Class 2- Clean Contaminated

• Primary closure
• Open/mechanical drainage
• Minor break in sterile technique occurred
• Controlled entry to aerodigestive (includes biliary tract) or genitourinary tract

Classification of Surgical Wounds (Class 3)

Acute, nonpurulent, inflamed operative wound or open, fresh wound, or any surgical procedure with major breaks in sterile technique or gross spillage from the gastrointestinal (GI) tract

Open fracture, colon resection with gross spillage of GI contents, penetrating trauma

Class 3: Contaminated

• Open traumatic wound (less than 4 hours old) with retained necrotic tissue
• Major break in sterile technique occurred
• Acute inflammation inflammation The body’s protective response to injury or tissue destruction present
• Entry to aerodigestive (includes biliary tract) or genitourinary tract with spillage

Classification of Surgical Wounds (Class 4)

Clinically infected operative wound or perforated viscera or old, traumatic wounds with retained necrotic tissue

Resection of ruptured appendix

Class 4: Dirty/ Infected

• Open traumatic wound (more than 4 hours old)
• Microbial contamination prior to procedure
• Perforated viscus (State Exam)

Closed Wound

The skin remains intact, but underlying tissues suffer damage. (Contusion/ Bruises)

Open Wound

The integrity of the skin is damaged.

Simple Wound

The integrity of the skin is compromised. There is no loss or destruction of tissue and there is no foreign body in the wound.

Complicated Wound

Tissue is lost or destroyed, or a foreign body remains in the wound. (Knives and bullet wounds)

Clean Wound

Wound edges can be approximated and secured. A clean wound is expected to heal by first intention first intention Type of healing that occurs with primary union that is typical of an incision opened under ideal conditions; healing occurs from side to side, dead space has been eliminated, and the wound edges are accurately approximated

Contaminated Wound

Contamination occurs when a dirty object damages the integrity of the skin. can become infected within a short period of time. Debridement of infected and/or necrosed tissue may be necessary, followed by thorough irrigation of the wound to further clean and wash out the contaminants, a procedure commonly referred to as an irrigation and debridement (I and D).

Abrasion

Scrape

Contusion

Bruise

Laceration

Cut or Tear

Puncture

Penetration

Thermal

Heat or cold

Approximated

Returned to proximity; brought together sides or edges

First Intention

Type of healing that occurs with primary union that is typical of an incision opened under ideal conditions; healing occurs from side to side, dead space has been eliminated, and the wound edges are accurately approximated. Wounds heal with no separation of the edges and minimal scarring

Chronic Wound

Wound that persists for an extended period of time

may develop because of an underlying physical condition that the patient suffers, for example, from pressure sores and decubitus ulcers. may also be due to infection.

Inflammatory Process

is the body’s protective response to injury or tissue destruction. serves to destroy, dilute, or wall off the injured tissue.

Classic Signs of inflammation

• Pain
• Heat
• Redness
• Swelling
• Loss of function

Why does an inflammation reaction occurs

when injured tissues release histamine from the damaged cells. The histamine causes the small blood vessels in the area to dilate, increasing the blood flow to the area, resulting in heat, redness, and swelling.

Phase of wound healing by first intention

Phase 1: Lag Phase or Inflammatory Response Phase

This stage begins within minutes of injury and lasts approximately 3–5 days.

This stage of repair controls bleeding through platelet aggregation, delivers blood to the injured site through vessel dilation, and forms epithelial cells for repair. A scab forms on the surface to seal the wound, preventing serous leakage and microbial invasion

Phase of wound healing by first intention

Phase 2: Proliferation Phase

This stage begins on approximately the 3rd postoperative day and continues for up to 20 days. Fibroblasts multiply and bridge the wound edges. The fibroblasts secrete collagen that forms into fibers that give the wound approximately 25–30% of its original tensile strength

Phase of wound healing by first intention

Phase 3: Maturation or Differentiation Phase

This stage begins on the l4th postoperative day and lasts until the wound is completely healed (up to l2 months). During this phase, the wound undergoes a slow, sustained increase in tissue tensile strength with an interweaving of the collagen fibers.

Cicatrix

A small, white, mature surface scar, called this appears during the maturation phase.

Second Intention (Granulation)

healing occurs when a wound fails to heal by primary union. It generally occurs in large wounds that cannot be directly approximated or in which infection has caused breakdown of a sutured wound. It also occurs in a wound in which primary wound closure would result in infection. Second intention healing may be allowed following the removal of necrotic tissue or after a wide debridement.

Third Intention (Delayed Primary Closure)

or delayed primary closure, occurs when two granulated surfaces are approximated. The traumatic (Class III or Class IV) surgical wound is debrided and purposely left open to heal by second intention (granulation) for approximately 4 to 6 days. The patient may be treated with systemic antibiotics and special wound care techniques may be used to treat or prevent infection, such as packing the wound with antibiotic-impregnated fine mesh gauze. The infection-free wound is then closed and allowed to finish the healing process through first intention (primary closure).

The first consideration is the physical condition of the patient,

Age: Pediatric and geriatric patients may have decreased vascularity or poor muscle tone.

