, or skin.

Needles that are manufactured with suture strands inserted into one end are referred to as __ or __ needles. These needles are continuous with the suture strand, and the hole created in the tissue by the needle should be completely filled by the suture strand when suturing. __ needles may have a single-arm attachment or a double-arm attachment. The __ is a single needle swaged to the suture strand. These may by used for interrupted or continuous suturing.

Needles that are manufactured with suture strands inserted into one end are referred to as *eyeless or swaged needles*. These needles are continuous with the suture strand, and the hole created in the tissue by the needle should be completely filled by the suture strand when suturing. *Eyeless needles* may have a single-arm attachment or a double-arm attachment. The *single-arm attachment* is a single needle swaged to the suture strand. These may by used for interrupted or continuous suturing.

Over time, fibrin strands form a __ through the clot to form a stronger, more solid plug that can withstand the pressure of blood within the vessel.

Over time, fibrin strands form a *matrix* through the clot to form a stronger, more solid plug that can withstand the pressure of blood within the vessel.

Packed red blood cells (PRBCs)

Packed red blood cells (PRBCs) Red blood cell (RBCs) from 1 unit of whole blood after most of plasma is removed To restore oxygen-carrying capacity

The classic signs of inflammation are:

Pain. Heat. Redness. Swelling. Loss of function.

dehiscence

Partial or total separation of a layer or layers of tissue after closure of the wound

anastomosis

Pathological, surgical, or traumatic formation of an opening between two normally separate organs or spaces

immunosuppressed patient

Patient whose immune system has decreased due to disease, or intentionally decreased with immunosuppressive drugs for organ transplant patients to prevent organ rejection

Platelets

Platelets Platelets removed from 1 unit of whole blood Enhances blood's clotting ability when platelet count is low—less commonly used

Synthetic materials can be used as a bridge for tissues that cannot be brought together without placing a great deal of tension on the tissues. They may also be used as a reinforcement for fascia defects. Surgeons often make use of meshes to strengthen the damaged fascia during hernia repair. Advantages of synthetic meshes include:

Pliable (except for stainless steel mesh). Easy to cut to create the correct size to be implanted. Easy to suture into place in open or endoscopic procedures. Porous: Pores in mesh allow fibrous tissue to grow through the mesh, strengthening the tissues.

Prior to administration, blood products must be carefully identified as to the proper __ and __. __ individuals should perform this identification; individuals who can perform the identification are the surgical technologist, registered nurse, surgeon, and anesthesia care provider. One individual reads aloud while the other checks and verifies the information. The information for blood group, Rh type, and unit number must match the tag on the blood bag, the patient's armband, and the patient's chart, and these should be checked by the two-individual verbal method listed above. The __ order should also be double-checked, as should the expiration date on the blood bag. Finally, the product itself should be inspected for __. If clots are present or any of the information does not match correctly, the blood must not be administered and is returned to the blood bank. In addition, the patient's __ should be checked for final verification of identification.

Prior to administration, blood products must be carefully identified as to the *proper product and patient*. Two individuals should perform this identification; individuals who can perform the identification are the surgical technologist, registered nurse, surgeon, and anesthesia care provider. One individual reads aloud while the other checks and verifies the information. The information for blood group, Rh type, and unit number must match the tag on the blood bag, the patient's armband, and the patient's chart, and these should be checked by the two-individual verbal method listed above. The *physician's order* should also be double-checked, as should the expiration date on the blood bag. Finally, the product itself should be inspected for *clots*. If clots are present or any of the information does not match correctly, the blood must not be administered and is returned to the blood bank. In addition, the patient's *armband* should be checked for final verification of identification.

collagen

Protein that consists of bundles of reticular fibers that form the white, inelastic fibers of fascia, ligaments, and tendons

Prothrombin reacts with __ to form thrombin. Thrombin then reacts with __ and forms fibrin, which has an ability to stabilize blood clots. If any of these factors are deficient, bleeding may continue.

Prothrombin reacts with *thromboplastin* to form thrombin. Thrombin then reacts with *fibrinogen* and forms fibrin, which has an ability to stabilize blood clots. If any of these factors are deficient, bleeding may continue.

debridement

Removal of devitalized tissue and contaminants

cicatrix

Scar

granulation

Second intention wound healing in which the wound is left open to heal and the space is filled in from the bottom upward with granulation tissue

Seroma:

Seroma: Mass or swelling caused by the localized accumulation of serum within a tissue or organ that can sometimes develop after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid. Larger seromas are more likely to undergo secondary infection.

Silicone __ have, for the most part, replaced umbilical tape as isolation/retraction devices for vessels, nerves, or ducts. The elasticity of the __ makes them ideal for retraction of delicate structures or for temporary occlusion of a vessel. __ are colored for easy identification of different adjacent structures. Typically, white and yellow loops are for nerves or ducts, red loops are for arteries, and blue loops are for veins. They are packaged in pairs.

Silicone *vessel loops* have, for the most part, replaced umbilical tape as isolation/retraction devices for vessels, nerves, or ducts. The elasticity of the vessel loops makes them ideal for retraction of delicate structures or for temporary occlusion of a vessel. Vessel loops are colored for easy identification of different adjacent structures. Typically, white and yellow loops are for nerves or ducts, red loops are for arteries, and blue loops are for veins. They are packaged in pairs.

Sinus tract formation:

Sinus tract formation: A sinus is an abnormal tract between two epithelium-lined surfaces that is open at one end only. Its occurrence is highest in bladder, bowel, and pelvic procedures. Abnormal drainage is a common sign. Surgery is often required to correct this condition.

granuloma

Small inflamed area in tissue usually the result of an infection and often occur in the lungs

The __ stapler ejects two ligating clips side by side and then divides the tissue between the clips with a single activation. It is especially useful during gastrointestinal procedures for division of the greater omentum.

The *ligating dividing stapler* ejects two ligating clips side by side and then divides the tissue between the clips with a single activation. It is especially useful during gastrointestinal procedures for division of the greater omentum.

Some patients have congenital bleeding disorders that will affect bleeding during the surgical procedure. __ is the most common of these and manifests itself as a clotting deficiency. Preoperative testing is useful in determining whether these conditions exist.

