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Horizontal Mattress Suture

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101. Nephrectomy, Partial (Treatment)

are approximated manually. With the assistant approximating the edges of the parenchymal defect as depicted in image #5 above, close the defect over a Surgicel/Gelfoam roll to aid in parenchymal pressure and hemostasis. Two strips of Gelfoam wrapped in Surgicel can be used to bolster the renal capsule along the edges of the defect to reduce the risk of tearing. Lay the 2 strips along the length of the defect on each side. Pass several 2-0 polyglycolic acid horizontal mattress sutures through the renal capsule (...) , closure of the parenchyma with horizontal sutures over the length of the defect with fat or Oxycel or closure with Gelfoam and Surgicel bolsters) have been successfully used. These methods depend on the strength of the renal capsule. Use of Gore-Tex allows for even distribution of tension along the length of the closure. Small bleeding vessels are easily tamponaded. Gore-Tex also allows the surgeon to tie the sutures with the desired tension without risking tear of the kidney capsule, especially when

2014 eMedicine.com

102. Nail Surgery (Treatment)

, trimmed, and reattached to the nail bed and the LNFs by using horizontally placed mattress sutures. Stitches are removed in 10 days, when the nail is firmly adherent to the nail bed. Anesthesia is usually not required, but, when indicated, a digital block may be performed. Repair of simple lacerations Superficial lacerations that are limited to the nail plate and involve less than 3 mm of the nail bed usually heal independent of surgical repair as the injured nail grows out. [ , ] Larger lacerations (...) original anatomical site. Hemostasis is achieved with electrocoagulation, Monsel solution, or aluminum chloride solution. The wound may be allowed to heal by secondary intention. Alternatively, the wound may be closed by passing sutures through the nail plate and the LNF. When dressing the wound, the lateral nail groove is packed with iodoform or petroleum jelly gauze. A nonadherent dressing (eg, Telfa) is applied, followed by the placement of a bulky dressing or cling that is secured with elastic tape

2014 eMedicine.com

103. Nasal Reconstruction (Treatment)

include proper flap design, wide undermining to minimize wound-closure tension, meticulous hemostasis, delicate handling of tissue, and strict preservation of a highly vascular muscular flap base. Surgical attention should be directed toward the delicate handling of tissue and properly everting buried sutures, because incision lines on the nasal tip and alae are more visible than incision lines placed elsewhere on less sebaceous skin. Any flap should be carefully sized in both the horizontal dimension (...) not have any identifiable relaxed skin tension lines; therefore, closures in this area should be oriented vertically to prevent alar asymmetry. As with all linear closures on the nose, the tissue should be undermined at the level of the perichondrium. The wound is approximated by using buried vertical mattress sutures following meticulous hemostasis. Particular attention is paid to wound-edge eversion on the sebaceous areas of the nose, because surgical scars tend to invert in thickly skinned areas

2014 eMedicine.com

104. Superior Labrum Lesions (Overview)

Med . 2005 Apr. 33(4):507-14. . Silberberg JM, Moya-Angeler J, Martín E, Leyes M, Forriol F. Vertical Versus Horizontal Suture Configuration for the Repair of Isolated Type II SLAP Lesion Through a Single Anterior Portal: A Randomized Controlled Trial. Arthroscopy . 2011 Dec. 27(12):1605-13. . Coleman SH, Cohen DB, Drakos MC, et al. Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med . 2007 (...) of a type II superior labrum anterior posterior (SLAP) lesion. Arthroscopic placement of a suture anchor in the superior glenoid. Arthroscopic suture placement for superior labrum anterior posterior (SLAP) lesion repair. Arthroscopic appearance of a superior labrum anterior posterior (SLAP) lesion after repair with a suture anchor. Simple mattress suture configuration with a single anchor. (Arthroscopy. 2007 Feb;23(2):135-40.) of 8 Tables Contributor Information and Disclosures Author Riley J Williams

2014 eMedicine.com

105. Ectropion (Treatment)

at the gray line with either sharp Westcott scissors or a 15 blade. (The author does not find it necessary to split the lid.) The meibomian orifices of the lateral strip are trimmed away. The lateral conjunctiva is scraped to avoid epithelial inclusion cysts. To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a single horizontal mattress suture) can be placed about 4 mm posterior to the lateral orbital rim at the Whitnall tubercle (at or above the level of the inferior pupil). Suitable (...) . [ ] Next: Surgical Care The correct surgical treatment of ectropion depends on the etiology. [ ] Horizontal lid laxity is often seen with ectropion and usually can be corrected with a lateral tarsal strip procedure. Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure. Tarsal ectropion requires reinsertion of the lower lid retractors. Augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion. The use

