Indications of types of sutures and time for stitch removal.
\r\n\tThe discovery of Nylon by Wallace Hume Carothers, a Harvard-educated world-renowned organic chemist born in Burlington, IA in 1896, successfully crowned the attempts developed by E.I du Pont de Nemours & Company to investigate the structure of high molecular weight polymers and to synthesize the first synthetic polymeric fibre.
\r\n\tWhen it hit the market, it was in the form of stockings and all the women in the US wanted to get their hands on a pair. Despite the successful launch of Nylon on the synthetic fibre market and the high expectations created by its extraordinary features, the unexpected war events in 1941 diverted the production of the new synthetic fibre almost exclusively on military applications. Parachutes, ropes, bootlaces, fuel tanks, mosquito nets and hammocks absorbed the production of Nylon, which helped to determine the WWII events. When the war ended and production returned to pre-war levels, consumers rushed to the department stores in search of stockings, accessories and high-fashion garments.
\r\n\tEven if the world of high fashion now seems to more appreciate the use of natural fibres, Nylon is one of the most widely used polymers for the production of technical fibres and fabrics, automotive and micromechanical components. The global nylon 6 & 66 market is expected to reach USD 41.13 billion by 2025, by the following growth at 6.1% CAGR owing to the Increasing focus on fuel-efficient and less polluting vehicles.
\r\n\t
\r\n\tThe amazing success story of Nylon still continues. While its wide availability inspired the development of innovative applications, such as the additive manufacturing, on the other hand, proper disposal after use of high amounts of Nylon resin energised the development of efficient recycling methodology, including chemical recycling. Moreover, the production of Nylon precursors from biomass has become desirable due to the depletion of fossil hydrocarbons and to reduce greenhouse gas (GHG) emissions. This unique combination of technical and socio-economic driving forces is one that aims to further promote the development of Nylon as one of the most suitable ""best polymers"" with a low ecological footprint.
\r\n\t
\r\n\tThe aim of this publication is to unveil the relationships between the chemical structure and the outstanding properties of the broad family of polyamides and to describe the most recent use of Nylon in fostering new applications and promoting a culture aware of environmental sustainability.
Morphogenesis, the evolutionary process of shape and structure development of organisms or their parts, is driven by certain types of cell shape changes or, in other words, deformations. One type of such deformations is the apical constriction—visible shrinkage of the apical side of cells, leading to bending of epithelia—cell sheets, which surround organs throughout the body. First occurring at early stages of embryogenesis, the apical constriction results initially flat epithelia to be bent obtaining three-dimensional form, which, depending on physiological context and morphogenetic stage, leads to different consequences. It has been first hypothesized in [1] that in various developmental systems the apical constriction may drive the bending of epithelia. Using bulky mechanical construction, the hypothesis of Rhumbler is first practically tested in [2]. The testing mechanism consists of 13 identical bars (cell walls) that are kept apart by means of stiff tubes connecting their centres (cell kernels), and are held in a row by rubber bands connecting their ends (cell membrane). In the first stage, the rubber bands at both sides are stretched equally and the mechanism is in straight equilibrium. Shortening the rubber bands at, for instance, the upper side uniformly in each segment (cell), the mechanism is bent on the side of the greater tension, as it could be expected. Thus, Rhumbler’s hypothesis could take place.
A more illustrative, computer model for verifying Rhumbler’s hypothesis is suggested in [3], where bars and bands are replaced by virtual cells. Prescribing certain mechanical properties to the cell membrane and cytoplasmic components, and assuming that as a result of deformations the volume of a single cell is preserved, which is implicitly done by Rhumbler and Lewis, a model of cuboidal epithelia folding is suggested, based on the local behaviour of individual cells. The model is demonstrated on the example of ventral furrow formation in Drosophila. A sequence of cells in the form of a cylindrical shell, representing the cross section of ventral furrow, is deformed such that apical constriction occurs in its lower row of cells. Increasing the applied stresses, different steps of the furrow formation are illustrated. Figure 1 expresses how much Odell’s model is close to the real microscopic picture [4].
Ventral furrow formation in Drosophila according to [3] (upper) and [4] (lower).
Much is known about the causes of the apical constriction, but some issues still remain unexplored [5–8]. The most studied causes include contraction of actin filaments—fibrous network localized at the cortex of the cell, by interacting with motor protein myosin—the most known converter of chemical energy into mechanical work. Under influence of myosin, actin fibres contract leading to shrinkage of the cell in the area of their localization [9, 10]. The contraction size and principal direction of the fibres, that is, the microscopical deformation of a single cell, mainly depend on the tissue type: actin-myosin network contraction may deform columnar (occurring, for instance, in digestive tract and female reproductive system) or cuboid (resp. in kidney tubules) cells into trapezoidal-, wedge- or bottle-shaped cells. The deformation size strongly depends also on the emplacement of deforming cells: cells with different placement are constricted differently, so that macroscopically one observes localized wrinkles (see Figure 2).
Apical constriction of ventral furrow at different times [10].
Because of the mechanical nature of cell shape change, in particular, apical constriction, its theoretical study first of all must rely on mechanical principles and constitutive laws. In early mechanical models, the tissue is modelled as a continuum material, so that the position and behaviour of individual cells are unimportant, that is, only macroscopic deformation of the tissue is studied. Moreover, the height of the cells (viz. the thickness of the tissue) is supposed to be negligible with respect to other measures, such that the deformation of the tissue can be described in terms of its mid-surface. In such models, the actin network is not explicitly accounted and the contraction forces are modelled as a force term acting on the outer surface of the epithelium. The actin network is explicitly accounted in [11], where thin elastic shell model based on linear Cauchy relations is derived to describe apical constriction in initially non-flat epithelia. The model is tested to simulate apical constriction in initially flat, cylindrical and spherical tissues. Ventral furrow formation in Drosophila is simulated (see Figure 3), and it becomes evident from comparison of Figures 1 and 3 that the model, being three-dimensional, is in good correspondence with that from [3]: Figure 1 corresponds to cross section of cylindrical shell from Figure 3. However, it does not involve the behaviour of individual cells and describes only macroscopic deformation. For further introduction into other mechanical models, we refer to [11–26].
