2-皮肤和皮下组织的缝合

nullnull骨科缝合技术基础培训 Basic Training on Orthopedic Suture Technique 中华医学会骨科学分会创伤学组 推荐医师培训项目皮肤及皮下组织缝合皮肤及皮下组织缝合北京积水潭医院　　创伤骨科 刘兴华 2008年11月内容概要内容概要伤口愈合 缝合方法 开放伤口处理 缝合小技巧 皮瓣 缝线选择null伤　口　愈　合伤口愈合分期伤口愈合分期炎症期 0-7天增生期 7-21天增生期 7-21天伤口愈合分期瘢痕成熟期 21天-1年瘢痕成熟期 21天-1年伤口愈合分期各种组织自然愈合时间各种组织自然愈合时间伤口愈合方式伤口愈合方式影响伤口愈合的因素 影响伤口愈合的因素 年龄 体重 营养状况 脱水状态 血液供应 免疫反应 合并慢性疾病 药物或放射治疗 吸烟 组织张力强度变化曲线图组织张力强度变化曲线图 缝合后组织张力强度最初为0，之后2周大约可恢复至正常强度的10%，1月后可恢复至正常的40%。10周后，组织张力强度为正常时的80%。伤口愈合伤口愈合上皮细胞是伤口愈合时唯一可再生的细胞，上皮再生在伤口闭合后随即启动。 伤口闭合后不久，基底层细胞迁移到伤口／切口处真皮组织以闭合接近关闭的伤口。Hunt TK, Van Winkle W Jr. Normal repair. In: Hunt TK. Fundamentals of Wound Management. New York: Appleton Century Crofts, 1979.伤口愈合评分 Hollander Wound Evaluation Scale伤口愈合评分 Hollander Wound Evaluation Scale无错位（absence of stepoff) 伤口对合不齐 (contour irregularities) 伤口对合边距超过2mm (wound margin separation greater than 2 mm) 边缘内翻 (edge inversion) 过分扭曲 (excessive distortion) 整体美观度 (overall cosmetic appearance ) ( 0-6 分，６分最佳) 伤口愈合评分 Modified Hollander Wound Evaluation Scale伤口愈合评分 Modified Hollander Wound Evaluation ScaleStep-off borders Contour irregularities Scar width Edge inversion Excessive inflammation Overall cosmetic appearance of the wound ( 0-6 score, 0 is the optimal) 缝　合　方　法缝　合　方　法伤口的解剖层次伤口的解剖层次疤痕美观效果注意技术原则疤痕美观效果注意技术原则缝合后伤口有稍许外翻 缝线足够紧张又不能过紧 如需深层缝合以减少皮肤张力，要埋结 缝合方法缝合方法间断缝合法 优点 容易调节张力 一个部位失效影响不大 缺点 需各个打结，操作时间长 需更多缝线 伤口内异物更多连续缝合法 优点 操作时间缩短 伤口内异物较少 缺点 一个部位失效可影响全局 调节张力不容易 可能破坏血供更严重较深伤口的关闭----皮下缝合较深伤口的关闭----皮下缝合较深伤口的关闭---皮下缝合较深伤口的关闭---皮下缝合间断缝合间断缝合垂直褥式缝合垂直褥式缝合水平褥式缝合水平褥式缝合连续缝合 　Baseball Stitch连续缝合 　Baseball Stitch连续缝合 　Baseball Stitch连续缝合 　Baseball Stitch连续锁边缝合 Running-Lock Closure连续锁边缝合 Running-Lock Closure连续锁边缝合　Running-Lock Closure连续锁边缝合　Running-Lock Closure连续锁边缝合　　Running-Lock Closure连续锁边缝合　　Running-Lock Closure连续皮内缝合连续皮内缝合连续皮内缝合连续皮内缝合开放伤口的处理开放伤口的处理开放伤口处理原则开放伤口处理原则清创最重要 关闭伤口方式依据伤口情况及术者经验决定 小伤口处理小伤口处理伤口处理伤口处理尽力使疤痕顺应皮肤张力松弛线 皮肤张力松弛线常与其下肌肉纤维长轴垂直 伤口处理伤口处理分层缝合 保持皮缘外翻 皮缘松松接触伤口处理伤口处理张力过大有可能组织坏死伤口处理伤口处理伤口双侧缝合组织深度应一致以防皮缘重叠 伤口处理伤口处理简单间断缝合：注意避免内翻 垂直褥式缝合：可能疤痕较大皮内缝合伤口处理伤口处理水平褥式缝合 外翻皮缘 可能影响皮缘血运“狗耳朵”的处理“狗耳朵”的处理复杂伤口处理复杂伤口处理复杂伤口处理复杂伤口处理缝合方式一复杂伤口处理复杂伤口处理缝合方式二不规则伤口处理不规则伤口处理缝合小技巧缝合小技巧不扯断缝合线情况下破坏缝线材料的记忆性不扯断缝合线情况下破坏缝线材料的记忆性Prolene等具有相当强的记忆性，可能影响缝合打结的牢固度。 正确方法： 不扯断缝合线情况下破坏缝线材料的记忆性不扯断缝合线情况下破坏缝线材料的记忆性不正确方法针线因牵拉离断用持针器持捏缝针用手指持捏缝针三角缝合法三角缝合法尖端不恰当缝合会导致尖端坏死缝合不恰当，使得尖端对位出现间隙进而造成尖端缺血性坏死缝合入针点距离尖端过近三角缝合法三角缝合法正确缝合方法三角缝合法三角缝合法正确缝合方法 缝合入位 对合整齐小切口的延迟闭合缝合小切口的延迟闭合缝合所有内缝线固定位置后，从两端向中间打结穿皮垂直褥式缝合穿皮垂直褥式缝合适于小而深的切口止血的辅助手段— 连续锁边缝合止血的辅助手段— 连续锁边缝合由于压力效果很好，要注意避免缝合过紧，防止出现组织绞窄坏死。 