Basic Suturing Workshop

Lianne Beck, MD Emory Family Medicine January 2013

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
Mucosa

5-7 days
5-7 days

Subcutaneous
Peritoneum

7-14 days
7-14 days

Fascia
0 5 7 14

14-28 days
21 28

Tissue Healing Time/Days

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

Non-absorbable

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 companys 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%, &

Lidocaine (Xylocaine) with epinephrine

Vasoconstriction Decreased bleeding Prolongs duration

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

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, joints 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

Langers 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 dont 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 wounds 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 JOINTS: 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

Obstetrics and Gynecology Episiotomy Repair

Ricardo Rodriguez, MD Providence hospital Department of Obstetrics and Gynecology

Episiotomy

Traditionally used to facilitate delivery of the infant

Reduce second stage of labor

1700s focus on protecting intact perineum

Allow slow controlled dilation and delivery

1828 Ferdinand von Ritgen

Described prpcedure using extension rather than flexion for delivery of

fetal head

1893 Karl August Scudart

Fisrt mediolateral incision report

1900s J. B. DeLee
Believed everyone should have episiotomy with forcep delivery to reduce

trauma to pelvic floor less potential fetal trauma Twilight birthing came about

1970s 1980s
Questioning routine use of episiotomy Gradual decrease in use

Episiotomy

Episiotomy

ACOG
Do not support routine or liberal use Use for maternal or fetal indications Avoiding severe maternal lacerations Facilitating difficult deliveries

Indications depend on clinical judgment

Non reassuring fetal heart rate

Shoulder dystocia
Operative vaginal delivery Breech Delivery

Episiotomy

Extension Tears

Generally 1st and 2nd degree tears are simple to repair If you havent done many 3rd and 4th degree tears call for help Gyn or Colorectal

Episiotomy and Vaginal Repairs

Goal is to return all structures to normal anatomy Use the hymen remnant as key landmark Suture used 2-0 Vicryl or monocryl common 2-0 chromic maybe used but some patients can have reactions Give plenty of anesthesia Even patients with epidurals can benefit from local injection due to varying levels of anesthesia

Nerve Dermatomes

Stage I Onset of labor to 10cm dilation T10 L1(Sympathetic fibers) Stage II 10 cm the birth of the baby S 2- S4 (Pudendal nerves, somatic) Stage III Delivery of the Placenta T10 L1 (Sympathetic fibers)

Epidural

Epidural
Catheter into epidural potential space

A good spinal or epidural will cover T10 to S5 for vaginal delivery and T4 to S1 for CS Achieved by Location of tip Dose concentration os volume of medication Affected by Patient position Anatomic variations Synechiae

Episiotomy Repair

Episiotomy Repair Pearls

Return normal anatomy and use the least amount of suture material possible Count the tray before starting the procedure and after including sponges and 4x4s
Recommend not using 4x4s or non tagged gauze. Use lap sponges with

the blue radio opaque handle

Put in one lap sponge past the point of repair by the cervix
This will stop blood from oozing down obscuring the field while doing the

repair Make sure you take out and count the laps and instruments If blood soaks the lap sponge and starts to drip down inspect cervix for tears and cavity for possible retained placenta

Anesthesia anesthesia anesthesia

Test the area by using pick ups to pinch where you will be stitching Nothing worse than a patient closing her legs and kicking while both your

hand and a needle are in an enclosed space

Episiotomy Repair

Episiotomy Repair

Episiotomy Repair

Episiotomy Repair

Pain after Episiotomy

Ice packs Oral motrin vs toradol Pudental block Opioid analgesics Topical lidocaine not effective Pain out of proportion
Can be sign of vulvar, paravaginal, ischiorectal hematoma or

cellulitis. Examine patient if stable non expanding hematoma can monitor If hematoma is expanding take to the OR for management

Episiotomy Break Down

Breakdown is rare but can be serious If no sign of infection you can take the patient to the OR right away If there is pus or drainage admit for antibiotic then take to OR after 2 or 3 days of antibiotics and no signs of infection Can also leave open after antibiotics and debriedment for second intention healing This can leave the area scarred and affect patients quality of life Needs to be addressed early to avoid complications such as necrotizing fasciitis, cellulitis which may need much more extensive surgical repair

Episiotomy Repair 3rd degree

http://www.youtube.com/watch?v=vPZxkM juKp4