Wound Closure Manual (PDF) - Penn Medicine

In peripheral nerve repair, precise
suturing often requires the aid of
an operating microscope. Suture
gauge and needle fineness must be
consistent with nerve size. After
the motor and sensory fibers are
properly realigned, the epineurium
(the outer sheath of the nerve) is
sutured. The strength of sutures in
this area is less of a consideration
than the degree of inflammatory
and fibroplastic tissue reaction.
Fine sizes of nylon, polyester, and
poly-propylene are preferred.
MICROSURGERY
The introduction of fine sizes of
sutures and needles has increased
the use of the operating microscope.
ETHICON introduced the first
microsurgery sutures—ETHILON*
sutures—in sizes 8-0 through
11-0. Since then, the microsurgery
line has expanded to include
PROLENE* sutures and coated
VICRYL* sutures. Literally all
surgical specialties perform some
procedures under the operating
microscope, especially vascular and
nerve anastomosis.
Skin
Brain
Galea
OPHTHALMIC SURGERY
The eye presents special healing
challenges. The ocular muscles, the
conjunctiva, and the sclera have good
blood supplies; but the cornea is an
avascular structure. While epithelialization
of the cornea occurs rapidly
in the absence of infection, full
thickness cornea wounds heal slowly.
Therefore, in closing wounds such as
cataract incisions, sutures should
remain in place for approximately
21 days. Muscle recession, which
involves suturing muscle to
sclera, only requires sutures for
approximately 7 days.
Nylon was the preferred suture
material for ophthalmic surgery.
While nylon is not absorbed,
progressive hydrolysis of nylon
in vivo may result in gradual loss of
tensile strength over time. Fine sizes
of absorbable sutures are currently
used for many ocular procedures.
Occasionally, the sutures are
absorbed too slowly in muscle
recessions and produce granulomas
to the sclera. Too rapid absorption
has, at times, been a problem in
cataract surgery. Because they
induce less cellular reaction than
Skull
Dura mater
FIGURE
17
LAYERS
OF SUTURES
SURROUNDING
A DRAIN
CHAPTER 2 35
surgical gut and behave dependably,
VICRYL sutures have proven useful
in muscle and cataract surgery.
While some ophthalmic surgeons
promote the use of a "no-stitch"
surgical technique, 10-0 coated
VICRYL (polyglactin 910) violet
monofilament sutures offer distinct
advantages. They provide the security
of suturing immediately following
surgery but eliminate the risks
of suture removal and related
endophthalmitis.
The ophthalmologist has many
fine size suture materials to choose
from for keratoplasty, cataract,
and vitreous retinal microsurgical
procedures. In addition to
VICRYL* sutures, other monofilament
suture materials including
ETHILON sutures, PROLENE
sutures, and PDS* II sutures may
be used. Braided material such as
virgin silk, black braided silk,
MERSILENE* sutures, and coated
VICRYL sutures are also available
for ophthalmic procedures.
UPPER ALIMENTARY
TRACT PROCEDURES
The surgeon must consider the
upper alimentary tract from the
mouth down to the lower
esophageal sphincter to be a
potentially contaminated area.
The gut is a musculomembranous
canal lined with mucus membranes.
Final healing of mucosal wounds
appears to be less dependent upon
suture material than on the wound
closure technique.
The oral cavity and pharynx
generally heal quickly if not infected.
Fine size sutures are adequate in this
area as the wound is under little
tension. Absorbable sutures may be
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