Wound Healing and Suture Knowledge ASR Certification Prep Kim Bayer, SRS, BS, CVT, LATg

Wound Healing and Suture Wound Healing and Suture KnowledgeKnowledge

ASR Certification Prep

Kim Bayer, SRS, BS, CVT, LATg

Tissue Handling / TechniqueTissue Handling / Technique

Goal isGoal is to minimize traumato minimize trauma Gentle Gentle

use minimal tension with tissueuse minimal tension with tissueRetractors should be placed to avoid excessive Retractors should be placed to avoid excessive tensiontension

Proper use of instrumentsProper use of instruments

DO NOT CRUSHDO NOT CRUSH Use Proper TechniqueUse Proper Technique Keep Tissue MoistKeep Tissue Moist

Dry tissue is dead tissueDry tissue is dead tissue Minimize TimeMinimize Time

IncisionsIncisions Heal side-to-side, not end-to-endHeal side-to-side, not end-to-end

– There is little advantage to making an incision too There is little advantage to making an incision too small to easily view the surgical sitesmall to easily view the surgical site


Different surgical techniques Different surgical techniques induce different levels of induce different levels of damagedamage

cutting with sharp instrumentcutting with sharp instrument minimal traumaticminimal traumatic cuts / divides the cells cuts / divides the cells little adjacent cell damagelittle adjacent cell damage

cutting with scissorscutting with scissors causes crush and tear traumacauses crush and tear trauma relatively traumaticrelatively traumatic adjacent cell damageadjacent cell damage


blunt dissection between / along tissue planesblunt dissection between / along tissue planesminimal traumaminimal trauma


clamping tissue with hemostats / etc.clamping tissue with hemostats / etc. causes crushing of the cellscauses crushing of the cells very traumaticvery traumatic causes release of vasoconstrictors, clotting causes release of vasoconstrictors, clotting

factors factors proper for clamping vessels for ligation / proper for clamping vessels for ligation /

hemostasishemostasis


provide provide gentlegentle retraction with proper retraction with proper instrumentsinstruments


Keep Tissue MoistKeep Tissue Moist

““The solution to pollution is The solution to pollution is dilution”dilution”

Irrigate, rinse the incision surgery siteIrrigate, rinse the incision surgery siteLavage, irrigate body cavitiesLavage, irrigate body cavities

HemostasisHemostasis Bleeding should be stopped whenever possibleBleeding should be stopped whenever possible

– Excessive bleeding may cause hematomas or increase Excessive bleeding may cause hematomas or increase dead spacedead space

– Hematomas prevent wound apposition and retard healingHematomas prevent wound apposition and retard healing– Blood is a natural food for micro-organisms and a large Blood is a natural food for micro-organisms and a large

clot will help protect them from the body’s immune clot will help protect them from the body’s immune systemsystem» Bacteria inside the clot will be protectedBacteria inside the clot will be protected

Bleeding may be slowed or stopped by applying Bleeding may be slowed or stopped by applying pressure, clamping, electro/thermocautery, and with pressure, clamping, electro/thermocautery, and with various chemicalsvarious chemicals– Excessive pressure may lead to tissue necrosisExcessive pressure may lead to tissue necrosis

Dead Space and a Clean WoundDead Space and a Clean Wound Remove all non-essential materialRemove all non-essential material

Wounds with excessive debris should be Wounds with excessive debris should be thoroughly lavaged with an appropriate sterile fluid thoroughly lavaged with an appropriate sterile fluid (isotonic saline, LRS, Tis-U-Sol, etc.) to flush them (isotonic saline, LRS, Tis-U-Sol, etc.) to flush them awayaway

Dead Space is an open area in closed tissueDead Space is an open area in closed tissue– Filled with room air, it prevents tissue apposition, Filled with room air, it prevents tissue apposition,

provides a space for blood and other fluid influx, and provides a space for blood and other fluid influx, and may harbor micro-organismsmay harbor micro-organisms

