Trauma Service ConferenceTrauma Service Conference

Suturing TechniqueSuturing Technique

陳昭文 醫師陳昭文 醫師高雄醫學大學附設醫院外傷科高雄醫學大學附設醫院外傷科

基本傷口縫合技巧基本傷口縫合技巧KNOW HOW/WHEN/WHY?KNOW HOW/WHEN/WHY?

傷口癒合傷口癒合傷口準備傷口準備傷口縫合傷口縫合

Trauma Service / KMUHTrauma Service / KMUH

Step 1 : Step 1 : 瞭解傷口癒合過程瞭解傷口癒合過程

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Wound Healing - AWound Healing - A

Inflammatory Phase Inflammatory Phase • Immediate to 2-5 daysImmediate to 2-5 days • Hemostasis Hemostasis

Vasoconstriction Vasoconstriction Platelet aggregation Platelet aggregation Thromboplastin makes clotThromboplastin makes clot

• Inflammation Inflammation Vasodilation Vasodilation PhagocytosisPhagocytosis

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Wound Healing - AWound Healing - A

Inflammatory Phase Inflammatory Phase •紅紅 ,, 腫腫 ,, 熱熱 ,, 痛痛•脆弱 脆弱 完全靠外在力量封閉傷口 完全靠外在力量封閉傷口•為避免過度發炎為避免過度發炎

清創徹底清創徹底 移除異物移除異物 無創傷性縫合技巧無創傷性縫合技巧

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Wound Healing - BWound Healing - B Proliferative Phase Proliferative Phase

• 2 days to 3 weeks2 days to 3 weeks • Granulation Granulation

Fibroblasts lay bed of collagen Fibroblasts lay bed of collagen Fills defect and produces new capillariesFills defect and produces new capillaries

• Contraction Contraction Wound edges pull together to reduce defeWound edges pull together to reduce defe

ctct • Epithelialization Epithelialization

Crosses moist surface Crosses moist surface Cell travel about 3 cm from point of origin iCell travel about 3 cm from point of origin i

n all directionsn all directions

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Wound Healing - BWound Healing - B

Proliferative Phase Proliferative Phase • 傷口張力部份恢復傷口張力部份恢復• 病患本身及傷口狀態之影響病患本身及傷口狀態之影響

營養不良營養不良 組織缺氧組織缺氧 貧血貧血 慢性病慢性病

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Wound Healing - CWound Healing - C

Remodeling Phase Remodeling Phase • 3 weeks to 2 years3 weeks to 2 years • New collagen forms which New collagen forms which

increases tensile strength increases tensile strength to wounds to wounds

• Scar tissue is only Scar tissue is only 80 80 percent as strong as percent as strong as original tissue original tissue

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Step 2 : Step 2 : 瞭解如何準備傷口縫合瞭解如何準備傷口縫合

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Skin preparationSkin preparation

LavageLavage• Quantity is better than qualityQuantity is better than quality

Watch out critical areasWatch out critical areas• Eyes, perineum, peripheral skin…Eyes, perineum, peripheral skin…

Adequate drapeAdequate drape Adequate anesthesiaAdequate anesthesia

Trauma Service / KMUHTrauma Service / KMUH

Preparation – Debridement Preparation – Debridement

Wound irrigationWound irrigation• Alcoholic HibitaneAlcoholic Hibitane• Alcohol-Betadine Alcohol-Betadine 70% Alcohol 70% Alcohol

避免使用於眼周避免使用於眼周 ,, 口內口內 ,, 會陰會陰 ,, 或傷口內或傷口內• N/S or L/R solutionN/S or L/R solution

移除異物與壞死組織移除異物與壞死組織

Trauma Service / KMUHTrauma Service / KMUH

沖洗藥劑與組沖洗藥劑與組織傷害比較織傷害比較

%damage %damage without without saline saline irrigationirrigation

%damagew%damagewith saline irrith saline irrigationigation

AlcoholAlcohol 100100 100100

HH22OO22 100100 9090

SoapSoap 9090 2525

B-iodineB-iodine 55 00

Tap waterTap water 55 00

SalineSaline 00 00

Trauma Service / KMUHTrauma Service / KMUH

局部麻醉劑使用局部麻醉劑使用 - Xylocaine - Xylocaine

Avoid acid painAvoid acid pain• Add 1ml NaHCO3 in 20 ml XylocaineAdd 1ml NaHCO3 in 20 ml Xylocaine

