Basic Suturing Workshop Lianne Beck, MD Assistant Professor Emory Family Medicine Residency Program June 2014

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.

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 0 5 7 14 21 28 Tissue Healing Time/Days

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

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

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

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.

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.

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

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

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

Non-absorbable Absorbable Not biodegradable and permanent Nylon (Ethilon) 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.

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

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

Suture Materials

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

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

Suture Sizes

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

Surgical Needles

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

Scalpel Blades

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

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

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

Local Anesthetics

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

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

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

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

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.

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

Basic Laceration Repair Principles And Techniques

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.

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

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

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

Simple Interrupted Suturing Rule of halves 1

Simple Interrupted Suturing Rule of halves 3 1 1 2

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

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.

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.

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

Simple, Interrupted http://www.youtube.com/watch?v=PFQ5-tquFqY

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!!

Two Handed Tie

Two Handed Tie

One-Hand Tie

One-Hand Tie

Continuous Locking and Nonlocking Sutures http://www.youtube.com/watch?v=xY4cAqk30K4 http://cal.vet.upenn.edu/projects/surgery/5000.htm

http://www.youtube.com/watch?v=sgOaBojcX-c https://www.youtube.com/watch?v=hIqTDvofekM

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

http://www.youtube.com/watch?v=824FhFUJ6wc

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

Horizontal Mattress http://www.youtube.com/watch?v=9DdaooEXshk

http://www.youtube.com/watch?v=I7C7nsl5Tuk

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).

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.

Patient instructions and follow up care Wound care After the first 24-48 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.

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.

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.

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

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

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 http://www.youtube.com/watch?v=oa13wriWTus&feature=related http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1

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

Biopsy Methods Punch & Shave: http://www.youtube.com/watch?v=7CzDEok8Wmo Elliptical Excision: http://www.youtube.com/watch?v=BAhXuoB0wMo&feature=related

EBM Take Home Points Suturing is preferred technique for skin laceration repair LOE SORT C Saline or tap water should be used for wound irrigation LOE SORT B Use of white petrolatum to promote wound healing is as effective as antibiotic ointment LOE SORT B Tissue adhesives show comparable results with regards to cosmetic, infection or dehisence rates LOE SORT A

References http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf 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. www.uptodateonline.com; 2009, topic lacerations, etc. http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf http://www.mnpa.us/handouts/Session%2005%20%20-%20%20Basic%20Suturing%20%202010%20MNPA.pdf http://www.practicalplasticsurgery.org/docs/Practical_01.pdf http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE8-7EB5D06CE8DF/0/wound_healing_manual.pdf Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family Physicians. AAFP Scientific Assembly. 2010. http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/assembly/2010handouts/071.Par.0001.File.tmp/071-072.pdf