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Wound Closure 57
In surgery, it is important to recognise the factors that affect wound healing, and
these include the wound closure surgical technique, the degree of contamination, the
health status and level of comorbidity of the patient, their age, drug history of steroid
use or chemotherapy, nutrition and hydration status, radiotherapy, iatrogenic manip-
ulation and others, such as smoking or the temperature of the environment (Ballweg
etal.2013; Grubbs and Manna2023).
Wound Closure
There are two types of wound closure: primary (which works by primary intention)
and non- primary (by secondary or tertiary intention).
If the skin is closed at the end of the original surgery, irrespective of wires,
wicks, drains or other devices or objects extruding through the incision, the closure
is said to be primary, as it leads to wound healing by primary intention into a clean,
neat and thin scar (Chhabra etal.2017). The term ‘primary closed’ is used to clas-
sify procedures with multiple incisions for laparoscopic sites which are closed
primarily (NHSN2024).
Non- primary closure of surgical wounds, on the other hand, occurs when the
skin is not sutured or glued to approximate dermal edges at the conclusion of the
original procedure. The wound may be left to heal by secondary intention, in which
case it is left open (with deep tissue layers either also left open or closed by some
means) to allow for granulation tissue to form contraction of the wound edges and
eventual epithelialisation, as is the case when the wound is located in high- tension
areas, is non- linear or has become chronic (Azmat and Council2023). One example is
a laparotomy wound closed to the level of the deep tissue layers (‘fascial layers’ or
‘deep fascia’) but not at the level of the skin where the incision was made.
Finally, wound healing by tertiary intention (or delayed primary closure) occurs
when the process of secondary intention is intentionally interrupted, usually after the
granulation phase, and the wound is mechanically closed (Chhabra etal.2017). These
wounds may suffer debridement, be temporarily ‘packed’ with gauze or other material
and may or may not have applied ‘wound vacs’, plastics or other synthetic devices
(NHSN2024). Planned tertiary wound closure has been described as effective in high- risk
abdominal wounds during gynaecologic surgery (Kelly etal.2022).
Coagulation
Vasoconstriction
Vasodilation
Polymorphonuclear neutrophils predominant
Fibroplasia and granulation tissue formation
Inflammation
Macrophages predominant
Maturation and remodeling
Angiogenesis
Epithelialization
123
Minutes 60 Hours 24 48 Days 7 14 Weeks 7 10 Months 12 Years
4 5 10 20 30 1 2 3 4 5 6 12 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2
Contraction
– incomplete basement membrane
– complete basement membrane
50% of normal tissue strength
FIGURE5.4 Phases of wound healing. Figure attribution: Mikael Häggström, Public domain,
via Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/File:Wound_
healing_phases.svg.
58 Chapter 5 Assisting with Surgical Incisions and Wound Closure
Techniques forSkin Closure
Suturing
The essential materials to consider in any suturing are the needle, the suture material
and the instruments required, namely the appropriate needle holder, forceps and
suture- cutting scissors. Needles can vary in both body curvature and shape of the tip.
They need to, generally, be rigid, slim and sharp enough to resist distortion or cause
trauma with the intended use, and they need to be easily held without rotating
(Mastenbjörk and Meloni2019). A ‘cutting’ (as opposed to ‘tapered’ or ‘round’) needle is
the most appropriate type for closing skin, which is a tough tissue that can neverthe-
less tear, because it is bevelled and has sharp edges (Ballweg etal.2013).
Sutures vary hugely, between being natural (e.g. silk) or synthetic (e.g. nylon or
monocryl), formed of mono or multifilament (also called ‘braided’) materials, being
absorbable (such as polyglactin, of which Vicryl
TM
is an example) and non- absorbable
(e.g. prolene), in their sizes (the higher the number, the smaller is the size) and in sev-
eral characteristics (tensile strength, plasticity, elasticity, memory, pliability, biocom-
patibility and antibacterial properties), and there are all kinds of combinations of
these aspects (Saalabian etal.2011; Mastenbjörk and Meloni2019).
For closing a surgical wound at the skin level, a non- absorbable suture with a
cutting needle is the most indicated (or one with extended absorption of up to six
months) because of the time that skin takes to heal (longer than the colon or bladder,
for example) (WHO2005; Azmat and Council2023).
Other Closing Devices
Other closing materials include tissue adhesives (or ‘glue’, indicated for topical appli-
cation in easily approximated skin edges), staples (less affordable than sutures, but
appropriate for speedy and particularly infection- prone closures) and tapes/strips
(usually as additional reinforcement for sutures) (Saalabian et al. 2011; Ballweg
et al.2013). The same principles of eversion of wound edges and of appropriate
tension apply.