• Nutritional status: Dietary deficiencies can alter the healing process.
• Obesity: The weight and pressure of adipose tissue may make it difficult to achieve a secure wound closure and contribute to incisional hernia. Adipose tissue also has a poor blood supply contributing to slow healing.
• Disease (chronic or acute): Metabolic disease, cardiovascular or respiratory insufficiency, malignancy, and infection all negatively impact wound healing.
• Smoking: Smoking causes vasoconstriction, diminishes oxygenation, and causes coughing that can put stress on a healing wound.
• Radiation exposure: Patients undergoing radiation treatment in large doses may experience a decrease in blood supply to the irradiated tissue.
• Immunocompromised orimmunosuppressed patientsimmunosuppressed patientsPatient whose immune system has decreased due to disease, or intentionally decreased with immunosuppressive drugs for organ transplant patients to prevent organ rejection immunosuppressed patients Patient whose immune system has decreased due to disease, or intentionally decreased with immunosuppressive drugs for organ transplant patients to prevent organ rejection : The patient’s immune system may be deficient due to congenital or acquired conditions.

The second consideration is intraoperative tissue handling,

• Length and direction of the incision
• Dissection technique (sharp or blunt)
• Duration of surgery
• Amount of tissue handling (tissue should be handled as little and as gently as possible)
• Achievement of hemostasis
• Precise tissue approximation
• Elimination of dead space
• Secure wound closure

The third consideration is the application of the principles of asepsis through the use of sterile technique:

Any microbial contamination of the wound could lead to an infection, causing an increase in morbidity or mortality.

Dehiscence

is the partial or total separation of a layer or layers of tissue after closure. frequently occurs between the 5th and 10th postoperative day and is seen most often in debilitated patients with Friable(easily torn) tissue. The patient often reports a “popping” or tearing sensation associated with coughing, vomiting, or straining. can result in retrograde infection (infection that travels backwards or inwards into the abdominal cavity), peritonitis, or evisceration if an abdominal incision is involved.

Evisceration

is protrusion of the viscera through the edges of a totally separated wound.is an emergency situation that requires immediate surgical intervention to replace the viscera and close the wound.

Hemorrhage:

may be concealed or evident and occurs most frequently in the first few postoperative hours. can result in postoperative shock. Surgery is frequently required to achieve hemostasis.

Infection

occurs when microbial contamination overrides the resistance of the host. It results in increased morbidity and mortality. In addition to antibiotic therapy, additional surgery may be required as part of the treatment regimen

Adhesion

is an abnormal attachment of two surfaces or structures that are normally separate. Fibrous tissue can develop within the peritoneal cavity because of previous surgery, infection, improper tissue handling, or the presence of a foreign body (lint or glove powder granule). The fibrous tissue that develops can cause abnormal attachments of the abdominal viscera that may cause pain and/or bowel obstruction.

Herniation

is a result of wound dehiscence and occurs most often in lower abdominal incisions. is usually discovered 2–3 months postoperatively and could result in bowel incarceration. Surgery may be required to correct this condition.

fistula

is an abnormal tract between two epithelium-lined surfaces that is open at both ends. It occurs most often after bladder, bowel, and pelvic procedures. Abnormal drainage is a prevalent sign. Surgery is required for correction.

Sinus Tract

is an abnormal tract between two epithelium-lined surfaces that is open at one end only. Its occurrence is highest in bladder, bowel, and pelvic procedures. Abnormal drainage is a common sign. Surgery is often required to correct this condition.

Suture complications

occur because of either a failure to properly absorb the suture material or an irritation caused by the suture that results in inflammation. It occurs most frequently with silk and is characterized by an evisceration (referred to as “spitting”) of the suture material from the wound or sinus tract formation.

Keloid scar

is a hypertrophic scar formation and occurs most frequently in dark-skinned individuals. Corticoid injections and use of pressure dressings can help reduce the size of the scar, but plastic surgery may be required for correction.

Dead Space

Separation of wound layers that have not been closely approximated or air that has become trapped between tissue layers The space may allow for serum or blood to collect and provide a medium for microbial growth, resulting in a wound infection. is eliminated by use of proper suturing techniques, wound drains, and/or pressure dressings.

Wound Drains

are devices that have been designed to remove unwanted fluids or gases from the body. can occur preoperatively, intraoperatively, and postoperatively.

Dressings

For a contaminated wound the skin and subcutaneous tissues are generally left open and packed loosely with fine mesh gauze, such as Iodoform. If the wound is still infected, it is allowed to heal by second intention. For this type of healing the wound should be repacked twice daily with wet-to-dry dressings

Sutures

Factors that influence the choice of this and technique include the health of the patient and whether preexisting conditions, such as diabetes, are present that can affect the wound-healing process.

