WOUNDCLOSURE MANUAL
                           WOUND HEALING
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                                                                          PREFACE
                                                                                                                                                                         his manual has been prepared for the medical professional who
                                                                                                                                                     would like to learn more about the practice of surgery–the
                                                                                             T 
                                                                                                                                                     dynamics of tissue healing, the principles of wound closure, and the
                                                                                                                                                     materials available to today’s practitioners. Most important, it
                                                                                                                                                     touches on some of the critical decisions which must be made on a
                                                                                                                                                     daily basis to help ensure proper wound closure. 
                                                                                                                                                     ETHICON PRODUCTS, a Johnson & Johnson company, is the
                                                                                                                                                     world’s leading marketer of surgical sutures and is the only U.S.
                                                                                                                                                     company that offers an adhesive with microbial protection as an
                                                                                                                                                     alternative to sutures for topical skin closure.
                                                                                                                                                     ETHICON enjoys a reputation for developing quality products to
                                                                                                                                                     enhance the lives of patients and for providing outstanding service
                                                                                                                                                     to customers. We hope you find this manual useful. But, above all,
                                                                                                                                                     we hope that it reflects our high regard for the men and women
                                                                                                                                                     who have chosen the medical profession as a career.
                                                                                                                                                                                                                                                 ~     ETHICON PRODUCTS ~
      CONTRIBUTING EDITOR
           David, L. Dunn, M.D., Ph.D.
           Jay Phillips Professor and Chairman of Surgery,
           University of Minnesota
           We thank Dr. Dunn for his contributions to the Wound Closure
           Manual. Dr. Dunn is currently the Jay Phillips Professor and
           Chairman of Surgery at the University of Minnesota. This
           department has a long-standing tradition and has attained
           national and international recognition for excellence in training
           academic general surgeons and surgical scientists. He is also the
           Division Chief of General Surgery, Head of Surgical Infectious
           Diseases, Director of Graduate Studies, and Residency Program
           Director of the Department of Surgery.
           Dr. Dunn has published over 400 articles and book chapters in the
           areas of Surgical Infectious Diseases and Transplantation. He has
           received regional and nationwide recognition in several
           academic organizations and is a Past-President of the Surgical
           Infection Society, the Association for Academic Surgery, the
           Minnesota Chapter of the American College of Surgeons, the
           Society of University Surgeons and the Society of University
           Surgeons Foundation.
                  TABLE OF CONTENTS
                          WOUND HEALING                                                      Knot Tying......................................................... 24
                  1 AND MANAGEMENT                                                                     Knot Security............................................ 24
                                                                                                       Knot Tying Techniques Most Often Used.......... 25
              The Wound.......................................................... 2                    Square Knot............................................. 25
                        Recovery of Tensile Strength............................ 2                     Surgeon’s or Friction Knot............................ 26
                        Patient Factors that Affect Wound Healing......... 2                           Deep Tie................................................. 26
                        Surgical Principles....................................... 4                   Ligation Using a Hemostatic Clamp............... 26
              Classification of Wounds................................... 5                            Instrument Tie.......................................... 26
              Types of Wound Healing................................... 6                              Endoscopic Knot Tying Techniques.................. 26
                        Healing by Primary Intention........................ 6                         Cutting the Secured Sutures.......................... 26
                        Healing by Second Intention.......................... 7              Suture Removal................................................. 26
                        Delayed Primary Closure.............................. 7              Suture Handling Tips....................................... 27
                                                                                             Suture Selection Procedure............................. 27
                                                                                                       Surgery within the Abdominal Wall Cavity....... 28
                  2 THE SUTURE                                                                         Closing the Abdomen.................................. 30
                                                                                                       Closing Contaminated or Infected Wounds........ 40
              What is a Suture?............................................... 10
              Personal Suture Preference............................... 10
              Suture Characteristics....................................... 11                    3 THE SURGICAL NEEDLE
                        Size and Tensile Strength.............................. 11
                        Monofilament vs. Multifilament.................... 11                Elements of Needle Design............................. 42
                        Absorbable vs. Nonabsorbable Sutures.............. 12                Principles of Choosing a Surgical Needle..... 44
              Specific Suturing Materials.............................. 13                   Anatomy of a Needle........................................ 45
                        Synthetic Absorbable Sutures......................... 14                       The Needle Eye......................................... 45
                        Nonabsorbable Sutures................................ 16                       The Needle Body....................................... 46
                        Synthetic Nonabsorbable Sutures.................... 17                         Straight Needle......................................... 46
              Common Suturing Techniques....................... 18                                     Half-Curved Needle................................... 47
                        Ligatures................................................. 18                  Curved Needle.......................................... 47
                        The Primary Suture Line............................. 19                        Compound Curved Needle........................... 47
                        Continuous Sutures.................................... 19                      The Needle Point...................................... 48
                        Interrupted Sutures.................................... 22           Types of Needles...............................................    48
                        Deep Sutures............................................ 22                    Conventional Cutting Needles....................... 49
                        Buried Sutures.......................................... 22                    Reverse Cutting Needles............................... 49
                        Purse-String Sutures................................... 22                     Side Cutting Needles................................... 50
                        Subcuticular Sutures................................... 22                     Taper Point Needles................................... 50
                        The Secondary Suture Line........................... 23                        Taper Surgical Needles................................ 51
                        Stitch Placement........................................ 23                    Blunt Point Needles.................................... 52
                                                                                             Needleholders.................................................... 52
                                                                                                       Needleholder Use....................................... 52
                                                                                                       Placing the Needle in Tissue......................... 53
                                                                                             Needle Handling Tips...................................... 53