Wound Closure Techniques and Medicinal Leeches
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Questions and Answers

Why does bleeding continue for 24-48 hours after a medicinal leech detaches from a wound?

  • The leech creates a large wound that takes time to clot.
  • The leech leaves behind bacteria that prevent clotting.
  • Anticoagulants and vasodilators introduced by the leech. (correct)
  • The leech continues to secrete blood into the wound.

    • What is a major infectious risk associated with the use of medicinal leeches?

  • Streptococcus pyogenes
  • Escherichia coli
  • Staphylococcus aureus
  • Aeromonas hydrophila (correct)

    • What is the primary reason for incisional discomfort and pressure necrosis when closing a wound?

  • Poor tissue granulation.
  • Inadequate regional blood supply.
  • Apposing incision edges under excessive tension. (correct)
  • Using the wrong suture material.

    • Which technique is LEAST likely to be used to reduce tension on a wound closure?

    <p>Applying direct pressure to the wound. (C)</p> Signup and view all the answers

    Why is it important to avoid excessive tension when positioning an animal for surgery?

    <p>To avoid compromising blood flow to the skin. (A)</p> Signup and view all the answers

    What is the primary purpose of using walking sutures in wound closure?

    <p>To obliterate dead space and distribute tension across the wound surface. (B)</p> Signup and view all the answers

    When placing walking sutures, where should the suture be placed through the fascia of the body wall relative to the bite through the subdermal fascia or deep dermis?

    <p>At a distance closer to the center of the wound. (B)</p> Signup and view all the answers

    What is the main reason for using external tension-relieving sutures?

    <p>To prevent sutures from cutting out due to excessive pressure on the skin. (D)</p> Signup and view all the answers

    A surgeon is closing a high-tension wound and decides to use vertical mattress sutures for tension relief. At what distance from the primary row of sutures should the tension relieving row be placed?

    <p>1 to 2 cm away from the primary row of sutures. (D)</p> Signup and view all the answers

    When should tension-relieving vertical mattress sutures typically be removed?

    <p>Around the third day after surgery. (A)</p> Signup and view all the answers

    Which skin stretching method allows for the greatest amount of skin recruitment compared to the other options listed?

    <p>Skin stretchers (C)</p> Signup and view all the answers

    A surgeon aims to close a large wound with minimal tension and scarring. Which suture type would be MOST appropriate for initial deep closure?

    <p>Subdermal sutures (C)</p> Signup and view all the answers

    What is the typical timeframe for interval injections when using inflatable tissue expanders?

    <p>Every 2 to 7 days (C)</p> Signup and view all the answers

    What is achieved by placing sutures in the subdermal or subcuticular tissue?

    <p>Bring skin edges into apposition and reduce tension on skin sutures (A)</p> Signup and view all the answers

    A patient reports discomfort following injections of an inflatable tissue expander. Which of the following would be MOST appropriate to manage the discomfort?

    <p>Administer an NSAID (B)</p> Signup and view all the answers

    Select the option that explains the primary function of walking sutures:

    <p>Advance skin edges together (A)</p> Signup and view all the answers

    When performing a V-to-Y plasty, what is the primary goal?

    <p>To provide an advancement flap of skin to cover a wound. (A)</p> Signup and view all the answers

    When is presuturing typically performed relative to the surgery?

    <p>24 hours before surgery (B)</p> Signup and view all the answers

    How should the central member of a Z-plasty be oriented in relation to the lines of tension?

    <p>Parallel to the greatest lines of tension. (A)</p> Signup and view all the answers

    For large wound reconstruction, which of the following is generally preferred over tissue expanders?

    <p>Axial pattern flaps (D)</p> Signup and view all the answers

    What is an important consideration when planning the excision of skin tumors?

    <p>Skin tension, elasticity and the direction of skin tension lines. (D)</p> Signup and view all the answers

    What is the recommendation regarding surgical margins for removing malignant skin tumors?

    <p>Margins of more than 2 to 3 cm may be indicated. (B)</p> Signup and view all the answers

    Why is it important to clip a large area and aseptically prepare the skin prior to removing a skin tumor?

    <p>To allow for skin flaps if needed for closure. (C)</p> Signup and view all the answers

    What geometric shape is typically resected to prevent or correct 'dog ears'?

    <p>Triangle (C)</p> Signup and view all the answers

    Under what circumstances are relaxing incisions MOST indicated?

    <p>On distal extremities or around eyes and anus. (B)</p> Signup and view all the answers

    What is a primary disadvantage of multiple punctate relaxing incisions compared to simple relaxing incisions?

    <p>They have a higher risk of circulatory compromise. (C)</p> Signup and view all the answers

    How do simple relaxing incisions typically heal?

    <p>By contraction and epithelialization. (B)</p> Signup and view all the answers

    In the context of wound closure, what is the purpose of undermining the skin before creating relaxing incisions?

    <p>To allow for easier skin apposition. (A)</p> Signup and view all the answers

    After excising a tumor, why might relaxing incisions be considered?

