vicryl rapide wound breakdowns

Re: vicryl rapide wound breakdowns

Charlotte Marshall — Wed, 15 Jan 2014 17:46:08 GMT

I like horizontal mattress sutures myself though I do use cruciate and inverted cruciate (and simple interrupted) sometimes. My boss thinks horizontal mattress sutures don't look as neat but they do if you do them properly. He likes simple interrupted for everything but if there has been any tension on the wound I find his stitches can be fiddly to remove!

I've never tried the vicryl rapide we just have the ordinary stuff. I normally only use it intradermally. I do find that when colleagues have used it externally to stitch pads it does not seem to last long enough.

Re: vicryl rapide wound breakdowns

Hannah Wynne Richards — Wed, 15 Jan 2014 16:51:49 GMT

We were once having a glasses hunt-------------- they were on top of my head.

Wynne

Re: vicryl rapide wound breakdowns

Linda Filshie — Wed, 15 Jan 2014 15:52:32 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Linda Filshie"]Which bit of extra buried suture material would that be? The criss -cross bit is tied above the skin, the amount of suture material "in" the animal is the same as for a horizontal mattress. It's essentially just a modified mattress, so I don't quite understand the aversion.[/quote]

Somebody's just said that they ought to be done upside-down, so the extra bit of material is buried.

[/quote]

Possible. Not ought. I'm not usually one for pedantry, but I think there's sufficient distinction between the words to make it necessary.

Re: vicryl rapide wound breakdowns

Evelyn Barbour-Hill — Wed, 15 Jan 2014 15:52:06 GMT

[quote user="Glenn Hodgson"] My 1st boss used to put them in good and tight to "stop them coming undun".... I then had to dig them out/remove them.[/quote]

Urghh Competence is important in any pattern!

Seeing as we're way off topic: do lots of you use a stitch-cutter scalpel to remove sutures.... and if so do you use it one-handed (no forceps)? I've never done anything but pull the knot up (with forceps or often just finger and thumb) and cut underneath with stitch scissors. If you can't pull the knot up to show a bit of loop, you did 'em too tight in the first place.

The greatest difficulty for me these days is that I have to put my glasses on, and I've always left them somewhere.....

Re: vicryl rapide wound breakdowns

Evelyn Barbour-Hill — Wed, 15 Jan 2014 15:36:23 GMT

Somebody's just said that they ought to be done upside-down, so the extra bit of material is buried.

[quote user="Linda Filshie"] Fewer knots to cut in a wriggling patient than for SI...[/quote]

Is that really a serious consideration? If so, again, using nice horizontal mattress will halve the number of knots.

What I would say is that I don't understand the aversion to simple interrupted.

I'm going to make myself really unpopular here, so first can I say I'm not attacking all you people using the criss-cross things, and all those other exciting near-near-far-far-near Victor Sylvester patterns, very successfully. I'm beginning to hold the opinion that many of these patterns have been adopted at the insistence of university lecturers, who don't really know that the pattern is superior, but do get bored with the skin once they have cleverly performed their ever-so-clever internal surgery and just want to whop it back together by the quickest possible means.

Re: vicryl rapide wound breakdowns

Hannah Wynne Richards — Wed, 15 Jan 2014 12:02:02 GMT

I'd just order him to stop. It's obviously a problem, so he can either like it or lump it.

Wynne

Re: vicryl rapide wound breakdowns

Linda Filshie — Wed, 15 Jan 2014 11:32:28 GMT

[quote user="Mark Holmes"]Linda - didn't want to quote loads of text. Yes that it the picture in slater but it is is dpossible to turn the whole thing upside down. The cruciate part - the cross is then buried. Visually it looks - and behaves like two simple interrupted sutures. Only one will have a knot.

[/quote] Ah-ha, all becomes clear! Not a pattern I was ever taught/have seen used in UK or overseas - though I would describe it as an inverted cruciate :p Totally off topic, I know. I shall stop now!

Re: vicryl rapide wound breakdowns

Anthony Todd — Wed, 15 Jan 2014 10:38:29 GMT

[quote user="Michael Woodhouse"]

Buster collars are the spawn of Satan and used to cover up for bad technique.

Gentle tissue handling, not over-tight sutures and adequate analgesia and you just don't need them.

[/quote]

+1 to that but shouldn't be a need for analgesia either unless there was pre-existing tissue trauma. Surgeons should aim to be atraumatic!!

That goes for human surgeons as well!!!

Re: vicryl rapide wound breakdowns

Francisco Gomez — Wed, 15 Jan 2014 10:17:20 GMT

Coming back to the issue of using vicryl rapid on skin wounds...

The vast part of the wound tension in my ops is dealt with before the last set of skin sutures. I do only use skin sutures to 'appose' the edges of the wound really. Not sure how a different sort of material would make that much more of an issue.

I use single interruptus non absorbable sutures in most of my ops. Unless the patient is unhandable, then normal vicryl so I don't have to ga/sedate to take them off.