Some patients have congenital bleeding disorders that will affect bleeding during the surgical procedure. *Hemophilia* is the most common of these and manifests itself as a clotting deficiency. Preoperative testing is useful in determining whether these conditions exist.

Stainless steel, titanium, and absorbable polysorb staples are frequently used during a surgical procedure. The staples are designed to form a noncrushing __ shape when inserted into tissue. This shape allows blood to pass through the line of staples, preventing tissue necrosis, and promoting healing.

Stainless steel, titanium, and absorbable polysorb staples are frequently used during a surgical procedure. The staples are designed to form a noncrushing *B shape* when inserted into tissue. This shape allows blood to pass through the line of staples, preventing tissue necrosis, and promoting healing.

Standard lengths for non-needled suture material are 54 in. for absorbable material and 60 in. for nonabsorbable material. These strands may be cut in half-, third-, or quarter-lengths by the surgical technologist. Single-strand ligating material is available in precut lengths of 18-, 24-, and 30-in. strands. Superficial bleeders will usually require ligatures no more than 18 in. in length. Deep bleeders require a suture length of between 18 and 30 in. Ligating methods include the __, __, __, and __.

Stapling devices include ....types. Stapler styles are available to accommodate open and endoscopic procedures.

Stapling devices include *skin, fascia, linear (stapling and cutting), ligating, intraluminal, and endoscopic types*. Stapler styles are available to accommodate open and endoscopic procedures.

packing

Sterile fine-mesh gauze that is loosely placed in a chronic wound or one that has been left open to heal by second intention

swaged

Strand of suture material with an eyeless needle attached by the manufacturer; the needle is continuous with the suture strand

Surgical needles are used to insert suture material into tissue and are available in a wide variety of sizes, shapes, and diameters. However, only a few types are used consistently. They are made of steel and should be strong and rigid enough so that they do not bend or break during suturing. The needles must be smooth and free of any burrs or corrosion along the needle body and on the needle point. Needles can be described in terms of the following characteristics:

Suture complications:

Suture complications: Suture complications occur because of either a failure to properly absorb the suture material or an irritation caused by the suture that results in inflammation. It occurs most frequently with silk and is characterized by an evisceration (referred to as spitting) of the suture material from the wound or sinus tract formation.

inflammation

The body's protective response to injury or tissue destruction

Suture material may be __, meaning that it is made from naturally occurring substances, such as cellulose, an animal product, or tissue; or __, consisting of polymers from petroleum-based products. Natural absorbable sutures are digested by body enzymes that attack the suture strand, eventually destroying it. Synthetic absorbable sutures are hydrolyzed by the body. Water within the tissue penetrates the strand and breaks down the synthetic fiber's polymer chain, resulting in minimal tissue reaction.

Suture material may be *natural*, meaning that it is made from naturally occurring substances, such as cellulose, an animal product, or tissue; or *synthetic*, consisting of polymers from petroleum-based products. Natural absorbable sutures are digested by body enzymes that attack the suture strand, eventually destroying it. Synthetic absorbable sutures are hydrolyzed by the body. Water within the tissue penetrates the strand and breaks down the synthetic fiber's polymer chain, resulting in minimal tissue reaction.

Suture material may be classified as __, meaning it is capable of being absorbed by tissue within a given period of time, or __, meaning that it resists enzymatic digestion or absorption by tissue. Suture material can also be classified as monofilament, made of a single thread-like structure, or multifilament, consisting of multiple thread-like structures braided or twisted into a single strand. Barbed sutures, like their name, have barbs extending from the surface that anchors to tissue rendering the suture knotless.

Suture material may be classified as *absorbable*, meaning it is capable of being absorbed by tissue within a given period of time, or *nonabsorbable*, meaning that it resists enzymatic digestion or absorption by tissue. Suture material can also be classified as monofilament, made of a single thread-like structure, or multifilament, consisting of multiple thread-like structures braided or twisted into a single strand. Barbed sutures, like their name, have barbs extending from the surface that anchors to tissue rendering the suture knotless.

Suture materials have distinguishing characteristics that can be compared. Physical characteristics include ...... Sutures may vary in pliability, how easily they pass through tissue, and how easily they tie and knot security. Each suture has a certain predictable effect on the tissue on which it is used. Tables 11-5 and 11-6 provide the key information the surgical technologist should remember.

Suture materials have distinguishing characteristics that can be compared. Physical characteristics include *configuration, capillarity, ability to absorb fluid, size (diameter), tensile strength, knot strength, elasticity, and memory.* Sutures may vary in pliability, how easily they pass through tissue, and how easily they tie and knot security. Each suture has a certain predictable effect on the tissue on which it is used. Tables 11-5 and 11-6 provide the key information the surgical technologist should remember.

monofilament suture

Suture that is manufactured from one strand of natural or synthetic material

Sutures are designed to support healing tissues as well as hold tissue edges together until they heal. Sutures should have a certain amount of __ to accommodate tissue swelling and strains placed on the wound by coughing or body movements. With the exception of some __ suture materials such as surgical steel, sutures are treated as foreign material by the body and the longer they dwell within tissues, the more likely the tissues will react negatively and impair the healing process. Ideally, the absorbable sutures should be completely absorbed by the time the tissue no longer requires them for stability. Therefore, suture absorption time should closely coincide with the time that it takes the tissue to heal.

Sutures are designed to support healing tissues as well as hold tissue edges together until they heal. Sutures should have a certain amount of *elasticity* to accommodate tissue swelling and strains placed on the wound by coughing or body movements. With the exception of some *inert* suture materials such as surgical steel, sutures are treated as foreign material by the body and the longer they dwell within tissues, the more likely the tissues will react negatively and impair the healing process. Ideally, the absorbable sutures should be completely absorbed by the time the tissue no longer requires them for stability. Therefore, suture absorption time should closely coincide with the time that it takes the tissue to heal.

Sutures are placed so the __ is located under the layer to be closed and is not projecting outward.

Sutures are placed so the *knot* is located under the layer to be closed and is not projecting outward.

secondary suture line

Sutures placed to support and ease the tension on the primary suture line, thus reinforcing the wound closure and obliterating any dead spaces

seroma

Swelling within a tissue or organ caused by the localized accumulation of serum

Tendon sutures may be pulled through __ and tied over a button to prevent tissue damage. __ may be clamped onto the ends of subcuticular sutures after skin closure.

