1. Basic Suturing Workshop
By Shauna O’Sullivan
Resident Orientation Course 2012

2. Objectives Describe the principles of wound healing
Identify the various types and sizes of suture material
Identify the different injectable anesthetic agents
Demonstrate different types of closure techniques
Recommend appropriate wound care and follow-up

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

4. Model of Wound Healing
(1) Hemostasis: within minutes after injury, platelets aggregate at the injury site to form a fibrin clot
(2) Inflammatory: bacteria and debris are phagocytosed and removed
Factors are released that cause the migration and division of cells involved in the proliferative phase
Phases are sequential, yet overlap

5. Model of Wound Healing
(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

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

7. CDC Surgical Wound Classification
Type 1 “Clean” Wounds:
1-5% risk of infection
Non-traumatic
No inflammation present
No break in technique
Example: elective groin hernia repair
- 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.

8. CDC Surgical Wound Classification
Type II Clean-Contaminated Wounds:
3-11% risk of infection
Non-sterile body region entered under controlled conditions and without unusual contamination
(GI or GU tract, biliary tract, respiratory tract, oropharynx and etc.
Or minor breaks in technique
- 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.

9. CDC Surgical Wound Classification
Type III Contaminated Wounds:
10-17% risk of infection
Major break in sterile technique
Gross spillage from Gastrointestinal (GI) tract
Infected GI, Urinary or biliary tract
Fresh traumatic would (through unprepped skin)
- 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.
- 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.

10. CDC Surgical Wound Classification
Type IV Dirty or infected Wounds:
Infection risk of >27% risk
Wounds associated with perforated viscus; cross clean tissue to drain pus
Traumatic wounds with:
Imbedded foreign body
Delayed presentation (> hours for face and scalp; > 6 hours elsewhere)
- 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.

11. 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

12. Closure Types Secondary closure (secondary intention)
Wound is left open and closes naturally (granulation)
Examples: gingivectomy, gingivoplasty, tooth extraction sockets, poorly reduced fractures

13. Closure Types 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

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

15. Types of Sutures Absorbable or non-absorbable Natural or synthetic
Monofilament or multifilament (braided)
New antibacterial sutures

16. Suture Size
Sizes 3 to 12-0
Numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller
Smaller  Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

17. Suture Material Non-Absorbable Absorbable Not biodegradable, permanent
Nylon
Prolene
Stainless steel
Silk (natural, can break down over years)
Degraded via inflammatory response
Vicryl
Monocryl
PDS
Chromic
Cat gut (natural)
- Non-absorbable: Not a truly permanent material known to be broken down over a prolonged period of time –years
- Absorbable: Degradation and elimination in 1 of 2 ways – 1. By inflammatory reaction using tissue enzymes and 2. By hydrolysis
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.

18. Indications Non-absorbable Absorbable Skin repair Fascia under tension
Vascular (blood vessel) repairs
Subcutaneous repair
Intraoral mucosa (including tongue)
Fascia not under tension

19. Suture Material Natural Suture Synthetic Biological orgin
Cause inflammatory reaction
Catgut (connective from cow or sheep)
Silk (from silkworm fibers)
Chromic catgut
Synthetic polymers
No inflammatory response
Nylon
Vicryl
Monocryl
PDS
Prolene
Natural: Catgut-dervived from the small intestine of healthy sheep; treated with chromic acid to delay absorption

20. Suture Material Monofilament Multifilament (braided)
Single strand of suture material
Minimal tissue trauma
Smooth tying but more knots needed
Resists harboring organisms
Nylon, Monocryl, Prolene, PDS
Fibers are braided or twisted together
More tissue resistance
Easier to handle
Fewer knots needed
Vicryl (braided), Silk (braided), Chromic (twisted)

21. Suture Materials

22. Suture Selection Tips Do not use dyed sutures on the skin
Non-absorbable use for skin, tendons and fascia
Use up to 6 months
Less scarring but must be removed
Absorable used for GI, urinary and biliary
Use monofilament on the skin as multifilament harbor BACTERIA

23. Suture Sizes
General rule : 6-0 on face, 5-0 on hand, & 4-0 elsewhere on body

24. Surgical Needles Classified according to shape and type of point
Curved or straight
Tapered point, cutting or reverse cutting
2 basic configurations for curved needles
Cutting: cutting edge can cut through tough tissue, such as skin
Tapered: no cutting edge; used for softer tissue inside the body

25. Surgical Needles
Cutting
Tapered

26. Needle Anatomy

27. Surgical Instruments

28. Scalpel Blades
- The most commonly used scalpel blades are the #10 and #15 blade
#10 Blade is better for long, straight incisions – held with the shaft of the scalpel in the palm of the hand with the index finger on the top of the blade
#15 Blade is well suited for short, tortous incisions; holding the scalpel as if it were a pencil may facilitate control

29. Instrument Holding
Scalpel: Hold with the shaft of the scalpel in the palm of the hand with the index finger on the top of the blade

30. Instrument Holding
Forceps should be held between the thumb and index finger
Needle driver: Place the thumb and finger slightly into the instrument’s ring

