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JoslynJoslyn Albright, MD Albright, MDGeneral Surgery
PGY-4 Research Resident
Basic Wound Closure & Basic Wound Closure &
Knot TyingKnot Tying
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ObjectivesObjectives
Provide basic information on commonlyProvide basic information on commonlyused suture materialsused suture materialsReview general principles of woundReview general principles of woundclosureclosureProvide a general overview of basicProvide a general overview of basic
surgical knot tyingsurgical knot tying
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Suture MaterialSuture Material
Generally categorized by threeGenerally categorized by threecharacteristics:characteristics:
Absorbable vs. non Absorbable vs. non --absorbableabsorbableNatural vs. syntheticNatural vs. syntheticMonofilament vs. multifilamentMonofilament vs. multifilament
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Absorbable Suture Absorbable Suture
Degraded and eventually eliminated in one of Degraded and eventually eliminated in one of two ways:two ways: Via inflammatory reaction utilizing tissue enzymes Via inflammatory reaction utilizing tissue enzymes Via hydrolysis Via hydrolysis
Examples:Examples: CatgutCatgut ChromicChromic
Vicryl VicrylMonocrylMonocrylPDS (PDS ( polydioxanonepolydioxanone suture)suture)
http://ecatalog.ethicon.com/sutures-absorbable
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NonNon --absorbable Sutureabsorbable Suture
Not degraded, permanentNot degraded, permanentExamples:Examples:
ProleneProlene (polypropylene)(polypropylene)
EthibondEthibond (polyester/Dacron)(polyester/Dacron)NylonNylonStainless steelStainless steel
Silk*Silk*
(*not a truly permanent material; known to be broken(*not a truly permanent material; known to be broken
down over a prolonged period of timedown over a prolonged period of time years)years)
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Natural SutureNatural Suture
Biological originBiological originCause intense inflammatory reactionCause intense inflammatory reaction
Examples:Examples: CatgutCatgut purified collagen fibers frompurified collagen fibers fromintestine of healthy sheep or cowsintestine of healthy sheep or cows
ChromicChromic coatedcoated catgutcatgut Silk Silk
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Synthetic SutureSynthetic Suture
Synthetic polymersSynthetic polymersDo not cause intense inflammatory reactionDo not cause intense inflammatory reactionExamples:Examples:
Vicryl VicrylMonocrylMonocrylPDSPDS
ProleneProleneNylonNylon
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Monofilament SutureMonofilament Suture
Grossly appears as single strand of sutureGrossly appears as single strand of suturematerial; all fibers run parallelmaterial; all fibers run parallelMinimal tissue traumaMinimal tissue trauma
Resists harboring microorganismsResists harboring microorganismsTies smoothlyTies smoothlyRequires more knots than multifilament sutureRequires more knots than multifilament suture
Possesses memoryPossesses memoryExamples:Examples:
MonocrylMonocryl , PDS,, PDS, ProleneProlene , Nylon, Nylon
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Multifilament SutureMultifilament Suture
Fibers are twisted orFibers are twisted or braidedbraided togethertogetherGreater resistance in tissueGreater resistance in tissueProvides good handling and ease of tyingProvides good handling and ease of tyingFewer knots requiredFewer knots requiredExamples:Examples:
Vicryl Vicryl (braided)(braided)Chromic (twisted)Chromic (twisted)Silk (braided)Silk (braided)
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Suture DegradationSuture Degradation
Suture MaterialSuture Material Method of Method of DegradationDegradationTime toTime to
DegradationDegradation
CatgutCatgut ProteolyticProteolyticenzymesenzymes DaysDays
Vicryl Vicryl,, MonocrylMonocryl HydrolysisHydrolysis Weeks toWeeks tomonthsmonths
PDSPDS HydrolysisHydrolysis MonthsMonths
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Suture SizeSuture Size
Sized according to diameter withSized according to diameter with 00 as reference sizeas reference sizeNumbers alone indicate progressively larger sutures (Numbers alone indicate progressively larger sutures ( 11 ,, 22 , etc), etc)Numbers followed by aNumbers followed by a 00 indicate progressively smallerindicate progressively smallersutures (sutures ( 22--00 ,, 44--00 , etc), etc)
SmallerSmaller -------------------------------------------------------------------------- LargerLarger
.......... 33--00 ...... 22--00 ...... 11--00 ...... 00 ...... 11 ...... 22 ...... 33 ..........
