Kuliah Suturing

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TECHNIC SUTURING

Efman Manawan

FK UNSRI 2012


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wound classification Clean

Uninfected operative wound in which noinflammation is encountered and no systemictracts are entered (respiratory, alimentary etc)

Closed by primaryintention and are

usually not drained


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Clean, contaminated

Operative wound in which systemictract(s) are entered under controlledconditions and

without contamination


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Contaminated

Includes: Open traumatic wounds (open fractures,

penetrating wounds)

Operative procedures involving:

Microorganisms multiply so rapidly that acontaminated wound can becomeinfected within 6 hours


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Infected

Heavily contaminated/infected

wound prior to operationIncludes:

Perforatedviscera

Abscesses


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Suture Material

Generally categorized by three

characteristics:Absorbable vs. non-absorbable

Natural vs. syntheticMonofilament vs. multifilament


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Absorbable Suture

Degraded and eventually eliminated inone of two ways:Via inflammatory reaction utilizing tissue

enzymesVia hydrolysis

Examples: Catgut

Chromic , Vicryl

Monocryl

PDS


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Non-absorbable Suture

Not degraded, permanent

Examples:

Prolene

Nylon

Stainless steelSilk


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Natural Suture

Biological origin

Cause intense inflammatory reaction

Examples: Catgut purified collagen fibers from intestine

of healthy sheep or cows

Chromiccoated catgut

Silk


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Synthetic Suture

Synthetic polymers

Do not cause intense inflammatory

reaction

Examples:

VicrylMonocryl , PDS , Prolene

Nylon


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Suture Packaging


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Monofilament Suture

Grossly appears as single strand of suturematerial; all fibers run parallel

Minimal tissue trauma

Resists harboring microorganisms Ties smoothly

Requires more knots than multifilament suture

Possesses memory

Examples:

Monocryl, PDS, Prolene, Nylon


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Multifilament Suture

Fibers are twisted or braided together

Greater resistance in tissue

Provides good handling and ease of tying

Fewer knots required

Examples:

Vicryl (braided)

Chromic (twisted)

Silk (braided)


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Suture Degradation

Suture MaterialMethod of

DegradationTime to

Degradation

CatgutProteolyticenzymes

Days

Vicryl, Monocryl HydrolysisWeeks to

months

PDS Hydrolysis Months


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Suture Size

Sized according to diameter with 0 as reference size

Numbers alone indicate progressively larger sutures (1, 2,etc)

Numbers followed by a 0 indicate progressively smallersutures (2-0, 4-0, etc)

Smaller -------------------------------------Larger

.....3-0...2-0...1-0...0...1...2...3.....


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Needles

Classified according to shape and

type of point

Curved or straight (Keith needle) Taper point, cutting, or reverse

cutting


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Needles

Curved

Designed to be

held with a needle

holder

Used for most

suturing

Straight

Often hand held

Used to securepercutaneously

placed devices

(e.g. central and

arterial lines)


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Needles

Taper-point needle

Round body

Used to suture soft

tissue, excluding

skin (e.g. GI tract,

muscle, fascia,peritoneum)


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Needles

Cutting needle

Triangular body

Sharp edgetoward innercircumference

Used to sutureskin or toughtissue


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Instruments: Needle (I) The main types of needle include:

Tapered

Gradually taper to the point and cross-sectionreveals a round, smooth shaft

Used for tissue that is easy to penetrate, suchas bowel or blood vessels

Cutting Triangular tip with the apex forming a cutting

surface

Used for tough tissue, such as skin (use of atapered needle with skin causes excesstrauma because of difficulty in penetration)

Reverse cutting needle

Similar to a conventional cutting needleexcept the cutting edge faces down instead ofup

This may decrease the likelihood of sutures

pulling through soft tissue


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Instruments: Needle (II) Most sutures with the suture material swaged onto the

base of the needle Shapes vary from a quarter circle to five-eighths of a

circle, depending on how confined the operating field is

Choice of needle should alter the tissue to be sutured aslittle as possible and is dependent on:

The tissue being sutured(when in doubt aboutselection of a taper pointor cutting needle, choosethe taper for everything

except skin sutures) Ease of access to the

tissue

Individual preference


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Instruments: Forceps & needle-holder

Small toothed

forceps (Addison

forceps) grasp

the skin edgesduring suturing

Hold in the first

three fingers in asimilar way to a

pen


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Grasp the needle-

holder by partiallyinserting thethumb and ringfinger into the

loops of thehandle

The free index

finger providesadditional controland stability


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Tensile strength

Force necessary to break a suture Important to consider in areas of tension (linea

alba)

Tissue reaction

Undesirable since inflammation worsens thescar

Maximal between Day 3&7

Non-absorbable or absorbable Monofilament or multifilament

I t t P ti f t t i l


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Instruments: Properties of suture material

Handling of a suture

Memory

Tendency to stay in one position

Leads to difficulty in tying sutures and knotunravelling

Elasticity Ability to return to its original length after

stretching

High elasticity sutures should be used in

oedematous tissue

Knot strength

Force required for a knot to slip

Important to consider when ligating arteries


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Instruments: Monofilament or multifilament

Monofilament (Ethilon or Prolene)

Consists of a single smooth strand

Less traumatic since they glide throughtissues with less friction

May be associated with lower rates ofinfection

More likely to slip and should be secured

with 5 or 6 throws (in contrast to 3throws with multifilament)

Preferred for skin closure because theyprovide a better cosmetic result


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Multifilament (Mersilk or Mersilene)

Consists of multiple fibres woventogether

Easier to handle and tie and knots areless likely to slip


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Instruments: Non-absorbable suture material

Composed of materials which can be:

Naturally occurring (Mersilk, cotton and steel)

Synthetic (Prolene, Ethilon, Nurolon, etc)

Sutures may be: Left in place indefinitely(during closure ofabdominal fascia)

Removed following

adequate healing(closure of superficiallaceration)


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Instruments: Absorbable suture material

Composed of biodegradable materialswhich can be:

Naturally occurring (degraded enzymatically)

Catgut

Consists of processed collagen from animal intestines

Broken down after 7 days

Chromic catgut Consists of intestinal collagen treated with chromium

Loses tensile strength after 2-3 weeks and is brokendown after 3 months


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Synthetic Degraded non-enzymatically by

hydrolysis when water penetrates thesuture filaments and attacks thepolymer chain

Tend to evoke less tissue reaction thanthose occurring naturally

Subclassified according to

degradation time


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Instruments: Size of suture material

Size originally scaled from 0-3

As technology advanced and sutures became smaller,extra 0s were added

Scale now ranges from 3 (largest) to 12/0 (smallest)

Size Uses

7/0 and smaller Ophthalmology, microsurgery

6/0 Face, blood vessels

5/0 Face, neck, blood vessels

4/0Mucosa, neck, hands, limbs, tendons,

blood vessels3/0 Limbs, trunk, gut blood vessels

2/0 Trunk, fascia, viscera, blood vessels

0 and largerAbdominal wall, fascia, drain sites,

arterial lines, orthopaedics


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Instruments: Suture material summary

Mersilk

Natural

NurolonEthibond

Braided

EthilonProlene

Monofilament

Synthetic

Non-absorbable

Catgut

Natural

Vicryl rapide

Synthetic

Short term

Braided vicryl

Braided

Monocryl

Monofilament

Medium term

Panacryl

Braided

PDS II

Monofilament

Long term

Absorbable


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Arming the needle-holder

Grasp the needle two-thirds the distance fromits pointed end

Avoid grasping the needleat its proximal or distalextremities since this willprevent damage to thesuture

Open the suture packetwith one tear to revealthe needle


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Wound Closure

Basic suturing techniques:

Simple sutures

Mattress sutures

Subcuticular sutures

Goal: approximate, not strangulate


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Simple Sutures

Simple interruptedstitch

Single stitches,

individually knotted(keep all knots on

one side of wound)

Used for

uncomplicated

laceration repair and

wound closure


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Mattress Sutures

Horizontal mattressstitch

Provides added strength

in fascial closure; also

used in calloused skin(e.g. palms and soles)

