SUTURING WORKSHOPwww.belmatt.co.uk

Objectives

• Identify the various types and sizes of suture material.• Choose the proper instruments for suturing.• Given a list of injectable anesthetic agents, identify

the different agents and correct dosages.• Determine whether a wound requires suturing.• Under supervision, anesthetize, clean, and close a

wound with sutures.• Recommend appropriate laceration care and

follow-up.

Suture Materials

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

Suture Materials

• ABSORBABLE: lose their tensile strength

within 60 days.

• NON-ABSORBABLE:

Absorbable Sutures

PLAIN GUT:Derived from the small

intestine of healthy sheep.

Loses 50% of tensile strength by 5-7 days.

Used on mucosal surfaces.

CHROMIC GUT:Treated with chromic

acid to delay tissue absorption time.

50% tensile strength by 10-14 days.

Used in episiotomy repairs.

•Polyglycolic acid (Dexon®)

BraidedLow-memory50% tensile strength = 25 daysSites = subcutaneous closure skin

Polydioxanone (PDS®)

• Monofilament• 50% tensile strength = 30+ days• Sites = need for prolonged strength,

Polyglycan 910 (Vicryl®)

• Braided, synthetic polymer• 50% tensile strength for 30 days• Used: subcutaneous

Non-absorbable Sutures

• Nylon (Ethilon®): of all the non-absorbable suture materials, monofilament nylon is the most commonly used in surface closures.

Non-absorbable Sutures

• Polypropylene (Prolene®): appears to be stronger then nylon and has better overall wound security. • BRAIDED: includes cotton, silk, braided nylon and

multifilament dacron. Before the advent of synthetic fibers, silk was the mainstay of wound closure. It is the most workable and has excellent knot security. Disadvantages: high reactivity and infection due to the absorption of body fluids by the braided fibers.

Suture Sizes

• 5-0 is small, and 2-0 is big• The usual sizes = 3-0 or 4-0• Examples: • might use 5-0 on the face• 2-0 on the plantar surface of a foot

Surgical Needles

• Wide variety with different companyʼs 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 Needles

Surgical Instruments

Needle Holders

Forceps

• Tissue forceps • Dressing forceps

Iris Scissors

• Iris scissors are predominantly used to assist in wound debridement and revision.

Dissection Scissors

Used for heavier tissue revision as necessary for wound undermining.

Suture Removal Scissors

Hemostats

• Clamping small blood vessels• Hemorrhage control• Grasping• Exposing• Exploring• Visualizing

A Cheap Skin Hook

• Put a hypodermic needle on a small syringe or use a hemostat to hold the needle• Bend the tip of the needle back (sterile technique)• General principle: Minimize trauma in handling

tissue

Scalpels

Scalpel Blades

#15 blade

Dermabond®

• 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

Anesthetic Solutions

• Lidocaine (Xylocaine®) • Most commonly used• Rapid onset • Strength: 0.5%, 1.0%, & 2.0% • Maximum dose:

• 5 mg / kg• 300 mg

• 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc• 300 mg = 0.03 liter = 30 ml

Anesthetic Solutions

• Lidocaine (Xylocaine®) with epinephrine• Vasoconstriction• Decreased bleeding• Prolongs duration • Strength: 0.5% & 1.0%• Maximum individual dose:

• 7mg/kg, OR• 500mg

Anesthetic Solutions

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

Anesthetic Solutions

• Mepivacaine (CARBOCAINE):• Slower onset than Lidocaine• Longer duration• Strength: 1%• DOSE: maximum individual dose 5mg/kg

Anesthetic Solutions

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

Injection 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

Complicated Wounds

Wounds or lacerations withNerveTendonMajor vessel

Wounds or lacerations of theEyeEyelidsBitesSeverely contaminated wounds.

Wounds entering theThoracicor abdominal cavities.

Wound Evaluation

• Time of incident• Size of wound• Depth of wound• Tendon / nerve involvement• Bleeding at site

Contraindications

• Redness• Edema of the wound margins• Infection• Fever

Contraindications

• Puncture wounds• Animal bites• Tendon, verve, or vessel involvement• Wound more than 12 hours old

Closure Types

• Primary closure (primary intention)

• Secondary closure (secondary intention)

• Tertiary closure (delayed primary closure)

Wound Preparation

• Most important step for reducing the risk of wound infection.• Remove all contaminants and devitalized tissue

before wound closure.• IRRIGATE• CUT OUT DEAD, FRAGMENTED TISSUE

• If not, the risk of infection and of a cosmetically poor scar are greatly increased

Wound Preparation

Personnel Precautions

Wound Preparation

• Wound cleansing solution• Wound scrubbing• Irrigation• Take only the soft, flexible part from an 18 gauge IV

needle (angiocath)• Put angiocath tip on 20 cc or 50 cc syringe

• Debridement

Basic Laceration Repair

Principles And Techniques

Principles 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

Definition of Terms• Bite• Throw• Percutaneous (deep) closure • Dermal closure • Interrupted closure • Continuous closure (running sutures)

Principles And Techniques

Suture Techniques

Suture Procedures

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

Suturing

Rule of halves

Suturing

Rule of halves

Suturing

• 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

Suturing

• 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.

Follow the needleʼs arc

• Rotate your wrist to follow the arc of the needle.• Principle: minimize trauma to the skin, and donʼt

bend the needle. Follow the path of least resistance.

Suturing

• 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.

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.

Suturing

• Cut the ends of the suture 1/4-inch from the knot.

• The remaining sutures are inserted in the same manner

The trick to an instrument tie

• Always place the suture holder parallel to the woundʼs 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!!

Simple, Interrupted

Vertical Mattress

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

Horizontal Mattress

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

Suturing - finishing

• After sutures placed, clean the site with normal saline.• Apply a small amount of Bacitracin and cover with a

sterile non-adherent dressing.

Suturing - before you go…

• Need for tetanus globulin and/or vaccine?• Dirty (playground nail) vs clean (kitchen knife)• Immunization history

• Tell pt to return in one day for recheck, for signs of infection or complications.

Suture Removal

Time frame for removing sutures:Average time frame is 7-10 days

FACE: 4-5 daysBODY & SCALP: 7 daysSOLES, PALMS, BACK OR OVER JOINTS: 10 days

Any suture with pus or signs of infections should be removed immediately.

Suture Removal

1. Clean with hydrogen peroxide to remove any crusting or dried blood

2. Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin

3. Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4

Suture Removal

Once all sutures have been removed, count the sutures

The number of sutures needs to match the number indicated in the patient's health record