Principles of Surgery

During Surgery Suture and Knot Tying Suture patterns may be classified as interrupted or continuous, by how they appose tissues (ex: appositional, everting, or inverting), or by which tissues they primarily appose (ex: subcutaneous or subcuticular.) Appositional sutures bring tissue in close approximation. Everting sutures turn the tissue outward, away from the patient and toward the surgeon. Inverting sutures turn tissue away from the surgeon, or toward the lumen of a hollow viscus organ. Subcutaneous sutures are placed to eliminate dead space and provide some apposition of skin so that less tension is placed on skin sutures. Subcutaneous sutures are generally placed in a simple continuous manner, however in some instances such as where drainage might be necessary, simple interrupted sutures are preferable. Subcuticular closure may be used in place of skin sutures to reduce scarring or eliminate the need for suture removal for situations such as fractious animals or castrations. The suture is begun by burying the knot in the dermis. Suture is advanced in the subcuticular tissue, but in contrast to a continuous subcutaneous line, bites are parallel to the long axis of the incision. The suture line is completed with a buried knot. Absorbable suture material is preferred for subcuticular suture patterns. Suture patterns

Simple interrupted sutures Simple continuous sutures Continuous lock sutures Continuous horizontal mattress sutures Cross sutures

Simple Interrupted Sutures

Each suture is a loop of suture material passed perpendicular (or at a slight angle) to the plane of the tissue with its ends emerging on opposite sides of the wound an equal distance from the wound edge on each side. Sutures should be removed 7 to 10 days after surgery. The advantage of simple interrupted sutures is that if one suture fails, the others remain intact. The tension of each suture can be determined individually.

Simple Continuous Sutures

A pattern of a progressive series of sutures inserted without interruption perpendicular to the plane of the tissue with only the beginning and end of the suture being tied. These sutures are indicated in tissues that require minimal holding but maximal tissue apposition. They are also effectively used to suture subcutaneous tissue and fascia in nontension planes. Sutures should be removed 7 to 10 days after surgery. Simple continuous sutures are weaker but more rapidly placed than interrupted sutures. They allow tension adjustment after placement and create an air- and liquid-tight seal. If a break occurs anywhere along the suture, the entire suture line may disrupt.

Continuous Lock Sutures

A continuous lock pattern, also called a "blanket stitch" or Ford interlocking suture. A progressive series of sutures inserted uninterruptedly in the skin like a simple continuous suture, partially locking each passage through the tissue. This type of suture is indicated when speed as well as some suture security are needed for closure. Following the placement of each suture, the needle passes above the unused suture material to lock the suture in place as it is tightened. Sutures should be removed 7 to 10 days after surgery. Suture placement is more rapid than for interrupted suture pattern and pattern has greater stability than other continuous patterns in the event of a partial break along the suture line. The pattern requires an increased amount of suture material and does not readily allow tension adjustment after placement. It is more difficult to remove than a simple continuous suture.

Continuous Horizontal Mattress Sutures

A progressive series of sutures placed uninterruptedly in the same plane as the tissue. It is indicated when speed is necessary in wound closure, when some eversion is not objectionable and when some tension is desired. A similar pattern may be used as a subcutaneous suture pattern to close deep tissues and as a continuous intradermal suture. Sutures should be removed 7 to 10 days after surgery. Wound closure is more rapid than when an interrupted suture pattern is used and the pattern permits accurate approximation of the wound edges with reduced tension.

This pattern does not have good security, and a break anywhere along the suture may cause the entire line to disrupt.

Cross Sutures

A cross-stitch or "baseball stitch" is a double continuous suture pattern. It is indicated for suturing thick skin when haste is required. A simple continuous line is placed, followed by placement of a second line from the opposite direction. The first row of sutures is placed deep, wide and loose to approximate the full thickness of the skin edges. The second row is used for fine approximation of the superficial wound edges. Sutures should be removed 7 to 10 days after surgery. This pattern can be placed with relative rapidity and the double row gives much greater security to the suture line.

Knot Tying Instrument Tie Technique Formation of the first throw using uncrossed suture ends: The instrument tie is usually performed with a needle holder held in the surgeon's dominant (right) hand. The first throw of the square knot is initiated by placing the needle perpendicular to and above the suture end held by the non-dominant (left) hand.

Suture held by the left hand is wrapped over and around the needle holder.

The needle holder, surrounded by the looped suture, grasps the free end of the suture and withdraws it through the loop. The resulting loop of the first throw will have a figure "8" shape.

The figure 8 shaped loop must be converted into a rectangular loop by crossing hands. The throw is advanced to the skin by applying tension in lateral directions.

The second throw is initiated by passing the needle holder over the suture held by the left hand. A second suture loop is formed by wrapping the suture around the tip of the needle holder.

With a loop of suture wrapped around the needle holder, the needle holder is moved to grasp the free end of the suture.

By withdrawing the free end of the suture through the loop, a rectangular shaped second throw is formed.

This second throw is advanced against the first by applying tension to the suture ends in lateral directions.

After Surgery Monitor Anesthetic Recovery

Remain with animal recovering from anesthesia until the animal is able to hold itself in a sternal position (on its chest, able to hold its head up). Keep endotracheal tubes in place as long as possible; remove when animal begins to chew or swallow. Assess the ability of animal to maintain normal physiology such as body temperature and fluid balance.

Watch for post-procedural complications

Provide analgesia for any procedures with potential for pain or distress. Provide antibiotics to prevent post-procedural infections. Watch incisions for swelling, exudates, pain or dehiscence. Pay attention to catheters & devices. Monitor for procedure-related complications such as organ failure, thrombosis, etc.

Animal records

Post-operative records are required by the USDA on all animals except rats and mice, and must be readily available for review. Records on rats and mice may be abbreviated, and can be included as part of research data collected, but should also be available for review. Information included in records: o Daily observations and treatments given. o Anesthetic agents: dose and time administered. o Intra-operative assessments.

Recovery observations.

After Surgery Daily Observations of the Animal Reminder: Note post-operative observations of animal in medical record. Check to see that the animal is:

Active: Bright, Alert & Responsive Inquisitive Eating Drinking Producing normal urine & feces

Look for these signs of concern:

Rough hair coat Crusty red eyes Paralysis Abnormal or lack of urine & feces Fecal/urine soiling of coat Diarrhea Dehydration Thin appearance Vocalizing

Check the animal's body weight and calculate the % change from pre-op weight. Significant body weight loss (?20%) may necessitate euthanasia. Daily observations of sutures / staple line Reminder: Include post-operative observations of surgery site in medical record. Look for these signs of concern:

Redness Swelling around or under incision Missing sutures/staples Discharge (oozing) from incision

Incisions that do not appear to be healing should be examined by a veterinarian. Sutures and/or staples should be removed by 2 weeks following surgery to prevent irritation and infection.

Summary Ingredients of a good surgical technique:

Asepsis at all times Gentle tissue handling Effective hemostasis Maintenance of sufficient blood supply to tissues Proper use of surgical instruments Accurate tissue apposition Appropriate use of monitoring equipment Support of vital organ functions Expeditious performance of the surgical procedure