Understand the concept of Langer’s Lines. What are “two” advantages of using this knowledge when doing minor surgery?
Also known as cleavage lines - topological lines drawn on a map of the human body
Historically were defined by the direction in which the skin of a human cadaver will split when struck with a spike
Thought to correspond to the natural orientation of collagen fibers in the dermis
Generally lie parallel to the orientation of the underlying muscle fibers – will influence your surgical techniques.
Knowing the direction of Langer’s lines within a specific area of the skin is important for minimizing scars and the tension on the wound.
Incisions made parallel to these lines heal faster and produce less scarring than those that cut across.
Keloids are more common when incisions are made across Langer’s lines.
What are the “problem areas” of the body for increased risk of scarring/keloids?
The upper chest and back and the shoulders are problem areas - surgery/wounds in these areas tend to produce more scarring and keloids
How do Kraissl’s lines compare to Langer’s Lines?
Langer’s lines were defined in cadavers
Kraissl’s lines have been defined based on observations in living people
When a wound occurs what, essentially, is the body’s only interest?
The body is only interested in survival of the organism, not how great the healed lesion looks or if 100% function is restored.
What are the 3 phases of healing, list and describe what is happening in each step.
Inflammatory
- immediate, 2-5 days, bleeding stops (constriction, platelets clot, scab formation), inflammation (blood supply opens, cleansing of the wound)
Proliferative
- 5 days to 3 weeks, granulation (new collage laid down, new capillaries fill in defect), contraction, wound edges pull together), epithelialization (cells cross over the moist surface)
Maturation
- 3 weeks to 2 years, collagen forms which increases tensile strength in wounds, scar tissue is only 80 percent as strong as original tissue
What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?
Tissue strength is typically only about 5-6% two weeks after the injury
Understand the difference between clean, clean-contaminated, dirty/contaminated and infected wounds.
¥ Clean - sterile conditions (free from microorganisms) and are not predisposed to infection. Closed by “primary closure” and hopefully no break in aseptic technique occurs during the surgery to compromise the result. Ex: Heart surgery
¥ Clean-contaminated: patient has injured self and contaminated the wound area prior to being seen. Non-significant contamination ( 6 hr elapse before medical care) This scenario greatly increases the chance of systemic infection or at least a prolonged infection at the site of the injury. In these cases it is difficult for the surgeon to close the wound primarily and often the wound is left to close via “secondary intention”. This tends to result in increased scarring and may result in some loss of function
¥ Infected - intense inflammatory reaction and frank infectious process (appendicitis, cholecystitis)
Is there a “Golden Period” of time for closing lacerations?
If the wound occurred less than 8 hours earlier on the body or 12-24 hours earlier on the face
What factors involving the patient and surgeon affect wound repair?
- close the wound efficiently
- end up with a small scar that is as inconspicuous as possible
- no infection occurring during the healing process.
Only a portion of those goals are within our ability as a surgeon to control; a portion is dependent upon the patient.
Surgeon’s responsibility is in the areas of aseptic and quality technique taking into consideration the following:
¥ length and direction of the incision
¥ dissection technique
¥ tissue handling
¥ good hemostasis
¥ removal of necrotic tissue and foreign materials
¥ choice of closure materials
¥ elimination of dead space in the wound
¥ closing with sufficient tension
¥ anticipation of stressors placed upon the wound post-operatively
¥ immobilization of the wound
The patients overall health status will affect many of the decisions that the surgeon makes prior to and during the procedure and the ultimate outcome: - patient’s age
- patient’s weight
- patient’s nutritional status
- dehydration
- inadequate blood supply to the wound site (DM)
- patient’s immune response
- chronic disease
- malignancies
- debilitating injuries
- localized or systemic infection
- patient use of corticosteroids
- immunosuppressive or antineoplastic drugs
- hormone use
- radiation therapy
Understand the concept of “Healing by First (Primary) Intention”. What are the goals and outcomes of this method?
