basic suturing workshop lianne beck, md emory family medicine december 2010
TRANSCRIPT
Basic Suturing WorkshopBasic Suturing Workshop
Lianne Beck, MD
Emory Family Medicine
December 2010
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– 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, verve, 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
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
Two Handed TieTwo Handed Tie
One-Hand TieOne-Hand 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-c
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
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