Chapter 11- hemostasis, wound healing, and wound closure

Tonsil Sponges

Round sponge

fascia staplers

not much different than skin staplers and are disposable staplers shaped like a gun and discharge single wide stainless steel staples into tissue

Infection

occurs when microbial contamination overrides the resistance of the host

vessel loops

have for the most part replaced umbilical tape as isolation/ retraction devices for vessels, nerves, or ducts. Are used for delicate structures. white & yellow loops are for nerves and ducts, red are for arteries and blue are for veins.

Classification of Surgical Wounds

Classified into 4 categories according to the degree of microbial contamination & referred to in the patient record by Roman numeral

ligating dividing stapler

ejects 2 ligating clips side by side and then divides the tissue btw the clips with a single activation. Useful in gastrointestional

Ideal wound healing

involves restoration of continuity, strength, function, and appearance to the tissue.

French-eyed needle

loaded by pulling the taut strand into a v-shaped area just above the eye.

Hematoma

localized swelling filled with blood resulting from a break in a blood vessel

packaging of suture

lot #, surgical application, product code #,suture size, material , and size of needle, length & color, expiration date, shape, and quantity of needles, (needles are written in red)

Granuloma`

mass of inflamed granulation tissue, usually associated with ulcerated infections

split lead shots

may be clamped onto the ends of subcuticular sutures after skin closure

Hemorrhage

may be concealed or evident and occurs most frequently in the first few postop hours. Usually results in postop shock

eyeless needles

may have a single arm attached or double arm

closed eye needles

may have round or square holes and are loaded by inserting the end of the suture material through the hole.

extracorporal method

refers to creating a knot outside the body prior to instrument transfer through the trocar cannula to the tissue site

intracorporeal method

refers to the surgeon using instruments inserted through a trocar cannula to facilitate the internal suturing of tissues and knot tying, ie endoloop, endostitch

Herniation

result of wound dehiscence and occurs most often in lower abdominal incisions.

closing the skin

with interrupted or continuous monofilament, nonabsorbable sutures on a cutting needles or with stainless steel staples. Polypropylene, or nylon are preferred

Additional Classification of Traumatic Wounds by Mechanism Injury:

•Abrasion- scrape •Contusion-bruise •Laceration- cut/tear •Puncture- penetration •Thermal-hot/cold

figure of 8 stick tie

tissue or vessel to be tied is held with a hemostat, the surgeon throws the first knot ,it is then passed back and forth through the tissue around the 2 sides of the clamp> then tied

The suture diameter is referred to as the:

"Gauge" of the suture

multifilament ties

Should be cut 1/8 in. due to its inability to slide

Preferred suture for closure in orthopedic/ abdominal fascia procedures

#1 & #0

Ligatures/Ties

(Stick ties when needle is attached) strands of suture material used to tie off blood vessels

What Suture material Resists enzymatic digestion or absorption by tissue?

Non-Absorbable

Chemical Hemostasis

-Absorbable gelatin (gelfoam) -Absorbable collagen (avitene) -Microfibrillar collagen -Oxidized cellulose (Nu-Knit, and Surgi-Cel) -Silver nitrate -Epinephrine -Thrombin

Types of Mechanical Hemostasis

-Hemostatic instruments -Ligatures -Clips -Sponges -Pledgets -Bone Wax -Pressure Devices

Common Blood Components

-Whole Blood -Packed Red blood cells (PRBCs) -Fresh-frozen plasma (FFP) -Platelets

Class (III) 3- Contaminated Wound

-acute inflammation present -major break in sterile techn -open traumatic wound(less than 4hrs old) with retained necrotic tissue -entry to aerodigestive or genitourinary tract with spillage Definition: 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 Examples: Open fracture, colon resection with gross spillage of GI contents, penetrating trauma

Class (IV) 4- Dirty/Infected

-perforated viscus -microbial contamination prior to procedure -open traumatic wound(more than 4 hrs) Definition: Clinically infected operative wound or perforated viscera or old, traumatic wounds with retained necrotic tissue Examples: Resection of ruptured appendix

