E-Quiz Ethicon ASEAN 2012

ABDOMINAL WALL ANATOMY & FASCIA CLOSURE (Part I) Pre-reading material

Compiled by Dr. Vikram Jaisinghani Mayteedol Nat

Content:

Skin: anatomy Wound healing Factors affecting wound healing

Complications of Wound healing

 Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing

Basic Anatomy of Skin and Fascia (I)

A cross section of skin and fascia is shown on the pic

on next page. As you know, these tissues are composed of layers:

Skin: composed of the outer epidermis and inner dermis,

containing hair, sweat glands, nerve endings, and capillaries Subcutaneous tissue: a layer of loose connective tissue, containing larger blood vessels and fat Fascia and muscle: composed of muscle and muscle aponeuroses, which form the fascia, covering deeper structures

Basic Anatomy of Skin and Fascia (II)

Epidermis

Dermis
Subcutaneous tissue (fat)

Fascia/Muscle

Skin and Fascia

The layers just described are clearly seen here. On the top you see the reflected skin and subcutaneous tissue, which have been pulled back to expose the muscle layer below.
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1 = skin and subcutaneous tissue; 2 = fascia

Skin anatomy
Skin has 2 layers: The outer epidermis and the underlying dermis Epidermis: Provides waterproofing and serves as a barrier to infection, there are no blood vessels Dermis: Layer which contains the appendages of skin Connective tissue Basement membrane (anchors dermis) Nerve endings (touch/heat) Sweat glands Sebaceous glands Apocrine glands Hair follicles Lymphatic vessels Blood vessels

Skin anatomy:

 Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing

Wound healing
Classification of wounds
Types of wound healing

Phases of wound healing

Factors that influence wound healing

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Classification of Acute Skin Wounds

Abrasions
Bites Burns Lacerations
Traumatic

Punctures Incisions
Surgical

Strecker-McGraw et al. Emerg Med Clin North Am. 2007;25:1-22.

Classification of Acute Skin Wounds

Acute skin wounds fall into 2 general categories:

traumatic and surgical.

Traumatic injuries include abrasions, bites, burns,

lacerations, and punctures. There is usually a delay between the time of injury and presentation to a medical facility for treatment. Infection is a significant concern with these injuries. Surgical wounds include puncture and incisions. There is no time delay between wound occurrence and presentation, and the controlled setting of a medical facility is designed to minimize infection risk.

Traumatic Wounds and Lacerations

Traumatic wounds are common and bear extensive

medical costs
US >26 million/year = $35 billion1,2 EU >42 million/year = 15 billion3

Physical exam should be careful and meticulous4

Time and mechanism of injury Potential for infection Hemostasis

Tendon, vascular, and joint injuries Neurovascular exam Patient history

Foreign bodies

Timeframe for closure: maximum of 24 hours from

the time of injury5

1. 2. 3. 4. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary. CDC NEISS All Injury Program 2005 Results. EU Injury Database Report 2009. Lammers. Principles of wound management. In: Roberts and Hedges. Clinical Procedures in Emergency Medicine. 5th ed. Saunders Press; 2010. 5. Pfaff and Moore. Emerg Med Clin North Am. 2007;25:189.

Classification of wounds
Bacterial presence: Contamination: Bacteria are present, but not proliferating Colonization: Bacteria proliferating without host reaction Infected tissue: Deposition and proliferation of microorganisms in the tissue with consequent host reaction

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Defining Wound Healing

A healed wound is one where1
Connective tissues have been repaired and wound has been

completely epithelialized by regeneration that has returned to its normal anatomic structure and function without the need for continued drainage or dressing
Some wounds fail to heal properly resulting in

chronic, non-healing wounds that need continued management2 Aberrations in certain phases of healing can result in excessive healing example: hypertrophic scars, keloids2
1. Enoch SE and Leaper DJ. Surgery. 2008;26:31-37. 2. Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.

