1. Basic Suturing Workshop
Lianne Beck, MD
Emory Family Medicine
January 2013

2. Objectives Describe the principles of wound healing
Identify the various types and sizes of suture material.
Choose the proper instruments for suturing.
Identify the different injectable anesthetic agents and correct dosages.
Demonstrate various biopsy methods: punch, excision, shave.
Demonstrate different types of closure techniques: simple interrupted, continuous, subcuticular, vertical and horizontal mattress, dermal
Demonstrate two-handed, one-handed, instrument ties
Recommend appropriate wound care and follow-up.

3. Critical Wound Healing Period
Tissue
Skin
Mucosa
Subcutaneous
Peritoneum
Fascia
5-7 days
5-7 days
7-14 days
7-14 days
14-28 days
Tissue Healing Time/Days

4. Model of Wound Healing
(1) Hemostasis: within minutes post-injury, platelets aggregate at the injury site to form a fibrin clot.
(2) Inflammatory: bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase.
(3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction
(4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis.
Phases are sequential, yet overlap

5. Wound Healing Concepts
Patient factors
Wound classification
Mechanism of injury
Tetanus/antibiotics/local anesthetics
Surgical principles and wound prep
Suture/needle/stitch choice
Management/care/follow-up

6. Common Patient Factors
Age
Blood supply to the area
Nutritional status
Tissue quality
Revision/infection
Compliance
Weight
Dehydration
Chronic disease
Immune response
Radiation therapy

7. CDC Surgical Wound Classification
Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.
Clean-contaminated: (3-11% risk) operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

8. CDC Surgical Wound Classification
Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.
Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.
This classification scheme has been shown in numerous studies to predict the relative probability that a wound will become infected. Clean wounds have a 1%-5% risk of infection; clean-contaminated, 3%-11%; contaminated, 10%-17%; and dirty, over 27% (2,3,7). These infection rates were affected by many appropriate prevention measures taken during the studies, such as use of prophylactic antimicrobials, and would have been higher if no prevention measures had been taken.

9. Surgical Principles Incision Dissection Tissue handling Hemostasis
Moisture/site
Remove infected, foreign, dead areas
Length of time open
Choice of closure material/mechanism
Primary or secondary
Cellular responses
Eliminate dead space
Closing tension
Distraction forces and immobilization/care

10. Suture Materials Criteria Tensile strength Good knot security
Workability in handling
Low tissue reactivity
Ability to resist bacterial infection

11. Types of Sutures Absorbable or non-absorbable (natural or synthetic)
Monofilament or multifilament (braided)
Dyed or undyed
Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller)
New antibacterial sutures

12. Non-absorbable Absorbable Not biodegradable and permanent Nylon
Prolene
Stainless steel
Silk (natural, can break down over years)
Degraded via inflammatory response
Vicryl
Monocryl
PDS
Chromic
Cat gut (natural)
Nylon (Ethilon®): of all the non-absorbable suture materials, monofilament nylon is the most commonly used in surface closures.
 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.

13. Natural Suture Synthetic Synthetic polymers Biological
Do not cause inflammatory response
Nylon
Vicryl
Monocryl
PDS
Prolene
Biological
Cause inflammatory reaction
Catgut (connective from cow or sheep)
Silk (from silkworm fibers)
Chromic catgut

14. Multifilament (braided)
Monofilament
Multifilament (braided)
Single strand of suture material
Minimal tissue trauma
Smooth tying but more knots needed
Harder to handle due to memory
Examples: nylon, monocryl, prolene, PDS
Fibers are braided or twisted together
More tissue resistance
Easier to handle
Fewer knots needed
Examples: vicryl, silk, chromic

15. Suture Materials

16. Suture Selection Do not use dyed sutures on the skin
Use monofilament on the skin as multifilament harbor BACTERIA
Non-absorbable cause less scarring but must be removed
Plus sutures (staph, monocryl for E. coli, Klebsiella)
Location and layer, patient factors, strength, healing, site and availability

17. Suture Selection Absorbable for GI, urinary or biliary
Non-absorbable or extended for up to 6 mos for skin, tendons, fascia
Cosmetics = monofilament or subcuticular
Ligatures usually absorbable