Re: vicryl rapide wound breakdowns

Glenn Hodgson — Wed, 15 Jan 2014 09:47:26 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Glenn Hodgson"]Cruciate sutures vs simple. Faster to place,[/quote]

Minutely. But if you are anxious to save that tiny bit of knot-tying time, why not use nicely-done horizontal mattress sutures? Neat and exact apposition of cut edges, damn nearly as good as simple, without the extra buried suture material of the criss-cross things.

[quote user="Glenn Hodgson"] easier to remove.[/quote]

How so?

[/quote]

Not Anxious, Takes more that a bit of string to make me anxious. Felt like I needed to justify Myself tough.

I don't use those mattressy thingies over cruciate out of habit. My 1st boss used to put them in good and tight to "stop them coming undun".... I then had to dig them out/remove them. Also in my hands cruciates give neat and exact apposition of cut edges, more so than Mattress would as I haven't used them for 10 years.

Extra burried crissycrossy bit> Hasn't crossed my mind to bother about this until now. I agree it is a con. though.

Easier to remove, how so>.

Half as many of them vs. SI. and a longer cutty bit vs. SI and mattress. You will clearly see this from my diagram below Cutty bit A is longer than cutty bit B.

)

Re: vicryl rapide wound breakdowns

Mark Holmes — Wed, 15 Jan 2014 07:27:26 GMT

Linda - didn't want to quote loads of text. Yes that it the picture in slater but it is is dpossible to turn the whole thing upside down. The cruciate part - the cross is then buried. Visually it looks - and behaves like two simple interrupted sutures. Only one will have a knot.

Re: vicryl rapide wound breakdowns

Michael Woodhouse — Tue, 14 Jan 2014 23:45:57 GMT

I use cruciates for skin in almost everything (cat spay to cow caeser). You don't need to do them tight, that's when you get problems. Because of the extra material it is easier to get the blade under the suture to remove.

Re: vicryl rapide wound breakdowns

Linda Filshie — Tue, 14 Jan 2014 23:26:23 GMT

[quote user="Evelyn Barbour-Hill"]

[/quote] Which bit of extra buried suture material would that be? The criss -cross bit is tied above the skin, the amount of suture material "in" the animal is the same as for a horizontal mattress. It's essentially just a modified mattress, so I don't quite understand the aversion.

I was going to draw a picture but Dr Google saved me from my own inept artistry: here's what I understand to be a cruciate suture - from Slatter [quote user="Evelyn Barbour-Hill"]<

[quote user="Glenn Hodgson"] easier to remove.[/quote]

How so?

[/quote] Fewer knots to cut in a wriggling patient than for SI...

Re: vicryl rapide wound breakdowns

Evelyn Barbour-Hill — Tue, 14 Jan 2014 23:11:43 GMT

[quote user="Glenn Hodgson"]Cruciate sutures vs simple. Faster to place,[/quote]

[quote user="Glenn Hodgson"] easier to remove.[/quote]

How so?

Re: vicryl rapide wound breakdowns

Glenn Hodgson — Tue, 14 Jan 2014 23:01:27 GMT

Cruciate sutures vs simple. Faster to place, easier to remove. Justified

Seriously though, surgeon pref imporrant. As long as it works!

Re: vicryl rapide wound breakdowns

Mark Holmes — Tue, 14 Jan 2014 22:55:21 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Mark Holmes"]What's wrong with cruciate sutures?[/quote]

Clumsy and leave a scar.

[quote user="Mark Holmes"]Personally don't find vicryl great for skin as the knots are prone to unravel too easily, if I do I place a drop of skin glue on the knot to secure it.[/quote]

If it unravels too easily when you've pulled it (the knot of course, not the suture!) properly tight, you are using too heavy a gauge of material.

[/quote] If you put the cruciate suture in upside down it doesn't scar. You are left with two horizontal lines. One with a knot.

Re: vicryl rapide wound breakdowns

Utlendigur — Tue, 14 Jan 2014 22:55:07 GMT

[quote user="Evelyn Barbour-Hill"]Anyone who wishes to use (as an external skin suture) anything more complicated than simple interrupted (or horizontal mattress interrupted, with a minimal bite, at a pinch) needs to be able to justify their choice. [/quote]

[quote user="Mark Holmes"] What's wrong with cruciate sutures? Personally don't find vicryl great for skin as the knots are prone to unravel too easily, if I do I place a drop of skin glue on the knot to secure it.[/quote]

They pucker the skin. Even placed loosely they seem to dig in as the skin edges swell. If there's any blood or discharge from the wound it collects under the sutures (more so than simple interrupted) and turns into solid lumps round the knots. Seem to cause more irritation -> more patient interference with wounds.

Going back to the original problem - not sure how the rotas/branches work but could you book a few of the disgruntled clients in with the vet who is using the rapide "just for a final check". Post-op discharge sheets including which vet did the op are also useful

Re: vicryl rapide wound breakdowns

Evelyn Barbour-Hill — Tue, 14 Jan 2014 22:52:40 GMT

[quote user="Mark Holmes"]What's wrong with cruciate sutures?[/quote]

Clumsy and leave a scar.

