皮肤和皮下组织的缝合

1、1,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,2,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,3,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,4,伤口愈合,5,伤口愈合分期,炎症期 0-7天,6,增生期 7-21天,伤口愈合分期,7,瘢痕成熟期 21天-1年,伤口愈合分期,8,各种组织自然愈合时间,9,伤口愈合方式,10,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

2、吸烟,11,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%。,12,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.,13,伤口

3、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，分最佳),14,伤口愈合评分Modified Hollander Wound Evaluation Scale,

4、Step-off borders Contour irregularities Scar width Edge inversion Excessive inflammation Overall cosmetic appearance of the wound ( 0-6 score, 0 is the optimal),15,缝合方法,16,伤口的解剖层次,17,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,18,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

5、,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,19,较深伤口的关闭-皮下缝合,20,较深伤口的关闭-皮下缝合,21,间断缝合,22,垂直褥式缝合,23,水平褥式缝合,24,连续缝合 Baseball Stitch,1,25,连续缝合 Baseball Stitch,26,连续锁边缝合 Running-Lock Closure,27,连续锁边缝合Running-Lock Closure,28,连续锁边缝合Running-Lock Closure,29,连续皮内缝合,30,连续皮内缝合,31,开放伤口的处理,32,开放伤口处理原

6、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,33,小伤口处理,34,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,35,伤口处理,分层缝合 保持皮缘外翻 皮缘松松接触,36,伤口处理,张力过大有可能组织坏死,37,伤口处理,伤口双侧缝合组织深度应一致以防皮缘重叠,38,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,39,伤口处理,水平褥式缝合 外翻皮缘 可能影响皮缘血运,40,“狗耳朵”的处理,41,复杂伤口处理,42,复杂伤口处理,缝合方式一,43,复杂伤口处理,缝合方式二,44,不规则伤口处理,45,缝合小技巧,4

7、6,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：,47,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,48,三角缝合法,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,49,三角缝合法,正确缝合方法,50,三角缝合法,正确缝合方法 缝合入位 对合整齐,51,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,52,穿皮垂直褥式缝合,适于小而深的切口,53,止血的辅助手段 连续锁边缝合,由于压力效果很

8、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。,54,连续混合褥式缝合,保证最大限度的皮缘外翻,55,连续混合褥式缝合,保证最大限度的皮缘外翻,56,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,57,斜位缝合,改变张力方向,58,Mercedes 皮瓣大面积缺损的多皮瓣闭合,设计了三个三角,缝合三角形每条底边与缺损的切点，部分闭合切口,适用于头皮、躯干、四肢等,59,Mercedes 皮瓣大面积缺损的多皮瓣闭合,缺损的进一步闭合,采用内缝合闭合,适用于头皮、躯干、四肢等,60,皮瓣,61,Fusiform ( Eliptical) E

9、xcision,62,Dog Ear,63,Advancement Flap,64,Rotation Flap,65,Z-Plasty,66,Note Flap,67,Bilobe Flap,68,Rhombic Flap,69,缝 线 选 择,70,Suture Classification,Natural or Synthetic (man made) Monofilament or Multifilament (braided) Absorbable or Non-Absorbable,71,The Ideal Suture,Minimal tissue reaction Smoothn

10、ess - minimum tissue drag Low Capillarity Max tensile strength Ease of handling - Minimum memory Knot security Consistency of performance Predictable performance Cost effectiveness,72,Multifilament (braided),Suture Classification,Monofilament,73,Braided v Monofilament,Has capillary action Increased

11、infection risk Less smooth passage Less tensile strength Better handling Better knot security,No capillary action Less infection risk Smooth tissue passage Higher tensile strength Has memory More throws required,74,These are absorbed within the living tissue Two main characteristics are: Tensile str

12、ength retention Absorption rate,Absorbable Sutures,Maxon: Day 14: 75% Absorption: 180 days Caprosyn: Day 10: 30% Absorption: 56 days,75,Characteristics of Non-Absorbable Sutures,Permanent Only used when long term support is required Removed when used for skin (e.g. in A+E) Tissue reaction generally

13、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,76,可吸收缝线,77,不可吸收缝线,78,缝合线 规格与张力强度,79,80,A Comparison of Three Methods of Wound Closure Following Ar

14、throplastyA Prospective, Randomised, Controlled trial,Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42,81,A Comparison of Three Methods of Wound Closure Following ArthroplastyA Prospective, Randomised, Controlled trial,Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42,82,Khan,RJK, Fick D, Yao F. J Bone Joint Surg Br, 2006, 88-B: 238-42,A Comparison of Three Methods of Wound Closure Following ArthroplastyA Prospective, Randomised, Controlled trial,83,A Comparison of Three Methods of Wound Closure Fol