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Suture WorkshopReview and practice for clinical

efficiency in most settings ContosoP h a rm a c e u tic a ls

Jeremy Nelson

Meet your Facilitators

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Carol Gorney

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ObjectivesW hat to expect

WhatCom pare types, sizes,

style of suture m aterial/technique

WhyD iscuss the

appropriate situation for suture style and

type

HowD em onstrate

proficient skill at several suturing

techniques

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WhatWe suture in varius settings

Outpatient primary care

Urgent care

Retail care

Emergency care

Specialty care

Surgical care.

This is a bread and butter skill that some will do daily and others will do occasionally. This workshop should have value for all of you.

This will NOT be a detailed wound lecture

• Types of wounds • Facial• Deep and superficial• Cheek/zygoma• eyebrow

• Lip• Oral mucosa and tongue• Scalp• Ear• Corporal• Extremities• Overlying joints

• Genital/perineal

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• Silk

• Nylon (Ethilon, Dermalon)

• Polypropelene (Prolene, Surgilene)

• Polybutester (Novafil)

• Natural, easy to handle and tie

• Braided

• Monofilament

• high tensile strength

• min tissue rxn, cheap

• Synthetic plastic monofilament

• elastic properties

• comes in blue

• Synthetic monofilament

• More elastic, less suture marks

• Easy to handle

• Weakest tensile strength of non absorbables, Not common for minor wounds;Chesttubes/central lines

• unties, more knots required

• Unties more than nylon, expensive, loose after swelling recedes

• Unties more than nylon, expensive, loose after swelling recedes

Non Absorbable – used for most surface lacerations

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• Fast Absorbing Gut

• Chromic Gut

• Vicryl (polyglycolic acid)

• Vicryl Rapide

• Poliglecarprone 25 (Monocryl)

• Polyglycolic acid (Dexon)

• Polydioxoanone (PDS)

• Polyglyconate (Maxon)

• 4-6 days, weakest, unties

• Tissue rxns high

• 10-14 days, fair strength

• Most tissue reactivity

• 30 days,braided,strong

• Handles well, knot stable

• 7-10 days, braided,

• Min tiss rxn, mod strength

• 1-2weeks, handles easy

• Fair strength

• 30days, braid, high friction

• 5-6wks, mono, stiff

• 5-6wks, mono, pliable, strong

• Face, esp in combo w/ tape

• If removal difficulty expected

• Mouth, tongue, nailbed

• Deep, nailbed, mouth

• Face, scalp, under splint/cast

• Face, subcuticular

• Cosmetic, not for high tension

• Deep Closure

• Deep Closure

• Deep Closure

Absorbable Sutures

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Suture Selection at your discretion

• 19 trial Meta analysis (1748 patients) comparing non absorbable vs absorbable sutures in surgical and traumatic lacerations.

• Equivalent Cosmetic Outcomes

• No significant difference for wound infection or dehiscence• Follow up insufficient in several studies

• Suture material should be individualized for patients based upon clinical discretion.

• Absorbable vs Nonabsorbable Sutures for Skin Closure: A Meta-Analysis of Randomized Controlled Trials; Xu B, Xu B, Wang L, Chen C, Yilmaz TU, Zhang W, He B. Ann Plast Surg. 2016;76(5):598.

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Suturing techniques

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• Percutaneous Skin Closure• Superficial wounds, 1 layer closures

• Can use either absorbable or non absorbable sutures

• Simple interrupted• Verticle mattress• Horizontal mattress

• Figure of 8• Buried

• Simple Running• Simple Running Locking• Subcuticular Running

• Dermal Closure• Deeper wounds require closure to prevent• Abscess, hematoma, increased surface

wound tension

• Should use absorbable sutures

• Simple Buried• Buried Horizontal Mattress

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Simple InterruptedMost commonly used

Simple method of closing traumatic and surgical wounds

Needle penetrates at 90°

Equal width at base as surface

Width and depth equal on both sides

Width and depth determined by the wound location and dermal thickness.

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Simple BuriedDermal Closure

Use to decrease tension on percutaneous sutures to improve cosmesis

Prevent abscess/hematoma/fluid collectionBury the knot

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Vertical Mattress

“far far, near near”To decrease wound tension

To evert the edgesIf wound needs deep closure

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Horizontal Mattress

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Figure of 8/cruciate mattress

Hybrid suture. Decreases suture timePunch biopsy closure

Low tension wounds.

Secondarily used after deep sutures.

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Half Buried SutureGood for cornersCosmetic approach for less suture lines/scarsHairline

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Simple Running SutureGreat time saver.

Good for straight wound with little tensionAfter placing deep retention suturesBe sure to space evenly or it will make dimples and corners in the tissue.

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Running Locked Suture

• When the wound is under tension

• Lock (bring suture around the loop) before closing loop

• Can start with simple and lock as need, or continually for appearance.

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Subcuticular RunningCosmetic stitchWhen suture dimples or lines need to be avoidedBe careful about spacing or it will dimple the tissueBury the knot

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Demonstrations

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• https://youtu.be/TFwFMav_cpE• Duke University Suture Skills Course

https://youtu.be/TFwFMav_cpE

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Questions?

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Thank YouJeremy Nelson & Carol Gorney