Other applications for skin staples include:
- nTo hold nasal feeding and oxygen tubes in place;
- To hold IV and epidural catheters in position;
- To hold traumatic skin flaps in position over the subcutaneous bed from where they originated;
- For marking wound entrances and incision lines for radiographs;
- For holding dressings and bandages in place;
- As a skin "electrode" for ECG leads, where the alligator clips are clipped to the staple that is inserted into the skin, allowing
for good ECG tracings and better patient comfort when compared to the use of alligator clips being attached to the patient.
The definition of wound dead space is a space where, after its closure, air is present. According to surgical research performed
in laboratory animals there are only two ways that dead space can be effectively obliterated. These are by using compression
dressings that literally force the air out of the wound pocket; and by using a multi-holed drain that is applied to constant
suction, which draws the air out of the pocket. Silicone suction drains and the suction reservoirs are available commercially
from several sources and can be autoclaved and used as well (Photo 2, p. 7).
Photo 2: A silicone suction drain and reservoir that have been autoclaved. These types of drains effectively tolerate steam
Although somewhat controversial, some surgeons believe that subcutaneous subcuticular sutures that also suture into superficial
fascia are effective in closing wound dead space. Others believe suturing is only partially effective in obliterating wound
dead space. A study published about 10 years ago suggested that suturing and the use of closed suction drains are more effective
than either of the techniques used alone. Older studies revealed that the suture technique alone causes compartmentalization
of the dead space but does not close dead space as well as suction drains when the two methods were compared individually.
Penrose drains are only effective in obliterating dead space if external compression is also applied to the wound. My clinical
experience with these methods mimics what has been reported from laboratory findings. I use a suction drain in place of tacking
sutures as the principal method of managing dead space along with use of external compression dressings. I rarely use Penrose
drains in clean or surgically created wounds and dead space associated with them unless the wound can be compressed with an
external dressing. Research has also shown that unless a Penrose drain is sterilely covered that within six hours the bacteria
that come in contact with the exposed drain are also able to be cultured at the tip of the inside portion of the drain. Therefore,
their external portions should always be under a dressing if at all possible. Studies have shown that suction drains with
a small amount of antibiotic ointment placed at their exit sites carries a very low risk of infection compared to uncovered
Photos 3 A-D (top left to bottom right): A dog that had a very large tumor on the side of her chest that was removed. A. Before
removal; B. After removal showing incision and reservoir bulb of suction drain in place; C. Close-up of active suction reservoir
and the skin staples; D. Following an inner dressing change using a trap door effect so that further dressings can be changed
easily without removing the entire outer bandage. Note the use of safety pins to reclose the opened outer bandage.
Placement and activation of a suction drain:
- Create a small access channel for the drain to course through from subcutaneous dead space pocket to a subdermal location
approximately 4 cm to 5 cm long by pushing the tips of a hemostat from the pocket through the subdermal fat.
- Using the tip of a 15 blade, make a small opening in the skin over the bulge where the tips of the curved hemostat are palpated
and push the tips through the hole to the outside.
- Grasp the multi-holed end of the silicone drain and pull it through the access channel.
- Position the section of the drain with multiple holes in the subcutaneous pocket so it extends the entire length of the pocket.
- Secure the drain at the skin exit site with a suture wrapped around it multiple times.
- Close the wound edges routinely with a subcuticular continuous pattern followed by either skin staples or sutures.
- Attach the external end of the drain to the silicone bulb reservoir that accompanies the drain.
- Open the evacuation port on the suction bulb and squeeze the bulb to empty the air out and then reclose the port. The collapsed
silicone bulb then provides 30 mm to 50 mm Hg of suction on the drain at all times. Other suction reservoir systems can be
used as well as the silicone bulb. One is made with a spring inside (Schnyder Hemavac). Another has a reservoir inside a plastic
bottle and the bottle is manually collapsed (Davol). Homemade devices can be used involving syringes where the plunger is
held out with needle, pin or charged Vacutainers.
The suction drain is kept in place for a minimum of several days. The reservoirs need to be recharged as necessary to keep
the suction continuous (Photo 3 A-C, p. 8). The suction literally draws the entire pocket closed and keeps it closed for several
days, allowing fibrin adhesion formation to occur thus joining the two surfaces together. The drain continues to be activated
until fluid removed on a daily basis is next to nothing. A rule of thumb is when the amount drained is at or below 1 ml/kg/day.
This fluid represents the amount of lymphatic fluid that is commonly in the wound's region normally that can be collected.
A simple method of changing internal dressings in bandages used to protect closed surgical wounds involves the creation of
trap doors in the outer bandages with the closure being done with safety pins (Photo 3, p. 8).