Class (I) 1 - Clean Wound

-primary closure -no inflammation is encountered -closed wound drainage device if necessary -incision made under ideal surgical conditions -no break in sterile techn during a procedure -no entry to aerodigestive or genitourinary tract Definition: Uninfected, Uninflamed operative wound in which the respiratory, alimentary, genital, or uninfected urinary tracts are not entered Examples: Coronary artery bypass graft, total hip, breast biopsy, craniotomy

Class(II) 2-Clean Contaminated Wound

-primary closure -open/mechanical drainage -minor break in sterile techn occurred - controlled entry to aerodigestive or genitourinary tract Definition: Uninfected operative wound; respiratory, alimentary, genital, or urinary tract is entered under controlled circumstances without unusual contamination Examples: Appendectomy, cholecystectomy, tonsillectomy

benefits of skin staplers

1- less tissue reaction 2- accelerated wound healing 3-less operating and anesthesia time 4-efficiency

disadvantages of skin staplers

1-cost 2-precisions

conventional cutting needles

3 cutting edges that are directed along the inner curve of the needle

subcuticular skin closure suture size

3-0 & 4-0

size for dural incisions

4-0

suture size for aortic anastomosis

4-0 & 5-0

Raytec

4X4

suture size for smaller vessel anastomoses

6-0 & 7-0 (coronary or carotid arteries)

suture size for microvascular and eye procedures

8-0 & 11-0

Fibrin Glue [Biological Hemostasis]

A Biologic Adhesive & Hemostatic agent Consists of fibrinogen, cyroprecipitate derived from human plasma, calcium chloride, & thrombin

Physical Condition of the Patient includes:

AGE ALLERGIC RESPONSE NUTRITIONAL STATUS OBESITY DISEASE (chronic/acute) SMOKING IMMUNOCOMPROMISED

Adhesion

An abnormal attachment of 2 surfaces or structures that are normally separate

Fistula

An abnormal tract between two epithelium-lined surfaces that is open at BOTH ends

Sinus Tract Formation

An abnormal tract between two epithelium-lined surfaces that is open at ONE end only

Wound

Any tissue that has been damaged by surgical or traumatic means

Monofilament Suture

Are relatively inert and do not readily harbor bacteria -Glide through tissues more easily than multifilament sutures= minimal tissue damage b/c they encounter little resistance within the tissue -Do NOT hold knots as well as multifilament sutures & are relatively difficult to handle Examples: -Prolene -Monocryl -Chromic -Plain-gut

Patties (Cottonoids)

Are smaller compressed radiopaque sponges used in neurosurgical procedures

Chronic Wounds

Are those that persist for an extended period of time -may develop b/c of an underlying physical condition that the patient suffers (i.e.- from pressure sores and decubitus ulcers). -A chronic wound may also be due to infection

Incidental Wounds

Are wounds that can happen as a result of therapy or treatment -Can occur from tissue being nicked with an instrument or trocar wounds on unattended tissues during a suture procedure Also known as: Iatrogenic wound

Tensile Strength

At about the third month plateaus is about 70-80% of original strength

Phase 2: Proliferation Phase

Begins approx. the 3rd postoperative day & continues for up to 20 days. -Fibroblasts multiply and bridge the wound edges. - 25-30% of orig tensile strength. -On the 5th to 8th day the capillaries and lymphatic networks are reformed by the 10th day

Phase 3: Maturation or Differentiation Phase

Begins on the 14th post-op day & last until wound is completely healed (up to 12 months) Scar forms with a pale tissue color called cicatrix.

Phase 1: Lag Phase or Inflammatory Phase

Begins within minutes of injury to 3-5 days. Defined by the physiological changes associated with inflammation manifested as heat, redness, swelling, pain, and loss of function. -Scabs form, 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

Unintentional Wound

Classified in several ways according to severity: ‌•Traumatic injury ‌•Closed wounds ‌•Open wound(s) ◦Simple wound ◦Complicated wound ◦Clean wound ◦Contaminated wound ◦Delayed full-thickness injury

what effects the patients ability to naturally form blood clots?

