Chapter 7: Sutures, Needles, and Instruments Note that this lesson will focus on the history and development of suture and operative instrumentation. From Tighe SM: Instrumentation for the operating room, ed 8, St. Louis, 2012, Mosby. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Learning Objectives Identify the objectives for using suture. Describe the physical and handling characteristics of suture materials. Describe the types of sutures and differentiate their properties. Match the general category of suture to its indication for use. Identify the types of surgical needles and describe the indications for use. Describe common methods of wound closure and hemostasis. Paraphrase the learning objectives listed on the slide or, to build interactivity, have the learners take turns reading the objectives aloud. NOTE: Objectives continue on the next slide. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc. 2

Learning Objectives (Cont.) Differentiate among the major categories of instrumentation and the indications for their use. Identify key concepts in selecting and preparing instrumentation for surgical procedures. Describe the consequences of incorrect instrument, sharps, and soft goods (sponge) counts. Paraphrase the learning objectives listed on the slide or, to build interactivity, have the learners take turns reading the objectives aloud. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc. 3

Suture Materials This is a transition slide. The learning objectives addressed in this section of the lesson are: Identify the objectives for using suture. Describe the physical and handling characteristics of suture materials. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Suture Materials Suture (noun): all materials used to sew severed body tissues together and hold them until healed Suture (verb): the act of stitching cut or torn edges of tissue together Ligature: a strand of suture material used to tie off blood vessels to prevent bleeding Review pertinent historical facts relating to suture as noted in the text. Discuss that suture material evolved over the last half of the 20th century and now includes synthetic fibersnylon, polyester, polypropylene, and polymer combinations. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Physical Characteristics Physical configuration Monofilament vs. multifilament Capillarity Diameter 7: largest; 11-0: smallest Tensile strength Knot strength Elasticity Memory Define monofilament as single stranded and multifilament as numerous fibers rendered into a single thread by twisting or braiding. Define capillarity as the ability to transmit fluid along the strand. Discuss that diameter is measured in millimeters and expressed as zeros; the smaller the diameter, the more zeros. Note that the surgeon selects the smallest size possible to prevent tissue reactivity. Define tensile strength as the amount of weight necessary to break the suture. Note that knot strength is the force necessary for a knot to slip. Define elasticity as the suture’s ability to retain its original form and memory as the capacity to return to its former shape. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Handling Characteristics Pliability Friction coefficient Tissue drag Knot tying Knot slippage Define pliability as how easily the material bends. Note that the coefficient of friction refers to how easily the suture slips through the tissue. Discuss that a high coefficient tends to drag through tissue. It is difficult to tie because the knots do not set easily. Some suture is coated to reduce its coefficient of friction (should be labeled on the suture package). Discuss that a variety of knot-tying techniques are used and how the suture handling characteristics may influence the knot chosen or the number of “throws” required to ensure a secure knot. (Note: examples of different knots are shown in the slide.) From Phillips N: Berry & Kohn’s operating room technique, ed 12, St. Louis, 2013, Mosby. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Tissue Reaction Characteristics Inflammatory and fibrous cell reaction Absorption Potentiation of infection Allergic reaction Emphasize that because suture is a foreign substance, it will always cause some form of tissue reaction. Discuss that the reaction begins when the suture inflicts injury during insertion. The tissue reacts to the suture material itself. WBCs, macrophages, and fibroblasts arrive. Generally around 7 days later fibrous tissue with inflammation is present. The suture material is then encapsulated (nonabsorbable) or absorbed. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Types of Suture Material This is a transition slide. The learning objectives addressed in this section of the lesson are: Describe the types of sutures and differentiate their properties. Match the general category of suture to its indication for use Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Types of Suture Material Absorbable Nonabsorbable Surgical gut Collagen Synthetic absorbable Silk Cotton Nylon Polyester fiber Polypropylene Stainless steel Barbed suture Note that suture is generally classified as either absorbable of nonabsorbable. Discuss that absorbable suture is a sterile flexible strand prepared from collagen derived from healthy mammalian tissue or from a synthetic polymer. It may be impregnated with coating, softening, or antimicrobial agents and may have color added. It can be digested by enzymatic activity or hydrolyzed and assimilated into the tissues and varies in size, treatment, color, packaging, and resistance to absorption. Note that gut was the first suture developed. It is derived from collagen of the