Sutterlin - Suture Basics 2

7/25/2019 Sutterlin - Suture Basics 2

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Suture Techniques

in Primary CareShawn A. Sutterlin, PA-CWatauga Orthopaedics


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Obecti!es

"#e!iew wound types and classi$cation

"%nderstand the principles o& woundhealing"'escribe the ( types o& wound closure

"O!er!iew o& Suture materials"Wound closure techniques


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Wound

Classi$cation")our Classes

"Clean"Clean-contaminated

"Contaminated"'irty*in&ected


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Clean Wounds

"+ost common is electi!e surgicalincision"Primary closure

"- rate o& in&ection


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Clean

Contaminated"Wounds contaminated by local

/ora despite aseptic technique

"Cholecystectomy, appendectomyand hysterectomy

"(- in&ection rate


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Contaminated

"Open traumatic wounds in nonsterileen!ironment

"Open &ractures"Surgical procedures in which there is

a gross de!iation &rom sterile

technique 0emergent open cardiacmassage1

"2-3 in&ection rate


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'irty or 4n&ected

"5ross*hea!y contamination oracti!e in&ection

"Per&orated !iscera, abscess andtraumatic wounds

"673 in&ection rate


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Wound 8ealing

")our Stages

"8emostasis"4n/ammatory

"Proli&erati!e"#emodeling


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Phase 49

8emostasis":asoconstriction stimulated byendothelial inury

"Platelet aggregation"Coagulation cascade is acti!ated

and $brin clot &ormed

"Platelets release pro in/ammatorymediators and P'5) in preparation&or subsequent phases


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8emostasis


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Phase 449

4n/ammatory"4n/ammatory mediators released":asodilation - pro!ides increased

blood supply to inury site

"4ncrease !ascular permeability -allows plasma proteins, W;Cs, into

inured tissue

"+igration o& W;Cs &rom circulationinto interstitium and phagocytose

debris*microbes


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4n/ammation


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Phase 4449

Proli&erati!e"Angiogenesis

"5ranulation"$broblasts deposit e


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Phase 4449

Proli&erati!e

"=pitheliali>ation

"?eratinocytes"Contraction

")ibroblast release o& actin


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Phase 4:9

#emodeling"Collagen remodeled along tension

lines

"Cells no longer needed areremo!ed by apoptosis

"+ay ta?e many months


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Patient &actors" Age

"Weight

"@utrition"'ehydration

" ;lood supply

" 4mmunocompromised" Chronic 'isease

" #adiation therapy


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Wound Closure

"Primary closure"Secondary closure

"Tertiary closure


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Primary Closure

"+ost common

"Pre&erred method when appropriate"Wounds are re-appro


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Secondary Closure

"nown as healing by secondary intention

"Wound edges are le&t un-approation o!er granulation tissue

"Appropriate in wounds with so&t tissueloss or se!ere contamination not closableby primary or tertiary means


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Tertiary Closure

"Contaminated wound is 4B'd andle&t open &or se!eral days

"Wound is then closed as in primaryclosure when ris? o& complicationsdeclines

"Pre&erred method &or high energyand highly contaminated wounds


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Suture +aterials

"Traits needed by suture

"Tensile Strength"not security"=ase o& handling

"Dow tissue reacti!ity


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Characteristics

"Si>e"Tensile Strength

"+ono$liment 0nylon, prolene,monocryl1

"+ulti$liment 0!icryl, ethibond, Sil?1"Absorbable"@on Absorbable


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Characteristics

"'yed"%ndyed

"Si>es -2 to E


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Suture Si>ing


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Absorbable

";ro?en down in tissues by

hydrolysis, en>ymes andin/ammation

"Time to resorb !aries by materialand diameter

"includes !icryl, monocryl, P'S, gut.


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@on Absorbable

"@ot bro?en down by hydrolysis or

in/ammatory reaction"Walled oF in body by $broblasts or

physically remo!ed 0s?in sutures1

"4ncludes nylon, prolene, stainlesssteel, sil?, polyester 0ethibond1


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Suture


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Si>e by Docation


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@eedles

"Cutting - s?in and other toughtissue

"Taper - so&ter tissues inside body0bowel,!essels1. 'ilates tissues

";lunt - &elt to pose less ris? o&needle stic?s. +ost use&ul in&ascial closure.


