Basics of Suturing

critical wound healing period

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

surgical wound classification- clean

-1-5% risk of infection

-operative incisional without penetrating infectious organs

surgical wound classification- 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

-biliary tract, appendix, vagina, and oropharynx

surgical wound classification- contaminated

-10-17% risk

-open, fresh, accidental wounds, operations with gross spillage from GI tract

surgical wound classification- dirty or infected

->27% risk

-old traumatic wounds, necrotic tissue, perforated viscera

-postoperative infection predicted

closure types

sutures

suture needles

types of sutures- non-absorbable v. absorbable

types of sutures- biological v synthetic polymers

types of sutures- monofilament v multifilament/braided

chromic gut, fast gut, coated vicryl, monocryl, PDS II

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

-absorbable for mucosa, GI, biliary, GU

-non-absorbable for skin, tendons, fascia

-cosmetics = monofilament, subcuticular

-location and layer, patient factors, strength, healing, site, availability

suture sizes- location, superficial non-absorb, deep absorb

general guidelines- face (except eyelids)

-deep dermal: 4-0 vicryl

-superficial: 6-0 nylon/prolene OR 5-0 fast gut

general guidelines- intraoral/tongue

-deep/muscle: 3-0/4-0 vicryl

-superficial: 3-0 chromic gut

general guidelines- scalp

-deep dermal/galea: 3-0 vicryl

-superficial: 4-0 nylon/prolene OR 3-0 chromic gut OR staples

anesthetic solutions- lido and lido with epi

anesthetic solutions- cautions

-due to its vasoconstriction properties, avoid using lidocaine with epinephrine on:

-ears, nose

-fingers, toes

injection techniques

types of closures

simple interrupted suturing

-stitch is tied separately

-used in skin or underlying tissue layers

-more exact approximation of wound edges can be achieved with this technique than with the running stitch

-rule of halves: matches wound edges better, avoids dog ears, vary from rule when too much tension across wound

suturing technique

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

-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 writs to follow arc of the needle

-principle: minimize trauma to the skin, don’t bend the needle, follow path of least resistance

-evert wound edges, scars contract over time

finishing the simple interrupted suture

-do not position knot directly over wound edge

-number of throws depends on size of suture: 3-0 = 3 throws, 6-0 = 6 throws

-on each throw, reverse the order of wrap

-cut the ends of the suture 1/4-inch from knot

deep suture technique

matching uneven skin edges

continuous locking and non-locking sutures

running or continuous stitch

-made with one continuous length of suture material

-close tissue layers which require close approximation

-speed of execution, and accommodation of edema during the wound healing process

-greater potential for mal-approximation of wound edges with the running stitch than with the interrupted stitch

-needle at a 90 degree angle to the skin within 1-2mm of the wound edge and in the superficial layer

-exit through the opposite side equidistant to the wound edge and directly opposite the initial insertion

subcuticular suture

-usually for closing surgical incisions

-require clean wound edges

-best cosmetic result

vertical mattress

-good for everting wound edges and areas with high tension (over joints, chest, back)

horizontal mattress

-good for wounds under high tension (back, chest, over joints)

-good for hemostasis