Congenital hemostatic defects & Acquired hemostatic disorders

Ultra Sonic (Harmonic) Scalpel

Consists of a single-use titanium blade attached to a hand piece and a portable generator. Generator converts from electrical to mechanical energy causing the blade to move by rapid ultrasonic motion which cuts and coags simultaneously. The movement causes it to produce a sticky coagulum that seals the vessels.

Contaminated Wound

Contamination occurs when a dirty object damages the integrity of the skin. -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)

Whole Blood

Contents: All components of blood- [not commonly used] Use: To treat trauma-induced hemorrhage

Platelets

Contents: Platelets removed from 1 unit of whole blood Use: Enhances blood's clotting ability when platelet count is low- (less commonly used)

Packed Red Blood Cells (PRBCs)

Contents: RBCs from 1 unit of whole after most of plasma is removed Use: To restore oxygen-carrying capacity

Fresh-frozen Plasma (FFP)

Contents: The fluid component of blood containing clotting factors removed from 1 unit of whole blood Use: Restores clotting factors; usually 1 unit of FFP is give for every 4 units of PRBCs

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 -Poikilothermia (inability to regulate core body temperature) -Causes of ischemia are: arterial embolism, atherosclerosis, thrombosis, and vasoconstriction

Wound Drains

Designed to remove fluids or gases from the body -can occur: Pre-Op, Intra-Op, Post-Op

Kittners & Peanuts

Dissecting sponges (small tightly rolled gauze)

Suture Complications

Either a failure to properly absorb the suture material or an irritation caused by a suture that results in inflammation -Occurs most frequently with SILK & is characterized by an Evisceration (referred to as: "Spitting") of the suture material from the wound or sinus tract formation

Sutures should have a certain amount of ______________ to accommodate tissue swelling and strains placed on the wound by coughing or body movements

Elasticity

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,legs -cause an additional wound complication called dehiscence

Multifilament Suture

Exhibit a characteristic called: Capillarity-(the capability to harbor bacteria and retain tissue fluids that can be communicated along the length of the strand) -Handle well & hold knots securely -Their multistrand configuration affords them greater tensile strength, pliability, and flexibility Examples: -Vicryl -Silk ties

Pressure Devices

External pressure to a vessel, occludes the flow of blood until a clot can form (with the use of a tourniquet). -Prophylactically, pressure devices such as sequential stockings, may also be used to prevent venous stasis and deep venous thrombosis

Postoperative Wound Drains

Goal: prevention of infection and other complications

Barbed Sutures

Have barbs extending from the surface that anchors to tissue rendering the suture knotless

Hemolytic Transfusion Reactions

If blood isn't properly matched, including Rh factor, prior to transfusion, it can be fatal. Conscious patients exhibit- rapid pulse, shortness of breath, pounding of heart, jaundiced and pallor mostly on palms. Unconscious patients do not show those signs - general loss of blood, lowered blood oxygen saturation level due to RBC inability to carry oxygen. if occurs blood transfusion must stop and sample sent to lab to determine mismatch. Urine output must be closely monitored as hypervolemia may hinder kidney function

Intentional Wounds

Include: chemical wounds, occlusion banding, surgical site incision or excision. ‌•Incision- intentional cut ‌•Excision- removal of tissue. ‌•Occlusion banding- intentional wound that results from ischemia of tissue by means of banding. ‌•Chemical wounds- most used in plastics but overall uncommon form of intentional wound, is placed on skin in effort to denude or coag the area (often causes Inflammation and reepithelialization)

Autotransfusion

Is the reinfusion of the patients own blood whether donated prior to surgery or collected & reinfused intraoperatively This process is preferable to use of homologous blood b/c it uses the patient's own blood, eliminating the danger of a compatibility mismatch or disease transmission

Keloid Scar

Keloid Formation- 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

Bone Wax

Made of refined and sterilized bees wax, used as a mechanical barrier to seal off oozing blood

Seroma

Mass or swelling caused by the localized accumulation of serum w/in a tissue or organ that can sometimes develop after surgery. -When small vessels rupture blood plasma can seep out -Larger seromas are more likely to undergo secondary infection

