How to apply practical suturing, stapling, wound drainage techniques

How to apply practical suturing, stapling, wound drainage techniques

There are three practical surgical techniques that can be effective in the management of either traumatic or surgical wounds: use of a suture (polybutester) that has an inherent elastic property that stretches when edema or tension occurs; use of skin staples to rapidly close wounds; and use of suction drains that effectively obliterate dead space. Each of the described uses discussed have been applied in literally hundreds of clinical cases with time savings and a decrease in complication rate being realized.

Suture properties Polybutester (Novafil, by Davis & Geck) is a unique monofilament non-absorbable suture material available since the mid-1980s. It has an elastic property that allows for edema and tension to be accommodated for, thus preventing strangulation of the tissues' blood supply and also protects against tissue tearing and suture breakage. I began using the material first for routine fascia and skin closure in 1985 because it had properties that were similar to polypropylene, being non-reactive and with an excellent track record for superiority in strength and knot security. After several hundred abdominal fascial continuous closures without complications, I expanded its use to the stomach, intestine, esophagus, blood vessels, other fascia and the skin. Today, it is a suture I reach for when faced with closures that are prone to significant tension and edema.

Because it has a superior stretch quality, the polybutester is used as a continuous, interrupted, near-far-far-near (NFFN) and either interrupted or continuous vertical mattress suture for fascial and skin closures. Size 2-0 to 4-0 Novafil are used to bring the subcutaneous tissues and skin together with the same exterior suture. Since I am not in favor of burying suture of any kind in traumatic wounds because it enhances the chance for infection to develop, I have used the polybutester a great deal for this type of closure. The most common pattern used is the NFFN with the far bites providing closure of the deep subcutaneous tissues and the near bites apposing the skin. Research has shown that even having one buried suture in a clean-contaminated wound increases the likelihood of infection occurring by 200 percent. Using the vertical mattress or the NFFN allows for apposition of the deep and superficial subcutaneous and subdermal layers without requiring the buried sutures. Using the polybutester also prevents strangulation of tissues and resists pullout and suture breakage. Because of its bio-inertness, strength and knot security, it is used in human medicine for cardiovascular applications.

Polybutester is available as swaged-on needles of cutting and taper variety and in a fine vascular type or a general closure-circle.

Skin stapling The use of skin staples saves significant amounts of surgical closure time when compared to standard suture closure. This equates to a more economical way to close traumatic and intentional surgical wounds, less wound infection and less overall complications. In a simple, unpublished study, I compared the time required to close 4 cm skin incisions with simple interrupted sutures, a simple continuous suture, or staples applied with the use of a commercial staple gun that holds 35 skin staples (Kendall Animal Health).

The interrupted suture closure took on average 90 seconds, the continuous closure 50 seconds and the staple closure 12 seconds. Clinical healing was similar in all cases except a few of the staples had fallen out or had become turned, yet at the time of suture or staple closure (at 10 days to 14 days), the end result and cosmetic effect was similar in all closures. Removal of staples was judged to be easier and less stressful for the patient with the staples versus skin sutures. From this study and clinical experience, I recommend staples over suture closure with traumatic or surgically induced skin incisions whenever possible. With small traumatic lacerations that are clean and not requiring debridement, the use of skin staples to close them has been found to be quite practical, often only requiring a local anesthetic and mild sedation. In some cases, the wound is simply pinched together and the staple gun fired as needed to effect a closure without the need for even a local block with less discomfort to the patient. The only contraindication for the use of skin staples is in very fine skin closure when the tissues involved are delicate, e.g., the eyelid.

Photo 1: Close up of a staple in place.
Skin staples are available in either regular or wide width with usually 35 staples together in a disposable plastic gun. The staple guns are available from many manufacturers. I use the regular width on the skin wounds of cats and some dogs where the skin is thin or their size is generally under 30 kg. Although the wider staples can be used exclusively in all dogs and cats, in my experience the wider staples are more prone to rotate or fall out, especially in cats and dogs less than 20 kg in weight or in thin-skinned auxiliary and inguinal areas where much movement occurs.

Steps in staple closure

  • Perform the preparation of skin and hair (by widely prepping) if this has not been done prior;
  • Irrigate the tissues just prior to closure;
  • Use an Adson, Brown-Adson or other similar forceps to pick up the edges of the wound and gain approximation;
  • While holding the apposition, place a staple in the skin to appose both sides of the wound (there will be a slight mounding effect brought about by the staples. This is preferred to having any gap between the staples;
  • Complete the skin closure by placing one staple approximately every centimeter (Photo 1, p. 6). In some incisions where there is some tension or thinness there may be a need to place two staples every centimeter.

Emergency cases In the emergency management of traumatic wounds, the advantages of staple closure of small lacerations versus suturing are speed, no laceration surgical pack or suture is necessary and most often, only a small amount of sedation, if any, is needed. The same is true for the amount of local anesthetic required. In many cases, I just spray lidocaine or ethyl chloride into the laceration enough to provide analgesia. With proper application of skin staples there is a small gap between the top of the staple and the skin, allowing for swelling. Patients then tolerate the staples better with less effort to try and remove them.