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West China Hospital of Sichuan University

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1 West China Hospital of Sichuan University
Surgical incision of the special treatment program West China Hospital of Sichuan University Zhou Yong Li Fuyu

2 handling infected incision

3 Influence surgical site infection:
Wound infection to be hospitalized days and costs will increased more than 4 times Infection factors 50% from patients ,35% from health care workers. Endogenous factors: From the surrounding skin, hair follicles, mucous membranes or hollow organs Exogenous factors: the surgical staff, air, equipment Blood-borne factor; underlying diseases, age, nutritional factors; Surgical injury first barrier: skin and mucous membranes - microorganisms into the wound - the body defense mechanism The incidence of SSI directly affect patients' satisfaction with surgical results and the assessment of medical institutions

4 surgical site infection Prevention:
Aseptic, fine operation and to stop bleeding, reduce wound irritation Pre-operative shower:Chlorhexidine twice; Pre-operative skin preparation tools:Hair clippers Routine disinfection and can not completely kill the bacteria on the surface of skin, skin and hair follicles to prevent the use of antimicrobial film of bacteria: attention to dry skin around the disinfectant, films do not wrinkle! Focus on brush hand 、in surgery have two pairs of gloves to change gloves; Repeated disinfection of disposable sterile clothing VS sterile clothing: wearing a disposable waterproof sterile clothing: a doctor before surgery and no SHOWER. Electric knife and cut liquefaction: consider subcutaneous fat sharp cut 30min-1h preoperative use of antibiotics; surgery to keep the body temperature and tissue perfusion; operative time, blood transfusion, to protect the incision. Preoperative control of blood glucose, upper respiratory tract infection, nasal bacteria and bacteria control Early postoperative application of erythromycin ointment, Eric gauze covering the incision continued antibiotic

5 First, infection factors on wound healing
Liquefaction necrosis of things, prevent new connections on both sides of the wound granulation tissue, delayed wound healing. Wound infection, the hydrogen ion index (pH) alkaline, blood clot liquefaction. The healing process of connective tissue and new capillaries in the bridge break. Pyogenic bacteria produce toxins and enzymes, leading to wound tissue necrosis, dissolution of collagen fibers and collagen, increased tissue damage. Impede wound healing. After infection, the activation of inflammatory cytokines (macrophage-derived growth factor), chemotactic into fiber cells, stimulate proliferation of inflammatory granulation tissue. Infected wound healing scar thick, leather-free structure and skin appendages.

6 Second, the conventional treatment of infected wound:
Need to remove sutures, open incision, drainage (or drainage placed pieces). The need for timely clean the incision wound, timely medication. Wait for the new granulation tissue gradually filled from the bottom of the incision closed incision (EGF drugs). Butterfly tape (temporary fixed cut) impede wound drainage, sterile, appropriate suture tension. (Infected wound healing requires a dynamic adjustment of suture tension prevent excessive growth of granulation extrusion) Requires twice suturing incisions, suturing time delay.

7 Third, the lack of conventional treatment methods:
Can’t processing closing and open incision of the drainage at the same time. Open wound drainage, need to re-suture. Unable to wound drainage and wound healing needs to provide different suture tension. Incision from the bottom of the slow proliferation of granulation, filling wound: healing time delay, poor healing. Thick scar may affect tissue function, especially in joints and other parts the second suture: local anesthesia pain, the combined difficulties, the time is not easy to grasp, the high failure rate.

8 Incision Category: 1、Clean incision (Ⅰ type sterile incision): refers to non-traumatic, uninfected wounds; surgery did not enter the respiratory tract, gastrointestinal tract, urogenital tract and oropharynx area. If subtotal thyroidectomy surgery and so on. 2、Possible contamination of the incision (Ⅱ type incision): Is contaminated with a surgical suture wound, Such as gastrectomy ; the skin is not easy to complete sterilization of the site; 6 hours after debridement of the wound suture; New suture the incision cut again and so on 3、Pollution incision (Ⅲ type incision): near the infected area is directly exposed to infectious agents or incision, such as suppurative appendicitis, intestinal obstruction, necrosis, surgery, local old wounds with necrotic tissue in wounds.

