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TECHNIC SUTURING

Efman E.U.Manawan Mkes.,SpB-KBD


FK UNSRI 2010

CDC wound classification


Clean
Uninfected operative wound in which no
inflammation is encountered and no systemic
tracts are entered (respiratory, alimentary etc)
Closed by primary
intention and are
usually not drained

Clean, contaminated
Operative wound in which systemic
tract(s) are entered under controlled
conditions and
without contamination

Contaminated
Includes:
Open traumatic wounds (open fractures,
penetrating wounds)
Operative procedures involving:

Microorganisms multiply so rapidly that


a contaminated wound can become
infected within 6 hours

Infected

Heavily contaminated/infected
wound prior to operation
Includes:
Perforated
viscera
Abscesses

Suture Material
Generally categorized by three
characteristics:
Absorbable vs. non-absorbable
Natural vs. synthetic
Monofilament vs. multifilament

Absorbable Suture
Degraded and eventually eliminated in
one of two ways:
Via inflammatory reaction utilizing tissue
enzymes
Via hydrolysis

Examples:
Catgut
Chromic
Monocryl
PDS

, Vicryl

Non-absorbable Suture
Not degraded, permanent
Examples:
Prolene
Nylon
Stainless steel
Silk

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

Suture Packaging

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

Method of
Degradation
Proteolytic
enzymes

Time to
Degradation
Days

Vicryl,
Monocryl

Hydrolysis

Weeks to
months

PDS

Hydrolysis

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)

Smaller ------------------------------------Larger
.....3-0...2-0...10...0...1...2...3.....

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)

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

Instruments: Needle (I)


The main types of needle include:
Tapered
Gradually taper to the point and cross-section
reveals a round, smooth shaft
Used for tissue that is easy to penetrate, such
as bowel or blood vessels

Cutting
Triangular tip with the apex forming a cutting
surface
Used for tough tissue, such as skin (use of a
tapered needle with skin causes excess
trauma because of difficulty in penetration)

Reverse cutting needle


Similar to a conventional cutting needle
except the cutting edge faces down instead of
up
This may decrease the likelihood of sutures
pulling through soft tissue

Instruments: Needle (II)


Most sutures with the suture material swaged onto the base
of the needle
Shapes vary from a quarter circle to five-eighths of a
circle, depending on how confined the operating field is
Choice of needle should alter the tissue to be sutured as
little as possible and is dependent on:
The tissue being sutured
(when in doubt about
selection of a taper point
or cutting needle, choose
the taper for everything
except skin sutures)
Ease of access to the
tissue
Individual preference

Instruments: Forceps & needle-holder

Small toothed
forceps (Addison
forceps) grasp
the skin edges
during suturing
Hold in the first
three fingers in a
similar way to a
pen

Grasp

the needleholder by partially


inserting the thumb
and ring finger into
the loops of the
handle
The free index
finger provides
additional control
and stability

Tensile strength
Force necessary to break a suture
Important to consider in areas of tension (linea
alba)

Tissue reaction
Undesirable since inflammation worsens the
scar
Maximal between Day 3&7

Non-absorbable or absorbable
Monofilament or multifilament

Instruments: Properties of suture material

Handling of a suture
Memory
Tendency to stay in one position
Leads to difficulty in tying sutures and knot
unravelling

Elasticity
Ability to return to its original length after
stretching
High elasticity sutures should be used in
oedematous tissue

Knot strength
Force required for a knot to slip
Important to consider when ligating arteries

Instruments: Monofilament or multifilament

Monofilament (Ethilon or Prolene)


Consists of a single smooth strand
Less traumatic since they glide through
tissues with less friction
May be associated with lower rates of
infection
More likely to slip and should be secured
with 5 or 6 throws (in contrast to 3
throws with multifilament)
Preferred for skin closure because they
provide a better cosmetic result

Multifilament (Mersilk or Mersilene)


Consists of multiple fibres woven
together
Easier to handle and tie and knots are less
likely to slip

Instruments: Non-absorbable suture material


Composed of materials which can be:
Naturally occurring (Mersilk, cotton and steel)
Synthetic (Prolene, Ethilon, Nurolon, etc)

Sutures

may be:

Left in place indefinitely


(during closure of
abdominal fascia)
Removed following
adequate healing
(closure of superficial
laceration)

Instruments: Absorbable suture


material
Composed of biodegradable materials
which can be:
Naturally occurring (degraded enzymatically)
Catgut
Consists of processed collagen from animal intestines
Broken down after 7 days

Chromic catgut
Consists of intestinal collagen treated with chromium
Loses tensile strength after 2-3 weeks and is broken
down after 3 months

Synthetic
Degraded non-enzymatically by
hydrolysis when water penetrates the
suture filaments and attacks the polymer
chain
Tend to evoke less tissue reaction than
those occurring naturally

