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Sutures, Needles, and Wound Care Techniques Lisa M. Campeau, M.D.

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Sutures, Needles, and Wound Care Techniques Lisa M. Campeau, M.D.
Sutures, Needles, and
Wound Care Techniques
Lisa M. Campeau, M.D.
LSU School of Medicine
Critical Concepts
2014-2015
Wound Care Intro
●
Goals of Wound Closure
–
Obliterate dead space ie subcutaneous closure
–
Even distribution of tension along deep suture
lines
–
Maintain tensile strength across the wound
until tissue strength is adequate
–
Approximate and evert epithelium
–
Maximize cosmetic results!!! This is
often the most important factor to the
patient. Symmetry is the key to cosmesis
Potential Complications
●
Hypertrophic scar
●
Wide or deep scar
●
●
●
Keloid – more a patient factor than a
closure factor
Wound dehiscence
Infection – important to use sterile field
and aseptic technique due to the fact that
you are actually implanting a foreign body
ie suture
Factors Contributing to
Complications
●
●
●
Patient Factors
–
Poor nutritional status
–
Diabetes
–
Poor skin quality
High Tension Across Wound
–
Inadequate subcutaneous closure
–
Poor suturing technique
Poor Suture Selection
–
Too small to support tension across wound
Sutures
●
3 Basic Classes
–
Collagen
–
Absorbable – natural or synthetic,
monofilament or braided
–
Non-absorbable – natural or synthetic,
monofilament or braided
Collagen Sutures
●
Gut Sutures– Plain and Chromic
–
Plain gut has adequate tensile strength for 710 days and is gone in 70 days
–
Chromic gut maintains strength for 10-14 days
and is resorbed in 90 days
–
May be used for repair around lips when rapid
dissolution and no suture removal is preferred
Absorbable Sutures
●
●
Naturals
–
Degraded by enzymatic reaction of tissue
resulting in moderate tissue reaction to
presence of suture
–
gut sutures=collagen sutures
Synthetics
–
Degraded by hydrolysis resulting in
significantly less tissue reaction
–
Vicryl (braided), PDS, Maxon, Dexon,
Monocryl (all 4 monofilaments)
Non-absorbable Sutures
●
●
Naturals
–
Moderate tissue reaction results in
encapsulation
–
Silk & Cotton (braided), Stainless Steel
(monofilament)
Synthetics
–
Minimal tissue reaction in the skin over the
sort term
–
Nylon & Prolene (monofilament), Ethibond
(braided)
Monofilament versus Braided
●
●
Monofilament ie Nylon & Prolene (syn/nonabs),
Steel (natl/nonabs), PDS, Maxon, Dexon,
Monocryl (syn/abs), Gut (natl abs)
–
Decreased bacterial penetration
–
Low resistance through tissue
–
Will crush and fracture if clamped
Braided ie Silk & Steel (natl nonabs), Ethibond
(syn nonabs), Vicryl (syn/abs)
–
Increased tensile Strength
–
Pliable and flexible
–
Absorbs fluid and bacteria more
Suture Sizes
●
Size is a matter of diameter and is denoted in
zeroes
●
The more zeroes, the smaller the diameter
●
#1>0>2-0>3-0>4-0>5-0>6-0>7-0
●
Size is directly related to tensile strength so use
larger suture for wounds requiring more tension
to close (If you have to pull really hard, you’re
likely to break your suture. Get a bigger one and
consider changing your closure technique!)
Suture Selection
●
Smallest to “Git ‘er done!” – which means
to accomplish a tension-free closure
–
What tensile strength is required?
–
Suture caliber that is too small for the
job can cut through skin, cause the
wound to dehisce, or result in a wide
scar
Special Considerations
●
Mobility
–
●
Skin Thickness
–
●
Thinner needs smaller caliber but be careful
in thin elderly skin
Cosmesis
–
●
Will require more tensile strength
Smaller caliber suture/smaller diameter
needle
Risk of Infection
–
Use a monofilament and minimize tension
Alternate Closure Techniques
●
Staples
●
Steristrips –especially with an adhesive ie
mastisol or benzoin
●
Dermabond – strength is equivalent to 5-0
mylon
–
Limited to 4-5 cm incisions
–
Can not get in the wound
–
Not for wounds with high infection risks,
stellate margins, muco-cutaneous borders, or
high tension
Intro to Needles
●
●
●
●
●
Needles are stainless steel alloys
Wound closure and healing are affected by the
initial tissue injury caused by needle penetration
and suture passage
Want smallest diameter needle to pass suture
through the tissue
Stable in the needle driver/holder
Sharp enough to penetrate tissue with minimal
resistance
Anatomy of a Needle
●
●
●
●
Point – From the tip to the max cross-section
of the body
Body – Interacts with driver, transmits
penetrating force to the point
Swage – Allows continuous unit with suture.
