WOUND

CLOSURE
GUIDE PROF. N NATH
DR. A MAJHI
PRESENTED BY DR. IPSEET MISHRA

HISTORY OF WOUNDS
Initially, wounds were left open
Herbal balms and ointments
A South American method of wound closure involved using large
black ants
East African tribes ligating blood vessels with tendons strips, and
closing wounds with acacia thorns pushed through the wound
By 1000bc, Indian surgeons were using horsehair, cotton and
leather sutures
Romans used linen and silk and metal clips, called fibulae.
Oldest suture 1100BC
Primary and secondary closure 2000 yrs. ago
Recent wound closure less that 200 yrs. old

Four distinct phases

1. Hemostasis

Vasoconstriction and coagulation

2. Inflammation

Vasodilation release of inflammatory mediators and migration of WBCs

Occurs in the first few days

3. Tissue Maturation
Angiogenesis Granulation - Epithelialization

New tissue formation occurs over the next 10-14 days

4. Tissue remodeling

Wound contraction and tensile strength is achieved

Occurs in the next 6-12 months

TYPES OF WOUNDS
CLEAN WOUNDS

CLEAN AND
CONTAMINATED
WOUNDS

CONTAMINATED
WOUNDS

DIRTY OR INFECTED
WOUNDS

Elective surgical
incision

Contaminated by local
flora despite aseptic
technique

Open traumatic
wounds in nonsterile
environment

Gross/heavy
contamination or
active infection

Primary closure

Cholecystectomy,
appendectomy and
hysterectomy

Open fractures

Perforated viscera,
abscess and traumatic
wounds

1-5% rate of infection

3-11% infection rate

10-17% infection rate

>27% infection rate

TYPES OF WOUND CLOSURE

Primary closure - Most common and Preferred method with clean wound
- Dermis-dermis apposition with Best cosmetic outcome

Secondary closure - Known as healing by secondary intention

- Wound edges are left un-approximated
- Appropriate in wounds with soft tissue loss or severe
contamination not closable by primary or tertiary means

Tertiary closure - Contaminated wound is I&Dd and left open for several days
complications

- Wound is then closed as in primary closure when risk of

declines
- Preferred method for highly contaminated wounds
- Skin grafting another type

GENERAL CONSIDERATIONS

Irrigate frequently to minimize contaminants and maintain moist wound bed

Do not pinch tissues with forceps, Gently lift wound edges to place suture

Handle tissues as little as possible

Limit the time and force used in retracting tissues

Approximate, dont strangulate

Debridement, if needed with Repair of structures and Replacement of lost

tissues where indicated

Skin cover if required and Skin closure without tension

IDEAL WOUND CLOSURE

Meticulous
Easily and readily applied
Painless
Low risk to provider
Inexpensive
Minimal scarring
Low infection rate

There is no ideal wound closure technique that would be appropriate for

all situations, and the ideal suture is yet to be produced.
Suture material: desired characteristsics

Easy to handle
Predictable behaviour in tissues
Predictable tensile strength
Sterile
Glides through tissues easily
Secure knotting ability
Inexpensive
Minimal tissue reaction
Non-capillary
Non-allergenic
Non-carcinogenic
Non-electrolytic
Non-shrinkage

SUTURE CHARACTERISTICS
1.Physical structure - Monofilament sutures smooth, slides through tissues easily
without any sawing action, difficult to knot effectively, easily
damaged by gripping
- Polyfilament sutures - easier to knot, responsible for persistent
infection or sinuses.
2. Strength - depends upon its constituent material, its thickness and how it is handled in
the tissues.

3.Tensile behaviour - plastic and elastic materials, suture memory, sutures lose
50 per cent of their strength at the knot.

4. Absorbability absorbable or non-absorbable suture materials

5. Biologic behaviour - depends upon the constituent raw material,
- synthetic materials that have a greater predictability and elicit
minimal tissue reaction have non-carcinogenic property.

NEEDLES
The needle should be grasped by the needle holder approx. 1/3 rd of the way back from the
rear of the needle avoiding both the shank and the point.
Round-bodied needles designed to separate tissue fibres rather than cut through them and
are used in intestinal and cardiovascular surgery.
Cutting needles are used where tough or dense tissue needs to be sutured, such as skin and
fascia.
The choice of needle shape tends to be dictated by the accessibility of the tissue to be
sutured. For e.g. Hand-held straight needles on skin, Half circle needles in the gastrointestinal
tract, J-shaped needles for vagina, Quarter circle needles for eye and Compound curvature
needles for oral cavity.

KNOTTING TECHNIQUES
The knot must be tied firmly, but without strangulating the tissues.
The knot must be unable to slip or unravel.
The knot must be as small as possible to minimise the amount of foreign material.
The knot must be tightened without exerting any tension or pressure on the tissues being ligated,
i.e. the knot should be bedded down carefully, only exerting pressure against counterpressure from the index finger or thumb.
During tying, the suture material must not be sawed.
The suture material must be laid square during tying
When tying an instrument knot, the thread should only be grasped at the free end

 The standard surgical knot is the reef knot , with a third throw for security, although with
monofilament sutures such as for vascular surgery, six to eight throws are
required for security.
A granny knot involves two throws of the same type of throw and is a slip knot. It may be useful in
achieving the right tension in certain circumstances, but must be followed by a standard reef knot
to ensure security.
When added security is required, a surgeons knot using a two throw technique is advisable to
prevent slippage.
When using a continuous suture technique, an Aberdeen knot may be used for the final knot.
When the suture is cut after knotting, the ends should be left about 12 mm long to prevent
unravelling, particularly important when using monofilament material.

