Suturing basics

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Competency
 Given

a pt presenting with a laceration in an office or urgent / emergent care setting and standard supplies and equipment, treat the wound appropriately.

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Objectives
     

Identify the various types and sizes of suture material. Choose the proper instruments for suturing. Given a list of injectable anesthetic agents, identify the different agents and correct dosages. Determine whether a wound requires suturing. Under supervision, anesthetize, clean, and close a wound with sutures. Recommend appropriate laceration care and follow-up.
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Suture Materials
 Criteria
Tensile strength Good knot security Workability in handling Low tissue reactivity Ability to resist bacterial infection

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Suture Materials


ABSORBABLE: lose their tensile strength within 60 days.

NONABSORBABLE:

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Absorbable Sutures
PLAIN GUT: Derived from the small intestine of healthy sheep. Loses 50% of tensile strength by 5-7 days. Used on mucosal surfaces. CHROMIC GUT: Treated with chromic acid to delay tissue absorption time. 50% tensile strength by 10-14 days. Used in episiotomy repairs.

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Polyglycolic acid

) (Dexon

Braided Low-memory 50% tensile strength = 25 days Sites = subcutaneous closure skin

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Polydioxanone
 Monofilament  50% tensile

) (PDS

strength = 30+ days  Sites = need for prolonged strength,

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Polyglycan 910
 Braided,

) (Vicryl

synthetic polymer  50% tensile strength for 30 days  Used: subcutaneous

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Non-absorbable Sutures Non Nylon (Ethilon): of

all the nonabsorbable suture materials, monofilament nylon is the most commonly used in surface closures.

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Non-absorbable Sutures Non

Polypropylene (Prolene): appears to be stronger then nylon and has better overall wound security. BRAIDED: includes cotton, silk, braided nylon and multifilament dacron. Before the advent of synthetic fibers, silk was the mainstay of wound closure. It is the most workable and has excellent knot security. Disadvantages: high reactivity and infection due to the absorption of body fluids by the braided fibers.
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Suture Sizes
 5-0 is  The
small,

and 2-0 is big

usual sizes = 3-0 or 4-0  Examples:

might use 5-0 on the face 2-0 on the plantar surface of a foot

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Surgical Needles
 Wide

variety with different companys naming systems  2 basic configurations for curved needles
Cutting: cutting edge can cut through tough

tissue, such as skin Tapered: no cutting edge. For softer tissue inside the body

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Surgical Needles

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Surgical Instruments

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Needle Holders

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Forceps


Tissue forceps

Dressing forceps

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Iris Scissors
 Iris scissors

are predominantly used to assist in wound debridement and revision.

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Dissection Scissors
Used for heavier tissue revision as necessary for wound undermining.

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Suture Removal Scissors

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Hemostats
 Clamping

small blood vessels  Hemorrhage control  Grasping  Exposing  Exploring  Visualizing

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A Cheap Skin Hook

 Put a

hypodermic needle on a small syringe or use a hemostat to hold the needle  Bend the tip of the needle back (sterile technique)  General principle: Minimize trauma in handling tissue

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Scalpels

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Scalpel Blades

#15 blade

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 Dermabond
 

A sterile, liquid topical skin adhesive Reacts with moisture on skin surface to form a strong, flexible bond Only for easily approximated skin edges of wounds
punctures from minimally

invasive surgery simple, thoroughly cleansed, lacerations rxdentistry.net

Anesthetic Solutions
 Lidocaine (Xylocaine) Most commonly used Rapid onset Strength: 0.5%, 1.0%, & 2.0% Maximum dose:
 

5 mg / kg 300 mg
1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc 300 mg = 0.03 liter = 30 ml
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Anesthetic Solutions
 Lidocaine (Xylocaine)
Vasoconstriction Decreased bleeding Prolongs duration Strength: 0.5% & 1.0% Maximum individual dose:  7mg/kg, OR  500mg
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with epinephrine

Anesthetic Solutions


CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on:

Eyes Ears Nose Fingers Toes Penis Scrotum

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Anesthetic Solutions
 Mepivacaine

(CARBOCAINE):

Slower onset than Lidocaine Longer duration Strength: 1% DOSE: maximum individual dose 5mg/kg

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Anesthetic Solutions
 BUPIVACAINE
Slow onset Long duration Strength: 0.25% DOSE: maximum individual dose 3mg/kg

(MARCAINE):

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Injection Techniques
   

25, 27, or 30-gauge needle 6 or 10 cc syringe Check for allergies Insert the needle at the inner wound edge

   

Aspirate Inject agent into tissue SLOWLY Wait After anesthesia has taken effect, suturing may begin

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Complicated Wounds
Wounds or lacerations with Nerve Tendon Major vessel Wounds or lacerations of the Eye Eyelids Bites Severely contaminated wounds.
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Wounds entering the Thoracic or abdominal cavities.

