Oxtober 2010 1 Confidential

Skills Stations Suture Techniques

Tom Abelson, MD Peter J. Evans, MD, PhD Jonathan L. Schaffer, MD MBA

Cleveland Clinic

© Cleveland Clinic 2015 DOS Course 2015 1

• How was it made? – Shear Low energy Straight line Minimal damage – Compression Blunt impact perpendicular Complex Infection risk – Tension Blunt impact at angle Flap, complex Infection risk

• When was it done? • Where was it done? • Location, size, shape, margins, depth, neuro and vascular status • Comorbidities, meds, allergies • Tetanus status

– Clean > 10 years toxoid – At risk wounds > 10 years toxoid and immune globulin or > 5 years toxoid

• Foreign body • Washout with sterile saline, ringers • Debridement • Antibiotics

Wounds by Definition Traumatic

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• Healing is side to side

• Promote wound healing – Decrease tissue loss – Facilitate hemostasis – Minimize scar formation

• Cleaning the edges – Bevel the incision to undermine edge, ie outwards – Provides better eversion of edges

• Closure – Avoid tension on edges – Undermine the edges to mobilize the edges – Preserve subdermal blood supply – Approximate without strangulation

Goals of Wound Care

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• Clean – Standard surgical wound

• Clean-contaminated – Clean wounds that are contaminated by entry into a viscus

resulting in minimal spillage of contents

• Contaminated – Lacerations, fractures, gross spillage from the GI tract, resulting

from a break in aseptic technique – Within 6 hours of initial colonization a wound can be infected

• Dirty-infected – Caused by perforated viscera, abscesses, or a prior clinical

infection – Ongoing infection at time of surgery may lead to a 400% increase

in infection rates

Wound Classification

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• Inflammatory Phase Day 0 to 5 – Inflammatory process with leukocytes – Epithelialization / migration (as early as 48 hours) – Swelling, redness, warmth – Suture holds it together

• Migration / Proliferation Phase Day 5 to 14 – Fibroblasts form collagen and start return of tensile strength

• Maturation Phase Day 14 to years – Collagen orients along stress lines – Increases tensile strength – Contraction

Wound Healing

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• Absorbable or non-absorbable – Dyed or undyed – Synthetic predominates today

• Filament – Monofilament = single strand

– Best when contamination is possible, ie skin – Multifilament = bundle of strands

– Stronger

• Size – 3-0 larger than 4-0 – 0 larger than 3-0

• Needle – Cutting for skin

– Triangular and cutting edge on inside curve – Blunt or taper for deeper tissues

– Circular and tapered

Suture Material

Smaller ---------------------Larger .....3-0...2-0...1-0...0...1...2...3.....

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• Redness

• Edema of the wound margins

• Infection

• Fever

• Puncture wounds

• Animal bites

• Tendon, nerve, or vessel involvement

• Wound more than 12 hours old (body) and 24 hrs (face)

Contraindications to Suturing

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Instrument Holding

• Forceps should be held between the thumb and

index finger

• Needle driver: Place the thumb and finger

slightly into the instrument’s ring

www.emedicine.medscape.com www.bumc.bu.edu DOS Course 2015 8

Contraindications to Suturing

• Redness

• Edema of the wound

margins

• Infection

• Fever

• Puncture wounds

• Animal bites

• Tendon, verve, or vessel

involvement

• Wound more > 12° old

(body) and 24 °(face)

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Anesthetic Solutions

• Lidocaine (Xylocaine®) –Most commonly used –Rapid onset –Strengths

–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

• Never use –Eyes, Ears, Nose Fingers,

Toes, Penis, Scrotum

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• Can add Bicarb to decrease pain of injection – 1mL for every 10mL local – Slow injection – Start through wound

