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ABDOMINAL WALL ANATOMY
& FASCIA CLOSURE (Part I)
Pre-reading materialCompiled by
Dr. Vikram Jaisinghani
Mayteedol Nat
E-Quiz
Ethicon ASEAN
2012
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Content:
Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
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Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
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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 muscleaponeuroses, which form the fascia, covering deeper
structures
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Basic Anatomy of Skin and Fascia (II)
Epidermis
Dermis
Subcutaneous
tissue (fat)
Fascia/Muscle
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Skin and Fascia
1
2
1 = skin and subcutaneous tissue; 2 = fascia
The layers just described are clearly seen here. On the top you see
the reflected skin and subcutaneous tissue, which have been pulledback to expose the muscle layer below.
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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
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Skin anatomy:
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Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
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Wound healing
10
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
Punctures
Incisions Surgical
Strecker-McGraw et al. Emerg Med Clin North Am. 2007;25:1-22.
Traumatic
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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 betweenthe 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.
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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
Foreign bodies
Timeframe for closure: maximum of 24 hours from
the time of injury51. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.
2. CDC NEISS All Injury Program 2005 Results.
3. EU Injury Database Report 2009.
4. 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.
Tendon, vascular, and joint injuries
Neurovascular exam
Patient history
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Classification of wounds
Bacterial presence:
Contamination: Bacteria are present, but not proliferating
Colonization: Bacteria proliferating without host reaction
Infected tissue: Deposition and proliferation of micro-
organisms in the tissue with consequent host reaction
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Defining Wound Healing
Ahealed 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 inexcessive 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.
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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 arenot 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)
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Phases of Primary Wound healing (I)
Exudative /Inflammatory phase Proliferative phase Remodeling phase
0-5 days suture material is the
sole factorin 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
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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 fromthe suture material.
Exceptions:
Epidermis
Serosa, mucosa and submucosa of the small
intestine. These tissue types adhere within 24-48hours (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 (II)
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4-6 days
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
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weeks
Phases of Primary wound healing (IV)
3. Reparative phase: 21 days 1 year
From now on, the stability of the tissue closureis 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.
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The Phases of Wound Healing (V)
ECM = extracellular matrix; MMP = metalloproteinases; TIMP = tissue inhibitors of metalloproteinases.
Enoch S and Leaper DJ. Surgery. 2008;26:31-37.
0.1 0.3 1 3 10 30 100 300
Days after wounding (log scale)
Further synthesis
of ECM
MMP and TIMP activity
IV Remodelling and scar formation
Maximumre
sponse
VScarmaturation
Neutrophils
Phagocytosis
Lymphocytes
Macrophages
II Inflammatory phase
ECM formation
Angiogenesis and
granulation tissue
formation
Re-epithelialization
Coagulation
Plateletactivation
IHemostasis
Alterations in one or more of these
phases could result in chronic wounds
Abnormalities in these phases result
in hypertrophic scars and keloids
III Proliferative phase
Cytokines and growth factors
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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 isgranulation 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
Weeks MonthsDays
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Tenets of Halsted
Halsted delineated his tenets over a century ago, but they
continue to guide surgeons in the optimal care of patientstoday. 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 tensionFoy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention andManagement. Saunders; 2009:11-22.
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Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
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Factors Influencing Wound Healing
Operative/
Surgeon
Factors
TissueFactors
PatientFactors
Wound
Healing
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Factors Influencing Wound Healing
Wound healing is influenced by 3 different, but equallyimportant factors:
Tissue Factors: The condition of the wound-
contamination, tissue destruction, etc
Patient factors: immunosuppression, nutritional
status, etc
Operative/surgeon factors: prolonged operativetimes, hypothermia, etc
Cl ifi ti f F t Th t M I d W d
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Classification of Factors That May Impede Wound
Healing
Factors affecting wound healing can be furtherclassified 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.
Cl ifi ti f F t Th t M I d
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Classification of Factors That May Impede
Wound Healing
Advanced age
Metabolic factors
Immunosuppression/persisting disease
Deficiency syndromes
Shock of any cause Infection
Presence of foreign body and
foreign body reactions
Increased skin tension Blood supply
Continued presence of micro-
organisms
Infection
Systemic Local
Leaper. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed.Edward Arnold Ltd; 2008.
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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 behaviorsput 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)
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Some Wounds Are More Likely to be Infected
Operative wounds can be stratified based on the levelof 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.
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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 ofSSI1
1.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.
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Class Definition
I Clean No trauma effect
No inflammation
No breach of sterility
Tracheobronchial system, GI tract and urogenital
tract intact
II Clean-
contaminated
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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Classification of wounds based on infection
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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
IV Dirty
Infected
Bacterial infection in OP area
Draining of abscesses
Traumatic wounds with necrosis, foreign bodies andexit of faeces
Old wounds
Bite wounds or similar
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Classification of wounds based on infection
Suture Contamination Can Increase Risk of
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Suture Contamination Can Increase Riskof
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
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Suture Contamination Can Increase Riskof
Infection (II)
A B
C D
1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.
2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.
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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 surgicalintervention. 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
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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 toone 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
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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 long-handled holders are needed for sutures placed deep inside
the body.
Summary: Proper Suturing Technique: Critical
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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 woundKnots 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
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Tissue Specific Healing Time Guides the Choice of
Tissue Repair Material
14-28 days
7-14 days
7-14 days
8-12 weeks
*Minimum healing times shown here are for healthy individuals without medical complications.
14-28 days
7-14 days
7-14 days
8-12 weeks
Weeks
5-7 days
5-7 days
Wound closure is about more than just skin. As seen here,
different tissue types require different lengths of time to achievecomplete healing. This is an important factor to consider when
selecting a closure method or material.
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Skin: anatomy
Wound healing
Factors affecting wound healing
Complications of Wound healing
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Examples of Wound Healing Complications
Dehiscence InfectionScarring
Images courtesy of David Leaper, MD.
d l l
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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
Harahap (ed). Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.
-
Elevated Depressed Hypertrophic Keloids
Complicated scars: When healing is impaired abnormal scarringmay result. Several examples of complicated and abnormal scarring are
shown here
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Wound Healing Complications: Dehiscence, SSI
Dehiscence is the failure of tissue edges to
close after surgical re-approximation. Thisis 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.
d l
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Wound Healing Summary
Healing of acute wounds: a complex, dynamicseries ofevents
Optimal wound healing byprimary intention; not possible
in all cases
Manyfactors 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
li i l i l i
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Clinical Article Review:
Please read the attached clinical article entitled:
Finding the Best Abdominal Closure: An Evidence-
based Review of the LiteratureAuthors: Adil Ceydeli, MD, James Rucinski, MD, &
Leslie Wise, MD
S i l P d di
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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)
S i l P d di
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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 regardto 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)
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THANK YOU!