Chapter 25: Suturing Techniques and Wound Care

INTRODUCTION

WOUND HEALING

The process of wound healing is generally divided into four stages: inflammation, fibroblast proliferation, contraction, and remodeling. There are three types of wound healing:

• First intention. The wound is closed by routine primary suturing, stapling, or gluing. Epithelialization occurs in 24–48 hr in an uninfected wound.

• Secondary intention. The wound is not closed by suturing, stapling, or gluing but closes by spontaneous contraction and epithelialization at a rate of 1 mm/day (granulation). Most often used for wounds that are infected and packed open.

• Third intention. (also called delayed primary closure). The wound is left open for a time and then sutured at a later date. Often used with grossly contaminated wounds.

GENERAL PRINCIPLES OF WOUND CLOSURE

The decision on how to close a wound is based on many factors. They include the nature of the wound (traumatic vs. intentional wounds such as in the operating room, crush, or puncture wounds), location (e.g., scalp, face, trunk, and joint), degree of contamination, patient factors (allergies, diabetes, and patient age), and physician preference. Primary closure of wounds is usually the preferred approach unless there is significant contamination, obvious infection (pus, severe inflammation, or redness), or delayed presentation of traumatic wounds (beyond 12 hr on the body or 24 hr on the face). Traumatic wounds with concerning characteristics can often be managed with oral antibiotics and packed with saline-soaked gauze packing using a wet-dry closure method that debrides the wound over several days with closure by either secondary (granulation) or third intention (delayed primary closure). Puncture wounds that cannot be irrigated and any wound associated with an abscess cavity should not be closed. Consideration is also given not to close certain animal or human bites due to the risk of infection. Bites that are closed should also be given antibiotics and re-evaluated for signs of infection.

Bleeding from the wound itself (not associated with major vascular injury) should be controlled with direct pressure or using 1% epinephrine with lidocaine topically or by infiltration. Caution is recommended in the use of epinephrine in digits, tip of the nose, ears, and the penis. Wounds can be closed by suture, staples, tissue adhesives, and wound closure adhesive strips.

SUTURE MATERIALS

(See Tables 25-1 and 25-2)

Suture materials can be broadly defined as absorbable and nonabsorbable. Absorbable sutures can be thought of as temporary and include plain catgut, chromic catgut, and synthetic materials such as polyglactin 910 (Vicryl), polyglycolic acid (Dexon), and poliglecaprone (Monocryl). Left inside the body, these materials are resorbed after a variable period of ...