+ Epinephrine ?+ Epinephrine ?• 延長藥效延長藥效 , , 減緩出血減緩出血• 避免用於皮瓣或四肢末端避免用於皮瓣或四肢末端

施打麻藥方式施打麻藥方式•由近而遠 由近而遠 病患較易忍受疼痛 病患較易忍受疼痛•保持移動 保持移動 避免血管內注射 避免血管內注射

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Digital Nerve BlockDigital Nerve Block

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Xylocaine (Lidocaine)Xylocaine (Lidocaine) Onset 1-5 minsOnset 1-5 mins Duration 30-120minsDuration 30-120mins Max Dose 4.5mg/kgMax Dose 4.5mg/kg

• 1ml(2%)x1000mg=20mg1ml(2%)x1000mg=20mg• 60kg60kgX4.5mg/kg=270mg X4.5mg/kg=270mg 13.5ml13.5ml

CNS過度興奮 頭暈

耳鳴 抽筋

眼振

Cardiopulmonary

低血壓心肌抑制

呼吸抑制

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Risky Area for Epinephrine Use Risky Area for Epinephrine Use

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Premedication? Premedication?

ValiumValium• Is probably the drug of choiceIs probably the drug of choice• Increase tolerance to local anesthetics Increase tolerance to local anesthetics • Increase producting sedation and some amIncrease producting sedation and some am

nesianesia• Avoiding use on patients with liver diseaseAvoiding use on patients with liver disease

Demeral, Morphine, Fentanyl… Demeral, Morphine, Fentanyl…

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Know our Pals - Suture MaterialsKnow our Pals - Suture Materials

可吸收線可吸收線 (Absorbable)(Absorbable)• Natural - CatgutNatural - Catgut• Synthetic – Dexon, Vicryl, PDSSynthetic – Dexon, Vicryl, PDS

不可吸收線不可吸收線 (Non-absorbable)(Non-absorbable)• Natural - silkNatural - silk• Synthetic – Nylon, Surgilon, ProleneSynthetic – Nylon, Surgilon, Prolene

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SUTURE SIZE AND DIAMETER  USP SIZE  

DIAMETER LIMITS

(mm)

METRIC SIZE

ABSORBABLE SUTURES

(Catgut Chromic and Plain)

NON-ABSORBABLE

AND SYNTHETIC

ABSORBABLE SUTURES

- 6-0 0.070 - 0.099 0.7

6-0 5-0 0.100 - 0.149 1

5-0 4-0 0.150 - 0.199 1.5

4-0 3-0 0.200 - 0.249 2

3-0 2-0 0.300 - 0.339 3

2-0 0 0.350 - 0.399 3.5

0 1 0.400 - 0.499 4

1 2 0.500 - 0.599 5

2 3,4 0.600 - 0.699 6

- 5 0.700 - 0.799 7

Trauma Service / KMUHTrauma Service / KMUH

Trauma Service / KMUHTrauma Service / KMUH

Realize our pals – Needle TipRealize our pals – Needle Tip

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Realize our pals – Needle CurvatureRealize our pals – Needle Curvature

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Realize our pals – Read the EnvelopeRealize our pals – Read the Envelope

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Selection of Sutures MaterialSelection of Sutures Material

EyelidEyelid FaceFace Oral cavityOral cavity ScalpScalp LipLip TrunkTrunk LimbsLimbs Hands/feetHands/feet

6/06/0

5/0, 6/05/0, 6/0

4/04/0

3/0, 4/03/0, 4/0

4/0, 5/04/0, 5/0

4/04/0

3/0, 4/03/0, 4/0

4/0, 5/04/0, 5/0

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Timing of Sutures RemovalTiming of Sutures Removal

EyelidEyelid FaceFace Oral cavityOral cavity ScalpScalp LipLip TrunkTrunk LimbsLimbs Hands/feetHands/feet

3-53-5 (days) (days)

3-53-5

7-8…or dissolve7-8…or dissolve

7-127-12

3-53-5

6-126-12

6-146-14

7-127-12

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Another Choice…Another Choice…

Trauma Service / KMUHTrauma Service / KMUH

Step 3 : Step 3 : 如何縫合傷口如何縫合傷口 ??

Trauma Service / KMUHTrauma Service / KMUH

How to use your instrument?How to use your instrument?

