Wounds

11/03/2024 1
 Wounds

• Discontunity or break in the surface

epithelium.
• Caused by a transfer of any form of energy into
the body which can be either to an externally
visible structure like the skin or deeper
structures like muscles, tendons or internal
organs.
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 Wound Healing

• Mechanism whereby the body attempts to restore

the integrity of the injured part.
• In healthy individuals with clean wound, it starts
immediately and follows the following stages.
 Hemostasis and inflammation.
 Proliferation.
 Maturation and remodeling.
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 Hemostasis and
Inflammation
 Characterized by vaso-constriction, clot formation
and release of platelets and other substances
 Infiltration by inflammatory cells such as
polymorphonuclear lymphocytes (PMN) and
macrophages.
 Increase vascular permeability
 Begins immediately and ends in 2-3 days.
 Classic inflammatory response seen.
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 Proliferative phase

• Starts on 3rd day and lasts till 2nd-3rd

week
• fibroblast activity with the
production of collagen and ground
substance.
• Angioneogenesis - the growth of new
blood vessels
• Re-epithelialisation of the wound
surface 11/03/2024 5

• Granulation tissue – seen in the early

 Maturation/Remodeling
phase
• Realignment of collagen fibres along
the lines of tension,
• Decreased wound vascularity and
wound contraction
• Increase in tissue strength of the
wound
• May take 6 – 12 months.

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 Types of Healing
• Healing by intention - clean wound closed
primarily to approximate the ends. Healing takes
place by epithelialization and leaves minimal
scar.
• Healing by intention – in contaminated wounds,
which are not primarily closed. Healing takes place
by granulation tissue formation, tissue contraction
and epithelialization.
• Healing by intention - left open initially for various
reasons and closed later (delayed primary
closure)
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Factors affecting healing

• Advanced age – healing delayed because of

decreased supply of cutaneous nerves and blood
vessels , Loss of collagen and ability to produce
more collagen
• Nutrition – deficiencies in vitamin C, zinc,
protein…delay healing
• Ischemia/anemia – decreased nutrient and
oxygen delivery
• Metabolic diseases – like in DM healing
impaired and rate of infection increased
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 Ctd…

• Steroids – reduce collagen synthesis

• Immunosuppression – healing
impaired in diseases like HIV/AIDS
• Infections - Bacteria produce
inflammatory mediators that inhibit the
inflammatory phase of wound healing
and prevent epithelialization

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Abnormal wound healing

• Keloids - proliferative
scars characterized by
excessive collagen deposition.
• grow beyond the borders of
the original wounds
• Rarely regress with time
• Hypertrophic scars -
raised scars within the
confines of the original wound
• frequently regress
spontaneously. 11/03/2024 12
Hypertrophic
scars

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• Rx – intralesional CS, surgery, radiation,
pressure, topical retinoids….
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 Contracture

• Exaggerated
contraction in
the size of a
wound
• Scars cross
joints and
restrict range
of mov’t at
joints. 11/03/2024 15
 Assessment of wound

• Wound might be associated with severe

life threatening injuries
• Approach to a patient begins with
assessment of the ABCs
• The wound is addressed after more
urgent problems are ruled out

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 1. History

• Mechanism, extent, site… of injury

• helps to determine the presence of a foreign body,
associated injuries and the prognosis for
development of infection or scarring.
• Time of injury
• Delayed presentation is associated with poor
outcomes like delayed healing, infection & poor
cosmetic outcome
• Patient's past and current medical and
vaccination/immunization history that may influence wound
healing 11/03/2024 17
 2. Examination of wound

• Site, extent, depth & configuration of wound

• Presence of non-viable or devitalized tissue
• Degree of contamination
• Presence of foreign body & other contaminants
• Neurovascular & tendon injury
• Injury to underlying structures, such as bone fracture
 Wounds that involve joints, nerves, flexor tendons, or
other underlying structures (eg, fascia, major blood
vessels) may require operative exploration
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Granulation Epithelial
tissue tissue

Undermining
Tunneli
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ng
Exudate

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11/03/2024 21
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 Classifications

• Simple wound when only skin is involved.

