DELAYED PRIMARY SUTURE

INDICATIONS These are mostly the contraindications to immediate primary suture given in Section 54.2.

You toileted the patient’s wound as in Section 54.1, and have decided on delayed primary suture. You have now brought him back to the theatre 3 days later to look at his wound.

Figure 54.7: MORE SUTURE METHODS—ONE. A, sutures pulled too tight—never draw them as tight as this. B, horizontal continous sutures. C, interrupted sutures. D, horizontal mattress sutures. E, vertical mattress sutures. F, to I, suturing with a hypodermic needle. J, and K, and L, M, and N, removing dog ears. Kindly contributed by Peter Bewes

If there are no signs of infection, close it by the same methods as for immediate primary suture. Disturb it as little as possible, irrigate it with saline to remove blood clot. Excise any necrotic tissue. Clean its edges, but don’t freshen them. If necessary, undercut them (54-6). Bring them together with interrupted monofilament sutures. Apply a pressure dressing and, if necessary, splint his limb as before.

CAUTION! (1) Control all bleeding. Use packs and avoid ligatures if you can. A haematoma will ruin the chance of success. (2) Don’t close the wound under tension.

If there are signs of infection, l eave the wound open for secondary suture (54.6), or a secondary skin graft.

If you have had to excise any necrotic tissue, delay suture for two more days.

If you cannot bring the edges together, consider grafting. If the gap is more than 6 to 8 cm you will probably have to graft it. If the wound is on a patient’s forearm, hand, or calf, you will have to graft much smaller areas. POSTOPERATIVE CARE If the wound is superficial, leave it for 10 to 12 days. If it is large and deep, inspect it in the theatre after 5 days. Remove the stitches at 10 to 12 days and start exercises.