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Suturing. Objectives. Principles of wound closure Wound assessment & preparation Local Anaesthetic Wound closure: Choosing the right suture Simple skin closure techniques Suture removal. History 1: 1000 BC.

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  1. Suturing

  2. Objectives • Principles of wound closure • Wound assessment & preparation • Local Anaesthetic • Wound closure: • Choosing the right suture • Simple skin closure techniques • Suture removal

  3. History 1: 1000 BC In the tenth century BC, the ant was held over the wound until it seized the wound edges in its jaws. It was then decapitated and the ant's death grip kept the wound closed.

  4. History 2: Medieval times The thorn, used by African tribes to close tissue, was passed through the skin on either side of the wound. A strip of vegetable fibre was then wound around the edge in a figure eight.

  5. History 3: Early C20th The tough membrane of sheep intestine was provided to the surgeon pre-sterilised and required threading through the eye of the needle before use Separate needles, known as “Mayo needles”, are still in use in some surgical procedures today

  6. History 4: World War II • Post world war saw medical advances • The swaged on needle, where the thread fits into the hollow end of the needle, as only a single length of thread passes through the tissue, trauma is reduced. • Most modern sutures are this type

  7. Why suture? Lowers risk of infection Better Cosmesis Speeds healing Process Reduces pain Protects underlying Tissue Earlier return to function

  8. Methods of skin closure Steristrips Glue Staples

  9. How to describe a wound • Puncture/ Stab wound – is deeper than it is in length, often need exploring in theatre • Incision – is longer than it is deep. Both are sharp trauma • Laceration – tearing from blunt (ie. not sharp) trauma • Graze/ abrasion – disruption of the skin only usually by friction • Bruise/ contusion – involves broken small in the subcutaneous tissues. Cannot become yellow before 18 hours

  10. Principles of wound closure In preparing a wound for closure: • Ensure you enable the apposition of viable tissue: • Avoid skin edge step or “dog ears” • Debride/remove damaged tissue • Low tension: • Allow for post-trauma swelling & LA infiltration • Avoid strangulation • Layers: • Restoration of tissue planes

  11. How old is the wound? (< 6hrs) Are there signs of/potential for infection Do the wound edges appose each other? What was the mechanism of injury? Should you consider secondary closure? Wound assessment Is suturing always appropriate?

  12. 4 Stages in wound closure • Control haemorrhage • Apply pressure or seek expert help? • Assess damage: • Where is it? • Viscera, bone, nerves, major blood vessels, tendons. • Pain? • Local, regional or general anaesthetic? • Consider oral or IV analgesia • Eliminate foreign bodies • X-Rays?

  13. Local Anaesthetics

  14. Local anaesthesia: pharmacology • Effects “C” (pain) fibres (mainly) • L.A.s vary greatly in potency, toxicity, duration of action, stability & solubility in water & ability to penetrate mucous membranes • TOXICITY! Signs & symptoms: • Dizzy or light-headed • Sedation • Numbness of the lips & mouth • Twitching • Convulsions • Cardio-vascular collapse (rapid in accidental IV injection)

  15. Local anaesthesia: administration • Local infiltration: • Most common choice • Regional Block • Ring or Beirs block • No tissue distortion • Wide field of anaesthesia • Requires expertise Remember: LAs are sensitive to pH = less effective in an inflamed environment (e.g. abscess)

  16. Local anaesthesia Most L.A.s cause vasodilation: Adding a vasoconstrictor (adrenaline): • Reduces local blood flow • Slows the rate of absorption & prolongs effect of L.A.s Remember LA + adrenaline: • Must be used in low doses: • If < 50 mls = TOTAL dose of adrenaline must not exceed 500micrograms or conc. of 1:200,000 (5 micrograms/ml) • Must NEVER be used in areas supplied by end arteries i.e. penis or digits as can cause constriction leading to necrosis

  17. Local Anaesthesia Dose determined by weight & nature of procedure

  18. Do not forget analgesia; this is not only humane, but facilitates remainder of management. Analgesia

  19. Wound Closure

  20. Types of material Multifilament (braided) Monofilament • Less infection risk • Smooth tissue passage • Higher tensile strength • Has memory • More throws required • Increased infection risk • Less smooth passage • Less tensile strength • Better handling • Better knot security

  21. Types of needle Spread rather than pierce tissue. Used in myocardium, peritoneum and anastomoses More specialist usage Has third cutting edge on outer edge of needle Minimises scarring and increases strength in eg. tendon repair, cosmetic surgery For vascular and/ or friable tissue eg. liver/kidney/uterus Have at least two cutting edges for difficult to penetrate tissue such as skin


  23. Suture removal

  24. Any questions

  25. Summary • Assess the wound… and also assess the patient • Remember ‘CAPE’ • Ensure adequate analgesia and anaesthesia • It’s a very dextrous procedure: practice!

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