IMMEDIATE PRIMARY SUTURE

You have just toileted the wound as in Section 54.1, and have now to decide if it is suitable for immediate or delayed primary suture. For face wounds goto Section 61.1.

INDICATIONS (1) In most parts of the body, primary suture is only indicated if a wound: (a) is clean cut, as by a knife or broken glass, (b) is less than 6 hours old, (c) contains no doubtfully viable tissue, and (d) can be sutured without undue tension. (2) Most wounds of the head, face, and neck, and small clean wounds on the hands, arms, and scalp, are suitable for immediate primary closure for up to 24 hours because their blood supply is so good. (3) Close all wounds of the dura, and the pleural and peritoneal cavities, by immediate primary suture. If necessary, you can leave the tissues over them for delayed suture.

If all the other conditions apply, except that you cannot bring the skin edges together, you may be able to close the wound by primary skin grafting (57.5).

CONTRAINDICATIONS These are also mostly the indications for delayed primary suture. They are: (1) Wounds more than 6 hours old, or with dirty or damaged tissue. (2) All severe wounds, crush injuries, gunshot wounds and bites, either human or animal. (3) Any wound in which immediate or delayed primary split skin grafting might be a better way of providing skin cover, for example degloving injuries. (4) Wounds in severely shocked patients whose peripheral circulation is so poor as to seriously weaken wound repair (5) All open fractures (69.7). (6) Most open joint wounds (69.8). (7) Wounds in anyone who is about to be sent on a long journey. (8) Lack of antibiotics, so that you have nothing to give a patient if his wound does become infected. (9) ALL war wounds, especially all missile wounds.

METHODS FOR IMMEDIATE PRIMARY SUTURE

Before you start to close a wound, be sure to control bleeding adequately. Failure to do this is a common cause of infection, necrosis, and breakdown. Close the patient’s skin and deep tissues with interrupted monofilament sutures.

If a wound is shallow and the cosmetic result is important, you may be able to use subcuticular sutures as in I, and J, Fig. 61-2.

If the cosmetic result Is not important, use deep interrupted sutures, as in in B, and C, Fig. 54-5. Insert them at 90 to his skin. Put them across the wound, close to the skin edges, so that if they do interrupt the blood supply, they do so in as little skin as possible.

If the wound is deeper, or fat is friable, use interrupted vertical mattress sutures as in A, Fig. 54-5. The large bite closes spaces deep in the wounds, and the small one prevents inversion of the skin edges.

Don’t drain the wound; if you expect much discharge, close it by delayed primary suture.

CAUTION! (1) Don’t make the sutures too tight, or put them too close. Exudate should be able to escape from between them. (2) Close all dead spaces. If you cannot bring the skin edges together, you may be able to undercut them. The level at which you do this is important: (1) In the face, undercut just deep to the dermis (61.1). (2) In the scalp, undercut between the galea and the pericranium. (3) If more than minimal undercutting is necessary in the limbs, do it between the superficial and deep fascia. If you cannot easily bring the skin edges together, graft the wound.

CAUTION! (1) Undercutting more than 1 cm has its dangers, especially haematoma formation. Split skin grafting may be safer. If you fear infection, mesh it (57.5).(2) Always leave some fat under the skin. If you undermine it too superficially, it will necrose.

POSTOPERATIVE CARE Leave skin sutures in from 4 to 14 days, depending on the thickness and blood supply of the patient’s skin. Four days will be enough on the neck or scalp. Ten to 14 days may be necessary on the lower leg, feet, and toes. Remove them earlier if there is increasing pain, pyrexia or pus.

DIFFICULTIES WITH A SUTURED WOUND

If a patient’s WOUND BLEEDS WITHIN 24 HOURS (reactionary haemorrhage), a ligature has slipped, or a clot has become dislodged. Bleeding is sudden, and may be massive. Prevent it by tying careful double ligatures on larger vessels.

If his WOUND BLEEDS AFTER 24 HOURS (secondary haemorrhage), sepsis has probably eroded a blood vessel. There may be a small warning bleed before a large vessel bursts. Prevent it by preventing sepsis (2.3).

The treatment for both kinds of haemorrhage is the same. Try to control bleeding with large pressure dressings, such as laparotomy pads. If this fails, take the patient to the theatre, open his wound gently, and tie the vessel. If you cannot find the source of the bleeding, pack it, and remove the pack in the theatre 3 days later. If local pressure fails to control the bleeding, you may very rarely need to tie the vessel proximally (3.3 etc.).

If his WOUND FAILS TO HEAL, or leaves a sinus, think first of a foreign body. If this might be a possibility explore it.

Figure 54.6: UNTERCUTTING THE EDGES OF A WUND. The levels at which you should do this vary with the wound. A, undermining the face superficial to the branches of the facial nerve, using either a scalpel (B), or scissors (C). D, and E, undercutting the skin of the limbs between the superficial and deep fascia. F, and G, undercutting the scalp between the galea and the pericranium. After Ian McGregor with kind permission.