Page 24 - Manual of Equine Field Surgery

20 PRESURGICAL PREPARATION AND ASSESSMENT

have been shown to be excellent tension sutures; use either right or left one-hand ties to take full

however they are time consuming to insert. In one advantage of their utility.

retrospective study, an increased incisional infec-

tion rate was associated with closure of the linea

alba using a near-far-far-near suture pattern." TISSUE ADHESIVES

Subcutaneous or Subcuticular Patterns Various tissue adhesives, such as cyanoacrylates,

collagen gelatin, and fibrin glue, are used for

Subcutaneous or subcuticular suture patterns are primary wound closure.P:" Advantages include

used to close the subcutaneous or subcuticular rapid and painless application, hernostatic and

tissue prior to skin closure. Subcuticular patterns bacteriostatic properties, the provision of a

can also be used in place of a typical skin closure water-resistant protective coating, no need for

pattern (see Figure 3-5). The first part of the suture removal, and an acceptable cosmetic

suture pattern is placed by starting approximately result. It is generally thought that tissue adhe-
15

8 to lOmm from the apex of the incision i11 the sives may have some benefits in small incisions or

subcutaneous tissue, directing the needle toward wounds in which primary suture closure is indi-

the apex of the incision, and emerging in either cated, whereas larger wounds are unlikely to

the subcutis or subcutaneous tissue depending on benefit from tissue adhesives. Wounds healing by

the pattern desired. The second bite of the suture second intention may benefit from tissue adhesive

starts at the apex and emerges approximately 8 to sprays after a healthy granulation tissue bed has

lOmm from the apex in the subcutaneous tissue. formed.16

The knot is then tied and thus is "buried." The

third bite of the suture is superficial to the knot

and closer to the apex of the incision to effectively DEAD SPACE

reinforce burying the knot. The remainder of the

suture pattern is placed somewhat similar to a Dead space allows the seepage and accumulation

continuous horizontal mattress pattern, with the of blood and serum in a warm and moist envi-

needle crossing the incision at right angles or ronment that is ideal for bacterial proliferation,

slightly "behind" where the previous suture thus encouraging infection. Dead space may be

emerged. A knot similar to the start is placed at dealt with by layered wound closure when ade-

the end of the incision. The last two bites start in quate tissue is available, by compression bandages,

17
the subcutaneous tissue and the needle is directed by drainage, or by suture obliteration, although

toward the apex and somewhat more superficial. the latter may promote wound infection in con-

The last bite starts with the needle reversed at the taminated wounds. Walking sutures can be used

same level of emergence as the previous bite, to advance a skin flap over the wound bed at the

directing the needle toward the subcutaneous same time the dead space is eliminated (Figure

tissue about 8 to 10 min from the apex. The knot 3-11). A stent or tie-over bandage can be used to

is tied and the free end of the suture is cut. The help obliterate dead space in wounds in which cir-

needle is passed into the subcutaneous tissue at cumferential bandaging is not possible. This type

the level of the knot, emerging through the skin of bandage protects the wound and may provide

about 10 to 15 mm perpendicular to the incision relief to the primary suture line as well as direct

line. The needle and suture are then pulled tight pressure over areas of dead space ( see Figure

to help bury the knot, and the suture is cut at the 25-12). .

skin level.

Securing sutures is most commonly performed

using instrument ties. However, every surgeon DRAINS

should be able to use one- and two-hand tie tech-

niques to secure sutures. The ability to use these Drains are used when a large dead space remains

techniques gives the surgeon significant flexibility after suture closure or there is sufficient tissue

to apply secure ligatures and sutures in various damage so that continued seepage of fluids is

situations where the use of instrument ties is expected. Drains can be therapeutic to remove

problematic. Ideally, the surgeon should be able to existing fluid accumulation or prophylactic to