Tendon sutures may be pulled through *buttonholes* and tied over a button to prevent tissue damage. *Split lead shots* may be clamped onto the ends of subcuticular sutures after skin closure.

The __ specifies diameter range for suture materials. The diameter of stainless steel sutures is identified by the Brown and Sharpe (B and S) commercial wire gauge numbers. Suture size is numerical; as the number of 0s increase, the diameter becomes smaller. For example, 3-0 or 000 is smaller in diameter than 1-0 or 0. The smaller the size, the less tensile strength of the suture. The largest available suture for use in surgery is #5; it is approximately the size of commercial string.

The *United States Pharmacopeia (USP)* specifies diameter range for suture materials. The diameter of stainless steel sutures is identified by the Brown and Sharpe (B and S) commercial wire gauge numbers. Suture size is numerical; as the number of 0s increase, the diameter becomes smaller. For example, 3-0 or 000 is smaller in diameter than 1-0 or 0. The smaller the size, the less tensile strength of the suture. The largest available suture for use in surgery is #5; it is approximately the size of commercial string.

The __, suture is a primary suture line consisting of a single strand of suture placed as a series of stitches often used for closure of long incisions. The strand is tied after the first stitch is placed at one end and tied again after the last stitch is placed at the other end. Evenly distributed tension along the suture line is a hallmark of the continuous suture closure (Figure 11-19). The surgical assistant "follows" or "runs" the suture by holding the lower quarter of the suture taut and away from the area of closure. This process keeps the proper amount of tension on the suture line and keeps the suture strand out of the surgeon's line of view.

The *continuous, or running, suture* is a primary suture line consisting of a single strand of suture placed as a series of stitches often used for closure of long incisions. The strand is tied after the first stitch is placed at one end and tied again after the last stitch is placed at the other end. Evenly distributed tension along the suture line is a hallmark of the continuous suture closure (Figure 11-19). The surgical assistant "follows" or "runs" the suture by holding the lower quarter of the suture taut and away from the area of closure. This process keeps the proper amount of tension on the suture line and keeps the suture strand out of the surgeon's line of view.

The __ involves a needle swaged to each end of the suture strand. These are commonly used for anastomosis of vessels, allowing the center of the suture to be sewn to the center of the vessel with one suture end sewn to the left and the other to the right. The stitches meet in the middle on the opposite side of the vessel.

The *double-arm attachment* involves a needle swaged to each end of the suture strand. These are commonly used for anastomosis of vessels, allowing the center of the suture to be sewn to the center of the vessel with one suture end sewn to the left and the other to the right. The stitches meet in the middle on the opposite side of the vessel.

The __ is reported to and monitored by the anesthesia care provider, who will make the determination in consultation with the surgeon if blood replacement is necessary. Some types of surgery, such as cardiovascular or prostate surgery, will often call for blood replacement due to the high volume of blood loss.

The *estimated blood loss (EBL)* is reported to and monitored by the anesthesia care provider, who will make the determination in consultation with the surgeon if blood replacement is necessary. Some types of surgery, such as cardiovascular or prostate surgery, will often call for blood replacement due to the high volume of blood loss.

The __ is the portion of the needle where the suture strand is attached. Surgical needles may be closed-eyed, french-eyed, or eyeless (swaged)

The *eye* is the portion of the needle where the suture strand is attached. Surgical needles may be closed-eyed, french-eyed, or eyeless (swaged)

The __ is a layer of tough connective tissue covering the body's muscles. It is the primary supportive soft tissue structure of the body and great care must be taken to close the abdominal __ layer securely. This layer heals slowly and must endure the brunt of wound stress; therefore, interrupted, heavy-gauge, nonabsorbable multifilament suture is preferred for added strength. If an absorbable suture material is used, it should be slow absorbing and have high tensile strength. If the __ layer is weak, polypropylene surgical mesh may be sutured in with polypropylene sutures for structural support.

The *fascia* is a layer of tough connective tissue covering the body's muscles. It is the primary supportive soft tissue structure of the body and great care must be taken to close the abdominal fascia layer securely. This layer heals slowly and must endure the brunt of wound stress; therefore, interrupted, heavy-gauge, nonabsorbable multifilament suture is preferred for added strength. If an absorbable suture material is used, it should be slow absorbing and have high tensile strength. If the fascial layer is weak, polypropylene surgical mesh may be sutured in with polypropylene sutures for structural support.

The __ needle is loaded by pulling the taut strand into a V-shaped area just above the eye. This type of needle is loaded more quickly than a closed-eyed needle, but still results in more tissue damage than the eyeless needle.

The *french-eyed needle* is loaded by pulling the taut strand into a V-shaped area just above the eye. This type of needle is loaded more quickly than a closed-eyed needle, but still results in more tissue damage than the eyeless needle.

The ___ technique is the technique of choice to close tissues that are under tension. Abdominal fascia and tendons are examples of tissue that are closed by interrupted suture technique. The interrupted suture line is also the suture technique of choice to close infected tissues. The __ suture "interrupts" the pathway of the bacteria, localizing the area of infection to a smaller area of the wound (Figure 11-21). For these and other reasons, Dr. Halsted condoned the use of small-gauge, interrupted sutures for wound closure; see Box 11-1 for the historical Halsted's principles of suture technique. T

The *interrupted suture technique* is the technique of choice to close tissues that are under tension. Abdominal fascia and tendons are examples of tissue that are closed by interrupted suture technique. The interrupted suture line is also the suture technique of choice to close infected tissues. The interrupted suture "interrupts" the pathway of the bacteria, localizing the area of infection to a smaller area of the wound (Figure 11-21). For these and other reasons, Dr. Halsted condoned the use of small-gauge, interrupted sutures for wound closure; see Box 11-1 for the historical Halsted's principles of suture technique.

The __ provides an intense and concentrated beam of light that is able to cut and coagulate tissue at the same time with very little surrounding tissue destruction.

The *laser* provides an intense and concentrated beam of light that is able to cut and coagulate tissue at the same time with very little surrounding tissue destruction.

The__ is used to staple and transect the tissue (Figure 11-29). __ deliver two double staple lines (similar to the one produced by the linear stapler) and contain a knife blade that passes between the two staple lines, dividing the tissue. The __ is especially useful during gastrointestinal procedures. A variation of the __ is available for endoscopic procedures (Figure 11-30). The staplers are operated manually or by battery power.