不可用于血供少的部位。连续混合褥式缝合连续混合褥式缝合保证最大限度的皮缘外翻连续混合褥式缝合连续混合褥式缝合保证最大限度的皮缘外翻斜位缝合斜位缝合改变张力方向闭合鼻唇沟缺损会使嘴角翘起水平调整张力方向则无此问题斜位缝合斜位缝合改变张力方向Mercedes 皮瓣 大面积缺损的多皮瓣闭合Mercedes 皮瓣 大面积缺损的多皮瓣闭合适用于头皮、躯干、四肢等了三个三角缝合三角形每条底边与缺损的切点，部分闭合切口Mercedes 皮瓣 大面积缺损的多皮瓣闭合Mercedes 皮瓣 大面积缺损的多皮瓣闭合适用于头皮、躯干、四肢等缺损的进一步闭合采用内缝合闭合null皮　　瓣Fusiform ( Eliptical) ExcisionFusiform ( Eliptical) ExcisionnullDog EarAdvancement FlapAdvancement FlapRotation FlapRotation FlapZ-PlastyZ-PlastyNote FlapNote FlapBilobe FlapBilobe FlapRhombic FlapRhombic Flapnull缝 线 选 择nullSuture ClassificationNatural or Synthetic (man made) Monofilament or Multifilament (braided) Absorbable or Non-AbsorbableThe Ideal SutureThe Ideal SutureMinimal tissue reaction Smoothness - minimum tissue drag Low Capillarity Max tensile strength Ease of handling - Minimum memory Knot security Consistency of performance Predictable performance Cost effectivenessnullMultifilament (braided)Suture ClassificationMonofilamentBraided v MonofilamentBraided v MonofilamentHas capillary action Increased infection risk Less smooth passage Less tensile strength Better handling Better knot securityNo capillary action Less infection risk Smooth tissue passage Higher tensile strength Has memory More throws required null These are absorbed within the living tissue Two main characteristics are: Tensile strength retention Absorption rateAbsorbable SuturesMaxon: Day 14: 75% Absorption: 180 days Caprosyn: Day 10: 30% Absorption: 56 days Characteristics of Non-Absorbable SuturesCharacteristics of Non-Absorbable SuturesPermanent Only used when long term support is required Removed when used for skin (e.g. in A+E) Tissue reaction generally low (except silk) However silk, linen and even nylon will lose tensile strength over a period of time True non-absorbable sutures include polyester, polyethylene, polybutester, polypropylene and steel可吸收缝线可吸收缝线不可吸收缝线不可吸收缝线缝合线— 规格与张力强度缝合线— 规格与张力强度nullA Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial A Comparison of Three Methods of Wound Closure Following Arthroplasty A Prospective, Randomised, Controlled trial We consider that skin staples are the skin closure of choice for both hip and knee replacements.Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42谢谢！谢谢！