Suturing Procedures Guidance, Exercises of Medicine

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School of Medicine, Dentistry & Nursing

Suturing Procedures

Guidance

Suturing - Contents

• Introduction Content Page No.
• Criteria for undertaking programme
• Learning Outcomes
• Practitioners’ Role in Suturing
• Anatomy & Physiology of the skin
• The healing process
• Types of Wounds
• Wound management & suturing
• Suture Material & Needles
• Tissue Adhesive
• Infection Control
• Pharmacology
• Procedural Guidelines (general)
• Advice to patients post-suturing
• Guidelines for Good practice
• Theoretical Assessment
• Record of Supervised practice
• Record of Completion of Programme
• Practitioner’s Evaluation Questionnaire
• References & Bibliography
• Authors, Contributors & Reviewers
• Appendix A (suturing check list)

The Practitioner's role in suturing Health care practitioners have become increasingly autonomous in anticipating and responding to individual patient needs in the context of changing health care. Practitioners need to consider methods of addressing needs in an innovative, flexible way but must first consider the implications of acquiring, developing and maintaining new skills. When developing new skills, it is not the activity that is the issue, but the context in which it is undertaken that is important. Integral to this is accountability, which encompasses responsibility, autonomy and authority. Anatomy and physiology of the skin Refer to an anatomy textbook and label this diagram of the skin.

Epidermis This is composed of keratinised, stratified, squamous epithelium which varies in thickness in different parts of the body, for example it is thick and heavily keratinised over the palms of the hands and the soles of the feet. There are no blood vessels or nerve endings in the epidermis. It consists of 5 layers of cells. The deeper layers contain interstitial fluid, which is drained away as lymph. Damage repair occurs via the germinal cell layer at the base of the epidermis. Repaired epidermis has normal cell structure and function. Dermis This is the living part of the skin and is the only area that bleeds when cut. It is composed of bundles of collagen which give it tensile strength, elastic which gives skin its elastic recoil and a gel matrix in which the collagen bundles, tissue cells, blood vessels and nerves are embedded. The following structures are contained within the dermis:

• Blood vessels

• Lymph vessels
• Sensory nerve endings
• Sweat glands and their ducts
• Hairs and their roots and follicles
• Sebaceous glands
• Arrectores pilorum. Repair to the dermis requires granulation. Hair follicles, sweat and sebaceous glands do not regenerate when granulation occurs. The nerve supply to the wounded area is also damaged. The scar tissue that forms is therefore dry in nature and less sensitive to further injury. **Principle functions of the skin

1. Protection** It provides a barrier against aqueous, chemical or mechanical injury, viral or bacterial invasion and environmental irradiation’s. 2. Thermoregulation It does this by utilising the circulatory system and by sweating (2.43 joules of body heat are lost for each programme of sweat evaporated from the body surface). 3. Sensation It contains nerve receptors which are sensitive to the stimuli of pain, temperature, pressure and touch.
2. Metabolisation The biosynthesis of Vitamin D takes place in the skin and this is important for bone structure and formation. 5. Communication Scarring from damage to the skin can result in altered body image. This in turn may alter the methods a person uses to communicate in order to compensate for this change.(Benbow, 1995)

Healing by Primary Secondary and Tertiary Intention

1. Primary Intention: The wound margins are very close together. Epithelialisation and the laying down of collagen fibres takes place quickly due to this marrying of the wound edges. Surgical incisions or clean, sutured trauma wounds heal in this fashion. 2. Secondary Intention: The wound margins are not joined and granulation is needed to heal from the base of the wound. More collagen is required to form new tissue and epithelialisation takes longer as the cells have a greater distance to migrate over the wound surface. Leg ulcers and pressure sores heal in this manner. (Emmet, 1992, Hollingsworth, 1994 ) 3. Tertiary Intention: Occurs when a wound, which breaks down, is resutured at a later date, bringing two opposing granulating surfaces together. This results in a deeper and more pronounced scar, e.g. surgical debridement. (Collier, 1996 ) The Healing Environment