    <p>To facilitate skin closure around the resulting defect. (B)</p> Signup and view all the answers

    What suture pattern is MOST likely pre-placed before multiple punctate incisions are made?

    <p>Continuous subcuticular suture (C)</p> Signup and view all the answers

    Why might relaxing incisions be utilized before radiation therapy?

    <p>To allow skin closure around fibrotic wounds. (C)</p> Signup and view all the answers

    What is the purpose of placing a padded material, like a Penrose drain or IV tubing, beneath suture loops when using vertical or horizontal mattress sutures?

    <p>To relieve tension on the skin edges, preventing tissue damage and necrosis. (B)</p> Signup and view all the answers

    Which suture pattern is NOT explicitly mentioned as a method to relieve tension on wound edges?

    <p>Continuous unidirectional sutures. (D)</p> Signup and view all the answers

    What is the primary risk associated with using horizontal mattress sutures, even with stenting techniques?

    <p>Elevated potential for impairing local cutaneous blood flow to the skin edges. (A)</p> Signup and view all the answers

    How can skin 'dog ears' or puckers be prevented along a suture line during wound closure?

    <p>By placing sutures closer together on the convex side and farther apart on the concave side of the defect. (A)</p> Signup and view all the answers

    What surgical technique involves outlining a dog ear with an elliptical incision to remove the redundant skin?

    <p>Outlining with an elliptic incision and apposing the skin edges in a linear fashion. (A)</p> Signup and view all the answers

    In managing a dog ear by incising it centrally, what is the recommended approach for handling the resulting triangular flaps?

    <p>Excise both triangles and appose the edges, creating a linear suture line. (D)</p> Signup and view all the answers

    Which statement accurately describes the relationship between skin elasticity and the formation of dog ears?

    <p>Thin, elastic skin is less prone to the formation of dog ears than thick skin. (D)</p> Signup and view all the answers

    Besides surgical correction, what is a potential outcome for dog ears over time?

    <p>Dog ears usually flatten spontaneously without intervention. (C)</p> Signup and view all the answers

    Flashcards

    Medicinal leech

    Hirudo medicinalis, used to mimic venous outflow by creating a bleeding wound.

    Hirudiniasis

    Infection risk associated with using leeches, notably with Aeromonas hydrophila.

    Tension Lines

    Lines formed by the predominant pull of fibrous tissue in skin, affecting wound healing.

    Tension relief methods

    Techniques to reduce skin tension during surgery, including undermining and suture patterns.

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    Evaluating skin tension

    Assessing how much tension tissue can tolerate, important in reconstructive surgery.

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    Subdermal and Subcuticular Sutures

    Sutures using 3-0 or 4-0 materials with a buried knot for wound closure.

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    Walking Sutures

    Interrupted sutures that advance skin toward the center by distributing tension.

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    External Tension Relieving Sutures

    Sutures designed to prevent cutting out by dispersing pressure on the skin.

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    Vertical Mattress Suture

    A tension-relieving technique placed 1-2 cm away from primary sutures.

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    Tension-relieving Suture Removal

    Vertical mattress sutures are typically removed by the third day post-surgery.

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    Skin Prestretching

    Stretching skin before surgery to reduce tension during closure.

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    Presuturing

    Technique involving sutures placed before surgery to stretch skin.

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    Skin Stretchers

    Noninvasive devices that stretch skin around the surgical site.

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    Inflatable Tissue Expanders

    Inflatable devices used to gradually stretch skin over time.

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    Adjustable Sutures

    Sutures that can be tightened post-placement for better tension control.

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    Subdermal Sutures

    Sutures placed in subdermal fascia to reduce tension on skin sutures.

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    Stent

    A device used to support a structure, often in surgical contexts.

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    Penrose Drain

    A type of drain made from soft tubing, often used in surgeries.

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    Dog ears

    Puckers or folds that can form at the end of suture lines.

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    Preventing Dog Ears

    Using unequal suture spacing to avoid puckering at suture lines.

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    Far-near-near-far pattern

    A suture technique that helps relieve tension in the incision.

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    Dog Ear Correction

    Incising a dog ear into triangles to reshape the suture area.

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    Thin vs. Thick skin

    Thin skin is less prone to dog ears than thick skin.

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    V-to-Y Plasty

    A surgical technique providing an advancement flap to cover a wound.

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    Z-Plasty

    A procedure to reduce tension and facilitate wound closure by creating a Z-shaped incision.

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    Skin Tension Lines

    Predominant directions of skin elasticity that affect wound healing.

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    Excision Margin for Tumors

    The recommended area of healthy tissue to remove around a tumor during excision.

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    Tension Management in Surgery

    Techniques like undermining and incision planning to reduce skin tension during operations.

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    Elliptic Resection

    Removing an elliptical skin segment to prevent dog ears.

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    Triangle Resection

    Corrects dog ears by removing a large triangle of skin.

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    Double Triangle Resection

    Involves removing two smaller triangles to correct puckering.

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    Relaxing Incisions

    Incisions that allow skin closure around fibrotic areas.