Ventral furrow formation in Drosophila according to [11].
The physical and geometrical characteristics of individual cells are taken into account by mechanical model suggested in [27] describing three-dimensional deformations of cell sheet. Both actin-myosin network contractile tensions and cell-cell adhesion stresses are involved to contribute in epithelial tissue bending. Prescribing specific mechanical characteristics to cytoplasmic components and to the kernel, the effective energy of a cell, which is assumed to be a hexagonal prism with constant volume, is expressed in terms of its basal length. As a result of simulations, it is particularly established that when adhesion stresses, distributed on lateral sides of the cell, are large enough, the effective energy has two local minima, that is, there are two equilibrium cell shapes. More particular, depending on position, cell shape may be discontinuously transited from squamous to columnar forms. Figure 4 shows that there is a whole domain in the plane of lateral adhesion and actin-myosin tensions for which the effective energy has two local minima.
\nEpithelial cell aspect ratio as a bistable phenomenon [27]: αl is the contractile force and Λa is the actin-myosin tension.
In mathematical terms, it means that the total energy of the tissue is not lower semi-continuous, which implies that there is no convergence of its minimizers, and, therefore, it becomes impossible to derive real deformation of the tissue [28, 29]. To be more illustrative, consider a membrane, that is, a tissue without bending stiffness, which is compressed by boundary stresses. The only way that the membrane can accommodate a compressed state is due to wrinkling [30]. Wrinkles may occur more and more finely, so the limiting deformation will be smooth, but evidently it will not minimize the membrane energy.
To overcome such difficulties, the membrane energy density is usually substituted by its quasi-convex envelope [28], which ensures the lower semi-continuity of its total energy. In calculus of variations, there are several ways to construct or even compute convex envelopes for functionals, depending on first- and second-order derivatives [28, 31–36].
Another possibility for incorporating the lack of lower semi-continuity of membrane energy functionals is accounting the bending stiffness of the membrane and adding to the energy the bending contribution [37]. So, it is established in [33, 34] that the total energy of a membrane with some bending stiffness and thickness
of deformation
However, the most rigorous and general approach seems to be the derivation of low-order energies from general three-dimensional non-linear elasticity by means of
By suggested improvements, it is supposed to get rid of disadvantages of previous models and take into account the fact that the total energy of the tissue can have two local minima. Thus, we are intended
to account the height of each individual cell, so the model is fully three-dimensional,
to pick up strongly localized internal forces to model the phenomenon of apical constriction more precisely,
to introduce stretching and bending contributions into the total elastic energy of the epithelial tissue, thus making the model more realistic and convenient not only for qualitative but also for quantitative analysis,
to use the quasi-convexification of the total energy, so the real three-dimensional deformations of the epithelial tissues can be identified as minimizers of the total energy by a gradient flow technique.
The former allows making simplified toolboxes for analysing three-dimensional deformations of epithelial tissues. The rough diagram of the improved model looks like in Figure 5, so that the characteristics of each individual cell are important, as well as the actin belt is explicitly involved in the model.
Diagrams of a single-cell layer: cross section (left) and 3D shape (right).
The chapter is organized as follows: In Section 2, some preliminary definitions and main notations are brought to make the chapter independent of outer sources. In Section 3, known results from
We begin with the definition of concepts used throughout the paper, which and much more on this topic can be found in [28, 29].
There are different concepts of convexity in higher dimensions, such as quasi-, poly-, rank-one and separately convexity. Here, we use all but poly-convexity, so it is of no use to enlarge the chapter by its definition.
Definition 1 (quasi-convexity). A function
for every bounded open set
Definition 2 (rank-one convexity). A function is said to be rank-one convex if
for every
Definition 3 (separately convexity). A function
is convex for every
In other words, a function
In general, convexity implies quasi-convexity, which implies rank-one convexity, and finally rank-one convexity implies separately convexity.
The quasi-convexity notion is generalized by Meyers [38] for functionals depending on higher-order derivatives. We refer to [32, 35, 36] for practical use of the definition.
Definition 4 (k-quasi convexity). A function is said to be k−quasi-convex if
for every open-bounded set
In particular,
We widely use the quasi-convex envelope of
It is evident that for any
Deformation is always denoted by
respectively, in which
Definition 5. Energy density function
If for all
then it is called isotropic.
In other words, frame indifferent energy densities are invariant against three-dimensional rotations before a deformation is applied and that isotropic energy densities are invariant against two-dimensional rotations after a deformation is applied.
Definition 6 (short (
Definition 7 (isometric deformation). A deformation
Short deformations result compressive stresses, while isometric deformations do not allow stretching or compression. The case
Rigorous derivation of two-dimensional energy functionals for thin bodies from three-dimensional functionals is of particular interest. There are several ways for dimension reduction, such as asymptotic expansion, Γ-convergence technique, and so on (for general survey, see [43]). In [44], a hierarchy of plate models is derived as Γ-limit of three-dimensional elastic energy functional when the thickness of the body
and
denotes the rescaled elastic energy of the body, with
The total energy of the body will be
The Γ-limit
for
We combine the results of [44–48] in Theorem 1.
