Chapter 11 Review

Define hemophilia.

a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.

· Class III: Contaminated

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

Describe the process of following a suture during a continuous running closure.

o 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 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.

Demonstrate knowledge of keloid formation.

o Keloid: a 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.

· Class I: Clean

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

· Class II: Clean Contaminated

o Primary closure o Open/mechanical drainage o Minor break in sterile technique occurred o Controlled entry to aerodigestive (includes biliary tract) or genitourinary tract

Describe dead space and surgical techniques used to eliminate dead space.

· A space formed between tissues that are normally anatomically connected. · What can dead space fill up with? o fluid (the usual choice) or gas · What can dead space caused by? o - by excessive dissection → either by a surgeon or by a traumatic event, such as a big dog grabbing a little dog and shaking him o - removal of masses or body parts o - skin flap/graft reconstruction → because this by its nature involves a lot of dissection and removal of stuff from one location to another · Why is dead space not ideal? o - slows healing o - increases chances that the wound will become infected. · How does dead space cause slow healing and infection risk? o It makes it physically difficult for fibrin to bridge and fibroblasts to crawl across from one tissue plane to the other · What impact does the presence of fluid in the space have? o Blood supply is also compromised · What impact does the presence of gas have? o fluid in the space decreases the opsonic activity of antibodies, disrupts the interaction between phagocytes and bacteria o Gas accumulation within dead space makes your patient feel as if she is made out of bubble wrap, which also slows wound healing · How can dead space be minimized? o Avoid creating dead space when operate →using meticulous, minimalist technique o avoid undermining o do NOT, dissect the subcutaneous tissue away for several centimeters on either side of midline o Can be eliminated by the use of proper suturing techniques, wound drains and or pressure dressings.

Review abdominal wall layers.

· Abdominal wounds are closed in layers. From inner to outer, these layers include the peritoneum, fascia, muscle, subcutaneous, subcuticular, and skin layers. o Peritoneum: it's 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. o Fascia: It is a layer of tough connective tissue covering the body's muscles. § It is 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 the 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. o Muscle: § 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. § If they are incised, however, they should be loosely approximated with interrupted absorbable sutures. o Subcutaneous: § 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. Plain gut is often the preferred suture material for subcutaneous closure. o Subcuticular: § 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. o 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.

Describe the use of bolsters during wound closure.

· 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

Describe the use of cyanoacrylate and common trade names for this product.

· Cyanoacrylate is a synthetic adhesive used for skin closure: o 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

Describe the process of debriding a surgical wound.

· 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)

Demonstrate knowledge of Halsted related to tissue handling and suturing.

· Dr. William Halstead was a famous surgeon who was the professor of surgery at Johns Hopkins Hospital from 1893 to 1922. · Notable contributions include development of the penrose drain and introduction of the use of the surgical glove and use of hemostats for clamping bleeding vessels. · However, he is well known for his principles of tissue handling and suturing techniques. · The following are Halstead's suture technique principles: o It should be understood that these principles were based on the only two suture materials that were available for use in that time period; with the development of improved synthetic suture materials, wound closure can be performed by the surgeon using various techniques with few complications. · Suturing techniques: o Interrupted sutures should be used to promote greater strength along the wound; each suture should be tied separately. If one knot slips or breaks, all other knots will hold. o Interrupted sutures are a barrier to infection, preventing microbes from traveling along a continuous suture strand. o Sutures are as fine as is consistent with security. A suture stronger than the tissue in which it is placed is unnecessary. o Suture should be cut close to the knots. Long ends can increase tissue inflammation and irritation. o A separate needle should be used for each skin stitch. o Dead space in the wound is prevented and eliminated o Two fine sutures are used instead of one large suture. o Silk material should not be used in the presence of infection. o Undue tension should not be placed on the tissue by the suture to avoid strangulation of the blood supply.

Describe suturing methods used during laparoscopic procedures.

· Endoscopic Suturing o 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. o A common method is forming extracorporeal slip locking knots with subsequent transfer of the knot to the tissue site. o 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. § Endostitch 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.

Describe evisceration of an abdominal wound.

· Evisceration is the 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.

