TECNICAS DE CIERRE DE HERIDA

Indications Surgical wounds. Traumatic wounds.

Contraindications Absolute Multiple comorbidities precluding safe intervention. Active infection. Foreign body (except surgical implants). Active bleeding. Relative Impaired healing (corticosteroids, malnutrition, radiation, chronic disease).

Informed Consent Usually implied with consent for major procedure, must obtain consent otherwise. Potential Risks Scarring (normal and abnormal). Bleeding (may require reoperation or transfusion). Infection (may require antibiotics or reoperation). Failure of operation or need for secondary intention healing. Need for revision.

Equipment Instruments Appropriate instruments vary by wound type but include at a minimum a needle driver and tissue handling forceps. Sutures Consist of both a needle and suture material, each with multiple subtypes and characteristics. The needle and suture material may vary widely based on different types of wounds in different locations. Needle Table 42–1: Point characteristics. Swage: the method of attaching the suture material to the needle. Channel swage: a channel is crimped over suture material (swage diameter > body diameter). Drill swage: suture material is placed in the drill hole at the rear of needle, which is then crimped (swage diameter < body diameter). Nonswaged: eyed needle (similar to sewing needle). Closed-eye needles require suture material to be passed through the eye each time it is threaded. French eye needles have a posterior slit allowing suture to be placed in the eye without direct threading; this causes more tissue trauma and reduced suture integrity (eye > body diameter). Pop-off: swage is designed to allow suture material to be gently removed from the needle with traction. Table 42–2: Needle body characteristics. Designed to transmit the penetrating force to the point. Varied alloy characteristics can make a needle soft or firm (ductility). Diameter: gauge or thickness of needle. Table 42–1. Needle characteristics—point. Category Type Description Tissue Use Diagram   Conventional cutting Triangular point that changes to a flattened body with one cutting edge on the concave surface of the needle (surface seeking) Skin and tendon     Reverse cutting Cutting edge on convex curvature of the needle (depth-seeking) Stronger than conventional cutting Dense tissue, including skin, oral mucosa, and tendon   Cutting Side-cutting (spatula) Flat with 2 cutting edge to reduce tissue injury and improve depth control Ocular tissues     Taper-point (round needle) Stretches tissue without direct cutting action to minimize tearing Sharpness increases with taper ratio (slope) (8–12:1) and decrease with tip angle (20–35 degrees) Easily penetrated tissues, including abdominal viscera, dura, and peritoneum   Blunt Blunt Dissects through tissue rather than cutting it Friable tissue, including kidney and liver   Table 42–2. Needle Characteristics—body. Type Notes Diagram Straight Used in easily accessible tissue   Tissue is manipulated to allow passage of needle (eg, Keith needle) Curved Most common Chord length: linear distance between tip and swage (bite width)   Needle follows predicable path through tissue with even tension distribution Needle length: distance between tip and swage along curvature of needle   Radius: distance form center of arc of rotation of needle to needle itself—determines bite depth Compound Compound curved: variable radius   Used in ophthalmologic and microsurgical procedures

Patient Preparation Nothing by mouth the evening before surgery if the patient will be undergoing general anesthesia. Preoperative antibiotics per institutional policy and based on wound characteristics. Anesthesiology consultation as needed. Anesthesia Under general anesthesia, no additional preparation is necessary. In a conscious patient, local anesthetic (lidocaine, bupivacaine, etc) must be used. Wound Preparation Wound must be clean. Clean wounds may need no specific preparation prior to closure. Highly contaminated wounds should be irrigated (bulb, pulse-lavage, etc). Lacerations. May use a prefabricated syringe-mounted ocular flushing system. A saline bottle with 5–10 needle punctures provides a low-cost, effective irrigator in the acute setting. Skin edge. Complex lacerations and damaged skin edges should be resected to healthy tissue where possible. "Freshen" skin edges to allow more accurate apposition of wound margins. Hair is generally removed to fully expose wounds and reduce infection.

Patient Positioning The wound should be fully exposed and at comfortable working distance from the surgeon. A light source is often necessary in the emergency department setting.