• Complex wound when it involves underlying
nerve ,vessels and tendon.
• Classification
A.TIDY / UNTIDY
B.ACUTE/CHRONIC
C.CLOSED/OPEN
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 Tidy wound

By sharp instrument E.g.: surgical

incisions, cut from glass or knives
• Skin would be sharp and clean
• Contain no devitalized tissue
• Can be closed immediately
• Tendons,arteries and nerves can
be involved but repair is usually
possible. 11/03/2024 24
 Untidy wound
Result from crushing,
tearing, avulsion or burn
Skin wounds would be
multiple and irregular
Fractures are common
Contain devitalized
tissue
Healing is unlikely to
occur and if it does there 11/03/2024 25

will be wound
complications
Acute and chronic wound
• Acute wounds - Heal in a predictable
manner and time frame
E.g stab injuries
• Chronic-wounds - failed to proceed
through the orderly process that
produces satisfactory anatomic and
functional integrity.
E.g, Pressure ulcer, leg ulcer
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Pressure ulcer
• These can be defined as tissue necrosis with ulceration
due to prolonged pressure.
• Pressure sore frequency in descending order
■ Ischium
■ Greater trochanter
■ Sacrum
■ Heel
■ Malleolus (lateral then medial)
■ Occiput
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Staging of pressure
sores.
1. Non-blanchable
erythema without a
breach in the
epidermis
2. Partial-thickness skin
loss involving the
epidermis and dermis
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3. Full-thickness skin loss
extending into the
subcutaneous tissue but not
through underlying fascia
4. Full-thickness skin loss
through fascia with
extensive tissue destruction,
maybe involving muscle,
bone, tendon or joint
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• the bed-bound patient should be turned
at least every 2 hours.
• the wheelchair-bound patient being
taught to lift themselves off their seat
for 10 seconds every 10 minutes.

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 CLOSED/ OPEN
• CLOSED
• Contusion
• Hematoma
• Abrasion
• OPEN
• Incised
• Lacerated
• Penetrated
• Crushed etc...
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 Contusion and
hematoma
• Contusion - caused by
internal bleeding into
the interstitial tissues
at different levels, usually
initiated by blunt trauma
which causes damage
through physical
compression
• Haematoma - when the
amount of blood is
sufficient to create a
localized collection. 11/03/2024 32
 Abrasion

• made by a scraping
injury to the skin surface,
typically in an irregular
fashion
• Usually the epidermis is
scrapped away exposing
the dermis
• Most are superficial and
will heal by 11/03/2024 33
epithelialisation
 Incised wound

• An incision is defined as a
very regular cut made by
a sharp object such as a
knife, glass or blade.
• Has sharp edge and is
less contaminated.
• Primary suturing is ideal
for these wounds as it
gives a neat and clean
scar.
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 Laceration

• Lacerations - surface is cut in an

irregular fashion down to the
underlying tissue.
• deeper than abrasions and more
irregular than incised wounds.

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 Penetrating wound

• A wound in w/c the skin is

broken and the agent causing the
wound entering subcutaneous
tissue or deeply lying structure or
cavity. Eg. Stab injuries,
bullet injuries
• Internal organs may be
involvoved. So all patients
should be admitted.
11/03/2024 36
 Crushing wound
• Caused by a blunt injury
due to vehicle,
earthquake, wall collapse
and indurstrial accidents.
• may cause severe
hemorrhage, death of
tissue and crushing of
blood vessels.
• They are associated with
degloving and
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 Clean wounds (class I) -
include those in which no
Surgical infection is present
wound • only skin microflora
classification potentially contaminate the
wound,
• No hollow viscus that
contains microbes is
entered.
• Class I D wounds are
similar except that a
prosthetic device (e.g.,
mesh or valve) is inserted.
• Eg. Hernia repair,
thyroidectomy
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Clean/contaminated
wounds (class II) –
• include those in
which a hollow viscus
with indigenous
bacterial flora is
opened under
controlled
circumstances
without significant
spillage of contents
• Eg. Appendictomy,
Cholecystectomy,
elective GI surgery
11/03/2024 39
Contaminated wounds
(class III) –
• open accidental wounds
encountered early after
injury,
• Extensive introduction of
bacteria into a normally
sterile area of the body
due to major breaks in
sterile technique
• gross spillage of viscus
contents such as from the
intestine.
• incision through inflamed,
but nonpurulent tissue.
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• Dirty wounds (class IV)
–
• traumatic wounds in
which a significant delay
in treatment has occurred
and in which necrotic
tissue is present,
• created in the presence of
overt infection as
evidenced by the presence
of purulent material,
• Those created to access a
perforated viscus
accompanied by a high
degree of contamination.
11/03/2024 41
 Wound Management
• The goal is to establish a good environment to assist wound
healing and prevent infection.
• Adequate hemostasis locally to stop bleeding.
• Adequate irrigation to reduce bacterial load and foreign
particles.
• Careful debridement to remove all dead tissues and non-
vascularized fragments.
• Careful decision on whether to close or leave the wound
open for later closure.
• Supplementing with antibiotics and tetanus prophylaxis
as required.
• Improving host response by correcting systemic diseases
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 Irrigation & Debridement

