Transcript Basics of Suturing Orientation

Basic Suturing Workshop
By Shauna O’Sullivan
Resident Orientation Course 2012
Objectives
• Describe the principles of wound healing
• Identify the various types and sizes of suture material
• Identify the different injectable anesthetic agents
• Demonstrate different types of closure techniques
• Recommend appropriate wound care and follow-up
Critical Wound Healing Period
Tissue
Tissue Healing Time/Days
Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days
0
5 7
14 28
Model of Wound Healing
• (1) Hemostasis: within minutes after injury, platelets
aggregate at the injury site to form a fibrin clot
• (2) Inflammatory: bacteria and debris are
phagocytosed and removed
– Factors are released that cause the migration and division
of cells involved in the proliferative phase
Model of Wound Healing
• (3) Proliferative: angiogenesis, collagen deposition,
granulation tissue formation, epithelialization, and
wound contraction
• (4) Remodeling: collagen is remodeled and realigned
along tension lines and cells that are no longer
needed are removed by apoptosis
Wound Healing Concepts
• Patient factors
• Wound classification
• Mechanism of injury
• Tetanus, antibiotics,
local anesthetics
• Surgical principles and
wound prep
• Suture, needle, stitch
choice
• Management, follow-up
CDC Surgical Wound Classification
• Type 1 “Clean” Wounds:
– 1-5% risk of infection
– Non-traumatic
– No inflammation present
– No break in technique
– Example: elective groin hernia repair
CDC Surgical Wound Classification
• Type II Clean-Contaminated Wounds:
– 3-11% risk of infection
– Non-sterile body region entered under controlled
conditions and without unusual contamination
• (GI or GU tract, biliary tract, respiratory tract,
oropharynx and etc.
– Or minor breaks in technique
CDC Surgical Wound Classification
• Type III Contaminated Wounds:
– 10-17% risk of infection
– Major break in sterile technique
– Gross spillage from Gastrointestinal (GI) tract
– Infected GI, Urinary or biliary tract
– Fresh traumatic would (through unprepped skin)
CDC Surgical Wound Classification
• Type IV Dirty or infected Wounds:
– Infection risk of >27% risk
– Wounds associated with perforated viscus; cross clean
tissue to drain pus
– Traumatic wounds with:
• Imbedded foreign body
• Delayed presentation (> 12-24 hours for face and scalp; > 6
hours elsewhere)
Closure Types
• Primary closure (primary intention)
– Wound edges are brought together so that they
are adjacent to each other (re-approximated)
– Examples: well-repaired lacerations, well reduced
bone fractures, healing after flap surgery
Closure Types
• Secondary closure (secondary intention)
– Wound is left open and closes naturally
(granulation)
– Examples: gingivectomy, gingivoplasty, tooth
extraction sockets, poorly reduced fractures
Closure Types
• Tertiary closure (delayed primary closure)
– Wound is left open for a number of days and then
closed if it is found to be clean
– Examples: healing of wounds by use of tissue
grafts
Suture Materials
• Criteria
– Tensile strength
– Good knot security
– Workability in handling
– Low tissue reactivity
– Ability to resist bacterial infection
Types of Sutures
• Absorbable or non-absorbable
• Natural or synthetic
• Monofilament or multifilament (braided)
• New antibacterial sutures
Suture Size
• Sizes 3 to 12-0
– Numbers alone indicate progressively larger sutures,
whereas numbers followed by 0 indicate progressively
smaller
Smaller -------------------------------------Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....