18. Suture Sizes

19. Surgical Needles Wide variety with different company’s 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

20. Surgical Needles

21. Surgical Instruments
Tissue Forceps, Dressing Forceps, Needle Holder (Driver), Iris scissors (debridement/revision), Dissection Scissors (heavier tissue revision, wound undermining), Hemostats (clamping blood vessels, grasping,exploring), Suture Removal Scissors

22. Scalpel Blades

23. Anesthetic Solutions Lidocaine (Xylocaine®) with epinephrine
Vasoconstriction
Decreased bleeding
Prolongs duration
Strength: 0.5% & 1.0%
Maximum individual dose:
7mg/kg, or
500mg
Lidocaine (Xylocaine®)
Most commonly used
Rapid onset
Strength: 0.5%, 1.0%, & 2.0%
Maximum dose:
5 mg / kg, or
300 mg
1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc
300 mg = 0.03 liter = 30 ml

24. Anesthetic Solutions
CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on:
Eyes, Ears, Nose
Fingers, Toes
Penis, Scrotum

25. Anesthetic Solutions BUPIVACAINE (MARCAINE): Slow onset Long duration
Strength: 0.25%
DOSE: maximum individual dose 3mg/kg

26. Local Anesthetics

27. Injection Techniques 25, 27, or 30-gauge needle 6 or 10 cc syringe
Check for allergies
Insert the needle at the inner wound edge
Aspirate
Inject agent into tissue SLOWLY 
Wait…
After anesthesia has taken effect, suturing may begin

28. Wound Evaluation Time of incident Size of wound Depth of wound
Tendon / nerve involvement
Bleeding at site

29. When to Refer
Deep wounds of hands or feet, or unknown depth of penetration
Full thickness lacerations of eyelids, lips or ears
Injuries involving nerves, larger arteries, bones, joints or tendons
Crush injuries
Markedly contaminated wounds requiring drainage
Concern about cosmesis

30. Contraindications to Suturing
Redness
Edema of the wound margins
Infection
Fever
Puncture wounds
Animal bites
Tendon, verve, or vessel involvement
Wound more than 12 hours old (body) and 24 hrs (face)

31. Closure Types Primary closure (primary intention)
Wound edges are brought together so that they are adjacent to each other (re-approximated)
Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery
Secondary closure (secondary intention)
Wound is left open and closes naturally (granulation)
Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced fractures
Tertiary closure (delayed primary closure)
Wound is left open for a number of days and then closed if it is found to be clean
Examples: healing of wounds by use of tissue grafts.

32. Wound Preparation
Most important step for reducing the risk of wound infection.
Remove all contaminants and devitalized tissue before wound closure.
IRRIGATE w/ NS or TAP WATER (AVOID H2O2, POVIDONE-IODINE)
CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor scar are greatly increased
Personal Precautions

33. Basic Laceration Repair
Principles And Techniques

34. Langer’s Lines
The general course of bundles of connective tissue within the dermis. Wounds that cross these lines tend to be widened by the inherent tension.

35. 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

36. Types of Closures
Simple interrupted closure – most commonly used, good for shallow wounds without edge tension
Continuous closure (running sutures) – good for hemostasis (scalp wounds) and long wounds with minimal tension
Locking continuous - useful in wounds under moderate tension or in those requiring additional hemostasis because of oozing from the skin edges
Subcuticular – good for cosmetic results
Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimizing tension across the wound
Horizontal mattress – good for fragile skin and high tension wounds
Percutaneous (deep) closure – good to close dead space and decrease wound tension

37. Simple Interrupted 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

38. Simple Interrupted Suturing
Rule of halves 1

39. Simple Interrupted Suturing
Rule of halves 3 1 1 2

40. 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

41. 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.
Rotate your wrist to follow the arc of the needle.
Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance.

42. 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.

44. Simple Interrupted 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.
Cut the ends of the suture 1/4-inch from the knot.
The remaining sutures are inserted in the same manner

45. Simple, Interrupted

46. The trick to an instrument tie
Always place the suture holder parallel to the wound’s 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!!

