Or use something else of a polymer ilk.
And of drains, there are plenty for blood or infection,
You'll find in the hospital a massive collection.
The only big choice is just when to use 'em,
And how to place 'em and not to abuse 'em.
The first question many of my patients have before elective or emergency surgery is: “Will there be a big scar?” It's almost as if it doesn't matter what goes on below the skin level.
Vanity, Vanity—the touchstone of humanity!
Well, let's move on. In the past one hundred years we have developed all kinds of suture materials, each with its own particular advantages and disadvantages. Some are nonabsorbable, like the old silk and wire to the newer Prolene, nylon, Nurolon, polypropylene, Ti-Cron, and other chemical polymers, while others are absorbable, which means they dissolve in the body's tissue anywhere from a few weeks to a few months after usage. Among the absorbable sutures are the old catgut, which comes in plain or chromated varieties, to the newer synthetic materials like polyglycolic acid (PDS) sutures and vicryl. Some sutures used on the skin have to be removed, while others used just under the skin in the subcuticular layer, are placed like hem stitches and never have to be removed; they eventually dissolve. Nowadays, the thread comes attached to the needle, and it's very rare that the nurse has to thread a needle for the surgeon. This saves time and, because the thread is amazingly fitted into the back end of the needle, the atraumatic needle, the hole made while suturing is exactly the diameter of the needle itself.
For suturing the fascia, the strong structure holding in your abdomen, and for suturing tendons and heavy structures, we use heavy suture material, whereas for delicate structures like facial skin, children's skin or blood vessels we use finer material that leaves less scarring. Sutures are graded numerically from the very thick #2 to the very fine, thinner than a human hair, 100 used for some types of eye surgery.
Using too weak a suture material may result in wound breakdown, and the surgeon must take the overall wound healing into consideration as we have discussed in Chapter 21. When an area is under tension, the sutures need to be left in longer; when there is no tension and a more plastic closure is desired, the sutures may be taken out earlier and replaced with paper strips called Steri-Strips to hold the wound together without leaving suture marks.
There are several types of wound closures as illustrated. Simple sutures are for the run of the mill closures, mattress sutures for coapting the skin edges a little more securely, and retention sutures for holding large areas together with huge sutures that can be loosened or tightened as needed. There are subcuticular sutures and Steri-Strips as mentioned above. In deep wounds, such as the abdominal wall, a layered closure is performed as shown in Diagram 3.
Now let's move on to drains. Why do we use them? The simple answer is just as it sounds, to drain something out of a wound, whether it is blood, serum from a seroma, bile, infection, pus, or the expectation that there will be an infection or pus. Examples are as follows: with a ruptured appendix, many surgeons will place a drain in the area of the rupture to drain off debris and infected material with the expectation that pus will form and need to get out of the body. With some extensive cancer surgeries, there may be large raw areas that may drain small but steady amounts of serum or blood for a short time. After certain plastic surgery, such as breast implants, reduction mammoplasties, or mastectomies, tube drains may be placed to assure an absolutely dry operative field and prevent formation of hematomas or seromas. These may be JacksonPratt drains, Davol sump drains, or Hemovacs. Sometimes, the surgeon will place a soft rubber drain called a Penrose in a wound or in the subcutaneous tissue to keep a wound open and allow infection to dissipate. Drains, if left long enough, will form a tract so that, when they are removed, an opening is still left through which fluids such as bile or pus can drain if needed. It usually takes about seven to ten days to form a tract, so that's how long we usually leave drains in an area of infection.
Sometimes a seroma, which is a collection of watery fluid or hematoma, may form several days after surgery, and a patient will need to have this aspirated with a needle and syringe. If the fluid collection recurs, then a drain can be placed under a local anesthetic. This can happen in areas such as the axilla or armpit after lymph node dissection, or after some big hernia operations, when artificial mesh is used to close a weak abdominal wall.
When drains, small or large, are removed, the surgeon will usually give the patient some pain medication before pulling the tube, although most times the procedure is almost painless.
Another method of closing skin or connective tissue is by the use of staples. These may vary tremendously in size and shape, but for the most part they look like staples in a paper stapler. They can be used for closing skin incisions, especially when infection is present and, generally, they leave a very clean incision.
Whereas years ago intestines had to be sewn together in two layers in a tedious procedure, today we have stapling apparatus that can connect one loop of intestine to another in less than a minute, and do so in a more exacting fashion than a surgeon could accomplish with a needle and thread. In laparoscopic surgery (see Chapter 15), special staplers have been devised to clip off blood vessels and the gall bladder duct, to amputate the appendix, and staple off the fallopian tube in a tubal ligation. Neurosurgeons use staplers to clamp off aneurysms in the brain, and general surgeons routinely use staplers to occlude blood vessels in many types of surgery, such as thyroid resections, hernias, liver and spleen surgery. There is even a special device that ligates or ties off, divides and staples tissue in one motion, called the LDS stapler. There are staplers that can connect two loops of colon together end-to-end and even connect blood vessels end-to-end.
The field of mechanization continues to improve each year and makes surgery safer, more rapid and less risky for the patient and the surgeon alike.
Chapter 25
LABORATORY VALUES
You may not want to be a number
But you are, ain't that a bummer.
And if you don't have pretty data,
Well, you're just a second rater!
Face it. We're just a large accumulation of chemicals. Suffice it to say the status of our bodies is often wrapped up in laboratory values, so you might as well know what the major ones stand for! It's not my intention to describe all the laboratory data, but rather to give you the most common ones and show how they reflect what's going on in your body. It may seem boring, but then give it a try. If you don't like it, go on to the next chapter!
First, there's the CBC or complete blood count. This includes the hemoglobin and hematocrit, which measure the amount of red blood cells (RBC's) in the bloodstream. These cells carry, among other things, oxygen to the cells to keep you alive. Normal values of hemoglobin (Hg) range from 1315 grams, and all these values will vary with sex, age, and body habitus; hematocrit (Hct) should be about three times the hemoglobin, or 39 to 45%. Lowered Hct and Hg will indicate acute or chronic blood loss or other conditions, including malnutrition, cancer, or deficiency in the bone marrow, where blood is made, or in the building products of blood, such as calcium (Ca). It is usually the first laboratory data your doctor looks at. The sedimentation rate of red cells (sed rate) is a vague estimation of disease, but can be used to monitor certain illnesses, recurrent disease, or responses to medications; it is normally in the range of 1020.
Included in the CBC is the WBC or white blood count, which is a measure of many different types of blood cells, as long as they're not red, including polys, monocytes, eosinophils, and basophils. The important thing is that, when there is an elevation of the WBC above the normal range of 3,0009,000, it may mean something's going on, such as infection or acute or chronic disease. Usually, the higher the WBC, the more serious the situation! As an example, in appendicitis the WBC may be anywhere from normal to 14,000 or more; with a ruptured appendicitis, where the appendix has burst and caused peritonitis and severe infection,