Characteristics of Primary Intention Healing Process: ¥ start with a clean wound ¥ close promptly ¥ produce minimal edema ¥ have no local infection ¥ have no serious discharge ¥ heal in a minimum of time ¥ heal with good skin edge approximation ¥ heal with minimal scar formation
What are the two possibilities that lead to a wound “Healing by Secondary Intention”? Can it be a reasonable choice made by the patient or surgeon? What are its advantages and disadvantages?
Two possible scenarios:
1. Wound fails to heal via primary (first) intention a more complicated and prolonged process:
¥ excessive tissue trauma and/or loss
¥ imprecise approximation of tissues
2. Choosing to leave a wound open on purpose, e.g. a “paper cut”, abrasion or draining an abscess.
¥ wound is allowed to heal on its own without closure
¥ heals from the inner layers toward the surface (“granulation from below”)
This is a slow process in either case with a scar formed from granulation tissue containing myofibroblasts. As the wound heals it is best to remove excess granulation tissue (“proud flesh”) protruding above the wound margin with a scalpel or scissors or it may prevent epithelialization of the wound. The wound then contracts over time so as to reduce the size of the ultimate scar, which is still usually larger than in the case of primary intention
Conclusion: suturing may not offer any advantages over conservative treatment of small hand lacerations, HOWEVER: Most physicians and most patients tend to feel very uncomfortable leaving them open.
Describe the steps in “Delayed Primary Closure (DPC)”. When should it be used? What are its advantages?
STEPS:
1. Debride the wound of non-vital tissues
2. Leave the wound open
3. Pack the wound with a sterile dressing
4. Cover with a supporting bandage – REPEAT DAILY.
WHAT HAPPENS: The healing “open” wound gradually gains sufficient resistance to infection and granulation tissue covers the raw edges.
5. When healthy granulation tissue develops (usually in 4-6 days) you can draw granulated surfaces together.
6. Carefully approximate the skin edges and underlying tissues with sutures as accurately as possible in the same manner as for a primary closure.
TYPICAL RESULT – uncomplicated closure with low risk of infection, and a “reasonable” scar, better overall than an infected wound
Studies have shown that the optimum time for delayed closure that maximally decreases the wound infection risk is about 96 hours.
An early clinical study of DPC found a reduced infection rate of 50% in 104 extremity wounds.
Several reviews in the surgical literature recommend DPC for heavily contaminated wounds, like combat wounds and major trauma where there is extensive tissue loss and high risk of infection and which even after proper cleansing have a high incidence of infection if closed primarily.
Use of an antimicrobial may be needed depending on the dirtiness of the wound and the amount of tissue damage
What are the advantages of using a “running locking” stitch”? Where on the body is this a good stitch to use?
Used when you want a watertight seal.
Good for gathering loose skin.
Running stiches:
¥ Running stitches are a convenient, rapid means of suturing well-approximated tissue with equal wound edges on which little tension is placed.
¥ They tend to be much faster to perform than simple interrupted stitches.
¥ Running stitches are valuable on eyelids, neck, scrotum, or wherever loose skin is found.
¥ Running stitches can be used to rapidly apply equal tension to wound edges and to obtain good eversion of the wound edges.
Know the various steps to preforming and I and D of an abscess.
- Anesthetize the skin, using more lidocaine than usual – increased circulation at the inflamed site carries the drug away rapidly!
- Open the lesion with a #11 scalpel.
a. Two incision choices: - A “cruciate” incision helps prevent premature wound closer during drainage/healing.
- A linear incision along skin lines tends to produce less scarring.
- Let the contents drain from the opening.
- Then gently express the contents of the abscess (Caution: this can be very painful).
- If needed, break up pockets within the cavity using a hemostat and blunt dissection.
- Pack the cavity with an iodine impregnated gauze, or place a Penrose drain.
- Dress the wound after applying calendula or minor surgery tincture.
- Have the patient change the dressing daily and return in three days for the doctor to change the drain remove any new pus
- Repeat until the induration and redness clear and the wound is healing well.
- Another option is to have the patient gradually advance the drain (an inch or so) out of the opening each day, trim off the end (known as “advancing the drain”) and re-bandage.