BASIC SUTURE METHODS

Simple interrupted

Simple running

Locked running

Horizontal mattress

Vertical mattress

Subcuticular

Subcutaneous (buried knot)

SIMPLE INTERRUPTED SUTURE

Most common closure performed

Used in superficial wounds with minimal tension

Distance from entry point of needle to edge of

wound should be approx. same as depth of tissue
being sutured, and each successive suture should
be placed at twice this distance apart.

SIMPLE CONTINOUS SUTURE

Best in short lacerations with no tension

Helps with hemostasis and is rapid

If one knot fails, the entire closure is compromised

Contraindicated in infected tissues as infection can

propagate along suture line

Too much tension or slack too be avoided

LOCKED CONTINOUS SUTURE

Used in wounds closed with moderate tension
Helpful in obtaining hemostasis
Similar concerns with knot security and integrity
of closure

HORIZONTAL MATTRESS SUTURE

For fragile tissue
Distributes tension over wider area
Helps evert skin edges

VERTICAL MATTRESS SUTURE

Used for maximal edge eversion
Minimizes dead space in deeper
tissues
Helps minimize tension

SUBCUTICULAR SUTURE
Provides optimum cosmetic
results
Not for contaminated or infected
wounds

SUBCUTANEOUS SUTURE
Buries the knot
Useful for minimizing dead space
in deeper wounds
Helps relieve tension on skin
closure
May be used in dermis as well
SMEAD-JONES / FAR-AND-NEAR
a double loop technique alternating far and near
stitches
greater mechanical strength
used for approximating fascial edges, especially for
patients at risk for fascial disruption or infection

AFTER CLOSURE

SUTURE REMOVAL

Apply antibiotic ointment

Non adherent sterile dressing

Splint if appropriate

Tetanus Prophylaxis

Chest and extremities: 8-10 days

Antibiotics

Joints, palms, soles: 10-14 days

Schedule follow up 2-3 days

Face: 3-5 days

Scalp: 7 days

STAPLERS
More rapidly placed
Less foreign body reaction
Scalp, trunk, extremities
Do not allow for meticulous closure
Advantages
Rapid application
Low tissue reactivity

Disadvantages
Less meticulous closure
May interfere with some older generation
imaging techniques (CT, MRI)

ADHESIVE TAPES
Less reactive than staples
Use of tissue adhesive adjunct (benzoin)
Poor outcome in areas of tension
Seldom used for primary closure
Use after suture removal

Advantages
Least reactive with Lowest infection rate
Rapid application
Patient comfort and Low cost
No risk of needle stick

Disadvantages

Frequently falls off and Cannot get wet

Lower tensile strength than sutures
Highest rate of dehiscence
Requires use of toxic adjuncts
Cannot be used in areas of hair

TISSUE ADHESIVES
Derma bond - a solution of n-butyl-2-cyanoacrylate monomer.
Topical use only
Outcome equal to 5-0 and 6-0 facial repairs
Less pain and time - Slough off in 7-10 days
Act as own dressing - No antibiotic ointment

Advantages
Rapid application and Patient comfort
Resistant to bacterial growth and No risk of needle stick

Disadvantages
Lower tensile strength than suture
Dehiscence over high tension areas (joints)
Not useful on hands and Cannot bathe or swim

IMMEDIATE AND DELAYED COMPLICATIONS WITH

WOUND CLOSURE
Immediate complications
- formation of hematoma
- wound infection
Late complications
- scar

formation
excess tension
lack of eversion of the edges
- hypertrophic scarring and keloid formation
- stitch marks
- wound necrosis

SPECIAL CONSIDERATION

ABDOMINAL SHEATH CLOSURE

MASS CLOSURE TECHNIQUE

- is currently used by most surgeons
- Closure of abdomen with No.1 nylon, polypropylene or polydioxanone (PDS)
- Sutures to be placed 1 cm away from the wound edge and at 1-cm intervals. The length
of the suture used should be four times the length of the wound.
- The peritoneum need not be sutured. Peritoneal closure is thought to predispose to
adhesion formation.
- Subcutaneous fat layer is usually not approximated but if it is very thick, 2/0 or 3/0
polyglactin (Vicryl) interrupted sutures may be used to obliterate the potential dead
space.

INTERRUPTED CLOSURE
The peritoneum is left to heal by mesothelial regeneration, thereby reducing the
chances of adhesion formation.
The posterior rectus sheath/ tranversus aponeurosis/ internal oblique muscles
are sutured using polyglactin 910, PDS no.1 or nylon/ polypropylene no.1.
The muscle layer can safely be left alone without suturing, especially when it is
split and not cut.
The anterior rectus sheath/ external oblique aponeurosis is sutured with a no.1
PDS, nylon or polypropylene continuous suture.
Subcutaneous fat and skin are then dealt with as usual.

INTERRUPTED X- TECHNIQUE
A new Interrupted X technique was developed which is a modification of the
figure of eight suture.
A detailed vector force analysis of this technique was carried out by two eminent
Professors of Biomedical Engineering from Indian Institute of Technology-IIT
Delhi (Prof KB Sahay and Prof Sneh Anand) after a thorough study of the
abdominal wall musculo-aponeurotic layers in cadavers and on a foam model.
The theoretical superiority of X suture over a continuous suture was established
particularly in reducing the cut trough force a randomized trial(RCT) was
launched on 210 patients undergoing laparotomy at AIIMS.

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