Theorem 1. Let the stored energy density function is frame indifferent and satisfy
and in a neighbourhood of
Then
(i) (Membrane theory [45]). Suppose
Then
then
among all
(ii) (Constrained membrane theory [46]). Suppose that
among all short deformations
(iii) (Non-linear bending theory [47]). Suppose
among all isometric deformations , which belong to The non-linear strain satisfies
where 2symG=GT+G, amin is the solution of
In all cases, there is convergence of energy, that is,
For
with
are rescaled by
respectively.
Then, we have
Theorem 2. (iv) (Linearized isometry constraint). Suppose 2<α<3 and set β=2α−2, γ=2(α−2), 2δ=γ. If 2<α<52, suppose in addition that Ω is simply connected. Then, −Chβ≤infεh≤0. If r(h) is a β-minimizing sequence then there exist constant R(h)∈SO(3) and c(h) ∈ ℝ3 such that
Moreover, the pair (v¯,R¯) minimizes the functional
subject to
(v) (von Kármán theory). Suppose that α=3 and set β=4, γ=2, δ=1. Then and for a subsequence of a β-minimizing sequence, (1) and (2) hold and the limit triple (u¯,v¯,R¯) minimizes von Kármán functional
(vi) (Linearized von Kármán theory). Suppose α>3 and set β=2α−2, γ=α−1 and
Moreover, the non-linear strain satisfies
In all cases, we have convergence of the rescaled energy
Remark 1. (i) Practically, Theorems 1 and 2 establish Γ-convergence and give the Γ-limits of three-dimensional non-linear energy functional in the range β∈[0,53)∪[2,∞). The range β∈[53,2) remains unexplored.
(ii) Even in the case
(iii) In particular, when α=β=2, for isotropic homogeneous bodies we obtain
in which λ and μ are Lamé constants, coinciding with plate energy derived by Kirchhoff much earlier in [49].
As was mentioned in Section 1, there are two ways to relax the epithelial elastic energy. The first way is to relax the stretching energy for deformation regimes corresponding to compressive stresses. For that reason, Pipkin‘s procedure [41] seems to be the most common tool.
Suppose that the stretching energy density function
where it turns to zero, that is, attains its minimum. On elastic energies with two minima, see [50]. This assumption is motivated by bistability of cell shapes during apical constriction (see Figure 4).
We restrict attention to deformations
and denote
In view of frame indifference of
From quasi-convexity of
is rank one, we have
therefore
we see that
Under assumptions made, we have
Since
If we denote by
Besides opportunity of explicit relaxation, in [41] the derivation of criteria for convexity and quasi-convexity is described. In view of rank-one convexity,
For convexity of
must be satisfied. Above
The other way is the adding of pure bending contribution to the elastic energy of the tissue. Since actin-myosin network contraction leads to compressive or non-stretching stresses, we have to incorporate the elastic energy mainly for such deformations. According to Section 3 for non-stretching stresses, we have
(short deformations and compressive stresses)
(isometric deformations, neither stretch nor compressive stresses)
The deformation regime
We assume that the tissue is homogeneous and isotropic, so according to Remark 1
Furthermore, the membrane energy density function we take in the following form [52, 53]:
which is valid for large deformations of incompressible hyper-elastic membranes. Above,
in which the incompressibility condition
For any fixed
Since in the uniaxial tension regime
Then,
The correspondent tension is defined by
Since
and
It is evident, that when we substitute
Forces driving tissue deformation are strongly localized and in general are compressive. Force
In this section, we summarize main results of finite element analysis of a single layer tissue model, the elastic energy of which is given by
in which
In Figure 6, we bring the model of a single-cell (element) and cell-cell junction (in red). All structures (plate and shell) considered in this section entirely consist of such cell groups. In all tissues considered below, the height of a cell
We consider
initially flat rectangular plate (Figure 7 (left)),
cylindrical shell (Figure 9 (left)),
spherical shell (Figure 11 (left)).
Single-cell model (left) and adherens junction model (right): diagonals of the top hexagon imitate actin fibres, red areas between cells imitate junction bonds.
Apical constriction of initially flat tissue. It consists from 5050 elements or cells and has 529,245 DOFs.
von Mises stress distribution in deformed configurations.
Apical constriction of initially cylindrical tissue. It consists from 5975 elements or cells and has 621,375 DOFs.
von Mises stress distribution in deformed configurations.
Apical constriction of initially spherical tissue. It consists from 3126 elements or cells and has 325,245 DOFs.
Elements of the middle part of the rectangular tissue are compressed in apical sides to imitate apical constriction in cells. Increasing the compressing stresses, the tissue is bent and a blaster-shaped pattern is formed as shown in Figure 7 (right). The quantitative picture of the stresses arising in the tissue is drawn in Figure 8.
von Mises stress distribution in deformed configurations.
Next, we consider a cylindrical shell to imitate ventral furrow (generally all tubular patterns) formation. Elements of the top part of the cylinder are constrained in the apical sides by compressing the links standing for apical fibres (see Figure 9). Increasing the compressing stresses, the ventral furrow formation is simulated similar to stages presented in Figure 1. The quantitative picture of the stresses arising in the tissue is drawn in Figure 10.
Finally, a spherical shell is simulated. Cells at the top of a semi-sphere are constrained in apical sides and depending on values of compressing stresses various stages of blastopore formation in archenteron can be described (see Figure 11 (right)). The quantitative picture of the stresses arising in the tissue is drawn in Figure 12.
Analysis based on lower semi-continuous energy functionals reveals real three-dimensional deformations of soft epithelial tissues. Having different forms for different deformation regimes, such as compressive stresses (short deformations), uniaxial tensions collinear to principal directions of the first fundamental form, no stretching or pure bending stresses (isometric deformations) and stretching stresses (large deformations), the resulting total energy is lower semi-continuous, so the existence of its minimizers, that is, real deformations, is ensured. Particular energy density functions are chosen and the explicit form of the total energy functional is obtained, thereby the discretization is made easy.