Two-step stitch:

Simple stitch made

Needle reversed and 2ndsimple stitch made

adjacent to first (same

size bite as first stitch


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Mattress Sutures

Vertical mattress stitch Affords precise

approximation of skin

edges with eversion

Two-step stitch:

Simple stitch made

far, far relative to

wound edge (large bite) Needle reversed and

2nd simple stitch made

inside firstnear,

near (small bite)


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Subcuticular Sutures

Usually a running stitch,but can be interrupted

Intradermal horizontalbites

Allow suture to remainfor a longer period oftime withoutdevelopment ofcrosshatch scarring


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Steri-strips

Sterile adhesive tapes

Available in differentwidths

Frequently used withsubcuticular sutures

Used following staple or

suture removal Can be used for delayed

closure


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Staples

Rapid closure of wound

Easy to apply

Evert tissue whenplaced properly


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Simple Interrupted Suture

Si l i t t d tit h St 1&2


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Simple interrupted stitch: Steps 1&2

Grasp the skin edge with theforceps and slightly evert the skinedge

Then pronate the needle-holderso that the needle will pierce theskin at 90o

Ensure the trailing suture materialis out of the way to avoid tangling

Drive the needle through thefull thickness of the skin bysupinating the needle-holder

Keeping the shaft of the needleperpendicular to the skin allowsthe curvature of the needle totraverse the skin asatraumatically as possible

Images courtesy of BUMC


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Release the needle and

pronate the needle-holder Regrasp the needle proximal to

its pointed end

Maintain tension with theforceps to prevent the needle

from retracting

Again, supinate the needle-

holder to rotate the needleupwards and through thetissue


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Regrasp the needle in order torearm the needle-holder (due to

HIV risks it is better to use the

forceps to do this)

Grasp and slightly evert the

opposing skin edge with theforceps

Pronate the needle-holder

Si l i d i h S 7&8


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Again, supinate the needle-holder to rotate the needlethrough the skin, keeping theshaft 90 to the skin surface

After releasing the needle,

pronate the needle-holderbefore regrasping the

needle



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and again supinate the needle-

holder to rotate the needle through

the skin

Pull the suture material through the

skin until 2-3 cm is left protruding

Discard the forceps and use your

free hand to grasp the long end in

preparation for an instrument tie

Place the needle-holder between

the strands

Si l i d i h S 11&12


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Wrap the long strand around the

needle-holder to form the loop for the

first throw of a square knot

Rotate the needle-holder awayyourself and grasp the short end of

the suture


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Now draw the short end back through

the loop towards yourself

Now tighten the first throw

Si l i d i h S 15&16


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The throw should be tightened just

enough to approximate the skin edges

but not enough to strangulate the

tissue

To begin the second throw of the

square knot, wrap the long strandaround the needle-holder by

bringing the long strand towards

yourself


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Rotate the needle-holder towards

yourself to retrieve the short end

Grasp the short end and draw it

through the loop by pulling it awayfrom yourself

Simple interrupted stitch: Step 19&20


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Simple interrupted stitch: Step 19&20

Finally, tighten the second throw

securely against the first

Ensure the knot is to one side of the

wound to avoid involvement in the clot

In one hand hold the scissors asshown

With the other hand maintaintension on the suture material

Slide the tips of the scissors down

the strands to the point where theywill be cut

Cut the suture material leaving 4-5mm tails (important for removal ofexternal non-absorbable sutures)


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Vertical Mattress Stitch


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S t l


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Suture removal

Sutures should be removed:Face: 3-4 days

Scalp: 5 days

Trunk: 7 days

Limb: 7-10 days

Foot: 10-14 days


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Steps involved in removal:

Reassure patient that the procedure is not

painful

Cleanse the skin with hydrogen peroxide

Grasp one of the suture tails with forceps and

elevate Slip the tip of the scissors under the suture and

cut close to the skin edge (to minimise the

length of contaminated suture that will be

pulled through the wound)

Gently pull the knot with the forceps and

reinforce the wound Proxi-Strips if required

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