Suture Workshop Intermediate Skills

1. Suture Workshop Intermediate Skills Chris Vincent Thursday, November 2, 2006

2. Topics • Instruments • Type • Handling • Suture • Material • When to use • Local Anesthesia • Type • Amount • Wound Closure • Undermine / Deep • Vertical / Horizontal Mattress • Sub / Intra cuticular

3. Instruments • Scalpel • #10, #11, #15 • Forceps • With teeth • Without teeth (plain)

4. Scalpel Blades #10: Major Surgery, C-Section, Skin Paring #11: I & D, “stab” wounds for drains, tubes #15: Minor Skin, Plastic Surgery

5. Forceps Plain: Use on peritoneum, mucosa With Teeth: Use on skin

6. Instrument Handling

7. Instrument Handling

8. Instrument Handling

9. Instrument Handling

10. Instrument Handling • Hold the instrument like you would hold a pen, pencil, or chop-sticks!!

11. Instrument Handling

12. Instrument Handling

13. Instrument Handling

14. Suture • Needles • Material • Sizes • Special Cases

15. Suture Selection – Needles • Cutting - for dermal, subcuticular or full skin thickness penetration • Tapered - for subcutaneous or organ wall closures Tip – when in doubt ask for cutting

16. Suture Selection - Material • Subcuticular • Absorbable, braided • Vicryl or Dexon • Usually 2-0 to 4-0 • External (skin surface) • Usually non-absorbable, monofilament to reduce tissue reactivity and scars or “train track” marks • Nylon or Prolene (3-0 to 6-0)

18. Suture Selection - Size • Subcutaneous – 2-0 to 4-0 depending on need for strength, wound tension (e.g. larger suture over joints) • Neck, Scalp, Face (skin or surface): 5-0 or 6-0 • Trunk, Extremities (skin or surface): 4-0 • Palm, Sole, Back (skin or surface): 3-0 • If child, use one grade smaller size (e.g. 5-0 instead of 4-0, etc.)

19. Suture Selection – Special Cases • Mouth, mucosa (vagina): use chromic or plain gut – will dissolve faster than Vicryl or Dexon • Eyelid, mouth edge, under breasts: use silk (if clean wound) as ends are softer and less irritating • Children (especially face – surface skin) use plain gut and tell parent to wash with H2O2 daily – no need to remove. Also useful if you think pt will not F/U for SR

20. Local Anesthesia Tip: don’t use epi for fingers, toes, penis (& nose?)

21. Wound Closure • Undermine – reduce wound tension • Deep • Mattress • Horizontal • Vertical • Sub/Intra cuticular

22. Wound Closure - Undermine

23. Wound Closure - Undermine

24. Wound Closure - Undermine

25. Wound Closure - Undermine • Tips • Keep ends on same side (“Don’t cross the streams” -Ghostbusters) • Cut close to the knot, but don’t cut the knot!!

26. Wound Closure – Deep 1

27. Wound Closure – Deep 2

28. Wound Closure – Deep 3

29. Wound Closure – Deep 4 Don't cross the streams!!

30. Wound Closure – Deep 5

31. Wound Closure – Deep 6

32. Wound Closure - Mattress • Two types • Vertical • Horizontal • Both used to evert wound edges • V. Matt. useful to close deep space and skin w/ single stitch, and in uneven depth wounds • H. Matt. faster than simple interrupted as ½ the knot tying, useful in high tension wounds or as stay suture • Both may cause tissue strangulation

33. Wound Closure – Vert Mattress 1

34. Wound Closure – Vert Mattress 2

35. Wound Closure – Vert Mattress 3

36. Wound Closure – Hznt Mattress 1

37. Wound Closure – Hznt Mattress 2

38. Wound Closure – Hznt Mattress 3

39. Wound ClosureVertical vs. Horizontal Mattress

40. Wound Closure - Subcuticular • Used in cosmetically sensitive areas e.g. face • Running stitch that is easy to place and remove • Wound must be shallow or dead space eliminated with deep sutures • No tension on wound • Wound edges must be even in depth

41. Wound Closure – Subcuticular 1

42. Wound Closure – Subcuticular 2

43. Wound Closure – Subcuticular 3

44. Wound Closure – Subcuticular 4

45. Wound Closure – Subcuticular 5

46. Wound Closure – Subcuticular 6

47. Videos and Practice