On the basis of obtained energy functional, a three-dimensional discretized model of epithelial tissues undergoing combined stretching and bending deformations is constructed. Discretization elements correspond to single cells forming the tissue. Actin fibres and cell-cell adhesion links, mainly contributing on the tissue energy, are explicitly embedded in elements. Deformations characteristic to specific embryonic tissues (ventral furrow, neutral tube, neurosphere) observed earlier are described quantitatively increasing contractile stresses in fibres.
We thankfully dedicate the chapter to the blessed memory of our good fellow and colleague, a candidate of physical and mathematical sciences, Hamlet V. Hovhannisyan (1956–2016), who unexpectedly died before he could realize his best scientific ideas.
The theoretical part of the chapter is investigated under the guidance of Doctor, Professor Benedikt Wirth, Institute for Computational and Applied Mathematics, University of Münster, whom we are heartily thankful. The work of As. Kh. and S. O. was made possible in part by a research grant from the Armenian National Science and Education Fund (ANSEF) based in New York, NY, USA.
Inner (dot) product | |
Lamé coefficients | |
Principal stretches | |
Rescaled three-dimensional total energy | |
Measure of bounded open set | |
Gradient (nabla) operator | |
Midsurface of the epithelium | |
Rank of the matrix F | |
Tensor product | |
dist | Usual distance in three-dimensional Euclidean space |
d | Diameter of actin fibres |
E | Three-dimensional elastic energy |
Bending energy | |
Rescaled three-dimensional elastic energy | |
Membrane energy | |
Young’s modulus of actin fibres | |
Young’s modulus of a cell | |
Young’s modulus of cell-cell links | |
h | Thickness of the epithelium or a single cell |
r | Side of a single cell |
W | Membrane energy density function |
The quasi-convex envelope of W | |
II | The second fundamental form associated with deformation r |
I | The first fundamental form associated with deformation r |
n | Unit normal vector |
r | Deformation acting from |
SO(3) | The group of all rotations about the origin of three-dimensional Euclidean space |
This chapter will try and help general practitioners master minor surgical procedures.
General practitioners require these procedures for diagnostic or therapeutical reasons, in the outpatient setting as well in the emergency (excision of skin lesions or wound suturing for example). For that reason, the training of the general doctors in minor surgery is an additional tool for good medical practice and acquiring skills in minor surgical procedures has become a critical part of medical training.
Minor surgical procedures do not involve very sophisticated devices. However, some basic requirements in terms of infrastructure and equipment must be met [1, 2].
It is recommended that each facility has a specific room for these procedures. This room (Figure 1) must include:
Well-equipped room of minor surgery.
Surgical room: a well-ventilated room, with a suitable temperature, it is imperative that is clean, but it does not require sterile isolation. The surgical room should be cleaned properly at the end of the surgical session, particularly after contaminated procedures (e.g. abscesses).
Operating table: It should be easily accessible from all sides, Height-adjustable and articulated tables. It is essential that allows the doctor to work in comfort, both standing and sitting.
Doctor’s stool: A height-adjustable stool on wheels.
Side table: it is used to place the surgical instruments and material used during the surgery.
Lamp: It is necessary to have a directional light source, and it must provide adequate lighting with, at least, 45,000 lux of illuminance. It is advisable to have another auxiliary lamp with a magnifying glass.
Showcase and containers: For storing consumables and surgical instruments. There should also be properly marked containers for bio contaminated material, and a disposal system in accordance with current health legislation.
Resuscitation equipment: Including material for vascular access, airway intubation, saline, drugs for resuscitation (e.g. epinephrine, atropine, bicarbonate) and a defibrillator.
Performing minor surgical procedures carries some risk of transmission of infectious diseases (such as HCV and HIV), both from patient to doctor and vice versa. To minimize this risk, all physicians performing invasive procedures should adopt and apply universal precautions, which include:
Surgical attire: surgical shirts and trousers (“scrubs”) or gowns and sterile gloves. Surgical masks and eye goggles is considered highly desirable but not essential. Disposable gowns are very useful.
Hand washing: Hygienic scrubbing is suitable for minor surgery and involves using a normal soap solution (no brush) and washing thoroughly all skin folds for at least 20 seconds. Time span from scrubbing to glove placement should never exceed 10 minutes.
Sterile glove placement: Outer surface of the glove should be sterile, therefore they cannot be touched with the hands, only with the other glove; nonetheless, the inner or powdered part of the glove can be touched.
The quality, condition and type of instruments used in any procedure can affect its outcome. Choosing the right instruments for each surgical intervention is, therefore, an important issue [1].
Scalpel: A number 3 handle with leaves number 15 for dissection and 11 for incisions and withdrawal of points. The scalpel blade is installed on the handle in a unique position, matching the blade guide with the handle guide. The scalpel is handled with the dominant hand like a pencil (Figure 2), allowing small and precise incisions. To increase precision, hand should be partially supported on the working surface. Skin should be tightened perpendicularly to the direction of the incision using the contralateral hand, cutting the skin perpendicularly. In hairy areas (eyebrows or scalp), to avoid damaging the follicles, the incision should be parallel to the hairshafts.
Correct way of managing of the scalpel.
Scissors: The scissors allows us both the cutting dissection of the tissues and the blunt dissection.
A 14 cm long curved blunt May scissors (cutting scissors) and an 11.5 cm curved blunt Metzenbaum scissors (dissecting scissors) should be available.
Scissors are handled by inserting the distal phalange of the thumb and fourth finger into the rings, then supporting the second finger on the branches of the scissors. Usually scissors are inserted with the tip closed and are then opened, separating the tissues in the anatomical layers, except for sharp dissection they are inserted with the tip open, then cutting the tissue.
Needle-holder: needle-holders are meant to hold curved needles while stitching. The needle is held 2/3 of the way back from its point. A small or medium (12–15 cm). Long needle holders are not recommended.
