Basic Suturing Workshop

Lianne Beck, MD
Assistant Professor
Emory Family Medicine Residency Program
June 2014

Objectives
Describe the principles of wound healing
Identify the various types and sizes of suture material.
Choose the proper instruments for suturing.
Identify the different injectable anesthetic agents and correct
dosages.
Demonstrate various biopsy methods: punch, excision, shave.
Demonstrate different types of closure techniques: simple
interrupted, continuous, subcuticular, vertical and horizontal
mattress, dermal
Demonstrate two-handed, one-handed, instrument ties
Recommend appropriate wound care and follow-up.
Critical Wound Healing Period
Tissue

Skin

Mucosa

Subcutaneous

Peritoneum

Fascia

5-7 days
5-7 days
7-14 days
7-14 days
14-28 days
0 5 7 14 21 28
Tissue Healing Time/Days
Model of Wound Healing
(1) Hemostasis: within minutes post-injury, platelets aggregate at the
injury site to form a fibrin clot.
(2) Inflammatory: bacteria and debris are phagocytosed and removed,
and factors are released that cause the migration and division of cells
involved in the proliferative phase.
(3) Proliferative: angiogenesis, collagen deposition, granulation
tissue formation, epithelialization, and wound contraction
(4) Remodeling: collagen is remodeled and realigned along tension
lines and cells that are no longer needed are removed by apoptosis.
Wound Healing Concepts
Patient factors
Wound classification
Mechanism of injury
Tetanus/antibiotics/local anesthetics
Surgical principles and wound prep
Suture/needle/stitch choice
Management/care/follow-up
Common Patient Factors
Age
Blood supply to the
area
Nutritional status
Tissue quality
Revision/infection
Compliance
Weight
Dehydration
Chronic disease
Immune response
Radiation therapy
CDC Surgical Wound Classification
Clean: (1-5% risk of infection) uninfected operative wounds in
which no inflammation is encountered and the respiratory, alimentary,
genital, or uninfected urinary tracts are not entered. In addition, clean
wounds are primarily closed, and if necessary, drained with closed
drainage. Operative incisional wounds that follow nonpenetrating
(blunt) trauma should be included in this category if they meet the
criteria.

Clean-contaminated: (3-11% risk) operative wounds in which
the respiratory, alimentary, genital, or urinary tract is entered under
controlled conditions and without unusual contamination. Specifically,
operations involving the biliary tract, appendix, vagina, and
oropharynx are included in this category, provided no evidence of
infection or major break in technique is encountered.

CDC Surgical Wound Classification
Contaminated: (10-17% risk) open, fresh, accidental wounds,
operations with major breaks in sterile technique or gross spillage from
the gastrointestinal tract, and incisions in which acute, nonpurulent
inflammation is encountered.

Dirty or infected: (>27% risk) old traumatic wounds with
retained devitalized tissue and those that involve existing clinical
infection or perforated viscera. This definition suggests that the
organisms causing postoperative infection were present in the
operative field before the operation.

Surgical Principles
Incision
Dissection
Tissue handling
Hemostasis
Moisture/site
Remove infected,
foreign, dead areas
Length of time open
Choice of closure
material/mechanism
Primary or secondary
Cellular responses
Eliminate dead space
Closing tension
Distraction forces and
immobilization/care


Suture Materials
Criteria
Tensile strength
Good knot security
Workability in handling
Low tissue reactivity
Ability to resist bacterial infection
Types of Sutures
Absorbable or non-absorbable (natural or synthetic)
Monofilament or multifilament (braided)
Dyed or undyed
Sizes 3 to 12-0 (numbers alone indicate progressively
larger sutures, whereas numbers followed by 0 indicate
progressively smaller)
New antibacterial sutures
Non-absorbable
Not biodegradable
and permanent
Nylon (Ethilon)
Prolene
Stainless steel
Silk (natural, can
break down over
years)

Degraded via
inflammatory response
Vicryl
Monocryl
PDS
Chromic
Cat gut (natural)

