Suture WorkshopSuture Workshop
FM / Rural Clerkship
CompetencyCompetency
Given a pt presenting with a laceration in an office or urgent / emergent care setting and standard supplies and equipment, treat the wound appropriately.
ObjectivesObjectives
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 MaterialsSuture Materials
Criteria – Tensile strength– Good knot security– Workability in handling– Low tissue reactivity– Ability to resist bacterial infection
Suture MaterialsSuture Materials
ABSORBABLE:
lose their tensile strength within 60 days.
NON-ABSORBABLE:
Absorbable SuturesAbsorbable 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 (DexonPolyglycolic acid (Dexon®®))
Braided
Low-memory
50% tensile strength = 25 days
Sites = subcutaneous closure skin
Polydioxanone (PDSPolydioxanone (PDS®®))
Monofilament50% tensile strength = 30+ daysSites = need for prolonged strength,
Polyglycan 910 (VicrylPolyglycan 910 (Vicryl®®))
Braided, synthetic polymer50% tensile strength for 30 daysUsed: subcutaneous
Non-absorbable SuturesNon-absorbable Sutures
Nylon (Ethilon®): of all the non-absorbable suture materials, monofilament nylon is the most commonly used in surface closures.
Non-absorbable SuturesNon-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 SizesSuture Sizes
5-0 is small, and 2-0 is bigThe usual sizes = 3-0 or 4-0Examples:
– might use 5-0 on the face– 2-0 on the plantar surface of a foot
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
Needle Holders
Forceps Forceps
Tissue forceps Dressing forceps
Iris ScissorsIris Scissors
Iris scissors are predominantly used to assist in wound debridement and revision.
Dissection ScissorsDissection Scissors
Used for heavier tissue revision as necessary for wound undermining.
Suture Removal ScissorsSuture Removal Scissors
Hemostats
Clamping small blood vesselsHemorrhage controlGraspingExposingExploringVisualizing
A Cheap Skin HookA 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
ScalpelsScalpels
Scalpel BladesScalpel Blades
#15 blade
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
Anesthetic SolutionsAnesthetic 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 SolutionsAnesthetic Solutions
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
Mepivacaine (CARBOCAINE):– Slower onset than Lidocaine– Longer duration– Strength: 1%– DOSE: maximum individual dose 5mg/kg
Anesthetic SolutionsAnesthetic Solutions
BUPIVACAINE (MARCAINE):– Slow onset– Long duration– Strength: 0.25%– DOSE: maximum individual dose 3mg/kg
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
Complicated WoundsComplicated Wounds
Wounds or lacerations withNerveTendonMajor vessel
Wounds or lacerations of theEyeEyelidsBitesSeverely contaminated wounds.
Wounds entering the
Thoracic
or abdominal cavities.
Wound EvaluationWound Evaluation
Time of incidentSize of woundDepth of woundTendon / nerve involvementBleeding at site
ContraindicationsContraindications
RednessEdema of the wound marginsInfectionFever
ContraindicationsContraindications
Puncture woundsAnimal bitesTendon, verve, or vessel involvementWound more than 12 hours old
Closure TypesClosure Types
Primary closure (primary intention)
Secondary closure (secondary intention)
Tertiary closure (delayed primary closure)
Wound PreparationWound 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 PreparationWound Preparation
Personnel Precautions
Wound PreparationWound Preparation
Wound cleansing solutionWound scrubbingIrrigation
– 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 RepairBasic Laceration Repair
Principles And Techniques
Principles And TechniquesPrinciples And Techniques
Minimize trauma in skin handlingGentle 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 TermsDefinition of Terms
– Bite– Throw– Percutaneous (deep) closure – Dermal closure – Interrupted closure – Continuous closure (running sutures)
Principles And TechniquesPrinciples And Techniques
Suture Techniques
Suture ProceduresSuture Procedures
SuturingSuturing
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
SuturingSuturing
Rule of halves
SuturingSuturing
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.
Follow the needle’s arcFollow the needle’s arc
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.
SuturingSuturing
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.
SuturingSuturing
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 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!!
Simple, InterruptedSimple, Interrupted
Vertical MattressVertical Mattress
Good for everting wound edges (neck, forehead creases, concave surfaces)
Horizontal MattressHorizontal Mattress
Good for closing wound edges under high tension,And for hemostasis.
Suturing - finishingSuturing - 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…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 RemovalSuture 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 RemovalSuture 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 RemovalSuture 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