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.