* Materials and Methods
* Presentation of products
* Control group
* Experimental group
* Presentation of results and discussion
* Results stapler use in the closure of dermal skin
* Results Mononylon (R) suture using 3-0 in the closing of skin
The biological characteristics of the repair has historical roots in the earliest known medical writings deal extensively with the wound care, the physicians of ancient Egypt, Greece, India and Europe created appropriate methods to address them and felt the need to remove foreign bodies, cover them with material and employ the use of sutures, techniques that over the decades have been evolving.
The purpose of this study was to compare the level of effectiveness of two suture materials for skin after ovariohysterectomy surgery Mononylon (R) suture 3-0 and dermal stapler.
For this, use was evaluated in thirty canine undergoing ovariohysterectomy, measuring the reduction of the lesions treated and the level of healing through the observation of the development parameters as scab, scar whitening, granulation tissue formation and reduction of wound size over time.
The results showed a favorable outcome in patients after suture both materials. However, it was in the experimental group using dermal stapler where there was a more pronounced reduction of wound size after the first week of treatment and less healing time than in the control group which was sutured with sutures Mononylon (R) 3-0.
Keywords: Dermal Stapler – Disposable suture stapler.
The Biological Characteristics of the repair have historical roots, in the first Known medical writings; They deal Extensively With The care of the wound. The former doctors in Egypt, Greece, India and Europe created Appropriate methods for treating them and warned about the need to remove foreign bodies, cover them with material and use sutures, techniques That With The passage of Decades have evolved.
The purpose of this study was to compare the performance of two “skin suture” products after surgery, “ovariohysterectomy monofilament suture 3-0” and “dermal stapler”.
For That purpose, its use was in thirty canines EVALUATED submitted to “ovariohysterectomy”, measuring the reduction of lesions treated, and the level of healing through the observation of parameters Such as the development of crust, whitening of the scar, granulation tissue formation and reduction in the size of the wound in time.
The results Obtained favourable Showed to evolution in patients after suture, with Both products. However, was in the use of experimental Group with dermal stapler, where there was a more noticeable reduction in the size of the wound from the first week of treatment, and to Shorter time of healing than in the Control group Which was sutured with “suture monofilament absorbable 3-0 “.
Key words: Dermal stapler – Disposable suture stapler for.
The response of living tissue to injury is the basis and foundation of surgical practice. From a biological standpoint, tissue injury and its aftermath involved in most of the general medical problems (Rivera, 2006).
The biological characteristics of the repair has historical roots in the earliest known medical writings deal extensively with the wound care, the physicians of ancient Egypt, Greece, India and Europe created appropriate methods to address them and felt the need to remove foreign bodies, cover them with material and employ the use of sutures, techniques that over the decades have evolved (Rivera, 2002).
The wound healing is a basic response to living life and generally produces satisfactory restoration of tissue integrity (Rivera, 2002).
A mid-sixteenth century French surgeon Ambroise Par noted that minimize tissue damage allowing faster healing and effective (Rivera, 2002).
The wound is the area where the continuity is interrupted understood cellular anatomical continuity solution external body coverings, mucous coating or surface of organs (Rivera, 2006).
The curable injured tissue regeneration, repair or a combination of both. Tissue regeneration is the replacement of damaged or lost tissue with tissue structurally and functionally similar. Tissue repair is a defense mechanism that protects the vascular integrity after the production of tissue damage (Pope, 1996).r> All wounds or skin incisions, are closed with sutures or handled as open wounds, undergo the same sequence of chemical events and cellular healing observed in other tissues. The initial inflammatory response is followed by repair processes and finally ripening remodeling or tissue scarring (Pope, 1996).
As compared to surgical incisions should seek to minimize the damage by appropriate use of sutures, in this case was evaluated wound healing product ovariohysterectomy those having a size of between 8 -10 cm long. using the skin stapler which provides stainless steel brackets points with dimensions of 6.9 mm wide and 3.6 mm high, which ensures a reduction in the post-surgical recovery to make better apposition of the anatomical Injured edges, a tighter seal, provides the necessary tension to depth and the thickness of the skin, are U-shaped staples and closed after firing form B obtained, which ensures the synthesis and hemostasis, tissue without isquemizar not make full contact with the dorsal edge of the wound which reduces the risk of infections (Inurrieta, 2004).
