basic wound closure and knot tying

8/7/2019 Basic Wound Closure and Knot Tying

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JoslynJoslyn Albright, MD Albright, MDGeneral Surgery

PGY-4 Research Resident

Basic Wound Closure & Basic Wound Closure &

Knot TyingKnot Tying


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ObjectivesObjectives

Provide basic information on commonlyProvide basic information on commonlyused suture materialsused suture materialsReview general principles of woundReview general principles of woundclosureclosureProvide a general overview of basicProvide a general overview of basic

surgical knot tyingsurgical knot tying


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Suture MaterialSuture Material

Generally categorized by threeGenerally categorized by threecharacteristics:characteristics:

Absorbable vs. non Absorbable vs. non --absorbableabsorbableNatural vs. syntheticNatural vs. syntheticMonofilament vs. multifilamentMonofilament vs. multifilament


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Absorbable Suture Absorbable Suture

Degraded and eventually eliminated in one of Degraded and eventually eliminated in one of two ways:two ways: Via inflammatory reaction utilizing tissue enzymes Via inflammatory reaction utilizing tissue enzymes Via hydrolysis Via hydrolysis

Examples:Examples: CatgutCatgut ChromicChromic

Vicryl VicrylMonocrylMonocrylPDS (PDS ( polydioxanonepolydioxanone suture)suture)

http://ecatalog.ethicon.com/sutures-absorbable


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NonNon --absorbable Sutureabsorbable Suture

Not degraded, permanentNot degraded, permanentExamples:Examples:

ProleneProlene (polypropylene)(polypropylene)

EthibondEthibond (polyester/Dacron)(polyester/Dacron)NylonNylonStainless steelStainless steel

Silk*Silk*

(*not a truly permanent material; known to be broken(*not a truly permanent material; known to be broken

down over a prolonged period of timedown over a prolonged period of time years)years)


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Natural SutureNatural Suture

Biological originBiological originCause intense inflammatory reactionCause intense inflammatory reaction

Examples:Examples: CatgutCatgut purified collagen fibers frompurified collagen fibers fromintestine of healthy sheep or cowsintestine of healthy sheep or cows

ChromicChromic coatedcoated catgutcatgut Silk Silk


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Synthetic SutureSynthetic Suture

Synthetic polymersSynthetic polymersDo not cause intense inflammatory reactionDo not cause intense inflammatory reactionExamples:Examples:

Vicryl VicrylMonocrylMonocrylPDSPDS

ProleneProleneNylonNylon


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Monofilament SutureMonofilament Suture

Grossly appears as single strand of sutureGrossly appears as single strand of suturematerial; all fibers run parallelmaterial; all fibers run parallelMinimal tissue traumaMinimal tissue trauma

Resists harboring microorganismsResists harboring microorganismsTies smoothlyTies smoothlyRequires more knots than multifilament sutureRequires more knots than multifilament suture

Possesses memoryPossesses memoryExamples:Examples:

MonocrylMonocryl , PDS,, PDS, ProleneProlene , Nylon, Nylon


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Multifilament SutureMultifilament Suture

Fibers are twisted orFibers are twisted or braidedbraided togethertogetherGreater resistance in tissueGreater resistance in tissueProvides good handling and ease of tyingProvides good handling and ease of tyingFewer knots requiredFewer knots requiredExamples:Examples:

Vicryl Vicryl (braided)(braided)Chromic (twisted)Chromic (twisted)Silk (braided)Silk (braided)


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Suture DegradationSuture Degradation

Suture MaterialSuture Material Method of Method of DegradationDegradationTime toTime to

DegradationDegradation

CatgutCatgut ProteolyticProteolyticenzymesenzymes DaysDays

Vicryl Vicryl,, MonocrylMonocryl HydrolysisHydrolysis Weeks toWeeks tomonthsmonths

PDSPDS HydrolysisHydrolysis MonthsMonths


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Suture SizeSuture Size

Sized according to diameter withSized according to diameter with 00 as reference sizeas reference sizeNumbers alone indicate progressively larger sutures (Numbers alone indicate progressively larger sutures ( 11 ,, 22 , etc), etc)Numbers followed by aNumbers followed by a 00 indicate progressively smallerindicate progressively smallersutures (sutures ( 22--00 ,, 44--00 , etc), etc)

SmallerSmaller -------------------------------------------------------------------------- LargerLarger

.......... 33--00 ...... 22--00 ...... 11--00 ...... 00 ...... 11 ...... 22 ...... 33 ..........


