Implant Materials Live Session PDF

IMPLANTED MATERIALS LIVE SESSION ALISON LIVESEY OCTOBER 2024 George 1 year old MN Labrador » George has been vomiting for 1 week » He has not eaten anything since then » Owner says he frequently eats stones » You admit him to take radiographs » This is his radiograph » Why is he vomiting? #uni...

IMPLANTED MATERIALS LIVE SESSION ALISON LIVESEY OCTOBER 2024 George 1 year old MN Labrador » George has been vomiting for 1 week » He has not eaten anything since then » Owner says he frequently eats stones » You admit him to take radiographs » This is his radiograph » Why is he vomiting? #universityofsurrey 2  » You suspect an exploratory laparotomy is required as an FB is in the intestines » The stone has a sharp point and you have concerns about perforation » George is to be stabilised then taken to surgery #universityofsurrey 3 Prior to the surgery you look in the cupboard » Are these suture materials and needles suitable for an enterotomy/ enterectomy? » Have a chat with your neighbour? Are they absorbable/non-absorbable? » What about the needle? What about the size of suture material? » Monofilament/multifilament? What suture pattern? » Are there other considerations for this patient? Cat Gut 0 0 (3.5 metric) #universityofsurrey 4 Prolene-polypropylene #universityofsurrey 5 Prolene-polypropylene Properties » Synthetic material » Non absorbable » No loss of strength for years » Poor handling, high memory » Used for skin and tendon repair » Would not use for repair of intestine » Reverse cutting needle not suitable #universityofsurrey 6 Vicryl/Polyglactin 910 #universityofsurrey 7 Vicryl/Polyglactin 910 » Synthetic braided/multifilament material » Time to absorption 56-70 days » 25% loss at 14 days » 50% loss at 21 days » 75% loss at 28 days » Used for ligation/tissue approximation » Braided material more likely to wick bacterial » Reverse cutting needle not suitable #universityofsurrey 8 Chromic cat gut Properties » Natural material/absorbable » Comes from mucosa and submucosa cattle and sheep » Very good handling » Marked foreign body reaction » Loss of strength 33% 7 days » 67% 28 days » Full absorption 42 days » Loses strength more rapidly if infection present » Not suitable for intestinal anastomosis » For anastomosis must use swaged needle #universityofsurrey 9 Finally you find this-PDS Polydioxanone #universityofsurrey 10  » Synthetic absorbable monofilament » Less wicking than multifilament » High memory but less drag » Need to have appropriate number of throws in continuous pattern » Useful for where extended support is required » Time to total absorption 180 days(predictable) » 14-20% loss 14 days » 41% -50% loss 42 days » 86% loss 56 days » Round bodied needle #universityofsurrey 11 What’s wrong with this needle? You need a swaged needle What suture pattern for the enterotomy/enterectomy? #universityofsurrey 14 What suture pattern for the enterectomy? Simple Interrupted or continuous can be used for enterectomy or enterotomy #universityofsurrey 15 What are the other considerations for this patient? #universityofsurrey 16 What are the other considerations for this patient? » Hypovolaemia » Halstead’s Principles » Hypoproteinaemia » Hypothermia » Break in asepsis » Aseptic technique » Contaminated procedure/spillage of contents » Preserve blood supply » Analgesia » Minimise tension » Accurate tissue apposition » Minimise dead space » Haemostasis #universityofsurrey 17 You perform surgery on George » You remove this sharp pebble from his intestines » This has just perforated the lumen » You perform a successful end to end resection #universityofsurrey 18 Wound Classification Clean? Clean contaminated? Contaminated? Dirty? Wound classification (level of contamination)   #universityofsurrey 20 Enterectomy Williams, J. M. & Niles, J. D. (2015) BSAVA manual of canine and feline abdominal surgery. Second edition. John M. Williams & Jacqui D. Niles (eds.). Gloucester, England: British Small Animal Veterinary Association. #universityofsurrey 21 Other Suture Patterns Gambee Pattern-Used to reduce mucosal eversion. The needle is introduced as for simple interrupted but is returned to the mucosa and Simple Continuous muscularis before it crosses the incision. #universityofsurrey 22 To close the abdomen » Three layer closure » Close the linea alba » Close the subcutaneous tissues » Close the skin #universityofsurrey 23 Why would this not be suitable for linea alba? #universityofsurrey 24 Ophthalmic Surgery Cherry Eye Fossum, Theresa Welch. Small Animal Surgery Textbook, Elsevier, 2013. ProQuest Ebook Central,. https://ebookcentral.proquest.com/lib/surrey/detail.action?docID=1430761 #universityofsurrey 25 Suture characteristics Suture Absorbable Non absorbable Synthetic Natural Synthetic Natural Multifilament Monofilament Monofilament Monofilament Multifilament 12 Size Guides » USP-United states Pharmacopeia USP Metric 6 /0 0.7 5/0 1 4/0 1.5 3/0 2 2/0 3 0 3.5 1 4 #universityofsurrey 27 2 year old Female DSH Cat » Cat had kittens 8 weeks ago » Was speyed 3 days ago midline » Owner phoned to say suture hanging from wound » You ask her to come straight down » On the notes a simple continuous pattern was used in the linea alba #universityofsurrey 28 2 year old Female DSH Cat » What has happened? » What patient