The *linear cutter* is used to staple and transect the tissue (Figure 11-29). Linear cutters deliver two double staple lines (similar to the one produced by the linear stapler) and contain a knife blade that passes between the two staple lines, dividing the tissue. The linear cutter is especially useful during gastrointestinal procedures. A variation of the linear cutter is available for endoscopic procedures (Figure 11-30). The staplers are operated manually or by battery power.

The __, a fast-healing, thin membrane lining the abdominal cavity, lying beneath the posterior fascia, may not require suturing if the posterior fascia is closed properly. If the surgeon chooses to close the __, a continuous 3-0 absorbable suture is frequently utilized.

The *peritoneum*, a fast-healing, thin membrane lining the abdominal cavity, lying beneath the posterior fascia, may not require suturing if the posterior fascia is closed properly. If the surgeon chooses to close the peritoneum, a continuous 3-0 absorbable suture is frequently utilized.

The __ refers to the sutures that approximate wound edges for first intention healing. These sutures are placed in either an interrupted or continuous fashion. Other types of primary sutures include buried, purse-string, and subcuticular, which are used for specific purposes.

The *primary suture line* refers to the sutures that approximate wound edges for first intention healing. These sutures are placed in either an interrupted or continuous fashion. Other types of primary sutures include buried, purse-string, and subcuticular, which are used for specific purposes.

The __, of the needle is located between the suture strand and the point. Its size and shape are variable and choice depends on the type of tissue to be sutured. Typically, the heavier the tissue, the heavier the body. Length is determined by the depth of the "bite" of the tissue to be sutured. The shape of the body may be straight (Keith needle), 1/4 circle, 3/8 circle, 1/2 circle, or 5/8 circle. Microsurgical needles and retention suture needles are usually circle, as are needles for skin closure

The *shaft, or body*, of the needle is located between the suture strand and the point. Its size and shape are variable and choice depends on the type of tissue to be sutured. Typically, the heavier the tissue, the heavier the body. Length is determined by the depth of the "bite" of the tissue to be sutured. The shape of the body may be straight (Keith needle), 1/4 circle, 3/8 circle, 1/2 circle, or 5/8 circle. Microsurgical needles and retention suture needles are usually circle, as are needles for skin closure

The __ layer is an area of tough connective tissue just beneath the skin and just above the subcutaneous layer. A __ closure is often utilized to minimize scarring. Short lateral stitches are placed in a continuous or interrupted fashion just under the epithelial layer of the skin, in a line parallel to the wound. Absorbable sutures are preferred as opposed to nonabsorbable sutures because the surgeon need not remove them. Small-gauge sutures can be utilized for __ closure because the fascia endures the brunt of tension for the healing wound.

The *subcuticular layer* is an area of tough connective tissue just beneath the skin and just above the subcutaneous layer. A subcuticular closure is often utilized to minimize scarring. Short lateral stitches are placed in a continuous or interrupted fashion just under the epithelial layer of the skin, in a line parallel to the wound. Absorbable sutures are preferred as opposed to nonabsorbable sutures because the surgeon need not remove them. Small-gauge sutures can be utilized for subcuticular closure because the fascia endures the brunt of tension for the healing wound.

The __ consists of a single-use titanium blade attached to a handpiece and a portable generator. The generator converts the electrical energy into mechanical energy, thus causing the blade to move by rapid ultrasonic motion that simultaneously cuts and coagulates tissue. The vibrations of the blade denature protein molecules within the tissue, producing a sticky coagulum that seals the vessels. Additionally, the continuous denaturing of protein produces heat within the tissue to produce deeper coagulation. This continuous action does not cause a significant increase in temperature and therefore does not cause charring of the tissue or produce a smoke plume. Damage to adjacent tissue is minimal. Since electricity is not required to produce the cutting and coagulation effects on the tissue, a grounding pad is not necessary.

The *ultrasonic scalpel* consists of a single-use titanium blade attached to a handpiece and a portable generator. The generator converts the electrical energy into mechanical energy, thus causing the blade to move by rapid ultrasonic motion that simultaneously cuts and coagulates tissue. The vibrations of the blade denature protein molecules within the tissue, producing a sticky coagulum that seals the vessels. Additionally, the continuous denaturing of protein produces heat within the tissue to produce deeper coagulation. This continuous action does not cause a significant increase in temperature and therefore does not cause charring of the tissue or produce a smoke plume. Damage to adjacent tissue is minimal. Since electricity is not required to produce the cutting and coagulation effects on the tissue, a grounding pad is not necessary.

elasticity

The ability of tissue such a skin, lungs, or muscles to return to its normal shape after being pushed inward, stretched outward, or in some way manipulated

edema

The abnormal accumulation of fluid in the interstitial spaces of tissues causing swelling

The application of external pressure to a vessel, as with the use of a tourniquet, occludes the flow of blood until a clot has time to form. Prophylactically, pressure devices, such as sequential stockings, may also be used to prevent __ and __.

hemostasis

The arrest of the escape of blood through natural or artificial means

The conscious patient may exhibit __ and complain of __. The patient may experience rapid pulse, shortness of breath, and pounding of the heart. The skin may appear jaundiced and pallor may be exhibited, especially in the palms of the hands. The patient under general anesthesia will not show these signs, and the only signs noted may be a generalized __ and a lowered __ due to the inability of the red blood cells to carry oxygen.

The conscious patient may *exhibit fatigue and complain of lack of energy.* The patient may experience rapid pulse, shortness of breath, and pounding of the heart. The skin may appear jaundiced and pallor may be exhibited, especially in the palms of the hands. The patient under general anesthesia will not show these signs, and the only signs noted may be a generalized *loss of blood* and a *lowered blood oxygen saturation level* due to the inability of the red blood cells to carry oxygen.

hemolysis

The destruction of erythrocytes

The drawback to this type of closure is that if any segment of the continuous strand breaks, the entire suture line is jeopardized, resulting in __ or __. For this reason, continuous sutures should not be used to close tissues that are under a lot of tension. The use of a continuous suture technique is contraindicated in the presence of infection; bacteria and tissue fluids can travel along the length of a wound by way of a continuous suture strand, referred to as wicking. The following are brief descriptions of the various continuous suturing techniques.

