Download - Kuliah Suturing
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TECHNIC SUTURING
Efman Manawan
FK UNSRI 2012
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wound classification Clean
Uninfected operative wound in which noinflammation is encountered and no systemictracts are entered (respiratory, alimentary etc)
Closed by primaryintention and are
usually not drained
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Clean, contaminated
Operative wound in which systemictract(s) are entered under controlledconditions and
without contamination
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Contaminated
Includes: Open traumatic wounds (open fractures,
penetrating wounds)
Operative procedures involving:
Microorganisms multiply so rapidly that acontaminated wound can becomeinfected within 6 hours
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Infected
Heavily contaminated/infected
wound prior to operationIncludes:
Perforatedviscera
Abscesses
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Suture Material
Generally categorized by three
characteristics:Absorbable vs. non-absorbable
Natural vs. syntheticMonofilament vs. multifilament
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Absorbable Suture
Degraded and eventually eliminated inone of two ways:Via inflammatory reaction utilizing tissue
enzymesVia hydrolysis
Examples: Catgut
Chromic , Vicryl
Monocryl
PDS
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Non-absorbable Suture
Not degraded, permanent
Examples:
Prolene
Nylon
Stainless steelSilk
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Natural Suture
Biological origin
Cause intense inflammatory reaction
Examples: Catgut purified collagen fibers from intestine
of healthy sheep or cows
Chromiccoated catgut
Silk
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Synthetic Suture
Synthetic polymers
Do not cause intense inflammatory
reaction
Examples:
VicrylMonocryl , PDS , Prolene
Nylon
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Suture Packaging
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Monofilament Suture
Grossly appears as single strand of suturematerial; all fibers run parallel
Minimal tissue trauma
Resists harboring microorganisms Ties smoothly
Requires more knots than multifilament suture
Possesses memory
Examples:
Monocryl, PDS, Prolene, Nylon
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Multifilament Suture
Fibers are twisted or braided together
Greater resistance in tissue
Provides good handling and ease of tying
Fewer knots required
Examples:
Vicryl (braided)
Chromic (twisted)
Silk (braided)
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Suture Degradation
Suture MaterialMethod of
DegradationTime to
Degradation
CatgutProteolyticenzymes
Days
Vicryl, Monocryl HydrolysisWeeks to
months
PDS Hydrolysis Months
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Suture Size
Sized according to diameter with 0 as reference size
Numbers alone indicate progressively larger sutures (1, 2,etc)
Numbers followed by a 0 indicate progressively smallersutures (2-0, 4-0, etc)
Smaller -------------------------------------Larger
.....3-0...2-0...1-0...0...1...2...3.....
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Needles
Classified according to shape and
type of point
Curved or straight (Keith needle) Taper point, cutting, or reverse
cutting
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Needles
Curved
Designed to be
held with a needle
holder
Used for most
suturing
Straight
Often hand held
Used to securepercutaneously
placed devices
(e.g. central and
arterial lines)
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Needles
Taper-point needle
Round body
Used to suture soft
tissue, excluding
skin (e.g. GI tract,
muscle, fascia,peritoneum)
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Needles
Cutting needle
Triangular body
Sharp edgetoward innercircumference
Used to sutureskin or toughtissue
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Instruments: Needle (I) The main types of needle include:
Tapered
Gradually taper to the point and cross-sectionreveals a round, smooth shaft
Used for tissue that is easy to penetrate, suchas bowel or blood vessels
Cutting Triangular tip with the apex forming a cutting
surface
Used for tough tissue, such as skin (use of atapered needle with skin causes excesstrauma because of difficulty in penetration)
Reverse cutting needle
Similar to a conventional cutting needleexcept the cutting edge faces down instead ofup
This may decrease the likelihood of sutures
pulling through soft tissue
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Instruments: Needle (II) Most sutures with the suture material swaged onto the
base of the needle Shapes vary from a quarter circle to five-eighths of a
circle, depending on how confined the operating field is
Choice of needle should alter the tissue to be sutured aslittle as possible and is dependent on:
The tissue being sutured(when in doubt aboutselection of a taper pointor cutting needle, choosethe taper for everything
