References

1. Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev 6(4):428-442, 1993.

2. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 20(4):247-278, 1999.

3. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 326:281-286, 1992.

4. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery. Baseline results from the national surgical infection prevention project. Arch Surg 140:174-182, 2005.

5. Mangram A, Horan TC, Pearson ML, et al. The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 20(4):247-278, 1999.

6. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 121:251-254, 1971.

7. Hamilton HW, Hamilton KR, Lone FJ. Preoperative hair removal. Can J Surg 20:269-271, 274-275, 1977.

8. Alexander JW, Fischer JE, Boyajian M, et al. The influence of hair-removal methods on wound infections. Arch Surg 118(3):347-352, 1983.

9. Masterson TM, Rodeheaver GT, Morgan RF, et al. Bacteriologic evaluation of electric clippers for surgical hair removal. Am J Surg 148:301-302, 1984.

10. Food and Drug Administration. Topical antimicrobial drug products for over-the-counter human use: tentative final monograph for health-care antiseptic drug products-proposed rule (21 CRF Parts 333 and 369). Fed Regist 59:31441-31452, 1994.

11. Hardin WD, Nichols RL. Handwashing and patient skin preparation. In Malangoni MA, ed., Critical Issues in Operating Room Management. Philadelphia, PA: Lippincott-Raven, 1997: 133-149.

12. Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the healthcare infection control practices. MMWR Recomm Rep 51(RR-16):1-56, 2002.

13. Quebbemann EJ, Telford GL, Wadsworth K, et al. Double gloving. Protecting surgeons from blood contamination in the operating room. Arch Surg 127:213-216, 1992.

14. Association of Perioperative Registered Nurses. Recommended practices for maintaining a sterile field. AORN J 73(2):477-482, 2001.

15. Pierce L. Basic principles of aseptic technique. Plast Surg Nurs 17:48-49, 1997.

16. U.S. Department of Labor Occupational Safety & Health Administration. Regulations (preambles to final rules), section 9-IX. Summary and Explanation of the Final Standard (Construction Industries).

17. U.S. Department of Labor Occupational Safety & Health Administration. Regulations (standards—29 CFR). Bloodborne pathogens, parts 1910, 1030.

18. Letter from Greg Watchman to Sen. Brian P. Bilbray in response to the application of glove monitoring devices to aid in the detection of glove failures, 1997.

19. Naver LPS, Gottrup F. Incidence of glove perforation in gastrointestinal surgery and the protective effects of double gloves: a prospective randomized controlled study. Eur J Surg 166:293-295, 2000.

20. Laine T, Aarino P. How often does glove perforation occur in surgery? Comparison between single gloves and a double gloving system. Am J Surg 181:564-566, 2001.

21. Cardo DM, Culver DH, Ciesielski C, et al. A case-control study of HIV serocon-version in health care workers after percutaneous exposure. N Engl J Med 337:1485-1490, 1997.

22. Shapiro CN. Occupational risk of infection with hepatitis B and hepatitis C virus. Surg Clin North Am 75:1047-1056, 1995.

23. Zuckerman J, Clewley G, Griffiths P, et al. Prevalence of hepatitis C antibodies in clinical health-care workers. Lancet 343:1618-1620, 1994.

24. Petrosilla N, Puro V, Ipolito G, and the Italian Study Group on bloodborne Occupational Risk in Dialysis. Prevalence of hepatitis C antibodies in health-care workers. Lancet 344:339-340, 1994.

25. Lanphear BP, Linneman CC, Cannon CG, et al. Hepatitis C virus infection in health care workers: risk of exposure and infection. Infect Control Hosp Epidemiol 15:745-750, 1994.

26. Rhodes RS, Bell DM, eds. Prevention of transmission of bloodborne pathogens. Surg Clin North Am 75:1047-1217, 1995.

27. Chamberland ME, Ciesielski CA, Howard RJ, et al. Occupational risk of infection with human immunodeficiency virus. Surg Clin North Am 75:1057-1070, 1995.

28. Marcus R, Bell DM. Occupational risk of human immunodeficiency virus. In Devita VT, Hellman S, Rosenberg SA, eds., Aids: Etiology, Diagnosis, Treatment and Prevention, 4th ed. Philadelphia, PA: Lippincott-Raven, 1997: 645-654.

29. Centers for Disease Control and Prevention. Update: provisional public health service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR Morb Mortal Wkly Rep 1998.

30. Centers for Disease Control and Prevention. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. MMWR Morb Mortal Wkly Rep 46:603-606, 1997.

31. Krawczynski K, Alter MJ, Govindarajan S, et al. Studies on protective efficacy of hepatitis C immunoglobulins (HCIG) in experimental hepatis C virus infection [abstract]. Hepatology 18:110A, 1993.