The drawback to this type of closure is that if any segment of the continuous strand breaks, the entire suture line is jeopardized, resulting in *dehiscence or evisceration*. For this reason, continuous sutures should not be used to close tissues that are under a lot of tension. The use of a continuous suture technique is contraindicated in the presence of infection; bacteria and tissue fluids can travel along the length of a wound by way of a continuous suture strand, referred to as wicking. The following are brief descriptions of the various continuous suturing techniques.

The first throw is a single suture technique at end of wound; multiple subcuticular bites are made opposite each other the length of the wound. At the opposite end of wound, the throw is also a single suture technique. The wound is reinforced with steri-strips or Dermabond™, which minimizes needle penetration of the skin. __ suturing is useful for patients prone to developing keloids where needle holes in the skin promote excessive cicatrix formation.

The first throw is a single suture technique at end of wound; multiple subcuticular bites are made opposite each other the length of the wound. At the opposite end of wound, the throw is also a single suture technique. The wound is reinforced with steri-strips or Dermabond™, which minimizes needle penetration of the skin. *Subcuticular suturing* is useful for patients prone to developing keloids where needle holes in the skin promote excessive cicatrix formation.

pliability

The flexibility and/or how easily a material can be bent

The release of ADP causes more platelets to clump on the first layer, resulting in an initial __. In small vessels, this initial __ formation may be enough to stop the flow of blood. In larger vessels, however, a second, permanent __ must be formed.

The release of ADP causes more platelets to clump on the first layer, resulting in an initial *thrombus*. In small vessels, this initial thrombus formation may be enough to stop the flow of blood. In larger vessels, however, a second, permanent thrombus must be formed.

The four main types are __ based on the presence or absence of A and B red cell antigens. In addition, the blood contains agglutinins, which are antibodies that work against the A and B antigens. Individuals with type A blood naturally produce anti-B agglutinins and individuals with type B blood naturally produce anti-A agglutinins. An individual with type O blood, however, naturally produces both A and B agglutinins, making the O individual a universal donor. Type AB individuals produce neither antibody, and therefore type AB individuals may receive any type and are called universal recipients. If mismatched blood is transfused, a transfusion reaction occurs and may range from mild reaction to anaphylactic shock.

The four main types are *A, B, O, and AB*, based on the presence or absence of A and B red cell antigens. In addition, the blood contains agglutinins, which are antibodies that work against the A and B antigens. Individuals with type A blood naturally produce anti-B agglutinins and individuals with type B blood naturally produce anti-A agglutinins. An individual with type O blood, however, naturally produces both A and B agglutinins, making the O individual a universal donor. Type AB individuals produce neither antibody, and therefore type AB individuals may receive any type and are called universal recipients. If mismatched blood is transfused, a transfusion reaction occurs and may range from mild reaction to anaphylactic shock.

The goal of __ is prevention of infection and other complications. __ may include the use of drains and protection of the wound with different types of dressings.

The goal of *postoperative wound care* is prevention of infection and other complications. Postoperative wound care may include the use of drains and protection of the wound with different types of dressings.

The most common type of homologous blood replacement therapy used in the OR is the administration of __. Other blood products administered in the OR setting are described in Table 11-1.

The most common type of homologous blood replacement therapy used in the OR is the administration of *packed red blood cells (PRBCs)*. Other blood products administered in the OR setting are described in Table 11-1.

ligated

The placement of a suture tie around a vessel or other anatomical structure for the purpose of constriction (i.e., to control hemorrhage from a blood vessel)

The primary suture packet is color coded and identifies the product code, number, material, size (USP and metric), and needle type and number. A suture strand with only one needle is represented by a single, actual-sized needle silhouette on the packet. A __ suture is represented by two needle silhouettes. Any needle number greater than 2 is represented by a single needle silhouette, and the number of needles is written in __. Rapid-release needles, also referred to as controlled-release (CR), are designed to "pop off" the suture strand after a single suture has been placed. The primary suture packet is sterile and contained within an outer wrapper similar to a peel pack. The contents of the wrap are sterile; however, the outside of the package is not.

The primary suture packet is color coded and identifies the product code, number, material, size (USP and metric), and needle type and number. A suture strand with only one needle is represented by a single, actual-sized needle silhouette on the packet. A *double-armed (two-needle)* suture is represented by two needle silhouettes. Any needle number greater than 2 is represented by a single needle silhouette, and the number of needles is written in *red*. Rapid-release needles, also referred to as controlled-release (CR), are designed to "pop off" the suture strand after a single suture has been placed. The primary suture packet is sterile and contained within an outer wrapper similar to a peel pack. The contents of the wrap are sterile; however, the outside of the package is not.

The surgeon everts (turns outward) and approximates the skin edges with __ forceps with teeth and the operator positions the stapler at the approximated edges with the aid of an arrow located on the stapler head. A single squeeze and release of the mechanism positions the staple. Individual staples can also be used to close the tough tissue of the abdominal fascia. This layer is thick and heals slowly. The nonreactive nature of metallic staples makes them an ideal choice for fascia.

The surgeon everts (turns outward) and approximates the skin edges with *Adson tissue forceps with teeth* and the operator positions the stapler at the approximated edges with the aid of an arrow located on the stapler head. A single squeeze and release of the mechanism positions the staple. Individual staples can also be used to close the tough tissue of the abdominal fascia. This layer is thick and heals slowly. The nonreactive nature of metallic staples makes them an ideal choice for fascia.

The surgeon selects the best suture for the particular task and patient plus the wound closure technique that provides optimal patient recovery. Factors that influence the choice of suture and technique include *the health of the patient and whether preexisting conditions, such as diabetes, are present that can affect the wound-healing process.*

The surgeon should receive the needle holder and suture with the needle pointed ___. Keep in mind that needles loaded for a right-handed surgeon will need to be loaded in the opposite direction for a left-handed surgeon. The surgical technologist should control the trailing end of the suture to prevent snagging or dropping off the sterile field. After use, the surgeon should place the needle holder onto a neutral zone. The surgical technologist should not attempt to remove the armed needle holder from the surgeon's hands. Loaded needle holders are exchanged on a one-for-one basis. Once the surgical technologist receives the needle, it needs to be inspected for integrity.