Procedure Suture Closure Techniques Figure 42–1: Running continuous stitch. Widely used technique to close many wounds varying from lacerations to midline laparotomy wounds. Depth of bite and layers of tissue incorporated are dependent on site and tissue characteristics. Advantages of running technique. Allows expeditious wound closure. Closure is completed with one continuous length of suture material. Achieves approximation of wound margins. Disadvantages of running technique. Less reliable than interrupted closure. Wound edge eversion is difficult and there is greater potential for misalignment of wound edges, particularly if the tissue is pliable and the wound is long. Figure 42–2: Simple interrupted suture. Most common and basic suturing technique. Depth of bite and layers of tissue incorporated are dependent on site and tissue characteristics. Advantages of interrupted technique. Closure is completed suture by suture. The depth of bite, layers of tissue incorporated, and tension on the closure can be carefully adjusted for each individual stitch. Achieves accurate approximation of wound margins with optimal control. More reliable closure than continuous stitch. Disadvantages of interrupted technique. Time consuming. Multiple knots may contribute to foreign body response and additional scarring. Additional suture material may contribute to infections in the wound (suture abscess). Mattress suture: interrupted suturing technique in which the needle is passed through tissue multiple times. Figure 42–3: Horizontal mattress technique. The initial simple suture is placed perpendicular to the wound. Instead of tying the suture, the needle is advanced parallel to the wound margin and passed back through the tissue at an equal bite depth to a point on the initial wound edge equidistant to the length of advance on the opposite wound edge. The suture is tied and now lies parallel to the wound edge. Figure 42–4: Vertical mattress technique. The initial simple suture is placed perpendicular to the wound using a large bite depth. Instead of tying the suture, the needle is returned to the side of the initial bite at a smaller bite depth and without any advancement down the length of the wound. The suture is tied and now lies perpendicular to the wound edge. Figure 42–5: Half-buried horizontal mattress technique. Similar to the horizontal mattress technique, but the suture does not pass out of the tissue on the edge opposite the initial bite. The suture remains buried. Advantages of mattress suture techniques. Tissue eversion is easily controlled. Wound tension is distributed in friable tissue to prevent the suture from tearing through the tissue. Strong closure. Disadvantages of mattress suture techniques. Can create ischemic tissue either directly under the suture (vertical mattress) or constrict tissue within the confines of each suture leading to tissue ischemia (horizontal mattress). Figure 42–6: Purse-string suture. Used to close wounds by circumferential constriction of the wound edge. Commonly used in closing the end of a hollow viscus such as bowel or appendiceal stumps, around a catheter, or in reconstructive and cosmetic surgery. Uses a running suture technique. The suture is passed in and out of tissue around the circumference of the wound without entering the lumen of the viscera. As the suture reaches the origin, it can be tightened to reduce the circumference of the initial wound in a manner similar to the leather strings on a pliable "purse." If the technique is executed properly, the viscera can be reduced into the wound as the suture is tightened, creating a seal. Advantages of purse-string technique. Provides equal wound tension distribution around the circumference of the wound. Rapid closure. Disadvantages of purse-string technique. Creates pleating, which may lead to a poor seal, unfavorable scarring, or both. When used on skin, may lead to scar-widening as tissue stretches. Figure 42–7: Subcuticular suture. Used to close superficial skin edges to achieve accurate wound margin approximation. Sutures are not placed through the epidermis, thus avoiding potential scarring related to suture placement. The suture is introduced through normal skin and brought out of the deep tissue into the epidermal-dermal junction. The suture is then passed back into tissue and out of tissue at this same level, alternating edges of the wound (the suture should not penetrate epidermis). The suture exits deep tissue through the epidermis just distal to the wound. The tails are trimmed so they may be accessed to pull the suture out after several days (some prefer to tie or bury the suture). Advantages of subcuticular technique. Excellent control of wound margins increases the likelihood of a cosmetically pleasing outcome. May help avoid transverse "railroad track" scarring since sutures do not pass through the epidermis. Suture can be pulled out of the wound to reduce inflammatory response or suture erosion through the skin (spitting). Disadvantages of subcuticular technique. Closure is more time consuming than either staples or tissue glue. Figure 42–1 Figure 42–2 Figure 42–3 Figure 42–4 Figure 42–5 Figure 42–6 Figure 42–7 Nonsuture Closure Techniques Figure 42–8: Stapled closure. Used to close superficial skin edges. Skin edges are held up and everted using tissue forceps. A staple is deployed at this site. The process is repeated down the length of the wound. Advantages of stapled closure. Rapid skin edge closure. Individual staples can be removed in the event of wound infection. Disadvantages of stapled closure. May contribute to transverse hatching of the scar in a "railroad track" pattern. Staple removal can be uncomfortable. Tissue glue. Used to close superficial skin edges to achieve close edge approximation. Skin edges are approximated manually or with pull-out sutures. The wound is cleaned of necrotic debris, foreign material, and dried blood. A bed of glue is applied down the length of the wound, typically in one pass. Advantages of tissue glue. Rapid skin edge closure. Minimal tissue handling. Disadvantages of tissue glue. Glue cannot be removed easily if need be (eg, opening an infected wound). Expensive. Figure 42–8

Postoperative Care Wound edges should remain clean. Sutures should be removed several days (typical in face) or weeks following repair, depending on the location of the wound and characteristics of the tissue. Pain control with analgesics is appropriate. Antibiotics are not necessary for most wounds but may be recommended in contaminated wounds following closure.

Potential Complications Wound infection. Infected wounds, particularly those involving deep spaces, are typically opened to prevent systemic spread. Unfavorable scarring. Some scarring is expected, but hypertrophic scars, keloids, or wound contraction leading to functional limitation may occur, often without a known cause. Some wounds with unfavorable scarring may require scar revision. Figure 42–9: Standing cutaneous deformities ("dog ears") may be a result of individual wound length differences leading to excess tissue on one side of the wound, or occur in cases in which tissue rearrangement is necessary to achieve closure. These cutaneous deformities may persist and can often be addressed at primary closure. To remove a standing cutaneous deformity, the tissue leading to the deformity can be lifted away from the plane of tissue and resected in an elliptical fashion. If executed properly, the dimensions of the newly created ellipse will allow primary closure without a standing cutaneous deformity. Figure 42–9

Pearls and Tips Remember that not all wounds require or are well-managed by primary closure. To prevent injury to yourself and others, never handle needles directly. Returning suture by grasping the suture material instead of the needle will reduce the risk of the needle ejecting out of the needle holder. Use instruments appropriate for both the needle and the tissue you are suturing.

References Aston SJ, Beasley RW, Thorne CH, et al. Grabb and Smith's Plastic Surgery, 5th ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997. Baker SR, Swanson NA. Local Flaps in Facial Reconstruction. St Louis, MO: Mosby-Year Book; 1995. Evans GRD. Operative Plastic Surgery. Stamford, CT: Appleton & Lange; 2000. Johnson & Johnson. Ethicon Wound Closure Manual, 2001. Available at: http://www.orthonurse.org/portals/0/wound%20closure%20manual.pdf. Accessed August 12, 2008. McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications, 10th ed. Edinburgh, New York: Churchill Livingstone; 2000. Sanders RJ. Subcuticular skin closure—description of technique. J Dermatol Surg. 1975;1:61–64.[PubMed: 770536] [Full Text]