Suture Workshop 2012

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Suture Workshop 2012

• An Introduction to Basic Suturing
• Mrs Esther Mitchell
• MBChB MRCS Ed

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Objectives

• To be able to demonstrate interrupted sutures
• To handle instruments correctly
• To know common suture materials advantages and
  disadvantages
• Know how to achieve the best wound closure
  possible

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Sterility

• Open dressings packs / instruments
• Open sutures
• Open syringes needles
• Understand Skin prep, drapes, gloves/gowns

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Needle Holder

• Thumb ring finger into needle holders rings
• (NOT your middle finger)

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Forceps

• Grasp forceps between thumb middle finger,
  while index finger is used for stabilization.
• Like holding a pen!

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Surgical Scissors
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Needles

• Curved
• Cutting usual for skin
• Tapered
• Straight
• Hand held
• Instrument held

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Suture Sizes

• 7 Thickest
• 0 - Thick
• 11/0 - Finest
• Normal usage 1 to 5/0

• Face 5/0-6/0
• Scalp 3/0-4/0
• Abdomen 3/0-4/0
• Back 2/0-3/0
• Limbs 3/0-4/0

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Suture Material

• Absorbable/Non-absorbable
• Synthetic/Natural
• Braided/Non Braided

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Absorbable Vs Non Absorbable

• Absorbable
• Self dissolving
• Avoids removal in children
• Increased Scarring

• Non Absorbable
• Less scarring
• Decreased infection

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Synthetic vs Natural

• Synthetic
• Less tissue reaction
• Mass produced
• Developed for specific properties

• Natural
• Cheaper
• Traditional
• More tissue reactions

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Braided Vs Non-Braided

• Braided
• Inc Tensile strength
• gtFlexible
• Handles well
• Inc capillarity

• Non- Braided
• (monofilament)
• Less resistance
• Less infection
• Weaker

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Suture Materials
Absorbable Non-Absorbable
Vicryl Prolene
Monocryl Ethilon (Nylon)
PDS Ethibond
Catgut Silk
Steel
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Main Sutures

• Interrupted / Simple
• Continuous
• Mattress
• Subcuticlar

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Ligation - Tying of Sutures

• Hand Ties
• Longer learning curve
• Delicate placement possible
• Needs relatively long suture length
• More accurate

• Instrument Ties
• Relatively simple to learn
• Less delicate
• Uses less suture material
• Quick

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Interrupted suturing technique

• Sutures 3-4mm from wound edge
• Sutures 5-10mm apart in distance
• Start on side farthest to you
• Evert skin edges
• Grasp needle 2/3rd from tip
• Grasping tip causes blunting
• Grab subcutaneous tissue not skin

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Practice Practice Practice!!
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Local Anaesthetic

• Lignocaine 3mg/kg (70Kg, 21mls 1)
• Lignocaine Adrenaline 7mg/Kg (70Kg, 49mls 1)
• Always aspirate before injecting
• Check contra-indications
• Know side effects

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Adrenaline in LA

• Used at 1200 000 strength
• Never use more than 100mls
• Increases duration of action
• Reduces absorption, so more can be used without
  toxicity
• Causes vasoconstriction, good and bad
• Good stops bleeding, effects above
• Bad causes ischemia of extremities (fingers,
  toes, ears noses etc)

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Toxic effects of local anaesthetic

• Feeling Inebriated and Lightheaded
• Muscle twitching
• Convulsions
• Coma
• Respiratory arrest
• Arrhythmia
• Cardiac arrest
• MONITOR for 30mins post injection

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Factors Affecting Wound Healing

• LOCAL
• Contamination
• Foreign body
• Poor haemostasis
• Poor tissue handling

• SYSTEMIC
• Diabetes
• Anaemia
• Hypothyroidism
• Drugs steroids, anti-cancer drugs
• Immunosuppression
• Nutritional Status

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Alternatives to sutures

• Staples
• Adhesives eg wound glue
• Steri-strips

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Tidying up

• Dress wound
• Post op instructions to patient
• Signs and symptoms of infection
• Keep dry / change wet dressings
• Suture removal
• Other follow-up
• Dispose of Sharps
• Write Op note

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Suture Removal

• Face 3-5 days
• Scalp 5 days
• Limbs 7-10 days
• Trunk 7-10 days
• Foot 10-14 days

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Summary

• Suturing permits primary wound healing
• Good surgical technique is required
• Correct selection of suture and needle
• Optimise factors to encourage good wound healing
• Practice!!