Dr. Wahyu Prabowo S.PB

Wound healing and scarsThe goal of optimal wound closure is to

obtain a fine line scar that maintains both the form and appearance of the

tissue. It is important to let your patient know that any time there is an an

incision there is going to be a scar. However with careful technique and

close attention to tissue integrity this scar can be minimized. Know when it is

a closure that you should not attempt e.g. lip, eyelid, across a joint, tendon involved, or the web space of a hand.

Preparation• Plan the incision or type of closure• Gather equipment – irrigation, syringes, anesthetic,

instruments, suture, drapes, dressing.• Time out:

• Check patient name and sign a consent• Check what procedure is to be done

• Scrub glove and drape• Prepare the skin – betadine on the outside • Local anesthetic – lidocaine or bupivacaine• Debridement or incision• Undermining where necessary

Start in the center and swab in circles going outward

Instruments

adison forcep hemostat metzenbaum scissors suture scissors

Instruments

Needle holders suture removal scissors

blade handle bandage scissors

Handle and detachable blade

BASIC SURGICAL TOOLS

Scalpels

Conventional scalpel

Use of scalpels

Fiddle-bow-holding/Table knife holding Pencil-holding

The Scalpel‘Table knife holding’For routine skin incisions.Tissue division with

minimum trauma.Index finger guiding the

bladeDrawing the whole length

of blade.Blade 15 is the workhorse

of sharp dissectionDo not use blunt blades

The Scalpel ‘Pen holding’For finer work. Blade 10 is used for

finer dissection.Steady the arm by

using the little finger as a fulcrum.

Pass scalpels in a kidney dish.

Never pass it point-first across the table.

Change blades by using a haemostat .

Scissors

BASIC SURGICAL TOOLS

Use of ring-ended instruments with right and left hands

instrument-holding

BASIC SURGICAL TOOLS

Dissecting hemostatic forceps

Three mail functions: - dissecting tool, - grasping tool, - hemostatic tool.

Pean

Mosquito abdominal Pean

BASIC SURGICAL TOOLS

Electrocoagulating system

Monopolar Bipolar

BASIC SURGICAL TOOLS

Forceps

Anatomical forceps

Surgicalforceps

Ophtalmologicalforceps

Ring tip forceps Dental forceps

BASIC SURGICAL TOOLS

Use of forceps

Forceps must never be held in the palm!!!!!!

BASIC SURGICAL TOOLS

Forceps should be held like a pencil!

Bachaus towel clamp Schaedel towel clips

Towel-holding clamps

BASIC SURGICAL TOOLS

Hemostatic forceps

Traumatic Ι Atraumatic hemostatic forceps

Kocher Lumnitzer Bulldog Blalock Satinsky

BASIC SURGICAL TOOLS

Needle holders

Mathieu needle holder Hegar needle holder

BASIC SURGICAL TOOLS

Needle PositionNeedle should be secured 1/2 - 2/3 down the length needle from the tip

Organ clampsAllis

(lungs)Babcock (gallblader)

Ringed gallblader clamp

Klammer (intestinal clamp)

BASIC SURGICAL TOOLS

Sponge-holding clamp

Sponge-holding clamp

BASIC SURGICAL TOOLS

Handled sponge

Retracting and exposing instruments

These instruments are used to hold tissues and organs in order

to improve the exposure and hence the visibility and accessibility of the surgical field.

BASIC SURGICAL TOOLS

Hook Rake retractor Roux-retractor

BASIC SURGICAL TOOLS

French retractor Visceral retractor Abdominal wall retractor

BASIC SURGICAL TOOLS

Weilaner self-retractor Gosset self-retractor

BASIC SURGICAL TOOLS

Sterile instruments• Have the instruments been sterilized and

packed in sterile packages?• Has the indicator tape changed color• Is the package still sealed and double wrapped

Sterilize with:• Autoclave 15- 20 psi 220 to 250 degrees F• Gas • liquid

The Ideal Suture Material

Can be used in any tissueEasy to handleGood knot securityMinimal tissue reaction

The Ideal Suture MaterialUnfriendly to bacteria

Strong yet small

Won’t tear through tissues

Cheap

What’s It Used for?To bring tissue edges together and speed

wound healing (=tissue apposition)

Orthopedic surgery to help stabilize jointsRepair ligaments

Ligate vessels or tissues

- Double thread (traumatisation)- Lace time- Re-sterilisation- Care of needle-tip- Corrosion

