1. Slides by: Mark Jaffe, D.P.M., M.H.S.A. Associate Professor Nova Southeastern University Indiana University School of Medicine - Northwest Campus 12 th Annual INTERNATIONAL Human Cadaver Prosection Suture Workshop August 2, 2011

2. Objectives Review the types of wound closure Identify several types and sizes of suture material. Review blunt and sharp dissection techniques Choose and handle the proper instruments for instrument tying. Under supervision close a superficial wound on pig skin with sutures using the following techniques; simple-interrupted, horizontal mattress, vertical mattress, and continuous (running). Apply similar wound closure to human cadaver skin tissue.

3. Wound Closure Options Primary -Tape - Glue - Sutures - Staples Secondary Intention - Wound heals on its own with cleaning our only Intervention Delayed Primary - 4-6 days later

4. Primary Intention Most efficient method of wound healing; Resulting in faster healing times and a more cosmetically appealing scar. Usually performed in the first 6-8 hours but up to the first 24 hours (face,scalp).

5. Secondary Intention Wound left to heal gradually by granulation from the inside out with daily wound care. The consequences: - A longer healing period. - Increased risk of infection because the wound remain open longer. - A more unattractive scar.

6. Delayed Primary Closure Old or contaminated wounds are sometimes not sutured for the first 4-6 days following injury. Wounds are only repaired if NO sign of infection are present at the time of closure.

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

8. Suture Materials ABSORBABLE: lose their tensile strength within 60 days. NON- ABSORBABLE: Need to be removed

9. Absorbable Sutures PLAIN GUT: Derived from the small intestine of healthy sheep. Loses 50% of tensile strength by 5-7 days. Used on mucosal surfaces. CHROMIC GUT: Treated with chromic acid to delay tissue absorption time. 50% tensile strength by 10-14 days. Used in episiotomy repairs.

10. Polyglycan 910 (Vicryl ® ) Braided, synthetic polymer 50% tensile strength for 30 days Used: subcutaneous

11. Non-absorbable Sutures Nylon (Ethilon®): of all the non- absorbable suture materials, monofilament nylon is the most commonly used in surface closures. http://classes.kumc.edu/som/sur g900/Didactics/Lecture%20Handouts/Lect ure%20Links%20ppt/Suture%20Lab/Woun d_Closure_Manual1.pdfhttp://classes.kumc.edu/som/sur g900/Didactics/Lecture%20Handouts/Lect ure%20Links%20ppt/Suture%20Lab/Woun d_Closure_Manual1.pdf

12. Suture Sizes 5-0 is small, and 2-0 is big The usual sizes = 3-0 or 4-0 Examples: –might use 5-0 on the face –2-0 on the plantar surface of a foot

13. 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

14. Surgical Needles

15. The Suture Packaging STRAND SIZE MATERIAL STRAND LENGTH PRODUCT CODE NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE NEEDLE LENGTH COLOUR POINT TYPE NEEDLE CIRCLE

16. Surgical Instruments

17. Needle Holders

18. Forceps Tissue forceps Dressing forceps

19. Iris Scissors Iris scissors are predominantly used to assist in wound debridement and revision.

20. Dissection Scissors Used for heavier tissue revision as necessary for wound undermining.

21. Suture Removal Scissors

22. Hemostats Clamping small blood vessels Hemorrhage control Grasping Exposing Exploring Visualizing

23. Scalpel Blades #15 blade

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

25. Contraindications Redness Edema of the wound margins Infection Fever

26. Personnel Precautions Use Universal Precautions Glove Gown Mask Needle-Stick Injuries. http://www.osha. gov/SLTC/blood bornepathogens/ index.html http://www.osha. gov/SLTC/blood bornepathogens/ index.html

27. (Sterile) Wound Preparation Wound cleansing solution Wound scrubbing Irrigation –Take only the soft, flexible part from an 18 gauge IV needle (angiocath) –Put angiocath tip on 20 cc or 50 cc syringe Debridement Local anesthesia

28. Debridement Blunt Dissection Sharp Dissection Regardless of technique maintain control at all times.

29. 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

30. Suturing Rule of halves

31. Suturing Rule of halves

32. Suturing Basics 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

33. 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.

34. Follow the needle’s arc 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.

35. 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.

36. 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.

37. Suturing Cut the ends of the suture 1/4-inch from the knot. The remaining sutures are inserted in the same manner to prevent wound dehiscence

38. 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!!

39. Suture Techniques Simple Interrupted Horizontal Mattress Vertical Mattress Continuous

40. Types of Sutures

41. Simple, Interrupted The most commonly used and versatile suture in cutaneous surgery is the simple interrupted suture

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

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

44. Continuous or Running Running sutures are useful for long wounds in which wound tension has been minimized with properly placed deep sutures and in which approximation of the wound edges is good.

45. Suturing - finishing After sutures placed, check the suture line for dehisence. Gently clean the site with normal saline. Apply a small amount of topical antibiotic ointment and cover with a sterile non-adherent dressing (e.g., telfa, vaseline gauze). Instruct patient to keep the bandages clean and dry Schedule the patient for wound recheck within one week, sooner for signs of infection or complications

46. Suture Removal General Time frame for removing sutures: Average time frame is 7-10 days but may vary. For example: FACE: 4-5 days BODY & SCALP: 7 days SOLES, PALMS, BACK OR OVER JOINTS: 10 days Note: Any suture with pus or signs of infections should be removed immediately.

47. Suture Removal 1.Clean with hydrogen peroxide to remove any crusting or dried blood 2.Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin 3.Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4 4. Once all sutures have been removed, count the sutures 5. The number of sutures needs to match the number indicated in the patient's health record

48. Summary 1. Any Questions?