Like other instruments with rings, the needle support is handled equally. To facilitate the passage of the needle through the tissues, the needle holder should describe a prono-supination movement, and for a proper edge eversion of the wound the angle of entry of the needle should be 90°. The non-dominant hand holds the skin with a retractor or dissecting forceps, opposing the pressure of the needle.
Dissecting forceps: Use of a 12 cm-long Adson forceps with teeth to handle the skin, plus a toothless Adson forceps for suture removal or two standard forceps, one with and one without teeth. It is important not to manipulate the skin using non-toothed forceps.
They used with the non dominant hand, between the first, second and third fingers.
They allow the surgeon to expose the tissues to manipulate them.
Homeostats: homeostats are used to pull tissue, for homeostasis and, in some cases, for blunt dissection in absence of small scissors. Usually with 12 cm curved non-toothed Mosquito forceps.
For most minor surgical interventions, a basic set of surgical instruments is enough (Figure 3). But some surgical procedures require the use of special instruments or equipment, such as:
Basic set of instruments of minor surgery: Scalpel (handle of the number 3 for scalpel number 15), scissors of May, Adson forceps with teeth, needle-holders and mosquito forceps.
Biopsy punch: it is an instrument consisting of a handle and a cylindrical cutting edge (trephine) for obtaining tissue biopsies. It allows the surgeon to obtain full- thickness samples of the skin.
The most useful in minor surgery is the 4 mm punch but they are manufactured in different diameters. They are handled with the dominant hand, performing rotational movements of the instrument to cut the skin and obtain the sample [3].
Curette: it allows scraping of lesions on the skin Surface with a simple surgical technique that involves “scraping” or enucleating different types of superficial, hyperkeratotic or raised partial-thickness skin lesions.
Cryosurgical equipment: these are devices that spray a cryogen, which is usually liquid nitrogen that uses extremely cold temperatures to treat benign and malignant skin lesions (solar lentigines, common warts, myxoid cysts, actinic keratosis, etc.).
It is available, cost-effective, and rapid treatment that rarely requires anesthesia [4].
Electrocautery: it applies an electric current with ability to coagulate and cut through different tissues. There are different terminals depending on the type of procedure that is to be performed [5].
Different types of suture materials are available: threads, staples, adhesive sutures and tissue adhesives.
Depending on the material used for the suture, the operation time will be modified and will require anesthesia or not.
Conventional sutures require the use of anesthesia, operating time is increased, and tissue is traumatized, but provide a secure wound closure and minimal wound- dehiscence rate compared to other types of closure [6].
They are classified according to their origin (natural, such as silk, or synthetic polymers that produce less tissue reaction), their configuration (monofilament or multifilament), and their size (the thickness of the suture is measured using a zero-scale [USP system] (Figure 4). The most commonly used in minor surgery range from 2/0 to 4/0 or 5/0.
Information on suture: (1) caliber of the thread (system USP and metric), (2) trade name of the suture, (3) composition and physical structure of the thread, (4) length of the thread, (5) color of the thread, (6) model of needle (every manufacturer uses different references), (7) I draw from the needle to scale 1:1, (8) circumference of the needle (expressed in parts of circle), (9) section of the needle, (10) length of the needle, (11) expiry date, (12) indexes of the manufacturer, (13) indicator of sterile packing.
The size and type of suture will be selected depending on the anatomical site, the type of wound and on the patient’s features.
Nonabsorbable sutures: They are not degraded by the body and they are used for skin wounds in which stitches that are to be removed or for internal structures that must maintain a constant tension (like tendons and ligaments), Polypropylene and Nylon, causes minimal tissue reaction.
Silk: Suitable for skin suture and for removable sutures in general, it is easy to handle and tie.
Nylon: Indicated for precise skin sutures and internal structures that must maintain constant tension.
Polypropylene: Indicated in continuous intradermal skin closure. It is a very soft suture with high package memory and, therefore, it requires more knots for secure tying, and it is more expensive than Nylon.
Absorbable sutures: A suture is considered absorbable if, when placed under the skin surface, it loses most of its tensile strength in 60 days. It has low tissue reactivity, high tensile strength. They are use in dermal suturing, subcutaneous tissue, deep suturing and ligatures of small vessels. The most commonly used, are the synthetic sutures (polyglactin 910 [Vicryl], polyglycolic acid [Dexon]…).
The period of time (in days) recommended for the extraction of points, together with an indication of the type of suture is described in Table 1.
Anatomical region | Skin suturing | Subcutaneous suturing (Vicryl® or Dexon®) | Stitch removal | |
---|---|---|---|---|
Adults | children | |||
Scalp | Staples 2/0 silk | 3/0 | 7–9 | 6–8 |
Eyelids | 6/0 monofilament or silk | — | 3–5 | 3–5 |
Ears | 4/0–5/0 monofilament or silk | — | 4–5 | 3–5 |
Face, neck, nose, forehead | 4/0 monofilament or silk | 4/0 | 4–6 | 3–5 |
Lips | 4/0 monofilament or silk | 4/0 | 4–6 | 4–5 |
Trunk/abdomen | 3/0–4/0 monofilament | 3/0 | 7–12 | 7–9 |
Back | 12–14 | 14 | ||
Lower extremity | 3/0 monofilament | 3/0 | 8–12 | 7–10 |
Penis | 4/0 monofilament | 3/0 | 7–10 | 6–8 |
Foot and pulp of fingers | 10–12 | 8–10 | ||
Upper limb/hand | 8–10 | 7–9 | ||
Mouth and tongue | 3/0 Vicryl® | — | — | — |
Indications of types of sutures and time for stitch removal.
Needle selection depends on the type of tissue to be sutured, its accessibility and suture thickness.
