1. “Superior Suturing” Suturing Basics Assignment #1

2. Objectives  Recognize the proper instruments for suturing.  Become familiar with different types of closure techniques  Understand instrument tie

3. Surgical Instruments Tissue ForcepsNeedle Holder Iris scissors Surgical Suture

4. 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.  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.

5. Basic Laceration Repair Principles And Techniques

6. 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

7. 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

8. Simple Interrupted Suturing Rule of halves

9. Simple Interrupted Suturing Rule of halves

10. Suturing  The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees  Evert wound edges  Because scars contract over time

11. Suturing  Needle passes through the wound and comes out on the opposite side at a 90 angle, taking equal bites on both sides.  Rotate your wrist while performing the suture 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.

12. Suturing  Release the needle and grasp the portion of the needle protruding from the skin with the needle driver or forceps. 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.

13. 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 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

14. Wound eversion

15. Simple, Interrupted

16. 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!!

17. Complete Assessment Quiz #1

18. Reference Lianne Beck, MD Assistant Professor Emory University June 2014