Define the term friable in relation to surgical tissue.

· Friable means easily torn.

Review complications that may arise from tightly approximating tissue.

· If tissue is approximated too tightly, it can result in ischemia. · Ischemia is the decreased supply of oxygenated blood to a body part. Signs of acute limb ischemia including pain, pallor, pulseless, paresthesia, paralysis, and poikilothermia (inability to regulate core body temperature) · Some causes of ischemia are arterial embolism, atherosclerosis, thrombosis, and vasoconstriction.

Define tensile strength in relation to surgical suture material.

· Knot tensile strength is measured by the force in pounds that the suture strand can withstand before it breaks. o The tensile strength of the tissue is what determines the size and tensile strength of the suture the surgeon chooses. o The rule of thumb is the suture should be as strong as the tissue on which it is being used and the suture tensile strength should equal the tissue tensile strength.

Review the use of suture ligatures during surgical procedures.

· Ligatures are referred to as ties, are used to occlude vessels for hemorrhage control or for organ or extremity removal. o 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. · 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 technologists. · 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 inches in length. · Deep bleeders require a suture length of between 18 and 30 inches. · Ligating methods include the free-tie, ligature reel, instrument tie (tie-on-a-pass), and suture ligature (stick tie). · Free-Tie o Ligating material may be used as either single-strand ties or as continuous ties from a reel or other device. o Pre-cut 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 a reel and is not loaded onto a instrument. o 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 an surgeon's knot. The assistant then cuts the excess suture. Monofilament sutures, becaused the knots can slide and are typically cut leaving ¼ inch ends. § Multifilament sutures can be cut closer to the knot 1/8 in because they do not slide as readily as monofilament sutures. · Ligature Reel o May be wound with absorbable or nonabsorbable sutures and are typically used to occlude superficial bleeders. o Reels with absorbable suture material are frequently used on superficial bleeders of subcutaneous tissue just after the incision is made. o The most commonly used ligature reels are chromic, plain, polyglactin 910 (vicryl) sutures. § Silk ligature reels are still available for use as well. o 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. o The surgical technologist should prepare the reel by unhooking the end of the suture strand and pulling it 2 to 3 inches away from the reel so that the surgeon can grasp the suture without struggling to find the end. · Instrument Tie (Tie-on-a-Pass) o Deep bleeding vessels have been occluded with a hemostat clamp may be inaccessible for a free-hand ligature. Therefore, a suture is loaded on to 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. · Suture Ligature (Stick Tie) o Large vessels are typically occluded with suture ligatures or stick ties to prevent suture slippage that can lead to uncontrolled hemorrhage. o 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. o The ends of the suture are brought around the clamp so that the vessel is doubly ligated. o For superficial bleeders, 18 inch, stick ties are used and 27 in stick ties are used for deeper vessels. o Sizes 2-0 and 3-0 are the most commonly used stick-tie sizes and silk is the preferred suture material. o In theory, however, any suture material can be used as a stick-tie ligature; it depends on the tissue to be sutured.

Review different methods of hemostasis.

· Mechanical Hemostasis can be achieved with the use of several types of devices to control bleeding until a clot forms. o Hemostatic instruments o Ligatures o Clips o Sponges o Pledgets o Bone Wax o Pressure Devices · Biological Hemostasis o Fibrin glue is a biologic adhesive and hemostatic agent. · Thermal Hemostasis o Electrosurgery o Lasers o Argon Plasma Coagulation o Ultrasonic (Harmonic) Scalpel · Chemical Hemostasis o Absorbable gelatin (Gelfoam) o Absorbable Collagen (Avitene) o Microfibrillar collagen o Oxidized cellulose (Nu-Knit, Surgicel) o Silver Nitrate o Epinephrine o Thrombin

Describe the natural process that breaks down absorbable suture material.

· Natural absorbable sutures are digested by body enzymes that attack the suture strand, eventually destroying it.

Describe the least traumatic needle suture combination.

