EQUINE VETERINARY EDUCATION Equine vet. Educ. (2022) 34 (2) 67-72 doi: 10.1111/eve.13462


67


Clinical Commentary Simple techniques to decrease tension on sutured wounds of horses


G. Kelmer†* , E. Cypher‡ and J. Schumacher‡ †Large Animal Department, Veterinary Teaching Hospital, Koret School of Veterinary Medicine, The Robert H.


Smith Faculty of Agriculture, Food & Environment, The Hebrew University of Jerusalem, Rehovot, Israel; and ‡Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee, USA *Corresponding author email: gal.kelmer@mail.huji.ac.il


Keywords: horse; technique; tension; suture; wound closure


The report by Jansson et al. (2022) in this issue describes the use of random skin flaps to heal wounds of two horses. In one case, a Z-plasty was used successfully to aid closing a wound created when a sarcoid was excised from the horse’s face, and in the other case skin expanders and a rotational flap were used to close a fresh cutaneous defect, created by excising a chronic wound on the distal portion of the limb. Each technique was used to allow a cutaneous defect to be closed primarily, without tension. There is limited information describing clinical use of Z-


plasty and skin expanders in horses (Bowman and Swaim 1982; Whittaker et al. 2020), so the preceding article provides valuable information for equine practitioners. This accompanying clinical commentary describes basic techniques that can be used to allow cutaneous defects to be closed without tension. Horses are wounded frequently due to their flighty nature,


and these wounds are often accompanied by avulsion of skin, necessitating the use of tension-relieving techniques to enable primary repair. This is true especially of wounds of the extremities, where skin cannot be advanced easily to allow for tension-free primary repair. Skin can be stretched to close large wounds primarily


(Stashak and Schumacher 2016). Stretching relies on the viscoelasticity of the skin, which allows skin to elongate, when tensed, by mechanical creep and stress relaxation. Mechanical creep enables skin to be stretched, over time, beyond its normal limits of extensibility, when placed under a constant tension. It occurs because constant tension applied to skin straightens the randomly oriented collagen fibres in the dermis. When the skin is stretched, the tension required to hold it at a constant length decreases gradually, and this reduction in tension is referred to as stress relaxation. Simple techniques used to relieve tension on sutured wounds rely heavily on these biomechanical properties of the skin and include the following: presuturing the wound; applying a mesh overlay; applying tension sutures, such as horizontal or vertical mattress sutures, walking sutures or near-far-far-near (NFFN) tension sutures; and applying a skin stretching device. Another simple technique to relieve tension on a sutured incision, one that does not rely on stress relaxation, is to create relief incisions adjacent to the sutured wound. Presuturing entails placing heavy sutures preoperatively to


imbricate and stretch skin over a mass to be removed (Harrison 1991; Zide 1994). Sutures are placed using an inverting suture pattern, such as a Lembert suture pattern, 2– 8 h before the mass is to be removed. Sutures are inserted with the horse sedated and the surgical site desensitised with


local or regional anaesthesia. These sutures maximally stretch the skin surrounding the mass or wound, allowing the wound to be closed primarily after the mass has been excised. This is a simple, inexpensive method used to close a cutaneous wound, created by removing a lesion, that otherwise could not be closed (Fig 1). A mesh can be used to relieve tension on a wound


sutured under excessive tension, similar to the method that is used for repairing incisional body wall hernias (Kelmer and Schumacher 2008). Using this technique, a polypropylene or polyester mesh is centred over the sutured wound, and one edge of the mesh is anchored to the underlying skin using nonabsorbable sutures, inserted using a simple-interrupted pattern. The opposite edge of the mesh is anchored to the skin on the opposite side of the sutured wound using preplaced sutures inserted using a Mayo mattress suture pattern (also referred to as the vest-over-pants suture pattern). Tension on the sutured wound is transferred to the mesh when the preplaced sutures are tightened and tied. Two or more staggered rows of simple-interrupted sutures anchoring the mesh to skin are placed axial to each sutured


a)


b)


Fig 1: Illustration demonstrating presuturing to allow mass removal and skin apposition with less tension allowing primary closure.


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