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;e&ore Closing

"8emostasis

"=!aluate"4rrigate"'ebride de!itali>ed*contaminated

tissues

"Should it be closed primarilyG


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;e&ore Closing

"=!aluate the wound

"Time o& inury"Si>e and shape o& wound"So&t tissue loss

"5ross contamination*&oreignbody


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;e&ore Closing

"Wound depth

"@er!e, tendon, !ascularin!ol!ement

";one in!ol!ement 0open )


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Wound Preparation

" Single most important step in pre!entingcomplications

"Control bleeding"#emo!e all debris and de!itali>ed tissue

" 4rrigate copiously with @S

"'o not use iodine or hydrogen pero


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When to Consult

Specialist"'eep wounds to hands*&eet, thora


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When to @ot Close

" Acti!e in&ection

" =rythema*induration

" Puncture wounds

"8uman*animal bites

"'elayed onset o& treatment

" 7 hours &or body

" 7I hours &or &ace


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Anesthesia

"5eneral*spinal Anesthesia"%sed &or large wounds and more

in!asi!e procedures

"#egional Anesthesia"Didocaine*bupi!icaine in$ltrated

near peripheral ner!e to produceanesthesia distally in e


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Anesthesia

"Docal

"Anesthetic agent in&used directlyinto the tissues being treated

"+ost common method inoutpatient setting


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Didocaine"+ost common

" should be adequate &or most procedures

" Sodium channel bloc?er" #apid onset

" #elati!ely short duration o& action

"A!ailable with epinephrine

" helps control bleeding

" prolong duration o& action


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"Donger duration o& action"%se&ul in prolonged procedures aswell as post procedure pain control

"Also a!ailable with epinephrine

;upi!icaine


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Docal Anesthetics


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"'o not use local anesthetic withepinephrine on structures withlimited circulation

"ears, nose, $ngers, toes, penis

CautionJJ


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=quipment

5 l


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5eneral

Considerations"8andle tissues as little as possible" Dimit the time and &orce used in retracting

tissues

"'o not pinch tissues with &orceps, 5ently li&twound edges to place suture

" 4rrigate &requently to minimi>e contaminantsand maintain moist wound bed

" Appro


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@eedlePosition

@eedle should be secured*7 - 7*( down the length

needle &rom the tip


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Always cross s?in at K2degree angle


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#ule o& 8al!es

"Allows better appro


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#ule o& 8al!es

7(


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The 4nstrument Tie"8ow to tie a per&ect square ?not e!ery time

" Place needle dri!er parallel to and directlyo!er incision

"Always wrap needle end o!er dri!er towardtail

"When tightening each throw, mo!e needledri!er to opposite side o& incision.

"The ?ey is to always wrap O:=# needledri!er and to always alternate sides


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; i S t


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;asic Suture

+ethods"Simple interrupted"Simple running"loc?ed running"8ori>ontal mattress

":ertical mattress"#unning Subcuticular

"Subcutaneous 0buried ?not1


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Simple 4nterrupted

"+ost common closure per&ormed

"%sed in super$cial wounds withminimal tension.

"@ylon or prolene";e care&ul o& ?not security


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Simple 4nterrupted


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Simple Continuous

"#apid";est in short lacerations with no tension"8elps with hemostasis"4& one ?not &ails, the entire closure is

compromised

"Contraindicated in in&ected tissues asin&ection can propagate along suture line


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"%sed in wounds closed withmoderate tension

"8elp&ul in obtaining hemostasis

"Similar concerns with ?not securityand integrity o& closure

Doc?ed Continuous


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8ori ontal


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8ori>ontal

+attress

")or &ragile tissue"'istributes tension o!er wider area

"8elps e!ert s?in edges

8ori>ontal


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8ori>ontal

+attress


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:ertical +attress

"%sed &or mae tension


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:ertical +attress

#unning


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#unning

Subcuticular

"Pro!ides optimum cosmetic results"@ot &or contaminated or in&ected

wounds

#unning


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#unning

Subcuticular


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Subcutaneous

";uries the ?not

"%se&ul &or minimi>ing deadspace indeeper wounds"8elps relie!e tension on s?in

closure"+ay be used in dermis as well


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Subcutaneous


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A&ter Closure

"Apply antibiotic ointment

"@on adherant sterile dressing

"Splint i& appropriate"Tetanus

"Antibiotics"Schedule &ollow up 7-( days


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Suture #emo!al

")ace9 (- days"Scalp9 3 days"Chest and e

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Sutterlin - Suture Basics 2