ETHICON delivers value through a full line of proven products, innovative technology, and responsive business services. PREFACE his manual has been prepared for the medical professional who Twould like to learn more about the practice of surgery–the dynamics of tissue healing, the principles of wound closure, and the materials available to today’s practitioners. Most important, it touches on some of the critical decisions which must be made on a daily basis to help ensure proper wound closure. ETHICON PRODUCTS, a Johnson & Johnson company, is the world’s leading marketer of surgical sutures and is the only U.S. company that offers an adhesive with microbial protection as an alternative to sutures for topical skin closure. ETHICON enjoys a reputation for developing quality products to enhance the lives of patients and for providing outstanding service to customers. We hope you find this manual useful. But, above all, we hope that it reflects our high regard for the men and women who have chosen the medical profession as a career. ~ ETHICON PRODUCTS ~ CONTRIBUTING EDITOR David, L. Dunn, M.D., Ph. D. Jay Phillips Professor and Chairman of Surgery, University of Minnesota We thank Dr. Dunn for his contributions to the Wound Closure Manual. Dr. Dunn is currently the Jay Phillips Professor and Chairman of Surgery at the University of Minnesota. This department has a long-standing tradition and has attained national and international recognition for excellence in training academic general surgeons and surgical scientists. He is also the Division Chief of General Surgery, Head of Surgical Infectious Diseases, Director of Graduate Studies, and Residency Program Director of the Department of Surgery. Dr. Dunn has published over 400 articles and book chapters in the areas of Surgical Infectious Diseases and Transplantation. He has received regional and nationwide recognition in several academic organizations and is a Past-President of the Surgical Infection Society, the Association for Academic Surgery, the Minnesota Chapter of the American College of Surgeons, the Society of University Surgeons and the Society of University Surgeons Foundation. TABLE OF CONTENTS WOUND HEALING Knot Tying......................................................... 24 AND MANAGEMENT Knot Security............................................ 24 1 Knot Tying Techniques Most Often Used .......... 25 The Wound.......................................................... 2 Square Knot............................................. 25 Recovery of Tensile Strength............................ 2 Surgeon’s or Friction Knot............................ 26 Patient Factors that Affect Wound Healing......... 2 Deep Tie................................................. 26 Surgical Principles....................................... 4 Ligation Using a Hemostatic Clamp............... 26 Classification of Wounds................................... 5 Instrument Tie.......................................... 26 Types of Wound Healing................................... 6 Endoscopic Knot Tying Techniques.................. 26 Healing by Primary Intention........................ 6 Cutting the Secured Sutures.......................... 26 Healing by Second Intention.......................... 7 Suture Removal................................................. 26 Delayed Primary Closure.............................. 7 Suture Handling Tips....................................... 27 Suture Selection Procedure ............................. 27 Surgery within the Abdominal Wall Cavity....... 28 THE SUTURE Closing the Abdomen.................................. 30 2 Closing Contaminated or Infected Wounds........ 40 What is a Suture?............................................... 10 Personal Suture Preference............................... 10 Suture Characteristics....................................... 11 3 THE SURGICAL NEEDLE Size and Tensile Strength.............................. 11 Monofilament vs. Multifilament.................... 11 Elements of Needle Design ............................. 42 Absorbable vs. Nonabsorbable Sutures.............. 12 Principles of Choosing a Surgical Needle..... 43 Specific Suturing Materials.............................. 13 Anatomy of a Needle........................................ 44 Synthetic Absorbable Sutures......................... 14 The Needle Eye......................................... 45 Nonabsorbable Sutures................................ 16 The Needle Body....................................... 46 Synthetic Nonabsorbable Sutures.................... 17 Straight Needle......................................... 46 Common Suturing Techniques....................... 18 Half-Curved Needle................................... 46 Ligatures................................................. 18 Curved Needle.......................................... 46 The Primary Suture Line............................. 19 Compound Curved Needle........................... 47 Continuous Sutures.................................... 19 The Needle Point ...................................... 47 Interrupted Sutures.................................... 22 Types of Needles............................................... 47 Deep Sutures............................................ 22 Conventional Cutting Needles....................... 48 Buried Sutures .......................................... 22 Reverse Cutting Needles............................... 49 Purse-String Sutures................................... 22 Side Cutting Needles................................... 49 Subcuticular Sutures................................... 22 Taper Point Needles................................... 50 The Secondary Suture Line........................... 23 Taper Surgical Needles................................ 50 Stitch Placement........................................ 23 Blunt Point Needles.................................... 51 Needleholders.................................................... 51 Needleholder Use....................................... 52 Placing the Needle in Tissue ......................... 52 Needle Handling Tips...................................... 53 PRODUCT TERMS 4 PACKAGING 7 AND TRADEMARKS An Integral Part of the Product ..................... 56 RELAY* Suture Delivery System.................. 56 Modular Storage Racks................................ 56 Dispenser Boxes......................................... 57 8 PRODUCT INFORMATION Primary Packets........................................ 57 E-PACK* Procedure Kit.................................. 59 Expiration Date................................................. 60 Suture Sterilization........................................... 60 Anticipating Suture Needs............................... 61 INDEX Sterile Transfer of Suture Packets.................... 61 9 Suture Preparation in the Sterile Field............. 62 Suture Handling Technique.......................... 63 5 TOPICAL SKIN ADHESIVES DERMABOND* Topical Skin Adhesive....... 68 OTHER SURGICAL 6 PRODUCTS Adhesive Tapes................................................... 74 Indications and Usage................................. 74 Application.............................................. 74 After Care and Removal.............................. 74 Skin Closure Tapes..................................... 75 Polyester Fiber Strip................................... 75 Umbilical Tape ........................................ 75 Surgical Staples................................................. 75 Indications and Usage................................. 76 Aftercare and Removal................................ 76 PROXIMATE* Skin Staplers........................ 76 Looped Suture................................................... 77 Retention Suture Devices................................ 77 CHAPTER 1 WOUND HEALING AND MANAGEMENT 2 WOUND HEALING & MANAGEMENT THE WOUND point of rupture, relating to the thickness of tissue, the presence of nature of the material rather than edema, and duration (the degree to Injury to any of the tissues of its thickness. which the tissue has hardened in the body, especially that caused • Breaking Strength—The load response to pressure or injury). by physical means and with required to break a wound regard- interruption of continuity is defined less of its dimension, the more as a wound.1 Though most often PATIENT FACTORS THAT clinically significant measurement. AFFECT WOUND HEALING the result of a physical cause, a • Burst Strength—The amount of The goal of wound management burn is also considered a wound. pressure needed to rupture a is to provide interventions that Both follow the same processes viscus, or large interior organ. towards the restoration to efficiently progress wounds through health – otherwise known The rate at which wounds regain the biologic sequence of repair or as healing.1 strength during the wound healing regeneration. The patient's overall process must be understood as a health status will affect the speed of Wound healing is a natural and basis for selecting the most the healing process. The following spontaneous phenomenon. When appropriate wound closure material. are factors that should be considered tissue has been disrupted so severely by the surgical team prior to and that it cannot heal naturally 2,3,4 RECOVERY OF during the procedure. (without complications or possible TENSILE STRENGTH disfiguration) dead tissue and ✦ AGE — With aging, both skin Tensile strength affects the tissue's foreign bodies must be removed, and muscle tissue lose their