Transcript Document
Sutures and Suturing
Suture Materials
Criteria Tensile strength Good knot security Workability in handling Low tissue reactivity Ability to resist bacterial infection
Suture Material
Generally categorized by three characteristics: Absorbable vs. non-absorbable Natural vs. synthetic Monofilament vs. multifilament
Suture Material
Criteria Tensile strength Good knot security Workability in handling Low tissue reactivity Ability to resist bacterial infection
Absorbable Suture
Degraded and eventually eliminated in one of two ways: Via inflammatory reaction utilizing tissue enzymes Via hydrolysis Lose their tensile strength within 60 days.
Examples: “Catgut” Chromic Vicryl Monocryl PDS
Absorbable 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 (Dexon
®
)
Braided Low-memory 50% tensile strength = 25 days Sites = subcutaneous closure skin
Polydioxanone (PDS
®
)
Monofilament 50% tensile strength = 30+ days Sites = need for prolonged strength,
Polyglycan 910 (Vicryl
®
)
Braided, synthetic polymer 50% tensile strength for 30 days Used: subcutaneous
Non-absorbable Suture
Not degraded, permanent Examples: Prolene Nylon Stainless steel Silk* (*not a truly permanent material; known to be broken down over a prolonged period of time— years)
Non-absorbable Sutures
Nylon (Ethilon®): of all the non absorbable suture materials, monofilament nylon is the most commonly used in surface closures.
Non-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.
Natural Suture
Biological origin Cause intense inflammatory reaction Examples: “Catgut” – purified collagen fibers from intestine of healthy sheep or cows Chromic – coated “catgut” Silk
Synthetic Suture
Synthetic polymers Do not cause intense inflammatory reaction Examples: Vicryl Monocryl PDS Prolene Nylon
Monofilament Suture
Grossly appears as single strand of suture material; 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
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)
Suture Degradation
Suture Material “Catgut” Vicryl, Monocryl PDS Method of Degradation Proteolytic enzymes Hydrolysis Hydrolysis Time to Degradation Days Weeks to months Months
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 smaller sutures (“2-0”, “4-0”, etc)
Needles
Classified according to shape and type of point Curved or straight (Keith needle) Taper point, cutting, or reverse cutting
Needles
Curved Designed to be held with a needle holder Used for most suturing Straight Often hand held Used to secure percutaneously placed devices (e.g. central and arterial lines)
Surgical Needles
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
Needles
Taper-point needle Round body Used to suture soft tissue, excluding skin (e.g. GI tract, muscle, fascia, peritoneum)
Needles
Cutting needle Triangular body Sharp edge toward inner circumference Used to suture skin or tough tissue
Surgical Needles
Suture Packaging
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
Steri-strips
Sterile adhesive tapes Available in different widths Frequently used with subcuticular sutures Used following staple or suture removal Can be used for delayed closure
Staples
Rapid closure of wound Easy to apply Evert tissue when placed properly
Surgical Instruments
Needle Holders
Forceps
Tissue forceps Dressing forceps
Iris Scissors
Iris scissors are predominantly used to assist in wound debridement and revision.
Dissection Scissors
Used for heavier tissue revision as necessary for wound undermining.
Suture Removal Scissors
Anesthetic 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 Solutions
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
Mepivacaine (CARBOCAINE): Slower onset than Lidocaine Longer duration Strength: 1% DOSE: maximum individual dose 5mg/kg
Anesthetic Solutions
BUPIVACAINE (MARCAINE): Slow onset Long duration Strength: 0.25% DOSE: maximum individual dose 3mg/kg
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
Complicated Wounds Wounds or lacerations with Nerve Tendon Major vessel Wounds or lacerations of the Eye Wounds entering body cavities Thoracic Eyelids Bites Severely contaminated wounds.
Abdominal.
Contraindications
Redness Edema of the wound margins Infection Fever Puncture wounds Animal bites Tendon, verve, or vessel involvement Wound more than 12 hours old
Closure Types
Primary closure (primary intention) Secondary closure (secondary intention) Tertiary closure (delayed primary closure)
Wound 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 Preparation
Wound cleansing solution Wound scrubbing Irrigation Debridement
Principles And Techniques
Minimize trauma in skin handling Gentle apposition with slight eversion of wound edges Make yourself comfortable Adjust the chair and the light Change the laceration Debride crushed tissue
Definition of Terms
Bite Throw Percutaneous (deep) closure Dermal closure Interrupted closure Continuous closure (running sutures)
Wound Closure
Basic suturing techniques: Simple sutures Mattress sutures Subcuticular sutures Goal: “approximate, not strangulate”
Simple Sutures
Simple interrupted stitch Single stitches, individually knotted (keep all knots on one side of wound) Used for uncomplicated laceration repair and wound closure
Mattress Sutures
Horizontal mattress stitch 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 2nd simple stitch made adjacent to first (same size bite as first stitch)
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 first – “near, near” (small bite)
Subcuticular Sutures
Usually a running stitch, but can be interrupted Intradermal horizontal bites Allow suture to remain for a longer period of time without development of crosshatch scarring
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
Suturing
Rule of halves
Suturing
Rule of halves
Suturing
The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees
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.
Follow 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.
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.
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.
Suturing
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 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!!
Suturing - finishing
After sutures placed, clean the site with normal saline.
Apply a small amount of Bacitracin and cover with a sterile non adherent dressing.
Two-Hand Square Knot
Easiest and most reliable Used to tie most suture materials (click image to start video)
Instrument Tie
Useful when one or both ends of suture material are short Commonly used technique for laceration repair (click image to start video)
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 Removal
Time frame for removing sutures: Average time frame is 7-10 days FACE: 4-5 days BODY & SCALP: 7 days SOLES, PALMS, BACK OR OVER JOINTS: 10 days Any suture with pus or signs of infections should be removed immediately.
Suture Removal
1.
2.
3.
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
Suture 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
Knots
Turns The ends of the thread are looped once over each other Throws A throw is formed of one or more turns Knots A Knot consists of at least two throws laid on top of each other and tightened
Knots
Correct Knot Tumbled Knot