Postexposure prophylaxis for deadly bloodborne viral infections.

The purpose of this report is to discuss management of operating room personnel who have had occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and human T-cell lymphotropic virus type I (HTLV-I). HBV postexposure prophylaxis includes starting hepatitis B vaccine series in any susceptible unvaccinated operating room personnel who sustain an exposure to blood or body fluid during surgery. Postexposure prophylaxis with hepatitis B immune globulin (HBIG) is an important consideration after determining the hepatitis B antigen status of the patient. Ideally, all operating room personnel should be vaccinated with hepatitis B vaccine before they pursue their career in surgery. Immune globulin and antiviral agents (eg, interferon with or without ribavirin) should not be used for postexposure prophylaxis of operating room personnel exposed to patients with HCV; rather, follow-up HCV testing should be initiated to determine if infection develops. Postexposure prophylaxis for HIV involves a basic four-week regimen of two drugs (zidovudine and lamivudine; lamivudine and stavudine; or didanosine and stavudine) for most exposures. An expanded regimen that includes a third drug must be considered for HIV exposures that pose an increased risk for transmission. When developing a postexposure prophylaxis regimen, it is helpful to contact the National Clinicians' Postexposure Prophylaxis Hotline, (888) 448-4911. Prevention should be a major consideration in postexposure prophylaxis with the use of the double-glove hole indication system by all operating room personnel.

Reducing accidental injuries during surgery.

All surgical healthcare professionals and their patients should be aware of exposure to blood from individuals infected with potentially transmissible disease. The site that was most susceptible to sharp injuries was the index finger of the surgeon's hand. It is also important to note that needles cause the vast majority of sharp injuries. During the last two decades, there have been two revolutionary advances in preventing accidental needlestick injuries during surgery that include the development of blunt tapering point needles as well as the double-glove hole indication systems. During the innovative development of blunt taper point needles, a glove manufacturer, Molnlycke, Inc., devised non-latex and latex double-glove hole puncture indication systems that are being used throughout the world. The reliability of these double-glove hole indication systems in detecting holes in the outer glove has been reliably documented by scientific studies that are published in peer-reviewed journals. On the basis of these extensive quantitative studies, the authors recommended that the double-glove hole indication system be used in all operative procedures to prevent the transmission of deadly bloodborne viral infections.

Scientific basis for the selection of surgical staples and tissue adhesives for closure of skin wounds.

During the last four decades, there have been revolutionary advances in the development of skin staples as well as tissue adhesives. One of the purposes of this collective review is to provide an overview of recent advances in the development of metal and absorbable skin staples and tissue adhesives. In addition, we will provide technical considerations in the use of metal and absorbable skin staples and tissue adhesives during surgery. On the basis of extensive experimental studies, we would recommend the Autosuture™ Multifire Premium™ metal skin stapler. During a surgical operation, the rotating head of this skin stapler can have its skin stapling cartridge removed once for additional stapling. The revolutionary Insorb™ subcuticular skin stapler is designed to combine the cosmetic result of absorbable sutures with the rapid closure times associated with metal skin staplers, while eliminating the need for metal staple removal postoperatively. The Insorb™ absorbable staple is composed of a copolymer that is predominantly polylactide, which is absorbed over a period of a few months. The superior performance of the Insorb™ absorbable staple has been confirmed by experimental and clinical studies. In the last 20 years, surgeons have become increasingly interested in replacing sutures by means of adhesive bonds in the closure of surgical wounds. A recent collective review of clinical studies done with tissue adhesive has recommended that there is a need for well-designed randomized, controlled trials comparing tissue adhesives and alternate methods of closure, especially in patients whose health may interfere with wound healing.

Wound closure sutures and needles: a new perspective.