9 Wound healing Rating: A healing: is the skin on the joint, healing fine, no adverse reactions healing. B healing: is the right combination, poor healing, healing place with inflammation, such as redness, induration, hematoma, fluid, etc., but no purulent lesions without incision and drainage of local infection. C healing: is the right combination, poor healing, local wound infection with purulent lesions, and the need to deal with incision and drainage, wound healing time delay, thick scar that may affect the function

10 Fourth, pollution, infection, wound treatment recommended programs:
The open surface of the suture, drainage of infected material benefit (conventional suture drainage is not smooth). Ensure timely and proper dressing, clean the wound and promote wound healthy granulation. Infection deep wound,May lay aside the drainage piece to guarantee the effect. To be infection control, timely increased suture tension and close the incision, reducing hypertrophic scars. To avoid the second suture: local anesthesia, delayed healing, Cicatrization poor, thick scar. Possible make contamination or infection in the incision for access to Class A or B healing.

11 Fifth, alternative products:(LICHEN® NEEDLELESS SUTURE)
Select reason: a “no additional hurt, no foreign matter, open, reduce tension," the suture characteristics. No additional hurt: Needless the needlework to pierce the skin and Compression or cutting the skin No foreign matter:Suture the incision to avoid foreign body-induced inflammation, reduce scar. Open :Make the liquefied necrosis smooth discharge for infection wound , Keep the wound clean, to promote healthy granulation tissue growth and infections wound healing. Reduce tension: Wound closure can be adjusted according to the tension, and gradually closed the incision infection. Can be used in conjunction with antimicrobial absorbable suture line sparse subcutaneous tissue.

12 2.Clean the skin surface:
1 .suture of subcutaneous Use Description: First, the suture before the skin treatment: Suturing the subcutaneous layer: Suture the each skin layer, Optional intermittent (sparse) suture the dermis, so that the edge of the wound together more smooth skin. 2.Clean the skin surface: Blood stains the skin surface: It is recommended cleaned with saline. Skin disinfectant: absorbent gauze must be dry. Otherwise: will reduce the adhesion and the skin staples. 2.Clean the skin surface

13 1. Pre-together: Second, suture the incision steps: 1. Pre-together: Pushes the wound, causes the wound to turn the straight line, the cicatrization wound 2. Paste fixed: At the same time on both sides of the skin surface of the paste to the wound. Gently press the adhesive tape surface to ensure the close bond with the skin surface. Attention : avoid contamination Adhesive surface : Just use hand or tool to suture thorn band Avoid repeated Paste: Avoid repeatedly opened to re-paste, otherwise it will reduce adhesion. 2. Paste fixed:

14 Easy to wound exudate and secretions from;
3, increased suture tension adjustment: Fixed with the thumb (suppress) side of the lock, Hand or forceps traction spine out of about cm. When both sides of the wound skin flap closure, pull-out stop that locking suture strength. 4. Keep open the surface: You should normally leave open surface with cm Facilitate the observation of the wound together and the whole of the skin flap; Easy to wound exudate and secretions from; Easy cleaning and dressing wounds Incision on the bit: The wound edge of both sides of the skin fold at the same surface Incision of the joint: the wound on the same surface on both sides of the skin close to the edge together. Tension blisters: When the suture strength is too large (orange peel-like skin changes) because adhesion is very strong, strong pull to withstand the sticky side of stimulation, tension can cause skin blisters, should be avoided. 3, increased suture tension adjustment:

15 1, clean cut (Ⅰ type sterile incision): Is it necessary?
Recommended: incision of purpose - on with the skin incision; suture limitations and choice. Avoid needle puncture: needle itself can be the skin surface bacteria into the skin. Compression sutures to avoid cutting: to create new skin trauma, wound and scar. To avoid foreign body: help reduce wound inflammation, foreign body scar package. Open drainage: there is still such a small incision liquefied necrotic material requires discharged, to keep the wound clean and to ensure blood supply. Helping to ensure "Ⅰ type sterile incision" after use, fully achieve the grade healing.