except skin sutures) Ease of access to the
tissue
Individual preference
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Instruments: Forceps & needle-holder
Small toothed
forceps (Addison
forceps) grasp
the skin edgesduring suturing
Hold in the first
three fingers in asimilar way to a
pen
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Grasp the needle-
holder by partiallyinserting thethumb and ringfinger into the
loops of thehandle
The free index
finger providesadditional controland stability
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Tensile strength
Force necessary to break a suture Important to consider in areas of tension (linea
alba)
Tissue reaction
Undesirable since inflammation worsens thescar
Maximal between Day 3&7
Non-absorbable or absorbable Monofilament or multifilament
I t t P ti f t t i l
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Instruments: Properties of suture material
Handling of a suture
Memory
Tendency to stay in one position
Leads to difficulty in tying sutures and knotunravelling
Elasticity Ability to return to its original length after
stretching
High elasticity sutures should be used in
oedematous tissue
Knot strength
Force required for a knot to slip
Important to consider when ligating arteries
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Instruments: Monofilament or multifilament
Monofilament (Ethilon or Prolene)
Consists of a single smooth strand
Less traumatic since they glide throughtissues with less friction
May be associated with lower rates ofinfection
More likely to slip and should be secured
with 5 or 6 throws (in contrast to 3throws with multifilament)
Preferred for skin closure because theyprovide a better cosmetic result
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Multifilament (Mersilk or Mersilene)
Consists of multiple fibres woventogether
Easier to handle and tie and knots areless likely to slip
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Instruments: Non-absorbable suture material
Composed of materials which can be:
Naturally occurring (Mersilk, cotton and steel)
Synthetic (Prolene, Ethilon, Nurolon, etc)
Sutures may be: Left in place indefinitely(during closure ofabdominal fascia)
Removed following
adequate healing(closure of superficiallaceration)
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Instruments: Absorbable suture material
Composed of biodegradable materialswhich can be:
Naturally occurring (degraded enzymatically)
Catgut
Consists of processed collagen from animal intestines
Broken down after 7 days
Chromic catgut Consists of intestinal collagen treated with chromium
Loses tensile strength after 2-3 weeks and is brokendown after 3 months
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Synthetic Degraded non-enzymatically by
hydrolysis when water penetrates thesuture filaments and attacks thepolymer chain
Tend to evoke less tissue reaction thanthose occurring naturally
Subclassified according to
degradation time
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Instruments: Size of suture material
Size originally scaled from 0-3
As technology advanced and sutures became smaller,extra 0s were added
Scale now ranges from 3 (largest) to 12/0 (smallest)
Size Uses
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels
4/0Mucosa, neck, hands, limbs, tendons,
blood vessels3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
0 and largerAbdominal wall, fascia, drain sites,
arterial lines, orthopaedics
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Instruments: Suture material summary
Mersilk
Natural
NurolonEthibond
Braided
EthilonProlene
Monofilament
Synthetic
Non-absorbable
Catgut
Natural
Vicryl rapide
Synthetic
Short term
Braided vicryl
Braided
Monocryl
Monofilament
Medium term
Panacryl
Braided
PDS II
Monofilament
Long term
Absorbable
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Arming the needle-holder
Grasp the needle two-thirds the distance fromits pointed end
Avoid grasping the needleat its proximal or distalextremities since this willprevent damage to thesuture
Open the suture packetwith one tear to revealthe needle
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Wound Closure
Basic suturing techniques:
Simple sutures
Mattress sutures
Subcuticular sutures
Goal: approximate, not strangulate
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Simple Sutures
Simple interruptedstitch
Single stitches,
individually knotted(keep all knots on
one side of wound)
Used for
uncomplicated
laceration repair and
wound closure
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Mattress Sutures
Horizontal mattressstitch
Provides added strength
in fascial closure; also
used in calloused skin(e.g. palms and soles)
Two-step stitch:
Simple stitch made
Needle reversed and 2ndsimple stitch made
adjacent to first (same
size bite as first stitch
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Mattress Sutures
Vertical mattress stitch Affords precise
approximation of skin
edges with eversion
Two-step stitch:
Simple stitch made
far, far relative to
wound edge (large bite) Needle reversed and