Assisting withWound Closure
Assisting with wound closure demands knowledge of the several layers to be closed,
of the appropriate materials for each and of some fundamental principles (WHO2005;
Ballweg etal.2013):
• Closure in layers, matching opposite sides of each structure which, at the skin
level, allows for the technique of ‘everting the skin edges’, whereupon the tis-
sues fall back into a flat scar when sutures are removed or slowly absorbed.
• Landmarks (e.g. wrinkles, birthmarks and tattoos) need to be matched.
Wound Closure 59
• Sutures need to be placed equidistantly (or at incremental compensating
distances, if the wound is not linear) to avoid ‘dog- ears’.
• The tension applied on the wound by closure needs to be just adequate, making
the edges just barely touch, to avoid necrosis and prolonged inflammation
of tissues.
• Any dead space (which can host haematomas and/or offer a nidus for infec-
tion) needs to be removed, namely with the help of a few well- spaced deeper
sutures where needed.
The SFA can assist with everting skin edges with appropriate (usually ‘toothed’)
forceps and in ensuring proper alignment. In continuous suturing techniques, (such
as subcuticular or running sutures), the SFA can assist by following the suture to keep
the exact tension applied by the surgeon (and therefore avoiding the need to pull at
intervals, as the lone surgeon must do, and which can cause sutures to break) and to
keep the suture out of the way. In interrupted sutures (simple, vertical mattress or
horizontal mattress), assisting means cutting both ends of the suture every time it has
been tied, at a distance which will not lead to easy unravelling of the knot, but won’t
be unnecessarily long and risk hosting more microbes.
Closing aSurgical Wound
The SFA with an extended scope of practice may undertake the closing of the skin,
under the direction of the operating surgeon. There are many useful guides in suturing
technique and knot tying, and it is only through experiential practice and skills labs
that correct techniques can be developed.
Suturing techniques include interrupted simple, continuous simple, vertical
mattress, horizontal mattress, subcuticular, purse- string and retention/tension
(WHO 2005). There are other variations, such as the running locked suture, the
running horizontal mattress suture or the more advanced winch suture. The indica-
tions of each technique are too numerous to describe, and the steps for each are taken
up in entire books in surgical technique. The most important principles are (Masten-
björk and Meloni2019):
• Prior to suturing, the needle and suture must be checked as adequate.
• The needle holder should be held in the dominant hand, between the thumb
and ring fingers.
• The needle should be placed in the jaws of the needle holder at one- third the
distance from the eye and two- thirds from the tip and at right angles to it, both
in the vertical and in horizontal planes.
• The tissue forceps should be held as a pen in the non- dominant hand.
• To take the ‘bite’, the forceps should be used to gently evert the edge and allow
visualisation, and the needle should enter at right angles to the wound surface
and then be pushed following its natural curvature.
60 Chapter 5 Assisting with Surgical Incisions and Wound Closure
• The needle should be released and then pulled along the rest of its curvature
and along the suture material by grasping its emerging end with the
needle holder.
• The depth of, and the distance between, the bites must ensure exclusion of
dead space and proper alignment between edges.
• The most comfortable tends to be suturing from the dominant side to the non-
dominant side and/or from further to closer to the operator.
Significant variability also exists regarding know tying, and experiential learning
with concurrent feedback is critical. Sutures can be tied using instruments, one hand
or both hands and it is likely that SFAs will follow the common practice of the sur-
geons they assist. Intense repetition is essential, and some surgical trainers may also
recommend practice with the non-
dominant hand to achieve ambidexterity. The most
common surgical knots include square knot, surgeon’s knot, slip knot, reef knot and
Aberdeen knot. Essential principles of know tying include making them tight enough
to secure the suture and approximate the edges, but not too tight as to strangulate the
wound, and placing the knot not directly over the wound, but to one side of it (Mas-
tenbjörk and Meloni2019).
Wound Drainage
The placement of wound drains also falls out of the scope of SFA’s practice, but
knowledge of their indications and of the most appropriate draining techniques
for specific procedures is essential to their overall and specialist professional
knowledge as SFAs.
Drains can be left in cavities or surgical wounds to remove blood, pus or other
fluid which may otherwise accumulate in the cavity or wound. Passive, open
latex drains, for example, are placed in deep oozing wounds to prevent the
formation of haematomas, while suction (active) drains are used as standard in
chest pleural drainage and chest surgery, abdominal surgery and plastic surgery
flap procedures, for example (WHO2005; Ramesh etal.2023). Drains should be
closed systems, kept as short as possible to avoid the risk of retrograde infection
and placed near (but not in direct contact with) any anastomotic site (Ramesh
etal.2023).
