basic wound closure & knot tying primer vic vernenkar, d.o. dept. of surgery st. barnabas...

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Basic Wound Closure & Basic Wound Closure & Knot Tying Primer Knot Tying Primer Vic Vernenkar, D.O. Vic Vernenkar, D.O. Dept. of Surgery Dept. of Surgery St. Barnabas Hospital St. Barnabas Hospital

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Page 1: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Basic Wound Closure & Basic Wound Closure & Knot Tying PrimerKnot Tying Primer

Vic Vernenkar, D.O.Vic Vernenkar, D.O.

Dept. of SurgeryDept. of Surgery

St. Barnabas HospitalSt. Barnabas Hospital

Page 2: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

ObjectivesObjectives

Provide basic information on Provide basic information on commonly used suture materialscommonly used suture materials

Review general principles of wound Review general principles of wound closureclosure

Provide a general overview of basic Provide a general overview of basic surgical knot tyingsurgical knot tying

Page 3: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Suture MaterialSuture Material

Generally categorized by three Generally categorized by three characteristics:characteristics: Absorbable vs. non-absorbableAbsorbable vs. non-absorbable Natural vs. syntheticNatural vs. synthetic Monofilament vs. multifilamentMonofilament vs. multifilament

Page 4: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Absorbable SutureAbsorbable Suture

Degraded and eventually eliminated in Degraded and eventually eliminated in one of two ways:one of two ways: Via inflammatory reaction utilizing tissue Via inflammatory reaction utilizing tissue

enzymesenzymes Via hydrolysisVia hydrolysis

Examples:Examples: ““Catgut”Catgut” ChromicChromic VicrylVicryl MonocrylMonocryl PDSPDS

Page 5: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Non-absorbable SutureNon-absorbable Suture

Not degraded, permanentNot degraded, permanent Examples:Examples:

ProleneProlene NylonNylon Stainless steelStainless steel Silk*Silk*

(*not a truly permanent material; known to be (*not a truly permanent material; known to be broken down over a prolonged period of time—broken down over a prolonged period of time—years)years)

Page 6: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Natural SutureNatural Suture

Biological originBiological origin Cause intense inflammatory reactionCause intense inflammatory reaction Examples:Examples:

““Catgut” – purified collagen fibers from Catgut” – purified collagen fibers from intestine of healthy sheep or cowsintestine of healthy sheep or cows

Chromic – coated “catgut”Chromic – coated “catgut” SilkSilk

Page 7: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Synthetic SutureSynthetic Suture

Synthetic polymersSynthetic polymers Do not cause intense inflammatory Do not cause intense inflammatory

reactionreaction Examples:Examples:

VicrylVicryl MonocrylMonocryl PDSPDS ProleneProlene Nylon Nylon

Page 8: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Monofilament SutureMonofilament Suture

Grossly appears as single strand of suture Grossly appears as single strand of suture material; all fibers run parallelmaterial; all fibers run parallel

Minimal tissue traumaMinimal tissue trauma Resists harboring microorganismsResists harboring microorganisms Ties smoothlyTies smoothly Requires more knots than multifilament Requires more knots than multifilament

suturesuture Possesses memoryPossesses memory Examples:Examples:

Monocryl, PDS, Prolene, NylonMonocryl, PDS, Prolene, Nylon

Page 9: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Multifilament SutureMultifilament Suture

Fibers are twisted or braided togetherFibers are twisted or braided together Greater resistance in tissueGreater resistance in tissue Provides good handling and ease of Provides good handling and ease of

tyingtying Fewer knots requiredFewer knots required Examples:Examples:

Vicryl (braided)Vicryl (braided) Chromic (twisted)Chromic (twisted) Silk (braided)Silk (braided)

Page 10: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Suture DegradationSuture Degradation

Suture Suture MaterialMaterial

Method of Method of DegradationDegradation

Time to Time to DegradationDegradation

““Catgut”Catgut” Proteolytic Proteolytic enzymesenzymes DaysDays

Vicryl, Vicryl, MonocrylMonocryl HydrolysisHydrolysis Weeks to Weeks to

monthsmonths

PDSPDS HydrolysisHydrolysis MonthsMonths

Page 11: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Suture SizeSuture Size

Sized according to diameter with “0” as reference sizeSized according to diameter with “0” as reference size Numbers alone indicate progressively larger sutures Numbers alone indicate progressively larger sutures

(“1”, “2”, etc)(“1”, “2”, etc) Numbers followed by a “0” indicate progressively Numbers followed by a “0” indicate progressively

smaller sutures (“2-0”, “4-0”, etc)smaller sutures (“2-0”, “4-0”, etc)

Smaller Smaller --------------------------------------------------------------------------LargerLarger

.....”3-0”...”2-0”...”1-.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....0”...”0”...”1”...”2”...”3”.....

