Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Suture and Suture Technique
 


> ABSORBABLE SUTURE
> NON-ABSORBABLE SUTURE
> NEEDLES
> KNOT TYING



NEEDLES

Surgical needles are classified in three categories:

:: Round bodied
:: Cutting
:: Trochar.

Within these categories, there are hundreds of different types.

Use cutting needles on the skin, and for securing structures like drains. Use round bodied needles in fragile tissue, for example when performing an intestinal anastomosis. Do not use a cutting needle in this situation.

Trochar needles have a sharp tip but a round body. They are useful when it is necessary to perforate tough tissue, but when cutting the tissue would be undesirable, as in the linea alba when closing the abdominal wall.

Needles are attached to the suture commercially (sweged on: see Figure 4.5) or have eyes to pass the suture through (free needles). Sweged on needles are preferable, but every centre should have free needles available as an alternative when more expensive suture is unavailable or when a needle breaks off the suture before the task has been completed.

Figure 4.5
Figure 4.5


Techniques

There are many ways to secure tissue during an operative procedure and to repair discontinuity in the skin: tape, glue, staples and suture. The aim of all these techniques is to approximate the wound edges without gaps and without tension. Staples are an expensive alternative and glue may not be widely available. Suturing is the most versatile, least expensive and most widely used technique.

Suturing techniques include:

:: Interrupted simple
:: Continuous simple
:: Vertical mattress
:: Horizontal mattress
:: Subcuticular
:: Purse string
:: Retention/tension.

The size of the bite, and the interval between bites, should be consistent and will depend on the thickness of the tissue being approximated.

Use the minimal size and amount of suture material required to close the wound.

Leave skin sutures in place for an average of 7 days. In locations where healing is slow and cosmesis is less important (the back and legs), leave sutures for 10–14 days. In locations where cosmesis is important (the face), sutures can be removed after 3 days but the wound should be reinforced with skin tapes.

1 Use the needle driver to hold the needle, grasping the needle with the tip of the driver, between half and two thirds of the way along the needle. If the needle is held less than half way along, it will be difficult to take proper bites and to use the angle of the needle. Holding the needle too close to the end where the suture is attached may result in a flattening of the needle and a lack of control. Hold the needle driver so that your fingers are free of the rings and so that you can rotate your wrist and/or the driver.
2 Pass the needle tip through the skin at 90 degrees.
3 Use the curve of the needle by turning the needle through the tissue; do not try to push it as you would a straight needle.
4 Close deep wounds in layers with either absorbable or monofilament non-absorbable sutures (Figure 4.6).

Figure 4.6
Figure 4.6

Interrupted sutures

:: Most commonly used to repair lacerations
:: Permits good eversion of the wound edges, as well as apposition; entering the tissue close to the wound edge will increase control over the position of the edge
:: Use only when there is minimal skin tension
:: Ensure that bites are of equal volume
:: If the wound is unequal, bring the thicker side to meet the thinner to avoid putting extra tension on the thinner side
:: The needle should pass through tissue at 90 degrees and exit at the same angle
:: Use non-absorbable suture and remove it at an appropriate time.


Continuous/running sutures

:: Less time-consuming than interrupted sutures; fewer knots are tied and less suture is used
:: Less precision in approximating edges of the wound
:: Poorer cosmetic result than other options
:: Inclusion cysts and epithelialization of the suture track are potential complications
:: Suture passes at 90 degrees to the line of the incision and crosses internally under the top of the incision at 45–60 degrees.


Mattress sutures

:: Provide a relief of wound tension and precise apposition of the wound edges (Figures 4.7 and 4.8)
:: More complex and therefore more time-consuming to put in.

Vertical mattress technique

Vertical mattress sutures are best for allowing eversion of wound edges and perfect apposition and to relieve tension from the skin edges.

Figure 4.7
Figure 4.7

Figure 4.8
Figure 4.8

1 Start the first bite wide of the incision and pass to the same position on the other side of the wound.
2 The second step is a similar bite which starts on the side of the incision where the needle has just exited the skin. Pass the needle through the skin between the exit point and the wound edge, in line with the original entry point. From this point, take a small bite; the final exit point is in a similar position on the other side of the wound.
3 Tie the knot so that it does not lie over the incision line. This suture approximates the subcutaneous tissue and the skin edge.


Horizontal mattress sutures reinforce the subcutaneous tissue and provide more strength and support along the length of the wound; this keeps tension off the scar (Figures 4.9 and 4.10).

Horizontal mattress technique

1 The two sutures are aligned beside one another. The first stitch is aligned across the wound; the second begins on the side that the first ends.
2 Tie the knot on the side of the original entry point.

Figure 4.5
Figure 4.9

Figure 4.10
Figure 4.10


Continuous subcuticular sutures

:: Excellent cosmetic result
:: Use fine, absorbable braided or monofilament suture
:: Do not require removal if absorbable sutures are used
:: Useful in wounds with strong skin tension, especially for patients who are prone to keloid formation
:: Anchor the suture in the wound and, from the apex, take bites below the dermal-epidermal border
:: Start the next stitch directly opposite the one that precedes it (Figure 4.11).

Figure 4.11
Figure 4.11


Purse string sutures

l A circular pattern that draws together the tissue in the path of the suture when the ends are brought together and tied (Figure 4.12).

Figure 4.12
Figure 4.12


Retention sutures

:: All abdominal layers are held together without tension; the sutures take the tension off the wound edges
:: Use for patients debilitated as a result of malnutrition, old age, immune deficiency or advanced cancer; those with impaired healing and patients suffering from conditions associated with increased intra-abdominal pressure, such as obesity, asthma or chronic cough
:: Also use in cases of abdominal wound dehiscence
:: Monofilament nylon is a suitable material.


Retention sutures technique

1 Insert retention sutures through the entire thickness of the abdominal wall leaving them untied at first. Sutures may be simple (through-and-through) or mattress in type.
2 Insert a continuous peritoneal suture and continue to close the wound in layers.
3 When skin closure is complete, tie each suture after threading it through a short length of plastic or rubber tubing (Figures 4.13–4.16). Do not tie the sutures under tension to avoid compromising blood supply to the healing tissues.
4 Leave the sutures in place for at least 14 days.

Figure 4.13
Figure 4.13

Figure 4.14
Figure 4.14

 

Figure 4.15
Figure 4.15

 

Figure 4.16
Figure 4.16


> ABSORBABLE SUTURE
> NON-ABSORBABLE SUTURE
> NEEDLES
> KNOT TYING



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