Suture Material
Many different suture materials are available. The main classifications are absorbable or nonabsorbable. A more subtle subclassification is whether the suture material is braided or nonbraided. Unless there is a dire emergency, never use regular thread for sutures because of the risk of infection.
Nonabsorbable Sutures
Nonabsorbable sutures remain in place until they are removed. Because they are not dissolved by the body, they are less tissue-reactive and therefore leave less scarring as long as they are removed in a timely fashion. They are best used on the skin.
Absorbable Sutures
Absorbable sutures are dissolved by the body's tissues. The great advantage is that the sutures do not need to be removed. However, absorbable sutures tend to leave a more pronounced scar when used as skin sutures. Absorbable sutures are primarily used under the skin, where they are well hidden. It is sometimes difficult to get patients to return for suture removal. If this is a concern, use an absorbable suture for skin closure. You should warn the patient that absorbable sutures probably will result in a more noticeable scar than nonabsorbable sutures with later removal. Because it is often difficult to remove stitches from children (because of their crying and difficulty in staying still), absorbable materials should be used when suturing their wounds.
Braided Sutures
Braided sutures are made up of several thin strands of the suture material twisted together. Braided sutures are easier to tie than nonbraided sutures. However, braided sutures have little interstices in the suture material, which can be a place for bacteria to hide and grow, resulting in an increased risk of infection.
Nonbraided Sutures
Nonbraided sutures are simply a monofilament, a single strand. They are not made up of the little subunits found in a braided suture. Nonbraided sutures are recommended for most skin closures, especially wounds that may be at risk for infection
Suturing Techniques
When suturing the edges of a wound together, it is important to evert the skin edges—that is, to get the underlying dermis from both sides of the wound to touch. For the wound to heal, the dermal elements must meet and heal together. If the edges are inverted (the epidermis turns in and touches the epidermis of the other side), the wound will not heal as quickly or as well as you would like. The suture technique that you choose is important to achieve optimal wound healing.
Instruments Needed
Needle holder:
used to grab onto the suture needle.
Forceps:
used to hold the tissues gently and to grab the needle
Suture scissors:
used to cut the stitch from the rest of the suture material
How to Hold the Instruments
Whenever you use sharp instruments, you face the risk of accidentally sticking yourself. Needlesticks are especially hazardous because of the risk of serious infection (hepatitis, human immunodeficiency virus).
To prevent needlesticks, get in the habit of using the instruments correctly. Never handle the suture needle with your fingers.
1.Scissors-Place your thumb and ring finger in the holes. It is best to cut with the tips of the scissors so that you do not accidentally injure any surrounding structures or tissue (which may happen if you cut with the center part of the scissors).
2.Needle Holder-Place your thumb and ring finger in the holes. When using the needle holder, be sure to grab the needle until you hear the clasp engage, ensuring that the needle is securely held. You grab the needle at its half-way point, with the tip pointing upward. Try not to grab the tip; it will become blunt if grabbed by the needle holder. Then it will be difficult to pass the tip through the skin.
3.Forceps-Hold the forceps like a writing utensil. The forceps is used to support the skin edges when you place the sutures. Be careful not to grab the skin too hard, or you will leave marks that can lead to scarring. Ideally, you should grab the dermis or subcutaneous tissue—not the skin—with the forceps, but this technique takes practice. For suturing skin, try to use forceps with teeth, which are little pointed edges at the end of the forceps.
Placing the Sutures
For most areas of the body, except the face ,the sutures should be placed in the skin 3–4 mm from the wound edge and 5–10 mm apart. Sutures placed on the face should be approximately 2–3 mm from the skin edge and 3–5 mm apart.
Sutures placed elsewhere on the body should be approximately 3–4 mm from the skin edge and 5–10 mm apart.Start on the side of the wound opposite and farthest from you to ensure that you are always sewing toward yourself. By sewing toward yourself, the suturing process is made easier from a biomechanical standpoint.
Simple Sutures Indication.
This technique is the easiest to perform. It is used for most skin suturing.
Technique
1.Start from the outside of the skin, go through the epidermis into the subcutaneous tissue from one side, then enter the subcutaneous tissue on the opposite side, and come out the epidermis above.
2.To evert the edges, the needle tip should enter at a 90°angle to the skin. Then turn your wrist to get the needle through the tissues. 3.You can use simple sutures for a continuous or interrupted closure.
Interrupted Sutures
•Interrupted sutures are individually placed and tied.
•They are the technique of choice if you are worried about the cleanliness of the wound.
•If the wound looks like it is becoming infected, a few sutures can be removed easily without disrupting the entire closure.
•Interrupted sutures can be used in all areas but may take longer to place than a continuous suture.
Continuous Closure
•Place the sutures again and again without tying each individual suture.
•If the wound is very clean and it is easy to bring the edges together, a continuous closure is adequate and quicker to perform. •Continuous closure is the technique of choice to help stop bleeding from the skin edges, which is important, for example, in a scalp laceration.
Mattress Sutures Indication.
Mattress sutures are a good choice when the skin edges are difficult to evert. Sometimes you may want to close a wound with a few scattered mattress sutures and place simple sutures between them. It is a bit more technically challenging to place mattress sutures, but it is often worth the effort because good dermis-to-dermis contact is achieved
Technique
1.Start like a simple suture, go from the outside of the skin through the epidermis into the subcutaneous tissue from one side, then enter the subcutaneous tissue on the opposite side, and come out the epidermis above.