Page 12: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

NeedlesNeedles

Classified according to shape and type Classified according to shape and type of pointof point

Curved or straight (Keith needle)Curved or straight (Keith needle) Taper point, cutting, or reverse cuttingTaper point, cutting, or reverse cutting

Page 13: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

NeedlesNeedles

CurvedCurved Designed to be held Designed to be held

with a needle with a needle holderholder

Used for most Used for most suturingsuturing

StraightStraight Often hand heldOften hand held Used to secure Used to secure

percutaneously percutaneously placed devices (e.g. placed devices (e.g. central and arterial central and arterial lines)lines)

Page 14: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

NeedlesNeedles

Taper-point needleTaper-point needle Round bodyRound body Used to suture soft Used to suture soft

tissue, excluding tissue, excluding skin (e.g. GI tract, skin (e.g. GI tract, muscle, fascia, muscle, fascia, peritoneum)peritoneum)

Page 15: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

NeedlesNeedles

Cutting needleCutting needle Triangular bodyTriangular body Sharp edge toward Sharp edge toward

inner circumferenceinner circumference Used to suture Used to suture skinskin

or tough tissueor tough tissue

Page 16: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Suture PackagingSuture Packaging

Page 17: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Wound ClosureWound Closure

Basic suturing techniques:Basic suturing techniques: Simple suturesSimple sutures Mattress suturesMattress sutures Subcuticular suturesSubcuticular sutures

Goal: “approximate, not Goal: “approximate, not strangulate”strangulate”

Page 18: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Simple SuturesSimple Sutures

Simple interrupted Simple interrupted stitchstitch Single stitches, Single stitches,

individually knotted individually knotted (keep all knots on (keep all knots on one side of wound)one side of wound)

Used for Used for uncomplicated uncomplicated laceration repair laceration repair and wound closureand wound closure

Page 19: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Mattress SuturesMattress Sutures

Horizontal mattress Horizontal mattress stitchstitch Provides added Provides added

strength in fascial strength in fascial closure; also used in closure; also used in calloused skin (e.g. calloused skin (e.g. palms and soles)palms and soles)

Two-step stitch:Two-step stitch: Simple stitch madeSimple stitch made Needle reversed and Needle reversed and

2nd simple stitch made 2nd simple stitch made adjacent to first (same adjacent to first (same size bite as first stitch)size bite as first stitch)

Page 20: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Mattress SuturesMattress Sutures

Vertical mattress stitchVertical mattress stitch Affords precise Affords precise

approximation of skin approximation of skin edges with eversionedges with eversion

Two-step stitch:Two-step stitch: Simple stitch made – Simple stitch made –

“far, far” relative to “far, far” relative to wound edge (large bite)wound edge (large bite)

Needle reversed and Needle reversed and 2nd simple stitch made 2nd simple stitch made inside first – “near, near” inside first – “near, near” (small bite)(small bite)

Page 21: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Subcuticular SuturesSubcuticular Sutures

Usually a running Usually a running stitch, but can be stitch, but can be interruptedinterrupted

Intradermal Intradermal horizontal biteshorizontal bites

Allow suture to Allow suture to remain for a longer remain for a longer period of time period of time without without development of development of crosshatch scarringcrosshatch scarring

Page 22: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Steri-stripsSteri-strips

Sterile adhesive Sterile adhesive tapestapes

Available in different Available in different widthswidths

Frequently used with Frequently used with subcuticular suturessubcuticular sutures

Used following staple Used following staple or suture removalor suture removal

Can be used for Can be used for delayed closuredelayed closure

Page 23: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

StaplesStaples

Rapid closure of Rapid closure of woundwound

Easy to applyEasy to apply Evert tissue when Evert tissue when

placed properlyplaced properly

Page 24: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Two-Hand Square KnotTwo-Hand Square Knot

Easiest and most Easiest and most reliablereliable

Used to tie most Used to tie most suture materialssuture materials

Page 25: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Instrument TieInstrument Tie

Useful when one or Useful when one or both ends of suture both ends of suture material are shortmaterial are short

Commonly used Commonly used technique for technique for laceration repairlaceration repair

Page 26: Basic Wound Closure & Knot Tying Primer Vic Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

ReferencesReferences

Encyclopedia of Knots provided by Ethicon; available at Encyclopedia of Knots provided by Ethicon; available at www.jnjgateway.com/public/USENG/5256ETHICON_Encyclopedia_of_Knots.www.jnjgateway.com/public/USENG/5256ETHICON_Encyclopedia_of_Knots.pdfpdf (More extensive overview of knot tying with photos for those interested in (More extensive overview of knot tying with photos for those interested in surgery)surgery)

Blackbourne, LH, editor. Surgical Recall. 2Blackbourne, LH, editor. Surgical Recall. 2ndnd ed. Baltimore: Lippincott ed. Baltimore: Lippincott Williams & Wilkins; 1998Williams & Wilkins; 1998

Cameron, JL, editor. Current Surgical Therapy. 7Cameron, JL, editor. Current Surgical Therapy. 7thth ed. St. Louis: Mosby; ed. St. Louis: Mosby; 20012001

Edgerton, MT. The Art of Surgical Technique. Baltimore: Williams & Edgerton, MT. The Art of Surgical Technique. Baltimore: Williams & Wilkins; 1988 Wilkins; 1988 (Excellent resource for technical details of surgery)(Excellent resource for technical details of surgery)

Gomella, LG, Haist, SA. Clinician’s Pocket Reference. 9Gomella, LG, Haist, SA. Clinician’s Pocket Reference. 9thth ed. New York: ed. New York: McGraw-Hill Medical Publishing Division; 2002 McGraw-Hill Medical Publishing Division; 2002 (Useful book for anyone (Useful book for anyone doing clinical rotations!)doing clinical rotations!)