May allow “pop-off” effect. Is thickest part of
the needle
Needle Coating -- Silicon
Point Types
●
Taper – Round point which passes by stretch rather than cutting tissue
●
Conventional cutting –Point is triangular. Apex engages tissue first.
●
Reverse cutting -- Triangular point but base engages tissue first.
●
Beveled – Angle of cutting edge is decreased resulting in sharper point
●
Blunt – Rounded point to dissect through friable tissue by pressure
Needle Holders
●
●
●
Stability in the holder affects performance
of the needle
Jaws must be right size to hold needle
securely and prevent
rocking/twisting/turning without affecting
needle curvature
Handle must be right for the depth of the
job to be done
Loading the Holder
●
●
●
●
Important for the function of the needle
and the driver
Grasp needle ½ to ¾ of the way from its tip
Angle needle 30 degrees toward tip of
driver to allow full 360 degrees of needle
tip movement
Tighten driver to first ratchet – more only
if necessary
Improper Needle Placement
●
Can Result In
–
Bent needle
–
Difficult skin penetration
–
Poor angle of tissue entry
–
Unpredictable path of needle thru tissue
–
Increased tissue trauma
–
Tissue loss from cutting needles
–
Suture pull-through
–
Asymmetric wound closure
Instrument Use
●
Ring finger and thumb in the holes
●
Stabilize with the index finger
●
●
●
Pick the right forceps to minimize tissue
trauma and grasp to the needle
Toothed forceps cause less tissue crush ie
Adsons
Un-toothed forceps may grasp the needle
better ie Browns
Skin And Its Tension Lines
●
●
●
The majority of wound closure occurs in or
just below the dermis
You may have to close layers starting at the
fascial level to eliminate dead space and
minimize tension
Don't forget the check skin tension lines in
the area of interest
Facial Lacerations
●
VERY IMPORTANT TO REVIEW TENSION LINES
TO INSURE MOST COSMETIC CLOSURE
Lips
●
Line up the mucocutaneous border as well
as the wet-dry mucosal border
Eyebrows
●
●
Another critical area to line up borders
Be very cautious of using epinephrine in
your local anesthetic in the setting of:
–
Wound flaps
–
Thin skin
–
Fingers and toes
Suturing Techniques
●
Simple Interrupted
●
Simple Running aka Whip stitch
●
Locking Running aka Baseball
●
Vertical Mattress – interrupted only
●
●
Horizontal Mattress – interrupted or
running
Running Subcuticular
Simple Interrupted
Disadvantages
●
Traverses full thickness of dermis
●
Sides symmetric in depth, width, spacing
–
Requires more time to close
●
Easy to place
–
●
Greater tensile strength
Cross-hatching so remove
sutures as early as possible
●
Low wound edema so less impaired microcirculation
●
Easier to adjust wound
●
●
Ideally wider at base than apex to compress tissue upward which promotes edge eversion and limits
risk of depressed scar
Simple Interrupted
●
●
●
●
●
Can adjust asymmetry in
wound by varying distance
of needle insertion and
depth of bite
Large bites decrease
tension
Small bites coapt precisely
Close subcutaneous layers
to obliterate dead space
and decrease tension
Invert knots if close to the
surface
Simple Running Closure
●
Needs to be even in spacing and tension
●
Knots only at either end min scar
●
Can close long wounds quickly after easing tension with deep sutures
●
Less scarring – good for loose skin
●
Can use spaced simple interrupted stitches to off-set tension at the
surface level
Risks of simple running closure
Dehiscence of wound if suture
ruptures
Puckering of thin skin and
hypertrophic scarring
Difficulty in fine adjustments to wound
Locking Running Suture
●
Accomplished by passing needle through suture loop at each pass
●
Increased tensile strength
●
●
Minimizes wound oozing but impairs microcirculation so can cause
wound edge strangulation
Good for the scalp which tends to bleed
Vertical Mattress Closure
●
●
●
Variation on simple
interrupted
1 throw wide and deep/1
throw shallow and
narrow
Change the width based
on the wound tension
●
Maximal wound eversion
●
Decreases dead space
●
Decreases tension across
wound
Vertical Mattress Closure
