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Horizontal Mattress Suture

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101. 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

102. 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

103. 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

104. 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

105. 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

106. 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

107. Laparoscopic Pelvic Lymph Node Dissection (Overview)

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

108. 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

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. Scalp Reconstruction (Overview)

in a subcuticular manner to create a classic purse-string closure. An additional epidermal running horizontal mattress suture is then placed to minimize the defect and provide extended wound strength. This technique can be useful in larger defects of the scalp. [ ] Side-to-side closure See the list below: Advantages and disadvantages Side-to-side closure is often the preferred method to repair a scalp wound for a number of reasons. The healed wound has the potential to be cosmetically elegant, the repair (...) sutures. These buried sutures should be placed as subcutaneous buried vertical mattresses to maximize wound eversion. A large-caliber monofilament or braided suture such as 4-0 nylon or silk is recommended for the layer of cutaneous sutures. Interrupted cutaneous sutures allow for more precise wound apposition and eversion. Cutaneous vertical mattress sutures should be used as needed for maximal wound support and eversion. Wound care should consist of the application of a pressure dressing for 24

2014 eMedicine.com

111. 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

112. Craniofacial, Bilateral Cleft Nasal Repair

to expose the genu of the LLC, but later found that incision was unnecessary, as the LLCs could be approached through rim incisions. [ ] He now advocates bilateral vestibular rim incisions and alar base incisions. The LLCs are freed on their anterior surfaces through the nasal incisions. He then elevates and sutures the genu of the LLCs together. The lateral portion of each dome is suspended to the ipsilateral ULC near the septum. The freed alar bases are held to the prolabium medially via a mattress (...) in the cleft margin. The soft tissue between the domes is removed, and the domes are then sutured together. The nasal flap is closed in a V-Y advancement, lengthening the columella by approximately 5 mm. Mattress sutures over bolsters are placed to eliminate any dead space in the tip. At the second stage, 1 month later, the prolabium is lifted and mucosalmuscular flaps are sutured behind it, completing the lip repair. [ , ] Salyer Salyer performs his lip repair procedure, along with a limited nasal repair

2014 eMedicine Surgery

113. Craniofacial, Cleft Palate

posteriorly based flap is then elevated. The palatal muscles are detached from the hard palate. The eustachian tube orifice is identified. The nasal mucosal incision is made, leaving a free edge in the nasal mucosa. The palatal aponeurosis is divided, exposing the flap's palatal muscle for separation from the superior constrictor fibers lateral to it. Closure of the nasal side is then begun with 4-0 Vicryl, suturing the uvular tags with horizontal mattress sutures to minimize notching of the uvula (...) the palatal muscle flank. The anteriorly based flap on the right side is then brought across the cleft. The flap is somewhat difficult to mobilize adequately, and a small back-cut from its lateral end medially around the posterior margin of the alveolus improves mobility and facilitates dissection around the greater palatine vessels. Horizontal mattress sutures are then used to evert the stiff mucoperiosteum on the hard palate for closure. The closure is carried to the back of the mucoperiosteal incision

2014 eMedicine Surgery

114. Facelift, Mid Face

the cavity with saline and then with antibiotic-containing solution. The V-shaped incisions are advanced superiorly and closed in a "Y" configuration. The authors use 4-0 chromic horizontal mattress sutures. This has the effect of everting the wound edges, creating a valve system and decreasing the probability of saliva entering within the wound. Fat grafting is often used to augment facial volume or to correct asymmetry. A study by Stevens et al described the successful use of a triple-layer mid face (...) have eliminated the need to perform any periocular incision. The periosteum is raised over the entire anterior malar area and the anterior two thirds of the zygomatic arch. Tunnels are made over the zygomatic arch, and independent suture suspension of the SOOF, inferior malar soft tissues, and Bichat fat pad is performed. Next: Indications Mid face lifting has the following aesthetic and reconstructive applications: Reversal of aging changes Increasing the anteroposterior cheek dimensions

2014 eMedicine Surgery

115. Abdominal Wall Reconstruction

, which also inserts on the pubic crest. Transversus abdominis The transversus abdominis muscle is the innermost of the 3 flat abdominal muscles. The fibers of the transversus abdominis course predominantly in a horizontal orientation. It has 2 fleshy origins and 1 aponeurotic origin. The first fleshy origin is from the anterior three fourths of the iliac crest and lateral third of the inguinal ligament, while the second origin is from the inner surface of the lower 6 costal cartilages where (...) , Matthews BD, Brunt LM. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc . 2007 Mar. 21(3):378-86. . Vorst AL, Kaoutzanis C, Carbonell AM, Franz MG. Evolution and advances in laparoscopic ventral and incisional hernia repair. World J Gastrointest Surg . 2015 Nov 27. 7 (11):293-305. . . Hamilton JE. The repair of large or difficult hernias with mattressed onlay grafts of fascia lata: a 21-year experience. Ann Surg . 1968 Jan. 167(1):85-90