Absorbable
Natural Suture
Biological
Cause inflammatory
reaction
Catgut (connective
from cow or sheep)
Silk (from silkworm
fibers)
Chromic catgut
Synthetic
Synthetic polymers
Do not cause
inflammatory response
Nylon
Vicryl
Monocryl
PDS
Prolene

Monofilament
Single strand of suture
material
Minimal tissue trauma
Smooth tying but more
knots needed
Harder to handle due to
memory
Examples: nylon, monocryl,
prolene, PDS
Multifilament (braided)
Fibers are braided or twisted
together
More tissue resistance
Easier to handle
Fewer knots needed
Examples: vicryl, silk,
chromic
Suture Materials
Suture Selection
Do not use dyed sutures on the skin
Use monofilament on the skin as multifilament
harbor BACTERIA
Non-absorbable cause less scarring but must be
removed
Plus sutures (staph, monocryl for E. coli,
Klebsiella)
Location and layer, patient factors, strength,
healing, site and availability
Suture Selection
Absorbable for GI, urinary or biliary
Non-absorbable or extended for up to 6 mos
for skin, tendons, fascia
Cosmetics = monofilament or subcuticular
Ligatures usually absorbable

Suture Sizes
Surgical Needles
Wide variety with different companys
naming systems
2 basic configurations for curved needles
Cutting: cutting edge can cut through tough
tissue, such as skin
Tapered: no cutting edge. For softer tissue
inside the body
Surgical Needles
Surgical Instruments
Scalpel Blades
Anesthetic Solutions
Lidocaine (Xylocaine)
Most commonly used
Rapid onset
Strength: 0.5%, 1.0%, &
2.0%
Maximum dose:
5 mg / kg, or
300 mg
1.0% lidocaine = 1 g
lidocaine / 100 cc =
1,000mg/100cc
300 mg = 0.03 liter = 30 ml
Lidocaine (Xylocaine)
with epinephrine
Vasoconstriction
Decreased bleeding
Prolongs duration
Strength: 0.5% & 1.0%
Maximum individual
dose:
7mg/kg, or
500mg

Anesthetic Solutions
CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with epinephrine
on:
Eyes, Ears, Nose
Fingers, Toes
Penis, Scrotum
Anesthetic Solutions
BUPIVACAINE (MARCAINE):
Slow onset
Long duration
Strength: 0.25%
DOSE: maximum individual dose 3mg/kg
Local Anesthetics
Injection Techniques
25, 27, or 30-gauge
needle
6 or 10 cc syringe
Check for allergies
Insert the needle at the
inner wound edge

Aspirate
Inject agent into tissue
SLOWLY
Wait
After anesthesia has
taken effect, suturing
may begin
Wound Evaluation
Time of incident
Size of wound
Depth of wound
Tendon / nerve involvement
Bleeding at site
When to Refer
Deep wounds of hands or feet, or unknown depth
of penetration
Full thickness lacerations of eyelids, lips or ears
Injuries involving nerves, larger arteries, bones,
joints or tendons
Crush injuries
Markedly contaminated wounds requiring
drainage
Concern about cosmesis

Contraindications to Suturing
Redness
Edema of the wound margins
Infection
Fever
Puncture wounds
Animal bites
Tendon, nerve, or vessel involvement
Wound more than 12 hours old (body) and 24 hrs
(face)
Closure Types
Primary closure (primary intention)
Wound edges are brought together so that they are adjacent to each
other (re-approximated)
Examples: well-repaired lacerations, well reduced bone fractures,
healing after flap surgery

Secondary closure (secondary intention)
Wound is left open and closes naturally (granulation)
Examples: gingivectomy, gingivoplasty,tooth extraction sockets,
poorly reduced fractures

Tertiary closure (delayed primary closure)
Wound is left open for a number of days and then closed if it is
found to be clean
Examples: healing of wounds by use of tissue grafts.