The surgeon should receive the needle holder and suture with the needle *pointed toward the surgeon's chest*. Keep in mind that needles loaded for a right-handed surgeon will need to be loaded in the opposite direction for a left-handed surgeon. The surgical technologist should control the trailing end of the suture to prevent snagging or dropping off the sterile field. After use, the surgeon should place the needle holder onto a neutral zone. The surgical technologist should not attempt to remove the armed needle holder from the surgeon's hands. Loaded needle holders are exchanged on a one-for-one basis. Once the surgical technologist receives the needle, it needs to be inspected for integrity.

The surgical technologist chooses an appropriate __ based on the size of the suture needle to be used, the surgeon's preference, and the depth of the surgical wound. The needle holder is clamped approximately __ of the distance from the swaged end of the needle to the needle point. Tougher tissue may require the needle holder to be moved to the __ of the needle. The swaged area of the needle (that part of the needle in which the suture enters the needle) should never be clamped; that is the weakest section of the suture/needle. Modern suture packets allow the surgical technologist to load the needle without touching it.

The surgical technologist chooses an appropriate *needle holder* based on the size of the suture needle to be used, the surgeon's preference, and the depth of the surgical wound. The needle holder is clamped approximately *one-third* of the distance from the swaged end of the needle to the needle point. Tougher tissue may require the needle holder to be moved to the *half-point* of the needle. The swaged area of the needle (that part of the needle in which the suture enters the needle) should never be clamped; that is the weakest section of the suture/needle. Modern suture packets allow the surgical technologist to load the needle without touching it.

The surgical technologist should keep close track of the amount of irrigation fluids used; the amount of irrigation fluid used is __ from the total volume of fluid in the canister to provide an accurate measurement of blood loss.

The surgical technologist should keep close track of the amount of irrigation fluids used; the amount of irrigation fluid used is *subtracted* from the total volume of fluid in the canister to provide an accurate measurement of blood loss.

The surgical technologist should open only as many suture packets as are necessary because leftover sutures cannot be resterilized and must be discarded. Inexperienced surgical technologists tend to overcompensate for lack of suture knowledge by opening too many packets. However, if too few packets are opened, the surgical procedure may be prolonged unnecessarily while the circulator retrieves the additional sutures. __ between the surgical technologist and the surgeon, in addition to regularly updated preference cards, can minimize waste and keep supply costs down.

The surgical technologist should open only as many suture packets as are necessary because leftover sutures cannot be resterilized and must be discarded. Inexperienced surgical technologists tend to overcompensate for lack of suture knowledge by opening too many packets. However, if too few packets are opened, the surgical procedure may be prolonged unnecessarily while the circulator retrieves the additional sutures. *Good communication* between the surgical technologist and the surgeon, in addition to regularly updated preference cards, can minimize waste and keep supply costs down.

The type of __ applied varies with the type of procedure, specialty, surgeon preference, and patient status.

The type of *dressing* applied varies with the type of procedure, specialty, surgeon preference, and patient status.

The word __ is described as any tissue that has been damaged by surgical or traumatic means.

The word *wound* is described as any tissue that has been damaged by surgical or traumatic means.

When a blood vessel is injured, such as by being incised during surgery, the hemostatic process begins in order to stop the flow of blood. The body uses the process of __ to achieve hemostasis.

When a blood vessel is injured, such as by being incised during surgery, the hemostatic process begins in order to stop the flow of blood. The body uses the process of *coagulation* to achieve hemostasis.

The __ is a noninvasive, atraumatic device used for skin closure. It combines a zipper and two lateral adhesive strips. After surgery, the adhesive strips are placed on each side of the surgical skin incision; the surgical technologist should make sure the skin has been cleaned and is dry prior to placement. The surgical team may want to don clean gloves prior to handling the wound zipper. As the zipper is closed, it approximates the edges of the wound, providing a secure closure. It is recommended that the zipper be 3 to 4 cm longer than the surgical wound. Advantages include elimination of needle holes in the skin, elimination of the possibility of sharp injuries from suture needles when skin closure is being performed, and that it is faster than suturing.

The wound zipper is a noninvasive, atraumatic device used for skin closure. It combines a zipper and two lateral adhesive strips. After surgery, the adhesive strips are placed on each side of the surgical skin incision; the surgical technologist should make sure the skin has been cleaned and is dry prior to placement. The surgical team may want to don clean gloves prior to handling the wound zipper. As the zipper is closed, it approximates the edges of the wound, providing a secure closure. It is recommended that the zipper be 3 to 4 cm longer than the surgical wound. Advantages include elimination of needle holes in the skin, elimination of the possibility of sharp injuries from suture needles when skin closure is being performed, and that it is faster than suturing.

There are two methods of endoscopic suturing: __ and __. The __ method actually refers to creating the knot outside the body prior to instrument transfer through the trocar cannula to the tissue site. A common method is forming __ slip locking knots with subsequent transfer of the knot to the tissue site. The __ method simply refers to the surgeon using instruments inserted through the trocar cannula to facilitate the internal suturing of tissues and knot tying. There are also various devices available for __ placement of suture and knots, including Endoloop® and Endo Stitch™. The Endoloop® ligature is used to ligate tissue pedicles during endoscopic procedures. A suture is inserted through a long, thin plastic tube, which is formed into a loop with a knot. When ligature is in position, the tube is pulled upward to tighten the loop and knot.

There are two methods of endoscopic suturing: *extracorporal and intracorporeal*. The *extracorporeal method* actually refers to creating the knot outside the body prior to instrument transfer through the trocar cannula to the tissue site. A common method is forming extracorporeal slip locking knots with subsequent transfer of the knot to the tissue site. The *intracorporeal method* simply refers to the surgeon using instruments inserted through the trocar cannula to facilitate the internal suturing of tissues and knot tying. There are also various devices available for intracorporeal placement of suture and knots, including Endoloop® and Endo Stitch™. The Endoloop® ligature is used to ligate tissue pedicles during endoscopic procedures. A suture is inserted through a long, thin plastic tube, which is formed into a loop with a knot. When ligature is in position, the tube is pulled upward to tighten the loop and knot.

vessel loops

Thin strips made of silicone that can be placed around a vessel, nerve, or duct for the purposes of retracting or isolating; the loops are colored for easy identification of the retracted structures

Third Intention (Delayed Primary Closure)

Third intention healing, or delayed primary closure, occurs when two granulated surfaces are approximated. The traumatic (Class III or Class IV) surgical wound is debrided and purposely left open to heal by second intention (granulation) for approximately 4 to 6 days. The patient may be treated with systemic antibiotics and special wound care techniques may be used to treat or prevent infection, such as packing the wound with antibiotic-impregnated fine mesh gauze. The infection-free wound is then closed and allowed to finish the healing process through first intention (primary closure). The result is a wound that heals by contraction, granulation, and connective tissue repair with intermediate tensile strength and scarring. This method of repair works well for contaminated or dirty wounds.