Dead SpaceDead Space

Classification of WoundsClassification of Wounds CleanClean

– Standard surgical woundStandard surgical wound

Clean-contaminatedClean-contaminated– Clean wounds that are contaminated by entry into a viscus Clean wounds that are contaminated by entry into a viscus

resulting in minimal spillage of contentsresulting in minimal spillage of contents

ContaminatedContaminated– Lacerations, fractures, gross spillage from the GI tract, resulting Lacerations, fractures, gross spillage from the GI tract, resulting

from a break in aseptic techniquefrom a break in aseptic technique– Within 6 hours of initial colonization a wound can be infectedWithin 6 hours of initial colonization a wound can be infected

Classification of WoundsClassification of Wounds

Dirty-infectedDirty-infected– Caused by perforated viscera, abscesses, or a prior Caused by perforated viscera, abscesses, or a prior

clinical infectionclinical infection– Ongoing infection at time of surgery may lead to a Ongoing infection at time of surgery may lead to a

400% increase in infection rates400% increase in infection rates

ProblemsProblems InfectionInfection

– The source of infection should always be determinedThe source of infection should always be determined– Before closure of an infected wound the wound should Before closure of an infected wound the wound should

be drained, debrided, and a small opening or drain left be drained, debrided, and a small opening or drain left inin

DehiscenceDehiscence– Wound reopensWound reopens– May result from too much tension on tissue, improper May result from too much tension on tissue, improper

suturing technique, or improper suture materialssuturing technique, or improper suture materials

Wound HealingWound Healing

Skin and fascia are Skin and fascia are the strongest but the strongest but regain tensile strength regain tensile strength quite slowlyquite slowly

Stomach and small Stomach and small intestine are weak, but intestine are weak, but heal quicklyheal quickly

Physiology of Physiology of WoundWound Healing Healing

Phases of Wound HealingPhases of Wound Healing

Inflammatory PhaseInflammatory Phase

Migration /Proliferation PhaseMigration /Proliferation Phase

Maturation PhaseMaturation Phase

Incision

InflammatoryInflammatory Migration /ProliferationMigration /Proliferation MaturationMaturation

Healed

Physiology of Physiology of Wound HealingWound Healing

Inflammatory PhaseInflammatory Phase0 - 5 Day 0 - 5 Day

can be prolongedcan be prolonged inflammatory and “clean-up” processinflammatory and “clean-up” process

plasma, cells, fibrin, blood components plasma, cells, fibrin, blood components neutrophils, monocytesneutrophils, monocytes

• remove debris remove debris • ““remove the trash”remove the trash”

epithelialization / migration (as early as 48 hours)epithelialization / migration (as early as 48 hours)clinically characterized by swelling, redness, warmthclinically characterized by swelling, redness, warmthstrength due to suture strength due to suture

Incision

Inflammatory

PhysiologyPhysiology

Inflammatory ResponseInflammatory Response

Clinical SignsClinical Signs swellingswelling rednessredness warmth / heatwarmth / heat

Course / DurationCourse / Duration peak within 24 hours, peak within 24 hours, subsiding by day 3subsiding by day 3

Inflammation results in pain / Inflammation results in pain / discomfortdiscomfort

Wound Healing-PhasesWound Healing-Phases Phase 1Phase 1

– Inflammatory response Inflammatory response causes an outpouring causes an outpouring of tissue fluids, of tissue fluids, accumulation of cells accumulation of cells and fibroblasts, and and fibroblasts, and increased blood supplyincreased blood supply

– Leukocytes produce Leukocytes produce enzymes to dissolve enzymes to dissolve and remove damaged and remove damaged tissue debristissue debris

Wound Healing-PhasesWound Healing-Phases Phase 1 (day 1 to 5)Phase 1 (day 1 to 5)