Types of Wound healing

Wounds or incisions can heal in different ways: Primary healing - direct wound healing without complications (wound is closed with sutures) Secondary healing - indirect wound healing with complications; wound edges are not approached with sutures - Spaces between the wound edges are filled by granulation Tissue Tertiary healing - wound is filled by granulation tissue & is infection free (wound edges are approximated with sutures)

Phases of Primary Wound healing (I)

Exudative /Inflammatory phase Proliferative phase Remodeling phase

0-5 days suture material is the sole factor in holding together the wound Suture high tensile strength needed

5- 14 Days stabilization of the wound closure is gradually taken over by collagen Suture- highest tensile strength needed

7-14 days to a year suture material becomes irrelevant Presence of suture material is a Foreign material with side effects

Phases of Primary wound healing (II)

1. Exudative/Inflammatory phase: 0 - 5 days
Accumulation of body fluids Formation of proteins, blood cells, fibrin and antibodies Classic antigen-antibody reaction always accompanied by local inflammation Generally, the tissue does not provide any intrinsic stability and, therefore, fully relies on support from the suture material. Exceptions: Epidermis Serosa, mucosa and submucosa of the small intestine. These tissue types adhere within 24-48 hours (gastight and watertight). The colon becomes stable after 5-7 days.

Suture Material is responsible for the adaptation of the wound

hours

Phases of Primary wound healing (III)

2. Proliferative phase: 5-14 days

- Fibroblasts produce collagen, a fibrous, insoluble protein that generates connective tissue.
- Collagen grows in and increases the stability of the wound

4-6 days

Phases of Primary wound healing (IV)

3. Reparative phase: 21 days 1 year
From now on, the stability of the tissue closure is strengthened by the collagen fibers forming at the suture. At this point the suture material becomes irrelevant, although it can still cause side effects (like foreign-body reactions). As a rule, every absorbable material remains longer than it functions. Sensible and harmonic selection of the right suture material for the individual case (regarding tensile strength and absorption time) can influence wound healing to either positive or negative effect. It would not make sense to implant suture material of long-lasting break strength and a long absorption period in tissue that only needs medium-term stable and medium-term absorbable suture material.

weeks

The Phases of Wound Healing (V)

Coagulation Platelet activation III Proliferative phase II Inflammatory phase IV Remodelling and scar formation

Maximum response

I Hemostasis

Lymphocytes Phagocytosis Neutrophils

ECM formation Angiogenesis and granulation tissue formation Re-epithelialization 3 10

Further synthesis of ECM

MMP and TIMP activity

0.1

0.3

30

100

300

Days after wounding (log scale)

ECM = extracellular matrix; MMP = metalloproteinases; TIMP = tissue inhibitors of metalloproteinases.

Enoch S and Leaper DJ. Surgery. 2008;26:31-37.

V Scar maturation

Alterations in one or more of these phases could result in chronic wounds Abnormalities in these phases result in hypertrophic scars and keloids Macrophages Cytokines and growth factors

Stages of Secondary Wound healing

The phases of wound healing are the same as Primary healing.

However, the duration for each phase is longer and there is granulation tissue filling the wound. The scar formed is also not as good as compared to primary wound healing
Exudative (inflammatory) phase Proliferative phase Remodeling Phase

Days

Weeks

Months

Tenets of Halsted
Halsted delineated his tenets over a century ago, but they continue to guide surgeons in the optimal care of patients today. His principles are based on asepsis, and minimal physical trauma of tissue. His tenets were: Gentle handling of tissue Aseptic technique Sharp anatomic dissection of tissue Careful hemostasis, using fine, nonirritating suture material in minimal amounts Obliteration of dead space in the wound Avoidance of tension
Foy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention and Management. Saunders; 2009:11-22.

 Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing

Factors Influencing Wound Healing

Operative/ Surgeon Factors

Wound Healing
Tissue Factors Patient Factors

Factors Influencing Wound Healing

Wound healing is influenced by 3 different, but equally important factors:
Tissue Factors: The condition of the wound-

contamination, tissue destruction, etc Patient factors: immunosuppression, nutritional status, etc Operative/surgeon factors: prolonged operative times, hypothermia, etc

Classification of Factors That May Impede Wound Healing

Factors affecting wound healing can be further classified as local or systemic. Systemic factors are mostly patient-related, as shown. Local factors are mostly operative and relate to the condition of the wound. Note that infection plays a role in both cases, and while systemic factors are important to consider, they are often not within surgeons control.

Classification of Factors That May Impede Wound Healing

Systemic
Advanced age Metabolic factors Immunosuppression/

Local
Presence of foreign body and

persisting disease
Deficiency syndromes Shock of any cause Infection

foreign body reactions Increased skin tension Blood supply Continued presence of microorganisms Infection

Leaper. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed. Edward Arnold Ltd; 2008.

Factors Leading to Risk of Compromised Healing

Some patients are at higher risk of compromised healing because of underlying disease, habits or malnutrition. These conditions and behaviors put them at greater risk of delayed wound healing and infection.
Advanced age (>70 years old) Obesity

Smoking
Poor glucose control or hyperglycemia

Diabetes (type 1/2)

Nutritional or immunologic impairment

Low serum albumin concentration

A patient with even ONE of these risk factors is at greater risk of developing a surgical site infection (SSI)

Some Wounds Are More Likely to be Infected

Operative wounds can be stratified based on the level

of potential contamination, from clean to dirty. Not surprisingly, contaminated and dirty cases are more likely to develop a surgical site infection (SSI).
Several scoring systems have been developed to

further identify and classify risk due to intrinsic factors.

Classification of wounds:
Wounds are generally classified into 4 categories1: Class 1 = Clean Class 2 = Clean contaminated Class 3 = Contaminated Class 4 = Dirty infected Contaminated or dirty/infected wound classifications

are independently associated with increased risk of SSI1

1.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.

Classification of wounds based on infection

Class I Clean Definition No trauma effect No inflammation No breach of sterility Tracheobronchial system, GI tract and urogenital tract intact Opening of the GI tract Appendectomy Opening of the oropharynx Opening of the vagina Opening of the urinary tract collecting system for sterile urine Opening of the bile system with sterile bile minimal breach of sterility
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II Cleancontaminated

Classification of wounds based on infection

Class Definition

III Contaminated

Opening of the lower GI tract Traumatic wounds Opening of the collecting system with infected urine Opening of bile ducts with infected bile Breach of sterility Bacterial infection in OP area Draining of abscesses Traumatic wounds with necrosis, foreign bodies and exit of faeces Old wounds Bite wounds or similar
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IV Dirty Infected

Suture Contamination Can Increase Risk of Infection (I)

An important component of SSI risk lies in the suture

itself. All sutures are foreign bodies and represent a possible nidus of infection and biofilm development.
Biofilms: every suture acts as a medical implant,

increasing the risk of infection via bacterial colonization1

Suture Contamination Can Increase Risk of Infection (II)

A B

1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277. 2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.

Local Tissue Trauma Can Impede Healing

Clearly our efforts to help patients heal must be carefully weighed

against the potential to further harm the patient with surgical intervention. As is shown here, staple placement and the use of tissue adhesives can result in trauma and tension on the wound.
Tissue trauma can result from:
Devices used for closure
Handling of tissue

Proper Suturing Technique: Critical Components of Wound Healing (I)

In addition to appropriate suture material, proper skin

suturing technique is a critical component of wound healing. When the suture is tightened, the wound edges should evert slightly (the best conditions for primary healing).
- If the suture enters and exits from the skin at an acute angle, the wound may become inverted with poor healing, producing a poor cosmetic result needing revision.
As the suture is tightened, the knot should be drawn to

one side to facilitate suture removal. When a nonabsorbable suture is later removed, it needs to be cut immediately beneath the knot and pulled out by the knot.