47. Two Handed Tie

48. Two Handed Tie

49. One-Hand Tie

50. One-Hand Tie

51. Continuous Locking and Nonlocking Sutures

53. Vertical Mattress Good for everting wound edges
(neck, forehead creases, concave surfaces)

55. Horizontal Mattress Good for closing wound edges under high tension,
and for hemostasis.

56. Horizontal Mattress

59. Suturing - finishing
After sutures placed, clean the site with normal saline.
Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla).

60. Suturing - before you go…
Need for tetanus globulin and/or vaccine?
Dirty (playground nail) vs clean (kitchen knife)
Immunization history (>10 yrs need booster or >5 yrs if contaminated)
Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence)
It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures.

61. Patient instructions and follow up care
Wound care
After the first hours, patients should gently wash the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages.
Facial wounds generally only need topical antibiotic ointment without bandaging.
Eschar or scab formation should be avoided.
Sunscreen spf 30 should be applied to the wound to prevent subsequent hyperpigmentation.

62. Suture Removal Average time frame is 7 – 10 days
FACE: 3 – 5 d
NECK: 5 – 7 d
SCALP: 7 – 12 days
UPPER EXTREMITY, TRUNK: 10 – 14 days
LOWER EXTREMITY: 14 – 28 days
SOLES, PALMS, BACK OR OVER JOINTS: 10 days
Any suture with pus or signs of infections should be removed immediately.

63. Suture Removal
Clean with hydrogen peroxide to remove any crusting or dried blood
Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin
Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4. Count them.
Most wounds have < 15% of final wound strength after 2 wks, so steri-strips should be applied afterwards.

64. Topical Adhesives
Indications: selection of approximated, superficial, clean wounds especially face, torso, limbs. May be used in conjunction with deep sutures
Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-10 to slough), seal moisture, faster, clear, convenient, less supplies, no removal, less expensive
Contraindicated with infection, gangrene, mucosal, damp or hairy areas, allergy to formaldehyde or cryanoacrylate, or high tension areas

65. 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

66. Dermabond® Standard surgical wound prep and dry
Crack ampule or applicator tip up; invert
Hold skin edges approximated horizontally
Gently and evenly apply at least two thin layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky
Apply dressing

67. Follow Up Care with Adhesives
No ointments or medications on dressing
May shower but no swimming or scrubbing
Sloughs naturally in 5-10 days, but if need to remove use acetone or petroleum jelly to peel but not pull apart skin edges
Pt education and documentation

68. Biopsy Methods
Punch & Shave:
Elliptical Excision:

69. References
Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct. 355: 17.
Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988.
2009, topic lacerations, etc.
Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family Physicians. AAFP Scientific Assembly

70. Obstetrics and Gynecology Episiotomy Repair
Ricardo Rodriguez, MD
Providence hospital
Department of Obstetrics and Gynecology

71. Episiotomy Traditionally used to facilitate delivery of the infant
Reduce second stage of labor
1700’s focus on protecting intact perineum
Allow slow controlled dilation and delivery
1828 Ferdinand von Ritgen
Described prpcedure using extension rather than flexion for delivery of fetal head
1893 Karl August Scudart
Fisrt mediolateral incision report
1900’s J. B. DeLee
Believed everyone should have episiotomy with forcep delivery to reduce trauma to pelvic floor less potential fetal trauma
Twilight birthing came about
1970’s 1980’s
Questioning routine use of episiotomy
Gradual decrease in use

72. Episiotomy

73. Episiotomy ACOG Indications depend on clinical judgment
Do not support routine or “liberal” use
Use for maternal or fetal indications
Avoiding severe maternal lacerations
Facilitating difficult deliveries
Indications depend on clinical judgment
Non reassuring fetal heart rate
Shoulder dystocia
Operative vaginal delivery
Breech Delivery

74. Episiotomy

75. Extension Tears Generally
1st and 2nd degree tears are simple to repair
If you haven’t done many 3rd and 4th degree tears call for help Gyn or Colorectal

76. Episiotomy and Vaginal Repairs
Goal is to return all structures to normal anatomy
Use the hymen remnant as key landmark
Suture used
2-0 Vicryl or monocryl common
2-0 chromic maybe used but some patients can have reactions
Give plenty of anesthesia
Even patients with epidurals can benefit from local injection due to varying levels of anesthesia

