Suture Workshop

FM / Rural
Clerkship
 Competency
Given a pt presenting with a laceration in an
office or urgent / emergent care setting and
standard supplies and equipment, treat the
wound appropriately.
 Objectives
Identify the various types and sizes of suture
material.
Choose the proper instruments for suturing.
Given a list of injectable anesthetic agents,
identify the different agents and correct dosages.
Determine whether a wound requires suturing.
Under supervision, anesthetize, clean, and close a
wound with sutures.
Recommend appropriate laceration care and
follow-up.
 Suture Materials
Criteria
Tensile strength
Good knot security
Workability in handling
Low tissue reactivity
Ability to resist bacterial infection
 Suture Materials
ABSORBABLE: NON-
lose their tensile strength ABSORBABLE:
within 60 days.
 Absorbable Sutures
PLAIN GUT: CHROMIC GUT:
Derived from the small Treated with chromic
intestine of healthy acid to delay tissue
sheep. absorption time.
Loses 50% of tensile 50% tensile strength by
strength by 5-7 days. 10-14 days.
Used on mucosal Used in episiotomy
surfaces. repairs.
 Polyglycolic acid (Dexon)
Braided
Low-memory
50% tensile strength = 25 days
Sites = subcutaneous closure skin
 Polydioxanone (PDS)
Monofilament
50% tensile strength = 30+ days
Sites = need for prolonged strength,
 Polyglycan 910 (Vicryl)
Braided, synthetic polymer
50% tensile strength for 30 days
Used: subcutaneous
 Non-absorbable Sutures
Nylon (Ethilon): of all the non-
absorbable suture materials, monofilament
nylon is the most commonly used in surface
closures.
 Non-absorbable Sutures
Polypropylene (Prolene): appears to be
stronger then nylon and has better overall wound
security.
BRAIDED: includes cotton, silk, braided nylon
and multifilament dacron. Before the advent of
synthetic fibers, silk was the mainstay of wound
closure. It is the most workable and has excellent
knot security. Disadvantages: high reactivity and
infection due to the absorption of body fluids by
the braided fibers.
 Suture Sizes

5-0 is small, and 2-0 is big

The usual sizes = 3-0 or 4-0
Examples:
might use 5-0 on the face
2-0 on the plantar surface of a foot
 Surgical Needles
Wide variety with different companys
naming systems
2 basic configurations for curved needles
Cutting: cutting edge can cut through tough
tissue, such as skin
Tapered: no cutting edge. For softer tissue
inside the body
Surgical Needles
Surgical Instruments
Needle Holders
 Forceps
Tissue forceps Dressing forceps
 Iris Scissors
Iris scissors are predominantly used to assist
in wound debridement and revision.
 Dissection Scissors
Used for heavier tissue revision as necessary
for wound undermining.
Suture Removal Scissors
 Hemostats
Clamping small blood vessels
Hemorrhage control
Grasping
Exposing
Exploring
Visualizing
 A Cheap Skin Hook
Put a hypodermic needle on a small syringe
or use a hemostat to hold the needle
Bend the tip of the needle back (sterile
technique)
General principle: Minimize trauma in
handling tissue
Scalpels
 Scalpel Blades

#15 blade
Dermabond
A sterile, liquid topical skin
adhesive
Reacts with moisture on
skin surface to form a
strong, flexible bond
Only for easily
approximated skin edges of
wounds
punctures from minimally
invasive surgery
simple, thoroughly cleansed,
lacerations
 Anesthetic Solutions
Lidocaine (Xylocaine)
Most commonly used
Rapid onset
Strength: 0.5%, 1.0%, & 2.0%
Maximum dose:
5 mg / kg
300 mg
1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc
300 mg = 0.03 liter = 30 ml
 Anesthetic Solutions
Lidocaine (Xylocaine) with epinephrine
Vasoconstriction
Decreased bleeding
Prolongs duration
Strength: 0.5% & 1.0%
Maximum individual dose:
7mg/kg, OR

500mg
 Anesthetic Solutions
CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with epinephrine
on:
Eyes
Ears
Nose
Fingers
Toes
Penis
Scrotum
 Anesthetic Solutions
Mepivacaine (CARBOCAINE):
Slower onset than Lidocaine
Longer duration
Strength: 1%
DOSE: maximum individual dose 5mg/kg
 Anesthetic Solutions
BUPIVACAINE (MARCAINE):
Slow onset
Long duration
Strength: 0.25%
DOSE: maximum individual dose 3mg/kg
 Injection Techniques
25, 27, or 30-gauge Aspirate
needle Inject agent into tissue
6 or 10 cc syringe SLOWLY
Check for allergies Wait
Insert the needle at the After anesthesia has
inner wound edge taken effect, suturing
may begin
 Complicated Wounds