Needles are classified as triangular, spatulate or conical, according to their section. Triangular needles are considered the first choice in minor surgery, as they have sharp edges that allow suturing through highly-resistant tissues such as subcutaneous tissue, skin or fascia.
Curved needles are used with the needle holder, that is designed to hold needles atraumatically and safely. Short needle holders are preferred in minor surgery; however, they should be selected in accordance with the size of the needle and the surgical area.
Staples are applied by disposable staplers and they are available in different widths (R: normal staples, W: Wide staples). Staplers are preloaded with a variable number of staples. It has certain advantages such as the speed with which the suture is performed, low resistance and no tissue reaction.
They are applied with the dominant hand, while the non dominant hand everts the skin edges using dissecting forceps with teeth. Staple removal is performed using a staple extractor.
Indications: In linear wounds on the scalp, trunk and limbs, and for temporary closure of wounds in patients to be transferred or with other serious injuries.
Contraindications: Wounds on face and hands and regions that are going to be studied through CT or MRI.
It consists of adhesive tapes made of porous paper and capable of approximating the edges of a wound or incision. They are available in various widths and lengths, and it can be cut.
Indications: linear and superficial wounds with little tension. The regions where they are used most are: the face, chest, non-articular surfaces of the limbs and fingertips. They are also a good choice for elderly patients and to wound-reinforcement after stitch removal.
Any wound closed with adhesive suture should not be wet for the first few days, due to the risk of tape detachment.
Contraindications: irregular wounds, on the scalp and hairy areas, skin folds and joint surfaces.
Application and removal of adhesive sutures: For a good application the wound should be free of blood or secretions and dry. The suture tape is applied to the wound using dissecting forceps without teeth or fingers, first on one edge of the wound and then the other and along the wound.
Time for adhesive suture removal parallels time for conventional suture.
These products (cyanoacrylates) act as an adhesive, producing an epidermal plane closure, so they bind the most superficial epithelial layer (stratum corneum) and hold together the wound edges for 7–14 days. After this time, adhesive and stratum corneum are shed along.
Adhesive can be used in deeper wounds or with great tension, associated at sutures in the subcutaneous plane.
It have advantages when compared with sutures: More rapid repair time, less painful procedure, better acceptance by patients, no need for suture removal or follow-up, good cosmetically results. Finally they are safer than sutures because needlesticks are avoided [1, 7].
After cleanliness and hemostasis of the wound, tissue adhesive will be applied:
Using fingers or dissecting forceps to approximate the wound edges, apply the adhesive on the outer surface of the skin. Then Keep the edges in contact for 30–60 seconds. The process can be repeated 3 times.
The wound does not require dressings but should be kept dry 5 days. The glue will disappear after 7–10 days.
If adhesive contact the eyes, use of a generous amounts of ophthalmic antibiotic ointment should be placed within the eye and on the eyelid to break down the adhesive and reopening of eyelids with a gentle manual traction. If adhesive reach the cornea, it should be assessed for corneal abrasion.
The practice of any surgical procedure, however minimal, is not without risks. The possibility of complications during and after surgery must always be kept in mind. The results of surgical treatment are not always predictable, and depend on many factors, involving not only the physician’s skills, but also the patient.
There are two ways to dissect tissue: with a blunt dissection, separating the tissue, using Metzenbaum scissors or mosquito forceps, or cutting dissection, with a scalpel or scissors.
Incisions must parallel the minimal tension lines, which match skin relaxation lines and facial expression. Thus, they result in an acceptable scar, both functionally and cosmetically. There are diagrams of the relaxed skin tension lines, for correct incision planning before surgery.
The incision can be marked prior to skin antiseptic preparation or a previously sterilized marking pen can be used in the surgical field after skin preparation and draping.
For excisional biopsies, it is necessary to leave an adequate margin (1–2 mm) of healthy skin both around the lesion and in depth, depending on each lesion.
Incision: Used for drainage of abscesses or surgical exposure of deeper tissues (e.g., epidermal cysts, lipomas, lymph node biopsies). Depending of surgery or the anatomic area, Incisions can be angled, curved or straight.
Elliptical excision: Its should be oriented along the lines of minimal tension.
Usually the length of the ellipse should be 3 times its width and the ends form a 30° angle. Its used to remove skin lesions with a margin of healthy skin in depth and around lesion, and include all skin layers plus some subcutaneous fat (Figure 5). This technique allows diagnosis, treatment and facilitates closure producing good cosmetic results.
Characteristics of the elliptical excision.
It is the ideal technique to remove the majority of skin lesions [8, 9, 10].
The procedure involves the following steps:
Design of the incision
Preparation of the surgical field
Local anesthetic injection.
Superficial skin incision along the marked ellipse, going through the entire dermis to prevent jagged edges.
Using the nondominant hand the deep wedge-shaped incision is made (always under direct vision), until fat is reached and the lesion is, thus, removed en bloc.
Hemostasis of the surgical area.
Wound closure by layers
Cleaning the surgical area and dressing placement
After 48 hours the wound can be washed gently
Tangential excision: it is the technique of choice to remove very superficial lesions using scalpel or scissors, eliminating only the most superficial layers of the skin and for which diagnosis is certain. The defect created is allowed to heal by secondary intention. Tangential excision also called “skin shave”.
No surgical procedure is complete until the pathology report has been received and the patient informed of the results and prognosis.
Most episodes of bleeding in minor surgery can be controlled with pressure with a gauze or a surgical towel. It is recommended to apply a compressive bandage on the wound in the immediate postoperative period to reduce hematoma or seroma.
Tourniquet: Its allows the exploration of the wound and reduces the surgical time. Its use is limited to distal areas (the fingers nail surgery, etc.) and should not exceed 15 minutes.
