SCS wound closure

[NJPAIN]

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I know this has been discussed in the past so forgive me if it is repetitive.

As a non-surgeon wound closure remains the most challenging part of an SCS implant. I know it is not rocket science and that is why I do the implants (albeit not as frequently as I would like) myself rather than use a surgeon as I had in the first 15 yrs of practice. Regardless, the wound is what the patient sees on the surface and frequently uses to evaluate your work. Though I know that there is no substitute for experience, I get some comfort out of finding out the techniques and tricks of others. There really is nearly nothing in texts, etc that I have found that provides useful guidance in closing a wound in that region of the body. I would appreciate it if those of you who regularly do your own implants would share you techniques, tips, tricks, photos, references, etc.

 

[Jcm800]

briefly...

10 blade, bovie. I bovie the pocket. i use to use my fingers, but it hurts more and they bruise like crazy. But it works well with fingers especally in the old. Hemostatis with bovie, dont burn the skin, it looks bad. Irrigate like mad. close with 0-vicryl pop-offs, simple interupted for a deep layer. Run a 2-0 and close with either 4-0 vicryl or dermabond, or both sometimes


is that what you are asking about?

I know this has been discussed in the past so forgive me if it is repetitive.

As a non-surgeon wound closure remains the most challenging part of an SCS implant. I know it is not rocket science and that is why I do the implants (albeit not as frequently as I would like) myself rather than use a surgeon as I had in the first 15 yrs of practice. Regardless, the wound is what the patient sees on the surface and frequently uses to evaluate your work. Though I know that there is no substitute for experience, I get some comfort out of finding out the techniques and tricks of others. There really is nearly nothing in texts, etc that I have found that provides useful guidance in closing a wound in that region of the body. I would appreciate it if those of you who regularly do your own implants would share you techniques, tips, tricks, photos, references, etc.

 

[NEPain]

JCM, are you closing in 3 layers? the vicryl pop offs, the 2-0 running, and then 4-0 vicryl?

FWIW, I also irrigate a lot, and close in two layers, interrupted vicryl, and a running absorbable subcuticular.

Some people I know like to use staples for the skin, some use a running non absorbable to make sure he patient returns for the post op visit-they may not if the suture is absorbable and doesn't need to be removed.

 

[Jcm800]

JCM, are you closing in 3 layers? the vicryl pop offs, the 2-0 running, and then 4-0 vicryl?

FWIW, I also irrigate a lot, and close in two layers, interrupted vicryl, and a running absorbable subcuticular.

Some people I know like to use staples for the skin, some use a running non absorbable to make sure he patient returns for the post op visit-they may not if the suture is absorbable and doesn't need to be removed.

I only use absorbable sutures for closure. I will use silk to anchor. if you have a patient that doesnt show up for a post-op visit, you shouldnt be putting it in them...

i usually close three layers, but probably not necessary...i like a deep layer with the 0-pop-offs. then i run a 2-0 for sure. I will often run the 2-0 kinda deep, then for the skin edges either run a 4-0, less likely lately, or use dermabond. I have no problems with staples, i used to use them a lot, and still like them. I will staple pumps more often, because the incision is longer, and i get antsy. Usually the pumps are "deeper" so i have more of a skin edge and i think staples or 4-0 is better then dermabond, but i am too lazy to run the 4-0, so i will staple. If they are thin, then i get away with dermabond.

but yes, 3 layers for me, for which dermabond is a layer.

 

[Aether2000]

Consider ethibond for anchoring. Silk is not a permanent suture, nor a strong suture.

J Surg Res. 1994 Apr;56(4):372-7.
Mechanical comparison of 10 suture materials before and after in vivo incubation.
Greenwald D, Shumway S, Albear P, Gottlieb L.
Source
Division of Plastic Surgery, University of South Florida, Tampa 33606.
Abstract
The material properties of ten 2-O suture materials were evaluated tensiometrically at time = 0 and again after 6 weeks incubation in rats. All suture material was incubated and tested without knots. Specialized machinery was used with a custom securing apparatus to pull suture material apart at constant speed. Stress-strain curves were derived, and from these strength, toughness, strain at rupture, and elastic modulus were determined. Sutures tested included Vicryl [poly(glycolide-lactide)], Dexon (polyglycolic acid), Ethibond (polyester), silk, plain gut, chromic gut, Maxon (polyglyconate), PDS (polydioxanone), nylon, and Prolene (polypropylene). Elastic modulus was greatest for braided, least for monofilament, and intermediate for gut sutures, regardless of chemical composition (ANOVA, P = 0.0001). Strength, strain, and toughness decreased in all of the sutures over time in vivo with the exception of braided polyester (Ethibond), which remained stable. Silk demonstrated the least strength and toughness while PDS and Maxon were the strongest and toughest at time = 0. Vicryl, Dexon, and gut sutures were absorbed to the point that they could not be tested after 6 weeks in vivo. Performance tables are provided for all sutures.

 

[Jcm800]

Ethibond is good.

Consider ethibond for anchoring. Silk is not a permanent suture, nor a strong suture.

J Surg Res. 1994 Apr;56(4):372-7.
Mechanical comparison of 10 suture materials before and after in vivo incubation.
Greenwald D, Shumway S, Albear P, Gottlieb L.
Source
Division of Plastic Surgery, University of South Florida, Tampa 33606.
Abstract
The material properties of ten 2-O suture materials were evaluated tensiometrically at time = 0 and again after 6 weeks incubation in rats. All suture material was incubated and tested without knots. Specialized machinery was used with a custom securing apparatus to pull suture material apart at constant speed. Stress-strain curves were derived, and from these strength, toughness, strain at rupture, and elastic modulus were determined. Sutures tested included Vicryl [poly(glycolide-lactide)], Dexon (polyglycolic acid), Ethibond (polyester), silk, plain gut, chromic gut, Maxon (polyglyconate), PDS (polydioxanone), nylon, and Prolene (polypropylene). Elastic modulus was greatest for braided, least for monofilament, and intermediate for gut sutures, regardless of chemical composition (ANOVA, P = 0.0001). Strength, strain, and toughness decreased in all of the sutures over time in vivo with the exception of braided polyester (Ethibond), which remained stable. Silk demonstrated the least strength and toughness while PDS and Maxon were the strongest and toughest at time = 0. Vicryl, Dexon, and gut sutures were absorbed to the point that they could not be tested after 6 weeks in vivo. Performance tables are provided for all sutures.

 

[drf]

Popoff 2-0 vicryl deep. For pristine skin I subQ 3-0 or 4-0 monocryl and leave the end out and steri stripped after pulling here and there a bit to align wound edge. Then dermabond.

If I want a bit more tension, or going thru a nice previous scar I run a baseball stich 3-4-0.

If I'm even more worried about tension I staple. Or if area is already scarred and I don't mind adding some more.

 

[lobelsteve]

0 vicryl deep, 2-0 superficial, dermabond.

Still learning the Anulex peek T anchor speargun thing. I'm just over 50% at getting it into the fascia. If it were 100%, I'd be happier and feel better about it. Easier to use on octrodes than S8's based on the wound created.