Contemporary surgery has been very pleased to get innovation and refinement of existing mechanical sutures, new designs created by the availability of moldable plastics, light metals and make tough in today we have a wide range of products and alternatives to surgery (Bazurto and Tejada, 2005).
The basic principles of the design of these instruments are still valid since they were established and implemented in 1908 by Hult and Fisher, who designed to work in two stages. First tissues were subjected to immobilization and understanding in a second application of the staples (Bazurto and Tejada, 2005).
It is only by the sixties appearing earlier generations of mechanical sutures in the United States, of better quality and accuracy, staple cartridges and rechargeable anvils, until today which are disposable (Bazurto and Tejada, 2005 ).
Materials and Methods
For this study 30 patients were chosen dog (Canis family), with an average age between two and four years, undergoing ovariohysterectomy, which were divided into a control group of 15 individuals with monofilament suture stitched leather and a group 15 individuals experimental sutured with dermal skin stapler, which measured the size of the wound.
For suturing of skin ovariohistectomia used in female dogs skin stapler Manipler AZ, acquired Braun Medical, for the experimental group, in its turn the other product used was 3-0 nonabsorbable monofilament suture provided by the veterinary clinic.
Presentation of products
For the suture of wounds by ovariohysterectomy was divided into two groups randomly. They called two groups as follows:
Control Group 1: 3-0 Suture mononylon
Experimental Group 2: dermal stapler Manipler AZ (R)
To conduct the study and achieve the goals set by measuring the effectiveness of dermal stapler, studied female canine patients admitted to the Veterinary Clinic Full Animals, the selection criteria of these patients were presenting an average age between two and four years, race mestizos, who have not received other topical or oral treatments for a specific pathology, body condition 3 which is ideal to face a proper surgical procedure, thus avoiding the presentation of obese patients, debilitated or malnourished that could generate various alterations deterioration such as immunocompetence, inefficient healing, anemia, hypoproteinemia and reduced resistance to infection (Fossum, 2004). Once this evaluation by the treating physician were subjected to a fasting period of 12 hrs. maximum to avoid the presence of functional impairment as a result of hypoglycaemia. And with the intention to reduce the volume and acidity of gastric contents in order to reduce the risk of regurgitation and aspiration of these during surgery (Brady, Kinn et al, 2005).
Was performed to close skin Mononylon (R) suture horizontal mattress 3-0 point atraumatic needle, approximating the anatomical planes without generating tension.
Then he proceeded to clean postsurgical dressing sterile gauze over sodium chloride 0.9% warm, not to cause vasoconstriction in the area and interfere with the natural mechanisms of hemostasis, inflammation, scarring and more. The use of hot tap water is efficient, but it causes some tissue damage hypotonic thus discarded (Fossum, 2004).
The solution of 3% chlorhexidine is frequently used for washing wounds due to its broad spectrum of antimicrobial activity against spore and vegetative bacteria, fungi, protozoa and yeast (Fossum, 2004). In this study we used the povidone-iodine solution, and that damages the tissues to be cytotoxic to fibroblasts, and possible hypersensitivity reactions (Fossum, 2004). That may have altered the final evaluation.
Neither hydrogen peroxide used, even in small concentrations, because it is injured tissue and inadequate antiseptic being very harmful for neutrophils, fibroblasts and endothelial cells, therefore, should not be used as never solution for washing wounds (Fossum, 2004).
Suture of skin Fig. Mononylon (R) 3-0, point horizontal mattress
For the closure of dermal skin stapler was used Manipler AZ (R), which provides points of stainless steel of 6.9 mm width and 3.6 mm in height with distance from each other of approximately 5 mm.
Suture of skin Fig. dermal stapler
In both cases, after surgery and completed the cleaning step, we proceeded to measure the length of the wound in centimeters with a ruler (precision instrument for measuring injuries in different stages of healing) and entered the dermatological data to the card, leaving owners indications patients for wound care. Then the respective photographs were taken giving rise to day 1 of treatment.