– Inflammatory response phaseInflammatory response phase– Fluids flow into the wound and a scab formsFluids flow into the wound and a scab forms– Localized edema, pain, fever, and erythema Localized edema, pain, fever, and erythema

presentpresent– Basal cells migrate over the incision from the Basal cells migrate over the incision from the

skin to cover the woundskin to cover the wound– Closure material is the primary source of tensile Closure material is the primary source of tensile

strengthstrength

Wound Healing-PhasesWound Healing-Phases

Phase 2Phase 2

– Fibroblasts begin Fibroblasts begin forming collagen forming collagen fibers in the woundfibers in the wound»Beginning of the Beginning of the

return of tensile return of tensile strengthstrength


Phase 2 (day 5 to 14)Phase 2 (day 5 to 14)

– Fibroblasts migrate toward the wound siteFibroblasts migrate toward the wound site»Begin forming collagen fibersBegin forming collagen fibers

– Tensile strength rapidly increasesTensile strength rapidly increases

– Lymphatics recanalizeLymphatics recanalize

– Blood vessels budBlood vessels bud

– Granulation tissue formsGranulation tissue forms

– Capillaries developCapillaries develop

PhysiologyPhysiology

Maturation PhaseMaturation Phasebegins ~ day 14 and continues for monthsbegins ~ day 14 and continues for monthscollagen fibers become oriented along the collagen fibers become oriented along the

“stress” line of the incision and form “stress” line of the incision and form crosslinkscrosslinks

• increases tensile strengthincreases tensile strength

contractioncontraction

Incision

Maturation

Healed


Phase 3Phase 3

– Sufficient collagen is Sufficient collagen is now laid down to now laid down to withstand normal withstand normal stressstress


Phase 3 (day 14 until done)Phase 3 (day 14 until done)

– Tensile strength continues to improve for as Tensile strength continues to improve for as long as one yearlong as one year

– Skin regains 70 to 90% of its original strengthSkin regains 70 to 90% of its original strength– Collagen content remains constant but cross-Collagen content remains constant but cross-

links with other fiberslinks with other fibers– Scar is formed which grows paler as new vessel Scar is formed which grows paler as new vessel

construction tapers offconstruction tapers off– Wound contraction occurs over a period of Wound contraction occurs over a period of

weeks or monthsweeks or months

Wound Healing TypesWound Healing Types First IntentionFirst Intention

– Wound edges brought together during closure at the time of Wound edges brought together during closure at the time of surgerysurgery

Second IntentionSecond Intention– Wound is left open and heals from the bottom upWound is left open and heals from the bottom up– Slower than first intention and creates more granulation and scar Slower than first intention and creates more granulation and scar

tissuetissue

Third IntentionThird Intention– Wound is initially not closed and remains open until a granulation Wound is initially not closed and remains open until a granulation

bed formed, then the granulated tissue is closed using standard bed formed, then the granulated tissue is closed using standard techniquestechniques

– Useful in infected wounds Useful in infected wounds » Infected tissue should not be closed or it will dehissInfected tissue should not be closed or it will dehiss» Infection is resolved naturally, or with topical and systemic treatmentsInfection is resolved naturally, or with topical and systemic treatments

Closure / SuturingClosure / Suturing

Proper AppositionProper Apposition

Restore alignment of the Restore alignment of the tissuestissues

close / decrease dead close / decrease dead spacespace

balance adequate closure balance adequate closure with too much suturewith too much suture• suture is a foreign body and too suture is a foreign body and too

much can effect healingmuch can effect healing

Closure / SuturingClosure / Suturing Proper SutureProper Suture

use minimal size suture that has use minimal size suture that has sufficient strengthsufficient strength

knot securityknot security

absorbable vs. non-absorbableabsorbable vs. non-absorbable

SuturesSutures Ideal suture materialIdeal suture material

All-purpose, composed of material which could be All-purpose, composed of material which could be used in any surgical procedure (the only variables used in any surgical procedure (the only variables being size and tensile strength) being size and tensile strength)

Sterile Sterile Nonelectrolytic, noncapillary, nonallergenic, and Nonelectrolytic, noncapillary, nonallergenic, and

noncarcinogenicnoncarcinogenic Nonferromagnetic, as is the case with stainless Nonferromagnetic, as is the case with stainless

steel suturessteel sutures Easy to handleEasy to handle

SuturesSutures Ideal suture materialIdeal suture material

Minimally reactive in tissue and not predisposed Minimally reactive in tissue and not predisposed to bacterial growthto bacterial growth

Capable of holding securely when knotted Capable of holding securely when knotted without fraying or cutting without fraying or cutting

Resistant to shrinking in tissues Resistant to shrinking in tissues Absorbed with minimal tissue reaction after Absorbed with minimal tissue reaction after

serving its purposeserving its purpose Doesn’t exist!Doesn’t exist!