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    Punctate Relaxing Incisions

    Small, staggered incisions made to reduce tension in skin.

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    Wound Approximation

    Bringing the edges of a wound closer for better closure.

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    Cosmetic Outcome

    The aesthetic result following surgical correction methods.

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    Study Notes

    CVM 737A: Introduction to Surgery - Principles of Reconstructive Surgery - SA

    • Course: CVM 737A, Introduction to Surgery
    • Topic: Principles of Reconstructive Surgery - SA
    • Date of Lecture: January 16, 2025
    • Instructor: R. Randall Thompson, DVM, MSpVM (SA Surgery)
    • Affiliation: Liaison, DeBusk Veterinary Teaching Center, Associate Professor of Small Animal Surgery
    • Location: Lincoln Memorial University

    Learning Objectives

    • List methods for reducing tension when closing wounds surgically.
    • Summarize the direction of surgical incisions and reasoning.
    • Summarize considerations for planning skin tumor removal.
    • Summarize methods for recruiting skin to close wounds under tension.
    • Illustrate methods for preventing or correcting "dog ears" or puckers.

    Reconstructive Surgery

    • Common procedures: closing defects from trauma, correcting congenital abnormalities, and after removal of neoplasms.
    • Importance of correct techniques: to prevent complications and unnecessary costs.

    Techniques for Closing Defects

    • Relaxing incisions (e.g., V-to-Y, Z-plasty): used for large or irregular defects.
    • Tissue mobilization: moving tissue from other sites for large defects, especially on extremities.
    • Pedicle flaps: tissues partially detached from the donor area and moved to cover a defect.
    • Grafts: transferring a segment of skin to a distant (recipient) site.

    Planning Reconstructive Surgery

    • Factors to consider: location of the wound, elasticity of surrounding tissue, regional blood supply, and character of the wound bed (infection, granulation tissue, skin availability).

    Tension Lines and Tension Relief

    • Wound closure should be along tension lines for optimal healing and aesthetics.
    • Methods for reducing tension include undermining wound edges, selecting appropriate suture patterns (e.g., cruciform > simple interrupted), using relief incisions, skin stretching, and tissue expansion.
    • Positioning is crucial: avoiding pinning mobile skin, using pads, and appropriate joint flexion.
    • Secondary intention healing or flaps/grafts are options if primary apposition isn't possible.

    Tension Relief Methods

    • Undermining wound edges
    • Suture Patterns
    • Relief Incisions
    • Skin Stretching
    • Tissue Expansion

    Tension Lines

    • Formed by fibrous tissue pull in the skin.
    • Important to map in animals, considering breed, conformation, gender, and age variations.
    • Incisions parallel to tension lines heal better.
    • Perpendicular incisions cause gaping wounds and wider scar tissue.

    Prevention of "Dog Ears"

    • Correcting "dog ears" by placing sutures closer together on the convex side of a wound are crucial.
    • Sutures should be spaced farther apart on the concave side.
    • Outlining with an elliptic incision and removing redundant skin; apposing edges in linear or curvilinear fashion.
    • Incising the dog ear to form two triangles for excision or repositioning is another method.

    Relaxing Incisions

    • Allows closure around fibrotic wounds or over crucial structures: e.g., before radiation therapy, after tumor excision, on distal extremities, around the eyes and anus, over tendons, ligaments, nerves, vessels, or implants.
    • Different types include simple relaxing incisions, multiple punctate relaxing incisions.
    • Healing time: 25-30 days by contraction and epithelialization.

    V-to-Y Plasty and Z-Plasty

    • V-to-Y: advancement flap to cover the wound.
    • Z-Plasty: can be made adjacent to the wound to decrease tension and facilitate wound closure.
      • Central member should be parallel to tension lines and 1/3 to 1/2 the length of the incision.
      • "Limbs" of Z-plasty should form 60° angles towards the center of the Z.
      • Additional considerations include distance from primary incision (≥ 3 cm), rounding the Z tips, undermining tissue, and marking the tumor margins when removing tumors.

    Skin Removal for Tumors

    • Assess skin tension and elasticity, and avoid excessive tumor manipulation.
    • Plan incision direction, excision shape, and closure method.
    • Clip the large treatment area and perform aseptic preparation.
    • Excision should include the tumor, previous biopsy sites, and appropriate margins in 3 dimensions (length, width, depth).
    • Aggressive tumors require larger margins.

    Additional Flaps, Grafts, and Stenting

    • Techniques like advancement flaps, rotational flaps, transposition flaps, interpolation flaps, and tubed pedicle flaps.
    • Axial pattern flaps, incorporating direct cutaneous vessels for better perfusion.
    • Consider using stents to support suture loops beneath the tissue.

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    Principles of Reconstructive Surgery - CVM 737A Lecture Notes PDF

    Description

    This quiz covers essential knowledge related to wound closure techniques, including the use of medicinal leeches and common suturing methods. Test your understanding of the reasons for bleeding after leech detachment, the risks associated with them, and effective suture techniques to minimize tension on wounds. Perfect for veterinary surgery students or professionals.

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