Lacerations

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Lacerations Skin Closure848th FST
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Introduction

• Wounds that are closed are more likely to become
  infected
• Dirty wounds should not be closed
• They should be irrigated, debrided dressed

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Categories of Suture

• Absorbable vs. Non-absorbable
• Multifilament vs. Monofilament

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Absorbable Suture

• Gut
• Plain
• Chromic
• Dexon
• Vicryl
• PDS

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Surgical Gut

• Collagen
• Packed in 85 alcohol
• Cannot be resterilized
• Chromic
• Less reactivity
• Lasts longer
• Plain
• Lasts 3-7 days
• Rarely used
• Typically used in case of infection

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Dexon, Vicryl PDS

• Synthetic
• Non antigenic
• Advantages
• More consistent absorption than gut
• Disadvantages
• Untie
• Cut tissue

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Non-absorbable

• Retain tensile strength for 60 days
• May remain insitu indefinitely
• Silk, nylon, polyester polypropelene

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Silk

• Braided, dyed coated
• Holds knots well
• Easy to tie
• Possesses capillary action
• Should not be used in the presence of infection
• Provides refuge for bacteria
• Non-absorbable

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Cotton

• More tissue reaction than silk
• Potentiates infection until removed
• Not used in modern U.S. hospitals
• Except for umbilical tape

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Nylon (Dermalon Ethilon)

• Monofilament multifilament
• Has memory
• Stays coiled
• Knots slip
• Inert
• Causes little tissue reaction

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Prolene

• Popular monofilament
• Has memory
• First throw can slip
• Often used in vascular surgery

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Polyesters

• Coated Dacron (Polydek)
• Impregnated Dacron (Ethiflex)
• Multifilament
• Avoid using in contaminated wounds

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Stainless Steel

• Iron-nickel-chromium
• Strongest
• Non-reactive
• Used in cases of infection
• Difficult to use
• Cuts tissue and gloves

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Tissue Shearing

• Fat tears before 6-0 breaks
• Muscle tears before 4-0 breaks
• Fascia with
• No tension 4-0 or 5-0
• Moderate tension 2-0 or 3-0
• High tension 0 or 2-0
• Consider tissue reactivity

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Knot Slippage

• Contact Friction
• Braided multifilament
• Tie well hold knot
• Absorbable monofilament
• Tend to untie
• Use square knots to avoid untying

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Better to Increase the Number of Sutures than to
Increase the Size
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Skin Stapling

• More resistant to infection
• Does not provide an environment conductive to
  bacterial growth
• Remove after a few days possibly replace with
  steri strips
• Have no special tool?
• Insert hemostat under staple gently spread

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Regarding the use of Sutures

• When in doubt leave it out
• Closing a wound increases the chance of infection

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Characteristics of Needles

• Select to cause minimum of trauma
• Rigid enough not to break
• Sharp
• Resistant to corrosion
• Closed eye vs. swaged on
• Photo portrays a swaged on needle
• Beware of CR (controlled release) they detach
  easily from suture
• Consider type of tissue to suture

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Needles Types of Tissue

• Cutting
• Used for dense, thick, connective tissue such as
  skin
• Taper Cut
• Used for subcutaneous tissue
• Round
• Abdominal viscera, connective tissue other
  fragile tissue

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Needle Types
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Quick Quiz Which package has only strands no
needle? What kind of needle does suture A
upper left have (cutting or taper)? Which
kind of suture is this? Which is heavier suture
2-0 or 0?
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Holding Instruments
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Holding Instruments

• Hold the forceps like a pencil (or chop sticks)
• Hold the needle holder with the ring finger on
  one side thumb on the other
• Use your index finger to steady the working end
• Do not put your index finger in a ring-handled
  instrument

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Holding Instruments

• Gently pick up skin with forceps
• You can chose not to use them at all

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Holding Instruments

• Continue holding the skin with forceps until
  needle is retrieved
• Do not retrieve needle with forceps

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Needle Insertion

• Insert needle straight in
• Pretend the needle is straight
• Insert it at 90 to skin
• Requires pronation of the wrist initially (palm
  down)
• To drive needle through skin, supinate the wrist
  (turn palm up)
• The skin edges need to be everted, not inverted

Everted Inverted
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Needle Insertion

• Two Bites
• Insert the needle on one side of wound
• Outside to in
• Remove needle reload
• Reinsert needle retrieve it
• Inside to out
• Notice forceps can be used to push skin instead
  of pulling it

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Needle Insertion

• One Bite
• Insert needle on one side of wound go straight
  through to other side before coming out
• Notice that no forceps are used at this time

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Uneven Wound Edges

• Make the bite on one side at the same depth as
  the other side
• Note in illustration
• The bite on one side of the wound is deeper than
  on the other side
• This causes the wound edges to be uneven

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Removing the Needle

• Use the needle holder to remove the needle from
  the skin
• Avoid crushing tip of needle
• If the tip is crushed too much, it will bend a
  cutting needle will dull

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Removing the Needle

• Hold toward the thicker back part of the needle
• Avoid using forceps to pull out the needle
• Use forceps to continue holding the skin

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Door-knob

• Correct
• When you take hold of the needle position hand
  with palm down
• Turn the wrist naturally
• Incorrect
• If palm is up, it will be difficult to turn the
  wrist

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Tie Square Knots

• Let go of the needle
• Keep needle holder in your hand
• Hold suture with other hand a few inches from the
  wound

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Tie Square Knots

• Normally leave no daylight in between throws
• As tissue swells, bottom throw will tighten
  toward top throw
• In some cases, this is desirable

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Flap Closure

• To close a triangular flap without impairing
  blood supply
• Use three bites
• Start outside, then go horizontally under the
  skin (dotted line in drawing is suture under
  skin)
• Try not to damage the delicate triangle with
  forceps
• Continue horizontally through flap to other side
  of wound
• Come out on other side of wound tie loosely
• The fewer the suture the better

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3 Generic Techniques

• Simple Interrupted

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3 Generic Techniques

• Simple Running
• Continuous
• Vertical Mattress

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3 Generic Techniques

• Vertical Mattress

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3 Generic Techniques

• Vertical Mattress
• Everts skin edges

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3 Generic Techniques
Vertical Mattress
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Vertical Mattress

• Apply a simple stitch in the usual manner
• Turn the needle around on the needle holder
• Back-hand the needle through very edges of skin
• Or Back-hand the first part of the stitch

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Other Suture Techniques
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Removing Sutures

• Clean the area with water, saline, alcohol, etc.
• Remove suture with scissors or blade
• Do this in such a way that the least amount of
  exposed stitch gets dragged into the skin on
  removal

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Summary

• Irrigation
• Debridement
• Inversion vs. Eversion
• Sutures
• Suture Patterns

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Questions
Rick Jackson, MAJ