Suture Workshop

Suture Materials
 Criteria
– Tensile strength
– Good knot security
– Workability in handling
– Low tissue reactivity
– Ability to resist bacterial infection
 Suture Materials
 ABSORBABLE:  NON-
lose their tensile strength ABSORBABLE:
within 60 days.
 Absorbable Sutures
PLAIN GUT: CHROMIC GUT:
Derived from the small Treated with chromic
intestine of healthy acid to delay tissue
sheep. absorption time.
Loses 50% of tensile 50% tensile strength by
strength by 5-7 days. 10-14 days.
Used on mucosal Used in episiotomy
surfaces. repairs.
 •Polyglycolic acid (Dexon®)
Braided
Low-memory
50% tensile strength = 25 days
Sites = subcutaneous closure skin
 Polydioxanone (PDS®)
 Monofilament
 50% tensile strength = 30+ days
 Sites = need for prolonged strength,
 Polyglycan 910 (Vicryl®)
 Braided, synthetic polymer
 50% tensile strength for 30 days
 Used: subcutaneous
 Non-absorbable Sutures
 Nylon (Ethilon®): of all the non-
absorbable suture materials, monofilament
nylon is the most commonly used in surface
closures.
 Non-absorbable Sutures
 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.
 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
 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
Surgical Needles
Surgical Instruments
Needle Holders
 Forceps
 Tissue forceps  Dressing forceps
 Iris Scissors
 Iris scissors are predominantly used to assist
in wound debridement and revision.
 Dissection Scissors
Used for heavier tissue revision as necessary
for wound undermining.
Suture Removal Scissors
Scalpels
 Scalpel Blades

#15 blade
 Wound Evaluation
 Time of incident
 Size of wound
 Depth of wound
 Tendon / nerve involvement
 Bleeding at site
 Contraindications
 Redness
 Edema of the wound margins
 Infection
 Fever
 Contraindications

 Puncture wounds
 Animal bites
 Tendon, verve, or vessel involvement
 Wound more than 12 hours old
 Closure Types
 Primary closure (primary intention)

 Secondary closure (secondary intention)

 Tertiary closure (delayed primary closure)

 Wound Preparation
 Most important step for reducing the risk of
wound infection.
 Remove all contaminants and devitalized tissue
before wound closure.
– IRRIGATE
– CUT OUT DEAD, FRAGMENTED TISSUE
 If not, the risk of infection and of a cosmetically
poor scar are greatly increased
Wound Preparation

Personnel Precautions
 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
Basic Laceration Repair

Principles And Techniques

 Principles And Techniques
 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

Suture Techniques
Suture
Procedures
 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
 Suturing
Rule of halves
 Suturing
Rule of halves
 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
 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.
 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.
 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.
 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.
 Suturing
 Cut the ends of the suture 1/4-inch from the
knot.

 The remaining sutures are inserted in the

same manner
 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!!
Simple, Interrupted
 Vertical Mattress

Good for everting wound edges

(neck, forehead creases, concave surfaces)
 Horizontal Mattress

Good for closing wound edges under high tension,

And for hemostasis.
 Suturing - finishing

 After sutures placed, clean the site with

normal saline.
 Apply a small amount of Bacitracin and
cover with a sterile non-adherent dressing.
 Suturing - before you go…
 Need for tetanus globulin and/or vaccine?
– Dirty (playground nail) vs clean (kitchen knife)
– Immunization history
 Tell pt to return in one day for recheck, for
signs of infection or complications.
 Suture Removal
Time frame for removing sutures:
Average time frame is 7-10 days
FACE: 4-5 days
BODY & SCALP: 7 days
SOLES, PALMS, BACK OR OVER JOINTS:
10 days

Any suture with pus or signs of infections should

be removed immediately.
 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
 Suture Removal
Once all sutures have been removed, count
the sutures
The number of sutures needs to match the
number indicated in the patient's health
record