Ideally, the choice of the suture material should be based on the biological interaction of the materials employed, the tissue configuration, and the biomechanical properties of the wound. Measurements of the in vivo degradation of sutures separate them into two general classes: absorbable and nonabsorbable sutures. The nonabsorbable sutures and absorbable sutures are classified according to their origin. When considering an absorbable suture's tensile strength in vivo, we recommend that the manufacturer provides specific recommendations of its holding strength, rather than the percentage retained of its initial tensile strength. The newest advance in nonabsorbable sutures is polybutester suture, which is a block copolymer that contains butylene terephthalate (84%) and polytetramethylene ether glycol terephthalate (16%). The expanded polytetrafluoroethylene (ePTFE) suture has been expanded to produce a porous microstructure that is approximately 50% air by volume. The clinical performance of polybutester suture has been enhanced by coating its surface with a unique absorbable polymer. A search for a synthetic substitute for absorbable collagen sutures led to the development of the POLYSORB™ sutures that can reliably approximate tissues with a low risk for infection. The latest innovation in the development of monofilament absorbable sutures has been in the rapidly absorbing CAPROSYN™ suture. A new high-nickel stainless steel, SURGALLOY™, has been used recently to manufacture surgical needles. Biomechanical performance studies of cutting edge needles made of S45500 stainless steel alloy and SURGALLOY™ stainless steel demonstrated that needles made of SURGALLOY™ had superior performance characteristics over those made of S45500.

Scientific basis for the selection of skin closure techniques.

This scientific article was designed to teach the individual reader the scientific basis for suture and needle selection as well as to illustrate the appropriate surgical techniques involved in wound repair of skin incisions. Because the US Food and Drug Administration permits 1.5% of the sterile surgical gloves to have holes, the operating room personnel should wear sterile surgical double-glove hole indication systems that detect holes in the outer glove. From the surgeon's point of view, the rate of gain of strength of the skin wound is a key determinant of many decisions including when the suture can be removed, the level of patient activity, and the selection of the incision. Important considerations in wound closure are type of suture and mechanical performance, in vivo and in vitro. Measurements of the in vivo degradation of sutures separate them into two general classes, absorbable and nonabsorbable. Sutures that undergo rapid degradation in tissues, losing their tensile strength within 60 days, are considered absorbable. Those that maintain their tensile strength for longer than 60 days are considered nonabsorbable. For skin closure with nonabsorbable suture, we favor the use of the polybutester suture that is coated with an absorbable polymer, VASCUFIL™. When absorbable sutures are used for a dermal skin closure, the synthetic monofilament MAXON™ is recommended. Absorption of the suture is complete between 90 and 110 days. In either case, we would recommend that the suture be attached by a sewage attachment to a SURGALLOY™ reverse cutting stainless steel suture. Continuous percutaneous suture closure has definite, distinct advantages over interrupted suture closure. Although continuous dermal wound closure is technically more challenging for the surgeon than interrupted dermal suture closure, it has become an important wound closure technique. A monofilament absorbable synthetic MAXON™ attached to a reverse cutting edge SURGALLOY™ stainless steel needle is ideally suited for continuous dermal skin suture closure.

Scientific basis for the selection of vascular closure techniques.

If this educational program heightens the surgeon's, resident's, and student's interest in the biology of vascular wound closure and infection, the long years occupied in our search for improved methods of wound management would more than fulfill our expectations. As with any master surgeon, he/she must understand the tools of his/her profession. This linkage between a surgeon and surgical equipment is a closed kinematic chain in which the surgeon's power is converted into finely coordinated movements that result in vascular wound closure with the least possible scar and without infection. The description of wound repair of blood vessels will be confined to arterial surgery in which the surgeon attempts to establish a new non-wettable intima and to reestablish a strong elastic muscular media. Repair of vessel wall wounds is encountered in arteriotomy for vascular access as well as in artery-to-artery anastomoses. In both circumstances, wound repair is primarily at the suture line. The surgical needles of Syneture™ are produced from stainless steel alloys, which have excellent resistance to corrosion. A new high-nickel stainless steel, SURGALLOY ™, has been used recently by Syneture™ to manufacture surgical needles. We prefer a polybutester monofilament suture whose surface is coated with an absorbable polymer. This absorbable coating of the VASCUFIL™ monofilament sutures markedly reduces its drag forces in vascular tissue. The surgeon can practice using these sutures in femoral arteriotomies in animals.