Irrigation –

• most important means of

decreasing the incidence of
wound infection because soil
or small foreign bodies that
remain in a wound reduce
the inoculum of bacteria
required to cause infection
• Isotonic (normal) saline is
the recommended irrigation
solution
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• High pressure irrigation with normal
saline
• The irrigation fluid dislodges foreign
bodies, contaminants and bacteria.

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 Debridement

[Remove]+[whatever not supposed to be

there]

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11/03/2024 46
• Necrotic tissue impedes wound healing,
result in spread of bacterial damage to
deeper tissue, causing cellulites,
osteomyelitis, septicemia, limb
amputation or death.

11/03/2024 47
 Methods of debridement

• Mechanical
• Autolytic
• Enzymatic
• Sharp/surgical
• biologic

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Mechanical debridement
The use of some outside source to remove
dead tissue.
• Wet to dry dressing
• Hydrotherapy (whirlpool)

• Wound irrigation(pulsed lavage)

11/03/2024 49
Sharp/surgical debridement
• Its considered as gold standard
• Is used for adherent eschar and
devitalized or dead slough on the wound
surface.
• Create sharp wound edges
• Respect skin lines.
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Enzymatic debridement
• Considered safe, effective and easy to perform.
• Enzymes are effective wound surface cleaning
agents that accelerate eschar degradation and
debridement.
• Accomplished by applying topical enzymatic agents
to devitalized tissue.
• Enzymes that act on necrotic tissue are categorized
as proteolytic, fibrinolytics and collagenases
depending on the tissue component they target.
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Autolytic debridement
• It uses the body's endogenous enzymes to
slowly remove necrotic tissue from the wound
bed.
• May take longer than other methods.
• May be accomplished by the use of any moisture
retentive dressings hydrocolloids, hydrogels,
hypertonic dressings/gels, or transparent films.
• Its contraindicated in infected wounds.
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• Hydrocolloid dressings: These dressings
absorb wound exudate and form a gel-like
substance that helps retain moisture and
facilitate the breakdown of necrotic tissue.
• Hydrogel dressings: Hydrogels provide extra
moisture to dry wounds, aiding in the softening
and breakdown of dead tissue.
• Transparent film dressings: These create a
moist environment while allowing oxygen
exchange and keeping contaminants out.
11/03/2024 54
Maggot therapy (biological or larval therapy)
• Application of sterilized medicinal maggots
are placed in the wound bed or directly in to
the wound so they can roam around .
• Maggots are left in the wound for 2-3 days.
• Contraindications life or limb threatening
wound, psychological distress ,bleeding
abnormalities. Deep tracking wounds,
osteomyelitis or critical ischemia.
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 Procedure
 Wear cap, mask , gown and gloves
 Apply disinfectant such as povidone iodine on and
around the area.
 Drape the area properly
 Start debriding from The Base of the wound
 Consider every debridement as last debridement
 Debride tissues until red bleeding margins are seen.
 Irrigate the area with normal saline and bactericidal
agent.
 Dry the area with clean sponge and do dressing
11/03/2024 56
 Wound closure
• Primary closure - wounds presenting within 6-8
hours and can accurately be debrided
• Best choice in well vascularized tissues.
• Clean surgical wounds should be closed primarily
• Clean-contaminated wounds can be primarily closed if
they can be converted, into clean wounds
• Untidy, contaminated wounds which cannot be
converted to tidy wounds should not be closed
primarily
• All missile wounds, animal and human bites should
never be primarily closed unless strongly indicated
11/03/2024 57
• Secondary intention — Indications for
secondary closure (ie, by granulation) include
• Deep stab or puncture wounds that cannot
be adequately irrigated
• Contaminated wounds
• Small noncosmetic animal bites
• Abscess cavities
• Presentation after a significant delay
11/03/2024 58
Delayed primary closure —
• involves initial cleaning and debridement
of the wound followed by at least a 3-5 day
waiting period which allows the host defense
system to decrease bacterial load.
• for uncomplicated wounds that present after
the safe period for primary closure.
• Infected Wounds with high bacterial content.

