Closure, Dressings and Post-Surgical Devices

This is Unit Twenty-Six of Tech in Surgery Prep. Unit Twenty-Five ended with a conversion counted as one unbroken record. This unit closes the wound, dresses it, and prepares the patient and every device for the journey to recovery. Carry one idea through this lecture. The closing count and the surgeon's examination of the wound each catch what the other misses; neither replaces the other. Only when both are complete do the deep layers close over the space where a forgotten item could hide. A worked example near the end follows a laparotomy closed that way. By the end you will be able to prepare for closure and run the closing counts. To explain healing and dressings. To secure drains, tubes and catheters for transfer. And to protect the patient's skin and dignity, and report to recovery.

Five entries on preparing for closure, the closing counts, and closing layer by layer.

Ready before it starts.

TSC 626 Closure Begins Before Closing

Preparation for closing begins well before the surgeon starts to close. The scrub person sets out closing sutures by layer, prepares the dressing, and plans the closing count so it happens on time. Closing is when attention drifts, so preparation done earlier protects the counts done now.

Counting before sealing.

TSC 627 The Closing Count

The closing counts confirm every counted item is accounted for before the wound is sealed. Sponges and sharps are counted before a cavity within a cavity is closed. At the first layer of wound closure, sponges, sharps, small items and instruments are counted. At skin closure, sponges and sharps are counted again. The surgeon examines the wound before closing, a separate check. Results are announced, acknowledged and recorded, and any unreconciled count stops closure. The count and the examination each catch what the other misses, and a correct count never excuses skipping the examination.

Layers in reverse.

TSC 628 Closing in Layers

A wound is closed in layers, in reverse of the opening. In an abdomen, the peritoneum may be closed first; then the muscle layer and its sheath, including the midline; then the fatty layer, closed or left as the surgeon judges; then the skin, with suture, staples or glue; then the dressing. Each layer has the suture the surgeon chose for it. Knowing which layer comes next lets the scrub person pass the right suture before it is asked for; a skin suture handed up for fascia slows and can weaken the closure.

The deep layers.

TSC 629 Peritoneum and Fascia

The deeper layers of an abdominal closure are the peritoneum and the abdominal wall's connective tissue, including the rectus sheath and midline. They support the wall, and the surgeon chooses strong suture for them. The closing count happens before these layers close, while the abdomen can still be searched.

The surface layers.

TSC 630 Subcutaneous and Skin

The final layers are the subcutaneous tissue, fat and loose connective tissue, and the skin, closed with suture, staples or glue, often chosen for cosmetic outcome and preference. The count at skin closure is the last count before the dressing goes on.

Five entries on how wounds heal, and on dressings and negative pressure therapy.

Three ways to heal.

TSC 631 Primary, Secondary, Tertiary Intention

Wounds heal by primary, secondary or tertiary intention. Primary: edges closed together. Secondary: edges cannot meet, so the wound fills from the bottom. Tertiary: left open or reopened, often for infection, and closed later. Secondary and tertiary healing take longer and scar more, and open wounds must be protected from contamination.

What a dressing does.

TSC 632 Dressings and Their Purpose

A dressing covers and protects a wound, chosen for the wound and its drainage. It protects from contamination and injury, keeps the wound bed neither too dry nor too wet, absorbs drainage, and can support or gently compress with bandages or binders. It is applied with sterile technique over a fresh incision. It is the last item placed before the patient leaves the field, after the final count, so have it open and sized before closure ends.

Dressing with sterile technique.

TSC 633 Applying the Dressing

The surgical dressing is applied with sterile technique as soon as the skin is closed. The scrub person passes the materials, the incision is covered completely, and the dressing is secured with tape or a bandage. It is part of the sterile procedure, not something done after the field is broken down.

Many kinds of dressing.

TSC 634 Dressing Types

Dressing types include gauze, nonadherent dressings, petroleum gauze, transparent films, hydrocolloids, foams and alginates. Foams absorb without sticking, alginates manage heavy drainage, and films let the wound be seen. The preference card or surgeon names the dressing for each case.

Suction through a dressing.

TSC 635 Negative Pressure Wound Therapy

Negative pressure wound therapy applies gentle suction through a sealed dressing. The WHO surgical infection guideline suggests it preventively for adults on closed incisions in high-risk wounds, considering resources. The surgeon decides, and setup follows the manufacturer's instructions.

Five entries on the devices that go with the patient: drains, tape and binders, ostomies, and every tube.

Drains at the end.