Thermal Hemostasis

Most common means of obtaining hemostasis during a surgical procedure is the use of heat Examples: -Electrosurgery -Lasers -Argon Plasma Coagulation -Ultrasonic (Harmonic) Scalpel

Acquired hemostatic disorders

Most commonly seen in the OR are bleeding disorders caused by an outside source. (Liver disease, anticoagulant therapy w/heparin or warfarin and aplastic anemia.) Can be requested that the pt not take aspirin one week prior to surgery)

Electrosurgery

Most commonly used thermal hemostatic device (electrode and bovie pencil)

Second Intention (Granulation)

Occurs when a wound fails to heal by primary union -generally occurs in large wounds that cannot be directly approximated or in which infection has caused breakdown of a sutured wound. -Granulated tissue forms the wound causing closure by contraction. -The wound heals from bottom up leaving a weak union and 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.

Third Intention (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

First Intention

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 & minimal scarring. -Wound tensile strength plateaus at the third month at 70 to 80 percent of original strength

Ligating Clips

Often used in place of suture ligatures for small vessels that are needed to be ligated for short period of time (nonreactive clips); (titanium, stainless steel ,or plastic materials) When placed near the cut end of a vessel and squeezed shut, these clips occlude the vessel & stop the bleeding or clips are placed & the vessel divided

Suture Materials

Physical characteristics include: -Configuration -Capillarity -Ability to absorb fluid -Size (diameter) -Tensile strength -Knot strength -Elasticity -Memory 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

Laser

Provides an intense & concentrated beam of light that is able to cut and coagulate tissue at the same time with very little surrounding tissue destruction

Traumatic Injury

Refers to physical injuries of sudden onset and severity that require immediate medical attention. Are the result of a variety of blunt, penetrating, and burn injuries.

Dead Space

Separation of wound layers that have not been closely approximated or air that has become trapped between tissue layers -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

Suture Sizes

Size indicates the diameter of the suture material. 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.

Closed Wound

Skin remains intact, but underlying tissues suffer damage

What is the most Inert suture for tissue?

Stainless steel

Inflammation

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

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.

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

Open Wound

The integrity of the skin is damaged

Hemophilia

The most common congenital bleeding disorder& manifests itself as a clotting deficiency

Argon Plasma Coagulation

The use of argon gas in combination with monopolar electrical energy in the form of white light beam

Clean Wound

Wound edges can be approximated and secured. A clean wound is expected to heal by first intention

Ligatures

Ties. Used to occlude vessels for hemorrhaging -Single-strand ligating material is available in precut lengths of 18-, 24-, and 30-in. strands. -Ligating methods include the free-tie, ligature reel, instrument tie (tie-on-a-pass), and suture ligature (stick tie)

Complications of Wound Healing

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. -Many factors influence wound healing: •Hematoma •Dehiscence •Edema •Evisceration •Exudate •Gangrene •Granuloma •Hemorrhage •Infection •Adhesion •Herniation •Fistula •Sinus tract formation •Suture complications •Ischemia •Keloid scar/ Keloid formation •Seroma •Wound tension •Dead space

Complicated Wound

Tissue is lost or destroyed, or a foreign body remains in the wound

Vascular clamps

Used for delicate tissue and causes little damage

Pledgets

When bleeding occurs through needle holes in vessel anastomosis, small squares of Teflon(pledgets) are used as buttresses over suture line. Sewn over holes to prevent bleeding. Used in cardio and peripheral vascular cases

pursestring stitch

a drawstring is placed in a circular fashion around a structure in such a way that pulling on a suture ends tighten and close the opening. used in the right atrium and ascending aorta for introduction of cannulae for cardiopulmonary bypass

Rapid-release needles

also referred to as: Controlled-release (CR)- designed to "pop off" the suture strand after a single suture has been placed

heparin needl

attached to syringes and are used in cardiovascular procedures to irrigate open arteries with saline-heparin solution

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

suture anchors

are for ortho surgery for fixing tendons and ligaments to bone

retention sutures

are large gauge, interrupted, nonabsorbable sutures that are placed lateral to a primary suture line for wound reinforcement

bolsters

are pieces of plastic or rubber tubing threaded over the retention suture ends before the ends are tied.