The owner of each patient was given instructions personally on postoperative care of the wound and control days thus requesting their cooperation in this investigation. In order to obtain minimum error in the survey results. The contents of the following indications were both groups:
Your pet should wear the Elizabethan collar size indicated by the size of your pet, up to extraction points.
Avoid sudden exercise, jumping obstacles and climbing stairs
Perform healings sterile gauze dressing with saline only at temperature of 25 C. twice daily to the point of withdrawal.
Verify the presence of tolerance and adverse reactions in the wound.
Control at day 10 and 15 after surgery
All ratings were performed by a veterinarian in conjunction with the student thesis student, entering photography and respective controls in a table changes, thus ensuring homogeneity on clinical judgment.
PRESENTATION OF RESULTS AND DISCUSSION
An analysis of macroscopic and photo evolution of surgical wounds caused by ovariohysterectomy.
These wounds were observed over a range for this 15-day study, because in this period begins the long process of bleaching, corresponding to increased collagen deposition within the scar and regression of vascular channels, establishing controls on days 1, 10 and 15 postoperative.
The incisions were performed on these patients were sutured under aseptic conditions, representing an ideal environment for wound healing analyze closed, always with the idea of achieving complete hemostasis and tissue levels achieve precise anatomic apposition with suture material unresponsive, under proper aseptic to exist few bacteria and devitalized tissue, to make the inflammatory reaction and sent quickly thus giving favorable conditions to begin tissue repair. Surgical wounds under these conditions are called primary or healing by first intention, because the only incision causes a focal interruption of the continuity of epithelial basement membrane and death of a relatively small number of epithelial cells and tissue.
The first evaluation was performed surgical lesions was postoperative day 10. While healing begins immediately after the occurrence of the incision, the first 3 to 5 days is the process lag phase scar because inflammation mechanisms predominate and debridement as described by Fossum, surgical wounds, which were sutured good apposition between the edges, with minimum trauma and under aseptic conditions, showed no defect to be filled in by granulation tissue and thus healed by primary intention appropriately.
Results of using the stapler dermal skin closure
As evaluated after studying the healing of surgical wounds by ovariohysterectomy, there was evidence of trauma recovery on the eighth day after surgery, as in the photographs was observed in the absence of cutaneous vitality presenting bleeding, oozing pus or infection, kept a clean wound and no odor, is presented a suitable tissue viability.
After the eighth day, the wounds of the patients were in the maturation phase, as noted in the surgical incision line a bleaching product collagen deposition took scar as a white, hard consistency and appearance flattened. According to what described Fossum (2004), Scott et al (2002) and Cotran (2004) respectively, the number of capillaries in the tissue decreases causing will pale scar and into the maturation stage. According to these authors, this phase should occur in the second week post injury, but in the cases analyzed after application of staples, this happened on the eighth day. It is therefore achieved the objective of accelerating healing in the experimental group using skin stapler.
This information is corroborated Inurrieta (2004), noting that the use of this stapler for making a tighter seal, which resulted in a better anatomical apposition to face to better lesion edges, performs a proper synthesis and hemostasis without isquemizar tissues thereby increasing faster postoperative recovery.
Based on this and according to the established control day in the 10 day postoperative observation was noted that the wound was completely closed and some brackets were embedded by a tissue eversion epithelial maturation product of wound healing and which difficult to extract points with scissors extractor causing pain and skin irritation certain area, scissors hood serves not because it does not have a convenient way to perform the extraction and lacks the required quality because they do not take breaks good contact with the bracket to exert adequate pressure and cut in order to remove the staples then made use of hemostat which by rotational movements extraction was achieved also creating less trauma to the proceedings, on the basis of this observation in different patients it was established that the ideal time for removal of stitches is eight days after surgery, the wounds sustained eighth day before a type of eversion in the points was due to inadequate patient rest and exercise contraindicated as climbing stairs evil product care from the owners and the staples in not taking full contact with the dorsal edge of the wound are loose predisposed to be engaged with various objects.
Another important aspect is that the injury presented over time normally pale pink coloration caused by neovascularization at its best which agrees with the points made by Cotran (2004), describing the healing of wounds.
