Suturing Workshop

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Transcript of Suturing Workshop

  • Basic Suturing Workshop Lianne Beck, MDAssistant ProfessorEmory Family Medicine Residency ProgramJune 2014

  • ObjectivesDescribe the principles of wound healingIdentify 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, dermalDemonstrate two-handed, one-handed, instrument tiesRecommend appropriate wound care and follow-up.

  • Critical Wound Healing PeriodTissue

    Skin

    Mucosa

    Subcutaneous

    Peritoneum

    Fascia

    5-7 days 5-7 days 7-14 days 7-14 days 14-28 days0 5 7 14 21 28 Tissue Healing Time/Days

  • 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 ConceptsPatient factorsWound classificationMechanism of injuryTetanus/antibiotics/local anestheticsSurgical principles and wound prepSuture/needle/stitch choiceManagement/care/follow-up

  • Common Patient FactorsAgeBlood supply to the areaNutritional statusTissue qualityRevision/infectionComplianceWeightDehydrationChronic diseaseImmune responseRadiation therapy

  • CDC Surgical Wound ClassificationClean: (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 ClassificationContaminated: (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 PrinciplesIncisionDissectionTissue handlingHemostasisMoisture/siteRemove infected, foreign, dead areasLength of time openChoice of closure material/mechanismPrimary or secondaryCellular responsesEliminate dead spaceClosing tensionDistraction forces and immobilization/care

  • Suture MaterialsCriteria Tensile strengthGood knot securityWorkability in handlingLow tissue reactivityAbility to resist bacterial infection

  • Types of SuturesAbsorbable or non-absorbable (natural or synthetic)Monofilament or multifilament (braided)Dyed or undyedSizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller)New antibacterial sutures

  • Non-absorbableNot biodegradable and permanentNylon (Ethilon)ProleneStainless steelSilk (natural, can break down over years)

    Degraded via inflammatory responseVicrylMonocrylPDSChromicCat gut (natural)

    Absorbable

  • Natural SutureBiologicalCause inflammatory reactionCatgut (connective from cow or sheep)Silk (from silkworm fibers)Chromic catgutSyntheticSynthetic polymersDo not cause inflammatory responseNylonVicrylMonocrylPDSProlene

  • MonofilamentSingle strand of suture materialMinimal tissue traumaSmooth tying but more knots neededHarder to handle due to memoryExamples: nylon, monocryl, prolene, PDSMultifilament (braided)Fibers are braided or twisted togetherMore tissue resistanceEasier to handleFewer knots neededExamples: vicryl, silk, chromic

  • Suture Materials

  • Suture SelectionDo not use dyed sutures on the skinUse monofilament on the skin as multifilament harbor BACTERIANon-absorbable cause less scarring but must be removedPlus sutures (staph, monocryl for E. coli, Klebsiella)Location and layer, patient factors, strength, healing, site and availability

  • Suture SelectionAbsorbable for GI, urinary or biliaryNon-absorbable or extended for up to 6 mos for skin, tendons, fasciaCosmetics = monofilament or subcuticularLigatures usually absorbable

  • Suture Sizes

  • Surgical NeedlesWide variety with different companys naming systems2 basic configurations for curved needlesCutting: cutting edge can cut through tough tissue, such as skinTapered: no cutting edge. For softer tissue inside the body

  • Surgical Needles

  • Surgical Instruments

  • Scalpel Blades

  • Anesthetic SolutionsLidocaine (Xylocaine) Most commonly usedRapid onset Strength: 0.5%, 1.0%, & 2.0% Maximum dose:5 mg / kg, or300 mg 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc300 mg = 0.03 liter = 30 ml Lidocaine (Xylocaine) with epinephrineVasoconstrictionDecreased bleedingProlongs duration Strength: 0.5% & 1.0%Maximum individual dose:7mg/kg, or500mg

  • Anesthetic SolutionsCAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: Eyes, Ears, Nose Fingers, ToesPenis, Scrotum

  • Anesthetic SolutionsBUPIVACAINE (MARCAINE):Slow onsetLong durationStrength: 0.25%DOSE: maximum individual dose 3mg/kg

  • Local Anesthetics

  • Injection Techniques25, 27, or 30-gauge needle6 or 10 cc syringeCheck for allergiesInsert the needle at the inner wound edge

    AspirateInject agent into tissue SLOWLYWaitAfter anesthesia has taken effect, suturing may begin

  • Wound EvaluationTime of incidentSize of woundDepth of woundTendon / nerve involvementBleeding at site

  • When to ReferDeep wounds of hands or feet, or unknown depth of penetrationFull thickness lacerations of eyelids, lips or earsInjuries involving nerves, larger arteries, bones, joints or tendonsCrush injuriesMarkedly contaminated wounds requiring drainageConcern about cosmesis

  • Contraindications to SuturingRednessEdema of the wound marginsInfectionFeverPuncture woundsAnimal bitesTendon, nerve, or vessel involvementWound more than 12 hours old (body) and 24 hrs (face)

  • Closure TypesPrimary 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 cleanExamples: healing of wounds by use of tissue grafts.

  • Wound PreparationMost 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 TISSUEIf not, the risk of infection and of a cosmetically poor scar are greatly increasedPersonal Precautions

  • Basic Laceration RepairPrinciples And Techniques

  • Langers Lines

  • Principles And TechniquesMinimize trauma in skin handlingGentle apposition with slight eversion of wound edgesVisualize an Erlenmeyer flaskMake yourself comfortableAdjust the chair and the lightChange the laceration Debride crushed tissue

  • Types of ClosuresSimple interrupted closure most commonly used, good for shallow wounds without edge tensionContinuous closure (running sutures) good for hemostasis (scalp wounds) and long wounds with minimal tensionLocking continuous - useful in wounds under moderate tension or in those requiring additional hemostasis because of oozing from the skin edgesSubcuticular good for cosmetic resultsVertical mattress useful in maximizing wound eversion, reducing dead space, and minimizing tension across the woundHorizontal mattress good for fragile skin and high tension woundsPercutaneous (deep) closure good to close dead space and decrease wound tension

  • Simple Interrupted SuturingApply the needle to the needle driverClasp needle 1/2 to 2/3 back from tipRule of halves:Matches wound edges better; avoids dog earsVary from rule when too much tension across wound

  • Simple Interrupted SuturingRule of halves

  • Simple Interrupted SuturingRule of halves

  • SuturingThe needle enters the skin with a 1/4-inch bite from the wound edge at 90 degreesVisualize Erlenmeyer flaskEvert wound edgesBecause scars contract over time

  • SuturingRelease the needl