The SFA with an extended scope of practice may undertake suture and secure
wound drains and slightly different techniques can be used. Generally, a non-
absorbable suture is tied as an anchoring stitch on the skin close to the site where the
drain exits, and then the ends of the suture circle and are tied around the drain, caus-
ing indentation but not strangulation. A technique seen in cardiothoracic surgery
includes placing an extra simple interrupted suture across the wound before the drain
is passed through it, which is left loose (the ends are tied to one another distantly to
the wound to ensure the suture does not slip out) but later on tied to close the drain
exit wound once it is removed from the thorax.
References 61
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65
Surgical First Assistant: The Essentials of Practice, First Edition. Edited by Julie Quick and Mark Owen.
© 2025 John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 6
Assisting withHaemostasis
During Surgery
Georgina Lewis
Surgical Care Practitioner at Gloucestershire Hospitals NHS Foundation
Trust(GHNHST) and Casual Lecturer at Birmingham City University (BCU),
Birmingham UK
INTRODUCTION
“Haemostasis” is derived from the Greek ‘haem’ meaning blood, and ‘stasis’ meaning ‘to
stop’ (Whalan2006). Bleeding can occur during any surgical procedure with haemor-
rhage being associated with worse patient outcomes and more technically challenging
surgery (Frew etal.2021). Bleeding may be classified as ‘primary’ which is bleeding at
the time of surgery, ‘Reactionary’ which is bleeding which occurs within 24 hours of sur-
gery or ‘Secondary’ which occurs 7– 10days post- operatively. Secondary haemorrhage is
often due to erosion of a vessel from a spreading infection, such as when a heavily con-
taminated wound is closed primarily (Qureshi and Tai 2018; Guest2021). Successful
treatment of bleeding requires early recognition, a planned response and readily avail-
able resources (Shah etal.2023). The Perioperative Care Collaborative (PCC) (2018) posi-
tion statement identifies that the SFA should be competent in assisting with haemostasis,
to secure and maintain a clear operating field, including the indirect application of sur-
gical diathermy by the surgeon. However, only surgeons or those working in enhanced
roles, such as a surgical care practitioner (SCP) should directly apply haemostatic treat-
ments such as diathermy or sutures (RCS2023). This chapter explores the principles of
haemostasis and the role of the SFA in identifying risks, as well as assisting with the main
methods of achieving haemostasis.
66 Chapter 6 Assisting withHaemostasis During Surgery
SFAs must ensure that they are accustomed to the methods of achieving surgical
haemostasis and understand the standard haemostatic mechanisms (Hall etal.2016).
Particularly in emergency situations, such as intra- operative bleeding, it is important for
the SFA to remain calm, effectively communicate and ensure safety.
PRESSURE
The application of direct pressure is often the initial treatment for bleeding. Direct
pressure maintained for 15– 20 seconds on an injured vessel may be sufficient to control
the bleed. Arterial bleeding is generally easier to identify due to the stronger outer walls
of the artery generating a pulsatile flow of blood (see Figure6.1). Pressure applied either
manually or applying a clamp can control this bleeding (Chee et al. 2016). Venous
bleeding, on the other hand, can potentially be more dangerous as the relatively thinner
walls of veins mean that the source of the bleeding may be harder to identify and poten-
tially more difficult to control (Chee et al.2016). This can result in more sustained
bleeding, which is harder to control and potentially life threatening (Celentano
etal.2014). Pressure provided by the SFA can minimise blood loss while the surgeon
prepares a more definitive technique.
Pressure may also be applied in the form of packing. This technique may be utilised
as a temporary measure where pressure is applied until control is re- established or in
some circumstances, packs may be applied over the bleeding site and the patient closed
FIGURE6.1 The structure of blood vessels. Source: Begoon/Wikimedia Commons/CC BY 3.0.
Lumen
Endothelium
Smooth
muscle
Adventitia
Artery
Internal
elastic lamina
Basement
membrane
Vein
Lumen
Val ve
Endotheliu
m
Smooth
muscle
Adventitia
Venules
External
elastic lamina
Arterioles
Cross-sectional area
Arteriole Capillaries
Thoroughfare channel
Basement
membrane
Capillaries
Erythrocyte
(red blood cell)
Basal lamina
Pericyte
Endothelium
From heart
To heart
<