It is also noted that due to the aforementioned characteristics and also have a uniform tension in each staple firing, the tissue was not required to improper tension whereby besides reducing the healing time and the degree of tissue formation granulation was shown anatomical recovery and restoration of the epithelial surface incision almost disappearing, noting in this group (experimental) for controlling postoperative day 10 the wound length decreased by 40% and 15 in one day 56.4%.
Results Mononylon (R) suture using 3-0 in the closing of skin
The monofilament suture in skin closure has been used for years in surgery giving great benefits for their above characteristics within these one of the most important is that its structure is less hair, have less rolling resistance and lack insterticio to harbor microorganisms, but in comparison with the skin stapler is slower healing can remove points from day 10 onward where in addition to the control we observed that in this day the wound length decreased by 40% as in otherwise the experimental group at the end of the period that the reduction rate for this group was 7.0% compared with the initial measurement of the wound, which was varied if the degree of crusting and maturity evidencing wound in a good recovery but not translated into a reduction in size, this type of suture through higher risk of necrosis produce inhomogeneous strain performed at each point, as compared to the stapler can generate handsewn hematomas or seromas more frequently because many times there is no adequate approximation of the edges injured, at this point mention the aesthetics of the wound is not easily concealed by generating a thicker scar.
The decrease in wound size was greater in the experimental group using the stapler which is that there is a better anatomical apposition, reaffirming Ambroise Par, minimizing tissue damage allowing faster healing and effective, a most secure closure and seal epithelial favoring the synthesis and hemostasis without isquemizar tissues, which did decrease the healing time and reduction of the wound.
At the end of treatment (day 15), followed wounds normal course of maturation, and wound evidence drier, less vascularization present due to scar tissue in wounds that are formed from a cellular tissue covered by an epidermis observed practically normal since the eighth day post-surgery, with great reduction in their initial length of the wound without scab formation in any of these test cases, recovering the destroyed tissue in the line of incision.
According to the results obtained by statistical methods, using T-Student. Healing and wound reduction is shorter and efficient stapling use through the skin stapler which is significantly higher than the results obtained with Mononylon (R) 3-0 sutures.
It is important to note that in the experimental group the largest percentage reduction in wound could be observed in the patient princess with 66.7% in the control group and the patient Daisy with a 33.3% reduction in the rate of reduction lower wound in the experimental group was Maria Fernanda with a 40% reduction in the control group and Erna with 0% reduction, perhaps there could be an influence of age because the biggest percentage reduction in wound described in the younger patients, but greater emphasis on age is assigned to the fact that in the case of the experimental group there was a better and more precise anatomical apposition of the tissues, providing a better synthesis and hemostasis which agrees with results reported by authors as Pope (1996) and Inurrieta (2004), resulting in faster healing time and a considerable reduction in its length.
In the group of patients studied did not appear injured with some kind of adverse reaction, infection, itching or intolerance to sutures. All these records were obtained in controls (days 10 and 15 of treatment) and as described by the owners of the patients at the time of the visits.
It should be noted that none of the patients underwent a process of wound infection, which ensured that there was no bacterial contamination that may have damaged the scarring process. What if the patient was observed in the experimental group named Mia, an injured tissue eversion inlaid with two staples because up and down stairs which occurred when removing pain points and an anatomical alteration but did not alter the length of nor his healing wound, only an aesthetic alteration was observed in this area. For both studies whether the experimental and control dermal stapler suture Mononylon (R) 3-0 points extraction was performed after examining the lesions in both groups. Then he took the respective photograph and proceeded to extract these. This was done at day 10 for the experimental group may withdraw postoperative day 8. And on day 15 with Mononylon (R) points 3-0 and that although wounds with the application of these sutures were scar maturation phase, the tissue has not developed a resistance withdrawn if any significant stress before, which is dependent on the sealing material to maintain proper alignment.
* The use of skin stapler for closing wounds in skin ovariohysterectomy, accelerated skin regeneration zone and allowed healing occurs early, besides reducing the size of the wounds significantly, at least for a minimum period of 15 days. And your average reduction was 56.4% versus 7.0% in the control group.