Wound Preparation
Most important step for reducing the risk of wound
infection.
Remove all contaminants and devitalized tissue before
wound closure.
IRRIGATE w/ NS or TAP WATER (AVOID H2O2,
POVIDONE-IODINE)
CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor scar
are greatly increased
Personal Precautions

Basic Laceration Repair
Principles And Techniques
Langers Lines
Principles And Techniques
Minimize trauma in skin
handling
Gentle apposition with slight
eversion of wound edges
Visualize an Erlenmeyer
flask
Make yourself comfortable
Adjust the chair and the
light
Change the laceration
Debride crushed tissue
Types of Closures
Simple interrupted closure most commonly used, good for shallow
wounds without edge tension
Continuous closure (running sutures) good for hemostasis (scalp
wounds) and long wounds with minimal tension
Locking continuous - useful in wounds under moderate tension or in
those requiring additional hemostasis because of oozing from the skin
edges
Subcuticular good for cosmetic results
Vertical mattress useful in maximizing wound eversion, reducing
dead space, and minimizing tension across the wound
Horizontal mattress good for fragile skin and high tension wounds
Percutaneous (deep) closure good to close dead space and decrease
wound tension
Simple Interrupted Suturing
Apply the needle to the needle driver
Clasp needle 1/2 to 2/3 back from tip
Rule of halves:
Matches wound edges better; avoids dog ears
Vary from rule when too much tension across
wound
Simple Interrupted Suturing
Rule of halves
Simple Interrupted Suturing
Rule of halves
Suturing
The needle enters the
skin with a 1/4-inch
bite from the wound
edge at 90 degrees
Visualize Erlenmeyer
flask
Evert wound edges
Because scars contract
over time
Suturing
Release the needle from the needle driver, reach into the
wound and grasp the needle with the needle driver. Pull it
free to give enough suture material to enter the opposite
side of the wound.

Use the forceps and lightly grasp the skin edge and arc the
needle through the opposite edge inside the wound edge
taking equal bites.

Rotate your wrist to follow the arc of the needle.

Principle: minimize trauma to the skin, and dont bend the
needle. Follow the path of least resistance.

Suturing
Release the needle and grasp the portion of the
needle protruding from the skin with the needle
driver. Pull the needle through the skin until you
have approximately 1 to 1/2-inch suture strand
protruding form the bites site.

Release the needle from the needle driver and
wrap the suture around the needle driver two
times.
Simple Interrupted Suturing
Grasp the end of the suture material with the needle driver
and pull the two lines across the wound site in opposite
direction (this is one throw).

Do not position the knot directly over the wound edge.

Repeat 3-4 throws to ensuring knot security. On each
throw reverse the order of wrap.

Cut the ends of the suture 1/4-inch from the knot.

The remaining sutures are inserted in the same manner

Simple, Interrupted
http://www.youtube.com/watch?v=PFQ5-tquFqY
The trick to an instrument tie
Always place the suture holder parallel to the
wounds direction.
Hold the longer side of the suture (with the
needle) and wrap OVER the suture holder.
With each tie, move your suture-holding hand to
the OTHER side.
By always wrapping OVER and moving the hand
to the OTHER side = square knots!!
Two Handed Tie
Two Handed Tie
One-Hand Tie
One-Hand Tie
Continuous Locking and Nonlocking Sutures
http://www.youtube.com/watch?v=xY4cAqk30K4
http://cal.vet.upenn.edu/projects/surgery/5000.htm
http://www.youtube.com/watch?v=sgOaBojcX-c
https://www.youtube.com/watch?v=hIqTDvofekM

Vertical Mattress
Good for everting wound edges
(neck, forehead creases, concave surfaces)
http://www.youtube.com/watch?v=824FhFUJ6wc
Horizontal Mattress
Good for closing wound edges under high tension,
and for hemostasis.
Horizontal Mattress
http://www.youtube.com/watch?v=9DdaooEXshk
http://www.youtube.com/watch?v=I7C7nsl5Tuk
Suturing - finishing

After sutures placed, clean the site with
normal saline.
Apply a small amount of Bacitracin or
white petroleum and cover with a sterile
non-adherent compression dressing (Tefla).
Suturing - before you go
Need for tetanus globulin and/or vaccine?
Dirty (playground nail) vs clean (kitchen knife)
Immunization history (>10 yrs need booster or >5 yrs if
contaminated)