Wound Evaluation
 Time

of incident  Size of wound  Depth of wound  Tendon / nerve involvement  Bleeding at site

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Contraindications
 Redness  Edema

of the wound margins  Infection  Fever

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Contraindications
 Puncture wounds  Animal

bites  Tendon, verve, or vessel involvement  Wound more than 12 hours old

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Closure Types
 Primary

closure (primary intention) closure (secondary intention)

 Secondary  Tertiary

closure (delayed primary closure)

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Wound Preparation
 

Most important step for reducing the risk of wound infection. Remove all contaminants and devitalized tissue before wound closure.
IRRIGATE CUT OUT DEAD, FRAGMENTED TISSUE

If not, the risk of infection and of a cosmetically poor scar are greatly increased

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Wound Preparation

Personnel Precautions

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Wound Preparation
 Wound

cleansing solution  Wound scrubbing  Irrigation

Take only the soft, flexible part from an 18

gauge IV needle (angiocath) Put angiocath tip on 20 cc or 50 cc syringe

 Debridement
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Basic Laceration Repair

Principles And Techniques

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Principles And Techniques

trauma in skin handling  Gentle apposition with slight eversion of wound edges
 Minimize
Visualize an Erlenmeyer flask

 Make yourself comfortable Adjust the chair and the light  Change the laceration Debride crushed tissue
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Definition of Terms
Bite Throw Percutaneous (deep) closure Dermal closure Interrupted closure Continuous closure (running sutures)

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Principles And Techniques

Suture Techniques
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Suture Procedures

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Suturing
 Apply  Rule

the needle to the needle driver

Clasp needle 1/2 to 2/3 back from tip

of halves:

Matches wound edges better; avoids dog ears Vary from rule when too much tension across

wound

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Suturing
Rule of halves

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Suturing
Rule of halves

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Suturing
 The

needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees
Visualize Erlenmeyer flask Evert wound edges  Because scars contract over time

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Suturing


Release the needle from the needle driver, reach into the wound and grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound. Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites.
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Follow the needles arc

 Rotate

your wrist to follow the arc of the

needle.  Principle: minimize trauma to the skin, and dont bend the needle. Follow the path of least resistance.

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Suturing


Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site. Release the needle from the needle driver and wrap the suture around the needle driver two times.
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Suturing


Grasp the end of the suture material with the needle driver and pull the two lines across the wound site in opposite direction (this is one throw). Do not position the knot directly over the wound edge. Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap.
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Suturing
 Cut

the ends of the suture 1/4-inch from the knot. remaining sutures are inserted in the same manner

 The

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The trick to an instrument tie

 Always place

the suture holder parallel to the wounds direction.  Hold the longer side of the suture (with the needle) and wrap OVER the suture holder.  With each tie, move your suture-holding hand to the OTHER side.  By always wrapping OVER and moving the hand to the OTHER side = square knots!!
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Simple, Interrupted

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Vertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)
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Horizontal Mattress

Good for closing wound edges under high tension, And for hemostasis.
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Suturing - finishing
 After

sutures placed, clean the site with normal saline.  Apply a small amount of Bacitracin and cover with a sterile non-adherent dressing.

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Suturing - before you go

 Need

for tetanus globulin and/or vaccine?

Dirty (playground nail) vs clean (kitchen knife) Immunization history

 Tell

pt to return in one day for recheck, for signs of infection or complications.

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Suture Removal
Time frame for removing sutures: Average time frame is 7-10 days FACE: 4-5 days BODY & SCALP: 7 days SOLES, PALMS, BACK OR OVER JOINTS: 10 days Any suture with pus or signs of infections should be removed immediately.
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Suture Removal
1. 2.

3.

Clean with hydrogen peroxide to remove any crusting or dried blood Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin Pull the suture line through the tissue- in the direction that keeps the wound closed and place on a 4x4
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Suture Removal
Once all sutures have been removed, count the sutures The number of sutures needs to match the number indicated in the patient's health record

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