* By using the T-Student as statistical method was found that the stapler is more effective in dermal wound healing by ovariohysterectomy with respect to suturing Mononylon (R) 3-0 (see Annex II. Statistical Analysis).
* Both suture materials used in this study showed that its use allows for adequate healing without adverse reactions or intolerances by the patient to respect the times, but the material used in the experimental group is more effective in healing the tissue submitted granulating earlier in time also generating a greater reduction of wound.
* Both the experimental and control the largest percentage reduction in wound were observed in relatively young patients, while the percentage reduction in wound lower in both groups as were the older patients, obtaining greater reduction always in the experimental group treated.
Alvarez and Garcia, Section 5, Recipe Veterinary Handbook, first edition, 2002, p. 153-156
William and Linda BACHA BACHA, Chap.12, Color Atlas of Veterinary Histology, first edition, 1990, p. 87, 88
COTRAN, R., KUMAR, V., Collins, T., 2004, Structural and Functional Pathology, sixth edition, Madrid Spain, McGraw-Hill. 1475p.
D.C. BLOOD, Veterinary Dictionary, first edition, 1993, McGraw-Hill, p. 196, 522-523
DE LOS REYES SANCHEZ Monica, Cap. 2, Topics in reproduction in small animals, first edition, 2000, p. 29, 30
Fossum, THERESA WELCH, 2004. Integumentary System Surgery In his: Small Animal Surgery. Second Edition. Buenos Aires Argentina. Editorial Intermdica, 45-56, 73-75,103-106, 140-152, 163-164, 658-660P.
GARTNER, LESLIE.; HIATT, J. 2002. Text histology. Second Edition, Mexico DF. Editorial Mc Graw Hill. 311 – 318p.
Kolata, RONALD J, 1996. Cap. 2, Mechanisms and effects of trauma on: BOJRAB, JOSEPH. Pathophysiology and clinical surgery in small animals. Second Edition. Buenos Aires, Argentina. Editorial Intermdica. 8-11pp.
MERTON, DAWN, BOOTHE.; HARRY. 1996. Cap. 25. Skin In: BOJRAB, JOSEPH. Pathophysiology and clinical surgery in small animals. Second Edition. Buenos Aires, Argentina. Editorial Intermdica.11p.
KIRK MULLER & S (Scott, Danny W., Miller, William T., Griffin, Craig E.). Small Animal Dermatology, Editorial Intermdica, sixth edition, 2002, p. 1-2.
OTERO, Paul E. Anesthesiology in small animals. Faculty of Veterinary Science Text. University of Buenos Aires Argentina.
PAVLETIC, MICHAEL M, 1996. Cap. 25 Skin On: BOJRAB, JOSEPH. Pathophysiology and clinical small animal surgical, Second Edition. Buenos Aires, Argentina. Editorial Intermdica. 157-166p.
POPE, ERIC R, 1996. Cap. 24, cutaneous scarring: BOJRAB, JOSEPH. Pathophysiology and clinical surgery in small animals. Second Edition. Buenos Aires, Argentina. Editorial Intermdica.157 – 166 pp.
RIVERA, VICTOR. 2006. Physiology of healing. Text Book of Surgery. Ecuadorian Society of Ciruga.ttp :/ / [accessed: October 5, 2007].
SCOTT, D., MILLER, W. and Griffin, C. 2002., Dermatological Treatment In his: Muller & Kirk’s Small Animal Dermatology. Sixth edition. Buenos Aires, Argentina. Editorial Intermdica. 1, 2, 10 to 24, 242, 270-274pp.
WENDELBURG, K. Cap 1996. 25 Skin On: BOJRAB, JOSEPH. Pathophysiology and clinical small animal surgical, Second Edition. Buenos Aires, Argentina. Editorial Intermdica. 57-66pp.
Dr. Claudio Simon C. MV.
Small Animal Medicine Diploma Universidad De Chile
Internship in Dermatology University of Sao Paulo Brazil.
Full Animals Veterinary Clinic.
Dr. Giovanni Ramirez M.V. Moraga
University of the Americas