Suture Workshop

 

 

Core Skills:

  1. Suture selection
  2. Needle selection
  3. Laceration repair
  4. Skin Biopsy- punch, shave, excision

 

 

Online Reference:  Pfenniger’s Procedures in Primary Care (MD Consult)  (Graphics below are from this reference.)

 

Review Article on Laceration Management

Best Online Sites:

http://www.bumc.bu.edu/Departments/PageMain.asp?Page=5914&DepartmentID=69

http://www.bumc.bu.edu/Departments/PageMain.asp?Page=6067&DepartmentID=69

http://www.practicalplasticsurgery.org/techique-bk.html

Also useful, and specific information regarding plastic repair and perineal repair:

http://www.emedicine.com/derm/topic828.htm

http://www.plasticsurgery.org/medical_professionals/publications/Everyday-Wounds-Ch09-Suturing-Principles.cfm

http://www.moondragon.org/obgyn/procedures/suturing2.html#tampon

 

 

 

Suture Selection

See Table for types of suture, components and average duration of tensile strength.

 

 

Absorbable
Gut Plain Mammalian collagen 7 to 10 days  
Gut Chromic Mammalian collagen 21 to 28 days  
Polyglycolic acid (Dexon * ) Mono Synthetic polymer 20% in 15 days 5% in 28days  
Polydioxanone (PDS) Mono Polyester polymer 70% in 14 days 50% in 28 days  
Polyglactic acid (Vicryl) Braided Coated polymer 60% in 14 days 30% in 21 days  
Polyglyconate (Maxon) Mono PoIyester 81% in 14 days 59% In 28 days  
Nonabsorbable
Cotton Twisted fibers Cotton fiber 50% in 6 months 30% in 2 years  
Silk Braided Silkworm spun fiber Gone in one year  
Steel Mono Alloy Fe-Ni-Cr Indefinite  
Nylon (Ethilon, Dermalon) Mono Synthetic polymer Loses 20% a year  
Polyester (Mersilene) Braided Polyester Indefinite  
Polypropylene (Prolene ) Mono Synthetic polymer    

 

 

 

 

Needle Selection

Types:

1.    Cutting

2.   Tapered 

 

Suture Selection

•External – Nylon

•Subcuticular – Vicryl or Dexon

•Facial or scalp – gut or fine nylon

 

Undermining

•Separate layer below dermis from adipose layer

•Reduces wound tension

 

Interrupted Sutures

•Commonly used for laceration repair

•Deep stitches needed for dead space closure.  Invert if possible.

 

Interrupted Technique

•Enter/exit skin at perpendicular angle to encourage eversion of the skin layer.

 

Mattress Stitch

•Ideal for high tension wounds

•Holds deep layer as well as superficial

•Everts skin layer

 

Instrument Tie

•Initiate with a Surgeon’s knot to hold in place

•4 ties for most suture

 

Inverted Suturing

•Enter deep into tissue with needle initially

•Allows knot to be buried deep.

 

Subcuticular Stitches

•Running stitch through sub-Q layer.

•Anchor on at least one end, usually both ends.

•Inverted stitches to bury anchoring knots.

 

Punch Biopsy

•Circular punch after local anesthesia

•Specimen should contain full dermal thickness.

 

Shave Biopsy

 

Excisional biopsy

•3-4 to 1 ratio length to width for excisional biopsy

 

Triangular Laceration

•3 point suture to bring wound edges together

•Spares vascular supply to tip of skin wedge

 

Resolving “Dog Ears”

•Lift and fold over, then excise  the excess tissue.

 

Removal of Sutures
(Adults)

•Face and head – 5-7 days

•Trunk – 7 days

•Arms – 8 days

•Hands – 8-10 days

•Legs – 9 days

•Feet – 10 days

Children – about 1 day less at each site

 

What not to close

•Grossly contaminated wounds (sticks, dirt)

•Bites

•Gunshot or fragmentation wounds

•Wounds > 12 hours old.

 

Managing Contaminated Wounds

 

Delayed Primary Closure

•Wound closure done at day 5 post injury

•Will heal equally fast as normal primary closure

•Allows for wound to pass period of greatest risk of infection

•Debride dead tissue from wound before closing.