Phases of Wound Healing by First Intention Phase 2: Proliferation Phase

This stage begins on approximately the third postoperative day and continues for up to 20 days. Fibroblasts multiply and bridge the wound edges. The fibroblasts secrete collagen that forms into fibers that give the wound approximately 25 to 30 percent of its original tensile strength. New networks are formed from existing capillaries by the fifth to eighth day and lymphatic networks are reformed by the tenth day, many of which diminish during the final phase of wound healing.

Phases of Wound Healing by First Intention Phase 3: Maturation or Differentiation Phase

This stage begins on the fourteenth postoperative day and lasts until the wound is completely healed (up to 12 months). During this phase, the wound undergoes a slow, sustained increase in tissue tensile strength with an interweaving of the collagen fibers. Wound contraction resulting from the work of dermal and subcutaneous myofibroblasts is completed in approximately 21 days. Collagen density increases and formation of new blood vessels decreases, causing the scar tissue to pale. A small, white, mature surface scar, called a cicatrix, appears during the maturation phase.

Phases of Wound Healing by First Intention Phase 1: Lag Phase or Inflammatory Response Phase

This stage begins within minutes of injury and lasts approximately 3 to 5 days. It is defined by the physiological changes associated with inflammation manifested as heat, redness, swelling, pain, and loss of function. The warmth and redness associated with inflammation are a result of the arterial dilatation that increases blood flow to the area. This stage of repair controls bleeding through platelet aggregation, delivers blood to the injured site through vessel dilation, and forms epithelial cells for repair. A scab forms on the surface to seal the wound, preventing serous and serosanguinous, a mixture of serous fluid and blood, leakage and microbial invasion. Increased capillary permeability triggered by chemicals released by injured cells permits leakage of exudate, protein-rich fluid into the extravascular fluid compartment, resulting in edema and localized pain.

Three types of wound healing are identified. They are listed as __, __, and __. The type of wound healing will be determined by the type and condition of the tissue.

Three types of wound healing are identified. They are listed as *first intention (primary union), second intention (granulation), and third intention (delayed primary closure)*. The type of wound healing will be determined by the type and condition of the tissue.

Healing by first intention occurs in three distinct phases:

Tissue response to injury: (A) Phase 1, inflammatory response and debridement process, (B) Phase 2, collagen formation (scar tissue), (C) Phase 3, sufficient collagen laid down

compress

To apply pressure

Tourniquets are often used on extremities to keep the operative site free of blood. The provision of a bloodless field makes __ easier and reduces the __. Bleeding must be controlled prior to removal of the tourniquet, however, because the use of a tourniquet alone does not achieve hemostasis.

Tourniquets are often used on extremities to keep the operative site free of blood. The provision of a bloodless field makes *visualization easier and reduces the operative time*. Bleeding must be controlled prior to removal of the tourniquet, however, because the use of a tourniquet alone does not achieve hemostasis.

first intention

Type of healing that occurs with primary union that is typical of an incision opened under ideal conditions; healing occurs from side to side, dead space has been eliminated, and the wound edges are accurately approximated

Intraoperative tissue handling

Wound security Tissue handling Sterile technique Duration of surgery Methods of hemostasis Elimination of dead space Length and direction of incision Dissection technique (sharp or blunt)

USP suture sizes __ through__ are the most commonly used. Sizes #1 and #0 are used frequently for closure of orthopedic wounds and abdominal fascia. Suture sizes 4-0 and 5-0 are typically used for aortic anastomosis, whereas suture sizes 6-0 through 7-0 are used for smaller vessel anastomoses, such as those on the coronary or carotid arteries. Size 8-0 through 11-0 sutures are used for microvascular and eye procedures. Size 4-0 sutures are used to close dural incisions; size 3-0 and 4-0 sutures are used for most subcuticular skin closures. Suture lengths range from 5 in. to 59 in.

USP suture sizes *#1 through 4-0* are the most commonly used. Sizes #1 and #0 are used frequently for closure of orthopedic wounds and abdominal fascia. Suture sizes 4-0 and 5-0 are typically used for aortic anastomosis, whereas suture sizes 6-0 through 7-0 are used for smaller vessel anastomoses, such as those on the coronary or carotid arteries. Size 8-0 through 11-0 sutures are used for microvascular and eye procedures. Size 4-0 sutures are used to close dural incisions; size 3-0 and 4-0 sutures are used for most subcuticular skin closures. Suture lengths range from 5 in. to 59 in.

Uses of fibrin glue include __ as a liquid or spray to control bleeding and approximate wound edges of tissues that are difficult to suture; fixation of ocular implants and middle ear reconstructive procedures; and microsurgical anastomoses of nerves and blood vessels.

Uses of fibrin glue include *deep tissues* as a liquid or spray to control bleeding and approximate wound edges of tissues that are difficult to suture; fixation of ocular implants and middle ear reconstructive procedures; and microsurgical anastomoses of nerves and blood vessels.

Various devices are employed to keep retention sutures from cutting into the skin. __ are plastic devices that "bridge" the closed incision. Retention suture ends are brought up through holes on each end of the bridge and tied at the middle. A circular tightening device on the bridge allows tension to be adjusted on the retention sutures __ are pieces of plastic or rubber tubing threaded over the retention suture ends before the ends are tied. Once tied, the __ cover the retention sutures and prevent them from cutting into the skin

Various devices are employed to keep retention sutures from cutting into the skin. *Bridges* are plastic devices that "bridge" the closed incision. Retention suture ends are brought up through holes on each end of the bridge and tied at the middle. A circular tightening device on the bridge allows tension to be adjusted on the retention sutures *Bolsters* are pieces of plastic or rubber tubing threaded over the retention suture ends before the ends are tied. Once tied, the bolsters cover the retention sutures and prevent them from cutting into the skin

Vessels are ligated using a ligature of the smallest possible diameter in order to reduce __ and are often placed at the base of a hemostat that has been used to clamp the end of a vessel. The hemostat may then be removed, the ligature tightened and tied, and the ends cut as close to the knot as possible, yet not so close as to allow a knot to come undone, dependent upon the type of suture material being used. Thus, when the material used to tie off a bleeding vessel is of a monofilament type, the tails of the suture should be left approximately __ in. long from the knot. This will enhance the knot's security.