Wounds or lacerations with Wounds entering the

Nerve Thoracic
Tendon or abdominal cavities.
Major vessel

Wounds or lacerations of the

Eye
Eyelids
Bites
Severely contaminated
wounds.
 Wound Evaluation
Time of incident
Size of wound
Depth of wound
Tendon / nerve involvement
Bleeding at site
 Contraindications
Redness
Edema of the wound margins
Infection
Fever
 Contraindications

Puncture wounds
Animal bites
Tendon, verve, or vessel involvement
Wound more than 12 hours old
 Closure Types
Primary closure (primary intention)

Secondary closure (secondary intention)

Tertiary closure (delayed primary closure)

 Wound Preparation
Most important step for reducing the risk of
wound infection.
Remove all contaminants and devitalized tissue
before wound closure.
IRRIGATE
CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically
poor scar are greatly increased
Wound Preparation

Personnel Precautions
 Wound Preparation
Wound cleansing solution
Wound scrubbing
Irrigation
Take only the soft, flexible part from an 18
gauge IV needle (angiocath)
Put angiocath tip on 20 cc or 50 cc syringe
Debridement
Basic Laceration Repair

Principles And Techniques

 Principles And Techniques
Minimize trauma in skin handling
Gentle apposition with slight eversion of
wound edges
Visualize an Erlenmeyer flask
Make yourself comfortable
Adjust the chair and the light
Change the laceration
Debride crushed tissue
 Definition of Terms
Bite
Throw
Percutaneous (deep) closure
Dermal closure
Interrupted closure
Continuous closure (running sutures)
Principles And Techniques

Suture Techniques
Suture Procedures
 Suturing
Apply the needle to the needle driver
Clasp needle 1/2 to 2/3 back from tip
Rule of halves:
Matches wound edges better; avoids dog ears
Vary from rule when too much tension across
wound
 Suturing
Rule of halves
 Suturing
Rule of halves
 Suturing
The needle enters the skin with a 1/4-inch
bite from the wound edge at 90 degrees
Visualize Erlenmeyer flask
Evert wound edges
Because scars contract over time
 Suturing
Release the needle from the needle driver, reach
into the wound and grasp the needle with the
needle driver. Pull it free to give enough suture
material to enter the opposite side of the wound.

Use the forceps and lightly grasp the skin edge

and arc the needle through the opposite edge
inside the wound edge taking equal bites.
 Follow the needles arc
Rotate your wrist to follow the arc of the
needle.
Principle: minimize trauma to the skin, and
dont bend the needle. Follow the path of
least resistance.
 Suturing
Release the needle and grasp the portion of the
needle protruding from the skin with the needle
driver. Pull the needle through the skin until you
have approximately 1 to 1/2-inch suture strand
protruding form the bites site.

Release the needle from the needle driver and

wrap the suture around the needle driver two
times.
 Suturing
Grasp the end of the suture material with the
needle driver and pull the two lines across the
wound site in opposite direction (this is one
throw).

Do not position the knot directly over the wound

edge.

Repeat 3-4 throws to ensuring knot security. On

each throw reverse the order of wrap.
 Suturing
Cut the ends of the suture 1/4-inch from the
knot.

The remaining sutures are inserted in the

same manner
 The trick to an instrument tie
Always place the suture holder parallel to
the wounds direction.
Hold the longer side of the suture (with the
needle) and wrap OVER the suture holder.
With each tie, move your suture-holding
hand to the OTHER side.
By always wrapping OVER and moving the
hand to the OTHER side = square knots!!
Simple, Interrupted
 Vertical Mattress

Good for everting wound edges

(neck, forehead creases, concave surfaces)
 Horizontal Mattress

Good for closing wound edges under high tension,

And for hemostasis.
 Suturing - finishing

After sutures placed, clean the site with

normal saline.
Apply a small amount of Bacitracin and
cover with a sterile non-adherent dressing.
 Suturing - before you go
Need for tetanus globulin and/or vaccine?
Dirty (playground nail) vs clean (kitchen knife)
Immunization history
Tell pt to return in one day for recheck, for
signs of infection or complications.
 Suture Removal
Time frame for removing sutures:
Average time frame is 7-10 days
FACE: 4-5 days
BODY & SCALP: 7 days
SOLES, PALMS, BACK OR OVER JOINTS:
10 days

Any suture with pus or signs of infections should

be removed immediately.
 Suture Removal
1. Clean with hydrogen peroxide to remove
any crusting or dried blood
2. Using the tweezers, grasp the knot and
snip the suture below the knot, close to the
skin
3. Pull the suture line through the tissue- in
the direction that keeps the wound closed -
and place on a 4x4
 Suture Removal
Once all sutures have been removed, count
the sutures
The number of sutures needs to match the
number indicated in the patient's health
record