Suture Material
Non-Absorbable
Absorbable
• Not biodegradable,
• Degraded via inflammatory
permanent
response
– Nylon
– Vicryl
– Prolene
– Monocryl
– Stainless steel
– PDS
– Silk (natural, can break
– Chromic
down over years)
– Cat gut (natural)
Indications
Non-absorbable
Absorbable
• Skin repair
• Subcutaneous repair
• Fascia under tension
• Intraoral mucosa
• Vascular (blood vessel)
repairs
(including tongue)
• Fascia not under
tension
Suture Material
Natural Suture
• Biological orgin
• Cause inflammatory
reaction
– Catgut (connective
from cow or sheep)
– Silk (from silkworm
fibers)
– Chromic catgut
Synthetic
• Synthetic polymers
• No inflammatory
response
– Nylon
– Vicryl
– Monocryl
– PDS
– Prolene
Suture Material
Monofilament
Multifilament (braided)
• Single strand of suture
material
• Minimal tissue trauma
• Smooth tying but more
knots needed
• Resists harboring organisms
• Nylon, Monocryl, Prolene,
PDS
• Fibers are braided or
twisted together
• More tissue resistance
• Easier to handle
• Fewer knots needed
• Vicryl (braided), Silk
(braided), Chromic (twisted)
Suture Materials
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Suture Selection Tips
• Do not use dyed sutures on the skin
• Non-absorbable use for skin, tendons and fascia
– Use up to 6 months
– Less scarring but must be removed
• Absorable used for GI, urinary and biliary
• Use monofilament on the skin as multifilament harbor
BACTERIA
Suture Sizes
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General rule : 6-0 on face, 5-0 on hand, & 4-0 elsewhere on body
Surgical Needles
• Classified according to shape and type of point
– Curved or straight
– Tapered point, cutting or reverse cutting
• 2 basic configurations for curved needles
– Cutting: cutting edge can cut through tough tissue,
such as skin
– Tapered: no cutting edge; used for softer tissue inside
the body
Surgical Needles
Cutting
Tapered
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Needle Anatomy
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Surgical Instruments
Scalpel Blades
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Instrument Holding
• Scalpel: Hold with the shaft of the scalpel in the
palm of the hand with the index finger on the top of
the blade
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Instrument Holding
• Forceps should be held between the thumb and
index finger
• Needle driver: Place the thumb and finger slightly
into the instrument’s ring
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Wound Evaluation
• Time of incident
• Size of wound
• Depth of wound
• Tendon / nerve involvement
• Bleeding at site
When to Refer
• Deep wounds of hands or feet, or unknown depth of
penetration
• Full thickness lacerations of eyelids, lips or ears
• Injuries of nerves, larger arteries, bones, joints or
tendons
• Crush injuries
• Markedly contaminated wounds requiring drainage
Contraindications to Suturing
• Redness
• Animal bites
• Edema of the wound
• Tendon, verve, or vessel
margins
• Infection
• Fever
• Puncture wounds
involvement
• Wound more > 12° old
(body) and 24 °(face)
Wound Preparation
• Most important step for reducing the risk of wound infection
• Remove all contaminants and devitalized tissue before wound
closure
– Irrigate with Normal Saline
• If not, the risk of infection and of a cosmetically poor scar are
greatly increased
• Personal Precautions (Use sterile gloves)
Anesthetic Solutions
• Lidocaine (Xylocaine®) with epinephrine
– Vasoconstriction with ↓ bleeding
– Prolonged duration
– Strength: 0.5% & 1.0%
• Lidocaine (Xylocaine®)
– Most commonly used
– Rapid onset
– Strength: 0.5%, 1.0%, & 2.0%
Anesthetic Solutions
• CAUTION !!! Due to its vasoconstrictive properties
never use lidocaine with epinephrine on:
– Eyes, Ears, Nose
– Fingers, Toes
– Penis, Scrotum
Anesthetic Solutions
• Bupivacaine (Marcaine):
– Slow onset, long duration
– Strength: 0.25%
– DOSE: maximum individual dose 3mg/kg
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Injection Techniques for the
Anesthesia
• 25, 27, or 30-gauge
needle
• 6 or 10 cc syringe
• Aspirate
• Inject agent into tissue
SLOWLY
• Check for allergies
• Wait…
• Insert the needle at the
• After anesthesia has
inner wound edge
taken effect, suturing may
begin
Basic Laceration Repair
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Principles And Techniques
Types of Closure
• Simple interrupted closure – most commonly used, good
for shallow wounds without edge tension
• Continuous closure (running sutures) – good for
hemostasis (scalp wounds) and long wounds with
minimal tension
• Locking continuous - useful in wounds under moderate
tension or those requiring additional hemostasis
Types of Closure
• Subcuticular – good for cosmetic results
• Vertical mattress – useful in maximizing wound eversion,
reducing dead space, and minimize tension across the
wound
• Horizontal mattress – good for fragile skin + high tension
wounds
• Percutaneous (deep) closure – good to close dead space
+ decrease wound tension
Langer’s Lines
Simple Interrupted
• Most commonly used in the closure of skin
• Individual stitches placed and tied
• Perform if worried about the cleanliness of the
wound
– A few sutures can be removed easily if needed
• Can be used in all areas but takes more time
Simple Interrupted
Continuous Suture
• Place the sutures again and again without tying each
individual suture
• If clean wound, quicker and easier to bring edges
together
• Used for rapid closure of longer wounds and to stop
bleeding from skin edges
Continuous Interlocking
Vertical Mattress
Good for everting wound edges (neck, forehead creases,
concave surfaces)
Vertical Mattress
Horizontal Mattress
Good for closing wound edges under high tension,
and for hemostasis
Horizontal Mattress
Principles And Techniques
• Minimize trauma in skin handling
• Gentle apposition with slight eversion of wound edges
– Visualize an Erlenmeyer flask
• Make yourself comfortable
– Adjust the chair and the light
• Change the laceration
– Debride crushed tissue
Suturing
• Apply the needle to the needle driver
• Clasp needle 1/2 to 2/3 back from tip
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Suturing
• Rule of halves:
– Matches wound edges better; avoids dog ears
– Vary from rule when too much tension across wound
1
Suturing
Rule of halves
Suturing
• The needle enters the skin with a 1/4-inch bite from
the wound edge at 90 degrees
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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
1
4
2
3
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Suturing
• Use the forceps and lightly grasp the skin edge and arc
the needle through the opposite edge inside the wound
edge taking equal bites
• Rotate your wrist to follow the arc of the needle
• Principle: minimize trauma to the skin, and don’t bend
the needle
– Follow the path of least resistance
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
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
Suturing
• Repeat 3-4 throws to ensuring knot security
• On each throw reverse the order of wrap
• Cut the ends of the suture 1/4-inch from the knot
• The remaining sutures are inserted in the same
manner
The Trick to an Instrument Tie
• Always place the suture holder parallel to the wound’s
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!!
