TECHNIC SUTURINGEfman E.U.Manawan Mkes.,SpB-KBDFK UNSRI 2010

CDC wound classificationCleanUninfected 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, contaminatedOperative wound in which systemic tract(s) are entered under controlled conditions and without contamination

ContaminatedIncludes:Open traumatic wounds (open fractures, penetrating wounds)Operative procedures involving:Microorganisms multiply so rapidly that a contaminated wound can become infected within 6 hours

InfectedHeavily contaminated/infected wound prior to operationIncludes:Perforated visceraAbscesses

Suture MaterialGenerally categorized by three characteristics:Absorbable vs. non-absorbableNatural vs. syntheticMonofilament vs. multifilament

Absorbable SutureDegraded and eventually eliminated in one of two ways:Via inflammatory reaction utilizing tissue enzymesVia hydrolysisExamples:CatgutChromic , VicrylMonocrylPDS

Non-absorbable SutureNot degraded, permanentExamples:ProleneNylonStainless steelSilk

Natural SutureBiological originCause intense inflammatory reactionExamples:Catgut purified collagen fibers from intestine of healthy sheep or cowsChromic coated catgutSilk

Synthetic SutureSynthetic polymersDo not cause intense inflammatory reactionExamples:VicrylMonocryl , PDS , ProleneNylon

Suture Packaging

Monofilament SutureGrossly appears as single strand of suture material; all fibers run parallelMinimal tissue traumaResists harboring microorganismsTies smoothlyRequires more knots than multifilament suturePossesses memoryExamples:Monocryl, PDS, Prolene, Nylon

Multifilament SutureFibers are twisted or braided togetherGreater resistance in tissueProvides good handling and ease of tyingFewer knots requiredExamples:Vicryl (braided)Chromic (twisted)Silk (braided)

Suture Degradation

Suture MaterialMethod of DegradationTime to DegradationCatgutProteolytic enzymesDaysVicryl, MonocrylHydrolysisWeeks to monthsPDSHydrolysisMonths

Suture SizeSized according to diameter with 0 as reference sizeNumbers 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...1-0...0...1...2...3.....

NeedlesClassified according to shape and type of pointCurved or straight (Keith needle)Taper point, cutting, or reverse cutting

NeedlesCurvedDesigned to be held with a needle holderUsed for most suturingStraightOften hand heldUsed to secure percutaneously placed devices (e.g. central and arterial lines)

NeedlesTaper-point needleRound bodyUsed to suture soft tissue, excluding skin (e.g. GI tract, muscle, fascia, peritoneum)

NeedlesCutting needleTriangular bodySharp edge toward inner circumferenceUsed to suture skin or tough tissue

Instruments: Needle (I)The main types of needle include:TaperedGradually taper to the point and cross-section reveals a round, smooth shaftUsed for tissue that is easy to penetrate, such as bowel or blood vessels

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

Reverse cutting needleSimilar to a conventional cutting needle except the cutting edge faces down instead of upThis 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 needleShapes vary from a quarter circle to five-eighths of a circle, depending on how confined the operating field isChoice 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 tissueIndividual preference

Instruments: Forceps & needle-holderSmall toothed forceps (Addison forceps) grasp the skin edges during suturingHold 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 handleThe free index finger provides additional control and stability

Tensile strengthForce necessary to break a sutureImportant to consider in areas of tension (linea alba)Tissue reactionUndesirable since inflammation worsens the scarMaximal between Day 3&7Non-absorbable or absorbableMonofilament or multifilament

Instruments: Properties of suture materialHandling of a sutureMemoryTendency to stay in one positionLeads to difficulty in tying sutures and knot unravellingElasticityAbility to return to its original length after stretchingHigh elasticity sutures should be used in oedematous tissueKnot strengthForce required for a knot to slipImportant to consider when ligating arteries

Instruments: Monofilament or multifilamentMonofilament (Ethilon or Prolene)Consists of a single smooth strandLess traumatic since they glide through tissues with less frictionMay be associated with lower rates of infectionMore 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 togetherEasier to handle and tie and knots are less likely to slip

Instruments: Non-absorbable suture materialComposed 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 materialComposed of biodegradable materials which can be:Naturally occurring (degraded enzymatically)CatgutConsists of processed collagen from animal intestinesBroken down after 7 daysChromic catgutConsists of intestinal collagen treated with chromiumLoses tensile strength after 2-3 weeks and is broken down after 3 months

SyntheticDegraded non-enzymatically by hydrolysis when water penetrates the suture filaments and attacks the polymer chainTend to evoke less tissue reaction than those occurring naturallySubclassified according to degradation time