submucosal layer of the small intestine of sheep and the serosal layer of cattle or hogs. It is available as untreated (plain) or treated with chromium salts (chromic). Chromatization delays absorption. Absorption is influenced by type of body tissue and general health of patient. Gut is wet-packed in alcohol and should be used immediately after opening. Review that collagen sutures, derived from tendons of cattle, are purified and processed and usually used for fine suture material for the eye. Discuss that synthetic absorbable suture is absorbed by slow hydrolysis in the presence of tissue fluids. These sutures are a combination of lactic and glycolic acid polymers and retain tensile strength from 2 weeks up to 3 months. Note that new recombinant DNA technology is also used to produce synthetic absorbable sutures. Discuss that a nonabsorbable suture resists enzymatic digestion in living animal tissues. It becomes encapsulated or walled off by tissues surrounding it during wound healing. It is coated with Teflon, silicone, and other polymers. Its fibers may be uncolored, naturally colored, or impregnated with dyes. Review each type of suture as noted here: Silk: prepared from thread spun by silkworm larva. Treated to decrease capillarity. Available in sizes 9-0 to 5. Not truly nonabsorbable; loses tensile strength after 1 year and may disappear after several years. Cotton: composed of individual cotton fibers combed, aligned, and twisted into a strand. Rarely used; most commonly seen as umbilical tape. Nylon: available as monofilament and multifilament (braided). Has high tensile strength but poor knot security. Easily manufactured in smaller sizes (e.g., 11-0). Polyester: available as nontreated, coated, braided, or monofilament. Has good tensile strength and minimal tissue reaction, and does not absorb tissue fluids. Frequently used for general closure, valve replacements, graft to tissue anastomosis, and revascularization procedures. Polypropylene: available as clear or pigmented; monofilament. Used for cardiovascular, general, and plastic surgery. Extremely inert; can be used in presence of infection. High tensile strength with minimal tissue reaction. Available sizes range from 10-0 to 2. Stainless steel: available as mono- or multifilament. Very strong and inert in tissue. Can pull or tear tissue; requires exacting technique. Available in spools or precut lengths, with or without needles. Brown and Sharp (B&S) scale used to differentiate diameters. Barbed: self-anchoring suture that does not require knots. Available in 0 and 2-0 with straight and curved needles. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Surgical Needles This is a transition slide. The learning objective addressed in this section of the lesson is: Identify the types of surgical needles and describe the indications for use. From Phillips N: Berry & Kohn’s operating room technique, ed 12, St. Louis, 2013, Mosby. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Surgical Needles (Cont.) Vary in shape, size, point design, diameter Parts: Eye Body Point Review the three basic parts of needles as noted below. Refer to the Fig. 7-4 in the book when discussing each type. Eyesuture must be threaded through (section A of the figure) Types: French eye, spring (section B of the figure) Most suture used is a needle-suture combinationswaged; single strand is drawn through tissuesless traumatic. Discuss that the point where the suture is swaged to the needle is considered the eye. (section C of the figure) Bodyshaft; may be round, triangular, or flattened; straight or curved Pointchoice of needle point depends on density of tissue to be penetrated Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Types of Needle Points Taper Cutting Blunt Protect-Point Triangular Discuss the types of points as follows: Taper (blunted) pointtears less and leaves a smaller hole Cutting: for more dense tissue Blunt protect-point needles: alternative to taper pointsreduce the risk of blood exposure for surgical team Triangular: have cutting edges on three sides Reverse cutting: cutaneous suturing transects skin lateral to the wound, reduces tearing through the tissue Reverse Cutting Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Packaging, Storage, and Selection Types of packaging Outer peel-pack Inner pack: foil, plastic, or paper Single or multiple strands, with and without needles Color coding Selection Procedure Tissue Patient condition Surgeon preference Paraphrase the information on the slide to review packaging characteristics. Discuss the factors that influence the selection of suture. Note that although the perioperative nurse and surgical technologist are not responsible for selecting suture, they must be knowledgeable about the types and properties. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Suturing Techniques/ Wound Closures This is a transition slide. The learning objective addressed in this section of the lesson is: Describe common methods of wound closure and hemostasis. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Techniques for Wound Closure Primary suture line Obliterates dead space Prevents serum accumulation Approximates wound edges during healing Secondary suture line Supplements primary line Eliminates tension on primary line Reduces risk of evisceration Review the primary and secondary suture lines as noted on the slide. Ask the students to list the risks for dehiscence and evisceration. Note that factors include obesity, advanced age, poor nutrition, intra-abdominal pressure, diabetes, chemotherapy or radiation, renal or hepatic insufficiency, infection, and corticosteroid use. Transition to the next slide for an illustration of the primary suture line. