Basic Suturing Workshop

For Family Practitioner

students

Overview

• Wound evaluation & prep• Local anesthesia• Suture selection• Suturing techniques• Staples• Dermabond

ObjectivesThe participant will be able to :1. Discuss the principles and management of

wound repair.

2. Explain local anesthesia concepts, pharmacology and possible complications.

3. Perform simple interrupted suture technique.

4. discuss suture material choices and wound healing processes

Wound Management

• Anesthesia• Preparation• Sutures• Suture techniques

Skin Anatomy

• Epidermis• Dermis• Subcutaneous

Types of LacerationsSimple, Stellate, Avulsive, and Contused

Wound Status

• Clean• Contaminated• Delay

-Extremity – 12 hours-Face – 24 hours

Wound Evaluation

• Viability of tissue• Tissue loss• Depth of injury• Associated injuries

Foreign bodies on X-ray

• Pebbles• Paperclip• Windshield glass• Wood• Needle• Light bulb glass• Dark glass• Transparent glass

Don’t put your finger in!

FB Removal

Wound Cleansing Preparation• Hand washing• Hair removal• Anesthesia• Removal of gross foreign material• Immersion/soaking• Irrigation

Practical Suture Hints

• Comfort for you and patient• Adequate lighting• Usually sew toward yourself• Where to begin? Side of wound, middle,• landmarks• Flap? – enter flap first

Instruments

• Suture with needle• Needle holder• Forceps• Scissors• Hemostats

Anesthesia

• 1% LidocaineBlocks pain stimuli leaves pressure & touch sensation intact

• 2% LidocaineBlocks all awareness of stimuli including pressure & touch

Local Anesthetic Guidelines

• Never allow patient to view injection

• Always aspirate before injection

• Begin with topical dripping of med

• Inject within wound

Wound Cleansing

Method Mechanical cleansing Irrigation Debridement

Solutions NSS Betadine Hydrogen peroxide Shur Cleans

Wound Irrigation

• NSS 100-300 ml preferred• Most effective to remove debride• Use splash shield or 4X4 gauze• High volume• Low pressure

Suture Selection

• Small needles – fine repairs, e.g. face• Larger needles – bigger bites• More zeros (6-0) – smaller, thin suture• Smaller suture – less tensile strength

Suture Classifications

• Absorbable Chromic, Vicryl, Dexon Digested by body enzymes or Hydrolyzed by tissue fluids• Non-absorbable Ethilon, Monosof, Prolene, Silk Encapsulated or walled off

Absorbable Suture

• Chromic, Dexon, Vicryl• Below the skin• Special areas – inside the mouth• Situations where later removal difficult• Eliminate trauma of suture removal

Non-Absorbable

• Nylon/Ethilon• Prolene – hairy or keloid prone areas• Silk

Suture Selection

• Scalp 4-0 (blue)• Face 6-0• Back/Torso 3-0 or 4-0• Extremities 4-0 or 5-0

Wound Eversion

Wound Eversion

Best cosmetic results

• Smallest size needle• Monofilament• Good wound eversion

Skin Suture Placement

• Close wound in segments• Sutures equidistant from skin edge on either side• of wound• Evert skin edges• Wound margins loosely approximated• Repeatedly bisect the wound

“Wound edges should beapproximated, not strangulated!”

• Too tight = tissue necrosis• Too loose = edges not aligned

Knot Security

• Chromic 2-3 knots• Prolene 4-5 knots• Ethilon 3-4 knots

Key Steps

• Initiate tie with surgeon’s knot• Tighten the knot so it lays flat• Second throw in opposite direction• Two additional throws to secure knot

Suture Removal

• Face/Neck 3 - 5 days• Scalp 7 – 10 days• Joints 10 - 14 days• Back/Feet 10 - 14 days

Steri-strips

• Helpful for surface laceration• Non-motion areas• Avoid areas prone to getting wet• Can use with sutures or derma bond• Use Benzoin to provide additional adhesive

Tissue Glue Key Points

• Identify appropriate wound type• Cleanse and dry wound area• Apply three or four layers of tissue glue• Dry between each layer to bond skin edges

Dermabond• Possible for 1/3 of ED visits• Low tension areas e.g. face, trunk• Children, facial lacerations• Straight, superficial lacerations

Dermabond safety

• Moist gauze over eye• Trendelenburg position