Suturing Basics TOPICS Sutures Knots Wounds classification healing

Suturing Basics

TOPICS • • • Sutures Knots Wounds (classification & healing) Wound Closure Postoperative Wound Care Local Anaesthetics Surgical Instruments Scrubbing Obtaining Haemostasis Skin Flaps

Suture Material • 3 ways of classifying suture material: – Natural or Synthetic – Absorbable or Non-Absorbable – Monofilament or Braided/Twisted

Silk Catgut • Natural – Silk, linen, catgut • Synthetic polymer – Polypropylene, polyester, polyamide Polypropylene Polyester

• Absorbable – catgut, polydioxanone, polyglycolic acid – Used for deep tissues, membranes, & subcuticular skin closure • Non-Absorbable – polyester, nylon, stainless steel – Used for skin (removed) & some deep structures (tendons, vessels, nerve repairs – not removed)

• Monofilament – Polypropylene – Polydioxanone – Nylon • Multifilament – Catgut (twisted) – Polyester – Silk (braided)

HOW DOES THE SUTURE MATERIAL AFFECT THE SECURITY OF THE SUTURE-KNOT? • The security of any tied suture is improved by the use of certain patterns & the friction between threads. • Friction factor is affected by size of contact area between threads, tightness of tying, & suture material used. • How many knots ? ? ?

So what type should I use? • The most commonly used suture materials for interrupted & exposed skin sutures are nylon & polyprolene. • Sutures that are buried, or run in the skin (eg. subcuticular suture), may use either nonabsorbable, or absorbable materials.

Surgical Needle • Curvature * Most common, general use in all tissues –¼ – 3/8 * –½* – 5/8 – J-shaped

Using needle holder, grasp needle about 2/3 rds of the way back from point.

Needle Holder • Remember!!! Thumb & ring finger into needle holder’s rings (NOT your middle finger!)

X NOT YOUR MIDDLE FINGER!!!

Index finger stabilizes the instrument by resting on the shaft.

Surgical Scissors

Cutting Skin Sutures • With skin sutures, leave 3 -4 mm tail. – Tail = amount of suture left above knot – Tail is left because it helps prevent loosening or undoing of sutures. • REMEMBER: Always ask the surgeon the desired length of suture tail before cutting!!

Cutting Deep Sutures • Buried sutures are left within the body. • Cut the suture on the knot, leaving no tail behind. • REMEMBER: Always ask the surgeon the desired length of suture tail before cutting!!

FORCEPS • Grasp forceps between thumb & middle finger, while index finger is used for stabilization. • If possible, use forceps to grasp dermis, rather than epidermis or skin surface itself. This helps prevent marking & injuring of skin at wound edge.

SIMPLE INTERRUPTED suture

VERTICAL MATTRESS suture

VERTICAL MATTRESS suture • This suture is best used in creases & areas of natural inversion (eg. back of hand, or other sites of loose skin). • The 2 nd ‘mini-suture’ – in the same line as the main suture – Needle is inserted to pick up just the skin (epidermis & dermis) of both wound edges. – ensures eversion of the skin edges

Simple Interrupted vs. Vertical Mattress • This suture is best used in creases & areas of natural inversion (eg. back of hand, or other sites of loose skin).

How many knots? • With a braided material, such as silk, a 3 rd throw (replicating the first) would be placed to secure the knot. • If a slippery monofilament material, such as nylon were being used, one would place 5 or 6 throws of alternating construction in order to minimize knot slippage.

Important points to think about: • Tightly tied sutures can cause ischaemia & wound edge necrosis. Gentle but firm knots & minimal wound tension will minimize these factors. • Remember, keep skin edges everted, NOT inverted!

When can I remove the sutures? • Face: 3 -4 days • Scalp: 5 days • Trunk: 7 days • Arm or leg: 7 -10 days • Foot: 10 -14 days

Now you are ready to practice!

Practice!

KNOTS

KNOT TYING Is it really all that important? • A patient’s life may depend on the security of one ligature. Slippage of a tie may result in a life-threatening haemorrhage.

Tying Knots • Square (reef) knot • Surgeon’s knot

Square knot

Surgeon’s knot

What’s the difference between these 2 knots? • Square knot • Surgeon’s knot

Granny knot

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