Surgery STAT: Tie-over bandage: a solution for wounds in difficult locations

EDITOR'S NOTE: SurgerySTAT is a collaborative column between the American College of Veterinary Surgeons (ACVS) and DVM Newsmagazine. This month, John C. Chandler DVM, MS, Dipl. ACVS Small Animal Surgery, writes about a solution for wounds in difficult locations, the tie-over bandage. Dr. Chandler is with WestVet Animal Emergency and Specialty Center in Garden City, Idaho. In July, Peter J. Lotsikas, DVM, Dipl. ACVS Small Animal Surgery, writes about metacarpal and metatarsal fractures. Dr. Lotsikas is with Veterinary Orthopedic & Sports Medicine Group (VOSM) in Annapolis Junction, Md.

The tie-over bandage is a simple, inexpensive, versatile bandage that has many applications in veterinary medicine. It can be used with a variety of dressings and to cover wound configurations in many different locations. It is especially useful for covering areas that are otherwise challenging, such as the shoulder, neck, trunk, hip, inguinal region, perineum and caudal thigh.

The conventional tie-over bandage was first described for covering and protecting skin grafts. The technique involved placing long strands of suture material adjacent to the perimeter of a grafted area. The suture strands were then pulled over the dressing, twisted and secured with clips.

Photo 1: Inguinal wound.

A more useful variation was later developed that may be used in covering open wounds, skin grafts or surgically closed wounds.

This tie-over bandage involves placing multiple, loose, simple interrupted sutures into the healthy skin bordering the wound. These sutures will provide the loops to which the bandage will be secured, and should be placed 3mm to 4mm from the wound edge.

Photo 2: Inguinal tie-over bandage.

It is best to use a large (0 or 2-0) monofilament suture with good knot security. The dressing is applied to the wound bed. The protective outer layer is then secured by lacing umbilical tape through each of the preplaced loops. The tape is tied to itself to provide a firmly attached bandage.

Photo 3: Large wound over the dorsum of the trunk.

Photo 1 shows a difficult inguinal wound. A wet-to-dry dressing was placed and covered using a tie-over bandage (Photo 2). An example of a tie-over bandage being used to aid in treatment of a large wound over the dorsal trunk is shown in Photo 3 and Photo 4.

Photo 4: Trunkal tie-over bandage.

The tie-over bandage can be placed with the patient under sedation or general anesthesia. Local anesthetic may aid in placement of the loops in some animals. However, most animals will tolerate placing the suture loops by first piercing the skin with a 22g needle and then feeding the suture through the needle (Photo 5). Subsequent bandage changes usually can be performed without sedation.

Photo 5: Alternative technique for placement of a suture loop. Note that the needle is placed full-thickness through the skin.

Experience with the tie-over bandage has provided a few helpful hints. A minimum of five loops are needed to provide adequate points of fixation for the umbilical tape. When five loops are used, the umbilical tape can be laced in a "star" pattern.

If more than five loops are used, the umbilical tape can be laced similar to a shoelace. The loops should be large enough to allow easy passage of the umbilical tape using a mosquito hemostat or forceps, yet not so large that they crowd adjacent loops when pulled tight.

If loops are too long, it is difficult to obtain the amount of tension necessary to hold the dressing in place. A common mistake is to leave the umbilical tape too loose, resulting in slippage of the dressing. In addition to holding the dressing in place, the tension on the loops also may provide a degree of skin stretching to aid later in closure.

Tie-over bandages can be used to hold a variety of primary dressings in place. The most common primary dressings include wet-to-dry dressings and nonadherent dressings. Wet-to-dry dressings typically include saline-soaked (isotonic or hypertonic) gauze sponges or laparotomy pads.

Nonadherent dressings usually consist of Telfa or Vaseline-impregnated gauze. The protective layer of the tie-over bandage should consist of a layer of sterile gauze sponges, towels or laparotomy pads. A water-resistant paper surgical drape can be cut to size and placed over the protective layer to prevent contamination if desired.

Dr. Chandler is a board-certified ACVS small-animal surgeon. After completing his residency at Colorado State University, Dr. Chandler joined the WestVet Animal Emergency and Specialty Center in Garden City, Idaho.