[quote user="Mark Holmes"]Personally don't find vicryl great for skin as the knots are prone to unravel too easily, if I do I place a drop of skin glue on the knot to secure it.[/quote]

If it unravels too easily when you've pulled it (the knot of course, not the suture!) properly tight, you are using too heavy a gauge of material.

Re: vicryl rapide wound breakdowns

Mark Holmes — Tue, 14 Jan 2014 22:38:41 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Marie Kubiak"] Where breakdowns have occurred it has been used as external skin sutures not intradermals. Both as cruciate sutures and a ford interlocking pattern (that one really didn't last long...). So perhaps switching to an intradermal pattern may be as suitable as changing the material.[/quote]

Anyone who wishes to use (as an external skin suture) anything more complicated than simple interrupted (or horizontal mattress interrupted, with a minimal bite, at a pinch) needs to be able to justify their choice.

[/quote] What's wrong with cruciate sutures? Personally don't find vicryl great for skin as the knots are prone to unravel too easily, if I do I place a drop of skin glue on the knot to secure it.

Re: vicryl rapide wound breakdowns

Evelyn Barbour-Hill — Tue, 14 Jan 2014 19:29:26 GMT

Re: vicryl rapide wound breakdowns

Evelyn Barbour-Hill — Tue, 14 Jan 2014 19:22:53 GMT

[quote user="Michael Woodhouse"]

Buster collars are the spawn of Satan and used to cover up for bad technique.

Gentle tissue handling, not over-tight sutures and adequate analgesia and you just don't need them.

[/quote]

Re: vicryl rapide wound breakdowns

Martin Atkinson — Tue, 14 Jan 2014 17:58:24 GMT

[quote user="Marie Kubiak"]

[quote user="Martin Atkinson"]The issue here is not the Vicryl Rapide, I frequently use it, including in muscle layers for cat spays, and get no more wound breakdowns than with any other suture materials [/quote]

Interesting - the issue may well be the way it is used then rather than the material itself. Where breakdowns have occurred it has been used as external skin sutures not intradermals. Both as cruciate sutures and a ford interlocking pattern (that one really didn't last long...). So perhaps switching to an intradermal pattern may be as suitable as changing the material.

[/quote] When I use it I tend to do a continuous subcuticular suture with a few (depending on length of wound) simple interrupted sutures with whats left on the reel as the belt and braces. I occasionally use it as simple interrupted or cruciate sutures alone in fractious animals, on digits or places I think it may be difficult to remove sutures and get no problems either way. That said I amputated a tail a few weeks back and used a continuous mattress suture as I would on a pinna for example and it got a marked tissue reaction but the wound was healed, I just had to pick out the fragments of disintegrating VR to expedite full recovery. In this case it may have been more a secondary wound infection with the sutures acting as a nidus

Re: vicryl rapide wound breakdowns

Marie Kubiak — Tue, 14 Jan 2014 17:36:31 GMT

Thank you all for input, really good to have a broad set of views

[quote user="Mark Holmes"] Or you could just say " I'm not comfortable with this and for 3 months we'll be using that" if he's a reasonable adult he should be able to take it!

[/quote]

That should be the way to do it but unfortunately would only result in disagreement and a flat refusal. I fully accept I am pretty rubbish at being tactful so will take some of the blame for this. We do get on well overall but as a younger vet in a different department the expectation is to let the senior vet do what he wants and stay quietly within my area of expertise.

[quote user="Tim Charlesworth"]It should be fine for skin closures (presuming he is using it as a subcuticular or intradermal suture?)[/quote]

[quote user="Michael Woodhouse"]As in intra-dermals or conventional skin sutures? I'd never use absorbable in skin unless 100% buried[/quote]

[quote user="Alet Engelbrecht"]Yeah, aren't we meant to have a system of recording these complications anyway? In our practice we call it the 'cock-up book'[/quote]

They are recorded in a clinical governance book, which was useful - when we were sure we'd had the exact problem before we had a note of it and the cases involved last time round. But as only two of us are willing to use the book then it doesn't do a decent job and is only a token nod at fulfilling the RCVS requirements for practice status.

Marie

Re: vicryl rapide wound breakdowns

John Flynn — Tue, 14 Jan 2014 14:03:36 GMT

[quote user="Michael Woodhouse"]Buster collars are the spawn of Satan[/quote]

I'm sure I read somewhere that they were illegal in Canada and selling one even at a car-boot sale could result in imprisonment... or was that baby-walkers ;-)

Re: vicryl rapide wound breakdowns

Martin Atkinson — Tue, 14 Jan 2014 13:22:52 GMT

[quote user="Michael Woodhouse"]

Buster collars are the spawn of Satan and used to cover up for bad technique.

Gentle tissue handling, not over-tight sutures and adequate analgesia and you just don't need them.

[/quote]We've been here before Michael and I have to say that while the last 7 words of your first sentence (with maybe added before) may be relevant, and the first 10 words of the second sentence are very important you can still consider yourself very lucky if you've never had a pet interfere with its sutures after even the most careful surgery. Believe me your luck will change one day. Either that or you are in denial.