2014 eMedicine.com

106. Laparoscopic Pelvic Lymph Node Dissection (Treatment)

perforation can be minimized by limiting the use of electrocautery in the area of the intestine that needs mobilization in order to expose the pelvic lymph nodes. A short burst of electrical energy is sufficient to create a full-thickness injury to the bowel. In addition, abrasions that occur during mobilization of the colon should be covered using horizontal mattress sutures placed laparoscopically. [ ] By carefully identifying the obturator nerve (located in the posterior aspect of the dissection

2014 eMedicine.com

107. Scar Revision (Treatment)

traumatized during closure may develop wound dehiscence or undergo skin-edge necrosis, thus leaving unsightly scars. Likewise, wounds that are unevenly or improperly repaired, become infected, or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Traumatic wounds traditionally yield poorer eventual scars. Common etiologies of widened or dehisced scars include wounds closed under tension, repairs not formed parallel to relaxed skin tension lines (RSTLs), or wounds (...) realignment of the cutaneous landmarks may be performed on scars that are appropriately oriented in RSTLs. Z-plasty can be used to realign scars within RSTLs or correct any step-off deformity at the vermilion border. Scars crossing horizontally over the mentum generally follow RSTLs and therefore are best treated with a running W-plasty (see image below). Laterally based and more obliquely directed scars are good candidates for Z-plasty because the primary objective here is to redirect the scar

2014 eMedicine.com

108. Robotic and Laparoscopic Renal Surgery (Treatment)

are approximated manually. With the assistant approximating the edges of the parenchymal defect as depicted in image #5 above, close the defect over a Surgicel/Gelfoam roll to aid in parenchymal pressure and hemostasis. Two strips of Gelfoam wrapped in Surgicel can be used to bolster the renal capsule along the edges of the defect to reduce the risk of tearing. Lay the 2 strips along the length of the defect on each side. Pass several 2-0 polyglycolic acid horizontal mattress sutures through the renal capsule (...) , closure of the parenchyma with horizontal sutures over the length of the defect with fat or Oxycel or closure with Gelfoam and Surgicel bolsters) have been successfully used. These methods depend on the strength of the renal capsule. Use of Gore-Tex allows for even distribution of tension along the length of the closure. Small bleeding vessels are easily tamponaded. Gore-Tex also allows the surgeon to tie the sutures with the desired tension without risking tear of the kidney capsule, especially when

2014 eMedicine.com

109. Lip Reconstruction (Treatment)

polyglactin (Vicryl), braided polyglycolic acid (Dexon), or polydioxanone (PDS). Careful and meticulous reapproximation of the orbicularis oris is necessary to maintain competence of the oral sphincter. Third, the vermilion-cutaneous border should be realigned with an epidermal vertical mattress suture. Proper and exact restoration of this border is crucial for a good aesthetic outcome. Next, the dermis and subcutaneous tissue of the cutaneous lip is closed with absorbable sutures. Fourth, the surgeon (...) increased risk of infection. Therefore, the administration of antibiotics is indicated after lip surgery. Another consequence of the frequent motion of the lip is scar depression. To minimize this problem, the surgeon should aggressively evert and temporarily hyperevert the wound edges with subcutaneous sutures and epidermal vertical mattress sutures. Another common complication of lip surgery is hypertrophic scar formation, which should be detected early and treated with intralesional corticosteroids

2014 eMedicine.com

110. Upper Gastrointestinal Bleeding (Treatment)

is a horizontal mattress placed to control hemorrhage from the transverse pancreatic branch of the gastroduodenal artery. Failure to place this third stitch may result in recurrent bleeding that requires another emergent laparotomy of the abdomen. Vagotomy with antrectomy is reserved for patients whose conditions have failed to respond to more conservative attempts at surgical intervention and for those with aggressive and recurrent duodenal ulcer diathesis, such as gastric outlet obstruction. When performing (...) vagotomy 10 5 0.1 Truncal vagotomy and drainage 7 20-30 < 1 Truncal vagotomy and antrectomy Billroth I or Billroth II 1 30-50 0-5 Truncal vagotomy and antrectomy Roux-en-Y 5-10 50-60 0-5 The 3 most common operations performed for a bleeding duodenal ulcer are as follows [ ] : Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer Proximal (highly selective) gastric vagotomy with duodenostomy

