“Stiches in Time”

Would Repair Workshop

44th Refresher Course in Family Medicine

March 23, 2017

UPMC Shadyside Family Medicine

Residency Teiichi Takedai, MD, FAAFP

Susan Skef, MD

Disclosure

I have no actual or potential conflict of interest

in relation to this program/presentation.

Objectives

• Demonstrate techniques for efficient wound closure

• Review general principles to minimize complications related to

wound closure

• Improvement on surgical skills through hands-on practice

Course schedule

Group 1

• 3:30 - 3:45 introduction

• 3:45 - 4:10 Hands on practice

• 4:10 - 4:20 Review, Q & A

Group 2

• 4:20 – 4:35 introduction

• 4:35 – 4:50 Hands on practice

• 4:50 - 5:00 Review, Q &A

Why time efficient suture is important?

• Decrease wound infection rate

• Decrease wound complications

• Achieve better cosmetic results

• Increase patient satisfaction

• Increase productivity…

How can we achieve time efficient

wound closure/repair?

• Correct tissue handling

• Correct handling of instruments

• Correct apposition of wound edges

• Correct choice of wound closure techniques

• Correct choice of wound repair materials

Wound types

• Depth

• Location

• Mechanism of injury

• Tissue damage

• Contamination

Wound closure ------

• Hemostasis

• Better cosmetic result

• Faster healing

• Pain relief

• Decrease wound infection

to be closed… or not to be closed...

• Time passed after injury--- “golden hours”

• Severity of contamination

• Mechanism of injury

• Location

• Foreign body

• Tension of wound

Ideal wound closure

Layer to layer repair

Epithelium, dermis, fat, fascia: each layer put

together and approximated and heals.

Maintain blood supply to the wound edges

Layer to Layer

Certain period of stability Dermis: 4

weeks, Fascia 6 weeks

Strength of tissue recovers to 50% 6 weeks

Time for tensile strength of 50%

perforator

Vascular network

4 weeks

72 hours

Vascular network

Principles of wound closure

Layer to Layer

Suture marks due to embedding suture materials、skin necrosis due to too

much tension

Wound should not be approximated too tightly. Anticipate tissue swelling

1. Atraumatic handling of wound tissue) Minimize the wound

damage

Holding skin forcefully with forceps can damage the tissue

Hold dermis or subcutaneous tissue of wound edge

or hold with skin hook

2. Approximate counter part of the skin layers

Correct wound approximation

Inversion of epithelium, overlapping delays epithelialization

3. Do not strangulate

Need antibiotic?

• Evaluate any evidence of wound infection

• Mechanism of injury

• Contamination (bite wound, etc)

• Hours passed from injury

Tetanus prophylaxis

Administer Tdap if

• Less than three tetanus toxoid in past

• >10 years from last shot

Administer tetanus immunoglobulin if

•Puncture wound or contaminated wounds who have never had

tetanus immunization

Local anesthesia

• Minimum amount with achieving most effective anesthesia

• Max amount: 4.5 mg/kg up to 300 mg lidocaine without epinephrine;

7mg/kg up to 500 mg lidocaine with epinephrine

• 1% 1 vial 20 ml =200 mg

• Caution for location/extension/layer of infiltration

• Speed of infiltration (slow infiltration)

• Consider to apply chloroethyl spray on needle puncture site

http://www.amazine.co/25679/apakah-etil-klorida-karakteristik-manfaat-efek-sampingnya/

Wound repair materials

• Sutures

• Adhesive tape

• Tissue glue

• Staples

Suture/needle size

• 3-0, 4-0: trunk

• 4-0, 5-0: extremities, scalp

• 5-0, 6-0: face

Needle types

弾機針 （バネ穴）

普通孔針 （ナミ穴） Needle with thread（atraumatic needle）

Needle Shapes

Suture materials

・ Non-absorbable

suture ⑴ Silk…Higher tensile, easy to tie, does not loosen, reactivity to tissue.

⑵ Nylon Monofilament …Non reactivity against tissue

easy to loosen, not flexible for tying.

⑶ Bladed thread, Polyfilament

…Surgilon

Suture materials

・ Absorbable suture

⑴Catgut…Synthesized from submucosal layer tissue of mammal

⑵Synthetic absorbable suture Bladed

Polysorb, Dexon, Vicryl, etc. absorbed in 2-3 months

Monofilament

Maxon…monofilament. Half life of tension -4 weeks PDS

Ⅱ…Monofilament. Half life of tension > 6 weeks Monodiox

Hands on session

Get your instruments on the desk!

Handling instruments Needle holder

Handling instruments Needle holder

Basics of suturing technique

Handling instruments forceps

Handling instruments Scissors

Interrupted sutures

Forsch, Randall, 2008, Am Fam Physicians, 78(8)945-951

Running sutures

Forsch, Randall, 2008, Am Fam Physicians, 78(8)945-951

Mattress sutures

• Vertical mattress

• Horizontal Mattress

Forsch, Randall, 2008, Am Fam Physicians, 78(8)945-951

Dermal Suture

①Hold the left side wound edge with forceps and put needle through few

mm in subcutaneous layer and pull out from the wound edge. Do not

make it too close to the skin surface. ( no less closer than 1 mm from the

skin surface. Suture can be exposed from wound later if it is too close)

②Hold deep in dermis or subcutaneous tissue

of the opposite side of wound edge with

forceps. Insert needle from wound edge

surface and pass a few mm within dermis and

drive into subcutaneous layer.

Dermal suture

③Wound closure with interrupted suture with instrumental tie

Tips for dermal suture

Grab and approximate enough amount of dermis

Make it as mildly high profiled wound edge when the skin/tissues

are approximated. Be aware not to raise too much for face and

neck since it may not become flattened later.

＊Avoid dermal sutures on eye lids ( thin skin), palm/soles

( mechanical stimulation may occur with suture materials, scalp

( could damage hair follicle)

Subcuticular running

Forsch, Randall, 2008, Am Fam Physicians, 78(8)945-951

Questions?

Thank you for your participation!

References

• Sherris, David, Kern, Eugene, 1999. Basic Surgical Skills: Mayo

Clinic Scientific Press

• Worster, Brooke, Zawora, Michele, Heieh Christine. 2015, Am Fam

Physicians, 91(2):86-92

• Forsch, Randall, 2008, Am Fam Physicians, 78(8)945-951

• Takedai, Teiichi, Komuro, Yuzo. Advanced Surgical Techniques in

Primary Care Office Procedures, 2016, Pittsburgh, FMEC.