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Review the closure layers as shown on the slide. From Davis & Geck: Surgical atlas and suture guide, ed 2, Wayne, NJ, 1992, American Cyanamid Co. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Techniques for Wound Closure Interrupted Each stitch placed and tied individually Anastomotic repairs Fascial closure Skin closure Continuous Series of stitches First and last stitch tied Peritoneal closure Blood vessel closure Discuss the wound closure techniques as noted on the slide. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Techniques for Wound Closure (Cont.) Retention (stay) Each stitch placed and tied individually Bolstered to prevent skin damage Subcuticular Stitches buried under the epidermal layer of skin Purse string Continuous circular suture Discuss the wound closure techniques as noted on the slide. Emphasize that in perioperative nursing practice the act of suturing is considered a part of the education and subsequent role of the RNFA. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Ask the students to identify each of the stitch types shown on the slide. A. Interrupted B. Continuous C. Retention D. Subcuticular D. Purse-string From Davis & Geck: Surgical atlas and suture guide, ed 2, Wayne, NJ, 1992, American Cyanamid Co. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

General Considerations Opening packets Handling suture material Threading needles Knot tying Endoscopic techniques Discuss that suture must be kept sterile and opened properly onto the table; surgeon preference cards should be reviewed before surgery; and suture should be pulled with free ends secured to straighten it. Discuss that when suturing, the completed knot should be firm to prevent slipping but should be small with ends cut short. Excessive tension, sawing, and friction between the strands and inadvertent crush with clamps should be avoided. Endoscopic knots can be tied extracorporeally (outside) and slid in the trocar. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Skin Closure Skin staples Wound closure strips Surgical adhesives Review the indications for skin staples, wound strips, and adhesives. From Davis & Geck: Surgical atlas and suture guide, ed 2, Wayne, NJ, 1992, American Cyanamid Co. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Hemostasis Ligature ties Ligating clips Sponges Explain that hemostasis is an ongoing process during surgery. Bleeding may obscure visualization of the operative site and must be controlled. Hemostasis may be accomplished with suture materials, electrosurgical devices, lasers, and chemical agents. Discuss how ties are used: Hemostat placed on end of a structure Tie placed around the vessel Knot tied and tightened Excess cut off Review that a “tie on a pass” is a tie placed on a clamp with the long end extending from the tip. It is placed under the vessel or duct to be ligated. From Beth Israel Deaconess Medical Center, Boston, MA. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instruments This is a transition slide. The learning objective addressed in this section of the lesson is: Differentiate among the major categories of instrumentation and the indications for their use. Courtesy Codman & Shurtleff, Inc., Randolph, MA. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instruments (Cont.) Composition of surgical instruments 400 series stainless steel Die forging Milling Passivation Finishing Mirror Satin Ebonized Briefly discuss historical facts: Instrumentation dates back to 2500 bcEgyptians, Greeks, Hindus 1700s: coppersmiths, steelworkers, needle grinders made instruments 1800s: surgeons used kitchen knives, penknives, carpenter saws, and table forks Development of stainless steel ensured better quality and revolutionized instrumentation Instruments continue to evolve, especially for laparoscopic surgery Review the manufacturing process for instruments. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instrument Categories Cutting instruments (dissectors) Scalpels Scissors Drills Saws Osteotomes Rongeurs Adenotomes Dermatomes Discuss the types of instruments in the cutting category as noted on the slide. Note that dissectors may be sharp or blunt, and are used to cut or separate tissue. Provide examples of instruments in this category (e.g., Mayo, Metzenbaum, Iris, etc.). Courtesy Codman & Shurtleff, Inc., Randolph, MA. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instrument Categories (Cont.) Clamps Hemostats Occluding clamps Graspers and holders Forceps or pickups Needle holders Towel clamps Discuss the types of instruments in the clamp category. Note that clamps are designed for holding tissue. They have finger rings, shanks, ratchets on the shanks near the rings, a joint (usually a box lock), and a jaw, which is the working portion of the instrument and defines its use. Provide examples of instruments in this category (e.g., hemostat, Crile, Kocher, etc.). Courtesy Codman & Shurtleff, Inc., Randolph, MA. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instrument Categories (Cont.) Retractors Self-retaining Handheld Table mount Accessory and ancillary Suction tips Irrigators and aspirators Probes Dilators Mallets and screwdrivers Note that retractors hold back the wound edges, structures, or tissues to provide exposure of the operative site. Discuss how accessories enhance basic instrumentation and are often unique to the specialty. Provide examples of instruments in this category (e.g., Army-Navy, Richardson, Balfour, Yankauer, Hegar, etc.). Courtesy Codman & Shurtleff, Inc., Randolph, MA. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instrument Categories (Cont.) Endoscopic instrumentation Disposable or reusable Trocars Forceps/graspers Clip appliers Stapling devices Scissors Needle holders Aspiration and irrigation systems Discuss that endoscopic instrumentation will be covered in depth in future lessons and that a solid knowledge is vital to provide care to patients undergoing these procedures. Review the basic components of endoscopic instruments as noted on the slide. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Instrument Categories (Cont.) Stapling instruments Ligation and division Resection Anastomosis Skin and fascial closure Review the general types of stapling devices and their functions as noted below: Ligating and dividing staplers (LDSs) Gastrointestinal anastomosis (GIA) Thoracoabdominal (TA) End-to-end anastomosis (EEA) Laparoscopic hernia mesh Open hernia mesh Endo-GIA From Phillips N: Berry & Kohn’s operating room technique, ed 12, St. Louis, 2013, Mosby. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Selecting and Preparing Instruments for Patient Use Operating room or central supply personnel arrange instruments into trays Basic sets Basic table setups Scrub person sets up instruments Review the sequence of events that occurs in the selection and preparation of instruments for the patient. Emphasize the importance of a standardized method for setting up the back table to foster efficiency. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Care and Handling Proper use prolongs instrument life and quality Intraoperative cleaning with distilled water Inspection before and after use Storage Discuss that instrumentation is considered a major asset and expense for all institutions. Emphasize that proper care prolongs instrument life and reduces costs for the institution. Review the actions that the nurse and the surgical technologist take to care for surgical instruments. Discuss the instrument table breakdown process. Review the common parameters for instrument storage. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Perioperative Nursing Considerations This is a transition slide. The learning objectives addressed in this section of the lesson are: Identify safe practices for handling sharps and instruments. Describe the consequences of incorrect instrument, sharps, and soft goods (sponge) counts. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Surgical Counts Needles Sharps Soft goods Instruments Radiopaque 4 × 4s Laparotomy sponges Dissectors Round sponges Neurosurgical patties Instruments Review the items that are typically included in a surgical count. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Surgical Counts (Cont.) Baseline counts prior to patient’s arrival Subsequent counts as incision layers are closed Count begins at surgical siteimmediate surrounding areaMayo standback tableitems discarded from the field Review the parameters for counting objects in the OR, drawing on knowledge learned in past lessons. Review the wound layers that are closed and how each closure prompts a count. Discuss the actions that are taken to resolve an incorrect count. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Prevention of Retained Items Communication Consistent practices Wound exploration prior to closure Review the strategies that the perioperative team can take to prevent retained objects. Ask the students what additional strategies could be used to prevent retained objects. Emphasize that unintentional retention of objects has been identified as a “never event.” From King CA: To count or not to count: a surgical misadventure. Perioperative Nurs Clin 3(4): 395-400, 2008. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Sharps No-Touch Technique Neutral zone Impervious container Discuss the major features of the no-touch technique. Review the no-touch technique as follows: Sharps placed in a preassigned basin, tray collection device, or safe “neutral zone” Surgeon retrieves needle on needle holder Surgeon replaces needle and holder in neutral zone Scrub person retrieves it Two people do not touch the same sharp at the same time Segue to the summary. Courtesy William P. Schecter, M.D. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc.

Summary Suture is the generic term used for materials used to repair and reapproximate incised or torn tissues. Suture choice is determined by characteristics such as absorbable versus nonabsorbable, strength, braided or monofilament, ease of knot tying, and the inflammatory response of the tissue. Absorbable sutures include gut, collagen, synthetics such as polyglactin, and bioengineered substances such as poly-4-hydroxybutyrate. Expand on the information on the slide to summarize key points covered during this lesson. Alternatively, ask the students to summarize the content. Summation continues on next slide. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc. 38

Summary (Cont.) Nonabsorbable sutures include silk, cotton, nylon, polyester fiber, polypropylene, and stainless steel. Suture may be packaged as strands or in reels or used with needles. Needles may be eyed (and need to be manually threaded) or swaged onto suture. Instruments are broadly categorized into cutting instruments, clamps, retractors, and accessory instruments. The surgical count process is designed to avoid unintentional retention of sharps, soft goods, and instruments. Expand on the information on the slide to summarize key points covered during this lesson. Alternatively, ask the students to summarize the content. Pause for any questions before moving to the next lesson. Copyright © 2015, 2011, 2007 by Mosby, Inc., an imprint of Elsevier Inc. 39