2014 eMedicine Surgery

116. Blepharoplasty, Lower Lid Ectropion Surgery

for correction of ectropion in facial paralysis. Plast Reconstr Surg . 2005 Jan. 115(1):234-9. . Media Gallery Ectropion with keratinization of the lower lid. The snap-back test. Lower lid laxity obvious after snap-back test. Preparing the lateral tarsal strip. The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion. The suture is tied to the periosteum of the lateral orbital rim and tightened. of 6 Tables Contributor Information and Disclosures Author Mounir Bashour, MD, PhD (...) , tarsal, congenital, or neurogenic/paralytic. Surgical approaches are directed toward the underlying etiologic factors. Next: Problem Ectropion is an outward turning of the eyelid margin and occurs most often in the lower eyelid. It may be mild or severe and may involve all or part of the eyelid margin. See the image below. Ectropion with keratinization of the lower lid. Previous Next: Etiology Ectropion is most commonly seen as an involutional change associated with horizontal laxity of the involved

2014 eMedicine Surgery

117. Triangular Fibrocartilage Complex Injuries (Overview)

with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg . 2004 Jun. 8 (2):116-23. . Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res . 1984 Jul-Aug. 26-35. . Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg Am . 1993 Mar. 18 (2):334-40. . Tang JB, Ryu J, Kish V. The triangular fibrocartilage complex: an important component of the pulley for the ulnar wrist extensor. J (...) that the percentage of axial force transmitted through the ulna decreases by sequential removal of the horizontal portion of the TFCC. [ ] This percentage decrease is accentuated with more positive ulnar variance. In a cadaver study, Adams demonstrated that no significant kinematic or structural changes resulted from an excision that did not violate the peripheral 2 mm of the disk and that constituted less than two thirds of the disk area. [ ] TFCC tears are associated with a positive ulnar variance. Ulnar

2014 eMedicine Surgery

118. Ebstein Malformation: Surgical Perspective (Diagnosis)

demonstrates cardiomegaly, with evidence of severe right atrial enlargement. Surgical repair of Ebstein anomaly as described by Danielson. (A) The right atrium is incised and reduced, and the atrial septal defect is closed with a patch. The arrow identifies the large anterior leaflet. (B) Mattress sutures with felt pledgets are used to pull the tricuspid annulus and valve together in a horizontal plane, obliterating the atrialized right ventricle. (C) Sutures are tied after all have been inserted (...) . The arrow identifies the septal leaflet. (D) A posterior annuloplasty is used to narrow the orifice of the tricuspid annulus. (E) Completed repair, resulting in a competent tricuspid valve. Surgical repair of Ebstein anomaly as described by Carpentier. The anterior and posterior leaflets are detached from the tricuspid annulus. In type D lesions, fenestrations are used to create interchordal spaces for the passage of blood into the right ventricle outflow tract (insert). Mattress sutures with pledgets

2014 eMedicine Pediatrics

119. Posterior Glenohumeral Instability (Treatment)

described the reverse Bankart procedure in two patients, using drill holes placed through the glenoid rim to the medial bone and then securing the capsular flap with mattress sutures. [ ] In both of the cases described, the patient regained normal function. Reverse Putti-Platt repair The reverse Putti-Platt procedure was originally described by Severin, [ ] who shortened the infraspinatus only, and DePalma, [ ] who shortened the infraspinatus and the teres minor together. A subsequent report (...) the deltoid in line with its fibers, followed by dissection of the infraspinatus/teres minor interval. A horizontal incision is then made in the capsule to expose the joint. A Fukuda retractor is inserted to retract the humeral head and expose the posterior glenoid rim. Suture anchors are inserted into the glenoid rim. The sutures are used to perform the capsulorrhaphy and are then tied. Completion of the procedure demonstrates significant reduction of the posterior capsular redundancy. Posterior

2014 eMedicine Surgery

120. Lisfranc Fracture Dislocation (Treatment)

and the Lisfranc screw. Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin. Plate fixation The approach and initial fracture reduction for plate fixation are similar to those for screw fixation. Once the reduction has been achieved, the dorsal plate can be applied. Typically, this procedure is used for comminuted (...) that bioabsorbable screws are safe and that they eliminate the need for screw removal. Larger studies with long-term follow-up are needed to determine the true efficacy. [ ] Suture button fixation Several papers have addressed the use of suture button fixation in Lisfranc injuries with the hope of allowing some physiologic motion and to avoid putting screws across the articular cartilage of the first cuneiform and the second MT. Ahmed et al [ ] did a cadaveric study that showed more displacement with suture

2014 eMedicine Surgery

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