Basic Suturing Workshop Lianne Beck, MD Emory Family Medicine December 2010
Objectives
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 Period Tissue
Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days 0
5 7
14
21
Tissue Healing Time/Days
28
Model 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 Concepts
Patient factors Wound classification Mechanism of injury Tetanus/antibiotics/local anesthetics Surgical principles and wound prep Suture/needle/stitch choice Management/care/follow-up
Common 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 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 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 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 Materials
Criteria – Tensile strength – Good knot security
– Workability in handling – Low tissue reactivity – Ability to resist bacterial infection
Types 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
Absorbable
Non-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)
Natural Suture
Synthetic
Biological Cause inflammatory reaction – Catgut (connective from cow or sheep) – Silk (from silkworm fibers) – Chromic catgut
Synthetic polymers Do not cause inflammatory response – Nylon – Vicryl – Monocryl – PDS – Prolene
Monofilament
Multifilament (braided)
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
Fibers are braided or twisted together More tissue resistance Easier to handle Fewer knots needed Examples: vicryl, silk, chromic
Suture Materials
Suture 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 Selection
Absorbable for GI, urinary or biliary Non-absorbable or extended for up to 6 mos for skin, tendons, fascia Cosmetics = monofilament or subcuticular Ligatures usually absorbable
Suture Sizes
Surgical 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 Needles
Surgical Instruments
Scalpel Blades
Anesthetic 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 Solutions
CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes, Ears, Nose – Fingers, Toes – Penis, Scrotum
Anesthetic Solutions
BUPIVACAINE (MARCAINE): – Slow onset – Long duration
– Strength: 0.25% – DOSE: maximum individual dose 3mg/kg
Local Anesthetics
Injection 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 Evaluation
Time of incident Size of wound Depth of wound Tendon / nerve involvement Bleeding at site
When 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, ts or tendons Crush injuries Markedly contaminated wounds requiring drainage Concern about cosmesis
Contraindications 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 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 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 Repair
Principles And Techniques
Langer’s Lines
Principles 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 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 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 Suturing Rule of halves
Simple Interrupted Suturing Rule of halves
Suturing
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
Suturing
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.
Suturing
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 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, Interrupted
http://www.youtube.com/watch?v=PFQ5-tquFqY
The 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 Tie
Two Handed Tie
One-Hand Tie
One-Hand Tie
Continuous 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 Mattress
Good for everting wound edges (neck, forehead creases, concave surfaces)
http://www.youtube.com/watch?v=824FhFUJ6wc
Horizontal Mattress
Good for closing wound edges under high tension, and for hemostasis.
Horizontal Mattress
http://www.youtube.com/watch?v=9DdaooEXshk
http://www.youtube.com/watch?v=I7C7nsl5Tuk
Suturing - 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…
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 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 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 TS: 10 days
Any suture with pus or signs of infections should be removed immediately.
Suture 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 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
Dermabond®
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
Dermabond®
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 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 Methods
Punch & Shave: http://www.youtube.com/watch?v=7CzDEok 8Wmo
Elliptical Excision: http://www.youtube.com/watch?v=BAhXuoB 0wMo&feature=related
References
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-8AE87EB5D06CE8DF/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/asse mbly/2010handouts/071.Par.0001.File.tmp/071-072.pdf