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Horizontal Mattress Suture

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141. Upper Gastrointestinal Bleeding: Surgical Perspective (Follow-up)

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 Surgery

142. Vertebral Fracture (Follow-up)

. For a posterior approach, place the patient in the prone position with either horizontal or flexed positioning at the hips. For a lateral approach, the surgeon can use either the prone position or a modified lateral decubitus position. For the ventral approach, position the patient supine. Ensure that the anesthesiologist has proper intravenous access and access to the extremities and chest for intraoperative monitoring. Exercise the usual precautions of positioning and avoidance of pressure on peripheral (...) thoracolumbar plating system has been used for the treatment of burst fractures. Surgery is performed for neurologic deficits, deformity, progressive kyphosis, and late pain. Ghanayem and Zdeblick reported good success with this form of anterior arthrodesis. Previous Next: Postoperative Details Postoperative care of the surgical incision The incision is usually closed in a layered fashion, and the skin is either stapled or sutured. A dressing is applied and taped in place. Some surgeons keep the dressing

2014 eMedicine Surgery

143. Diaphragmatic Hernias, Acquired (Treatment)

with monofilament permanent sutures. Small lacerations may be repaired by using interrupted, horizontal mattress, or figure-eight stitches; larger lacerations may be repaired with continuous or double-layered closures. Absorbable sutures are associated with a high rate of recurrence. [ ] There is some limited evidence to suggest that the use of biologic mesh in traumatic diaphragmatic repair may be feasible, at least in chronic cases. [ ] Laparoscopic abdominal exploration in the setting of trauma has become

2014 eMedicine Surgery

144. Epilepsy Surgery (Treatment)

the skin with a foreign body in place is difficult, and CSF leaks are not uncommon. Because of this, the dressing is changed as often as needed. Some authors suggest placing a cable-retaining suture in the scalp, [ , ] both to attempt to secure the electrode and to decrease CSF leakage. The lead author has not found this to be helpful in decreasing CSF leakage, and all electrode companies manufacture quick-release connectors designed to break apart easily if tugged. Patients are monitored (...) is determined based on data gathered during the preoperative evaluation; usually, a large craniotomy is performed to accommodate up to an 8 × 8-cm grid. Prophylactic antibiotics and dexamethasone are routinely administered. Mannitol is not used unless necessary, because the putative space created by a fluid shift could adversely contribute to hematoma formation after closure. Once placed, the grid is sutured to the dura to prevent motion. Often, 1 or more strip electrodes are added to sample adjacent areas

2014 eMedicine Surgery

145. Flexor Tendon Lacerations (Treatment)

MGH suture Indianapolis four-strand suture An eight-strand cross-locked cruciate repair using 4-0 caliber double-stranded suture has also been described. [ ] Peripheral tendon (epitendinous) suture techniques are as follows: Simple running suture [ ] Running lock loop suture (Lin) Cross-stitch epitendinous repair technique (Silfverskiold) Halsted continuous horizontal mattress suture (Wade) Horizontal mattress intrafiber suture (Mashadi and Amis) A dorsal splint is recommended to keep the wrist (...) The Indianapolis protocol is indicated for patients with four-strand Tajima and horizontal mattress repair with an additional peripheral epitendinous suture. Patients should be motivated and understanding. Digits should have minimal or moderate edema and minimal wound complications. Two splints are used, the traditional dorsal-blocking splint—with the wrist at 20-30° of flexion, MCP joints in 50° of flexion, and IP joints in neutral—and the Strickland tenodesis splint. The latter allows full wrist flexion

2014 eMedicine Surgery

146. Atrioventricular Septal Defect: Surgical Perspective (Follow-up)

and IBL. Place interrupted horizontal mattress sutures through the crest of the VSD patch and then the SBL and IBL (see the image below). Two-patch technique. Interrupted horizontal mattress sutures are placed through the crest of the ventricular septal defect (VSD) patch and the inferior and superior bridging leaflets, dividing the common atrioventricular (AV) valve into right and left components. Pass these same sutures through the edge of the autologous pericardial patch for the closure of the ASD (...) . A patch of polytetrafluoroethylene (Gore-Tex) is fashioned and secured along the crest of the ventricular septal defect. Two-patch technique. Interrupted horizontal mattress sutures are placed through the crest of the ventricular septal defect (VSD) patch and the inferior and superior bridging leaflets, dividing the common atrioventricular (AV) valve into right and left components. Two-patch technique. The pericardial patch is secured to the crest of the prosthetic ventricular septum with the superior