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11/03/2024 61
• Antibiotics - Should be used only when there is an
obvious wound infection.
• Signs of infection to look for include erythema,
cellulitis, swelling, and purulent discharge.
• Tetanus prophylaxis - should be provided to
everyone depending on immunization status.
• Dressing - Covering a wound mimics the barrier role
of epithelium and prevents further damage. provides
hemostasis and limits edema.
• helps healing by controlling the level of hydration and
oxygen
11/03/2024 62
Suture materials

DBU 11/03/2024
 Suture materials
• Suture is a thread like material used to close surgical wounds and
unite two edges of cut tissue.

• The verb to suture denotes the act of sewing by bringing tissues

together and holding them until healing has taken place.

• If the material is tied around a blood vessel to occlude the lumen,

it is called a ligature or tie.

• A free tie is a single strand of material handed to the surgeon or

assistant to ligate a vessel.
DBU 11/03/2024
There are various characteristics of suture material
that are described with the following terms:
• Tensile strength - Measure of the ability of a
material or tissue to resist deformation and
breakage
• Plasticity - Measure of the ability to deform
without breaking and to maintain a new form
after relief of the deforming force
DBU 11/03/2024
• Pliability - Ease of handling of suture material;
ability to adjust knot tension and to secure knots.
• Capillarity - Extent to which absorbed fluid is
transferred along the suture.
• Suture size refers to the diameter of the suture
strand and is denoted by means of zeroes. The
smaller the suture, the less the tensile strength of
the strand.
11/03/2024 66
• Knot strength - Amount of force necessary to cause a
knot to slip
• Absorbable - Progressive loss of mass or volume of
suture material.
• Nonabsorbable - Surgical suture material that is
relatively unaffected by the biologic activities of the
body tissues and is therefore permanent unless removed.

DBU 11/03/2024
 Types of Suture Materials

• Broadly, sutures can be classified into absorbable or

non-absorbable materials.

• They can be further sub-classified into synthetic or

natural sutures, and monofilament or multifilament
sutures.

• Natural-made of natural fibers (e.g. silk or catgut)

• Synthetic-comprised of man-made materials (PDS or

nylon) DBU 11/03/2024
• Monofilament suture-a single
stranded filament suture(e.g
nylon, PDS*, or prolene)

• Multifilament suture – made

of several filaments that are
twisted together (e.g braided
silk or vicryl).

11/03/2024 69
Monofilament suture –
 This structure is relatively
more resistant to
harboring microorganisms
 It also exhibits less
resistance to passage
through tissue than
multifilament suture does.

DBU 11/03/2024
Multifilament suture-
 has greater tensile strength
and better pliability and
flexibility than
monofilament suture
material,
 it handles and ties well.
 Increased risk for
harboring microorganisms
11/03/2024 71
 Absorbable

• Absorbable sutures are broken down by the body via enzymatic reactions
or hydrolysis.

• Absorbable sutures provide temporary wound support until the wound

heals well enough to withstand normal stress

• The time in which this absorption takes place varies between material,
location of suture, and patient factors.

• are commonly used for deep tissues and tissues that heal rapidly;
• E.g. Catgut, Vicryl, PDS
DBU 11/03/2024
A. Surgical Catgut:

• Collagen manufactured from the submucosa of

sheep intestine or serosa of beef intestine.

