Transcript suturingworkshop

OBJECTIVES
Describe the principles of wound healing
Identify the various types and sizes of suture material.
Choose the proper instruments for suturing.
Identify the different injectable anesthetic agents and correct dosages.
Demonstrate various biopsy methods: punch, excision, shave.
Demonstrate different types of closure techniques: simple interrupted,
continuous, subcuticular, vertical and horizontal mattress, dermal
Demonstrate two-handed, one-handed, instrument ties
Recommend appropriate wound care and follow-up.
CRITICAL WOUND HEALING PERIOD
Tissue
Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days
0
5 7
14
21
Tissue Healing Time/Days
28
MODEL OF WOUND HEALING
(1) Hemostasis: within minutes post-injury, platelets aggregate at the
injury site to form a fibrin clot.
(2) Inflammatory: bacteria and debris are phagocytosed and
removed, and factors are released that cause the migration and
division of cells involved in the proliferative phase.
(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/care/follow-up
COMMON PATIENT FACTORS
Age
Blood supply to the
area
Nutritional status
Tissue quality
Revision/infection
Compliance
Weight
Dehydration
Chronic disease
Immune response
Radiation therapy
CDC SURGICAL WOUND CLASSIFICATION
Clean: (1-5% risk of infection) uninfected operative wounds in
which no inflammation is encountered and the respiratory,
alimentary, genital, or uninfected urinary tracts are not entered. In
addition, clean wounds are primarily closed, and if necessary, drained
with closed drainage. Operative incisional wounds that follow
nonpenetrating (blunt) trauma should be included in this category if
they meet the criteria.
Clean-contaminated: (3-11% risk) operative wounds in which the
respiratory, alimentary, genital, or urinary tract is entered under
controlled conditions and without unusual contamination. Specifically,
operations involving the biliary tract, appendix, vagina, and
oropharynx are included in this category, provided no evidence of
infection or major break in technique is encountered.
CDC SURGICAL WOUND
CLASSIFICATION
Contaminated: (10-17% risk) open, fresh, accidental wounds,
operations with major breaks in sterile technique or gross
spillage from the gastrointestinal tract, and incisions in which
acute, nonpurulent inflammation is encountered.
Dirty or infected: (>27% risk) old traumatic wounds with
retained devitalized tissue and those that involve existing clinical
infection or perforated viscera. This definition suggests that the
organisms causing postoperative infection were present in the
operative field before the operation.
SURGICAL PRINCIPLES
Incision
Dissection
Tissue handling
Hemostasis
Moisture/site
Remove infected,
foreign, dead areas
Length of time open
Choice of closure
material/mechanism
Primary or secondary
Cellular responses
Eliminate dead space
Closing tension
Distraction forces and
immobilization/care
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)
Dyed or undyed
Sizes 3 to 12-0 (numbers alone indicate progressively
larger sutures, whereas numbers followed by 0 indicate
progressively smaller)
New antibacterial sutures
NONABSORBABLE
Not biodegradable
and permanent
Nylon
Prolene
Stainless steel
Silk (natural, can
break down over
years)
Absorbable
Degraded via
inflammatory response
Vicryl
Monocryl
PDS
Chromic
Cat gut (natural)
Natural Suture
SYNTHETIC
Biological
Cause inflammatory
reaction
Catgut (connective from
cow or sheep)
Silk (from silkworm
fibers)
Chromic catgut
Synthetic polymers
Do not cause
inflammatory response
Nylon
Vicryl
Monocryl
PDS
Prolene
Monofilament
Multifilament (braided)
Single strand of suture
material
Fibers are braided or twisted
together
Minimal tissue trauma
More tissue resistance
Smooth tying but more knots
needed
Easier to handle
Harder to handle due to
memory
Examples: vicryl, silk,
chromic
Examples: nylon, monocryl,
prolene, PDS
Fewer knots needed
SUTURE MATERIALS
SUTURE SELECTION
Do not use dyed sutures on the skin
Use monofilament on the skin as multifilament
harbor BACTERIA
Non-absorbable cause less scarring but must be
removed
Plus sutures (staph, monocryl for E. coli, Klebsiella)
Location and layer, patient factors, strength,
healing, site and availability
SUTURE SELECTION
Absorbable for GI, urinary or biliary
Non-absorbable or extended for up to 6 mos for skin, tendons, fascia
Cosmetics = monofilament or subcuticular
Ligatures usually absorbable
SUTURE SIZES
SURGICAL NEEDLES
Wide variety with different company’s 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
SURGICAL NEEDLES
SURGICAL INSTRUMENTS
SCALPEL BLADES
ANESTHETIC SOLUTIONS
Lidocaine (Xylocaine®)
 Most commonly used
 Rapid onset
 Strength: 0.5%, 1.0%, & 2.0%
 Maximum dose:
 5 mg / kg, or
 300 mg
 1.0% lidocaine = 1 g lidocaine /
100 cc = 1,000mg/100cc
 300 mg = 0.03 liter = 30 ml
Lidocaine (Xylocaine®)
with epinephrine
 Vasoconstriction
 Decreased bleeding
 Prolongs duration
 Strength: 0.5% & 1.0%
 Maximum individual dose:
 7mg/kg, or
 500mg
ANESTHETIC SOLUTIONS
CAUTIONS: due to its vasoconstriction
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
LOCAL ANESTHETICS
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
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 involving nerves, larger arteries, bones,
joints or tendons
Crush injuries
Markedly contaminated wounds requiring
drainage
Concern about cosmesis
CONTRAINDICATIONS TO SUTURING
Redness
Edema of the wound margins
Infection
Fever
Puncture wounds
Animal bites
Tendon, verve, or vessel involvement
Wound more than 12 hours old (body) and 24 hrs
(face)
CLOSURE TYPES
Primary closure (primary intention)
 Wound edges are brought together so that they are adjacent to each other (reapproximated)
 Examples: well-repaired lacerations, well reduced bone fractures, healing
after flap surgery
Secondary closure (secondary intention)
 Wound is left open and closes naturally (granulation)
 Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly
reduced fractures
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.
