Basic Skin Suturing

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BASIC SKIN SUTURING

ETHICON SUTURES

WORKSHOP NOTES


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BASIC SKIN SUTURING

OBJECTIVES

At the end of this session, participants should anticipate being able to undertakethe following tasks;

Proficient handling of needleholder and appropriate needle passesSimple interrupted suturesInterrupted vertical mattress sutures

Interrupted horizontal mattress suturesCorrect tying of surgeon knot

BASIC TECHNIQUES

Needleholder Use

Grasp the needle with the tip of the needleholder jaws in an area approximatelyone-third to one-half of the distance from the swaged end to the point. Avoidplacing the holder on or near the swaged area, which is the weakest part of the

needle. Do not grasp the needle too tightly as the jaws of the needleholder maydeform, damage or bend it irreversibly. A single click of the needleholder isrecommended.

When selecting a needleholder, it must be the appropriate size for the needleselected. A very small needle should be held with small, fine jaws. The largerand heavier the needle, the wider and heavier the jaws of the needleholdershould be.

Needle Selection

In Emergency Departments, reverse cutting sutures are recommended. Thisassists in preventing tissue tear out, which is more likely when using aconventional cutting needle. Taper needles should be used for deep layerclosure.

Primary Closure

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It is essential to understand the importance of the correct placement of needlethrough tissue to achieve primary closure.

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Incorrect Technique

Potential dead space may be created through shallow needle passes. Inversionof tissue and poor healing also may result (sunken, red, weeping wounds)

Correct Technique

Closure of deeper layers, eliminating dead space, while correct alignment ofdermal and epidermal layers leads to eversion of tissue, enhancing primaryclosure.

In order to achieve this correct technique, it is essential to evert the wound edgewith a toothed forceps before inserting the needle and to invert the needle so theneedlepoint enters the tissue at 90 degrees. Allow the needle to follow its natural

curve, minimising the risk of needle bending or breaking. This will produce thesquare approximation required, as can be seen in the illustration.

There are two methods of passing the needle through tissue

A. Double Pass

Placing of the needle through the tissue, bringing it out into the middle ofthe wound, re-arming the needle, placing it back into the base of thewound and bringing it back equidistant on the other side. This method issuggested for inexperienced suturers and when performing a vertical

mattress suture, as the wounds sutured by this method are typicallydeeper.

B. Single Pass

Placing of the needle directly from one side of tissue to other side,retracting each skin edge with toothed forceps to achieve 90 degree anglerequired. It is utilised by more experienced practitioners and for shallowerlacerations.

Suture Tension

The suture material should be placed in such a way that there is no tension at thewound edges. It is inevitable that during the wound healing process a certainamount of swelling will occur. If sutures are placed too tightly initially, tissuedamage may occur. Approximate, do not strangulate!

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Facial Sutures

Given the rapid wound healing of facial tissue and the importance of cosmesis, itis recommended to use small delicate sutures, placed approximately 2-3mm from

wound edges.

Areas of Stretch/Tension

In areas such as joints and backs, where there is significant tissue tension, it isrecommended sutures are placed 5-6mm from wound edges. This will assist inminimising the risk of suture tear-out and wound dehiscence.

SURGICAL KNOT TYING

Surgeons knot

This knot is predominantly used for monofilaments, such as ETHILON* Sutureand PROLENE* Suture. For detail, refer to the ETHICON* Knot Tying Manual orthe ETHICON* Innovations in Wound Closure CD.

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BASIC SUTURING TECHNIQUES

SIMPLE INTERRUPTED SUTURE

This is the most commonly utilised skin closure suture. One advantage of thistechnique is that alternate sutures are removed to allow inspection andassessment of the wound before the removal of the remaining sutures.

Depending upon the status of wound healing, the remaining sutures can then beremoved. Alternatively, if wound healing is not sufficient, the wound can besupported by steri-strips and the remaining sutures can be left in place untilwound healing is further progressed.

All knots are to be placed at one side of the wound not over the wound line.This avoids the bulk of the knot irritating the wound and leading to delayedwound healing. The tails of the suture material are to be cut to approximately .3-.5cm long. Leaving these too long can allow the ends to enter the wound andcause extreme wound irritation, while cutting too short increases the risk of knotscoming undone.

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Demonstration of technique should now take place.

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2. INTERRUPTED VERTICAL MATTRESS SUTURE

This technique is employed for deeper wounds and over joints. It allows for extrasupport and closure of deeper tissue layers to avoid dead space.

This technique is never to be used in facial repairs as it causes additionalscarring. This technique is often referred to as the far, far, near, neartechnique. This refers to the fact that the first, deep passes are distal (approx.6mm) to the wound edges and deep in the base of the wound. The superficialpasses are proximal (approx. 2mm) to the wound edges and shallow within the

wound. It is critical for the success of this technique that the superficial passesare not too deep or too distal from the wound edges, as this does not createapproximation of the wound edges.

Needle approach must be different for the deep and superficial passes in thistechnique. For the deep pass, the needle enters in an inverted manner, as in thesimple interrupted technique, while for the superficial pass, the needle shouldapproach at an oblique angle of approximately 30 degrees, so that the needle isskied through the tissue. This will assist in avoiding picking up deeper tissuethan the ideal.

It is also critical to ensure that there is not too much tension in the suture line. Ifthe suture tension is too tight, it will restrict the re-vascularisation of the wound. Ifnecessary, remove the suture and replace with a correctly tensioned suture.Oedema will always occur in these deeper wounds and must be taken intoconsideration.


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3. INTERRUPTED HORIZONTAL MATTRESS SUTURE

This is a less frequently used technique. It may be of benefit in long, deeplacerations on legs etc. Anecdotal evidence suggests that it may add linearsupport to wounds.

This technique is never to be used in facial repairs as it causes additionalscarring.


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Basic Skin Suturing

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