buried stitch

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

bridges

are plastic devices that bridge the closed incisions

cutting needles

are typically used for the sclera of the eye, tendons, or skin

intraluminal staplers

are used to anastomose tubular structures w/in the gastrointestional tract. Used more in distal colon and rectum procedures

skin staplers

are used to approximate skin edges during skin closure usually 35 wide or regular width staples

Clamps

are used to compress the walls of vessels and to grasp tissue. (hemostat)

stick ties

are used to prevent suture slippage that can lead to uncontrollable hemorrhaging. for superficial bleeders- 18 in stick ties are used, for deeper vessels-27in are use

traction suturing

are used to retract a suture that may not be easily retracted w a conventional retractor instrument, nonabsorbable sutures are used and ends are clamped with a hemostat used in sclera of the eye, myocardium of the heart and tongue.

irrigation needles

aren't actually needles but small diameter cannulated tubes attached to a plastic needle hub for placement on a syringe. Used during eye and microsurgery

arterial or venous/cannula needle

assemblies employ a needle to introduce a plastic indwelling catheter into a vessel(used commonly in IVs)

tapercut needles

combine a sharp taper point with a cutting tip used primarily in vascular tissue

Edema

condition of abnormally large fluid volume in tissues between the bodys cells, can be either too much fluid or too little which then causes swelling

Gangrene

decay or death of a organ or tissue caused by lack of blood supply -It is a complication resulting from infectious or inflammatory processes. -may be caused by a variety of chronic diseases and post-traumatic, post-surgical, and spontaneous causes

simple interrupted stitch

each stitch is individually placed, tied, and cut for the length of the wound. Wound is approximated and everted

Proud Flesh

excessive granulated tissue

Exudate

fluid with high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissue or on tissue surfaces, usually as a result of inflammation

ligature reels

for absorbable- subcutaneous tissue. Most commonly used reels are chromic, plain,or polyglactin 910 sutures in sizes 2-0, 3-0, and 4-0

endoscopic suturing

has 2 methods extracorporal, and intracorporeal

blunt point

have a round shaft at the end in a blunt tip primarily used for kidney or liver due to tissue being so friable or weak

regular tapered point needles

have a round shaft w/o a, so they penetrate tissue w/o cutting it. Used for delicate tissue such as gastrointestinal tract

arterial needles

ie potts-Cournand needle/cannula assembly, used to introduce diagnostic or angioplasty guiding catheters over guiding wires into the arterial system

closing the peritoneum

is a fast healing, thin membrane lining the abdominal cavity may nit req suturing if posterior fascia is closed properly. a continuous 3-0 absorbable suture is frequently used

continuous or running stich

is a primary suture line consisting of a single strand of suture placed as a series of stitches often used for closure of a long incision. Should not be used on tissues that are under a lot of stress

subcuticular stitch

is a single suture technique at the end of wound; multiple subcuticular bites are made opposite ends other the length of the wound. Are usually reinforced with dermabond or steri strips

skin adhesive

is a sterile liquid that is applied topically after the area has been cleaned and remains 5-10 days after and comes off naturally

closing the subcuticular layer

is a tough layer if connective tissue beneath the skin and subcutaneous layer. Is often utilized to minimize scarring. Short lateral stitches are placed in a continuous or interrupted fashion just under the epithelial layer of skin, with absorbable sutures

closing the fascia

is a tough layer of connective tissue covering the bodys muscles. It heals slowly and endures the brunt of wound stress. therefore interrupted heavy-gauge, nonabsorbable multifilament suture is preferred. If fascia is weak polypropylene surgical mesh may be sutured in w polypropylene sutures

interrupted horizontal mattress

is a two-bite suture technique. The first bite is a simple the 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.

