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Lee Dresang: Hi. This Lee Dresang with the
University of Wisconsin Department of Family Medicine.
This suturing workshop video is shown in part to hands
on session which we hold for our residents each year.
The overall objective is to teach didactics ahead of
time so that the workshop time can focus on supervised
suturing. Specific objectives include learning
indications for suturing, when to refer, potential
complication, informed consent issues, instruments
needed, and suturing needle types. Also, anesthesia
options and technique, types of suturing, and ties and
follow up instructions. Indications may include
closing a laceration after a delivery or from trauma,
closure of skin or deeper incision from surgery or
after removal of a lesion. Referral may be preferable
with lacerations to the face, large lesions, and
vascular lesions. Potential complications include
bleeding, infection, anesthesia reaction, scar, scar
dehiscence, and need for repeat procedure. Verbal and
signed consent should be obtained before every
procedure, even minor procedures. Instruments needed
include a needle holder, tissue forceps, and scissors.
Absorbable and non-absorbable sutures are listed here.
The suture size 1 is bigger than 0, is bigger than
1'0, is better than 2'0. Needle size terminology
differs depending on the needle brands with vicryl,
for example, with obstetrical lacerations, CT and CT-1
are standard, CT-X is a larger needle, SH is a smaller
urology needle. Prior to cleaning and repairing a
laceration, adequate anesthesia is essential.
Lidocaine with epinephrine will last longer and result
in less bleeding, but has traditionally not been
recommended for extremities. Marcaine will last
longer than Lidocaine. It's essential to irrigate a
wound well before closing it. One should avoid
getting betadine into a wound. A simple interrupted
suture is easy to learn and fast to place, but may not
be able to withstand stress as well as others.
Vertical mattress suture results in good aversion of
skin edges and closes dead space and may provide some
extra strength, but it takes longer to place.
Horizontal mattress suture, again, may result in good
aversion of skin edges and provide extra strength but
it takes longer to place. We will soon demonstrate a
corner stitch which approximates angled skin flaps
without compromising blood supply. Subcutaneous
sutures may provide a better scar and there is no need
to have the suture removed. Compared with interrupted
sutures, continuous sutures are quicker to place and
divide tension equally along the skin edge. Locking
sutures traditionally are thought to provide better
hemostasis, non-locking to provide less risk of tissue
necrosis. In the upcoming videos, we will demonstrate
an instrument tie, a double handed tie, and a single
handed tie.
First we'll demonstrate a simple
interrupted suture with a instrument tie.
Demonstrating the length of the incision or
dividing in half to avoid dog ears. Place the
needle at a 90 degree angle. Use your wrist to
turn the needle through. Hold the end of the
suture to not pull it through, and leave a tail
long enough for tieing the suture. Place the
instrument between the two sutures, throw it twice
for a surgeon's knot, cross your hand and the
instrument to allow the knot to lie flat. Again,
put the instrument in the middle and cross, and the
knot again will be flat automatically as you cross
your hand in the instrument. With the non-braided
suture, four to six throws is adequate.
Now we will demonstrate a corner stitch with
a two handed tie. With the corner stitch, imagine a
plum line through the middle of the flat. The
first suture starts above the apex and is parallel
to the plum line, then lift the flap, and from one
side of the plum line to the other, place the
subcutaneous suture. Finally, in the other
direction, place another suture parallel to the
plum line that comes out parallel to where the
first suture went in. Then hold the end of your
suture as you pull through so you don't pull the
string all the way through and leave yourself a
long enough tag for a two handed tie. You'll cross
the top string above and the shorter string below.
With that longer string over your index finger,
take the shorter string and pull it over your index
finger, rotate your hand, pinch, and then pull, and
you'll see how the knot lies flat here. Now we did
not throw a surgeon's knot to start with, we'll
demonstrate that in a second. Here, you can see
that the corner stitch would avoid some necrosis to
the tip of the flap, which might otherwise face
vascular compromise with a series of simple
interrupted sutures. Here we'll throw a second
time to have a surgeons knot and you may appreciate
how this will stay better until you place your
second suture. For the second suture, with the
long end of suture, put your thumb behind it with
the short end, pull it over your thumb, again,
pinch and push the short end through the hole.
This time you'll want to cross your wrist, your
hands, to get the suture to lie flat. Now that
your second knot is tied, it won't slip, and from
here on, no surgeon's knot is necessary. Then
alternate back over your index finger pulling apart
behind your thumb, pinch through, pull through and
cross. Four to six throws is adequate.
Now we will demonstrate a vertical mattress
suture with a one handed tie. The first part of
this suture is placed distant from the skin edges,
grasping the needle with a forceps and not using a
hand to load the needle driver. Hold the end of
your sutures, you pull so you don't pull it all the
way through, then closer to the skin edges, come
back in the opposite direction. The vertical
mattress suture helps avert the skin edges and
gives more strength. It's good for areas such as
the back, which are under more tension. The
sutures is pinched between the third finger and the
thumb and over the index finger. The index finger
is bent and the short end caught with the back of
the second finger and pinched with the third finger
and pulled through the loop. The hands are crossed
to lay a flat knot. For the second half of the one
handed tie, pinch between the thumb and the
forefinger with the short end, pull the long end
over the third finger, bent, grasp the short end
with the third and fourth digit, pull through the
loop and lie a knot flat.
Speaker: Follow up instructions are
important once the suture is placed. Patients may be
advised to keep the incision dry for 24 hours, monitor
for signs of infection, particularly to call with
spreading redness, ***, and fever. Depending where
the sutures are placed, there may be a recommendation
for no heavy lifting or pelvic rest. Sutures are
generally removed sooner on the face after three to
five days to avoid scarring and left longer on lower
extremities and extensor surfaces perhaps as long as
two weeks. For the rest of the body sutures are
generally removed after seven to ten days. Suturing
is not just a cognitive but also a psychomotor skill.
We hope you find this video a helpful review of the
basics.