SUTURING SKILLS & TECHNIQES - Boston College€¦ · •Correct needle holder grasp and needle...
Transcript of SUTURING SKILLS & TECHNIQES - Boston College€¦ · •Correct needle holder grasp and needle...
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SUTURING SKILLS &
TECHNIQUES LISA M. ARELLO, MS, ANP, RNFA
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DISCLOSURES
None of the planners or presenters of this session have disclosed any conflict or commercial interest
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Suturing Skills and Technique
• OBJECTIVES: 1. Identify proper suture material as indicated
by wound. 2. Demonstrate proper basic suturing
techniques.
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OVERVIEW
• Phases of Wound Healing
• Factors Affecting Wound Healing
• Principles of Wound Closure
• Instrumentation and Suture
• Suturing Techniques
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Phases of Wound Healing
• Phase 1: Hemostasis and Inflammation • Days 1-5 • Vasoconstriction and platelet aggregation • Angiogenesis occurs in 48 hours • Poor tensile strength • Wound closure and healing dependent on
suture and good approximation
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Phase 2
• Fibroplasia and Proliferation • Days 5 to 14 • Inflammatory response ends • Neutrophils remove cellular debris and
release cytokines • Fibroblasts populate the wound to secrete
collagen and elastin ( wound matrix) • Wound contracture and strength begins
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Phase 3 • Maturation and Remodeling
• Day 14 to one year
• Formation and cross-linking of collagen fibers
• Fibrous connective tissue forms
• Scar formation and increased tensile strength
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Wound Maturation & Strength
• 20% at 2 weeks
• 50% at 5 weeks
• 80% at 10 weeks
• Remodeling and maturation continues for 1 year, minimum in adults, longer in kids • http://www.bumc.bu.edu/suturing-basics, W.
LaMorte, MD
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Why Suture?
• Facilitate healing and repair of tissues
• Close dead space and provide tensile strength
• Goal of wound closure is to achieve healing with normal function, absence of infection, and cosmetic/aesthetic result
• THE SKIN IS YOUR FRIEND
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Major Factors Affecting Healing
• Age
• Weight and obesity
• Nutritional status and dehydration
• Blood and O2 supply
• Edema, vascular disease
• Smoking
• Immune status
• Chronic disease, radiation treatments
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Principles of Wound Closure
• Tissue handling; Do No Harm
• Hemostasis
• Minimize bacterial contamination
• Removal of foreign body and debris
• Irrigation and tissue hydration
• Wound approximation
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Wound Assessment
• Nature and mechanism of injury
• Size of wound
• Location of wound
• Time of injury
• Contamination?
• Nerve, vessel, muscle, tendon involvement (prior to anesthesia)
• Debridement required?
• Health factors
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Needles
• Taper needles
• Smooth needle that gradually tapers to a
point • Less tissue tearing for delicate suturing • Bowel, fascia, blood vessels
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Needles
• Cutting needles • Cutting edge on inside curve • Better tissue penetration • Skin closure
• Reverse cutting needles • Cutting edge on outside of curve • Puncture directed away from wound edge
may decrease tissue tearing
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Other Instrumentation
• Forceps
• Smooth vs toothed
• Avoid crushing skin edges
• Create counter tension on the skin
• Facilitate needle passage
• Needle Driver
• Traditional vs. Gilleys
• “Palm it” for better control in awkward closures or thick skin
• Use fingers to support instrument and increased control
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Suture
Absorbable • Natural and synthetic
• Easily broken down by enzymatic hydrolysis
• Loss of tensile strength in less than 60 days
• Plain/chromic Cat gut, Monocryl, Vicryl, PDS
Non-Absorbable • Natural and synthetic
• Not readily broken down and can be left indefinite
• Maintain tensile strength for minimum of 60 days
• Silk, cotton, prolene, nylon, ethibond
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Suture
Monofilament • Single strand of material
• Less resistance, trauma
• Harbor less bacteria
• Tie down easily, but easily crimp
• Exception: Quill
Multifilament • Multi-strands, twisted or
braided
• Greater strength and flexibility
• Can be coated to reduce drag
• Less knot slippage
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Considerations for Successful Suturing
• Create right angles, enter perpendicular
• Hold instruments properly
• Right suture, right forceps
• Wound edge eversion and approximation, avoid tissue strangulation
• Do not touch or bend the needle
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Considerations for Successful Suturing
• Correct needle holder grasp and needle placement: 2/3 rule
• Running sutures for long incisions save time and create equal tension
• Retention sutures for extra strength
• Good, square knot tying
• Consider suture removal • Children, location of wound, type of suture
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Forcep Placement
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Scissor Placement
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Needle Holder and Needle Placement
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Enter Perpendicular to Skin
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Subcuticular Suture Placement
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Simple Interrupted Suture
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Knot Tied Correct Placement and Tension
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Suturing Techniques
• Simple interrupted
• Running or continuous
• Vertical mattress
• Horizontal mattress
• Subcuticular running or continuous
• Buried suture
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References • Gunson, T. Suturing Techniques. August, 2009.
www.dermnetnz.org/procedures/suturing/html/
• LaMorte, W. Basics of Wound Closure and Healing. November, 2011. www.bumc.bu.edu/generalsurgery/technical-training/suturing-basics.
• Mackay-Wiggan, J. Suturing Techniques. August, 2010. www.emedicine.medscape.com.
• Szulewski, A & McGraw, B. et al. Basic Suturing and Wound Considerations. August, 2011.
• Ethicon Wound Closure Manual, Johnson and Johnson, 1999.