Basic Suturing Basic Suturing

ObjectivesObjectives 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 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 PeriodCritical Wound Healing Period

Tissue

Skin

Mucosa

Subcutaneous

Peritoneum

Fascia

5-7 days

5-7 days

7-14 days

7-14 days

14-28 days

0 5 7 14 21 28

Tissue Healing Time/Days

Model of Wound HealingModel 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.

Types of SuturesTypes 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

Non-absorbableNon-absorbable Not biodegradable

and permanent– Nylon– Prolene– Stainless steel– Silk (natural, can

break down over years)

Degraded via inflammatory response– Vicryl– Monocryl– Chromic– Cat gut (natural)

AbsorbableAbsorbable

Natural SutureNatural Suture

Biological Cause inflammatory

reaction– Catgut (connective

from cow or sheep)– Silk (from silkworm

fibers)– Chromic catgut

SyntheticSynthetic

Synthetic polymers Do not cause

inflammatory response– Nylon– Vicryl– Monocryl– Prolene

MonofilamentMonofilament Single strand of suture

material Minimal tissue trauma Smooth tying but more

knots needed Harder to handle due to

memory Examples: nylon, monocryl,

prolene,

Multifilament (braided)Multifilament (braided) Fibers are braided or twisted

together More tissue resistance Easier to handle Fewer knots needed Examples: vicryl, silk,

chromic

Suture SelectionSuture 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 SelectionSuture Selection

Absorbable for GI, urinary or biliaryNon-absorbable or extended for up to 6 mos

for skin, tendons, fasciaCosmetics = monofilament or subcuticularLigatures usually absorbable

Surgical NeedlesSurgical 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 NeedlesSurgical Needles

Surgical InstrumentsSurgical Instruments

Anesthetic SolutionsAnesthetic 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 SolutionsAnesthetic Solutions

CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes, Ears, Nose – Fingers, Toes– Penis, Scrotum

Anesthetic SolutionsAnesthetic Solutions

BUPIVACAINE (MARCAINE):– Slow onset– Long duration– Strength: 0.25%– DOSE: maximum individual dose 3mg/kg

Injection TechniquesInjection 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 EvaluationWound Evaluation

Time of incidentSize of woundDepth of woundTendon / nerve involvementBleeding at site

When to ReferWhen 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 SuturingContraindications to Suturing

Redness Edema of the wound margins Infection Fever Puncture wounds Animal bites Tendon, nerve, or vessel involvement Wound more than 12 hours old (body) and 24 hrs

(face)

Closure TypesClosure 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

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 PreparationWound 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

Principles And TechniquesPrinciples And Techniques Minimize trauma in skin

handling Gentle apposition with slight

eversion of wound edges– Visualization

Make yourself comfortable– Adjust the chair and the

light Change the laceration

– Debride crushed tissue

Simple Interrupted SuturingSimple 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 SuturingSimple Interrupted Suturing

Rule of halves

Simple Interrupted SuturingSimple Interrupted Suturing

Rule of halves

SuturingSuturing 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

SuturingSuturing 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.

SuturingSuturing

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 SuturingSimple 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, InterruptedSimple, Interrupted

http://www.youtube.com/watch?v=PFQ5-tquFqY

The trick to an instrument tieThe 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 TieTwo Handed Tie

Two Handed TieTwo Handed Tie

Suturing - finishingSuturing - finishing

After sutures placed, clean the site with normal saline.

Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla).

Patient instructions and follow up carePatient 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.

.

Suture RemovalSuture 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 RemovalSuture 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.

ReferencesReferences

http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct.

355: 17. Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988. www.uptodateonline.com; 2009, topic lacerations, etc. http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf http://www.mnpa.us/handouts/Session%2005%20%20-%20%20Basic%20Suturing

%20%202010%20MNPA.pdf http://www.practicalplasticsurgery.org/docs/Practical_01.pdf http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE8-

7EB5D06CE8DF/0/wound_healing_manual.pdf Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family

Physicians. AAFP Scientific Assembly. 2010. http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/assembly/2010handouts/071.Par.0001.File.tmp/071-072.pdf