持針器夾住離針尖二分之一至三分之一處持針器夾住離針尖二分之一至三分之一處 垂直進針 垂直進針 保持最佳穿透力量 保持最佳穿透力量

Trauma Service / KMUHTrauma Service / KMUH

How to use your instrument?How to use your instrument?起手式起手式

Trauma Service / KMUHTrauma Service / KMUH

Method of Skin SutureMethod of Skin Suture Simple interruptedSimple interrupted

• Good for irregular woundsGood for irregular wounds Vertical mattressVertical mattress

• Good for thick and thin skinGood for thick and thin skin Horizontal mattressHorizontal mattress

• Looks bad earlyLooks bad early Half buriedHalf buried

• Good for flapsGood for flaps Continuous intradermalContinuous intradermal

• Cosmetic demandCosmetic demand Simple runningSimple running

• Quick, for linear woundsQuick, for linear wounds

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Simple Suture – Simple Principle Simple Suture – Simple Principle

Only one skin layerOnly one skin layer• the suture should be the suture should be wider at the bottomwider at the bottom • the knot should be tied the knot should be tied adequatelyadequately and and

cause no blanchingcause no blanching

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Ideal Ratio 1:1Ideal Ratio 1:1

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Ideal Dermis Apposition Ideal Dermis Apposition

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Simple interrupted sutureSimple interrupted suture

Trauma Service / KMUHTrauma Service / KMUH

Vertical Mattress SutureVertical Mattress Suture

Vertical Mattress Suture

適用於邊緣內翻傷口

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Vertical Mattress SutureVertical Mattress Suture

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Running “Continuous” SutureRunning “Continuous” Suture

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Common Error 1 – Common Error 1 – 跨距不均跨距不均

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Common Error 2 – Common Error 2 – 皮下死腔皮下死腔

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Common Error 3 - Common Error 3 - 上寬下窄上寬下窄

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Distance between SuturesDistance between Sutures EyelidEyelid FaceFace NoseNose ScalpScalp ForeheadForehead TrunkTrunk LimbsLimbs Volar handVolar hand Dorsal handDorsal hand

1-2 (mm)1-2 (mm)

2-42-4

3-43-4

10-1510-15

4-64-6

6-106-10

5-85-8

3-53-5

2-42-4

Trauma Service / KMUHTrauma Service / KMUH

Suturing TechniqueSuturing Technique

Removal of dog earsRemoval of dog ears• Some will subside. When removal is Some will subside. When removal is

necessary there are several methods.necessary there are several methods.

Trauma Service / KMUHTrauma Service / KMUH

Suturing TechniqueSuturing Technique

Triangular edgeTriangular edge• Method of insertion of three point suture Method of insertion of three point suture

to prevent strangulation of the tip of a to prevent strangulation of the tip of a flap flap

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Corner SutureCorner Suture

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Suturing TechniqueSuturing Technique

Atraumatic techniqueAtraumatic technique• Avoid crushing with forcepsAvoid crushing with forceps• Avoid sutures and needles unnecessarily larAvoid sutures and needles unnecessarily lar

gege• Avoid bites of tissue unnecessarily largeAvoid bites of tissue unnecessarily large• Avoid strangulation with knots too tightAvoid strangulation with knots too tight• Avoid drying of tissues Avoid drying of tissues

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Smooth or teethed forceps?Smooth or teethed forceps? SmoothSmooth

• Hold knots, tying suture or vesselsHold knots, tying suture or vessels Tooth (teethed)Tooth (teethed)

• Hold tissue Hold tissue 無齒鑷子易滑脫無齒鑷子易滑脫,,反需更用力反需更用力,,更易造成組織壓傷更易造成組織壓傷

Trauma Service / KMUHTrauma Service / KMUH

Suturing TechniqueSuturing Technique

Suturing sequenceSuturing sequence• 兩側端點先縫合兩側端點先縫合 , , 中間調整間距再縫中間調整間距再縫 , , 可避免可避免”” dog ear”dog ear”

• 較難縫合處可先處理對齊較難縫合處可先處理對齊• 重要之地標要優先對齊縫合重要之地標要優先對齊縫合

Trauma Service / KMUHTrauma Service / KMUH

Post-procedural CarePost-procedural Care

敷料保護敷料保護 滲液吸收滲液吸收 局部固定局部固定 適度壓力適度壓力 避免疤痕避免疤痕

Trauma Service / KMUHTrauma Service / KMUH

Practice makes perfect!Practice makes perfect!