2nd simple stitch made
inside firstnear,
near (small bite)
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Subcuticular Sutures
Usually a running stitch,but can be interrupted
Intradermal horizontalbites
Allow suture to remainfor a longer period oftime withoutdevelopment ofcrosshatch scarring
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Steri-strips
Sterile adhesive tapes
Available in differentwidths
Frequently used withsubcuticular sutures
Used following staple or
suture removal Can be used for delayed
closure
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Staples
Rapid closure of wound
Easy to apply
Evert tissue whenplaced properly
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Simple Interrupted Suture
Si l i t t d tit h St 1&2
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Simple interrupted stitch: Steps 1&2
Grasp the skin edge with theforceps and slightly evert the skinedge
Then pronate the needle-holderso that the needle will pierce theskin at 90o
Ensure the trailing suture materialis out of the way to avoid tangling
Drive the needle through thefull thickness of the skin bysupinating the needle-holder
Keeping the shaft of the needleperpendicular to the skin allowsthe curvature of the needle totraverse the skin asatraumatically as possible
Images courtesy of BUMC
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Simple interrupted stitch: Steps 3&4
Release the needle and
pronate the needle-holder Regrasp the needle proximal to
its pointed end
Maintain tension with theforceps to prevent the needle
from retracting
Again, supinate the needle-
holder to rotate the needleupwards and through thetissue
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Simple interrupted stitch: Steps 5&6
Regrasp the needle in order torearm the needle-holder (due to
HIV risks it is better to use the
forceps to do this)
Grasp and slightly evert the
opposing skin edge with theforceps
Pronate the needle-holder
Si l i d i h S 7&8
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Simple interrupted stitch: Steps 7&8
Again, supinate the needle-holder to rotate the needlethrough the skin, keeping theshaft 90 to the skin surface
After releasing the needle,
pronate the needle-holderbefore regrasping the
needle
Simple interrupted stitch: Steps 9&10
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Simple interrupted stitch: Steps 9&10
and again supinate the needle-
holder to rotate the needle through
the skin
Pull the suture material through the
skin until 2-3 cm is left protruding
Discard the forceps and use your
free hand to grasp the long end in
preparation for an instrument tie
Place the needle-holder between
the strands
Si l i d i h S 11&12
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Simple interrupted stitch: Steps 11&12
Wrap the long strand around the
needle-holder to form the loop for the
first throw of a square knot
Rotate the needle-holder awayyourself and grasp the short end of
the suture
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Simple interrupted stitch: Steps 13&14
Now draw the short end back through
the loop towards yourself
Now tighten the first throw
Si l i d i h S 15&16
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Simple interrupted stitch: Steps 15&16
The throw should be tightened just
enough to approximate the skin edges
but not enough to strangulate the
tissue
To begin the second throw of the
square knot, wrap the long strandaround the needle-holder by
bringing the long strand towards
yourself
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Simple interrupted stitch: Steps 17&18
Rotate the needle-holder towards
yourself to retrieve the short end
Grasp the short end and draw it
through the loop by pulling it awayfrom yourself
Simple interrupted stitch: Step 19&20
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Simple interrupted stitch: Step 19&20
Finally, tighten the second throw
securely against the first
Ensure the knot is to one side of the
wound to avoid involvement in the clot
In one hand hold the scissors asshown
With the other hand maintaintension on the suture material
Slide the tips of the scissors down
the strands to the point where theywill be cut
Cut the suture material leaving 4-5mm tails (important for removal ofexternal non-absorbable sutures)
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Vertical Mattress Stitch
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S t l
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Suture removal
Sutures should be removed:Face: 3-4 days
Scalp: 5 days
Trunk: 7 days
Limb: 7-10 days
Foot: 10-14 days
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Steps involved in removal:
Reassure patient that the procedure is not
painful
Cleanse the skin with hydrogen peroxide
Grasp one of the suture tails with forceps and
elevate Slip the tip of the scissors under the suture and
cut close to the skin edge (to minimise the
length of contaminated suture that will be
pulled through the wound)
Gently pull the knot with the forceps and
reinforce the wound Proxi-Strips if required