TSC 636 Drains at the End of the Case

At the end of the case, each drain is secured, usually by suture to the skin, its exit site dressed, and it is connected to its collection device off the field. The circulating nurse records each drain and its location, and these go into the recovery report with the dressings, so the next team knows exactly what is in place. Drains are devices, accounted for under the tracking process, and they are protected as the patient moves, because one pulled out can mean another procedure.

Holding the dressing on.

TSC 637 Tape and Securing Dressings

Dressings are secured with tape or bandages chosen for the skin and dressing. Common tapes include paper, cloth, waterproof and porous; rolled bandages on limbs start at the far end. Tape is chosen and applied as the dressing's instructions and facility practice direct.

Support beyond the dressing.

TSC 638 Binders and Supports

Bandages and binders add pressure and support beyond holding the dressing. An abdominal binder supports an abdominal incision, and elastic and rolled bandages support limbs. The surgeon decides whether a binder is needed and when it goes on.

An opening to the outside.

TSC 639 Ostomies in Plain Terms

An ostomy is a surgically created opening from an internal organ to the outside. A colostomy opens the colon through the abdomen; a urostomy creates an opening for urine. A new ostomy is dressed or fitted as the surgeon directs and reported to the recovery nurse.

Every tube before the move.

TSC 640 Catheters and Tubes at Transfer

At the end of surgery, every catheter, drain and tube is secured and recorded. Urinary catheters are secured with tubing free of kinks. Drains are secured and connected. Anesthesia checks the intravenous lines. Every tube is listed with its location for the report. During the move, someone is assigned to protect the lines, and afterwards each is checked again. A single tug during transfer can pull one out, so count them before the move and protect them during it.

Four entries on dignity, transfer, the skin check and the handoff, then two worked examples. The opening idea is paid off at the first.

Dignity to the end.

TSC 641 Dignity at the End of the Case

The patient's dignity matters as much at the end of surgery as at the start. As drapes come off, the patient is covered again promptly, with only what transfer needs exposed. The patient may be waking and aware, so conversation stays professional.

Off the table.

TSC 642 Moving the Patient Off the Table

Moving the patient from table to stretcher uses the same safe methods as moving them on: enough staff, a lateral transfer device, anesthesia managing the airway, and lines and drains protected. Falls are a risk at every transfer, so the patient is secured on the stretcher before it moves.

Checking the skin.

TSC 644 Skin Assessment at the End

At the end of surgery, the skin is checked for injury from positioning, devices or energy. Look at pressure points that bore weight, such as heels, elbows, the back of the head and, in prone cases, the face and chest. Look at the pad site after removing it, under straps and supports, and where prep may have pooled. Document what is found and report any injury to the surgeon and recovery nurse. Injuries found now can be followed; injuries missed are found later with no one knowing how.

The handoff to recovery.

TSC 645 Report to the Recovery Nurse

In recovery, the surgical team gives the recovery nurse a structured handoff. It covers the patient, the surgery and complications, anesthesia, drains and dressings, vital signs, fluids, medications, and needs such as allergies. Structured formats help make sure nothing important is left out.

A laparotomy, closed.

TSC 646 Closing a Laparotomy, Layer by Layer

A worked example, constructed for this course, pays off the opening idea. Morgan has closing sutures laid out by layer. Before the first layer closes, Morgan and the circulator count everything while the surgeon examines the abdomen, between bowel loops and under the wound edges. The count is correct and announced. The surgeon closes the deep layer with strong suture Morgan has loaded on a long holder; Morgan passes Mayo scissors for each tie and keeps the next suture ready. The fatty layer follows. At skin closure, sponges and sharps are counted again, and the skin is stapled. The dressing is ready, sized to the incision. Only when count and examination were both complete did the deep layers close.

Two drains, left and right.

TSC 647 Two Drains and a Dressing

A worked example, constructed for this course, follows a large abdominal operation with a drain on each side. Kai passes two loaded securing sutures one at a time, then passes the tubing off for the circulator to connect. The circulator labels the drains left and right on the record. Kai passes the main dressing and smaller ones for each drain site. Before the move, Kai and the circulator count every line aloud: two drains, a urinary catheter, and anesthesia's intravenous lines. During transfer, the circulator holds the drain tubing. The recovery report names both drains and their locations, so a change in either's output can be noticed and attributed correctly.

Look at what you can now do. You can prepare for closure, run the closing counts at the right moments alongside the surgeon's examination, and close in reverse layers with each suture ready. You can explain healing by primary, secondary and tertiary intention, and choose, apply and secure dressings, including negative pressure therapy where the surgeon chooses it. You can secure and record drains, ostomies, catheters and tubes, and protect them during transfer. And you can keep the patient covered, move them safely, check the skin, and give a structured report to recovery. Unit Twenty-Seven follows what happens after the patient leaves the room.