Suturing
Indications for suturing
1. Clean wounds with minimal skin loss allowing for
closure under minimal tension
2. Securing drains/lines to prevent loss (e.g. central
lines, intercostal drains)
3. Operative closure
Contraindications to suturing
1 . Actively infected wound.
2. Grossly contaminated wounds.
3. Animal bite.
4. Suspected significant underlying vital structure damage e.g.,
nerve/tendon/vessel.
5. Wounds with significant skin loss as this may place undue
tension on the wound.
The suturing procedure
• Good hand washing technique and sterile gloving.
• Inspect the wound for any hazards (i.e. sharps)
• Start traumatic wound management technique (removal of
foreign bodies and debris)
• Irrigate the wound with 1 L of normal saline
• Administer local anesthesia
• Start suturing
• Dress the sutured wound
The suturing procedure (cont’d)
• Dispose sharps in the sharps bin
• Prescribe oral antibiotic if necessary to reduce the risk of
infection (co-amoxiclav 3 times daily for 5 days).
• Tetanus prophylaxis should be considered.
Complications of suturing
1. Poor apposition of wound edges (not completely closed)
2. ‘Dog Ear’- unsightly and bulky ends to a wound due to uneven closure
3. Stitch Marks
4. Stitch Abscess- localised inflammation/infection around the suture
material, more common with absorbable sutures
5. Infection- more common with braided sutures
6. Dehiscence
7. Skin necrosis
Natural Vs synthetic
Natural: silk and catgut
• Advantages:
1. cheap
2. Good handling and secured knotting.
• Disadvantage: antigenic (causing tissue reactivity).
Natural Vs synthetic
Synthetic: from manmade materials (e.g., nylon, prolene, etc.)
• Advantages:
1. Minimal tissue reactivity
2. More predictable tensile strength
3. Stronger than natural sutures of the same size.
• Disadvantage: difficult to handle (especially monofilament sutures).
Absorbable vs. non-absorbable
• Absorbable: broken by the body inflammatory reaction
(enzymatic hydrolysis) and absorbed (variable time of
absorption according to the size and material used). In another
words, they loss their tensile strength with time (usually a
change in the tensile strength occurs after 60 days from
application). Generally used for tissues that heel rapidly.
• Non-absorbable: remains unchanged in the body (walled-off by
the inflammatory reaction) until it is removed manually if
indicated. In another words, they relatively keep their tensile
strength for ever. Generally used for tissues that heal slowly such
as fibrous tissue and fascia also used for the skin.
Monofilament Vs Multifilament
Monofilament: made of single strand filament
• Advantages
1. Less risk of infection.
2. Less tissue trauma (smooth surface = les friction).
• Disadvantages
1. Difficult to handle (mainly due to ‘’memory’’ feature; in which the suture
maintains than shape of its packing rather than being straight.
2. Less secured knots (easy to be undone)
Monofilament Vs Multifilament
Multifilament: made of multiple filaments twisted together.
• Advantages
1. Secured knotting
2. Easy handling
• Disadvantages
1. Higher risk of infection (spaces between the filaments ca harbour bacteria)
2. More tissue trauma (has higher friction than monofilament sutures.)
Coated vs non-coated
1. Sometimes sutures are coated for
• Giving an antibacterial feature.
• Ease of passage through tissue.
• Decrease tissue reactivity.
2. Coating is for braided sutures only.
3. Examples of coats: wax, silicon, etc.
Needle
Types of needles
According to needle overall shape and size
According to cross-sectional shape
1. Round body needles
a. Taper Point Used in soft, easily penetrated tissue; e.g.:
• Peritoneum, abdominal viscera.
• Vascular procedures; internal anastomoses.
b. Taper Cut : Used in dense fibrous connective tissue, calcific or sclerotic
tissue.
c. Blunt Point : Used in extremely friable tissues; e.g.: liver, kidney.
Taper Cut Taper Point
Blunt Point
According to cross-sectional shape
2. Cutting needles
a. Conventional Cutting: Used in the skin, sternum
b. Reverse Cutting Used in:
• Skin
• Tendon sheath.
• Oral mucosa.
• Ophthalmic/cosmetic surgery.
• Preferred in subcuticular skin closure.
Reverse Cutting Conventional Cutting
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