Decision Making for Surgical Reconstruction

Presenter: Dr Jon Hall MA VetMB CertSAS DipECVS MRCVS, Affiliated Lecturer, Staff Surgeon, Small Animal Surgery at the Department of Veterinary Medicine, Cambridge Veterinary School

‘The Webinar Vet’ now offers Friday coffee morning webinars from Cambridge University on a monthly basis and, having a spare half an hour on my hands, I decided give it a try. Needless to say I wasn’t disappointed. Last Friday’s discussion focused on surgical reconstruction and how to make the best decisions for your patients. Jon Hall led this webinar and managed to deliver an enormous amount of practical and relevant advice in less than an hour.

Initially Jon discussed a basic set of rules which need to be followed when surgically reconstructing a wound, the first of which includes not closing a wound if there is any doubt over the level of contamination and/or the degree of devitalisation. Another rule includes always investigating puncture wounds especially if over the thorax and/or abdomen and lastly, in the presence of very large or awkwardly positioned wounds the power of second intention healing should never be underestimated.

Jon went on to explain that if surgical reconstruction is appropriate and necessary, a good understanding of the blood supply and anatomy of the skin is necessary in order to make the best decisions. The sub dermal plexus is a key attribute in both cats and dogs and was discussed further within the webinar. Jon advised that once the blood supply is understood, planning for surgical intervention can be carried out and is vital if surgery is to be successful.

Incision lines can be drawn using a sterile pen and ideally should always be parallel to tension lines. If reconstruction is necessary on a distal limb, an attempt should also always be made to close wounds transversely. Another great tip offered by Jon within the webinar is to pick up the skin in the area where incisions are to be made and check its laxity. The skin can be pinched between the index finger and thumb at the points where the incisions are to be made and if the finger and thumb meet, then closure should be possible and relatively simple. However if the finger and thumb do not meet then closure will be under tension and there are more likely to be complications postoperatively.

Once reconstructive surgery is being performed, Jon discussed the use of a number of techniques to relieve tension including the undermining of skin and the use of walking sutures. Walking sutures recruit the elasticity of the skin away from the incision and can be useful, however the use of too many walking sutures when closing a defect can lead to vascular compromise. The use of barbed suture material can also be useful as it spreads tension across an incision line. Stents to prevent suture material cutting across the skin were also discussed and included the use of cut up drip lines across sutures. Jon did however warn us that he has used this technique and in some cases the drip lines caused areas of pressure necrosis to develop. Jon now prefers to use a Penrose drain across sutures to relieve tension.

Drain placement was also discussed especially where surgical reconstruction has taken place over high movement areas. Penrose drains are the classic choice but need to be placed in a dependant area to be effective. Jon’s preference is to use a closed active drain which can be placed in any position, is reasonably affordable and works well.

An overview on the use of skin flaps was discussed at the end of this webinar but the magnitude of this particular topic is huge and could not be fully covered within this webinar. However, with so much potential for the use of skin flaps in a variety of situations both Jon, and Anthony Chadwick (who facilitated this webinar) decided it would be a very good idea to run an expertise series on this topic which will hopefully become available on The Webinar Vet at some point in the future.

Spending just half an hour gathering ‘top tips’ and learning about the current thinking on specific topics is an excellent way to ensure your interest and knowledge level is maintained, and working in such a ‘time-short’ profession these monthly coffee mornings are, in my opinion, an exceedingly good idea.

Click here to view a preview of the webinar.

The Stethoscope (MRCVS)

 

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