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NeedlesNeedles

Classified according to shape and typeClassified according to shape and typeof pointof point

Curved or straight (Keith needle)Curved or straight (Keith needle)Taper point, cutting, or reverse cuttingTaper point, cutting, or reverse cutting


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NeedlesNeedles

CurvedCurvedDesigned to be heldDesigned to be heldwith a needle holderwith a needle holder

Used for most suturingUsed for most suturing

StraightStraightOften hand heldOften hand heldUsed to secureUsed to secure

percutaneouslypercutaneously placedplaceddevices (e.g. centraldevices (e.g. centraland arterial lines)and arterial lines)


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NeedlesNeedles

TaperTaper --point needlepoint needleRound bodyRound bodyUsed to suture softUsed to suture soft

tissue, excluding skintissue, excluding skin(e.g. GI tract, muscle,(e.g. GI tract, muscle,fascia, peritoneum)fascia, peritoneum)


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NeedlesNeedles

Cutting needleCutting needleTriangular bodyTriangular bodySharp edge towardSharp edge toward

inner circumferenceinner circumferenceUsed to sutureUsed to suture skinskin orortough tissuetough tissue


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Suture PackagingSuture Packaging


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Wound ClosureWound Closure

Basic suturing techniques:Basic suturing techniques:Simple suturesSimple suturesMattress suturesMattress suturesSubcuticularSubcuticular suturessutures

GoalGoal :: approximate, not strangulateapproximate, not strangulate


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Simple SuturesSimple Sutures

SimpleSimple InterruptedInterruptedSingle stitches,Single stitches,individually knottedindividually knotted(keep all knots on one(keep all knots on oneside of wound)side of wound)Used forUsed foruncomplicateduncomplicated

laceration repair andlaceration repair andwound closurewound closure


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Mattress SuturesMattress Sutures

Horizontal MattressHorizontal MattressProvides added strengthProvides added strengthinin fascialfascial closure;closure; alsoalsoused in calloused skin (e.g.used in calloused skin (e.g.palms and soles)palms and soles)TwoTwo --step stitch:step stitch:

Simple stitch then,Simple stitch then,

Needle reversed and 2ndNeedle reversed and 2ndsimple stitch madesimple stitch madeadjacent to firstadjacent to firstsame size bite as firstsame size bite as first

stitchstitch


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Mattress SuturesMattress Sutures

Vertical Mattress Vertical Mattress Affords precise Affords preciseapproximation of skinapproximation of skinedges withedges with eversioneversionTwoTwo --step stitchstep stitch ::

Simple stitch madeSimple stitch made far, farfar, far relative torelative to

wound edge (large bite)wound edge (large bite)Needle reversed and 2ndNeedle reversed and 2ndsimple stitch made insidesimple stitch made insidefirstfirst near, nearnear, near (small(small

bite)bite)


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SubcuticularSubcuticular SuturesSutures

Usually a runningUsually a runningstitch, but can bestitch, but can beinterruptedinterruptedIntradermalIntradermal horizontalhorizontalbitesbites

Allow suture to Allow suture toremain for a longerremain for a longerperiod of time withoutperiod of time withoutdevelopment of development of crosshatch scarringcrosshatch scarring


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SteriSteri --stripsstrips

Sterile adhesive tapesSterile adhesive tapes Available in different Available in differentwidthswidths

Frequently used withFrequently used withsubcuticularsubcuticular suturessuturesUsed following stapleUsed following stapleor suture removalor suture removalCan be used forCan be used fordelayed closuredelayed closure


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StaplesStaples

Rapid closure of Rapid closure of woundwoundEasy to applyEasy to apply

EvertEvert tissue whentissue whenplaced properlyplaced properly


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TwoTwo --Hand Square KnotHand Square Knot

Easiest and mostEasiest and mostreliablereliableUsed to tie mostUsed to tie most

suture materialssuture materials

(click image to start video)(click image to start video)


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Instrument TieInstrument Tie

Useful when one orUseful when one orboth ends of sutureboth ends of suturematerial are shortmaterial are short

Commonly usedCommonly usedtechnique fortechnique forlaceration repairlaceration repair

(click image to start video)(click image to start video)


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ReferencesReferencesEncyclopedia of Knots provided byEncyclopedia of Knots provided by EthiconEthicon ; available at; available at

www.jnjgateway.com/public/USENG/5256ETHICON_Encyclopedia_of_Knotwww.jnjgateway.com/public/USENG/5256ETHICON_Encyclopedia_of_Knot s.pdf s.pdf (More extensive overview of knot tying with photos for those int (More extensive overview of knot tying with photos for those int erested in surgery) erested in surgery)

BlackbourneBlackbourne , LH, editor. Surgical Recall. 2, LH, editor. Surgical Recall. 2 ndnd ed. Baltimore:ed. Baltimore: LippincottLippincott Williams & Williams & Wilkins; 1998Wilkins; 1998

Cameron, JL, editor. Current Surgical Therapy. 7Cameron, JL, editor. Current Surgical Therapy. 7 thth

ed. St. Louis:ed. St. Louis: MosbyMosby ; 2001; 2001

Edgerton, MT. The Art of Surgical Technique. Baltimore: WilliamEdgerton, MT. The Art of Surgical Technique. Baltimore: William s & Wilkins; 1988s & Wilkins; 1988(Excellent resource for technical details of surgery) (Excellent resource for technical details of surgery)

GomellaGomella , LG,, LG, HaistHaist , SA. Clinician, SA. Clinician s Pocket Reference. 9s Pocket Reference. 9 thth ed. New York: McGrawed. New York: McGraw --HillHillMedical Publishing Division; 2002Medical Publishing Division; 2002 (Useful book for anyone doing clinical rotations!) (Useful book for anyone doing clinical rotations!)

Special thanks to Drs. Thomas and Angelats for theirassistance in the development of this presentation.

basic wound closure and knot tying

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