Suturing Workshop

Basic Suturing WorkshopBasic Suturing Workshop

Lianne Beck, MD

Assistant Professor

Emory Family Medicine Residency Program

June 2014

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 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 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.

Wound Healing ConceptsWound Healing Concepts

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

Common Patient FactorsCommon 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 ClassificationCDC 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 ClassificationCDC 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 PrinciplesSurgical 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 MaterialsSuture Materials

Criteria – Tensile strength– Good knot security– Workability in handling– Low tissue reactivity– Ability to resist bacterial infection

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 (Ethilon)– Prolene– Stainless steel– Silk (natural, can

break down over years)

Degraded via inflammatory response– Vicryl– Monocryl– PDS– 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– PDS– 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, PDS

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

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

chromic

Suture MaterialsSuture Materials

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

Suture SizesSuture Sizes

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

Scalpel BladesScalpel Blades

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

Local AnestheticsLocal Anesthetics

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

Basic Laceration RepairBasic Laceration Repair

Principles And Techniques

Langer’s Lines

Principles And TechniquesPrinciples 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 ClosuresTypes 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 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

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

One-Hand TieOne-Hand Tie

Continuous Locking and Nonlocking SuturesContinuous 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-chttps://www.youtube.com/watch?v=hIqTDvofekM

Vertical MattressVertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)

http://www.youtube.com/watch?v=824FhFUJ6wc

Horizontal MattressHorizontal Mattress

Good for closing wound edges under high tension,and for hemostasis.

Horizontal MattressHorizontal Mattress

http://www.youtube.com/watch?v=9DdaooEXshk

http://www.youtube.com/watch?v=I7C7nsl5Tuk

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).

Suturing - before you go…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 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.

– Eschar or scab formation should be avoided. – Sunscreen spf 30 should be applied to the wound to

prevent subsequent hyperpigmentation.

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.

Topical AdhesivesTopical 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

DermabondDermabond®®

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

DermabondDermabond®®

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 AdhesivesFollow 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 MethodsBiopsy Methods

Punch & Shave: http://www.youtube.com/watch?v=7CzDEok8Wmo

Elliptical Excision: http://www.youtube.com/watch?v=BAhXuoB0wMo&feature=related

EBM Take Home PointsEBM Take Home Points

Suturing is preferred technique for skin laceration repair LOE SORT C

Saline or tap water should be used for wound irrigation LOE SORT B

Use of white petrolatum to promote wound healing is as effective as antibiotic ointment LOE SORT B

Tissue adhesives show comparable results with regards to cosmetic, infection or dehisence rates LOE SORT A

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

Ricardo Rodriguez, MD

Providence hospital

Department of Obstetrics and Gynecology

Obstetrics and GynecologyObstetrics and GynecologyEpisiotomy RepairEpisiotomy Repair

EpisiotomyEpisiotomy

Traditionally used to facilitate delivery of the infant– Reduce second stage of labor

1700’s focus on protecting intact perineum– Allow slow controlled dilation and delivery

1828 Ferdinand von Ritgen– Described prpcedure using extension rather than flexion for delivery of

fetal head 1893 Karl August Scudart

– Fisrt mediolateral incision report 1900’s J. B. DeLee

– Believed everyone should have episiotomy with forcep delivery to reduce trauma to pelvic floor less potential fetal trauma

– Twilight birthing came about 1970’s 1980’s

– Questioning routine use of episiotomy– Gradual decrease in use


ACOG– Do not support routine or “liberal” use – Use for maternal or fetal indications

Avoiding severe maternal lacerations Facilitating difficult deliveries

Indications depend on clinical judgment– Non reassuring fetal heart rate– Shoulder dystocia– Operative vaginal delivery – Breech Delivery

Extension TearsExtension Tears

Generally•1st and 2nd degree tears are simple to repair•If you haven’t done many 3rd and 4th degree tears call for help Gyn or Colorectal

Episiotomy and Vaginal Episiotomy and Vaginal RepairsRepairs

Goal is to return all structures to normal anatomy Use the hymen remnant as key landmark Suture used

– 2-0 Vicryl or monocryl common– 2-0 chromic maybe used but some patients can have

reactions Give plenty of anesthesia

– Even patients with epidurals can benefit from local injection due to varying levels of anesthesia

Nerve Dermatomes Nerve Dermatomes Stage I

– Onset of labor to 10cm dilation

– T10 – L1(Sympathetic fibers)

Stage II – 10 cm the birth of the baby– S 2- S4 (Pudendal nerves,

somatic) Stage III

– Delivery of the Placenta– T10 – L1 (Sympathetic

fibers)

EpiduralEpiduralEpidural

– Catheter into epidural potential space A “good” spinal or epidural will cover

T10 to S5 for vaginal delivery and T4 to S1 for CS

Achieved by

– Location of tip

– Dose concentration os volume of medication

Affected by

– Patient position

– Anatomic variations

– Synechiae

Episiotomy RepairEpisiotomy Repair

Episiotomy Repair PearlsEpisiotomy Repair Pearls

Return normal anatomy and use the least amount of suture material possible

Count the tray before starting the procedure and after including sponges and 4x4’s– Recommend not using 4x4’s or non tagged gauze. Use lap sponges with

the blue radio opaque handle Put in one lap sponge past the point of repair by the cervix

– This will stop blood from oozing down obscuring the field while doing the repair

– Make sure you take out and count the laps and instruments– If blood soaks the lap sponge and starts to drip down inspect cervix for

tears and cavity for possible retained placenta Anesthesia anesthesia anesthesia

– Test the area by using pick ups to pinch where you will be stitching– Nothing worse than a patient closing her legs and kicking while both your

hand and a needle are in an enclosed space

Episiotomy RepairEpisiotomy Repair

Pain after EpisiotomyPain after Episiotomy

Ice packs Oral motrin vs toradol Pudental block Opioid analgesics Topical lidocaine not effective Pain out of proportion

– Can be sign of vulvar, paravaginal, ischiorectal hematoma or cellulitis.

– Examine patient if stable non expanding hematoma can monitor

– If hematoma is expanding take to the OR for management

Episiotomy Break DownEpisiotomy Break Down

Breakdown is rare but can be serious– If no sign of infection you can take the patient to the OR

right away– If there is pus or drainage admit for antibiotic then take to

OR after 2 or 3 days of antibiotics and no signs of infection– Can also leave open after antibiotics and debriedment for

second intention healing This can leave the area scarred and affect patients quality

of life Needs to be addressed early to avoid complications such as

necrotizing fasciitis, cellulitis which may need much more extensive surgical repair

Episiotomy Repair 3Episiotomy Repair 3rdrd degree degree

http://www.youtube.com/watch?v=vPZxkMjuKp4

Suturing Workshop

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