2014 eMedicine.com

111. Superior Labrum Lesions (Treatment)

tears. [ ] The results of a prospective, double-blinded, randomized clinical trial suggest that patients who underwent repair of an isolated type II SLAP lesion through a single anterior portal realized similar clinical and functional outcomes whether a vertical or horizontal suture technique was used. Both techniques were shown to be comparably beneficial. [ ] Recently, the treatment of type SLAP lesions in conjunction with other intra- and extraarticular shoulder pathology has been studied (...) rotation, anterior-posterior translation, and inferior translation. After arthroscopic repair, total ROM, internal rotation, external rotation, and translation significantly decreased, returning to baseline values. Domb et al compared the biomechanical integrity of 3 commonly employed suture anchor configurations for the treatment of type II SLAP lesions [ ] : (1) single simple suture anterior to the biceps; (2) 2 simple sutures, 1 anterior and 1 posterior to the biceps; and (3) a single mattress

2014 eMedicine.com

112. Nasal Reconstruction (Overview)

include proper flap design, wide undermining to minimize wound-closure tension, meticulous hemostasis, delicate handling of tissue, and strict preservation of a highly vascular muscular flap base. Surgical attention should be directed toward the delicate handling of tissue and properly everting buried sutures, because incision lines on the nasal tip and alae are more visible than incision lines placed elsewhere on less sebaceous skin. Any flap should be carefully sized in both the horizontal dimension (...) not have any identifiable relaxed skin tension lines; therefore, closures in this area should be oriented vertically to prevent alar asymmetry. As with all linear closures on the nose, the tissue should be undermined at the level of the perichondrium. The wound is approximated by using buried vertical mattress sutures following meticulous hemostasis. Particular attention is paid to wound-edge eversion on the sebaceous areas of the nose, because surgical scars tend to invert in thickly skinned areas

2014 eMedicine.com

113. Surgical Treatment of Vulvar Cancer (Treatment)

is closed in layers with 2-0 polyglycolic absorbable suture, and the skin is closed with horizontal or vertical mattress sutures. The authors' preference is to use 3-0 polyglycolic acid for the mattress sutures and to reinforce the incision with a running 4-0 polyglycolic acid suture. The surgical defect is closed after a radical vulvectomy. (Photograph courtesy of Tom Wilson) Closure of a large single-incision radical vulvectomy. The complete wound breakdown rate from this procedure is often greater (...) free and remove the nodes from the medial portion of the femoral vein. After a deep groin node dissection, the sartorius muscle can be divided at its insertion on the anterior iliac spine and sutured to the inguinal ligament to cover the femoral vessels. Bring closed suction drains in through a separate incision and suture to the skin. Close Scarpa fascia with 3-0 absorbable sutures, and close the skin with mattress sutures or with staples. To initiate the radical vulvectomy, outline the lesion

2014 eMedicine.com

114. Scar Revision (Overview)

traumatized during closure may develop wound dehiscence or undergo skin-edge necrosis, thus leaving unsightly scars. Likewise, wounds that are unevenly or improperly repaired, become infected, or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Traumatic wounds traditionally yield poorer eventual scars. Common etiologies of widened or dehisced scars include wounds closed under tension, repairs not formed parallel to relaxed skin tension lines (RSTLs), or wounds (...) realignment of the cutaneous landmarks may be performed on scars that are appropriately oriented in RSTLs. Z-plasty can be used to realign scars within RSTLs or correct any step-off deformity at the vermilion border. Scars crossing horizontally over the mentum generally follow RSTLs and therefore are best treated with a running W-plasty (see image below). Laterally based and more obliquely directed scars are good candidates for Z-plasty because the primary objective here is to redirect the scar

2014 eMedicine.com

115. Laparoscopic Pelvic Lymph Node Dissection (Follow-up)

perforation can be minimized by limiting the use of electrocautery in the area of the intestine that needs mobilization in order to expose the pelvic lymph nodes. A short burst of electrical energy is sufficient to create a full-thickness injury to the bowel. In addition, abrasions that occur during mobilization of the colon should be covered using horizontal mattress sutures placed laparoscopically. [ ] By carefully identifying the obturator nerve (located in the posterior aspect of the dissection

