1. Basic Suturing

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 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
5-7 days
7-14 days
7-14 days
14-28 days
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.
Phases are sequential, yet overlap

5. 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

6. Non-absorbable Absorbable Not biodegradable and permanent Nylon
Prolene
Stainless steel
Silk (natural, can break down over years)
Degraded via inflammatory response
Vicryl
Monocryl
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.

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

8. 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,
Fibers are braided or twisted together
More tissue resistance
Easier to handle
Fewer knots needed
Examples: vicryl, silk, chromic

9. 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

10. 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

11. 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

12. Surgical Needles

13. 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

14. 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

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

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

17. 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

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

19. 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

20. 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)

21. 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.

22. 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

23. Principles And Techniques
Minimize trauma in skin handling
Gentle apposition with slight eversion of wound edges
Visualization
Make yourself comfortable
Adjust the chair and the light
Change the laceration
Debride crushed tissue

24. 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

25. Simple Interrupted Suturing
Rule of halves 1

26. Simple Interrupted Suturing
Rule of halves 3 1 1 2

27. 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

28. 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.

29. 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.

31. 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

32. Simple, Interrupted

33. 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!!

34. Two Handed Tie

35. Two Handed Tie

36. 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).

37. Patient instructions and follow up care
Wound care
After the 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. .

38. 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.

39. 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.

40. References
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.
2009, topic lacerations, etc.
Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family Physicians. AAFP Scientific Assembly