The Assyro-Babylonian civilization provides some of the earliest writings involving the practice of surgery. Although removal of the surgeon's hands following adverse outcomes, as described in the Code of Hammurabi, does not routinely occur today, the code does enlighten the reader about the thousands of years that have gone into refining current surgical technique. Irrespective of advances in knowledge and technology, the underlying principles of suturing remain consistent: apposition of wound edges until inherent healing processes provide strength and aesthetics, as well as protecting against bleeding and infection. Suture technique is a basic component of all surgical procedures and must be performed appropriately to avoid postoperative complications. Proper technique demands more than a modicum of skill and depends on practice and repetition.

Suturing typically involves a surgical needle with which to penetrate tissues and advance the suture threads. The needle consists of three major areas (Fig. 18-1). The point is the sharpest portion of the needle and can be tapered or cut in style. Taper points are generally used for easily penetrable tissues,

Matthew Hartwig, MD

Body

Body

Swaged Needle
Figure 18-1 The three major parts of a needle.

while cutting points are used for tougher tissues, such as skin. The body is the middle portion of the needle, which is grasped by the needle holder. The distal section of the needle holder jaws should clutch the needle securely, approximately one-third to one-half of the distance from the swaged end to the point. The swaged end involves the needle and suture attachment point, and is the weakest portion of the needle.

Proper use of the needle and needle holder is a primary component of suture technique. The needle holder is held with the first and fourth digits placed through the loops in the handle, while the second digit provides stabilization by applying pressure to the fulcrum (Fig. 18-2). The needle should enter perpendicular to the surface being sutured, and subsequent force applied in the same direction as the curve of the needle. The size of the bite (the amount of wound tissue included in the closure) is determined by the size of the needle. Do not take excessively large bites of tissue. Do not grasp the point or cutting edges with the needle holders when pulling the needle through the wound. This rapidly dulls the needle for future use.

The term suture refers to any material used for wound closure or ligation of structures. Historically, animal sinews and certain plant fibers have been described as being used for suture material. Modern materials vary greatly in composition, but can be divided into two broad categories: absorbable and nonabsorbable. The choice of suture type is determined by the characteristics of the wound being closed. Synthetic absorbable sutures are degraded via hydrolyzation, instead of enzymatic digestion, and therefore create less tissue reaction than natural absorbable sutures. Some typical synthetic absorbable sutures in use today include polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl), and polydioxanone (PDS II). Nonabsorbable sutures are considered not to degrade within the body and can be composed of single or multiple filaments. Commonly used nonabsorbable suture materials include silk, nylon, polypropylene, and metal wire. Because of their nonabsorbable nature, these sutures are used to approximate tissues over a

Figure 18-2 Proper handling of the needle holder assists in stability and skillful placement of each stitch. The first and fourth digits are placed through the handle loops while the second digit rests against the fulcrum for additional support.

long period of time. However, the lack of dissolution also serves as a possible nidus of infection, with braided nonabsorbable sutures the most likely to harbor infectious organisms.

There is an assortment of wound closure options, each with advantages and disadvantages. As with the suture material, details of the wound determine the type of closure selected by the surgeon. Wound closures can be divided into two broad categories: interrupted and continuous. With interrupted suturing techniques, each stitch is placed individually. In general, this allows the surgeon to make minor modifications during the closure to ensure proper alignment. Interrupted sutures also provide greater tensile strength and have a tendency to create less tissue edema. The primary disadvantage of interrupted sutures involves the longer duration of time required to close larger wounds. Continuous, or running, sutures involve multiple stitches being placed without interruption. Using continuous sutures can expedite the closure, but make perfect alignment more challenging and can decrease circulation to the wound. Also, dehiscence may occur if the suture were to break and unravel.

Three of the more commonly used closures include the simple, horizontal, and vertical mattress techniques. All three can be performed in an interrupted or continuous manner. The simple interrupted suture is the most versatile method of closing wounds (Fig. 18-3). In general, the distance between wound edges and the insertion and exit site of the needle should be equal. Also, the gap between each individual stitch should be equidistant. Typically, the base of the stitch is broader than the top. This creates a flask-shaped stitch, promotes wound eversion, and assists in avoiding excessive scarring as tissue retraction occurs during healing. The simple continuous suture provides the most rapid method of closing wounds. The first stitch is placed at one end of the wound and secured as in the simple interrupted closure. However, the suture is not cut. Instead, successive simple stitches are evenly situated along the length of the wound. The closure is finished by securing it with a knot between the tail of the suture and the loop of the last stitch placed.

