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Clean
wound classification
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:
Microorganisms multiply so rapidly that a contaminated wound can become infected within 6 hours
Infected
Suture Material
Generally categorized by three characteristics:
Absorbable vs. non-absorbable Natural vs. synthetic Monofilament vs. multifilament
Absorbable Suture
Degraded and eventually eliminated in one of two ways:
Via inflammatory reaction utilizing tissue enzymes Via hydrolysis
Examples:
Catgut Chromic Monocryl PDS , Vicryl
Non-absorbable Suture
Not degraded, permanent Examples:
Prolene Nylon Stainless steel Silk
Natural Suture
Biological origin Cause intense inflammatory reaction Examples:
Catgut purified collagen fibers from intestine of healthy sheep or cows Chromic coated catgut Silk
Synthetic Suture
Synthetic polymers Do not cause intense inflammatory reaction Examples:
Vicryl Monocryl , PDS , Prolene Nylon
Suture Packaging
Monofilament Suture
Grossly appears as single strand of suture material; all fibers run parallel Minimal tissue trauma Resists harboring microorganisms Ties smoothly Requires more knots than multifilament suture Possesses memory Examples:
Monocryl, PDS, Prolene, Nylon
Multifilament Suture
Fibers are twisted or braided together Greater resistance in tissue Provides good handling and ease of tying Fewer knots required Examples:
Vicryl (braided) Chromic (twisted) Silk (braided)
Suture Degradation
Suture Material Catgut Vicryl, Monocryl PDS Method of Degradation Proteolytic enzymes Hydrolysis Hydrolysis Time to Degradation Days Weeks to months Months
Suture Size
Sized according to diameter with 0 as reference size Numbers alone indicate progressively larger sutures (1, 2, etc) Numbers followed by a 0 indicate progressively smaller sutures (2-0, 4-0, etc)
Needles
Classified according to shape and type of point
Curved or straight (Keith needle) Taper point, cutting, or reverse cutting
Needles
Curved
Designed to be held with a needle holder Used for most suturing
Straight
Often hand held Used to secure percutaneously placed devices (e.g. central and arterial lines)
Needles
Taper-point needle
Round body Used to suture soft tissue, excluding skin (e.g. GI tract, muscle, fascia, peritoneum)
Needles
Cutting needle
Triangular body Sharp edge toward inner circumference Used to suture skin or tough tissue
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)
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 needleholder by partially inserting the thumb and ring finger into the loops of the handle The free index finger provides additional control and stability
Tensile strength
Force necessary to break a suture Important to consider in areas of tension (linea alba)
Tissue reaction
Undesirable since inflammation worsens the scar Maximal between Day 3&7
Handling of a suture
Memory
Tendency to stay in one position Leads to difficulty in tying sutures and knot unravelling
Elasticity
Ability to return to its original length after stretching High elasticity sutures should be used in oedematous tissue
Knot strength
Force required for a knot to slip Important to consider when ligating arteries
Multifilament (Mersilk or Mersilene) Consists of multiple fibres woven together Easier to handle and tie and knots are less likely to slip
Sutures
may be:
Left in place indefinitely (during closure of abdominal fascia) Removed following adequate healing (closure of superficial laceration)
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
Uses
Ophthalmology, microsurgery Face, blood vessels
5/0
4/0 3/0 2/0 0 and larger
Absorbable Short term Natural Catgut Synthetic Vicryl rapide Medium term Braided Braided vicryl Monofilament Monocryl Long term Braided Panacryl Monofilament PDS II
Open the suture packet with one tear to reveal the needle
Grasp the needle twothirds the distance from its pointed end Avoid grasping the needle at its proximal or distal extremities since this will prevent damage to the suture
Wound Closure
Basic suturing techniques:
Simple sutures Mattress sutures Subcuticular sutures
Simple Sutures
Simple interrupted stitch
Single stitches, individually knotted (keep all knots on one side of wound) Used for uncomplicated laceration repair and wound closure
Mattress Sutures
Horizontal mattress stitch
Provides added strength in fascial closure; also used in calloused skin (e.g. palms and soles) Two-step stitch:
Simple stitch made Needle reversed and 2nd simple stitch made adjacent to first (same size bite as first stitch
Mattress Sutures
Vertical mattress stitch
Affords precise approximation of skin edges with eversion Two-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 Sutures
Usually a running stitch, but can be interrupted Intradermal horizontal bites Allow suture to remain for a longer period of time without development of crosshatch scarring
Steri-strips
Sterile adhesive tapes Available in different widths Frequently used with subcuticular sutures Used following staple or suture removal Can be used for delayed closure
Staples
Rapid closure of wound Easy to apply Evert tissue when placed properly
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
Again, supinate the needleholder to rotate the needle upwards and through the tissue
Grasp and slightly evert the opposing skin edge with the forceps Pronate the needle-holder
After releasing the needle, pronate the needle-holder before regrasping the needle
and again supinate the needleholder 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
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
Now draw the short end back through the loop towards yourself
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
Grasp the short end and draw it through the loop by pulling it away from yourself
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 45mm tails (important for removal of external non-absorbable sutures)
Suture removal
Sutures should be removed:
Face: Scalp: Trunk: Limb: Foot: 3-4 days 5 days 7 days 7-10 days 10-14 days