SuturesSutures Surgeon should select suture materials forSurgeon should select suture materials for

– High uniform tensile strength (quality)High uniform tensile strength (quality)

– Permitting use of finer sizesPermitting use of finer sizes

» Suture should be the smallest diameter that will do the jobSuture should be the smallest diameter that will do the job

– Consistent uniform diameterConsistent uniform diameter

– SterileSterile

– Pliable for ease of handling and knot securityPliable for ease of handling and knot security

– Freedom from irritating substances or impurities for Freedom from irritating substances or impurities for optimum tissue acceptanceoptimum tissue acceptance

– Predictable performancePredictable performance

SuturesSutures SizeSize

– Generally stated in “oughts”; i.e., 3-0, 5-0, Generally stated in “oughts”; i.e., 3-0, 5-0, etc.etc.

– 2-0 is larger than 4-0, 0 is larger than 2-0, 2-0 is larger than 4-0, 0 is larger than 2-0, etc.etc.

– Some suture and wire is larger than 0, then Some suture and wire is larger than 0, then numbered 1 and highernumbered 1 and higher»2 is larger than 1, 6 is larger than 1, etc.2 is larger than 1, 6 is larger than 1, etc.

– From smallest to largest:From smallest to largest:»7-0, 3-0, 0, 1, 3, 7, etc.7-0, 3-0, 0, 1, 3, 7, etc.

SuturesSutures

MonofilamentMonofilamentMonofilament is a single strandMonofilament is a single strand

»Passes through tissue easily, won’t harbor micro-Passes through tissue easily, won’t harbor micro-organismsorganisms

»Ties easilyTies easily»May be weakened by crushing (clamping in forceps May be weakened by crushing (clamping in forceps

or needle holders)or needle holders)»Has more “memory”Has more “memory”

Continues to hold the shape as it lay in the packageContinues to hold the shape as it lay in the package

»Good for percutaneous suturesGood for percutaneous sutures»Knots may slip over time due to the slipperiness of Knots may slip over time due to the slipperiness of

the suture the suture

SuturesSutures

MultifilamentMultifilamentMultifilament is a bundle of strands, like ropeMultifilament is a bundle of strands, like rope

»Affords greater tensile strength, pliability, Affords greater tensile strength, pliability, flexibility, and knot securityflexibility, and knot security

»May harbor micro-organisms and “wick” them May harbor micro-organisms and “wick” them down the suturedown the suture

Should not be used for percutaneous suturesShould not be used for percutaneous sutures

SuturesSutures

AbsorbableAbsorbable

Absorbable suture holds temporarily but Absorbable suture holds temporarily but gradually loses tensile strength and is gradually loses tensile strength and is eventually mostly or completely absorbedeventually mostly or completely absorbed

Absorbable SuturesAbsorbable Sutures

Surgical Catgut:Surgical Catgut: Plain or Chromic Plain or ChromicAbsorbed by proleolytic enzymatic digestive process.Absorbed by proleolytic enzymatic digestive process.