Proper Suturing Technique: Critical Components of Wound Healing (II)

The final throw of the knot should be snugged

down, so that the knot cannot slip.

- The ends of the knot should be left long enough to be easy to grasp when they are being removed later, but not so long that they are tangled in adjacent sutures, or hair if the operative area has not been shaved.
Suturing should be undertaken using a no-touch

technique to reduce the risk of a needle-stick injury.

- Short-handled holders are used for skin closure, but longhandled holders are needed for sutures placed deep inside the body.

Summary: Proper Suturing Technique: Critical Components of Wound Healing (III)

Wound edges should be left slightly gaping to allow

swelling Edges should be everted The knot should be placed to one side of the wound Knots must be secure, with the ends long enough to grasp if the suture is to be removed Use no touch technique whenever possible
- Use appropriate needle holders

Leaper D. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed. Edward Arnold Ltd; 2008.

Tissue Specific Healing Time Guides the Choice of Tissue Repair Material
Wound closure is about more than just skin. As seen here, different tissue types require different lengths of time to achieve complete healing. This is an important factor to consider when selecting a closure method or material.

5-7 days 7-14 days 5-7 days 7-14 days 7-14 days 14-28 days 7-14 days 8-12 weeks 14-28 days 8-12 weeks

Weeks
*Minimum

healing times shown here are for healthy individuals without medical complications.

 Skin: anatomy
Wound healing Factors affecting wound healing Complications of Wound healing

Examples of Wound Healing Complications

Scarring

Dehiscence

Infection

Images courtesy of David Leaper, MD.

Wound Healing Complications: Scar Formation

Typical scar characteristics: Normal healthy scar tissue will develop with proper closure and healing:
Flat surface Narrow

Matches skin color

Complicated scars: When healing is impaired abnormal scarring

may result. Several examples of complicated and abnormal scarring are shown here Elevated Depressed Hypertrophic Keloids

Harahap (ed). Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.

Wound Healing Complications: Dehiscence, SSI

Dehiscence is the failure of tissue edges to

close after surgical re-approximation. This is typically at skin layers, although dehiscence of facial closure results in ventral hernia, as shown in top image. A major risk factor is surgical site infection (SSI), which can delay re-epithelialization and collagen formation as well as cause further tissue damage and disruption. Mechanism may be an underlying wound healing problem or surgical technique

Images courtesy of David Leaper, MD Lammers. Principles of Wound Management. In Roberts Clinical Procedures in Emergency Medicine. Saunders Press. 2010.

Wound Healing Summary

Healing of acute wounds: a complex, dynamic series of

events
Optimal wound healing by primary intention; not possible

in all cases
Many factors delay or impede wound healing: long-term

complications-steps can be taken to ensure best outcomes

SSI prevention is a critical factor in achieving optimal

acute and long-term wound healing

Clinical Article Review:

Please read the attached clinical article entitled:

Finding the Best Abdominal Closure: An Evidencebased Review of the Literature Authors: Adil Ceydeli, MD, James Rucinski, MD, & Leslie Wise, MD

Suture material: Product reading

Please read the following topics from the drop box before attempting the e-quiz. Topic: Suture tensile strength and mass absorption of Ethicon Sutures, Safil, Polysorb and Maxon Ethicon Suture Chart (General > Product Info) Safil, Polysorb and Maxons IFUs (General > Product Info) Suture comparison Strength & Inflammatory Response (General > Product Info)

Suture material: Product reading

Topic: Advantages and disadvantages of Monofilament vs Multifilament sutures and Natural vs Synthetic sutures Suture In-service (General > Presentation) Topic: Catgut conversion. Focus on evidence with regard to Catgut and OBGYN Cochrane Review sutures for episiotomy (Catgut Conversion > Evidence > Full Paper) Greenberg Advances in suture materials OBGYN (General > Evidence) A J Dart Suture materials conventional and stimuli responsive (General > Evidence)

THANK YOU!