2.Turn the needle in the opposite direction and go from outside the skin on the side that you just exited and come out the dermis below. Then enter the dermis on the opposite side and come out of the epidermis above.
3.Your suture is now back on the side on which you started.
Buried Intradermal Sutures
Indication-
This technique is useful for wide, gaping wounds and when it is difficult to evert the skin edges. When buried intradermal sutures are placed properly, they make skin closure much easier. The purpose of this stitch is to line up the dermis and thus enhance healing. The knot needs to be as deep into the tissues as possible (hence the term buried) so that it does not come up through the epidermis and cause irritation and pain.
Technique
1.Use a cutting needle and absorbable material.
2.Start just under the dermal layer and come out below the epidermis. You are going from deep to more superficial tissues
3.Now the technique becomes a bit challenging. You need to enter the skin on the opposite side at a depth similar to where you exited the skin on the first side, just below the epidermis. To do so, you should position the needle with the tip pointing down and pronate your wrist to get the correct angle. It will help to use the forceps (in the other hand) to hold up the skin. The needle should come out of the tissues below the dermis. Try to get as little fat in the stitch as possible; it does not contribute to the suture.
4.Tie the suture.
Figure-of-eight Sutures
Indication.This technique is useful for bringing together underlying tissues such as muscle, fascia, or extensor tendons. It is not commonly used for skin closure.
Technique
1.Usually a tapered needle and absorbable sutures are used.
2.Start on the side opposite from you. Go through the full thickness of tissues on that side, then finish the first half of the stitch by going from bottom to top on the opposite side. Advance just a little farther (1.0–1.5 cm) along the tissue. The needle should now be back on top of the tissue.
3.Now enter the first side (going from top to bottom) just across from the suture on the other side. Again go through the full thickness of the tissue and come out on the undersurface of the tissue.
4.Now enter the undersurface of the other side even with the first suture and come out on top.
5.The suture can now be easily tied.
Tying the Suture
The simplest way to tie the suture is by doing an “instrument tie".
Simple Sutures
1.Pull the suture through the skin so that just a short amount of suture material (a few centimeters) is left out.
2.Take the needle out of the needle holder.
3.Place your needle holder in the center between the skin edges parallel to the wound. One end of the suture should be on each side of the wound without crossing in the middle.
4.Wrap the suture that is attached to the needle once or twice around the needle holder in a clockwise direction.
5.Grab the short end of the suture with the needle holder.
6.Pull it through the loops, and have the knot lie flat. The short end of the stitch should now be on the opposite side.
7.Let go of the short end.
8.Bring the needle holder back to the center, parallel to the wound edges.
9.Repeat steps 4–8 at least one or two times more.
10.Cut the suture ends about 1 cm from the knot
Mattress Sutures
1.Pull the suture through the skin so that just a short amount of suture material (a few centimeters) is left out.
2.Take the needle out of the needle holder.
3.Both ends of the suture are on the same side. Place your needle holder between the ends of the suture.
4.Wrap the suture that is attached to the needle once or twice around the needle holder in a clockwise direction.
5.Grab the short end with the needle holder.
6.Pull it through the loops, and have the knot lie flat. The short end of the stitch should now be on the opposite side.
7.Let go of the short end.
8.Bring the needle holder back to the center, between the suture ends.
9.Repeat steps 4–8 at least one or two times more.
10.Cut the suture ends about 1 cm from the knot.
Continuous Suture
1.Do not pull the next to-the-last stitch all the way through; leave it as a loop.
2.Place your needle holder between the loop and the suture attached to the needle. The needle holder should be almost perpendicular to the wound.
3.Wrap the suture that is attached to the needle once or twice around the needle holder in a clockwise direction.
4.Grab the loop with the needle holder.
5.Pull it through, and have the knot lie flat. The short loop should now be on the opposite side.
6.Let go of the loop.
7.Bring the needle holder back to the center between the loop and the suture end.
8.Repeat steps 3–7 at least one or two times more.
9.Cut the suture ends about 1 cm from the knot.
Suture Removal
If the sutures are taken out within 7–10 days, suture removal is usually easy and should not cause more than a pinching sensation to the patient.
Simple Sutures-
1.Cut the suture where it is exposed, crossing the wound edges. 2.Remove the entire stitch by grabbing the knot with a clamp or forceps and pulling gently.
Mattress Sutures -
Removal of mattress sutures can be a little more difficult.
1. Grab the knot and try to lift it up a little; this should allow you to see a space between the suture strands
2.Cut one strand of the suture under the knot.
3.Remove the entire stitch by grabbing the knot with a clamp or forceps and pulling gently. This suture will be a little harder to remove than a simple suture.
4.If you accidentally cut both ends of the suture, you will leave suture material behind.
5.Look on the opposite side of the skin for the suture. Grab it with a clamp or forceps, and gently remove the remaining suture material.
Continuous Sutures-
1.Cut the suture in several places where it is exposed, crossing the wound edges.
2.Remove portions of the stitch by grabbing an end with a clamp or forceps and pulling gently.
3.The sutures to the knot must be cut in several places for removal.
by Lakdhes..
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