皮膚和皮下組織的縫合

1、1,骨科縫合技術(shù)基礎(chǔ)培訓(xùn)Basic Training on Orthopedic Suture Technique,中華醫(yī)學(xué)會骨科學(xué)分會創(chuàng)傷學(xué)組推薦醫(yī)師培訓(xùn)項(xiàng)目,,2,3,內(nèi)容概要,傷口愈合 縫合方法 開放傷口處理縫合小技巧皮瓣 縫線選擇,4,傷　口　愈　合,5,傷口愈合分期,炎癥期 0-7天,6,增生期 7-21天,傷口愈合分期,7,瘢痕成熟期 21天-1年,傷口愈合分期,8,各種組織自然愈合時間,9,傷口愈

2、合方式,10,影響傷口愈合的因素,年齡體重營養(yǎng)狀況脫水狀態(tài)血液供應(yīng)免疫反應(yīng)合并慢性疾病藥物或放射治療吸煙,11,組織張力強(qiáng)度變化曲線圖,縫合后組織張力強(qiáng)度最初為0，之后2周大約可恢復(fù)至正常強(qiáng)度的10%，1月后可恢復(fù)至正常的40%。10周后，組織張力強(qiáng)度為正常時的80%。,12,傷口愈合,上皮細(xì)胞是傷口愈合時唯一可再生的細(xì)胞，上皮再生在傷口閉合后隨即啟動。傷口閉合后不久，基底層細(xì)胞遷移到傷口／切口處真皮組織以閉合接近關(guān)閉

3、的傷口。,Hunt TK, Van Winkle W Jr. Normal repair. In: Hunt TK. Fundamentals of Wound Management. New York: Appleton Century Crofts, 1979.,13,傷口愈合評分Hollander Wound Evaluation Scale,無錯位（absence of stepoff)傷口對合不齊 (contour irr

4、egularities)傷口對合邊距超過2mm (wound margin separation greater than 2 mm)邊緣內(nèi)翻 (edge inversion)過分扭曲 (excessive distortion)整體美觀度 (overall cosmetic appearance )( 0-6 分，６分最佳),14,傷口愈合評分Modified Hollander Wound Evaluation Scal

5、e,Step-off bordersContour irregularitiesScar widthEdge inversionExcessive inflammationOverall cosmetic appearance of the wound( 0-6 score, 0 is the optimal),15,縫　合　方　法,16,傷口的解剖層次,17,疤痕美觀效果注意技術(shù)原則,縫合后傷口有稍許外翻縫線足夠緊張又不

6、能過緊如需深層縫合以減少皮膚張力，要埋結(jié),18,縫合方法,間斷縫合法優(yōu)點(diǎn)容易調(diào)節(jié)張力一個部位失效影響不大缺點(diǎn)需各個打結(jié)，操作時間長需更多縫線傷口內(nèi)異物更多,連續(xù)縫合法優(yōu)點(diǎn)操作時間縮短傷口內(nèi)異物較少缺點(diǎn)一個部位失效可影響全局調(diào)節(jié)張力不容易可能破壞血供更嚴(yán)重,,19,較深傷口的關(guān)閉----皮下縫合,20,較深傷口的關(guān)閉---皮下縫合,21,間斷縫合,22,垂直褥式縫合,23,水平褥式縫合,24,連續(xù)縫合

7、 　Baseball Stitch,1,25,連續(xù)縫合 　Baseball Stitch,26,連續(xù)鎖邊縫合 Running-Lock Closure,27,連續(xù)鎖邊縫合　Running-Lock Closure,28,連續(xù)鎖邊縫合　　Running-Lock Closure,29,連續(xù)皮內(nèi)縫合,30,連續(xù)皮內(nèi)縫合,31,開放傷口的處理,32,開放傷口處理原則,清創(chuàng)最重要關(guān)閉傷口方式依據(jù)傷口情況及術(shù)者經(jīng)驗(yàn)決定,33,小傷口處理,34

8、,傷口處理,盡力使疤痕順應(yīng)皮膚張力松弛線皮膚張力松弛線常與其下肌肉纖維長軸垂直,35,傷口處理,分層縫合保持皮緣外翻皮緣松松接觸,36,傷口處理,張力過大有可能組織壞死,37,傷口處理,傷口雙側(cè)縫合組織深度應(yīng)一致以防皮緣重疊,38,傷口處理,簡單間斷縫合：注意避免內(nèi)翻,垂直褥式縫合：可能疤痕較大,皮內(nèi)縫合,39,傷口處理,水平褥式縫合外翻皮緣可能影響皮緣血運(yùn),40,“狗耳朵”的處理,41,復(fù)雜傷口處理,42,復(fù)雜傷口處理

