Discussion points

• Aseptic vs sterile technique

• Surgical conscience
• Common surgical instruments
• Choice of anesthetic
• Preparing the wound
• Correct knot tying methods
• Wound closure with a variety of suturing techniques
• Common pitfalls
• Practical tips on improving your technique
• Guidelines for choosing the correct suture and needle
 Wound healing and scars
 Goal of wound closure  to obtain a fine line scar that
maintains both the form and appearance of the tissue.
 It is important to let your patient know that any time there is
an an incision there is going to be a scar.
 However with careful technique and close attention to
tissue integrity this scar can be minimized.
 Know when it is a closure that you should not attempt e.g.
lip, eyelid, across a joint, tendon involved, or the web space
of a hand.
 Preparation
• Plan the incision or type of closure
• Gather equipment – irrigation, syringes, anesthetic,
instruments, suture, drapes, dressing
• Time out:
• Check patient name and sign a consent
• Check what procedure is to be done
• Scrub glove and drape
• Prepare the skin – betadine on the outside
• Local anesthetic – lidocaine or bupivacaine
• Debridement or incision
• Undermining where necessary
Start in the center and swab in circles going outward
 Instruments

adison forcep hemostat metzenbaum scissors suture scissors

 Instruments

Needle holders blade handle suture removal scissors bandage scissors

 Sterile instruments
• Have the instruments been sterilized and packed in
sterile packages?
• Has the indicator tape changed color?
• Is the package still sealed and double wrapped?

Sterilize with:
• Autoclave 15- 20 psi 220 to 250 degrees F
• Gas
• Liquid
 Anesthetic
Lidocaine 1% or 2% - inject locally or a regional block
• gives anesthesia and reduces muscle movement

Bupivacaine (Marcaine) 0.25% or 0.5%

• gives anesthesia only

lidocaine and bupivacaine can be mixed half and half

Epinephrine can be added to increase anesthetic time and decrease

bleeding – don’t not use on, nose, toes, fingers, hose (penis)
May be buffered - 9:1 with sodium bicarbonate, to reduce pain on
injection (e.g. remove 2 mL of 1% lidocaine from 20 mL vial, and add
2 mL of sodium bicarbonate solution to vial)
 Anesthetic
Local Lidocaine (Xylocaine)1% or 2%
• Onset: 2 minutes
• Duration: 1.5 to 2 hours
• Action : anesthesia and reduced muscle movement
• Max dose: 4 mg/kg to 280 mg (14 ml 2%, 28 ml 1%)
Lidocaine with Epinephrine 1:100,000 or 1:200,000
• Onset: 2 minutes
• Duration: 1 – 3 hours
• Action : anesthesia and reduced muscle movement
• Max dose: 7 mg/kg to 500 mg (25 ml 2%, 50 ml 1%)
Bupivacaine (Marcaine) 0.25%
• Onset: 5 minutes
• Duration: 2 to 4 hours
• Action : anesthesia only
• Max dose: 2.5 mg/kg up to 175 mg (50 ml 0.25%, 25 ml 0.5%)
 Basic knot tying

1 2 3 4
1 – square knot
2 – granny knot
3 - slip knot
4 – surgeon’s knot
Instrument
tying
Surgical Wound Closure Guidelines
• Adequate debridement and hemostasis
• Atraumatic technique
• Alignment with the relaxed skin tension lines
• Angle of incision
• Perpendicular to skin surface or slightly undermined
• Angle incisions parallel to hair shafts
• Consider area of the body for vascularity and
tension on the wound
 Key Techniques

• Close dead space under the incision

• Close the tissue in layers
• Carefully align the wound edges
• Careful choice of the axis of incision or axis of closure
of the donor skin flaps
• Correct choice of deep and cutaneous sutures
 Bleeding
• Control with pressure directly over the wound
immediately
• Locate the nearest artery and put pressure there to give
yourself room to work
• If necessary, tie off the bleeding vessel
• Use a pressure bandage
 Simple Interrupted Sutures
• This suture is used for simple laceration closures or
closure of office procedures like biopsies or lesion
removals
• It is also the basic suture used inside the wound to
close deep sutures
• It is useful in that a few sutures can be removed at a
time instead of all at once to allow for slower sound
healing
Simple Interrupted Sutures
 Continuous Sutures
• The continuous suture as its name suggests, only has a
knot at the beginning and the end
• There are several methods of continuous suture –
locking and non-locking
• The knots must be very secure and minimal tesion on
the wound or the wound will come apart if one loop or
knot gives way
• The advantage is that it is very quick and the wound
tension is even across the wound
 Horizontal Mattress Suture
• Used with wounds with poor circulation
• Helps eliminate tension on wound edges
• Requires fewer sutures to close a wound
• Can be placed quite quickly
• Can be done as a continuous suture
Horizontal Mattress Suture
 Vertical Mattress Sutures
• Deep and shallow approximation of the tissue
• Can be used for wounds under tension
• Can be useful with lax tissue e.g. elbow and knee
• Should not be used on volar surface of hands or feet or
on the face because of blind placement of the deep
part of the suture
 Sub-Cuticular Closure
• Used for cosmetic closures
• Use an absorbable suture if you plan to leave the
sutures in and bury the knots
• Use either nylon or prolene (best) and keep the suture
sliding while you are closing. The suture then can be
easily removed with no exterior marks. The ends can
be taped or a knot on the skin
• At each entry point, enter across form the last exit with
slight overlap
Sub-Cuticular Closure
 Elliptical Incision
The ellipse should be three times as long as it is wide. This
will make closure of the wound much easier. If the lesion
you are removing is likely to be cancerous, make sure that
you leave wide margins of clear skin around the lesion.
Modified Ellipse
 3 Cornered Suture
• Used to close a skin flap which comes to a point
• Helps close the wound, but maintain circulation to the
tissue
• Places minimal tension on the wound edges
 Suture Materials
Suture material filament Absorbing Tissue Tensile Tensile cost Uses
properties reaction strength strength
retention
plain gut collegen absorbable moderate poor 2-4 days low Inside the wound where it
absorbs and wound healing is
quick
chromic gut collegen absorbable moderate poor 7-10 days low Inside the wound where it
absorbs and wound healing
time is average length

polygalactic braided absorbable mild poor 2-3 weeks moderate Inside the wound where it
acid (Vicryl) absorbs and longer wound
healing time is required,
such as tendons.
silk braided Non- high poor 1year low Skin closure or fascia
absorbable

nylon monofiliment Non- Very low good Loses low Skin closure or fascia or
absorbable 20%/yr where long term strength is
needed

Polypropylene monofiliment Non- minimal excellent indefinite high Sub-cuticular skin closure or
(Prolene) absorbable fascia or where permanent
strength is needed.
Polyester braided Non- minimal good indefinite high Internally where low reaction
(Mersilene) absorbable braided suture is required to
allow tissue to adhere to it.
stainless steel monofiliment Non- low excellent indefinite moderate Bone , tendons, strong
absorbable connective tissue where
permanent strength is required
 Care of the patient
How will you care for your patient and maintain a safe
environment?
Title
Title
Title
Skin Tear Repair
Foreign Body
Discharge Instructions
 Antibiotic Therapy and for how long
 Wound Care
 Return Visits
 Suture Removal
 Post Suture Removal Care