Conventional needlesClosed eyed

French-eyed

SURGICAL MATERIALS

Atraumatic needles

- Simple thread (atraumatic)- Manufactured connection of needle and threads

- No Lace time- No re-sterilisation- No Care of needle-tip- No Corrosion

SURGICAL MATERIALS

3/8 Circle 5/8 Circle¼ Circle ½ Circle

Multiple curved

J-shapedStraight

Progressive curved

Shape of needle

SURGICAL MATERIALS

Shape of its body

Round needle Triangular (Cutting) needle

SURGICAL MATERIALS

Taperpoint

Tapercutting

Blunt taper

Round needle

SURGICAL MATERIALS

Cutting needleConventional

Reverz cutting

Spatula

SURGICAL MATERIALS

Characteristics of Suture Material

Absorbable Vs. Nonabsorbable

Monofilament Vs. Multifilament

Natural or Synthetic

Absorbable SuturesInternalIntradermal/ subcuticularRarely on skin

Non-absorbable SuturePrimarily Skin

Needs to be removed later

Stainless steel = exceptionCan be used internally

Ligature Orthopedics

Can be left in place for long periods

Reading the Suture Label

Company

Needle

Size Order Code

NameAlso:

LENGTH

NEEDLE SYMBOL

COLOR

Absorbable or Non

Monofilament Vs. Multifilamentmemory easy to handleless tissue drag more tissue dragdoesn’t wick wicks/ bacteriapoor knot security good knot security- tissue reaction +tissue

reaction

Natural Vs. SyntheticNatural:

GutChromic GutSilkCollagen

All are absorbable

Gut/ Chromic GutMade of submucosa

of small intestines

Multifilament

Breaks down by phagocytosis: inflammatory reaction common

Gut/ Chromic GutChromic: tanned, lasts

longer, less reactive

Easy handling

Plain: 3-5 days Chromic: 10-15 days

Bacteria love this stuff!

Collagen and SilkNatural sutures

VERY reactive, absorbable

Ophthalmic surgery only

Non-absorbableNot biodegradable

and permanentNylon (Ethilon)ProleneStainless steelSilk (natural,

can break down over years)

Degraded via inflammatory responseVicrylMonocrylPDSChromicCat gut (natural)

Absorbable

Absorbable

1.Polyglycolic acid (Safil®, Safil Quick®, Dexon®) 2. Polyglactin (Vicril®, Vicryl Rapide®)3. Glycomer (Biosyn®)4. Polyglytone (Caprosyn®)5. Glyconate (Monosyn®)6. Polyglyconate (Maxon®)7. Polydioxanone (PDS II®, MonoPlus®)8. Lactomer (Polysorb®)9. Gut (Cromic Gut®, Plain Gut®)

SURGICAL MATERIALS

1. Polyamide (Dafilon® , Ethilon®, Supramid®, Nurolon®, Surgilon®)2. Polyester (Ethibond®, Ti-Cron®, Synthofil®, Dagrofil®, Mersilene®)3. Polybutester (Novafil®, Vascufil®)4. Polypropylene (Premilene®, Prolene®, Surgipro®)5. Silk (Silkam®, Virgin silk®, Mersilk®, Softsilk®)6. Steel (Steelex®, Steel wire®, Steel®)

Non-absorbable

SURGICAL MATERIALS

Natural SutureNatural Suture

BiologicalCause inflammatory

reactionCatgut

(connective from cow or sheep)

Silk (from silkworm fibers)

Chromic catgut

SyntheticSyntheticSynthetic polymersDo not cause

inflammatory responseNylonVicrylMonocrylPDSProlene

MonofilamentMonofilamentSingle strand of suture

materialMinimal tissue traumaSmooth tying but more

knots neededHarder to handle due to

memoryExamples: nylon,

monocryl, prolene, PDS

Multifilament (braided)Multifilament (braided)Fibers are braided or

twisted togetherMore tissue resistanceEasier to handleFewer knots neededExamples: vicryl, silk,

chromic

Vicryl (Polyglactin 910)Braided, synthetic, absorbableStronger than gut: retains strength 3 weeks Broken down by enzymes, not phagocytosisBreak-down products inhibit bacterial growth

Can use in contaminated wounds, unlike other multifilaments

Dexon and PGAPolymer of glycolic acidsBraided, synthetic, absorbableBroken down by enzymesBoth PGA and dexon have increased tissue

drag, good knot securityBoth are stronger than gut

PDS (polydioxine)Monofilament (less drag, worse knot security

– lots of “memory”)Synthetic, absorbableVery good tensile strength (better than gut,

vicryl, dexon) which lasts monthsAbsorbed completely by 182 days

Maxon (polyglyconate)Monofilament- memorySynthetic AbsorbableVery little tissue dragPoor knot securityVery strong

