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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


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    1. Suture Workshop Intermediate Skills Chris Vincent Thursday, November 2, 2006

    2. Topics • Instruments • Type • Handling • Suture • Material • When to use • Local Anesthesia • Type • Amount • Wound Closure • Undermine / Deep • Vertical / Horizontal Mattress • Sub / Intra cuticular

    3. Instruments • Scalpel • #10, #11, #15 • Forceps • With teeth • Without teeth (plain)

    4. Scalpel Blades #10: Major Surgery, C-Section, Skin Paring #11: I & D, “stab” wounds for drains, tubes #15: Minor Skin, Plastic Surgery

    5. Forceps Plain: Use on peritoneum, mucosa With Teeth: Use on skin

    6. Instrument Handling

    7. Instrument Handling

    8. Instrument Handling

    9. Instrument Handling

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

    11. Instrument Handling

    12. Instrument Handling

    13. Instrument Handling

    14. Suture • Needles • Material • Sizes • Special Cases

    15. 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

    16. 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)

    17. 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.)

    18. 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

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

    20. Wound Closure • Undermine – reduce wound tension • Deep • Mattress • Horizontal • Vertical • Sub/Intra cuticular

    21. Wound Closure - Undermine

    22. Wound Closure - Undermine

    23. Wound Closure - Undermine

    24. 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!!

    25. Wound Closure – Deep 1

    26. Wound Closure – Deep 2

    27. Wound Closure – Deep 3

    28. Wound Closure – Deep 4 Don't cross the streams!!

    29. Wound Closure – Deep 5

    30. Wound Closure – Deep 6

    31. 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

    32. Wound Closure – Vert Mattress 1

    33. Wound Closure – Vert Mattress 2

    34. Wound Closure – Vert Mattress 3

    35. Wound Closure – Hznt Mattress 1

    36. Wound Closure – Hznt Mattress 2

    37. Wound Closure – Hznt Mattress 3

    38. Wound ClosureVertical vs. Horizontal Mattress

    39. 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

    40. Wound Closure – Subcuticular 1

    41. Wound Closure – Subcuticular 2

    42. Wound Closure – Subcuticular 3

    43. Wound Closure – Subcuticular 4

    44. Wound Closure – Subcuticular 5

    45. Wound Closure – Subcuticular 6

    46. Videos and Practice