factors could make this happen? » What surgical factors could make this happen? #universityofsurrey 29 Patient factors » Poor immunity » Lack of blood supply-shock/dehydration » Underlying disease e.g Cushings (rare in cats) » Feline viral disease-FIP, FELV, FIV, Calici/FHV » Possibly pregnancy? Lactation? #universityofsurrey 30 Surgical Factors » Wrong Suture Material- e.g.catgut » Fascia heals slowly » Wrong size of suture material » Wrong number of throws » Polyglactin 910 (Vicryl) had been used » Need 4 throws at beginning, 6 at the end » Failure to incorporate fascia » Sutures too far apart » Sutures placed too close to edge » Break in asepsis » BAD LUCK #universityofsurrey 31 Other Factors » This cat had fluid in its abdomen at the time of initial surgery » Possibly there was an underlying cause e.g. FIP #universityofsurrey 32 3 year old MN Shih Tzu » Had surgery for grade 3 patellar luxation 4 weeks ago » Had a tibial tuberosity transposition » Now swelling developed over the stifle » What should we do? #universityofsurrey 33  4-year old FN DSH Cat » Presented straining to pass urine 2 week » Blood on urinary dipstick » Sediment examination showed calcium oxalate crystals » Radiographs taken » Calculus visible in the bladder #universityofsurrey 34 You perform a cystotomy » What sutures will you use? » What suture pattern will you use? » Does bladder heal well or badly? #universityofsurrey 35 Suture material » Use stay sutures to suspend the bladder and avoid abdominal contamination » Synthetic Absorbable material –polydioxanone/ poliglecaprone 25 3/0 or 4/0 (1.5 metric or 2 metric) » If thickened may have to use single layer appositional closure » Two layer closure preferred if possible » Use an inverting suture for a watertight closure #universityofsurrey 36 Inverting patterns » Used to invert » Water tight seal » Hollow viscous Cushing preferred to Connell-avoid suture in the bladder lumen Lembert Connell Cushing #universityofsurreyv 44 Poliglecaprone 25 (Monocryl) » Synthetic absorbable » Monofilament » Complete absorption 91-119 days » Quicker loss of strength than polydioxanone » 30-50% 7 days » Not suitable where prolonged strength required » Knot security not as good as multifilament #universityofsurrey 38 Stray Persian MN Cat-Brought in after RTA » You are worried there may be abdominal injuries and decide to xray » You take an xray » There are no abdominal injuries –But? #universityofsurrey 39 Radiograph-what is this? #universityofsurrey 40 Sub ureteral By pass-Used for Damage to Ureters #universityofsurrey 41 Charlie-4-Year old female entire pointer » Charlie has not eaten for 1 week » She has been diagnosed with pancreatitis » The decision has been made to pass an oesophagostomy tube » What suture do you need to hold this in place? #universityofsurrey 42  What suture do you need to hold this in place? #universityofsurrey 43 Chinese Finger Trap Suture Secure tubes exiting body Drains, feeding tubes » Tightens around tube when tube pulled » Simple interrupted with both free ends long » Double throw and then cross around tube with repeated double throws » Finish with knot Fossum, Theresa Welch. Small Animal Surgery Textbook, Elsevier, 2013. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/surrey/detail.action?doc #universityofsurrIeDy=1430761. 40 Feeding Tubes » Nasogastric » Oesophagostomy Tube » Gastrotomy tube-left side for feeding » Gastrostomy tubes can also be used for gastropexy (right side) » Gastropexy is fixing the stomach to body wall following torsion Naso-gastric tube BSAVA Manual of Canine and Feline Abdominal Surgery, edited by John Williams, and Jacqui Niles, British Small Animal Veterinary Association (B S A V A), 2016. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/surrey/detail.action?docID=4731770. Gastrotomy Tube #universityofsurrey 45 Normal Stomach » In normal patient only small amounts gas visible in the stomach » Gas shows as black on xray BSAVA Manual of Canine and Feline Abdominal Imaging, edited by Robert O'Brien, and Frances Barr, British Small Animal Veterinary Association (B S A V A), 2009. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/surrey/detail.action?docID=4894950. #universityofsurrey 46 Gastric dilation » Black gas visible in the stomach BSAVA Manual of Canine and Feline Abdominal Imaging, edited by Robert O'Brien, and Frances Barr, British Small Animal Veterinary Association (B S A V A), 2009. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/surrey/detail.action?docID=4894950. #universityofsurrey 47 Gastric Torsion » Duodenum rotates and forms “Popeye’s arm” » Surgically de-rotate and fix (pexy) pylorus to body wall to prevent recurrence » Different techniques are described » Tube gastro-pexy » Incisional gastropexy » Circumcostal gastropexy » Belt-loop gastropexy » Need a long lasting suture to stop recurrence #universityofsurrey 48 Most people use 2/0 3/0 suture material Incisional Gastropexy Tube gastropexy-tube enters through RHS body wall Purse String Suture » Temporary closure of hollow viscous around a structure Used in the anus to prevent faecal contamination » Securing tubes #universityofsurrey 50 What problems could exist with this implant? What is this used for? Ameroid constrictor Questions? #universityofsurrey 53 References #universityofsurrey 54 48