WOUND PREPARATION
Most important step for reducing the risk of wound
infection.
Remove all contaminants and devitalized tissue before
wound closure.
 IRRIGATE w/ NS or TAP WATER (AVOID H2O2,
POVIDONE-IODINE)
 CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor
scar are greatly increased
Personal Precautions
BASIC LACERATION REPAIR
PRINCIPLES AND
TECHNIQUES
Langer’s Lines
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
TYPES OF CLOSURES
●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 in those
requiring additional hemostasis because of oozing from the skin edges
●Subcuticular – good for cosmetic results
●Vertical mattress – useful in maximizing wound eversion, reducing dead
space, and minimizing tension across the wound
●Horizontal mattress – good for fragile skin and high tension wounds
●Percutaneous (deep) closure – good to close dead space and decrease wound
tension
SIMPLE INTERRUPTED SUTURING
Apply the needle to the needle driver
 Clasp needle 1/2 to 2/3 back from tip
Rule of halves:
 Matches wound edges better; avoids dog ears
 Vary from rule when too much tension across wound
SIMPLE INTERRUPTED SUTURING
Rule of halves
SIMPLE INTERRUPTED SUTURING
Rule of halves
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
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.
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.
SIMPLE INTERRUPTED 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.
Cut the ends of the suture 1/4-inch from the knot.
The remaining sutures are inserted in the same manner
SIMPLE, INTERRUPTED
http://www.youtube.com/watch?v=PFQ5-tquFqY
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!!
Two Handed Tie
TWO HANDED TIE
ONE-HAND
TIE
ONE-HAND
TIE
CONTINUOUS LOCKING AND NONLOCKING
SUTURES
http://www.youtube.com/watch?v=xY4cAqk30K4
http://cal.vet.upenn.edu/projects/surgery/5000.htm
http://www.youtube.com/watch?v=sgOaBojcX-c
VERTICAL MATTRESS
Good for everting wound edges
(neck, forehead creases, concave surfaces)
http://www.youtube.com/watch?v=824FhFUJ6wc
HORIZONTAL MATTRESS
Good for closing wound edges under high tension,
and for hemostasis.
HORIZONTAL MATTRESS
http://www.youtube.com/watch?v=9DdaooEXshk
http://www.youtube.com/watch?v=I7C7nsl5Tuk
SUTURING - FINISHING
After sutures placed, clean the site with normal saline.
Apply a small amount of Bacitracin or white petroleum and cover with a sterile nonadherent compression dressing (Tefla).
Suturing - before you go…
Need for tetanus globulin and/or vaccine?
 Dirty (playground nail) vs clean (kitchen knife)
 Immunization history (>10 yrs need booster or >5 yrs if contaminated)
Tell pt to return in one day for recheck, for signs of infection (redness,
heat, pain, puss, etc), inadequate analgesia, or suture
complications (suture strangulation or knot failure with possible
wound dehiscence)
It should be emphasized to patients that they return at the
appropriate time for suture removal or complications may arise
leading to further scarring or subsequent surgical removal of
buried sutures.
PATIENT INSTRUCTIONS AND FOLLOW
UP CARE
Wound care
 After the 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
Average time frame is 7 – 10 days
 FACE: 3 – 5 d
 NECK: 5 – 7 d
 SCALP: 7 – 12 days
 UPPER EXTREMITY, TRUNK: 10 – 14 days
 LOWER EXTREMITY: 14 – 28 days
 SOLES, PALMS, BACK OR OVER JOINTS: 10 days
Any suture with pus or signs of infections should be
removed immediately.
SUTURE REMOVAL
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. Count them.
Most wounds have < 15% of final wound strength
after 2 wks, so steri-strips should be applied
afterwards.
TOPICAL ADHESIVES
Indications: selection of 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
Contraindicated with infection, gangrene, mucosal, damp or
hairy areas, allergy to formaldehyde or cryanoacrylate, or
high tension areas
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
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 with at least 30 s between each layer,
hold for 60 s after last layer until not tacky
Apply dressing
http://www.youtube.com/watch?v=oa13wriWTus&feature=related
http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
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
BIOPSY METHODS
Punch & Shave: http://www.youtube.com/watch?v=7CzDEok8Wmo
Elliptical Excision: http://www.youtube.com/watch?v=BAhXuoB0wMo&feature=related