Local Anesthetics

Drug Dose Max Onset Duration

Procaine 10-15 mg/kg Rapid 30 min - 1hour

Tetracaine 1.5 mg/kg Moderate 2 hours

Lidocaine 5 mg/kg 5 - 30 min 2 hours

Lido with Epi 7 mg/kg 5 - 30 min 2-3 hours

Bupivacaine 2 mg/kg 7 - 30 min > 6 hours

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Types of Closure

• 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 those requiring additional

hemostasis

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Types of Closure

• Subcuticular – good for cosmetic results

• Vertical mattress – useful in maximizing wound

eversion, reducing dead space, and minimize tension

across the wound

• Horizontal mattress – good for fragile skin + high

tension wounds

• Percutaneous (deep) closure – good to close dead

space + decrease wound tension

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• Absorption of exudates

• Protection of wound closure

• Change at 48 hours

• Topical Abx can be helpful – Moisture, prevents contamination, bactericidal

• Steristrips for augmentation, tension relief

Dressings

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• Remove at appropriate time point – May be 5-7 days or as late as 21 days

• Grasp suture at the knot

• Cut between knot and skin

• Pull suture towards the incision to avoid tension

• Leave when in question

• Steristrip to follow

Suture Removal

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• More rapidly placed

• Less foreign body reaction

• Scalp, trunk, extremities

• Do not allow for meticulous closure

Staples

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• 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, lacerationsStandard 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

Dermabond®

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• 40yo M presents with laceration below knee after fall off bicycle, wearing a helmet, no LOC – Weight bear ok – Wants the laceration fixed

• How deep ?

• How wide ?

• In the joint ? – Entry – Exit – Often deceiving

• Violation of the joint capsule – Considered a surgical emergency

Laceration Near a Joint

http://www.lasvegasemr.com/foam-blog/knee-capsule-violation-bedside-rule-out-test

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• Intra-articular injection to assess capsule integrity – Normal saline – +/- methylene blue dye – Have 200 mL of normal saline ready, sterile – Flex knee 30 degrees – Inject, check for extravasation – Perform range of motion – its painful

– Check for extravasation

• Surgeon induced knee arthrotomy with n=30 – Volume 75 - 195 mL required to achieve 95% sensitivity

• Methylene blue improve sensitivity? – Higher volume injections - probably not due to

pressure alone – Air on CT used as well – unnecessary time delay

– My opinion – Yes, add methylene blue to improve sensitivity

Methylene Blue Test

http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343719 http://www.lasvegasemr.com/foam-blog/knee-capsule-violation-bedside-rule-out-test

https://dailyem.wordpress.com/2013/08/20/saline-load-test-is-the-joint-involved/ http://www.sparkpeople.com/mypage_public_journal_individual.asp?blog_id=5409176

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DOS CME Course 2011 20 DOS Course 2015 20

DOS CME Course 2011 21 Oxtober 2010 21 Confidential

Facial Lacerations Tom I. Abelson MD

Otolarygologist Department of Otolaryngology Head and Neck Institute Cleveland Clinic

© Cleveland Clinic 2014 DOS Course 2015 21

Cheek Lacerations

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• Do not place sutures through cartilage

• Try to place a suture layer in the perichondrium

• Skin and perichondrium can be closed in one layer where

the skin is very thin.

• Absorbable perichondrial suture should be un-died.

• Non-absorbable monofilament suture is best

Ear Lacerations With Cartilage Involvement

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Relaxed Skin Tension Lines

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Facial Lacerations Nima Shemirani

Eos Rejuvenation

Lasky Clinic, Beverly Hills CA

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• Basic principles of wound healing

• Suture and needle choices

• Techniques of effective closure to optimize scar outcomes

• Wound preparation

• Comparison of suture types

• Role of antimicrobials

Objectives

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• After ABCs, anesthetize laceration and explore locally

• Thoroughly clean all debris and blood from face to avoid missing a laceration

• Surgilube is a great way to clean dried blood – leave on for 2 minutes and wipe with 4x4