16 2, may contaminate the incision (Ⅱ type incision):
Recommended use: the promotion of wound clean and reduce infection. Early closure: Keep skin flap to the initial alignment; recommend the use of sparse subcutaneous interrupted sutures to keep the incision open, unobstructed drainage, will help reduce the incidence of infection; the conventional way of sewing the skin subcutaneous liquefaction necrosis may impede drainage discharge, often leads to swelling around the incision or cellulitis. Recommend dressing in advance: cut open conducive to the smooth discharge of liquid material, to be frequently changes the drug to keep the incision clean. Recommended after 72 hours, no signs of infection confirmed the incision, increased suture strength in time to ensure that skin flap close on the joint, to promote wound healing. Class Ⅱ incision as promoting use, to Class healing.

17 3, cut pollution (Ⅲ type incision):
Recommended use: the promotion of wound clean and reduce infection, to avoid the second (needle) suture. Early closure: Keep skin flap to the initial alignment; more effective early detection and treatment of subcutaneous foci, to avoid the occurrence of cellulitis, wound dressing process more convenient and effective; Has been festering wound infection: recommendations unlock staples, increased open incision and drainage patency; Foci deep incision: It is recommended to unlock and place the drainage films and to enhance drainage, clean dressing. Recommended infection control, and then gradually increase the suture tension, the last direct closed incision. Incision as promoting pollution (Ⅲ type incision) after use, to Class B or Class A healing effect.

18 Handling of liquefied tissue incision

19 一、Common organization of liquefaction-induced factors:
Use electric knife and thermal burn injury caused by cell degeneration occurs; Cut thicker subcutaneous fat tissue, the occurrence of blood supply disorders; Incision wound longer exposure time, pressure, injury (hooks); Incision organization associated with foreign body, inflammation, infection; Other factors.

20 Second, the organization liquefied adverse effects on wound healing:
Subcutaneous tissue necrosis, liquefaction, affecting normal wound healing; Accumulation of liquefied necrotic material, prevent new connections wound repair granulation and capillary; Accumulation of liquefied necrotic tissue material, a bacterial culture medium, easily lead to wound infection; Material containing liquefied necrotic tissue collagen and collagen fragments to stimulate scar granulation Lead to delayed wound healing

21 Third, the organization liquefied incision approach: The key is early drainage of the liquefied material An open suture, to facilitate the timely discharge of drainage of liquefied necrotic tissue material; An open suture, the wound will help ensure clean, healthy granulation promote wound; Suggested earlier to maintain moderate incision suture tension, essential for ensuring skin flap can be combined; Recommend dressing in advance, open incision, easy and smooth discharge of liquefied material; Proposed liquefied material smooth discharge, increased suture strength in time to ensure that skin flap tightly closed. Promote the organization as liquefied incision healing well to Class。

22 Tension cut processing

23 First. common predisposing factor in tension of the incision:
Surgery resulting in a larger tissue defects around the incision. Incision exposed a long time, pressure, injury (hooks), severe edema. Less subcutaneous fat, a special part of the incision. Special size cut (too much fat or muscle \ fascia weak) Increased pressure within the tissue or organ. Common in plastic surgery, orthopedics, thoracic surgery, general surgery (abdominal surgery).

24 Second, the conventional treatment of tension-cut:
Phase Ⅰ suture incision: the organization cutting force, increase the internal organization of the wound injury, damage to blood supply. Abdominal suture cutting effect of the latter part of the epidermis is very obvious, even cutting the bowel causing intestinal fistula Stage Ⅰ, Ⅱ period of closure the use of a butterfly tape, athletic and other auxiliary tools can not achieve a truly effective to reduce tension effect. Forced to temporarily give up the stage Ⅰ incision.

