The Starting Point:  Basic Surgical Skills                                             

Skin Incision Key Points (Scalpel)

• Plan your incision!
  • Clip fur at least 15cm wide of incision
  • Permanent marker prior to prep or sterile marker after draping (if needed)
  • If possible, follow lines of tension (final closed incision will be on/parallel to a line of tension)
  • Do not create a “biological tourniquet” with closure; it is better to leave it open a centimeter or so…it is not a “failure” it is a “rational plan”. (Best to prep owners that this is coming; if it is a “plan” not a “damn” it is accepted more readily.)
• Hold blade perpendicular to, not oblique to, the skin surface
• Exert enough, but not too much, pressure
  • Use fingers to stabilize/retract the skin perpendicular to incision line, i.e. create tension that the blade “splits”.
  • Advance fingers in stages with blade stopped/in contact with skin
  • Using tension, create and watch the gapping of the incision as you cut—adjust pressure every millimeter as you go
• Pencil grip—incisions < 3 cm
• Finger tip grip—long incisions
• Do not “saw” with a scalpel; do not repeatedly pickup
• Always brace hand when making a stab incision (“too deep” may be “too bad”)

Tissue handling

• Do not touch tissue unless necessary.
• Do not pickup tissue unless necessary.
• Use thumb forceps on acellular tissue preferentially (fascia vs. skin).
• Sharp dissection is less traumatic than blunt (blade < scissors < blunt dissection < gauze/finger dissection).
• Hemorrhage higher with sharp dissection (blade > scissors > blunt dissection > gauze/finger dissection).
• Blot with gauze—DO NOT wipe.
• Use damp gauze (saline…ring out)

Subcutaneous dissection

• Blade—one layer at a time; use fingers to spread perpendicular to incision **Create tension**.
• Scissors
  • Scissor cut: typical cutting motion; short incisions; do not open completely with each cut; use tips only.
• Push cut: e. running cut, like in cloth/paper; only have small opening in scissor blades; long incisions; less traumatic
• Blunt dissection: increases caution in highly vascular/nervous/vital areas; insert closedà open, small gapà remove open à close and repeat, many little spreads vs. one huge spread.

Subcutaneous closure

• Goal to reduce dead space with minimum of foreign material (suture).
• Bury knots routinely.
• Simple/cruciate interrupted pattern if tension relieving.
• Simple continuous / ”Lembert” if minimal tension.
• Tack to underlying layer every/every other to avoid pocket formation.

Skin closure

• Avoid crushing skin; do not “oppose” needle resistance with thumb forceps pinching skin.
• Needle passes easier when skin under tension

• • Immobilize with forceps on SQ pulling away from cut surface
  • Immobilize with fingers parallel to incision

• Intradermal/subcuticular layer

• • Bury knot 5-10 mm from end of incision
  • Start pattern at the beginning of incision (one technique—dive under knot and come out at very beginning in dermis)
  • Pop needle in dermis, rotate through arc of needle, watch for needle bulge, “whittle” it around until bulge is within dermis, pop out of dermis
  • Dove tail (back up 1-2mm each side) to avoid gapping
  • Smaller bites (less needle arc) in thinner skin to avoid bunching appearance

• Benefits:
  • No suture tract through skin (less bacterial access to incision; more cosmetic)
  • Better incision seal (less bacterial access to incision; more cosmetic)
  • Potentially no suture removal

• Skin sutures
  • 2/3 thickness of dermis à exact apposition (better seal, more cosmetic)
    
  • Use smallest size suture appropriate (3-0 or 4-0 most dogs/cat wounds)
  • Use monofilament (nylon, prolene, surgilene, steel) or coated multifilament suture (Vetafil, Braunamid, Supramid) for skin (exception—silk on eyelids +/- ok; remove 5-7d)
• Consider a “bolster” bandage on moderate/high risk incisions (tension, area of high movement, area of high lick) or all incisions (my preference).  Roll up a cigar of gauze/telfa/abdominal pad/bulk cotton (depending on incision length and patient size) and run a continuous suture over it (lace it up) with enough tension to slightly tent each bit in skin.  This immobilizes the incision, covers incision, reduces incision margin tension, kills deadspace.  Overall useful technique that adds 3-5min to procedure, and creates beautiful incision healing!!!  Remove 3-5d.

Lara Marie Rasmussen, DVM, MS
Diplomate, American College of Veterinary Surgeons
Direct Veterinary Surgery, PC