Hemostasis

is stopping the loss of blood (clot formation, pressure, ligation, or hemostatic agents)

secondary suture line

is useful for support of the primary suture line

what is the rule of thumb in regards to suture ?

it should be as strong as the tissue on which is it being used (tensile strength)

Laparotomy sponge

lap sponges or tape sponges

surgical needles

must be smooth and free of burrs and have the characteristics of- eye,point,body

loading the suture

must choose the appropriate needle holder, loaded 1/3rd the distance of the swagged end of needle. Do not tug and when passing the needle holder and suture w needle are pointed toward surgeons chest.

reverse cutting needles

opposing cutting edges in a triangular configuration that extend into the full length of the shaft.

continuous running/ locking stitch

or the blanket stitch. Increases wound edge eversion and reduces the skin tension more than simple continuous

interrupted vertical mattressq

or the two bite suture techn. first bite is placed close to the wound edge, the 2nd bite is placed slightly behind the 1st bite and deeper in the tissue

Dehiscence

partial or total separation of a layer or layers of tissue after closure -Frequently occurs between the 5th & 10th Post-op day & is seen most often in debilitated patients with friable (easily torn) tissue

side cutting needles

primarily for ophthalmic procedures bc they will not penetrate into deeper tissues and separate the tissue layers during placement

Evisceration

protrusion of the viscera through the edges of a totally separated wound -is an emergency situation that requires immediate surgical intervention to replace the viscera and close the wound

monofilament ties

should be cut 1/4in ends due to knots ability to slide

What is another name(s) for a Hemostat?

snap, clamp, crile, stat

alternative skin closure methods

surgical zipper, cyanoacrylate ie dermabond

button holes

tendon sutures may be pulled through these . and tied over the button to prevent tissue damage

Coagulation

the body uses this in order to stop blood flow. (thrombus, or clots), is naturally occurring

closing the muscle

typically not closed with suture bc they do not tolerate the material well. If incised they must be loosely approximated with interrupted absorbable sutures

simple continuous stitch

used for long straight incisions when the wound edges easily evert.

Sponges

used to apply pressure on bleeding areas or vessels (absorb blood)

meshes and fabric

used to bridge for tissues that cannot be brought together w/o placing a great deal of tension on the tissue or to reinforce fascia defects

hypodermic needles

used to inject medications into tissues or intravenous tubing

linear staplers

used to insert 2 straight, staggered ,evenly spaced, parallel rows of staplers into tissue, used to be transected w/in alimentary tract or thoracic cavity and other procedures

biopsy needles

used to obtain tissue samples w/in the body for biopsy

ligating clips

used to occlude a single small structure such as a blood vessel of a duct. Must be divided and have at least two individual clips placed, the structure is then divided by a scalpel or scissors . Useful in endoscopic procedures especially cholecystecotomy

linear cutters

used to staple and transect the tissue, it delivers 2 double staple lines and contains a knife blade that passes btw the 2 staple lines dividing tissue . Used for gastrointestional procedures

Factors that may modify the normal condition of tissues

vitamins, proteins, dehydration, carbohydrates, vascularization, radiation therapy, metabolic factors, age, weight, incision relative to fiber direction, thickness of tissue at a given time, amount of devitalized tissue w/in a wound, edema

umbilical tape

was once used to ligate the severed ends of the umbilical cords after child birth. Is best used moistened with saline and loaded on a hemostat

Classification of Suture Materials

•Absorbable- capable of being absorbed by tissue within a given period of time •Nonabsorbable- resists enzymatic digestion or absorption by tissue •Monofilament- single thread-like structure •Multifilament- multiple thread-like structures braided or twisted into a single strand

Three types of wound healing.

•First intention( primary union) •Second intention (granulation) •Third intention (delayed primary closure)

What are the Classic Signs of inflammation?

•Pain •Heat •Redness •Swelling •Loss of function

Phases of Wound Healing by First Intention

•Phase 1: Lag Phase or Inflammatory Response •Phase 2: Proliferation phase •Phase 3: Maturation or Differentiation phase

3 Main Factors that Influence Wound Healing

•Physical condition of the patient •External factors the patient may be experiencing •Suturing techniques and prevention of wound infection

Suture Technique and Prevention Wound Infections

•Surgical Site Infections: ◦ Incisional infections ◦ Nosocomial infections ◦ Deep Wound infections •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 ‌•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)

Individual disease processes affecting suture choice that the Surgical Tech should be aware of are:

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

External Factors

●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 OR 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