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Suture Workshop

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					Suture Workshop


        Fema B. Aquino, M.D.
         UAB Selma Family
             Medicine
           April 17, 2010
Objectives

 Learn the indications and contraindications of
  wound closure
 Provide basic information on commonly used
  suture materials & equipments
 Learn basic wound closure techniques
 Recommend appropriate laceration care and
  follow-up



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Suture Material

   1. Absorbable vs non-absorbable

   2. Natural vs synthetic

   3. Monofilament vs multi-filament




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Absorbable vs Non-absorbable
Absorbable Suture                      Non-absorbable Suture

      Degradation and elimination         Not degraded, permanent
      in one of two ways:                 Examples:
i.      By inflammatory reaction            - Nylon (Ethicon)
      using tissue enzymes
                                            - Prolene
ii.    By hydrolysis
                                          - Silk*
Examples:                               (*not a truly permanent material;
      Catgut, Chromic, Vicryl, PDS         known to be broken down
                                           over a prolonged period of
                                           time—years

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Natural vs Synthetic

Natural Suture                       Synthetic Suture

 Biological origin                   Synthetic Polymers
 Causes intense inflammatory         Do not cause intense
   reaction                            inflammatory reaction
 Examples:                           Examples:
 - Catgut-derived from the            - Vicryl (Polyglycan 910)
   small intestine of healthy         - Monocryl
   sheep
                                      - PDS ( Polydioxanone)
 - Chromic catgut-treated with
   chromic acid to delay              - Prolene
   absorption                         - Nylon
 - Silk
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Monofilament vs Multifilament
Monofilament Suture                Multifilament Suture
 Grossly appears as a single        Fibers are twisted or braided
  strand of suture material            together
 Minimal tissue trauma              Greater resistance in tissues
 Resists harboring micro-           Provides good handling and
                                       ease of tying
  organisms
                                     Fewer knots required
 Ties smoothly
                                     Examples:
 Requires more knots than
                                     - Vicryl (Braided)
  multifilament suture
                                     - Silk (Braided)
 Examples: Monocryl, Prolene,
                                     - Chromic (Twisted)
  PDS, Nylon


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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 smaller
   sutures (“2-0”, “4-0”, etc)-- 5-0 is small and 2-0 is big
  Example: 6-0 on the face, 2-0 on the plantar surface, 3-0,4-
   0, 5-0 on torso or extremities


  Smaller -------------------------------------
  Larger

    .....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

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Surgical Needles
  Classified according to the shape and type of point:
    - Curved or straight
    - Taper point, cutting or reverse cutting
  Two basic configurations for curved needles:




a. Cutting: edge can cut through      b. Tapered: no cutting edge, for
tissues, such as skin                 softer tissues inside the body



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Surgical Instruments
Scalpels

 The most commonly used scalpel blades are the
  #10 and #15 blade.




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#10 Blade

 Better for long, straight
  incisions
 Held with the shaft of
  the scalpel in the palm
  of the hand with the
  index finger on the top
  of the blade




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    #15 Blade

 Well suited for
  short, tortuous
  incisions
 Holding the scalpel
  as if it were a pencil
  may facilitate
  control



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Forceps


 The forceps
  should be
  held between
  the thumb
  and the index
  finger




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Needle Holder
 The most common method is to place the thumb
  and ring finger slightly into the instrument’s rings




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   Staples


 Rapid closure of
  wound
 Easy to apply
 Evert tissue when
  placed properly




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Dermabond®

              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
                simple, thoroughly cleansed,
                  lacerations
                Dermabond provides good
                  wound repair (1B)


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Wound Evaluation


    Time of incident
    Size of wound
    Depth of wound
    Tendon / nerve involvement
    Bleeding at site




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Contraindications

          Redness
          Edema of the wound margins
          Infection
          Fever
          Animal bites
          Tendon, nerve, or vessel involvement
          Wound more than 12 hours old
          Puncture wounds


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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

 There is no significant difference in infection rates after
  uncomplicated wound closure following irrigation with
  either direct tap water or sterile saline in the emergency
  department. (LOE 1B)