• Used in tissue that heals rapidly.

• Digested by body enzymes and absorbed by
tissue so that no permanent foreign body remains.

DBU 11/03/2024
Plain Surgical Catgut

• Lose tensile strength quickly, usually in 5 to 10 days

• Twisted multifilament with a monofilament appearance

• Absorption By phagocytosis. Complete mass absorption

in approximately 63 days. When used in in tissues with

increased levels of proteolytic enzymes(stomach,

cervix, vagina) it is more quickly absorbed.

DBU 11/03/2024
• Available in sizes 6-0 to 3
• Tissue reaction Moderate
• Used to ligate small vessels and to
suture subcutaneous fat.
• May be used for epidermal suturing
where sutures are needed for no more
than a week.
• These sutures are used only externally
on skin, notDBU
internally, particularly for
11/03/2024

facial cosmetic surgery

Contra indicated
• In the region of
infected wounds
• Known
sensitivities or
allergies to
collagen

11/03/2024 76
Chromic Surgical Catgut

• Is treated in a chromium salt

solution to resist absorption by
tissues.

• This treatment changes the

color from the yellow-tan shade
of plain surgical catgut to a
dark shade of brown.
DBU 11/03/2024
• Available in sizes 7-0 to 3
• May be dyed blue or black
• Absorption By phagocytosis. The rate of absorption is slowed
down by chromizing. Complete mass absorption in
approximately 90 days.

• Approximately 50% of tensile strength remain after 14 days.

11/03/2024 78
 B. Synthetic Absorbable Sutures

• Are absorbed by a slow hydrolysis process in the presence of

tissue fluids.

• They are used for ligating and suturing.

• They are extremely inert and have great tensile strength.
• Can be used in nearly all tissues.
• As a disadvantage, it tends to drag through the tissue rather than
passing smoothly.
DBU 11/03/2024
Polyglycolic acid (Dexon) suture

• Braided and coated multifilament

• Tissue reaction-Minimal
• Absorption -The hydrolytic action by which the material is
broken down results in total absorption in approximately 60 to 90
days. Approximately50% of tensile strength remain after 21 days.

• General soft tissue closing and/or ligation.

DBU 11/03/2024
Polyglactin 910 (Vicryl) suture

• Braided and coated multifilament.

• Tissue reaction- Minimal

• Composition -Polyglactine 910, a copolymer made of

90%glycolide and 10% L-lactide

DBU 11/03/2024
• Absorption The hydrolytic action by which the
material is broken down results in total absorption
between 56 and 70 days. Approximately 50% of
tensile strength remain after 21 days.

• General soft tissue closing and/or ligation.

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Polydioxanone (PDS) Suture

• Monofilament
• Tissue reaction-Minimal
• Absorption -The hydrolytic action by
which the material is broken down results
in total absorption in approximately 180
to 210 days. Approximately 50% of
tensile strength remain after 42 days.
DBU 11/03/2024
Poliglecaprone (Monocryl) suture

• Monofilament.
• Available in sizes 6-0 to 1.
• minimal tissue reaction.
• Absorption-By hydrolysis.
Absorption is essentially complete
between 90 and 120 days.
DBU 11/03/2024
 Non absorbable Suture

• This is a type of suture material that remains

unabsorbed by the tissue.
• Either left in the body, where it becomes embedded in
scar tissue, or it is removed when healing is complete.
• Are used to provide long-term tissue support.
• Uses include for tissues that heal slowly, such as
fascia or tendons, closure of abdominal wall, or
vascular anastomoses.
• E.g. Silk ,Nylon
DBU 11/03/2024
A. Surgical Silk
• An animal product made from the fiber spun by
silkworm larvae in making their cocoons.
• Widely used non-absorbable suture that is easy to
handle and is both supple and strong.
• Can be used in a wide variety of tissues, ranging
from ophthalmic to cardiovascular.

DBU 11/03/2024
• Has a multifilament structure and is treated with
Teflon or a similar coating to prevent tissue drag
and flaking.