2014 eMedicine Pediatrics

147. Epilepsy Surgery (Overview)

the skin with a foreign body in place is difficult, and CSF leaks are not uncommon. Because of this, the dressing is changed as often as needed. Some authors suggest placing a cable-retaining suture in the scalp, [ , ] both to attempt to secure the electrode and to decrease CSF leakage. The lead author has not found this to be helpful in decreasing CSF leakage, and all electrode companies manufacture quick-release connectors designed to break apart easily if tugged. Patients are monitored (...) is determined based on data gathered during the preoperative evaluation; usually, a large craniotomy is performed to accommodate up to an 8 × 8-cm grid. Prophylactic antibiotics and dexamethasone are routinely administered. Mannitol is not used unless necessary, because the putative space created by a fluid shift could adversely contribute to hematoma formation after closure. Once placed, the grid is sutured to the dura to prevent motion. Often, 1 or more strip electrodes are added to sample adjacent areas

2014 eMedicine Surgery

148. Atrioventricular Septal Defect: Surgical Perspective (Diagnosis)

are identified and marked with fine polypropylene sutures. Two-patch technique. A patch of polytetrafluoroethylene (Gore-Tex) is fashioned and secured along the crest of the ventricular septal defect. Two-patch technique. Interrupted horizontal mattress sutures are placed through the crest of the ventricular septal defect (VSD) patch and the inferior and superior bridging leaflets, dividing the common atrioventricular (AV) valve into right and left components. Two-patch technique. The pericardial patch (...) . The LV outflow tract is elongated and horizontally oriented. According to Studer et al and Piccoli et al, although frequently narrow, the LV outflow tract causes obstruction in only 4-7% of individuals with AVSDs. [ , ] Ventricular balance Both left and right AV valves may equally share the common AV valve orifice. This arrangement is termed a balanced defect. Occasionally, the orifice may favor the right AV valve (right dominance) or the left AV valve (left dominance). In marked right dominance

2014 eMedicine Pediatrics

149. Vertebral Fracture (Treatment)

. For a posterior approach, place the patient in the prone position with either horizontal or flexed positioning at the hips. For a lateral approach, the surgeon can use either the prone position or a modified lateral decubitus position. For the ventral approach, position the patient supine. Ensure that the anesthesiologist has proper intravenous access and access to the extremities and chest for intraoperative monitoring. Exercise the usual precautions of positioning and avoidance of pressure on peripheral (...) thoracolumbar plating system has been used for the treatment of burst fractures. Surgery is performed for neurologic deficits, deformity, progressive kyphosis, and late pain. Ghanayem and Zdeblick reported good success with this form of anterior arthrodesis. Previous Next: Postoperative Details Postoperative care of the surgical incision The incision is usually closed in a layered fashion, and the skin is either stapled or sutured. A dressing is applied and taped in place. Some surgeons keep the dressing

2014 eMedicine Surgery

150. Upper Gastrointestinal Bleeding: Surgical Perspective (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 Surgery

151. Triangular Fibrocartilage Complex Injuries (Treatment)

to the dorsal radioulnar (DRU) ligament. Reflect the DRU ligament and the periosteum over the lunate fossa. Place horizontal mattress sutures in the TFCC through drill holes placed in the dorsoulnar aspect of the distal radius. Wrist arthroscopy Indications for wrist arthroscopy include acute unstable tears, acute tears that fail to respond to conservative management, and chronic tears for which conservative management fails. [ , , , ] General arthroscopic principles are as follows: Debride to a stable (...) in the triangular fibrocartilage of the wrist joint. J Anat . 1978 Jun. 126 (Pt 2):367-84. . Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex 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

2014 eMedicine Surgery

152. 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

153. 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

154. 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

155. 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

156. 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

157. Superior Labrum Lesions (Follow-up)

labral lesions. J Bone Joint Surg Am . Jun 2002. 84-A(6):981-5. . Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes. Am J Sports 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 (...) 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, III, MD Associate Professor, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College; Director, HSS Institute for Cartilage Repair Riley J Williams, III, MD is a member of the following medical societies: , , , Disclosure: Received royalty from Arthrex Inc

2014 eMedicine.com

158. 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

159. Upper Gastrointestinal Bleeding (Follow-up)

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

160. Ectropion (Follow-up)

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

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