NONABSORBABLE SUTURESNatural or SyntheticMonofilament or multifilament

                           

NYLONSyntheticMono or MultifilamentMemoryVery little tissue reactionPoor knot security

Polymerized CaprolactumVetafil, Braunamid, SupramidMultifilament suture with protein coatingSyntheticGood knot security, easy handlingNot very reactiveDon’t use in contaminated woundUsually comes on a reel

PolypropyleneProlene, SurgileneMonofilament, SyntheticWon’t lose tensile strength over timeGood knot securityVery little tissue reaction

Stainless SteelMonofilament Strongest !Great knot securityDifficult handlingCan cut through tissuesVery little tissue reaction, won’t harbor

bacteria

Suture SizesSized #5-4-3-2-1-0-00-000-0000…30-0

BIGGER >>>>>>>>>>>>>>>>SMALLER00 = 2-0, “two ought”

SA : 0 through 3-0 (Optho 5-0 >>7-0)

LA : 0 through 3

Suture Sizes (cont)Stainless Steel

In gauges (like needles) Smaller gauge = bigger, stronger Larger gauge= smaller, finer

26 gauge = “ought”28 gauge = 2-0

Suture material filament Absorbing properties

Tissue reaction

Tensilestrength

Tensile strength retention

cost Uses

plain gut collegen absorbable moderate poor 2-4 days low Inside the wound where it absorbs and wound healing is quick

chromic gut collegen absorbable moderate poor 7-10 days low Inside the wound where it absorbs and wound healing time is average length

polygalactic acid (Vicryl)

braided absorbable mild poor 2-3 weeks moderate Inside the wound where it absorbs and longer wound healing time is required,such as tendons.

silk braided Non-absorbable

high poor 1year low Skin closure or fascia

nylon monofiliment Non-absorbable

Very low good Loses 20%/yr

low Skin closure or fascia or where long term strength is needed

Polypropylene (Prolene)

monofiliment Non-absorbable

minimal excellent indefinite high Sub-cuticular skin closure or fascia or where permanent strength is needed.

Polyester (Mersilene)

braided Non-absorbable

minimal good indefinite high Internally where low reaction braided suture is required to allow tissue to adhere to it.

stainless steel monofiliment Non-absorbable

low excellent indefinite moderate Bone , tendons, strong connective tissue where permanent strength is required

AnestheticLidocaine 1% or 2% - inject locally or a regional block

• gives anesthesia and reduces muscle movement

Bupivacaine (Marcaine) 0.25% or 0.5%• gives anesthesia only

lidocaine and bupivacaine can be mixed half and half

Epinephrine can be added to increase anesthetic time and decrease bleeding – don’t not use on fingers, nose, penis or toes

May be buffered - 9:1 with sodium bicarbonate, to reduce pain on injection (e.g. remove 2 mL of 1% lidocaine from 20 mL vial, and add 2 mL of sodium bicarbonate solution to vial)

AnestheticLocal Lidocaine (Xylocaine) 1% or 2%

• Onset: 2 minutes• Duration: 1.5 to 2 hours• Action : anesthesia and reduced muscle movement• Max dose: 4-5 mg/kg to 280-300 mg (14 -15 ml 2%, 28-30 ml 1%)

Lidocaine with Epinephrine 1:100,000 or 1:200,000• Onset: 2 minutes• Duration: 1 – 3 hours• Action : anesthesia and reduced muscle movement• Max dose: 7 mg/kg to 500 mg (25 ml 2%, 50 ml 1%)

Bupivacaine (Marcaine) 0.25%• Onset: 5 minutes• Duration: 2 to 4 hours• Action : anesthesia only• Max dose: 2.5 mg/kg up to 175 mg (50 ml 0.25%, 25 ml 0.5%)

Anesthetic SolutionsLidocaine (Xylocaine®)

Most commonly usedRapid onset Strength: 0.5%, 1.0%,

& 2.0% Maximum dose:

5 mg / kg, or 300 mg

1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc

300 mg = 0.03 liter = 30 ml

Lidocaine (Xylocaine®) with epinephrineVasoconstrictionDecreased bleedingProlongs duration Strength: 0.5% & 1.0%Maximum individual

dose: 7mg/kg, or 500mg

Anesthetic SolutionsCAUTIONS: due to its vasoconstriction

properties never use Lidocaine with epinephrine on: Eyes, Ears, Nose Fingers, ToesPenis, Scrotum