25 Third, the lack of conventional treatment methods:
Can not meet the safe, reliable and effective to reduce tension. Obvious limitations, the effect is not ideal. Can not cut the tension with changes in the dynamic adjustment of the incision suture tension. Can not produce sustained by reduction tension. Delayed wound healing, the combined effect of poor, thick scar affecting the function.

26 Fourth, the needle-suture device (the skin to reduce tension device) to reduce tension characteristics: Meet the Phase Ⅰ tension suture the incision to avoid cutting tissue, injury, damage to blood supply. Can cut the tension with changes in the dynamic adjustment of the size of the incision suture tension Can be implemented to reduce tension continued, the tension gradually closed the incision. The suture tension can be larger, according to the mechanical design principles of leverage, a point - line (long base-band) - surface (greater area of ​​3M adhesive tape) of the dispersion ratio decreases, even delivered to the farther from the incision of the skin surface. Avoid large forces on the incision sutured tissue caused damage. Solve the tension wound healing delay, the co-poor, thick scar affecting the function of the problem.

27 Fifth, the tension (tissue edema) incision to reduce tension treatment:
Suture needle-free device (the skin to reduce tension device) Ⅰ period suture the incision; Early in wound healing (tissue edema period) use: It is recommended to maintain appropriate suture tension to ensure that basic skin flap on the bit. (Due to higher adhesion to reduce tension devices to avoid the tension is too high tension lead to skin blisters) hours after the wound healing (edema period): It is recommended to increase timely suture tension to ensure that skin flap on the base of the joint spaces and can be. 4. Wound healing in the first 5-14 days (new granulation tissue repair period): timely adjust and maintain appropriate suture tension to ensure that at the close of the skin flap combined.

28 sixth、Plastic surgery incision to reduce tension handling:
1. Needle-less suture (the skin to reduce tension device) Ⅰ period suture the incision; 2. Early in wound healing: Propose to maintain the appropriate suture tension, essential for ensuring skin flap together. 3. In wound healing after 72 hours: Proposed increase in suture tension in time to ensure that skin flap at the close of the combined state. 4. Wound healing in 3-6 months (scar and reconstruction phase): Proposed incision scar tissue, keep reducing tension Avoid tension stimulation causes a thick scar tissue (keloids).

29 Surgical cases

30 Orthopedic surgery cases
Femoral surgery

31 Orthopedic surgery cases
Femoral surgery

32 Orthopedic surgery cases
Spinal surgery

33 Orthopedic surgery cases

34 Orthopedic surgery cases
Femoral surgery Spinal surgery

35 Orthopedic surgery cases
Forearm after 2 days

36 General surgery cases Thyroidectomy after 2 days and 6 days removal

37 General surgery cases Appendectomy surgery after 2 days and 6 days removal

38 Hepatobiliary surgery : Drainage tube placement

39 Anorectal surgery Cases

40 Anorectal surgery Cases

41 Pediatric surgery Example
Hernia surgery:After 2 days and 5 days after removal

42 Pediatric surgery Example
After vaginectomy 2 days and 5 days after removal

43 Gynecology surgical cases
Caesarean:Transverse incision Caesarean : vertical incision

44 Summary 1、Clean cut(Class Ⅰ sterile incision):Needle-less suture conducive to the timely drainage of liquefied necrotic,prevent infection、reduce the degree of scar. 2、Possible contamination of the incision(Class Ⅱ incision):Facilitate the early observation of drainage, treatment, and gradually closed the incision. 3、Cut pollution(Class Ⅲ incision):Easy to observe the drainage of early, timely treatment and medication, and gradually closed the incision. 4、Wound infection: to facilitate wound dressing, according to the needs of different periods of wound tension, and gradually win over the incision, increased two closing success rate.

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