Vessels are ligated using a ligature of the smallest possible diameter in order to reduce *tissue reaction* and are often placed at the base of a hemostat that has been used to clamp the end of a vessel. The hemostat may then be removed, the ligature tightened and tied, and the ends cut as close to the knot as possible, yet not so close as to allow a knot to come undone, dependent upon the type of suture material being used. Thus, when the material used to tie off a bleeding vessel is of a monofilament type, the tails of the suture should be left approximately *1/8 in.* long from the knot. This will enhance the knot's security.

The condition of the patient's tissue is an important factor in suture choice. Not all tissues are alike. Some tissues are stronger than others and some heal faster. Fascia and skin are strong but heal slowly. Gastrointestinal tissue is relatively weak but heals quickly. The normal strength and healing characteristics of a tissue are modified by the condition of that tissue in each patient. Some factors modifying the normal condition of tissue are as follows:

Vitamins Proteins Dehydration Carbohydrates Vascularization Radiation therapy Metabolic factors Age of the patient Weight of the patient Incision relative to fiber direction Thickness of tissue at a given time Amount of devitalized tissue within a wound Edema or induration (hardening and thickening of tissue)

When a cell-salvaging machine is not available, blood may be collected in a __ bag containing an anticoagulant and reinfused through a blood filter. Another available method is the use of a __ canister into which blood can be suctioned. There, it collects in a reservoir. When the canister reaches capacity, it is emptied and the contents are washed in red cell washer and reinfused. In many hospitals, this equipment is located in the blood bank and the blood must leave the OR for washing, so this method takes more time than the two previously outlined.

When a cell-salvaging machine is not available, blood may be collected in a *salvage collection bag* containing an anticoagulant and reinfused through a blood filter. Another available method is the use of a *sterile blood collection* canister into which blood can be suctioned. There, it collects in a reservoir. When the canister reaches capacity, it is emptied and the contents are washed in red cell washer and reinfused. In many hospitals, this equipment is located in the blood bank and the blood must leave the OR for washing, so this method takes more time than the two previously outlined.

When bleeding occurs through needle holes in vessel anastomosis, small squares of Teflon® called __ are used as buttresses over the suture line. Using suture, these are sewn over the hole in the vessel and exert outside pressure over the small needle holes to prevent bleeding and promote clotting. These are often used in __ and __ surgery.

When bleeding occurs through needle holes in vessel anastomosis, small squares of Teflon® called *pledgets* are used as buttresses over the suture line. Using suture, these are sewn over the hole in the vessel and exert outside pressure over the small needle holes to prevent bleeding and promote clotting. These are often used in *peripheral vascular and cardiovascular surgery.*

When laparoscopic procedures are performed, the abdomen must be distended or insufflated with . A __ needle that is attached to the tubing is introduced percutaneously into the abdomen to facilitate the delivery of the gas. See laparoscopic appendectomy or basic laparoscopy sections for additional details.

When laparoscopic procedures are performed, the abdomen must be distended or insufflated with . A *Veress needle* that is attached to the tubing is introduced percutaneously into the abdomen to facilitate the delivery of the gas. See laparoscopic appendectomy or basic laparoscopy sections for additional details.

When vascular injury occurs following trauma or in certain vessel diseases or surgery, the endothelial cells interact with ___ and ___ to form a blood clot at the site of injury.

When vascular injury occurs following trauma or in certain vessel diseases or surgery, the endothelial cells interact with *platelets and clotting factors* to form a blood clot at the site of injury.

Whole blood

Whole blood All components of blood—not commonly used Used to treat trauma-induced hemorrhage

With __ suturing, a drawstring suture is placed in a circular fashion around a structure in such a way that pulling on the suture ends tightens and closes an opening (Figure 11-20). __ sutures are placed into the cecum around the proximal portion of the appendix so that once the appendix is removed and the appendiceal stump is inverted into the lumen of the cecum, the suture ends can be tightened and tied, closing the opening into the cecum. __ sutures are also placed into the right atrium and ascending aorta for introduction of cannulae for cardiopulmonary bypass.

With *pursestring suturing*, a drawstring suture is placed in a circular fashion around a structure in such a way that pulling on the suture ends tightens and closes an opening (Figure 11-20). Pursestring sutures are placed into the cecum around the proximal portion of the appendix so that once the appendix is removed and the appendiceal stump is inverted into the lumen of the cecum, the suture ends can be tightened and tied, closing the opening into the cecum. Pursestring sutures are also placed into the right atrium and ascending aorta for introduction of cannulae for cardiopulmonary bypass.

With __ suturing, each stitch is individually placed, tied, and cut for the length of the wound. Wound edges are approximated and everted.

With *simple interrupted suturing*, each stitch is individually placed, tied, and cut for the length of the wound. Wound edges are approximated and everted.

With the __, tissue or vessel to be tied is held in a hemostat. The first throw is a surgeon's knot. Suture is then passed back and forth through the tissue around the two sides of the clamp in a figure-8 fashion and the suture is tied.

With the *figure-of-8 stick tie*, tissue or vessel to be tied is held in a hemostat. The first throw is a surgeon's knot. Suture is then passed back and forth through the tissue around the two sides of the clamp in a figure-8 fashion and the suture is tied.

Wound tension:

Wound tension: Excessive tension on the wound edges caused by heavy lifting or straining, or the wound being located on a highly mobile or high tension area such as the back, shoulders, or legs. Wound tension can cause an additional wound complication called dehiscence.

chronic wounds

Wound that persists for an extended period of time

Three main factors influence the rate at which wound healing occurs:

the physical condition of the patient, external factors the patient may be experiencing, and the suturing techniques and prevention of wound infection.

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