Types of Suture Material

may be classified as absorbable, meaning it is capable of being absorbed by tissue within a given period of time, or nonabsorbable, meaning that it resists enzymatic digestion or absorption by tissue

Monofilament

Suture that is manufactured from one strand of natural or synthetic material. made of a single thread-like structure. are relatively inert and do not readily harbor bacteria. They glide through tissues more easily resulting in minimal tissue damage because they encounter little resistance within the tissue. do not hold knots as well and are relatively difficult to handle.

multifilament,

consisting of multiple thread-like structures braided or twisted into a single strand. exhibit a characteristic called capillarity, which is the capability to harbor bacteria and retain tissue fluids that can be communicated along the length of the strand. should not be used in the presence of infection. handle well and hold knots securely. Their multistrand configuration affords them greater tensile strength, pliability, and flexibility. Many brands are coated for enhanced handling capability and easier passage through tissues.

Why should sutures have elasticity?

accommodate tissue swelling and strains placed on the wound by coughing or body movements.

Absorption of Surutres

With the exception of some inert suture materials such as surgical steel, sutures are treated as foreign material by the body and the longer they dwell within tissues, the more likely the tissues will react negatively and impair the healing process

Natural Material

meaning that it is made from naturally occurring substances, such as cellulose, an animal product, or tissue; are digested by body enzymes that attack the suture strand, eventually destroying it.

Synthetic Material

consisting of polymers from petroleum-based products. are hy-drolyzed by the body. Water within the tissue penetrates the strand and breaks down the synthetic fiber’s polymer chain, resulting in minimal tissue reaction.

Suture Sizes and Tensile Strength

indicates the diameter of the suture material. The suture diameter is referred to as the gauge of the suture. The surgeon will try to use the smallest-diameter suture that will support the tissue wound closure

What does choosing the smallest suture support?

(1) minimizes tissue trauma as the suture passes through tissues;

(2) contributes to minimizing the amount of foreign material implanted in the body.

The United States Pharmacopeia (USP)

specifies diameter range for suture materials. The diameter of stainless steel sutures is identified by the Brown and Sharpe (B and S) commercial wire gauge numbers.

Suture Size

is numerical; as the number of 0’s increase, the smaller the diameter. For example, 3-0 or 000 is smaller in diameter than 1-0 or 0. The smaller the size, the less tensile strength of the suture. The largest available suture for use in surgery is #5; it is approximately the size of commercial string.

Most common Suture Size

USP suture sizes #1 through 4-0 are the most commonly used.

Size #1 and #0

are used frequently for closure of orthopedic wounds and abdominal fascia.

Size #4-0 and # 5-0

are typically used for aortic anastomosis (Pathological, surgical, or traumatic formation of an opening between two normally separate organs or spaces anastomosis Pathological, surgical, or traumatic formation of an opening between two normally separate organs or spaces ,)

Size #6-0 through 7-0

are used for smaller vessel anastomoses, such as those on the coronary or carotid arteries

Size 8-0 through 11-0 sutures

used for microvascular and eye procedures

Size 4-0 sutures

are used to close dural incisions;

size 3-0 and 4-0 sutures

are used for most subcuticular skin closures.

tensile strength of tissue

is what determines the size and tensile strength of the suture the surgeon chooses. The rule of thumb is the suture should be as strong as the tissue on which it is being used; in other words, the suture tensile strength should equal the tissue tensile strength.

First choice of sutures is?

Absorbable sutures are often for tissue that does not need continued support

NonAbsorbable Sutures

are used where continued strength is necessary, for instance, to close abnormal openings in the heart. They are typically used to close the dura over the brain or spinal cord and for fascia and skin closure; for example, silk sutures are commonly used for ligat-ing vessels.

Some tissues are stronger than others and some heal faster.

Fascia and skin are strong but heal slowly, Gastrointestinal tissue is relatively weak but heals quickly. The normal strength and healing characteristics of a tissue are modified by the condition of that tissue in each patient.

factors modifying the normal condition of tissue

• Age of the patient
• Weight of the patient
• Metabolic factors
• Carbohydrates
• Proteins
• Vitamins
• Dehydration
• Vascularization
• Thickness of tissue at a given time
• Edema or induration (hardening and thickening of tissue)
• Incision relative to fiber direction
• Amount of devitalized tissue within wound
• Radiation therapy

Some individual disease processes affecting suture choice that the surgical technologist should be aware of are

• Diabetes mellitus
• Immune system diseases
• Pituitary gland dysfunction
• Localized infection
• Systemic infection

What does the packaging of a suture need?

• Surgical application
• Product code number
• Suture length and color
• Metric diameter equivalent of suture size and length
• Shape and quantity of needles (shown in silhouette)
• Needle point geometry
• Lot number
• Expiration date, if necessary

Double Armed Suture

represented by two needle silhouettes.

What represents a large needle on sutures

Any needle number greater than 2 is represented by a single needle silhouette and the number of needles is written in red.

Rapid release needles

also referred to as controlled release (CR), are designed to “pop off” the suture strand after a single suture has been placed

How are sutures packaged

primary is sterile and contained within an outer wrapper similar to a peel pack. The contents of the wrap are sterile; however, the outside of the package is not.

Ligatures

also referred to as ties, are used to occlude vessels for hemorrhage control or for organ or extremity removal.