2014 eMedicine.com

116. Lip Reconstruction (Follow-up)

polyglactin (Vicryl), braided polyglycolic acid (Dexon), or polydioxanone (PDS). Careful and meticulous reapproximation of the orbicularis oris is necessary to maintain competence of the oral sphincter. Third, the vermilion-cutaneous border should be realigned with an epidermal vertical mattress suture. Proper and exact restoration of this border is crucial for a good aesthetic outcome. Next, the dermis and subcutaneous tissue of the cutaneous lip is closed with absorbable sutures. Fourth, the surgeon (...) increased risk of infection. Therefore, the administration of antibiotics is indicated after lip surgery. Another consequence of the frequent motion of the lip is scar depression. To minimize this problem, the surgeon should aggressively evert and temporarily hyperevert the wound edges with subcutaneous sutures and epidermal vertical mattress sutures. Another common complication of lip surgery is hypertrophic scar formation, which should be detected early and treated with intralesional corticosteroids

2014 eMedicine.com

117. Scar Revision (Follow-up)

traumatized during closure may develop wound dehiscence or undergo skin-edge necrosis, thus leaving unsightly scars. Likewise, wounds that are unevenly or improperly repaired, become infected, or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Traumatic wounds traditionally yield poorer eventual scars. Common etiologies of widened or dehisced scars include wounds closed under tension, repairs not formed parallel to relaxed skin tension lines (RSTLs), or wounds (...) realignment of the cutaneous landmarks may be performed on scars that are appropriately oriented in RSTLs. Z-plasty can be used to realign scars within RSTLs or correct any step-off deformity at the vermilion border. Scars crossing horizontally over the mentum generally follow RSTLs and therefore are best treated with a running W-plasty (see image below). Laterally based and more obliquely directed scars are good candidates for Z-plasty because the primary objective here is to redirect the scar

2014 eMedicine.com

118. Robotic and Laparoscopic Renal Surgery (Follow-up)

are approximated manually. With the assistant approximating the edges of the parenchymal defect as depicted in image #5 above, close the defect over a Surgicel/Gelfoam roll to aid in parenchymal pressure and hemostasis. Two strips of Gelfoam wrapped in Surgicel can be used to bolster the renal capsule along the edges of the defect to reduce the risk of tearing. Lay the 2 strips along the length of the defect on each side. Pass several 2-0 polyglycolic acid horizontal mattress sutures through the renal capsule (...) , closure of the parenchyma with horizontal sutures over the length of the defect with fat or Oxycel or closure with Gelfoam and Surgicel bolsters) have been successfully used. These methods depend on the strength of the renal capsule. Use of Gore-Tex allows for even distribution of tension along the length of the closure. Small bleeding vessels are easily tamponaded. Gore-Tex also allows the surgeon to tie the sutures with the desired tension without risking tear of the kidney capsule, especially when

2014 eMedicine.com

119. Nephrectomy, Partial (Follow-up)

are approximated manually. With the assistant approximating the edges of the parenchymal defect as depicted in image #5 above, close the defect over a Surgicel/Gelfoam roll to aid in parenchymal pressure and hemostasis. Two strips of Gelfoam wrapped in Surgicel can be used to bolster the renal capsule along the edges of the defect to reduce the risk of tearing. Lay the 2 strips along the length of the defect on each side. Pass several 2-0 polyglycolic acid horizontal mattress sutures through the renal capsule (...) , closure of the parenchyma with horizontal sutures over the length of the defect with fat or Oxycel or closure with Gelfoam and Surgicel bolsters) have been successfully used. These methods depend on the strength of the renal capsule. Use of Gore-Tex allows for even distribution of tension along the length of the closure. Small bleeding vessels are easily tamponaded. Gore-Tex also allows the surgeon to tie the sutures with the desired tension without risking tear of the kidney capsule, especially when

2014 eMedicine.com

120. Nail Surgery (Follow-up)

, trimmed, and reattached to the nail bed and the LNFs by using horizontally placed mattress sutures. Stitches are removed in 10 days, when the nail is firmly adherent to the nail bed. Anesthesia is usually not required, but, when indicated, a digital block may be performed. Repair of simple lacerations Superficial lacerations that are limited to the nail plate and involve less than 3 mm of the nail bed usually heal independent of surgical repair as the injured nail grows out. [ , ] Larger lacerations (...) original anatomical site. Hemostasis is achieved with electrocoagulation, Monsel solution, or aluminum chloride solution. The wound may be allowed to heal by secondary intention. Alternatively, the wound may be closed by passing sutures through the nail plate and the LNF. When dressing the wound, the lateral nail groove is packed with iodoform or petroleum jelly gauze. A nonadherent dressing (eg, Telfa) is applied, followed by the placement of a bulky dressing or cling that is secured with elastic tape

2014 eMedicine.com

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