Suture Techniques in Primary Care

1. Suture Techniques in Primary Care • Shawn A. Sutterlin, PA-C • Watauga Orthopaedics

2. Objectives • Review wound types and classification • Understand the principles of wound healing • Describe the 3 types of wound closure • Overview of Suture materials • Wound closure techniques

3. Wound Classification • Four Classes • Clean • Clean-contaminated • Contaminated • Dirty/infected

4. Clean Wounds • Most common is elective surgical incision • Primary closure • 1-5% rate of infection

5. Clean Contaminated • Wounds contaminated by local flora despite aseptic technique • Cholecystectomy, appendectomy and hysterectomy • 3-11% infection rate

6. Contaminated • Open traumatic wounds in nonsterile environment • Open fractures • Surgical procedures in which there is a gross deviation from sterile technique (emergent open cardiac massage) • 10-17% infection rate

7. Dirty or Infected • Gross/heavy contamination or active infection • Perforated viscera, abscess and traumatic wounds • >27% infection rate

8. Wound Healing • Four Stages • Hemostasis • Inflammatory • Proliferative • Remodeling

9. Phase I: Hemostasis • Vasoconstriction stimulated by endothelial injury • Platelet aggregation • Coagulation cascade is activated and fibrin clot formed • Platelets release pro inflammatory mediators and PDGF in preparation for subsequent phases

10. Hemostasis

11. Phase II: Inflammatory • Inflammatory mediators released • Vasodilation - provides increased blood supply to injury site • Increase vascular permeability - allows plasma proteins, WBCs, into injured tissue • Migration of WBCs from circulation into interstitium and phagocytose debris/microbes

12. Inflammation

13. Phase III: Proliferative • Angiogenesis • Granulation • fibroblasts deposit extracellular matrix including collagen/elastin • Characteristic beefy red appearance

14. Phase III: Proliferative • Epithelialization • keratinocytes • Contraction • Fibroblast release of actin

15. Phase IV: Remodeling • Collagen remodeled along tension lines • Cells no longer needed are removed by apoptosis • May take many months

16. Patient factors • Age • Weight • Nutrition • Dehydration • Blood supply • Immunocompromised • Chronic Disease • Radiation therapy

17. Wound Closure • Primary closure • Secondary closure • Tertiary closure

18. Primary Closure • Most common • Preferred method when appropriate • Wounds are re-approximated acutely • Dermis-dermis apposition • Best cosmetic outcome

19. Secondary Closure • Known as healing by secondary intention • Wound edges are left un-approximated • Granulation tissue formed • Migration of keratinocytes provide re-epithelialization over granulation tissue • Appropriate in wounds with soft tissue loss or severe contamination not closable by primary or tertiary means

20. Tertiary Closure • Contaminated wound is I&D’d and left open for several days • Wound is then closed as in primary closure when risk of complications declines • Preferred method for high energy and highly contaminated wounds

21. Suture Materials • Traits needed by suture • Tensile Strength • Knot security • Ease of handling • Low tissue reactivity

22. Characteristics • Size • Tensile Strength • Monofiliment (nylon, prolene, monocryl) • Multifiliment (vicryl, ethibond, Silk) • Absorbable • Non Absorbable

23. Characteristics • Dyed • Undyed • Sizes 11-0 to 6

24. Suture Sizing

25. Absorbable • Broken down in tissues by hydrolysis, enzymes and inflammation • Time to resorb varies by material and diameter • includes vicryl, monocryl, PDS, gut.

26. Non Absorbable • Not broken down by hydrolysis or inflammatory reaction • Walled off in body by fibroblasts or physically removed (skin sutures) • Includes nylon, prolene, stainless steel, silk, polyester (ethibond)

27. Suture

28. Size by Location

29. Needles • Cutting - skin and other tough tissue • Taper - softer tissues inside body (bowel,vessels). Dilates tissues • Blunt - felt to pose less risk of needle sticks. Most useful in fascial closure.

30. Before Closing • Hemostasis • Evaluate • Irrigate • Debride devitalized/contaminated tissues • Should it be closed primarily?

31. Before Closing • Evaluate the wound • Time of injury • Size and shape of wound • Soft tissue loss • Gross contamination/foreign body

32. Before Closing • Wound depth • Nerve, tendon, vascular involvement • Bone involvement (open Fx) • Uncontrolled hemorrhage

33. Wound Preparation • Single most important step in preventing complications • Control bleeding • Remove all debris and devitalized tissue • Irrigate copiously with NS • Do not use iodine or hydrogen peroxide in the wound

34. When to Consult Specialist • Deep wounds to hands/feet, thorax, abdomen, or pelvis • Full thickness lac to eyelids, lips or ears • Lacerations which involve bone, joint, tendon, artery, muscle or nerve • Markedly contaminated wounds • Crush injuries • Concerns about cosmesis • You don’t feel comfortable

35. When to Not Close • Active infection • Erythema/induration • Puncture wounds • Human/animal bites • Delayed onset of treatment • 12 hours for body • 24 hours for face

36. Anesthesia • General/spinal Anesthesia • Used for large wounds and more invasive procedures • Regional Anesthesia • Lidocaine/bupivicaine infiltrated near peripheral nerve to produce anesthesia distally in extremity • Digital, wrist and ankle blocks most common

37. Anesthesia • Local • Anesthetic agent infused directly into the tissues being treated • Most common method in outpatient setting

38. Lidocaine • Most common • 1% should be adequate for most procedures • Sodium channel blocker • Rapid onset • Relatively short duration of action • Available with epinephrine • helps control bleeding • prolong duration of action

39. Bupivicaine • Longer duration of action • Useful in prolonged procedures as well as post procedure pain control • Also available with epinephrine

40. Local Anesthetics

41. Caution!! • Do not use local anesthetic with epinephrine on structures with limited circulation • ears, nose, fingers, toes, penis

42. Equipment

43. General Considerations • Handle tissues as little as possible • Limit the time and force used in retracting tissues • Do not pinch tissues with forceps, Gently lift wound edges to place suture • Irrigate frequently to minimize contaminants and maintain moist wound bed • Approximate, don’t strangulate

44. Needle Position • Needle should be secured 1/2 - 2/3 down the length needle from the tip

45. Always cross skin at 90 degree angle

46. Rule of Halves • Allows better approximation of tissues • Avoids “dog ears”

47. 3 1 2 Rule of Halves

48. The Instrument Tie • How to tie a perfect square knot every time • Place needle driver parallel to and directly over incision • Always wrap needle end over driver toward tail • When tightening each throw, move needle driver to opposite side of incision. • The key is to always wrap OVER needle driver and to always alternate sides

50. Basic Suture Methods • Simple interrupted • Simple running • locked running • Horizontal mattress • Vertical mattress • Running Subcuticular • Subcutaneous (buried knot)