77. Nerve Dermatomes Stage I Onset of labor to 10cm dilation
T10 – L1(Sympathetic fibers)
Stage II
10 cm the birth of the baby
S 2- S4 (Pudendal nerves, somatic)
Stage III
Delivery of the Placenta
T10 – L1 (Sympathetic fibers)
Stage I pain is largely from the uterus
Stage II with vaginal birth
Stage III goes back to T10L1
Student and resident pimp question: Visceral sensory fibers from the uterus, cervix, and upper vagina traverse through the Frankenhauser ganglion, which lies just lateral to the cervix, into the pelvic plexus, and then to the middle and superior internal iliac plexuses (Fig. 19-1). From there, the fibers travel in the lumbar and lower thoracic sympathetic chains to enter the spinal cord through the white rami communicantes associated with the T10 through T12 and L1 nerves. Early in labor, the pain of uterine contractions is transmitted predominantly through the T11 and T12 nerves. Motor pathways to the uterus are at T7 and T8 so any method below that level can cause pain relief without compromising the mechanics of the uterus

78. Epidural Epidural Catheter into epidural potential space
A “good” spinal or epidural will cover T10 to S5 for vaginal delivery and T4 to S1 for CS
Achieved by
Location of tip
Dose concentration os volume of medication
Affected by
Patient position
Anatomic variations
Synechiae
In primiparas by a mean of 38 min and in multiparas by 23 min

79. Episiotomy Repair
Whether its midline or lateral repair is the same

80. Episiotomy Repair Pearls
Return normal anatomy and use the least amount of suture material possible
Count the tray before starting the procedure and after including sponges and 4x4’s
Recommend not using 4x4’s or non tagged gauze. Use lap sponges with the blue radio opaque handle
Put in one lap sponge past the point of repair by the cervix
This will stop blood from oozing down obscuring the field while doing the repair
Make sure you take out and count the laps and instruments
If blood soaks the lap sponge and starts to drip down inspect cervix for tears and cavity for possible retained placenta
Anesthesia anesthesia anesthesia
Test the area by using pick ups to pinch where you will be stitching
Nothing worse than a patient closing her legs and kicking while both your hand and a needle are in an enclosed space

81. Episiotomy Repair
Make sure that the first stitch is done about 1cm posterior to the edge of the laceration due to vessel retraction or you will keep getting annoying bleeding that will drip down and make the repair more difficult

82. Episiotomy Repair
Crown stictch after bringing hymen remnant to normal anatomic position. Make sure that you just return normal anatomy for the patient. When we do cosmetic vaginoplasty and tightening we do a similar procedure to tighten the vagina back up to a condition prior to childbirth but taking aggressive bites can make the opening too small. Also with re-hymenization procedures key is to return normal anatomy

83. Episiotomy Repair
Whether its midline or lateral repair is the same. Note that prior to the corwn stitch the sutures is locked while after it is a simple running stitch

84. Episiotomy Repair
Whether its midline or lateral repair is the same. This area can b quite sensitive so test to see of lidocaine is still working..proper alignement is crucial here so you don’t have any dog ears that look like skin tags hanging from the patients opening

85. Pain after Episiotomy Ice packs Oral motrin vs toradol Pudental block
Opioid analgesics
Topical lidocaine not effective
Pain out of proportion
Can be sign of vulvar, paravaginal, ischiorectal hematoma or cellulitis.
Examine patient if stable non expanding hematoma can monitor
If hematoma is expanding take to the OR for management
Note that the tissues of the pelvis have a lot of room to expand. I have taken out 1300cc’s from a side wall hematoma before. Also note that most of the pregnant patients are young and generally in good health so they can tolerate and compensate for blood loss until they suddenly crash. Also remember that these patients have built up an increase of 50% plasma and 30% blood during the pregnancy so they can loose quite a bit more than a regular trauma patient.

86. Episiotomy Break Down Breakdown is rare but can be serious
If no sign of infection you can take the patient to the OR right away
If there is pus or drainage admit for antibiotic then take to OR after 2 or 3 days of antibiotics and no signs of infection
Can also leave open after antibiotics and debriedment for second intention healing
This can leave the area scarred and affect patients quality of life
Needs to be addressed early to avoid complications such as necrotizing fasciitis, cellulitis which may need much more extensive surgical repair

87. Episiotomy Repair 3rd degree