· Nonsuture needles such as hypodermic, arterial, intravenous, irrigation, biopsy, insufflation, and spinal needles are commonly utilized during surgical procedures. · Hypodermic needles are used to inject medications into tissues or intravenous tubing. o The surgical technologist uses them to withdraw medications into a syringe from a vial held by a circulator. o Also may be used to withdraw fluids from tissues. o They are produced in varying sizes and lengths. Needle lengths range in size from ½ to 4 in and gauge sizes range from 12 to 30 with smaller needles having larger gauge number. · 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). o 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. o 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 systems. · 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. · Irrigation needles are actually not needles but small-diameter cannulated tubes attached to a plastic needle hub for placement on a syringe. o The irrigation needles are available straight and angled, disposable or nondisposable, and in various lengths. They are commonly used during eye and microsurgery procedures. · When laparoscopic procedures are performed, the abdomen must be distended or insufflated with CO2. o A Veress needle that is attached to the CO2 tubing is introduced percutaneously into the abdomen to facilitate the delivery of the gas. · Large percutaneous biopsy needles are used to obtain tissue samples from within the body for biopsy. o This type of biopsy is sometimes guided with the aid of CT scan or fluoroscopy. § Examples of this type of needle include the Corsey 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; 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. o 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. o 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. o 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.

Review the phases of wound healing.

· Phase 1: Lag Phase or Inflammatory Response Phase o 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. o 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-filled fluid into the extravascular fluid compartment, resulting in edema and localized pain. o Leukocytes move to the endothelial lining of the small vesels 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. o 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. · Phase 2: Proliferation phase o This stage begins on approximately the third postoperative day and continues for up to 20 days. Fibroclasts 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. · Phase 3: Maturation or Differentiation phase o 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. Describe the types of wound healing. · First intention (Primary Union) o 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 wound edges have been accurately approximated. Wounds heal rapidly with no separation of the edges and minimal scarring. o Wound tensile strength plateaus at the third month at 70 to 80 percent of original strength. o Healing by first intention occurs in three distinct phases. · Second Intention (Granulation) o Occurs when a wound fails to heal by primary union. It generally occurs in large wounds thar can not 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. o May be allowed following the removal of necrotic tissue or after a wide debridement. o The wound is left open and allowed to heal from the inner layer to the outside surface. o Granulation tissue that contains myofibroblasts forms in the wound, causing closure by contraction. · Third Intention (Delayed Primary Closure) o Occurs when two granulated surfaces are approximated. o The traumatic such as Class III and Class IV surgical wounds are debrided and purposely left open to heal by second intention (granulation) for approximately 4 to 6 days. o 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. o The infection-free wound is then closed and allowed to finish the healing process through first intention (primary closure). o The result is a wound that heals by contraction, granulation, and connective tissue repair with intermediate tensile strength and scarring. o This method of repair works well for contaminated or dirty wounds.

Demonstrate knowledge of vessel loop color utilization.

· 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. o Typically, white and yellow loops are for nerves o Red loops are for arteries o Blue is for veins o Packaged in pairs

Describe the use of skin closure tapes.

· 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, ¼. and ½ in widths.

Review surgical stapling devices.

· Stapling devices include skin, fascia, linear (stapling and cutting), ligating, intraluminal and endoscopic types. · Skin: o Skin staplers are used to approximate skin edges during skin closure. 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. § Small staplers loaded with 5 to 10 staples are available to close small incisions. o 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. o A single squeeze and release of the mechanism positions the staple. o Individuals staples can also be used to close the tough tissue of the abdominal fascia. This layer is thick and heals slowly. o The nonreactive nature of metallic staples makes them an ideal choice for fascia. · Fascia: o Fascia staplers are not much different from skin staplers. o They are a disposable stapler shaped like a gun and discharge a single, wide stainless steel staple by squeezing the handle. o The staple first penetrates the fascia and then is formed to approximate the fascia. It is frequently used in abdominal, gynecological, and orthopedic surgery. · Linear staplers o Used to insert two straight, staggered, evenly spaced, parallel rows of staples into tissue. 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 staplers is available in various lengths. o 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. · Linear Cutters o It is used to staple and transect the tissue. Linear cutters deliver two double staple lines similar to the one produced by the linear stapler and contains a knife blade that passes between the two staple lines, dividing the tissue. The linear cutter is especially useful during gastrointestinal procedures. o A variation of the linear cutter is available for endoscopic procedures. The staplers are operated manually or by battery power. · Ligating Clips o It 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). o The structure is then divided with a scissors or a scalpel. o The stainless steel, titanium, tantalum, or absorbable clips are available in an automated disposable applier or may be manually loaded onto a reusable device. o A variation of the automated disposable applier is available for endoscopic procedures and is especially useful during cholecystectomy. · Ligating Dividing Stapler o It 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. · Intraluminal Staplers o Used to anastomose tubular structures within the gastrointestinal tract. o The stapler fires a double row of circular staples and then trims the lumen with a knife located within the head of the stapler. o These staplers are commonly used during resection and reanastomosis of the distal colon or rectum. o Other types of intraluminal staplers are used to surgically repair severe cases of hemorrhoid prolapse and to correct obstructed defecation syndrome.

