Wound Closure Manual (PDF) - Penn Medicine

Thus, sutures are needed for only
7 to 10 days.
THE FEMALE GENITAL TRACT
Surgery within this area presents
certain challenges. First, it is usually
regarded as a potentially contaminated
area. Second, the surgeon must
frequently work within a very
restricted field. Endoscopic technique
is frequently used in this area. Coated
VICYL* suture is an excellent choice
to prevent bacterial colonization.
Most gynecological surgeons prefer
to use absorbable sutures for repair of
incisions and defects. Some prefer
using heavy, size 1 surgical gut
sutures, MONOCRYL sutures, or
VICRYL sutures. However, the
stresses on the reproductive organs
and the rate of healing indicate that
these larger-sized sutures may only be
required for abdominal closure.
Handling properties, especially
pliability of the sutures used for
internal use, are extremely
important. Synthetic absorbable
sutures such as VICRYL* sutures in
size 0 may be used for the tough,
muscular, highly vascular tissues
in the pelvis and vagina. These
tissues demand strength during
approximation and healing. Coated
VICRYL* RAPIDE suture, for
example, is an excellent choice for
episiotomy repair.
TENDON SURGERY
Tendon surgery presents several
challenges. Most tendon injuries are
due to trauma, and the wound may
be dirty. Tendons heal slowly. The
striated nature of the tissue makes
suturing difficult.
Tendon repair fibroblasts are
derived from the peritendonous
tissue and migrate into the wound.
The junction heals first with scar
tissue, then by replacement with
new tendon fibers. Close apposition
of the cut ends of the tendon
(especially extensor tendons)
must be maintained to achieve
good functional results. Both the
suture material and the closure
technique are critical for successful
tendon repair.
The suture material the surgeon
chooses must be inert and strong.
Because tendon ends can separate
due to muscle pull, sutures with a
great degree of elasticity should be
avoided. Surgical steel is widely used
because of its durability and lack of
elasticity. Synthetic nonabsorbable
materials including polyester fibers,
polypropylene, and nylon may be
used. In the presence of potential
infection, the most inert monofilament
suture materials are preferred.
The suture should be placed to
cause the least possible interference
with the surface of the tendon, as
this is the gliding mechanism. It
should also not interfere with the
blood supply reaching the wound.
Maintenance of closed apposition
of the cut ends of the tendons,
particularly extensor tendons, is
critical for good functional results.
The parallel arrangement of tendon
fibers in a longitudinal direction
makes permanent and secure placement
of sutures difficult. Various
figure-of-eight and other types of
suturing have been used successfully
to prevent suture slippage and the
formation of gaps between the cut
ends of the tendon.
Many surgeons use the Bunnell
Technique. The suture is placed to
be withdrawn when its function as a
CHAPTER 2 39
holding structure is no longer necessary.
Referred to as a pull-out suture,
it is brought out through the skin
and fastened over a polypropylene
button. The Bunnell Technique
suture can also be left in place.
NUROLON* sutures, PROLENE*
sutures, PRONOVA* sutures and
ETHIBOND* EXCEL sutures may
be used for connecting tendon to
bone. Permanent wire sutures also
yield good results because healing is
slow. In periosteum, which heals
fairly rapidly, surgical gut or coated
VICRYL sutures may be used. In
fact, virtually any suture may be
used satisfactorily in the periosteum.
SUTURES FOR BONE
In repairing facial fractures,
monofilament surgical steel has proven
ideal for its lack of elasticity. Facial
bones do not heal by callus formation,
but more commonly by fibrous union.
The suture material must remain in
place for a long period of time—
perhaps months—until the fibrous
tissue is laid down and remodeled.
Steel sutures immobilize the
fracture line and keep the tissues in
good apposition.
Following median stemotomy,
surgeons prefer interrupted steel
sutures to close. Sternum closure may
be difficult. Appropriate tension must
be maintained, and the surgeon must
guard against weakening the wire.
Asymmetrical twisting of the wire may
cause it to buckle, fatiguing the metal,
and ultimately causing the wire to
break. Motion between the sides of
the sternum will result, causing
postoperative pain and possibly
dehiscence. Painful nonunion is
another possible complication. (In
osteoporotic patients, very heavy
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