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Suture Workshop Intermediate Skills. Chris Vincent Thursday, November 2, 2006. Topics. Instruments Type Handling Suture Material When to use Local Anesthesia Type Amount Wound Closure Undermine / Deep Vertical / Horizontal Mattress Sub / Intra cuticular. Instruments. Scalpel

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Suture workshop intermediate skills l.jpg

Suture Workshop Intermediate Skills

Chris Vincent

Thursday, November 2, 2006


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Topics

  • Instruments

    • Type

    • Handling

  • Suture

    • Material

    • When to use

  • Local Anesthesia

    • Type

    • Amount

  • Wound Closure

    • Undermine / Deep

    • Vertical / Horizontal Mattress

    • Sub / Intra cuticular


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Instruments

  • Scalpel

    • #10, #11, #15

  • Forceps

    • With teeth

    • Without teeth (plain)


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Scalpel Blades

#10: Major Surgery, C-Section, Skin Paring

#11: I & D, “stab” wounds for drains, tubes

#15: Minor Skin, Plastic Surgery


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Forceps

Plain: Use on peritoneum, mucosa

With Teeth: Use on skin






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Instrument Handling

  • Hold the instrument like you would hold a pen, pencil, or chop-sticks!!





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Suture

  • Needles

  • Material

  • Sizes

  • Special Cases


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Suture Selection – Needles

  • Cutting - for dermal, subcuticular or full skin thickness penetration

  • Tapered - for subcutaneous or organ wall closures

Tip – when in doubt ask for cutting


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Suture Selection - Material

  • Subcuticular

    • Absorbable, braided

    • Vicryl or Dexon

    • Usually 2-0 to 4-0

  • External (skin surface)

    • Usually non-absorbable, monofilament to reduce tissue reactivity and scars or “train track” marks

    • Nylon or Prolene (3-0 to 6-0)


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Suture Selection - Size

  • Subcutaneous – 2-0 to 4-0 depending on need for strength, wound tension (e.g. larger suture over joints)

  • Neck, Scalp, Face (skin or surface): 5-0 or 6-0

  • Trunk, Extremities (skin or surface): 4-0

  • Palm, Sole, Back (skin or surface): 3-0

  • If child, use one grade smaller size (e.g. 5-0 instead of 4-0, etc.)


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Suture Selection – Special Cases

  • Mouth, mucosa (vagina): use chromic or plain gut – will dissolve faster than Vicryl or Dexon

  • Eyelid, mouth edge, under breasts: use silk (if clean wound) as ends are softer and less irritating

  • Children (especially face – surface skin) use plain gut and tell parent to wash with H2O2 daily – no need to remove. Also useful if you think pt will not F/U for SR


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Local Anesthesia

Tip: don’t use epi for fingers, toes, penis (& nose?)


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Wound Closure

  • Undermine – reduce wound tension

  • Deep

  • Mattress

    • Horizontal

    • Vertical

  • Sub/Intra cuticular





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Wound Closure - Undermine

  • Tips

    • Keep ends on same side (“Don’t cross the streams” -Ghostbusters)

    • Cut close to the knot, but don’t cut the knot!!





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Wound Closure – Deep 4

Don't cross

the streams!!




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Wound Closure - Mattress

  • Two types

    • Vertical

    • Horizontal

  • Both used to evert wound edges

  • V. Matt. useful to close deep space and skin w/ single stitch, and in uneven depth wounds

  • H. Matt. faster than simple interrupted as ½ the knot tying, useful in high tension wounds or as stay suture

  • Both may cause tissue strangulation








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Wound ClosureVertical vs. Horizontal Mattress


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Wound Closure - Subcuticular

  • Used in cosmetically sensitive areas e.g. face

  • Running stitch that is easy to place and remove

  • Wound must be shallow or dead space eliminated with deep sutures

  • No tension on wound

  • Wound edges must be even in depth









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