Complications in Equine Surgery. Группа авторов

are essential in prevention of unnecessary hemorrhage [26].

      Suture needs to be of sufficient size to withstand the tensile forces placed on the loop and shear forces at the knot. Regardless of the knotting technique used, the use of monofilament suture is recommended because it appears to be stronger and provides more efficient hemostasis then multifilament suture [30]. Monofilament suture is also advised for laparoscopic ligating loops because the shape of the loop is usually maintained reasonably well by the increased stiffness [28, 29]. Ligature loops should be tied table‐side rather than pre‐tied and sterilized because sterilization can weaken the suture material and predispose to ligation failure [28]. A 4‐S modified Roeder knot using monofilament suture is recommended for maximal ligature loop strength [28].

      The performance of the single knot loop has been shown to be biomechanically superior to a double knot loop in tensile breaking strength because with the single knot loop the forces are equally divided over the whole ligature, whereas with a double knot loop the two loops of the ligature will have different tensions after every knot [27]. A transfixation ligature can be performed to prevent slippage of the ligature; however, postoperative bleeding may still occur due to ligature failure of one of the double knot loops [27]. Sliding knots have been shown to be quicker and behave similar to or better than a surgeon’s knot in establishing hemostasis of arteries [30].

      Tissue bulk can be overcome by dividing it into smaller sections (“divide and conquer method”) or multiple ligatures can be placed around a bulky structure to improve the hemostasis [26]. Clamping to crush the tissue and reduce its bulk, as well as “flashing” the clamp adjacent to the ligature being placed, are additional techniques for improving vessel occlusion and ligature security [26].

       Diagnosis

      Ligature loop failure can be observed intraoperatively under direct visualization or via laparoscopy. Postoperatively, incisional swelling or hemorrhage from the incision line can develop. Ultrasound and/or aspirate of the swelling are the most common diagnostics used to differentiate a hematoma from seroma or edema formation. Diagnosis of hemorrhage into a body cavity, such as pedicle ligation failure and development of a hemoperitoneum, are discussed in their respective chapters.

       Treatment

      When ligation failure occurs intraoperatively, the cause of the failure should be determined as to whether it is ineffective occlusion (knot slippage), loop slippage, or suture breakage and measures used to correct the failure. The use of ligating clips, staples, electrocautery and other electrosurgical instrumentation can be used in appropriate situations to provide hemostasis after ligature failure [28, 29]. If there is hematoma formation then treatment options differ depending on the degree and location. With mild hemorrhage and hematoma formation no treatment may be needed. For more significant hemorrhaging and hematoma formation there are multiple treatment options. If there is active hemorrhaging then the incision may need to be opened and hemostasis achieved via intraoperative methods discussed. Alternatively, compression or a compression bandage can be an effective means of hemostasis and prevention of hematoma formation.

       Expected outcome

      The prognosis is dependent on the degree of hemorrhage but incisional vessel ligation failure usually has a good outcome once time has been allowed for the hematoma to resolve. However, hematoma formation can increase morbidity to the patient, prolong wound healing time, and can increase treatment costs. Also, even mild hemorrhages can have an impact on the safety and efficiency of a given procedure, as well as effect outcome, depending on the situation [28].

References

      1 1 Mackenzie, D. (1973). The history of sutures. Med. Hist. 17 (2): 158–168.

      2 2 Kümmerle, J.M. (2012). Suture materials and patterns. In: Equine Surgery, 4e (ed. J.A. Auer and J.A. Stick), 181–202. St. Louis, Elsevier.

      3 3 Céleste, C. (2008). Selection of suture materials, suture patterns, and drains for wound closure. In: Equine Wound Management, 2e (ed. T.S. Stashak and C.L. Theoret), 193–224. Ames: Wiley‐Blackwell.

      4 4 Katz, S., Izhar, M., and Mirelman, D. (1981). Bacterial adherence to surgical sutures. A possible factor in suture induced infection. Ann. Surg. 194 (1): 35–41.

      5 5 Claeys, S. (2016). Dehiscence. In: Complications in Small Animal Surgery, 1e (ed. D. Griffon and A. Hamaide), 57–63. Ames: Wiley‐Blackwell.