Polyglactin 910Polyglactin 910 : Vicryl : Vicryl® ® Polyglycolic acidPolyglycolic acid: Dexon®: Dexon®Poliglecaprone 25Poliglecaprone 25: Monocryl: Monocryl®®PolydixanonePolydixanone: PDSII®: PDSII®PolyglyconatePolyglyconate: Maxon®: Maxon®

Absorbed by HydrolysisAbsorbed by Hydrolysis

SuturesSutures

NonabsorbableNonabsorbableNonabsorbable suture will retain tensile Nonabsorbable suture will retain tensile

strength and not be absorbedstrength and not be absorbed»Many nonabsorbable sutures (silk) will lose Many nonabsorbable sutures (silk) will lose

some tensile strength over timesome tensile strength over time»Useful for device fixation, areas of extreme Useful for device fixation, areas of extreme

tension, slow healing areas, or percutaneous tension, slow healing areas, or percutaneous skin sutures skin sutures

»Selected for procedures where the suture Selected for procedures where the suture should be permanentshould be permanent

Non-Absorbable SuturesNon-Absorbable Sutures

Monofilament Polypropylene:Monofilament Polypropylene:Polyester Fiber: Mersilene®,Polyester Fiber: Mersilene®,

Dacron®, Ethibond®, Ti.cron®Dacron®, Ethibond®, Ti.cron®Monofilament Nylon: EthilonMonofilament Nylon: Ethilon®, ®,

Dermalon®Dermalon®Braided Nylon: Nurolon®, Surgilon®Braided Nylon: Nurolon®, Surgilon®SilkSilkSurgical Stainless Steel WireSurgical Stainless Steel Wire

Conventional Cutting NeedleConventional Cutting Needle

needle body is triangular and has a sharpened needle body is triangular and has a sharpened cutting edge on the insidecutting edge on the inside

Primarily used for skin closure.Primarily used for skin closure.

Reverse Cutting NeedleReverse Cutting Needle

cutting edge on outer curvecutting edge on outer curve

For tough, difficult-to-penetrate tissuesFor tough, difficult-to-penetrate tissues

Taper Point NeedleTaper Point Needle

needle body is round and tapers smoothly to a needle body is round and tapers smoothly to a pointpoint

Used for soft, easily penetrated tissuesUsed for soft, easily penetrated tissues

Blunt Point NeedleBlunt Point NeedleTaper bodyTaper body

For blunt dissection and suturing friable tissueFor blunt dissection and suturing friable tissue

Spatula NeedleSpatula Needle

flat on top and bottom with a cutting edge along the flat on top and bottom with a cutting edge along the front to one sidefront to one side

Primarily used for eye surgeryPrimarily used for eye surgery

Surgeon’s KnotSurgeon’s Knot

Extra throws do not add appreciable strength Extra throws do not add appreciable strength to the knot and may, in fact, weaken it while to the knot and may, in fact, weaken it while adding extra bulkadding extra bulk

– An initial double throw followed by one or two An initial double throw followed by one or two single throws is more than sufficientsingle throws is more than sufficient

– The exception is nylon monofilament sutures, The exception is nylon monofilament sutures, where two successive double throws are useful to where two successive double throws are useful to prevent slippageprevent slippage

Suture PatternsSuture Patterns

Simple InterruptedSimple Interrupted

– Maintains strength Maintains strength and tissue position if and tissue position if one portion failsone portion fails

– Requires more time Requires more time and suture materialand suture material

– Has minimal holding Has minimal holding power against stresspower against stress

Suture PatternsSuture Patterns Horizontal MattressHorizontal Mattress

– Tension sutureTension suture

– Useful in skin of dog, cow, Useful in skin of dog, cow, and horseand horse

– Rapid and involves less Rapid and involves less suture materialsuture material

– Difficult to apply without Difficult to apply without excessive eversionexcessive eversion

– Should pass just below Should pass just below the dermisthe dermis

Suture PatternsSuture Patterns Horizontal MattressHorizontal Mattress

– Tightness should Tightness should be such that the be such that the skin edges just skin edges just meetmeet


Vertical MattressVertical Mattress


– Stronger than the Stronger than the horizontal mattresshorizontal mattress

– Time consuming Time consuming and requires more and requires more suture materialsuture material

Suture PatternsSuture Patterns Cross-mattressCross-mattress


– Brings tissue into Brings tissue into good appositiongood apposition» Useful in suturing Useful in suturing

stumps (amputations)stumps (amputations)

– Also useful for rib Also useful for rib apposition and apposition and abdominal muscle abdominal muscle closureclosure