Gain understanding of different mesh materials and characteristics of each type of mesh.

· Surgeons often make use of meshes to strengthen the damaged fascia during hernia repair. · Advantages of synthetic meshes include: o Pliable (except for stainless steel mesh) o Easy to cut to create the correct size to be implanted o Easy to suture into place in open or endoscopic procedures o Porous: pores in mesh allow fibrous tissue to grow through the mesh, strengthening the tissues · Polypropylene Mesh (Prolene Mesh): This is relatively inert material than 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. · Polytetrafluroethylene (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 an infection because its multifilament fiber construction can harbor bacteria.

Gain understanding of different suture needle configurations and the use of each type of needle.

· Surgical needles are used to insert suture material into tissue and are available on 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: eye, point, and body · Needle eyes: o 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) o Closed-eyed needles may have round or square holes and are loaded by inserting the end of the suture material through the hole. o 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. o 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-eye needle, but still results in more tissue damage than the eyeless needle. o Needles that are manufactured with suture strands inserted into one end are referred to a eyeless or swaged needles. These needles are continuous with the suture strand, and the hole created in tissue by the needle should be completely filled by the suture strand when suturing. o 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 be used for interrupted or continuous suturing. o 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. o Eyeless needles may have the suture strand permanently attached, may be controlled-release needle used for rapid, efficient placement of interrupted sutures. · Needle points: o May be cutting, tapered or blunt and the needle itself straight or curved. o 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. o Conventional cutting needles consist of three cutting edges that are directed along the inner curve of the needle. The needles place a place a small cut in the direction of the pull of the suture. o 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. o Side cutting needles are used primarily for ophthalmic procedures because they will not penetrate into deeper tissues and separate the tissue layers during placement. o 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 o Taper cut 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. o 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.

Review suture materials and characteristics of each suture type. Gain understanding of the chemical make up of common suture material.

· Suture materials have distinguishing characteristics that can be compared. o Physical characteristics include configuration, capillary, ability to absorb fluid, size (diameter), tensile strength, knot strength, elasticity, and memory. o Sutures may vary in pliability, how easily they pass through tissue, and how easily they tie and knot security. o Each suture has a certain predictable effect on the tissue on which it is used.

Review different suturing techniques.