11/03/2024 87
B. Surgical Cotton
 Manufactured from the fibers of the cotton plant.
 Supple and easy to handle.
 Has inferior strength and tendency to flake.
 Can be strengthening by dipping it into saline solution prior
to use.
 Its application is nearly identical to that of silk.
 Its used to umbilical cords or retract tissue structures during a
surgical procedure.
DBU 11/03/2024
C. Polyester Suture

• The strongest of all sutures except for surgical steel

• It is usually multifilament and may be coated with
Teflon

• Used in a wide variety of tissues, including facial,

cardiovascular,DBU
and ophthalmic. 11/03/2024
D. Nylon Suture
• Used primarily for skin closure, ophthalmic
procedures, and microsurgery.
• Produces minimal tissue reaction
• The major disadvantages of nylon are its elasticity
and stiffness, which necessitate the laying of many
knots.

DBU 11/03/2024
E. Polypropylene (Prolene) Suture

• Extruded into a monofilament strand

• The most inert of the synthetic materials and
almost as inert as stainless steel

• Easier to handle
DBU 11/03/2024
• Can be used in the
presence of infections

• Use in cardiovascular
surgery (heart prosthesis
or vascular anastomosis)
• Frequently used for
retention sutures
11/03/2024 92
F. Surgical Steel

• Monofilament
• Made of stainless steel and is the most inert type of
suture available.

• Used mainly in the orthopedic surgery to approximate

bone fragments. DBU 11/03/2024
 Suture Sizing

• USP-determined sizes range from heavy 10 (largest) to

very fine 12-0 (smallest); ranges vary with materials.

• Taking size 1 as a starting point, sizes increase with each

number above 1 and decrease with each 0 (zero) added.

• The more zeroes in the number, the smaller the size of

the strand.
DBU 11/03/2024
 Surgical Needles

• Surgical needles are needed to safely

carry suture material through tissue
with the least amount of trauma.

• Surgical needles may be straight like a

sewing needle or curved.

• The point, the body (or shaft), and the

eye.
DBU 11/03/2024
Point of the Needle
• The point portion of the needle extends from the tip to
the maximum cross-section of the body.
Body of the Needle
• The body, or shaft, varies in length shape, and gauge.
Eye of the Needle
• The eye is the segment of the needle where the suture
strand is attached.
DBU 11/03/2024
Point of the Needle
• Points of surgical needles are honed to the configuration
and sharpness desired for specific types of tissue.
Cutting Point.
 A cutting needle has at least two opposing cutting edges
(the point is usually triangular).
 A razor-sharp, honed cutting point may be preferred
when tissue is difficult to penetrate, such as skin, tendon,
and tough tissues in the eye.
DBU 11/03/2024
• Conventional cutting needles have three
cutting edges (a triangular cross-section that
changes to a flattened body).
• The third cutting edge is on the Inner,
concave curvature

DBU 11/03/2024
In reverse-cutting needles, the third cutting
edge is on the outer convex curvature of the
needle.
• These needles are stronger than
conventional cutting needles and have a
reduced risk of cutting out tissue

DBU 11/03/2024
Side-cutting (spatula) needles are flat on the top and
bottom surfaces to reduce tissue injury.

DBU 11/03/2024
Taper Point
Needles penetrate and pass through tissues by
stretching without cutting.
A sharp tip at the point flattens to an oval or
rectangular shape.
These needles are used in soft tissues, such as
intestine and peritoneum, which offer a small amount
of resistance to the needle as it passes through.
DBU 11/03/2024
• Blunt Point. These tapered needles are designed
with a rounded blunt point at the tip. They are used
primarily for suturing friable tissue, such as liver
and kidney.

DBU 11/03/2024
DBU 11/03/2024
 Placement of the Needle in the
Needle holder
Principles in handling needles and needle holders:

• Select a needle holder with appropriate-size jaws for the size

of the needle to be used

• Select an appropriate-length needle holder for the area of

tissue to be sutured

• Clamp the body of the needle in an area two third from the
point of the needle.
DBU 11/03/2024
• Never clamp the needle holder over the swaged area since
this area is the weakest area of an eyeless needle.

• Place the needle securely in the tip of the needle holder jaws
and close the needle holder in the first or second ratchet.

• Pass the needle holder with the needle point up and directed
toward the surgeon’s thumb when grasped.