What are the possible pitfalls of attempting to drain an abscess before it has formed (is “ripe”)?
Must wait for the abscess cavity to form (“ripen”) – doing an I and D too early will likely result in: bleeding without obtaining drainage and/or potential of spreading the infection!
Why use a cruciate incision?
A “cruciate” incision helps prevent premature wound closer during drainage/healing.
What does it mean to “advance the drain”?
Pulling the drain (an inch or so) out of the opening
T/F - Ellipses should be 3:1 configuration ratio with 30 degree angles at the ends.
True
Why is the goal to cut skin edges perpendicular to the surface when doing elliptical excisions?
Hold the scalpel at a 90 degree angle to the skin to produce perpendicular skin edges to allow for better eversion on closure
Know the options for when a wound dehisces.
Partial: (1 or more sutures open)
• watch for infection
• debride/clean/bandage prn
• monitor tension on remaining sutures
• let heal by “granulating in” (second intention)
Larger:
• open wound, debride/clean, irrigate
• re-suture if no sign of infection and less than 24 hours has passed
• if infection: may need to allow second intention closure and consider antibiotics
What are the two options as methods of anesthesia for removing part/all of a finger/toenail?
- Cleanse the finger and paint the area with povidone-iodine (Betadine) solution.
- Using a 27 gauge needle, slowly inject 1% lidocaine midway between the dorsal and palmar surfaces of the finger at the midpoint of the middle phalanx.
- Inject straight in along the side of the periosteum.
- Then pull back without removing the needle from the skin and fan the needle dorsally.
- Advance the needle dorsally and inject again
- Pull the needle back a second time and, without removing it from the skin, fan the needle in a palmar direction.
- Advance the needle and inject the lidocaine in the vicinity of the digital neurovascular bundle.
- With each injection, instill enough lidocaine to produce visible soft tissue swelling.
- Repeat this procedure on the opposite side of the finger if you wish to remove the whole nail.
- May need to inject additional anesthesia just beneath the distal end of the nail.
- Allow 10 to 20 minutes after the proximal injections to obtain good anesthesia before this distal injection, to reduce pain.
- Apply a tourniquet using two fingers of a non-sterile glove wrapped around the base of the digit and twisted in place with a hemostat to 1) control bleeding and 2) prolong the anesthesia effect.
- CAUTION – do not snug it too tight to avoid crushing the tissue or leave it on too long to avoid vascular damage, which might lead to gangrene!
For Anesthesia of a proximal finger:
- For anesthesia of the proximal finger a similar block may be performed at the proximal end of the proximal carpal.
- The connective tissue is looser, and the needle need not to be fanned into the digital septae as described on Method #1.
- Wait 3 – 10 minutes for adequate anesthesia.
- With painful crush injuries or with a prolonged procedure substitute 0.25% bupivacaine for lidocaine or mix 1:1.
- Toes are difficult to separate and it may be easier to perform a modified ring block at the base of the toe in the loose tissue over the dorsum of the proximal interphalangeal joint.
- Apply a tourniquet at the base of the digit and observe the precautions mentioned
Name two reasons for/advantages of using a Three-Point corner stitch.
The three-point corner stitch (as the four-point corner stitch) is used for lacerations and more advanced specialty and plastic surgery procedures.
Less tip ischemia
Name the several different ways to deal with “bleeders” that may appear in a surgical wound or traumatic laceration.
Larger bleeders (arterial)
• clamp with hemostat and tie off with dissolvable suture
• cauterize by touching the hyfrecator tip to the hemostat
tie off with a figure-of-eight suture
Contrast control of small bleeder (and “oozers”) with larger bleeders.
Oozers (venous)
• wait for them to stop on their own
• apply pressure with a sterile gauze
• clamp with hemostat then twist around several times
• cauterize with a battery powered high temp cautery pen (“hot wire loop”)
• cauterize with the hyfrecator tip directly to the tissue or touch it to the hemostat itself
Larger bleeders (arterial)
• clamp with hemostat and tie off with dissolvable suture
• cauterize by touching the hyfrecator tip to the hemostat
tie off with a figure-of-eight suture