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NeedlesNeedles
Classified according to shape and typeClassified according to shape and typeof pointof point
Curved or straight (Keith needle)Curved or straight (Keith needle)Taper point, cutting, or reverse cuttingTaper point, cutting, or reverse cutting
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NeedlesNeedles
CurvedCurvedDesigned to be heldDesigned to be heldwith a needle holderwith a needle holder
Used for most suturingUsed for most suturing
StraightStraightOften hand heldOften hand heldUsed to secureUsed to secure
percutaneouslypercutaneously placedplaceddevices (e.g. centraldevices (e.g. centraland arterial lines)and arterial lines)
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NeedlesNeedles
TaperTaper --point needlepoint needleRound bodyRound bodyUsed to suture softUsed to suture soft
tissue, excluding skintissue, excluding skin(e.g. GI tract, muscle,(e.g. GI tract, muscle,fascia, peritoneum)fascia, peritoneum)
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NeedlesNeedles
Cutting needleCutting needleTriangular bodyTriangular bodySharp edge towardSharp edge toward
inner circumferenceinner circumferenceUsed to sutureUsed to suture skinskin orortough tissuetough tissue
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Suture PackagingSuture Packaging
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Wound ClosureWound Closure
Basic suturing techniques:Basic suturing techniques:Simple suturesSimple suturesMattress suturesMattress suturesSubcuticularSubcuticular suturessutures
GoalGoal :: approximate, not strangulateapproximate, not strangulate
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Simple SuturesSimple Sutures
SimpleSimple InterruptedInterruptedSingle stitches,Single stitches,individually knottedindividually knotted(keep all knots on one(keep all knots on oneside of wound)side of wound)Used forUsed foruncomplicateduncomplicated
laceration repair andlaceration repair andwound closurewound closure
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Mattress SuturesMattress Sutures
Horizontal MattressHorizontal MattressProvides added strengthProvides added strengthinin fascialfascial closure;closure; alsoalsoused in calloused skin (e.g.used in calloused skin (e.g.palms and soles)palms and soles)TwoTwo --step stitch:step stitch:
Simple stitch then,Simple stitch then,
Needle reversed and 2ndNeedle reversed and 2ndsimple stitch madesimple stitch madeadjacent to firstadjacent to firstsame size bite as firstsame size bite as first
stitchstitch
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Mattress SuturesMattress Sutures
Vertical Mattress Vertical Mattress Affords precise Affords preciseapproximation of skinapproximation of skinedges withedges with eversioneversionTwoTwo --step stitchstep stitch ::
Simple stitch madeSimple stitch made far, farfar, far relative torelative to
wound edge (large bite)wound edge (large bite)Needle reversed and 2ndNeedle reversed and 2ndsimple stitch made insidesimple stitch made insidefirstfirst near, nearnear, near (small(small
bite)bite)
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SubcuticularSubcuticular SuturesSutures
Usually a runningUsually a runningstitch, but can bestitch, but can beinterruptedinterruptedIntradermalIntradermal horizontalhorizontalbitesbites
Allow suture to Allow suture toremain for a longerremain for a longerperiod of time withoutperiod of time withoutdevelopment of development of crosshatch scarringcrosshatch scarring
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SteriSteri --stripsstrips
Sterile adhesive tapesSterile adhesive tapes Available in different Available in differentwidthswidths
Frequently used withFrequently used withsubcuticularsubcuticular suturessuturesUsed following stapleUsed following stapleor suture removalor suture removalCan be used forCan be used fordelayed closuredelayed closure
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StaplesStaples
Rapid closure of Rapid closure of woundwoundEasy to applyEasy to apply
EvertEvert tissue whentissue whenplaced properlyplaced properly
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TwoTwo --Hand Square KnotHand Square Knot
Easiest and mostEasiest and mostreliablereliableUsed to tie mostUsed to tie most
suture materialssuture materials
(click image to start video)(click image to start video)
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Instrument TieInstrument Tie
Useful when one orUseful when one orboth ends of sutureboth ends of suturematerial are shortmaterial are short
Commonly usedCommonly usedtechnique fortechnique forlaceration repairlaceration repair
(click image to start video)(click image to start video)
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ReferencesReferencesEncyclopedia of Knots provided byEncyclopedia of Knots provided by EthiconEthicon ; available at; available at
www.jnjgateway.com/public/USENG/5256ETHICON_Encyclopedia_of_Knotwww.jnjgateway.com/public/USENG/5256ETHICON_Encyclopedia_of_Knot s.pdf s.pdf (More extensive overview of knot tying with photos for those int (More extensive overview of knot tying with photos for those int erested in surgery) erested in surgery)
BlackbourneBlackbourne , LH, editor. Surgical Recall. 2, LH, editor. Surgical Recall. 2 ndnd ed. Baltimore:ed. Baltimore: LippincottLippincott Williams & Williams & Wilkins; 1998Wilkins; 1998
Cameron, JL, editor. Current Surgical Therapy. 7Cameron, JL, editor. Current Surgical Therapy. 7 thth
ed. St. Louis:ed. St. Louis: MosbyMosby ; 2001; 2001
Edgerton, MT. The Art of Surgical Technique. Baltimore: WilliamEdgerton, MT. The Art of Surgical Technique. Baltimore: William s & Wilkins; 1988s & Wilkins; 1988(Excellent resource for technical details of surgery) (Excellent resource for technical details of surgery)
GomellaGomella , LG,, LG, HaistHaist , SA. Clinician, SA. Clinician s Pocket Reference. 9s Pocket Reference. 9 thth ed. New York: McGrawed. New York: McGraw --HillHillMedical Publishing Division; 2002Medical Publishing Division; 2002 (Useful book for anyone doing clinical rotations!) (Useful book for anyone doing clinical rotations!)
Special thanks to Drs. Thomas and Angelats for theirassistance in the development of this presentation.