Tell pt to return in one day for recheck, for signs of infection
(redness, heat, pain, puss, etc), inadequate analgesia, or suture
complications (suture strangulation or knot failure with possible
wound dehiscence)

It should be emphasized to patients that they return at the
appropriate time for suture removal or complications may arise
leading to further scarring or subsequent surgical removal of
buried sutures.
Patient instructions and follow up care
Wound care
After the first 24-48 hours, patients should gently wash
the wound with soap and water, dry it carefully, apply
topical antibiotic ointment, and replace the
dressing/bandages.
Facial wounds generally only need topical antibiotic
ointment without bandaging.
Eschar or scab formation should be avoided.
Sunscreen spf 30 should be applied to the wound to
prevent subsequent hyperpigmentation.
Suture Removal
Average time frame is 7 10 days
FACE: 3 5 d
NECK: 5 7 d
SCALP: 7 12 days
UPPER EXTREMITY, TRUNK: 10 14 days
LOWER EXTREMITY: 14 28 days
SOLES, PALMS, BACK OR OVER JOINTS: 10 days

Any suture with pus or signs of infections should be
removed immediately.
Suture Removal
Clean with hydrogen peroxide to remove any
crusting or dried blood
Using the tweezers, grasp the knot and snip the
suture below the knot, close to the skin
Pull the suture line through the tissue- in the
direction that keeps the wound closed - and place
on a 4x4. Count them.
Most wounds have < 15% of final wound
strength after 2 wks, so steri-strips should be
applied afterwards.
Topical Adhesives
Indications: selection of approximated, superficial, clean
wounds especially face, torso, limbs. May be used in
conjunction with deep sutures

Benefits: Cosmetic, seals out bacteria, apply in 3 min,
holds 7 days (5-10 to slough), seal moisture, faster, clear,
convenient, less supplies, no removal, less expensive

Contraindicated with infection, gangrene, mucosal, damp
or hairy areas, allergy to formaldehyde or cryanoacrylate,
or high tension areas
Dermabond

A sterile, liquid topical skin
adhesive
Reacts with moisture on skin
surface to form a strong, flexible
bond
Only for easily approximated
skin edges of wounds
punctures from minimally
invasive surgery
simple, thoroughly cleansed,
lacerations
Dermabond

Standard surgical wound prep and dry
Crack ampule or applicator tip up; invert
Hold skin edges approximated horizontally
Gently and evenly apply at least two thin layers on
the surface of the edges with a brushing motion
with at least 30 s between each layer, hold for 60 s
after last layer until not tacky
Apply dressing
http://www.youtube.com/watch?v=oa13wriWTus&feature=related
http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
Follow Up Care with Adhesives
No ointments or medications on dressing
May shower but no swimming or scrubbing
Sloughs naturally in 5-10 days, but if need to remove use
acetone or petroleum jelly to peel but not pull apart skin
edges
Pt education and documentation
Biopsy Methods
Punch & Shave:
http://www.youtube.com/watch?v=7CzDEok
8Wmo

Elliptical Excision:
http://www.youtube.com/watch?v=BAhXuoB
0wMo&feature=related

EBM Take Home Points
Suturing is preferred technique for skin laceration repair
LOE SORT C
Saline or tap water should be used for wound irrigation
LOE SORT B
Use of white petrolatum to promote wound healing is as
effective as antibiotic ointment LOE SORT B
Tissue adhesives show comparable results with regards to
cosmetic, infection or dehisence rates LOE SORT A
References
http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf
Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct.
355: 17.
Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988.
www.uptodateonline.com; 2009, topic lacerations, etc.
http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf
http://www.mnpa.us/handouts/Session%2005%20%20-
%20%20Basic%20Suturing%20%202010%20MNPA.pdf
http://www.practicalplasticsurgery.org/docs/Practical_01.pdf
http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE8-
7EB5D06CE8DF/0/wound_healing_manual.pdf
Jackson, E. Wound Care Suture, Laceration, Dressing: Essentials for Family
Physicians. AAFP Scientific Assembly. 2010.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/asse
mbly/2010handouts/071.Par.0001.File.tmp/071-072.pdf