The hemostats: The surgeon holds bleeding vessel with the tip of a hemostat without teeth and controls the bleeding. To avoid damaging important structures (for example, tendons or nerves) it is necessary to identify the bleeding vessel.
The ligatures: they are threads that tied around a blood vessel, occlude their light and prevent bleeding. After that, vessel should be fixed with a hemostat. The ligature should pass under the clamp and several knots must be tied.
In the hemostasis by electrocoagulation, the Bovie is used in coagulation mode.
This is the most appropriate for minor surgery, as it helps to distribute stress, and promotes the drainage of the wound. The number of sutures needed varies according to the length, shape and location of the laceration. In general, the sutures are placed away from each other so that no space appears on the edges of the wound.
Simple stitch (percutaneous): It is used alone or in combination with buried stitches in deeper wounds and it is considered the technique of choice.
Simple stitch with buried knot: Used to reduce tension within the wound and approximate the deep planes, before skin suturing. Absorbable material is used, the knot leaving in the depth of the wound, and is cut flush.
Mattress stitch or “U” stitch: It is useful in areas of loose skin (e.g., elbow, back of the hand), where the wound edges tend to invaginate. In addition this suture provides good obliteration of dead space, avoiding the need for buried sutures in shallow wounds.
Horizontal mattress stitch: provides a good eversion of wound edges, especially in areas where the dermis is thick or with high tension [6]
Half-buried horizontal mattress stitch: is used to suture wound angles or surgical edges of uneven thickness.
They are contraindicated if an infection is suspected and in very contaminated wounds.
Simple running suture: is a sequence of points with an initial knot and a final knot. It takes a short time to do it, but it makes it difficult to adjust the tension of the skin. It is rarely used in minor surgery.
Continuous intradermal suture (subcuticular): this type of suture allows the wound to be sutured without breaking the skin, avoids the “cross-hatching” and provides an optimal esthetic result. Non-absorbable monofilament suture material or absorbable material can be used. Intradermal sutures are used in wounds where it will be necessary to maintain the suture for more than 15 days. In minor surgery its usefulness is limited.
When a multifilament yarn is knotted (for example, Silk), three loops are usually sufficient (first a double loop plus two simple loops). When knotting a monofilament yarn (e.g., Nylon, polypropylene), an additional loop must be added to increase knot security. The knots should be placed on one side of the wound, rather than placed on top of the incision. This will allow a better visualization of the wound and will interfere less with the healing and facilitate the removal of points.
Local anesthetics block the transmission of nerve impulses and they causing, the absence of sensation in a specific part of the body, also other local senses may be affected.
Local anesthetics can be classified into two groups: esters and amides (lidocaine, mepivacaine, bupivacaine, prilocaine, etidocaine and ropivacaine). For their remarkable safety and efficacy we will only use amides. The association of vasoconstrictors allows better visualization of the surgical field. The most widely used is adrenaline and the maximum dose must not exceed 250 micrograms in adults or 10 micrograms/kg in children [11].
The concentration of the anesthetic is expressed in %. We must know that a concentration of 1% means that 100 ml of the solution contain 1 g of anesthetic. Therefore a 2 ml ampoule of 2% mepivacaine, its contain 40 mg (Table 2).
Due to the risk of necrosis and other alteration like delayed healing, adrenaline should not be used in acral areas (e.g., toes), or in traumatized and devitalized skin.
It is use in an intact skin and for lacerations and mucosae, especially in children. And their characteristics are shown in the Table 2.
Anesthetic | Mode of use | characteristics | Indications | Complications | Not indicated |
---|---|---|---|---|---|
LET® (4% lidocaine, 0.1% epinephrine 1:2000, 0.5% tetracaine) | 1–3 ml applied directly on wound for 15–30 minutes | Onset 20–30 minutes after application. | Can be effective in children for face and scalp lacerations and less effective in limbs | No important adverse effects reported | For mucosae and acral areas |
EMLA® lidocaine 25 mg/ml plus prilocaine 25 mg/ml, | 1–2 g of cream should be applied for each 10 cm2 of intact skin and occluded. Maximum dose is 10 g | Onset 60–120 minutes after application. Duration of effect is 30–120 minutes. Not useful on palms of hands and soles of feet | Admitted for procedures on intact skin: scraping and shaving, cryosurgery, electrosurgery, laser hair removal, pre-anesthesia for infiltration | Local mild irritation, contact dermatitis. There have been reports of Methemoglobinemia in children aged <6 months | For wounds or deep tissues |
Topical anesthetics used in minor surgical procedures and their characteristics.
Angular infiltration: From the point of entry, the anesthetic is infiltrated in three or more different directions, like a fan (Figure 6).
Perilesional infiltration: Starting from each point of entry the anesthetic is infiltrated in a single direction. The different points of entry will be forming a polyhedral figure.
Linear infiltration: If the lesion to be operated on is a skin laceration, the anesthetic should be directly infiltrated into the wound edges in a linear fashion. If the wound is bruised and has irregular edges, it is preferable to use a perilesional technique from the uninjured area, and follow along the margins of the wound to avoid introducing microbial contamination.
Anesthetic angular infiltration: it infiltrates following three or more different directions, like a fan.
The needle is inserted at the base of the proximal phalanx in a dorsal and lateral location, in the collateral palmar digital nerve, and then local anesthetic is injected (maximum 4 ml). The needle is removed and after aspiration proceeds to infiltrate again the subcutaneous plane.
The surgeon must wait 10–15 minutes to obtain a complete effect of the blockage.
It is important that general practitioners have an extensive knowledge of the lesions most frequently treated by minor surgery [12].
The following paragraphs contain an overview of the most important diagnostic consideration in lesions usually treated with minor surgery.
These lesions are easily treated with curettage, electrosurgery or cryosurgery. In case of doubt, an incisional biopsy should be sent for histopathological analysis.
