1. BASIC SUTURING WORKSHOP Uğur Anıl BİNGÖL, MD

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 7-14 days 14-28 days 0 5 7 14 21 28 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.

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. Age Blood supply to the area Nutritional status Tissue quality Revision/infection Compliance Weight Dehydration Chronic disease Immune response Radiation therapy COMMON PATIENT FACTORS

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.

9. 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 SURGICAL PRINCIPLES

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. 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) NON- ABSORBABLE Absorbable

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

14. Monofilament 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 Multifilament (braided) 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

22. SCALPEL BLADES

23. 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 Lidocaine (Xylocaine®) with epinephrine  Vasoconstriction  Decreased bleeding  Prolongs duration  Strength: 0.5% & 1.0%  Maximum individual dose:  7mg/kg, or  500mg ANESTHETIC SOLUTIONS

24. 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. 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 INJECTION TECHNIQUES

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

35. 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 PRINCIPLES AND TECHNIQUES

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

39. SIMPLE INTERRUPTED SUTURING Rule of halves

40. 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

41. 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 http://www.youtube.com/watch?v=PFQ5-tquFqY

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

51. CONTINUOUS LOCKING AND NONLOCKING SUTURES http://www.youtube.com/watch?v=xY4cAqk30K4 http://cal.vet.upenn.edu/projects/surgery/5000.htm

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

53. VERTICAL MATTRESS Good for everting wound edges (neck, forehead creases, concave surfaces)

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

55. HORIZONTAL MATTRESS Good for closing wound edges under high tension, and for hemostasis.

56. HORIZONTAL MATTRESS http://www.youtube.com/watch?v=9DdaooEXshk

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

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 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.

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

67. 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 FOLLOW UP CARE WITH ADHESIVES

68. BIOPSY METHODS Punch & Shave: http://www.youtube.com/watch?v=7CzDEok8Wmohttp://www.youtube.com/watch?v=7CzDEok8Wmo Elliptical Excision: http://www.youtube.com/watch?v=BAhXuoB0wMo&feature=relatedhttp://www.youtube.com/watch?v=BAhXuoB0wMo&feature=related