Ricardo Rodriguez, MD
Providence hospital
Department of Obstetrics and
Gynecology






Obstetrics and Gynecology
Episiotomy Repair
Episiotomy
Traditionally used to facilitate delivery of the infant
Reduce second stage of labor
1700s focus on protecting intact perineum
Allow slow controlled dilation and delivery
1828 Ferdinand von Ritgen
Described prpcedure using extension rather than flexion for delivery of
fetal head
1893 Karl August Scudart
Fisrt mediolateral incision report
1900s J. B. DeLee
Believed everyone should have episiotomy with forcep delivery to reduce
trauma to pelvic floor less potential fetal trauma
Twilight birthing came about
1970s 1980s
Questioning routine use of episiotomy
Gradual decrease in use
Episiotomy
Episiotomy
ACOG
Do not support routine or liberal use
Use for maternal or fetal indications
Avoiding severe maternal lacerations
Facilitating difficult deliveries
Indications depend on clinical judgment
Non reassuring fetal heart rate
Shoulder dystocia
Operative vaginal delivery
Breech Delivery
Episiotomy
Extension Tears
Generally
1
st
and 2
nd
degree tears
are simple to repair
If you havent done many
3
rd
and 4
th
degree tears call
for help Gyn or Colorectal
Episiotomy and Vaginal
Repairs
Goal is to return all structures to normal anatomy
Use the hymen remnant as key landmark
Suture used
2-0 Vicryl or monocryl common
2-0 chromic maybe used but some patients can have
reactions
Give plenty of anesthesia
Even patients with epidurals can benefit from local
injection due to varying levels of anesthesia
Nerve Dermatomes
Stage I
Onset of labor to 10cm
dilation
T10 L1(Sympathetic
fibers)
Stage II
10 cm the birth of the baby
S 2- S4 (Pudendal nerves,
somatic)
Stage III
Delivery of the Placenta
T10 L1 (Sympathetic
fibers)


Epidural
Epidural

Catheter into epidural potential space
A good spinal or epidural will cover
T10 to S5 for vaginal delivery and T4 to
S1 for CS
Achieved by
Location of tip
Dose concentration os volume of
medication
Affected by
Patient position
Anatomic variations
Synechiae


Episiotomy Repair
Episiotomy Repair Pearls
Return normal anatomy and use the least amount of suture material
possible
Count the tray before starting the procedure and after including
sponges and 4x4s
Recommend not using 4x4s or non tagged gauze. Use lap sponges with
the blue radio opaque handle
Put in one lap sponge past the point of repair by the cervix
This will stop blood from oozing down obscuring the field while doing the
repair
Make sure you take out and count the laps and instruments
If blood soaks the lap sponge and starts to drip down inspect cervix for
tears and cavity for possible retained placenta
Anesthesia anesthesia anesthesia
Test the area by using pick ups to pinch where you will be stitching
Nothing worse than a patient closing her legs and kicking while both your
hand and a needle are in an enclosed space

Episiotomy Repair
Episiotomy Repair
Episiotomy Repair
Episiotomy Repair
Pain after Episiotomy
Ice packs
Oral motrin vs toradol
Pudental block
Opioid analgesics
Topical lidocaine not effective
Pain out of proportion
Can be sign of vulvar, paravaginal, ischiorectal hematoma or
cellulitis.
Examine patient if stable non expanding hematoma can
monitor
If hematoma is expanding take to the OR for management

Episiotomy Break Down
Breakdown is rare but can be serious
If no sign of infection you can take the patient to the OR
right away
If there is pus or drainage admit for antibiotic then take to
OR after 2 or 3 days of antibiotics and no signs of infection
Can also leave open after antibiotics and debriedment for
second intention healing
This can leave the area scarred and affect patients quality
of life
Needs to be addressed early to avoid complications such as
necrotizing fasciitis, cellulitis which may need much more
extensive surgical repair
Episiotomy Repair 3
rd
degree

http://www.youtube.com/watch?v=vPZxkM
juKp4