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 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 • #10, #11, #15 • Forceps • With teeth • Without teeth (plain)
Scalpel Blades #10: Major Surgery, C-Section, Skin Paring #11: I & D, “stab” wounds for drains, tubes #15: Minor Skin, Plastic Surgery
Forceps Plain: Use on peritoneum, mucosa With Teeth: Use on skin
Instrument Handling • Hold the instrument like you would hold a pen, pencil, or chop-sticks!!
Suture • Needles • Material • Sizes • Special Cases
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
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)
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.)
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
Local Anesthesia Tip: don’t use epi for fingers, toes, penis (& nose?)
Wound Closure • Undermine – reduce wound tension • Deep • Mattress • Horizontal • Vertical • Sub/Intra cuticular
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!!
Wound Closure – Deep 4 Don't cross the streams!!
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
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