Gambee or CrushingGambee or Crushing

– Useful in intestinal Useful in intestinal anastamosesanastamoses» Permits minimal leakagePermits minimal leakage

– May reduce fluid May reduce fluid passage through the passage through the lumen underneathlumen underneath

– Crushing is similar to a Crushing is similar to a vertical mattress patternvertical mattress pattern

Suture PatternsSuture Patterns Simple ContinuousSimple Continuous

– Usually used for lines no Usually used for lines no longer than 5”longer than 5”

– Involves one diagonal pass Involves one diagonal pass and one perpendicular and one perpendicular passpass

– Provide minimal tension-Provide minimal tension-holding but hold tissue holding but hold tissue together in good appositiontogether in good apposition

– Creates a good sealCreates a good seal•More prone to failure if More prone to failure if any portion is brokenany portion is broken


Running Running

– Both deep and shallow Both deep and shallow passes advancepasses advance

– Regularity more difficultRegularity more difficult

– Slightly faster than a Slightly faster than a simple continuous patternsimple continuous pattern

– Weaker than a simple Weaker than a simple continuous patterncontinuous pattern


Ford InterlockingFord Interlocking

– More stable in the More stable in the event of partial failure event of partial failure or breakageor breakage

– Provides greater Provides greater tissue stabilitytissue stability

– Uses more suture Uses more suture materialmaterial


LembertLembert

– Closes hollow Closes hollow visceraviscera

– Provides inversion Provides inversion and creates a good and creates a good fluid-tight sealfluid-tight seal


HalstedHalsted

– Combination mattress Combination mattress and Lembert patternand Lembert pattern


ConnellConnell

– Begun with a single Begun with a single inverting vertical inverting vertical mattress suturemattress suture

– Continues for the Continues for the length of the length of the incisionincision

Suture PatternsSuture Patterns CushingCushing

– Modified Connell Modified Connell where the needle and where the needle and suture do not enter the suture do not enter the lumenlumen

– Provides a better fluid-Provides a better fluid-tight seal than the tight seal than the Connell patternConnell pattern

Suture PatternsSuture Patterns Parker-KerrParker-Kerr

– A single layer of A single layer of Cushing covered by a Cushing covered by a single layer of Lembertsingle layer of Lembert

– Used for infected Used for infected uterine stumps and uterine stumps and some bowel closuressome bowel closures

– Provides complete Provides complete clamping to prevent clamping to prevent leakage during suturingleakage during suturing


– Rochester-Carmalt Rochester-Carmalt forceps are used to forceps are used to clamp the lumen clamp the lumen shut and then shut and then slowly withdrawn slowly withdrawn while placed suture while placed suture is tightened to is tightened to prevent spillage of prevent spillage of contentscontents

Suture PatternsSuture Patterns Guard Guard

– Modified CushingModified Cushing

– Closes incisions of the Closes incisions of the rumen, intestine, and rumen, intestine, and uterusuterus

– Needle does not enter Needle does not enter the lumenthe lumen

– Starts slightly higher Starts slightly higher than start of incisionthan start of incision


Continuing Continuing Everting MattressEverting Mattress

– Provides increased Provides increased strengthstrength

– Rapid placementRapid placement


SubcuticularSubcuticular– Does not penetrate the Does not penetrate the

surface of the skinsurface of the skin

– Rapid and uses little Rapid and uses little suture materialsuture material

– Used to close the upper-Used to close the upper-most layer of the skin most layer of the skin incisionincision

– Requires no suture Requires no suture removalremoval


SubcutaneousSubcutaneous

– May use simple May use simple interrupted, simple interrupted, simple continuous, or continuous, or horizontal mattresshorizontal mattress

– Simple continuous is Simple continuous is fast and eliminates fast and eliminates dead spacedead space


Quilted Quilted

– Exteriorized skin Exteriorized skin suture through plastic suture through plastic tubing to resist tubing to resist excessive tension and excessive tension and stressstress