DBU 11/03/2024
• Hand the needle holder to the surgeon so that the
suture strand is free and not entangled with the
needle holder.
• Hold the free end of the suture in one hand while
passing the needle holder with the other hand
• Protect the end of the suture material from
dragging across the sterile field

DBU 11/03/2024
11/03/2024 10
7
 Characteristic of ideal suture
material
Must be sterile.  should excite minimum
tissue reactions.
Non-allergic.
 Not creating a situation
High tensile strength favored to bacterial
( breaking strength is growth.
high in small caliber).  Cheap, and can be used
Should be comfortably in any operation.
handled, easy to knot  Available in different
and hold securely. sizes.
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 Selection Of Suture Materials
• Different surgical stitches are used in various types of tissues
for different purposes.
• Important factors considered when selecting suture material
for surgery include:
 Type and site of the operation
 Healing characteristics of the tissue involved
 Properties of the suture and needle
 Security of knots
 Behavior of the material in presence of infection
 Suture size (The commonest surgical suture size is
between 4/0 and 2)
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 Suturing Techniques

The basic principles of suturing technique include:

 Inserting the needle at right angle and gently advance through the
tissue.

 Avoiding tension.
 Size and interval between bites are dependent on the tissue thickness
and type of tissue to be sutured.

 As a general rule, braided sutures should have three throws on the

knots, monofilament sutures should have five throws.
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 Forms Of Suturing Techniques

• Important types of suturing techniques commonly used

include:

• Simple interrupted
• Continuous simple
• Vertical and horizontal mattress
• Subcuticular stitches
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 Simple interrupted

• Insert the needle carefully at right angles to the tissue edges.

Advance through, gently avoiding shearing force.

• For long wounds being closed with interrupted sutures, it is

advisable to start in the middle and to keep on halving the
wound.

• Cut suture end about 0.5cm long to allow length for grasping
during removal.
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DBU 11/03/2024
 Continuous simple

• Place a single suture and ligate but only cut the

short end of the suture.
• Continue to place sutures along the length of the
wound keeping tension through an assistant
following by holding the suture at the same tension
as it is when handed.
• Take care and avoid too much tension.
• Secure the suture at the end by an additional reef
knot. DBU 11/03/2024
 Vertical and horizontal mattress

• Vertical mattress sutures are used when eversion of the skin edges
is needed and cannot be accomplished with simple sutures alone.
• Vertical mattress sutures leave obvious cross-hatching and must be
removed early.
• Horizontal mattress sutures also provide approximation of the skin
edges with eversion.
• They are particularly advantageous in thick glabrous skin (located
on the sole and palm). However, they produce more ischemia of
the wound edges (but are useful for hemostasis!).
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vertic
al
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 Subcuticular stitches

• This technique may be used with absorbable or non absorbable

sutures.

• For non-absorbable sutures, the ends may be secured by means of

beads.

• For absorbable sutures, the ends may be secured by means of buried

knots.

• Small bites of the subcuticular tissues on alternate sides of the wound

are taken and then pulled carefully together.
DBU 11/03/2024
 Knot Placement

• Interrupted stitches require individual knots, and therefore placement of

each knot can influence how well the wound heals and the cosmetic result.

1. The knot should be tied away from

• Vital structures

• Source of contamination

• Potential irritants

• Potential sources of increased inflammation

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 Knot Placement

2. The knot should be tied toward:

• The better blood supply.

• The area that provides the best security of the knot.

• If possible, where the mark would be less

noticeable.

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Surgical knots

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 Cutting Sutures

• Suture tails are trimmed close to the knot.

Considerations for cutting suture include the following:

• the suture is cut with the tips of the scissors.

• The tips of the scissors must be visible to ensure that other structures
are not injured by the cutting motion.

• A hemostat and/or a second suture should be available in the event

that the knot is inadvertently cut, releasing the sutured tissue.

DBU 11/03/2024
 Cutting Sutures

• A hemostat may be placed on one of the suture ends

to stabilize the suture to be cut.

• When removing a suture, a forceps is used to grasp

the suture at the knot.

• Cut the suture between the knot and the skin. Extract
the cut suture with forceps.
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