They are also known as epithelial cysts, epidermoid cysts, or improperly, “sebaceous cysts.” The cyst wall consists of normal stratified squamous epithelium derived from the follicular infundibulum. Queratin is the main component inside the cyst. Their treatment is surgical removal for cosmetic reasons or due to recurrent infections.
They are a form of benign epithelial hyperplasia induced by the human papillomavirus (HPV). Clinical presentations of cutaneous HPV infection include:
Verruca Vulgaris or plantar wart: you can use liquid nitrogen or salicylic acid.
It is presents as pearly white papules of 1–5 mm (sometimes even bigger) with central dimpling. They may appear isolated or in groups in the neck, trunk, anogenital area or eyelids. Their first choice treatment is cryosurgery, curettage.
Lipomas are slow-growing benign tumors of mature adipose tissue. They appear as soft, elastic, smooth or multilobulated tumors of variable size, with ill-defined borders, and not adherent to deep planes. The diagnosis is usually made clinically. But ultrasound can be helpful to distinguish a lipoma from an epidermoid cyst or a ganglion cyst [13]. They are generally asymptomatic and they are treated by surgical removal [2].
They are not malignant and their treatment is justified for cosmetic reasons.
They are acquired lesions in the form of macules or papules or small nodules (<1 cm) and are constituted by groups of melanocytes located in the epidermis, dermis or both areas and rarely in the subcutaneous tissue. Sun exposure contributes to the induction of these lesions.
It is located in sun-exposed areas such as bald scalp, the face, shoulders, ears, neck and the back of the hands. It is caused by damage from exposure to ultraviolet radiation. Actinic keratoses are more prevalent in males of middle-aged.
Actinic keratosis is considered a precancer. 13–25% it could develop into a squamous cell carcinoma.
If lesions are scarce and localized, they may be treated with liquid nitrogen.
It is the most common skin malignancy. Approximately 70% of basal cell carcinoma occurs on the face, and 15% presents on the trunk [14]. Exposure to ultraviolet (UV) radiation in sunlight, especially during childhood, is the most important factors that contribute to the development of Basal cell carcinoma.
This is a malignant tumor that usually appears on a previous premalignant lesion and requires a multidisciplinary therapeutical approach involving dermatologists, surgeons, radiotherapists, and chemotherapists [14].
Of all skin malignancies, melanoma has the worst prognosis, Five-year survival rates for people with melanoma depend on the stage of the disease at the time of diagnosis.
High-risk areas for minor surgery include the facial and cervical regions, axillary and supraclavicular regions, wrists, hands and fingers, the groin, the popliteal fossa and the feet.
We must consider those regions with a greater tendency to develop pathological scars (e.g., shoulder, sternal and interscapular region). Also the skin of black patients and children are especially prone.
For most basic minor surgical procedures, no preoperative work-up is needed. Table 3 summarizes the precautions of minor surgery in primary care.
-Surgery in the lower extremities in patients with Diabetes Mellitus and peripheral vascular disease. -In patients with arrhythmia, severe hypertension, hyperthyroidism, pheochromocytoma or pregnancy, do not add vasoconstrictor to local anesthetic -Anatomic areas of risk -In patients with chronic use of corticosteroids. Protocol for minor surgery in anticoagulated patients - 3 Day Suspend Sintrom ® - 2 Day Suspend Sintrom ® and add subcutaneous LMWH - 1 Day Suspend Sintrom ® and add subcutaneous LMWH, single dose - 0 Day INR Control. If between 1 and 1.6 proceed to surgery. LMWH single subcutaneous dose. Patient will take the usual dose of Sintrom ® (the same as before the suspension). +1 Day LMWH single subcutaneous dose usual dose of Sintrom ® +2 Day usual dose of Sintrom ® +3 Day LMWH single subcutaneous dose. Usual dose of Sintrom ® +4 Day usual dose of Sintrom ® INR will be obtained on day +10 (seven days after surgery) |
Precautions of minor surgery.
In patients with increased anxiety, 5–10 mg oral or sublingual diazepam, or 1–5 mg sublingual lorazepam can be administered 30 minutes before surgery.
Contraindications for minor surgery: Malignant skin lesion, allergy to local anesthetics, pregnancy (surgery should be deferred until the end of pregnancy, if malignancy is suspected, the patient should be referred to a specialist), an acute illness, doubt about patient’s motivations, patients with psychiatric disorders or uncooperative patients or refusal to sign the informed consent form is a contraindication for any minor surgery procedure or technique.
Direct oral anticoagulants [DOACs] (Dabigatran, Rivaroxaban, Apixaban, Edoxaban): If a moderate or high bleeding risk surgery, it can be omitted for approximately 2–3 days before a procedure, and resume 24 hours after surgery. However, cutaneous procedures (e.g., skin biopsy, tumor excision, bone marrow biopsy) generally considered to confer a low risk of bleeding [15].
Vasovagal syncope is the most frequent complication and is more common in young men. Even some patients lose consciousness.
Treatment consists in administering oxygen and iv. fluids if needed and, in severe cases use atropine (0.5–1 mg sc or iv). Generally, most of patients recover spontaneously over a period of seconds to a few minutes.
Infection can occur in up to 1% of minor surgical patients, symptoms such as fever and/or chills are only rarely seen. Infections are treated by removing some of the stitches, plus daily cleaning and disinfection of the wound and allowing the wound to close by secondary intention. If necessary an oral antibiotic regimen may be initiated and inserted drain into the wound.
Hematoma-seroma: is paramount suturing the wound in layers with no gaps and, applying a compressive bandage to prevent their formation.
Wound dehiscence: After wound dehiscence, repairs will take place by secondary intention.
Hypertrophic scar and keloid scarring.
The authors declare no conflict of interest.
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