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Wound Preparation

  Wound cleansing solution
  Wound scrubbing
  Irrigation
    Take only the soft, flexible part from an 18 gauge IV
     needle (angiocath)
    Put angiocath tip on 20 cc or 50 cc syringe
  Debridement



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Anesthetic solutions
    Lidocaine (Xylocaine®)
      Most commonly used
      Rapid onset
      Strength: 0.5%, 1.0%, & 2.0%

    Lidocaine (Xylocaine®) with epinephrine
        Vasoconstriction
        Decreased bleeding
        Prolongs duration
        Strength: 0.5% & 1.0%


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Anesthetic Solutions

 CAUTION: Due to its vasoconstriction properties
  never use Lidocaine with epinephrine on:
    - Eyes
    - Ears
    - Nose
    - Fingers
    - Toes
    - Penis
    - Scrotum


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Anesthetic Solutions

  Mepivacaine (Carbocaine):
    Slower onset than Lidocaine
    Longer duration
    Strength: 1%


  Bupivacaine (Marcaine):
    Slow onset
    Long duration
    Strength: 0.25%

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  Injection Techniques

 25, 27, or 30-gauge          Aspirate
  needle                    Inject agent into tissue
 6 or 10 cc syringe         SLOWLY
 Check for allergies       Wait…
 Insert the needle at the  After anesthesia has
  inner wound edge           taken effect, suturing
                             may begin



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 Use of sterile gloves

 Infection rate in patients undergoing
  uncomplicated laceration repair are not
  different when sterile gloves, rather than
  simply clean gloves, are worn. ( LOE 1B)




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Basic Laceration Repair




    Principles And Techniques
Simple Interrupted




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Continuous Suture
 A continuous suture is used for rapid percutaneous closure
of longer wounds
The needle bites are made at an angle of 45 degrees to the
axis of the wound




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Continuous Interlocking




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Principles And Techniques
  Minimize trauma in skin handling
  Gentle apposition with slight eversion of
   wound edges
    Approximate not strangulate
  Make yourself comfortable
    Adjust the chair and the light
  Change the laceration
    Debride crushed tissue



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Suturing
 Apply the needle to the needle driver
 Clasp needle 1/2 to 2/3 back from the tip




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                 Suturing

Rule of halves




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                 Suturing

Rule of halves




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 Simple Interrupted
• The needle enters the skin with a 1/4-inch bite from
  the wound edge at 90 degrees




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               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.



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                  Suturing
• Rotate your wrist to follow the arc of the needle




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                 Suturing
Principle: Minimize trauma to the skin, and don’t bend
the needle. Follow the path of least resistance.




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                   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 from the bites site.

 Release the needle from the needle driver and wrap
  the suture around the needle driver two times.
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                    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 ensure knot security. On each
  throw reverse the order of wrap.


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          Suturing

 Cut the ends of the suture 1/4-inch from the
  knot

 The remaining sutures are inserted in the
  same manner




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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!!

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          Suturing - finishing

 After sutures are placed, clean the site with normal saline

 Apply a small amount of Bacitracin and cover with a sterile
  non-adherent dressing

 Need for tetanus globulin and/or vaccine?
   Dirty (playground nail) vs clean (kitchen knife)
   Immunization history

 Tell patient to return in one day for recheck, for signs of
  infection or complications

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     Tetanus Prophylaxis

• Wound management and Tetanus Prophylaxis
 TIG : Tetanus Immunoglobulin
Previous doses of   Clean and minor               All other wounds
adsorbed Tetanus    wound
Toxoid              Tetanus Toxoid                Tetanus Toxoid
                                         TIG                         TIG
   <3 or Unknown         Yes                            Yes
                                         No                          Yes

        >/ 3        Only if last dose             Only if last dose
                    given             No          given             No
                    >/10 years ago                >/5 years ago




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          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


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      References

1.Access Medicine

2. Suturing basics

3.Up-todate

4.MD Consult




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