Abdominal Wall Anatomy & Fascia Closure_pre-reading1

7/29/2019 Abdominal Wall Anatomy & Fascia Closure_pre-reading1

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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




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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




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Wound healing

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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




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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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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.



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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




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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!

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