Subclassified according to
degradation time

Instruments: Size of suture material


Size originally scaled from 0-3
As technology advanced and sutures became smaller, extra
0s were added
Scale now ranges from 3 (largest) to 12/0 (smallest)
Size

Uses

7/0 and smaller

Ophthalmology, microsurgery

6/0

Face, blood vessels

5/0

Face, neck, blood vessels

3/0

Mucosa, neck, hands, limbs, tendons,


blood vessels
Limbs, trunk, gut blood vessels

2/0

Trunk, fascia, viscera, blood vessels

0 and larger

Abdominal wall, fascia, drain sites,


arterial lines, orthopaedics

4/0

Instruments: Suture material summary


N o n - a b s o r b a b le
N a tu ral
M e r s ilk

S y n th e tic
B r a id e d

M o n o f il a m e n t

N u ro lo n
E t h ib o n d

E t h ilo n
P r o le n e

A b s o r b a b le
S hort term

M e d iu m t e r m

L ong te rm

N a tu r a l

S y n t h e t ic

B r a id e d

M o n o f il a m e n t

B r a id e d

M o n o f il a m e n t

C a tgut

V ic r y l r a p id e

B r a id e d v ic r y l

M onocryl

Panacryl

PD S II

Arming the needle-holder

Open the suture packet


with one tear to reveal
the needle

Grasp the needle two-thirds


the distance from its
pointed end
Avoid grasping the needle
at its proximal or distal
extremities since this will
prevent damage to the
suture

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

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

Simple Interrupted Suture

Simple interrupted stitch: Steps 1&2

Images courtesy of BUMC

Grasp the skin edge with the


forceps and slightly evert the skin
edge
Then pronate the needle-holder so
that the needle will pierce the skin
at 90o
Ensure the trailing suture material
is out of the way to avoid tangling
Drive the needle through the
full thickness of the skin by
supinating the needle-holder
Keeping the shaft of the needle
perpendicular to the skin allows
the curvature of the needle to
traverse the skin as
atraumatically as possible

Simple interrupted stitch: Steps 3&4


Release the needle and pronate
the needle-holder
Regrasp the needle proximal to
its pointed end
Maintain tension with the
forceps to prevent the needle
from retracting

Again, supinate the needleholder to rotate the needle


upwards and through the
tissue

Simple interrupted stitch: Steps 5&6

Regrasp the needle in order to


rearm the needle-holder (due to
HIV risks it is better to use the
forceps to do this)

Grasp and slightly evert the


opposing skin edge with the
forceps
Pronate the needle-holder

Simple interrupted stitch: Steps 7&8

Again, supinate the needleholder to rotate the needle


through the skin, keeping the
shaft 90 to the skin surface

After releasing the needle,


pronate the needle-holder
before regrasping the
needle

Simple interrupted stitch: Steps 9&10

and again supinate the needle-holder


to rotate the needle through the skin

Pull the suture material through the


skin until 2-3 cm is left protruding
Discard the forceps and use your
free hand to grasp the long end in
preparation for an instrument tie
Place the needle-holder between
the strands

Simple interrupted stitch: Steps 11&12

Wrap the long strand around the needleholder to form the loop for the first
throw of a square knot

Rotate the needle-holder away


yourself and grasp the short end of
the suture

Simple interrupted stitch: Steps 13&14

Now draw the short end back through


the loop towards yourself

Now tighten the first throw

Simple interrupted stitch: Steps 15&16

The throw should be tightened just


enough to approximate the skin edges
but not enough to strangulate the tissue

To begin the second throw of the


square knot, wrap the long strand
around the needle-holder by
bringing the long strand towards
yourself

Simple interrupted stitch: Steps 17&18

Rotate the needle-holder towards


yourself to retrieve the short end

Grasp the short end and draw it


through the loop by pulling it away
from yourself

Simple interrupted stitch: Step 19&20

Finally, tighten the second throw


securely against the first
Ensure the knot is to one side of the
wound to avoid involvement in the clot

In one hand hold the scissors as


shown
With the other hand maintain
tension on the suture material
Slide the tips of the scissors down
the strands to the point where they
will be cut
Cut the suture material leaving 45mm tails (important for removal of
external non-absorbable sutures)

Vertical Mattress Stitch

Suture removal
Sutures should be removed:
Face:
Scalp:
Trunk:
Limb:
Foot:

3-4 days
5 days
7 days
7-10 days
10-14 days

Steps involved in removal:


Reassure patient that the procedure is not
painful
Cleanse the skin with hydrogen peroxide
Grasp one of the suture tails with forceps and
elevate
Slip the tip of the scissors under the suture and
cut close to the skin edge (to minimise the
length of contaminated suture that will be
pulled through the wound)
Gently pull the knot with the forceps and
reinforce the wound Proxi-Strips if required

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