Horizontal and vertical mattress sutures can both be used to support approximation of wound edges by decreasing tension. Vertical mattress stitches are a variation of the simple interrupted in which the first bite begins wide of the wound edge and travels deeply prior to exiting the wound on the opposite side (Fig. 18-4). Instead of securing the stitch at this time, the suture is brought back through the wound again, this time with entry and exit points closer and more superficial than the original bite. This technique provides superior eversion of wound edges and is able to close potential spaces deep within the

Figure 18-3 Drawing of simple interrupted suture placement. The bottom right diagram illustrates the "flask" shape of the stitch with a wider base—optimizing wound edge eversion. (Source: Adapted from Mackay-Wiggin J, Ratner D. eMedicine, 2005.)

Figure 18-4 The vertical mattress stitch includes deep and shallow bites through the wound to aid in reducing wound tension and to close any potential space at the base of the wound. (Source: Adapted from Mackay-Wiggin J, Ratner D. eMedicine, 2005.)

wound. A horizontal mattress suture also can greatly reduce tension and evert wound edges when properly used (Fig. 18-5). The needle is inserted and driven through the wound as if a simple stitch was being placed. However, the needle is reinserted approximately 0.5-1.0 cm lateral to, but on the same side as the first exit site. After passing through the wound again and exiting on the side of the original needle entry location, the stitch is secured with a knot. Although useful in many situations, mattress sutures are prone to producing suture marks, tissue strangulation, and wound necrosis if not performed appropriately. In order to minimize these complications, one should tighten only enough to approximate the wound edges and then remove the sutures as early as possible based on wound strength.

In general, the continuous subcuticular suture provides the best aesthetic result for closing wounds (Fig. 18-6). It does not provide significant wound strength, and therefore should only be used in wounds under minimal tension. The technique is essentially a buried continuous horizontal mattress in which a simple stitch is placed and secured at one end of the wound. The suture is then carried the length of the wound by taking horizontal bites through the papillary dermis on alternating sides until the wound is closed. If both anchoring knots are buried, it is possible to completely conceal the suture material below the epidermis and obviate suture marks, or crosshatching.

Suture removal also requires proper technique in order to achieve the best possible outcome. Although premature removal of sutures may lead to

Figure 18-5 The horizontal mattress stitch also provides additional support for wounds under tension. (Source: Adapted from Mackay-Wiggin J, Ratner D. eMedicine, 2005.)

dehiscence and disappointing cosmetic results, delay in suture removal may increase tissue reaction, scar formation, crosshatching, and the risk of infection. Proper timing of suture removal depends on the amount of tension and anatomic location of the wound. Typically, sutures are removed 1-2 weeks following wound closure. Sutures on the face are usually removed within 5-7 days. On the contrary, sutures on the lower extremities or in areas of mobility may need to stay in place for 3 weeks, or more. Buried sutures with absorbable material will dissolve over time and do not require later removal. In order to remove a suture, it should be gently elevated with forceps while one side is transected with scissors. The knot can then be grasped and slowly pulled

Figure 18-6 The subcuticular stitch is a modification of the horizontal mattress in which the suture is buried beneath skin level in order to improve the aesthetic appearance of a wound. (Source: Adapted from Mackay-Wiggin J, Ratner D. eMedicine, 2005.)

toward the suture line while the stitch slides free of the wound. Pulling the stitch away from the suture line may lead to wound separation. Often, sterile adhesive strips are placed on the wound following suture removal for additional support. This may help prevent spreading the wound scar.

A prerequisite for effective wound care is a thorough familiarity with the basic principles and mechanisms of wound healing and the clinical factors that may significantly impede this process. Briefly, the sequence of events in normal wound healing can be arbitrarily divided into four sequential phases: inflammation, epithelialization, fibroplasia, and maturation. The maximum tensile strength of a wound, which is typically reached by 8 weeks, is determined by the extent of collagen cross-linking and may approach 80 percent of the original level of strength. As will be described further below, essential components of wound healing include the maintenance of a moist environment,

Brian Lima, MD

adequate oxygen delivery, removal of necrotic tissue, optimizing nutritional status, and immediate recognition and treatment of wound complications, such as infections and fascial dehiscence.

During the initial evaluation of a wound, certain features must be noted, such as whether the wound is open or closed, and whether the wound is acute versus chronic (greater than 3 months). These important distinctions are critical for classifying wounds and determining the most appropriate mode of therapy. Careful attention to every descriptive detail of the wound must also be documented, including the presence or absence of erythema, induration, necrotic tissue, granulation tissue, drainage (purulent, serous, feculent, or sero-sanguinous), severe tenderness, and overall wound dimensions (Table 18-1). Awareness of these characteristics enables timely diagnosis of wound complications as well as tracking progress, or lack thereof, for any given wound. Therefore, simply stating that a wound is clean, dry, and intact will not always suffice.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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