●
Tends to cross-hatch so remove sutures as early as possible
●
Can decrease cross-hatching with bolsters between suture and skin
●
Other versions include pulley stitch and far-near, near-far in high tension
areas for tissue expansion
Horizontal Mattress Closure
●
For high tension areas to get maximal eversion
●
Can be used to augment other closure ie simple running
●
Likely to leave suture mark scars
●
Can be placed prior to an excision to facilitate skin expansion
●
Risk of strangulation if tied too tight
●
Half-buried version possible
The Corner Stitch
●
A suture directly at the tip can cause ischemia and necrosis
●
The corner stitch passes horizontally in the dermis or subq of the tip
●
Allows advancement of the flap then the legs of the laceration are
closed in any fashion
Running Mattress Closures
●
●
The horizontal mattress closure may be used in a running fashion if
tension is not too high across the wound
This allows for a faster, well everted closure but does limit ability to
adjust the wound
Running Subcuticular Closure
●
Can use nonabsorbable or absorbable suture
●
Removal of nonabs can be uncomfortable
●
Best cosmetic results
●
Wound needs to have minimal tension prior to epidermal closure
●
Most commonly used closure in uncontaminated wounds
Knot Tying
●
–
Instrument Ties
–
Used in cutaneous work
–
2 turns on first pass is a Surgeon’s Knot
–
To square properly must be laid down
perfectly parallel to previous throw or knot
will slip
–
May help to leave small loop after 2nd throw to
avoid strangulation
One-handed Ties/Two-handed Ties
The “Aberdeen Hitch”
Method for tying a running surface stitch
Involves sliding the held free end of the
suture thru a loop twice then pulling it all the
way thru the loop
The knot can then be inverted on an intact
suture
Suture Removal
●
●
●
●
●
Timing depends on anatomic location of
wound closure
Can range from 3 days to 2-3 weeks
Too early – wide scars and wound
dehiscence
Too late – suture scars, infection, tissue
reaction, difficult suture removal
Augmented by use of steri-strips after
suture removal
Suture Removal Technique
●
Elevate the knot and cut on the side that was buried
●
Pull suture out toward the wound to avoid spreading immature scar
●
Try to pull minimal contaminated suture through the skin
●
Consider adhesive and steri-strips especially if removing suture early
to minimize scarring
Special Considerations
●
●
Approaching the wounded
patient
Stop the bleeding with direct
pressure if possible
●
●
●
●
●
Provide pain relief as soon as
appropriate
H & P– rapid survey
–
Allergies to local anesthetics
–
Tetanus recently
–
Detailed exam of injured
area
●
●
Is the patient in the “golden
period” for wound closure?
What is the “golden period”?
Does the pt require general
anesthesia for wound
treatment?
Will extensive irrigation
(pulsevac) or debridement be
required?
Will the area be difficult to
numb?
The Procedure
●
●
Sterile field and aseptic technique are
critical
Irrigate wound with syringe and catheter
to provide some pressure
●
Consider dilute iodine or hibiclens
●
Beware the vasovagal response!!!
●
Line up landmarks first
Local Anesthetics
●
Lidocaine ranges from 0.5%-2% with 500 mg max
●
Bupivicaine (marcaine) max 300mg
●
Mepivicaine (carbocaine) max 300mg
●
Add NaHCO3 to lido to neutralize ph
●
●
●
●
Add epinephrine to increase duration of action, hemostasis, and
decrease systemic absorption
Be careful with adding epi in cardiac pts
Work as much thru the open wound as possible if not overly
contaminated
Work thru anesthetized field – start proximal
Healing by Secondary Intention
●
●
Reasons to leave a wound open
–
Necrosis or infection
–
Slow healing, granulation bed, pre-existing
scar
Other options
–
Skin grafting
–
Normal saline packing
–
Wound-vac therapy
Wound heals slowly by granulation
formation, wound contraction (which can be
significant despite the size of the wound),
and re-epithelialization. Any area that fails
to epithelialize can be grafted.
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