      6 6 Hanson, R.R. (2009). Complications of equine wound management and dermatologic surgery. Vet. Clin. N. Am. Equine Pract. 24 (3): 66–696.

      7 7 Hendrickson D. and Virgin, J. (2005). Factors that affect equine wound repair. Vet. Clin. N. Am. Equine Pract.: Wound Manag. 21 (1): 33–44.

      8 8 Hendrickson, D.A. (2012). Management of superficial wounds. In: Equine Surgery, 4e (ed. J.A. Auer and J.A. Stick), 306–317. St. Louis: Elsevier.

      9 9 Stashak, T.S. and Yturraspe, D.J. (1978). Consideration for selection of suture materials. Vet. Surg. 7 (2): 48–55.

      10 10 Campbell, A.L., Patrick, D.A., Liabaud, B. et al. (2014). Superficial wound closure complications with barbed sutures following knee arthroplasty. J. Arthroplasty. 29 (5): 966–969.

      11 11 Speer, D.P. (1979). The influence of suture technique on early wound healing. J. Surg. Res. 27 (6): 385–391.

      12 12 Cortez, R., Lazcono, E., and Miller, T. (2015). Barbed sutures and wound complications in plastic surgery: an analysis of outcomes. Aesthet. Surg. J. 35 (2): 178–188.

      13 13 Mair, T.S. and Smith, L.J. (2005). Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 2: Short‐term complications. Equine Vet. J. 37 (4): 303–309.

      14 14 Booth, L.C. and Feeney, D.A. (1982). Superficial osteitis and sequestrum formation as a result of skin avulsion in the horse. Vet. Surg. 11 (1): 2–8.

      15 15 Kawcak, C.E. and Baxter, G.M. (1996). Surgical materials and wound closure techniques. Vet. N. Am.: Equine Pract. 12 (2): 195–205.

      16 16 Bischofberger, A.S., Brauer, T., Gugelchuck, G. et al. (2010). Difference in incisional complications following exploratory celiotomies using antibacterial‐coated suture material for subcutaneous closure: Prospective randomized study in 100 horses. Equine Vet. J. 42 (4): 304–309.

      17 17 Sanders, R.E., Kearney, C.K., Buckley, C.T. et al. (2015). Knot security of 5 metric (USP 2) sutures: Influence of knotting technique, suture material, and incubation time for 14 and 28 days in phosphate buffered saline and inflamed equine peritoneal fluid. Vet. Surg. 44 (6): 723–730.

      18 18 Schroeder, D., Gillanders, L., Mahr, K. et al. (1991). Effects of immediate postoperative enteral nutrition on body composition, muscle function, and wound healing. J. Paren. Ent. Nutr. 15 (4): 376–383.

      19 19 Haubner, F., Ohmann, E., Pohl, F. et al. (2012). Wound healing after radiation therapy: review of the literature. Rad. Oncol. 7: 162.

      20 20 Théon, A.P. and Pascoe, J.R. (1994). Iridium‐192 interstitial brachytherapy for equine periocular tumors: treatment results and prognostic factors in 115 horses. Equine Vet. J. 27 (2): 117–121.

      21 21 Théon, A.P., Wilson, W.D., Magdesian, K.G. et al. (2007). Long‐term outcome associated with intratumoral chemotherapy with cisplatin for cutaneous tumors in equids: 573 cases (1995–2004). J. Am. Vet. Med. Assoc. 230 (10): 1506–1513.

      22 22 van Rijssel, E.J.C., Brand, R., Admiraal, C. et al. (1989). Tissue reaction and surgical knots: the effect of suture size, knot configuration, and knot volume. Obstet. Gynecol. 74 (1): 64–68.

      23 23 Laitinen‐Vapaavuori, O. (2016). Suture reactions. In: Complications in Small Animal Surgery, 1e (ed D. Griffon and A. Hamaide), 64–65. Ames: Wiley‐Blackwell.

      24 24 Boothe, H.W. (2003). Surgical materials, tissue adhesives, staplers, and ligating clips.