Instruments: Size of suture materialSize originally scaled from 0-3As technology advanced and sutures became smaller, extra 0s were addedScale now ranges from 3 (largest) to 12/0 (smallest)

SizeUses7/0 and smallerOphthalmology, microsurgery6/0Face, blood vessels5/0Face, neck, blood vessels4/0Mucosa, neck, hands, limbs, tendons, blood vessels3/0Limbs, trunk, gut blood vessels2/0Trunk, fascia, viscera, blood vessels0 and largerAbdominal wall, fascia, drain sites, arterial lines, orthopaedics

Instruments: Suture material summary

Arming the needle-holderGrasp the needle two-thirds the distance from its pointed endAvoid grasping the needle at its proximal or distal extremities since this will prevent damage to the sutureOpen the suture packet with one tear to reveal the needle

Wound ClosureBasic suturing techniques:Simple suturesMattress suturesSubcuticular sutures

Goal: approximate, not strangulate

Simple SuturesSimple interrupted stitchSingle stitches, individually knotted (keep all knots on one side of wound)Used for uncomplicated laceration repair and wound closure

Mattress SuturesHorizontal mattress stitchProvides added strength in fascial closure; also used in calloused skin (e.g. palms and soles)Two-step stitch:Simple stitch madeNeedle reversed and 2nd simple stitch made adjacent to first (same size bite as first stitch

Mattress SuturesVertical mattress stitchAffords precise approximation of skin edges with eversionTwo-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 SuturesUsually a running stitch, but can be interruptedIntradermal horizontal bitesAllow suture to remain for a longer period of time without development of crosshatch scarring

Steri-stripsSterile adhesive tapesAvailable in different widthsFrequently used with subcuticular suturesUsed following staple or suture removalCan be used for delayed closure

StaplesRapid closure of woundEasy to applyEvert tissue when placed properly

Simple Interrupted Suture

Simple interrupted stitch: Steps 1&2Grasp the skin edge with the forceps and slightly evert the skin edgeThen pronate the needle-holder so that the needle will pierce the skin at 90oEnsure the trailing suture material is out of the way to avoid tanglingDrive the needle through the full thickness of the skin by supinating the needle-holderKeeping the shaft of the needle perpendicular to the skin allows the curvature of the needle to traverse the skin as atraumatically as possibleImages courtesy of BUMC

Simple interrupted stitch: Steps 3&4Release the needle and pronate the needle-holderRegrasp the needle proximal to its pointed endMaintain tension with the forceps to prevent the needle from retractingAgain, supinate the needle-holder to rotate the needle upwards and through the tissue

Simple interrupted stitch: Steps 5&6Regrasp 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 forcepsPronate the needle-holder

Simple interrupted stitch: Steps 7&8Again, supinate the needle-holder to rotate the needle through the skin, keeping the shaft 90 to the skin surfaceAfter releasing the needle, pronate the needle-holder before regrasping the needle

Simple interrupted stitch: Steps 9&10and again supinate the needle-holder to rotate the needle through the skinPull the suture material through the skin until 2-3 cm is left protrudingDiscard the forceps and use your free hand to grasp the long end in preparation for an instrument tiePlace the needle-holder between the strands

Simple interrupted stitch: Steps 11&12Wrap the long strand around the needle-holder to form the loop for the first throw of a square knotRotate the needle-holder away yourself and grasp the short end of the suture

Simple interrupted stitch: Steps 13&14Now draw the short end back through the loop towards yourselfNow tighten the first throw

Simple interrupted stitch: Steps 15&16The throw should be tightened just enough to approximate the skin edges but not enough to strangulate the tissueTo 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&18Rotate the needle-holder towards yourself to retrieve the short endGrasp the short end and draw it through the loop by pulling it away from yourself

Simple interrupted stitch: Step 19&20Finally, tighten the second throw securely against the firstEnsure the knot is to one side of the wound to avoid involvement in the clotIn one hand hold the scissors as shownWith the other hand maintain tension on the suture materialSlide the tips of the scissors down the strands to the point where they will be cutCut the suture material leaving 4-5mm tails (important for removal of external non-absorbable sutures)

Vertical Mattress Stitch

Suture removalSutures should be removed:Face:3-4 daysScalp:5 daysTrunk:7 daysLimb:7-10 daysFoot:10-14 days

Steps involved in removal:Reassure patient that the procedure is not painfulCleanse the skin with hydrogen peroxideGrasp one of the suture tails with forceps and elevateSlip 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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