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

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

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

34. Wound Preparation
Most important step for reducing the risk of wound infection
Remove all contaminants and devitalized tissue before wound closure
Irrigate with Normal Saline
If not, the risk of infection and of a cosmetically poor scar are greatly increased
Personal Precautions (Use sterile gloves)
Infection rate in patients undergoing complicated laceration repair are not different when sterile gloves, rather than simply clean gloves, are worn (LOE 1 B)

35. Anesthetic Solutions Lidocaine (Xylocaine®) with epinephrine
Vasoconstriction with ↓ bleeding
Prolonged duration
Strength: 0.5% & 1.0%
Lidocaine (Xylocaine®)
Most commonly used
Rapid onset
Strength: 0.5%, 1.0%, & 2.0%

36. Anesthetic Solutions
CAUTION !!! Due to its vasoconstrictive properties never use lidocaine with epinephrine on:
Eyes, Ears, Nose
Fingers, Toes
Penis, Scrotum

37. Anesthetic Solutions Bupivacaine (Marcaine): Slow onset, long duration
Strength: 0.25%
DOSE: maximum individual dose 3mg/kg

38. Injection Techniques for the Anesthesia
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

39. Basic Laceration Repair
Principles And Techniques

40. Types of Closure
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 those requiring additional hemostasis

41. Types of Closure Subcuticular – good for cosmetic results
Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimize tension across the wound
Horizontal mattress – good for fragile skin + high tension wounds
Percutaneous (deep) closure – good to close dead space + decrease wound tension

42. 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. Should perform debridements and elliptical biopsy incisions parallel to the lines of least skin tension to minimize scarring
- Lines of Langer generally run parallel to natural skin folds or perpendicular to the underlying muscle fibers: for example horizontal on forehead and circumferential on forearm or leg

43. Simple Interrupted Most commonly used in the closure of skin
Individual stitches placed and tied
Perform if worried about the cleanliness of the wound
A few sutures can be removed easily if needed
Can be used in all areas but takes more time

44. Simple Interrupted

46. Continuous Suture
Place the sutures again and again without tying each individual suture
If clean wound, quicker and easier to bring edges together
Used for rapid closure of longer wounds and to stop bleeding from skin edges

47. Continuous Interlocking

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

49. Vertical Mattress
Vertical Mattress Suture

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

51. Horizontal Mattress

52. 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

53. Suturing Apply the needle to the needle driver
Clasp needle 1/2 to 2/3 back from tip

54. 1 Suturing Rule of halves: Matches wound edges better; avoids dog ears
Vary from rule when too much tension across wound 1

55. Suturing
Rule of halves 3 1 1 2

56. Suturing
The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees

57. 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

58. 2 1 4 3

59. Suturing
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

60. 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

61. 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

62. Suturing 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

63. 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!!

64. The Knot Weakest point of the suture ligature
Reduces the tensile strength of the suture by %
The surgeon must have a good working knowledge of the characteristics of the sutures he employs and the knots he uses

65. Categories of Knots Flat knots: Square, surgeon’s and granny
Tied with half hitches with equal tension on each segment of the suture
Sliding knots: Identical and non-identical
Half hitches tied with greater tension on one segment of the suture

66. Sliding Knots
Most surgeons use sliding knots rather than square knots because:
Crossing the Surgeons hands, sometimes required for square knots, leads to slippage
Tying deep ligatures is best accomplished by keeping constant tension on the sutures
Sliding knots require one more throw than square knots

67. Number of Knots Monofilament sutures require more knots
(knot slippage results in disruption)
- Usually five to six knots required
Coated sutures require more knots
Chromic requires “three squares” or four slip knots
Dexon or Vicryl requires four squares or five slip knots with “long tails”

68. Number of Knots (Throws)
Chromic: Three squares or four slip knots
Braided: (Dexon, Vicryl): four squares, five slip knots
*Monofilament: (Prolene, Maxon, PDS, Nylon)
five squares or six slip knots

69. Suturing – Finishing
After sutures are placed, clean the site with normal saline
Apply small amount of Bacitracin and cover with a sterile non-adherent dressing
Need for Tetanus globulin or vaccine?
Dirty versus clean
Prior Immunization history
Have patient return in one day for recheck, for signs of infection or complications

70. Tetanus Prophylaxis
Every 5 year update for tetanus toxoid is a good rule on all cases
Also use tetanus immune globulin) if:
Patient never immunized
Immunosuppressed
Allergic or severe local reaction of toxoid

71. Patient Instructions for Follow-Up
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.

72. Suture Removal Guidelines
Wound Location
Suture Removal (Days)
Scalp 7
Face
3-5
Chin
Trunk
7-10
Arm
Hand
10-14
Leg
Sole of Foot
14-21
Any suture with pus or signs of infections should be removed immediately

73. Suture Removal Clean with hydrogen peroxide to remove any crusting
Using pickups , 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 – apply steri-strips

74. Staples Rapid closure of wound Easy to apply
Evert tissue when placed properly

75. Topical Adhesives
Indications: Selected 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

76. Topical Adhesives Contraindications: Infection Gangrene
Mucosal, damp or hairy areas
Allergy to formaldehyde or cryanoacrylate
High tension areas

77. 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

78. 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
At least 30 sec between each layer, hold for 60 sec after last layer until not tacky and apply dressing

79. 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

80. Any Questions??