• Assess depth of wound, layers affected, and look for fractures which may be at the base of the laceration

Evaluation of Patient

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• Thoroughly cleanse the wound with copious irrigation

• If there is any debris – it must be removed, residual

debris will leave tatoos within the dermis (may need to

use scrub brush)

Principles of Wound Management

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• Only the dermis is capable of regeneration – Not the epidermis

• Wounds will contract as they heal

• Tension-free closure is essential – Help avoid widened scars

• Remove foreign bodies, devitalized tissue

Wound Physiology and Healing

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• Can be up to 9 degrees warmer than extremities

• High relative blood flow aids in preventing infection

without the use of antibiotics

• Sutures to be left in 5-7 days to avoid tracking

Features Involving Face

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• 3 parts – Point – Body – Swage

• Needle – Rounded at swage end – Flat within body

–Best place to hold with needle driver

Anatomy of a Needle

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Anatomy of a Needle

• A = swage – needle rotates

• B = body – needle secure

• C = point – point is blunted

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• Taper – Stretches tissue, good for deep, soft and elastic tissue

• Conventional cutting – 3rd edge along inner aspect of needle – Can pull needle through tissue inadvertently

• Reverse cutting – 3rd edge along outer aspect of needle, minimize needle pull through

Needle Choices

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• Jaws of needle driver should approximate 30-35% of the length of the needle

• A= just right B= too big C= too small

Needle driver choice

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• Ideal suture – Absorbable – Minimal reactivity – Minimal “memory” – Ease of use

• Absorbable – Fast gut, chromic gut, cat gut, Vicryl, Monocryl, PDS

• Non-absorbable – Nylon, Prolene

Suture Choices

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• Suture is tied on deep side of knot

• Important to enter and exit tissue at same levels

• Formation of “box” type knot (width=length)

Deep Suture Technique

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• Use layer of skin to match levels (dermis to dermis)

• This will help ensure a even edge closure

Matching Uneven Skin Edges

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• Wound will contract over time

• Need to evert wound edges to prevent depressions and widening of scar

Importance of Eversion

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• Penetrate skin and tissue at 90 degree angles

• Form a “box” with the suture

For Proper Eversion

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• Topical anesthetic may help

• For kids, give a dose of benadryl with topical

• Use 1% lido with epi (hemostasis) and bicarb in a 1cc bicarb to 9cc of lidocaine + epi

• For abscesses use 2% lido+epi (8cc) and bicarb (2cc)

• Use 30g needle and inject SLOWLY

• Try to enter the laceration in areas that are already anesthetized

Injection

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• Simple interrupted sutures should only be left in place for 3-4 days to prevent track marks

• Usually this is not enough time for adequate healing and wound strength

• Alternatively, use a sub-cuticular running suture with prolene or nylon and use steri-strips so you can leave sutures in longer

• Very important to get good deep closure

Forehead

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Example of Sub-Cuticular

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• Look for fat in the wound

• This is a sign that the orbital septum (continuous with the periosteum) has been violated - call occuloplastics

• Suture skin only with small bites, do not need to reapproximate orbicularis oculi - this may lead to scar contracture and inability to close eye

Eyelid

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• Extremely important to realign the vermillion

• A 1mm step-off in the closure will be noticeable

• Reaproximate the orbicularis oris musle to relieve tension in this active area

Lip

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• Skin is adherent to underlying cartilage

• Difficult to suture cartilage together and the overlap may lead to a deformity

• Just need to suture the overlying skin, the cartilage does not need to be sutured

Ear

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• Berk et al looked at 372 patients – 204 of whom had followed up 7 days later in 2004

• They concluded that wounds that were closed within 24 hours had no increased risk of infection if it is a clean laceration

Timing of Repair

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• 2 studies from Holger (2004) and Karounis (2004) showed no difference in long term cosmetic outcome scores when results were pooled together