9、,縫合方式一,43,復(fù)雜傷口處理,縫合方式二,44,不規(guī)則傷口處理,45,縫合小技巧,46,不扯斷縫合線情況下破壞縫線材料的記憶性,Prolene等具有相當(dāng)強(qiáng)的記憶性，可能影響縫合打結(jié)的牢固度。正確方法：,47,不扯斷縫合線情況下破壞縫線材料的記憶性,不正確方法,針線因牽拉離斷,用持針器持捏縫針,用手指持捏縫針,48,三角縫合法,尖端不恰當(dāng)縫合會導(dǎo)致尖端壞死,縫合不恰當(dāng)，使得尖端對位出現(xiàn)間隙進(jìn)而造成尖端缺血性壞死,縫合入針點(diǎn)距離尖端

10、過近,49,三角縫合法,正確縫合方法,50,三角縫合法,正確縫合方法縫合入位對合整齊,51,小切口的延遲閉合縫合,所有內(nèi)縫線固定位置后，從兩端向中間打結(jié),52,穿皮垂直褥式縫合,適于小而深的切口,53,止血的輔助手段— 連續(xù)鎖邊縫合,由于壓力效果很好，要注意避免縫合過緊，防止出現(xiàn)組織絞窄壞死。不可用于血供少的部位。,54,連續(xù)混合褥式縫合,保證最大限度的皮緣外翻,55,連續(xù)混合褥式縫合,保證最大限度的皮緣外翻,56,斜位縫合,改變

11、張力方向,閉合鼻唇溝缺損會使嘴角翹起,水平調(diào)整張力方向則無此問題,57,斜位縫合,改變張力方向,58,Mercedes 皮瓣大面積缺損的多皮瓣閉合,設(shè)計(jì)了三個三角,縫合三角形每條底邊與缺損的切點(diǎn)，部分閉合切口,適用于頭皮、軀干、四肢等,59,Mercedes 皮瓣大面積缺損的多皮瓣閉合,缺損的進(jìn)一步閉合,采用內(nèi)縫合閉合,適用于頭皮、軀干、四肢等,60,皮　　瓣,61,Fusiform ( Eliptical) Excision,62

12、,Dog Ear,63,Advancement Flap,64,Rotation Flap,65,Z-Plasty,66,Note Flap,67,Bilobe Flap,68,Rhombic Flap,69,縫 線 選 擇,70,Suture Classification,Natural or Synthetic (man made)Monofilament or Multifilament (braided) Abs

13、orbable or Non-Absorbable,71,The Ideal Suture,Minimal tissue reactionSmoothness - minimum tissue dragLow CapillarityMax tensile strengthEase of handling - Minimum memory Knot securityConsistency of performancePre

14、dictable performanceCost effectiveness,72,Multifilament (braided),Suture Classification,Monofilament,73,Braided v Monofilament,Has capillary actionIncreased infection riskLess smooth passageLess tensile streng

15、thBetter handlingBetter knot security,No capillary actionLess infection riskSmooth tissue passageHigher tensile strengthHas memoryMore throws required,74,These are absorbed within the living tissue Two main chara

16、cteristics are:Tensile strength retention Absorption rate,Absorbable Sutures,Maxon: Day 14: 75% Absorption: 180 daysCaprosyn: Day 10: 30% Absorption: 56 days,75,Characteristics of Non-Absorbable Sutures,Perma

17、nentOnly used when long term support is requiredRemoved 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 timeT

18、rue non-absorbable sutures include polyester, polyethylene, polybutester, polypropylene and steel,76,可吸收縫線,77,不可吸收縫線,78,縫合線— 規(guī)格與張力強(qiáng)度,79,80,A Comparison of Three Methods of Wound Closure Following ArthroplastyA Prospecti

19、ve, 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,Kha

20、n,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, R

21、andomised, Controlled trial,83,A Comparison of Three Methods of Wound Closure Following ArthroplastyA Prospective, Randomised, Controlled trial,We consider that skin staples are the skin closure of choice for both hip a