· Suturing techniques include the various methods for proper closure of wounds under any conditions. All wounds are not the same, and one technique for closure may not be applicable in all situations. · The primary suture line refers to the sutures that approximate wound edges for first intention healing. o 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. · Continuous Suturing Techniques o Also known as the 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 last stitch is placed at the other end. o Evenly distributed tension along the suture line is a hallmark of the continuous suture closure. o The surgical assistant "follows" or "runs" the suture by holding the lower quarter of the suture taut and away from the area of closure. § The process keeps the proper amount of tension on the suture line and keeps the suture strand out of the surgeon's line of view. o 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. o 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 the way of a continuous suture strand, referred to as wicking. · Simple Continuous o It is used for long, straight incisions when the wound edges easily evert. o 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. o 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. · Continuous Running/Locking o 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 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. o Subcuticular § 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 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. o Pursestring § With the 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. § 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. § Also, placed into the right atrium and ascending aorta for introduction of cannulae for cardiopulmonary bypass. · Interrupted suturing techniques o 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 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. · Simple Interrupted o Each stitch is individually placed, tied, and cut for the length of the wound. Wound edges are approximated and everted. · Interrupted Horizontal Mattress o It is a two-bite suture technique where there are two stitches are placed parallel to each other on each side of the wound. o 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 Vertical Mattress o 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 of the side where the first bite was placed. This technique is used for deep wounds and provides excellent eversion and skin approximation. · Figure-of-8-Stick Ties o 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. · Buried o Sutures are placed so the knot is located under the layer to be closed and is not projecting outward. · Traction Sutures o Used to retract a structure that may not be easily retracted with a conventional retractor instruments. § A non-absorbable 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: traction sutures are those placed into the sclera of the eye, the myocardium of the heart, or the tongue. · Secondary Suture Line o It 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. · Retention o They are large-gauge interrupted, nonabsorbable sutures placed lateral to a primary suture line for wound reinforcement. o These sutures may be placed through all layers of the tissue. o 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. o Retention sutures can also prevent wound disruption that may result from sudden increases in abdominal pressure created by postoperative vomiting or coughing. · Endoscopic Suturing o 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. o A common method is forming extracorporeal slip locking knots with subsequent transfer of the knot to the tissue site. o 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. § Endostitch 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.

Describe the role of U.S. Pharmacopeia (USP) in relation to surgical suture.

· The U.S. 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. o Suture size is numerical; as the number of 0s increase, the diameter becomes smaller. o 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 sture. The largest available suture for use in surgery is #5; it is approximately the size of commercial string. · 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. · Sizes 8-0 through 11-0 sutures are used for microvascular and eye procedures. · Size 4-0 sutures are used to close dural incisions; sizes 3-0 and 4-0 sutures are used for most subcuticular skin closures. · Suture lengths range from 5 in to 59 in.

Gain understanding of blood types and advantages of different blood types.

· The four main types are A, B, O and AB all based on the presence or absence of A and B red cell antigens. o The blood contains agglutinins which are antibodies that work against the A and B antigens. o Individuals with type A blood naturally produce anti-B agglutinins and individuals with type B blood naturally produce anti-A agglutinins. o 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.

Review possible postoperative wound complications. Describe inflammatory reactions in response to wound healing.

· Tissue disruption, whether intentional or accidental, leaves the patient vulnerable to infection and other complications, o Hematoma: localized swelling filled will blood resulting from a break in a blood vessel. o Dehiscence: partial or total separation of 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 which means, easily torn tissue. § Also can be caused by abdominal distention, too much tension on the wound, inappropriate type or strength of suture material, or improper suturing technique. o 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. o Evisceration: protusion 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. o 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. o 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. o Granuloma: Mass of inflamed granulation tissue usually associated with ulcerated infections. o Hemorrhage: concealed or evident and occurs most frequently in the first few postoperative hours. Can result in postoperative shock. Surgery is frequently required to achieve hemostasis. o Infection: Infection of a wound occurs when microbial contamination overrides the resistance of the host. It results increased morbidity or mortality. Additionally, to antibiotic therapy, additional surgery may be required as part of the treatment regimen. o 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. The fibrous tissue that develops can cause abnormal attachments of the abdominal viscera that may cause pain and or bowel obstruction. o Herniation: a result of wound dehiscence and occurs most often in lower abdominal incisions. o Fistula: 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, and needs surgery. o 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 needed. o Suture complications: Occurs 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. o Ischemia: Decreased supply of oxygenated blood to a body part. Signs of acute limb ischemia- 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. o Keloid: a 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. o 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 most likely to undergo secondary infection. o 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. o 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. Can be eliminated by the use of proper suturing techniques, wound drains and or pressure dressings.

Review the use of a traction stitch during a surgical procedure.

· Traction Sutures o Used to retract a structure that may not be easily retracted with a conventional retractor instruments. § A non-absorbable 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: traction sutures are those placed into the sclera of the eye, the myocardium of the heart, or the tongue.

Define the term homologous in relation to blood product donation.

· Transfusions involves someone collecting and infusing the blood of a compatible donor into him/herself.