The Knot
• Weakest point of the suture ligature
• Reduces the tensile strength of the suture by 30-35
%
• The surgeon must have a good working knowledge of
the characteristics of the sutures he employs and the
knots he uses
Categories of Knots
• Flat knots: Square, surgeon’s and granny
– Tied with half hitches with equal tension on each
segment of the suture
• Sliding knots: Identical and non-identical
– Half hitches tied with greater tension on one segment
of the suture
Sliding Knots
• Most surgeons use sliding knots rather than square knots
because:
– Crossing the Surgeons hands, sometimes required for
square knots, leads to slippage
– Tying deep ligatures is best accomplished by keeping
constant tension on the sutures
– Sliding knots require one more throw than square knots
Number of Knots
• Monofilament sutures require more knots
(knot slippage results in disruption)
- Usually five to six knots required
• Coated sutures require more knots
• Chromic requires “three squares” or four slip knots
• Dexon or Vicryl requires four squares or five slip knots
with “long tails”
Number of Knots (Throws)
• Chromic: Three squares or four slip knots
• Braided: (Dexon, Vicryl): four squares, five slip
knots
*Monofilament: (Prolene, Maxon, PDS, Nylon)
five squares or six slip knots
Suturing – Finishing
• After sutures are placed, clean the site with normal saline
• Apply small amount of Bacitracin and cover with a sterile nonadherent dressing
• Need for Tetanus globulin or vaccine?
– Dirty versus clean
– Prior Immunization history
• Have patient return in one day for recheck, for signs of
infection or complications
Tetanus Prophylaxis
• Every 5 year update for tetanus toxoid is a
good rule on all cases
• Also use tetanus immune globulin) if:
– Patient never immunized
– Immunosuppressed
– Allergic or severe local reaction of toxoid
Patient Instructions for Follow-Up
• First 24-48 hours, patients should gently wash the wound
with soap and water, dry it carefully, apply topical
antibiotic ointment, and replace the dressing/bandages
• Facial wounds generally only need topical antibiotic
ointment without bandaging
• Eschar or scab formation should be avoided
• Sunscreen spf 30 should be applied to the wound to
prevent subsequent hyperpigmentation.
Suture Removal Guidelines
Wound Location
Suture Removal (Days)
Scalp
7
Face
3-5
Chin
7
Trunk
7-10
Arm
7-10
Hand
10-14
Leg
10-14
Sole of Foot
14-21
Any suture with pus or signs of infections should be removed
immediately
Suture Removal
•
Clean with hydrogen peroxide to remove any crusting
•
Using pickups , 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 -count them
•
Most wounds have < 15% of final wound strength after
2 wks – apply steri-strips
Staples
• Rapid closure of wound
• Easy to apply
• Evert tissue when placed properly
Topical Adhesives
• Indications: Selected approximated, superficial, clean wounds
especially face, torso, limbs
– May be used in conjunction with deep sutures
• Benefits:
– Cosmetic, seals out bacteria, apply in 3 min, holds 7 days
(5-10 to slough), seal moisture, faster, clear, convenient,
less supplies, no removal, less expensive
Topical Adhesives
• Contraindications:
– Infection
– Gangrene
– Mucosal, damp or hairy areas
– Allergy to formaldehyde or cryanoacrylate
– High tension areas
Dermabond ®
• A sterile, liquid topical skin adhesive
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• 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
Dermabond®
• Standard surgical wound prep and dry
• Crack ampule or applicator tip up; invert
• Hold skin edges approximated horizontally
• Gently and evenly apply at least two thin layers on
the surface of the edges with a brushing motion
– At least 30 sec between each layer, hold for 60 sec after
last layer until not tacky and apply dressing
Follow Up Care with Adhesives
• No ointments or medications on dressing
• May shower but no swimming or scrubbing
• Sloughs naturally in 5-10 days, but if need to remove
use acetone or petroleum jelly to peel but not pull
apart skin edges
• Pt education and documentation
Any Questions??