Basic surgical skills

SCRUBS
Overview
 CDC wound classification
 Types of wound healing
 Instruments
– Suture material
– Needle
 Basic suturing technique
– Simple interrupted suture
– Suture removal
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:
– Spillage from the GI, or biliary tracts
– 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
• Wounds with undetected foreign body/necrotic tissue
Wound healing: Primary intention (I)
 Optimum closure method since wound heals in
minimum time with no separation of its edges and
minimal scar formation
 Takes place in 3 phases:
1. Inflammatory
• Begins immediately and completed by
Day 3-7
• Initially, haemostasis occurs
• Then the wound is prepared for repair
by:
– Extravasation of tissue fluid, cells and
fibroblasts
– Increasing blood supply to the wound
– Debridement of tissue debris by
proteolytic enzymes
• No increase in tensile strength of
tissue and wound healing is dependent
on approximation of edges by closure
material
Wound healing: Primary intention (II)
2. Proliferative
• Starts from Day 3 onwards
• Fibroblasts form a collagen matrix (granulation tissue)
• This matrix:
– Determines the tensile strength and pliability of the healing wound
– Becomes vascular, supplying the nutrients and oxygen necessary for
wound healing
• Tensile strength increases until wound is able to withstand normal
stress
Wound healing: Primary intention (III)
3. Remodelling
• May continue for a year or longer
• Following completion of collagen deposition, vascularity
decreases and any surface scar becomes paler
• Resulting scar size is dependent upon the initial volume of
granulation tissue

 The percentage recovery of the tensile

strength of the wound is:
– About 20% after 2 weeks
– About 50% after 5 weeks
– About 80% after 10 weeks
Wound healing: Secondary intention
 Occurs when the wound fails to heal by primary
intention due to:
– Infection
– Excessive trauma
– Tissue loss
– Imprecise approximation
of tissue (leaving dead
space)

 More complicated and prolonged than healing by

primary intention
 There may be excessive formation of granulation
tissue which:
– Contains myofibroblasts which lead to gradual but marked
wound contraction
– May protrude above the wound surface, prevent
epithelialisation and thus require treatment
Wound healing: Delayed primary closure

 Used in management of contaminated and

infected wounds with extensive tissue loss
and a high risk of infection (eg. trauma
following RTA, penetrating injury)
 Steps taken include:
– Debridement of nonviable tissues, usually under
sedation
– Leaving wound open with gauze packing inserted
– Wound approximation within 3-5 days if no
infection is evident
– If infection is present, the wound is allowed to
heal by secondary intention
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  needle-holder by

partially inserting the thumb and
ring finger into the loops of the
handle
 The free index finger provides
additional control and stability
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: 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
Mucosa, neck, hands, limbs, tendons,
4/0
blood vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
Abdominal wall, fascia, drain sites,
0 and larger
arterial lines, orthopaedics
Instruments: Suture material summary

N o n - a b s o r b a b le

N a tu r a l S y n t h e t ic

M e r s i lk B r a id e d M o n o f il a m e n t

N u r o lo n E t h ilo n
E t h ib o n d P r o le n e

A b s o r b a b le

S hort te rm M e d iu m t e r m Long term

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 ila 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
Simple interrupted stitch: Steps 1&2
 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
Images courtesy of BUMC
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 needle-

holder 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 needle-

holder 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

needle-holder 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 4-
5mm tails (important for removal
of external non-absorbable
sutures)
Suture removal
 Sutures should be removed:
– Face: 3-4 days
– Scalp: 5 days
– Trunk: 7 days
– Limb: 7-10 days
– Foot: 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
Summary
 Wound classification
– Clean
– Clean, contaminated
– Contaminated
– Infected
 Types of wound healing
– Primary intention
– Secondary intention
– Delayed primary closure
 Suture material
– Properties
• Natural or synthetic
• Non-absorbable or absorbable
• Monofilament or multifilament
– Size
• Ranges from 3 – 12/0
References
 Ethicon
– Knot Manual
http://www.jnjgateway.com/public/useng/5256e
thicon_encyclopedia_of_knots.pdf
– Wound Closure Manual
http://www.jnjgateway.com/public/useng/ethico
n_wcm_feb2004.pdf
 Student BMJ
– Taylor B and Bayat A, (May 2003, June 2003 &
July 2003), Basic plastic surgery techniques and
principles.
 Boston University School of Medicine
– http://www.bumc.bu.edu/departments/pagemain.
asp?page=5734&departmentid=69