Anesthetic SolutionsBUPIVACAINE (MARCAINE):

Slow onsetLong durationStrength: 0.25%DOSE: maximum individual dose 3mg/kg

Injection Techniques25, 27, or 30-gauge

needle6 or 10 cc syringeCheck for allergiesInsert the needle at

the inner wound edge

AspirateInject agent into

tissue SLOWLY Wait…After anesthesia has

taken effect, suturing may begin

Basic knot tying

1 2 3 4

1 – square knot2 – granny knot3 - slip knot4 – surgeon’s knot

Instrument tying

Surgical wound closure guidelines

• Adequate debridement and hemostasis• Atraumatic technique• Alignment with the relaxed skin tension lines• Angle of incision

• Perpendicular to skin surface or slightly undermined

• Angle incisions parallel to hair shafts• Consider area of the body for vascularity and

tension on the wound

Key techniques

• Close dead space under the incision• Close that issue in layers• Carefully align the wound edges• Careful choice of the axis of incision or axis of

closure of the donor skin flaps• Correct choice of deep and cutaneous sutures

Bleeding

• Control with pressure directly over the wound immediately

• Locate the nearest artery and put pressure there to give yourself room to work.

• If necessary tie off the bleeding vessel.

• Use a pressure bandage

Simple Interrupted sutures• This suture is used for simple laceration

closures or closure of office procedures like biopsies or lesion removals.

• It is also the basic suture used inside the wound to close deep sutures.

• It is useful in that a few sutures can be removed at a time instead of all at once to allow for slower sound healing

Continuous Sutures• The continuous suture as its name suggests,

only has a knot at the beginning and the end. • There are several methods of continuous

suture – locking and non-locking.• The knots must be very secure and minimal

tesion on the wound or the wound will come apart if one loop or knot gives way.

• The advantage is that it is very quick and the wound tension is even across the wound.

Horizontal Mattress Suture• Used with wounds with poor circulation• Helps eliminate tension on wound edges• Requires fewer sutures to close a wound • Can be placed quite quickly• Can be done as a continuous suture

Vertical Mattress Sutures• Deep and shallow approximation of the tissue• Can be used for wounds under tension.• Can be useful with lax tissue e.g. elbow and

knee.• Should not be used on volar surface of hands

or feet or on the face because of blind placement of the deep part of the suture.

Sub-cuticular closure• Used for cosmetic closures• Use an absorbable suture if you plan to leave

the sutures in and bury the knots• Use either nylon or prolene (best) and keep

the suture sliding while you are closing. The suture then can be easily removed with no exterior marks. The ends can be taped or a knot on the skin.

• At each entry point, enter across form the last exit with slight overlap.

Eliptical incisionThe ellipse should be three times as long as it is

wide. This will make closure of the wound much easier. If the lesion you are removing is likely to be cancerous, make sure that you leave wide margins of clear skin around the lesion.

3 Cornered Suture• Used to close a skin flap which comes to a point.• Helps close the wound, but maintain circulation

to the tissue.• Places minimal tension on the wound edges

Suture material filament Absorbing properties

Tissue reaction

Tensilestrength

Tensile strength retention

cost Uses

plain gut collegen absorbable moderate poor 2-4 days low Inside the wound where it absorbs and wound healing is quick

chromic gut collegen absorbable moderate poor 7-10 days low Inside the wound where it absorbs and wound healing time is average length

polygalactic acid (Vicryl)

braided absorbable mild poor 2-3 weeks moderate Inside the wound where it absorbs and longer wound healing time is required,such as tendons.

silk braided Non-absorbable

high poor 1year low Skin closure or fascia

nylon monofiliment Non-absorbable

Very low good Loses 20%/yr

low Skin closure or fascia or where long term strength is needed

Polypropylene (Prolene)

monofiliment Non-absorbable

minimal excellent indefinite high Sub-cuticular skin closure or fascia or where permanent strength is needed.

Polyester (Mersilene)

braided Non-absorbable

minimal good indefinite high Internally where low reaction braided suture is required to allow tissue to adhere to it.

stainless steel monofiliment Non-absorbable

low excellent indefinite moderate Bone , tendons, strong connective tissue where permanent strength is required

Care of the patientHow will you care for your patient and

maintain a safe environment?