– Useful for high-tension Useful for high-tension closuresclosures


Far-far, Near-nearFar-far, Near-near

– Tension patternTension pattern

– Overlapping suture Overlapping suture pattern provides pattern provides extra strength but extra strength but requires extra requires extra suture materialsuture material


Near-far, Far-nearNear-far, Far-near

– Tension patternTension pattern

– Overlapping suture Overlapping suture pattern provides pattern provides extra strength but extra strength but requires extra requires extra suture materialsuture material


Mayo MattressMayo Mattress

– Useful for midline Useful for midline abdominal closures, abdominal closures, abdominal hernia abdominal hernia repair, and repair, and secondary cleft secondary cleft palate repairpalate repair


BunnellBunnell

– Used for apposing Used for apposing tendonstendons»Requires a high degree Requires a high degree

of closure strengthof closure strength

– Uses non-absorbable Uses non-absorbable suturesuture

– Uses a double-armed Uses a double-armed suturesuture


Modified BunnellModified Bunnell

– Used for apposing Used for apposing tendonstendons» Requires a high degree Requires a high degree

of closure strengthof closure strength

– Uses non-Uses non-absorbable sutureabsorbable suture

– Uses a single-armed Uses a single-armed suturesuture


Cerclage WiringCerclage Wiring

– Used for fracture repairUsed for fracture repair

– Wire/pin placed in the Wire/pin placed in the bone center to hold it bone center to hold it togethertogether

– Wire winds about the Wire winds about the bone under the bone under the periosteumperiosteum


HemicerclageHemicerclage

– Wire goes through Wire goes through holes drilled in the holes drilled in the bonebone

Suture Patterns for Specific Suture Patterns for Specific TissuesTissues

Skin- simple interrupted, horizontal mattress, Skin- simple interrupted, horizontal mattress, vertical mattress, continuous apposing or evertingvertical mattress, continuous apposing or everting

Subcutaneous tissue- simple continuousSubcutaneous tissue- simple continuous

Fascia- simple continuous (primary), simple Fascia- simple continuous (primary), simple interrupted, vertical mattress, far-near, near-far, interrupted, vertical mattress, far-near, near-far, Mayo mattressMayo mattress

Peritoneum- simple continuous (two-layer), and Peritoneum- simple continuous (two-layer), and simple interruptedsimple interrupted– Very thin and fragile in horse, close muscle insteadVery thin and fragile in horse, close muscle instead

Suture PatternsSuture Patterns Vessels- simple interrupted and simple continuousVessels- simple interrupted and simple continuous

Viscera- direct appositional Cushing sutureViscera- direct appositional Cushing suture

Muscle- simple continuous, simple interrupted, and Muscle- simple continuous, simple interrupted, and horizontal mattresshorizontal mattress

Tendons- BunnellTendons- Bunnell

Bone- hemicerclage and cerclageBone- hemicerclage and cerclage

ReferencesReferences Clinical Textbook for Veterinary TechniciansClinical Textbook for Veterinary Technicians ; McCurnin, D.M.; ; McCurnin, D.M.;

W.B. Saunders Co., Philadelphia, 1994W.B. Saunders Co., Philadelphia, 1994

Ethicon Wound Closure ManualEthicon Wound Closure Manual; Available at ; Available at http://www.ethiconinc.com/wound_management/procedure/wound/

Fundamental techniques in Veterinary SurgeryFundamental techniques in Veterinary Surgery;; Knecht, C.D.; Allen, A.R.; Williams, D.J.: Johnson, J.H.; W.B. Knecht, C.D.; Allen, A.R.; Williams, D.J.: Johnson, J.H.; W.B.

Saunders Philadelphia, 1981Saunders Philadelphia, 1981

Davis + Geck Veterinary Suture Manual, 1991Davis + Geck Veterinary Suture Manual, 1991

http://www.ethiconinc.com/wound_management/procedure/wound/

http://www.ethiconinc.com/wound_management/procedure/wound/

Documents

Wound Healing and Suture Knowledge ASR Certification Prep Kim Bayer, SRS, BS, CVT, LATg