• 3 studies pooled showed no difference in hypertrophic scarring

• 7 studies pooled together revealed no difference in infection rate

Metanalysis of Absorbable vs Non-absorbable Suture (Al-Abdullah 2007)

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• Whatever method you choose, make sure you perform it correctly (dermabond, steri strips)

• Fast gut may have an unpredictable absorption rate, if it stays in too long, track marks may form as well as prolonged erythema

• Dermabond cannot get into the wound

• 6-0 Prolene is a good choice, gives control over wound closure and suture removal

Choice of Closure Method

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• Normal saline, water, Shur-Clens shown to be least toxic to fibroblasts and keratinocytes in vitro (Wilson et al 2005)

• Povidine-iodine and hydrogen peroxide among the most toxic, but iodine not shown to prevent infection (Gravett et al 1987)

• Since commercial detergents and normal saline have been shown to be equally effective in preventing infection, normal saline is adequate for cleaning of the wound

Choice of Irrigant / Cleanser

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• Nakamura and Daya did a review of clinical trials involving the use of anitbiotics

• They concluded that antimicrobials should be used in open fractures, intra-oral wounds and bites

• In addition, since there are no randomized trials for assessing risk factors, it is accepted that it would be appropriate to use antimicrobials for the previously mentioned risk factors

Appropriate Use of Antibiotics

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• Zen-like - need to visualize and practice entering and exiting the skin at 90 degree angles

• Formation of a “square” with the suture

• Wound eversion is necessary

• Have the proper equipment - need fine instruments with delicate lacerations, small children

• Most of all, be patient and achieve a correct closure, spending an extra 10 minutes will make for a better outcome

Pearls and techniques

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• Carry a needle driver in your pocket

• Practice opening and closing without using your fingers

• This will make it more efficient and help prevent inadvertently pulling the needle out

• Offer to sew buttons and zippers for colleagues

Practice

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• Proper suture placement and eversion of wound is essential for optimum scar outcome

• Antibiotics have not been shown to be effective in non-contaminated wounds

• Closure with fast gut appears to have similar wound outcomes when compared with non-absorable sutures at 1 year

• Dermabond has similar wound outcomes, but requires special attention when applying

• Cleaning of the wound with normal saline is adequate to prevent infection

Conclusions

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DOS CME Course 2011 54 DOS Course 2015 54

Summary:

Suture Techniques

Peter J. Evans, MD, PhD

Jonathan Schaffer, MD

Tom Abelson, MD

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Undermining

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• Simple suture – Even spacing on either side of wound – 4mm – Even spacing along the length of wound – 4mm – Tie knot down on the high side to create eversion – Re-approximate NOT strangulate

Most Used Suture Techniques

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Simple Suture

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http://www.youtube.com/watch?v=PFQ5-tquFqY

Simple, Interrupted

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• Mattress suture – Even spacing on either side of wound – 4mm – Even spacing along the length of wound – 4mm – Re-approximate NOT strangulate

Most Used Suture Techniques

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Good for closing wound edges under high tension and for hemostasis.

Horizontal Mattress

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http://www.youtube.com/watch?v=I7C7nsl5Tuk

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

Vertical Mattress Sutures

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• Healthy patient, well vascularized area – 10-12 days

• Diabetic patient, less well vascularized area – 14-18 days

• Antibiotics – Any contaminated wound – Less than trustworthy patient – “the part fits in a toilet”

When to Remove Sutures, etc.

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• Loss of cascade

• Document digital nerve function – may be transiently lost

• Suture skin with simple sutures – Prolene (blue)

• Refer to hand surgery

Flexor Tendon Injury

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Digital Dorsal Block

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• Small stab wound in inter-thenar area from falling down stairs and glass breaking in hand

• Profuse bleeding – ED put suture in superficial arch

• Compress and it stops – suture skin, then refer to hand

Complex Wounds

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DOS CME Course 2011 68 DOS Course 2015 68