• Moisture: A dressing that creates a moist healing environment may accelerate healing by up to 40%. (Collier, 1996)
• Removal of Dead Tissue and Exudate The presence of necrotic tissue, excess exudate and slough will delay wound healing. Excess exudate will saturate the wound and cause maceration at the wound edges where epithelialisation should be taking place. Hydrocolloids are good at debriding dirty wounds of this nature.
• Wound Protection There is a need to avoid any leakage that will link the wound with the outside environment and lead to infection. The dressing also needs to be non-adherent to prevent damage to the wound surface. The majority of occlusive dressings achieve good wound protection, but paraffin gauze may remove granulation tissue when changed.
• Acidity This is an area that the literature suggests requires further research. It has been put forward that acidity improves the oxygenation of the wound and a less alkaline environment helps to prevent infection. (Thomas, 1990 ). Hydrocolloids provide a healing environment of 5.6 - 6.7 pH.
• Oxygenation Obviously a vital element in wound healing. The formation of new blood vessels takes place more rapidly in a hypoxic environment, such as that provided by a hydrocolloid. The epidermis repairs more effectively in an oxygen-rich environment, such as that provided by semi- permeable film dressings.
• Temperature The ideal wound interface temperature is 37c. Mitotic activity slows down when wound temperature falls and takes 3 hours to return to normal, (Miller & Dyson 1997)

Types of wounds Sheehy (1992) describes six types of wound: a) Abrasions: Commonly referred to as “brush burn” and caused by skin rubbing on hard surfaces, the friction removes epithelial cells and possibly dermal. Healing is by secondary intention. b) Abscess: A cavity containing pus and surrounded by inflamed tissue formed as a result of suppuration in a localised infection. Healing usually occurs when abscess is drained or excised c) Avulsion: This type of wound produces full thickness skin loss. Healing is by secondary intention. d) Contusion: Collection of blood under the tissues without breaking the skin's integrity. e) Laceration: Two types of laceration

• Superficial (involves dermis/epidermis)
• Deep (extends through tissues) repair is by primary intention f) Puncture or Incision: Penetration of the tissues by a sharp object. Healing is by primary intention. It is important for the practitioner to be able to identify types of wounds to enable appropriate assessment and treatment.

toothbrush may also be necessary to remove dirt which, if left in place, could cause infection or tattooing.

Suturing Procedure

1. Selecting the suture material Suture material should be flexible enough for use in any operation, the only variable being determined by tensile strength. There are two types of sutures: a) Absorbable (temporary support) b) Non-absorbable (permanent support). A) Absorbable (catgut) This type of suture is capable of being absorbed by living mammalian tissue. It is manufactured from the submucosal layer of sheep intestine or the serosal layer of beef intestine, and is available in plain or chromic. Plain: looses half its strength in 10-14 days and all its effective strength in 21 days. Complete absorption occurs within 30-50 days. Chromic: looses half its strength in 11- 14 days and all its effective strength in 28 days. Complete absorption occurs within 45-90 days. B) Non - absorbable These sutures can be made from silk, polyester, polypropylene or stainless steel. 2. Selecting the Size of Suture Material If the suture used for wound closure is too thick wound healing can be delayed. Suture materials are gauged using metric figures however many individuals continue to refer to the old BPC gauges when referring to the size of materials used in suturing. In Metric, size 0.1 refers to the finest material, and 9 metric refers to the thickest. The table below shows comparisons between metric & BPC gauges. Metric 1 1.5 2 3 3.5 4 5 6 7 8 BPC 6/0 5/0 4/0 3/0 2/0 0 1 2 3 4 Figure 2. below lists the clinical application of different sutures Tissue Type of Suture BPC Ligature Catgut - coated vicryl Silk - mersilk

Skin Ethilon Prolene Mersilk

Subcuticular Coated Vicryl 2/0 - 1 Muscle Coated Vicryl 3/0 - 2 Stomach/Bowel Coated Vicryl 3/0 - 1 Tendons Prolene 8/0 - 2/ Cornea Ethilon Nerves Ethilon 10/0 - 5/ Figure3. below provides an approximate guide for skin suture gauges in adults and children:

3. Needle Strength Diameter of the wire from which the needle is manufactured is a major factor in determining its strength. A factor also to be considered is where the force is applied greater than that for which it is designed. The needle should bend, not break. When bending occurs, it is an indication that the critical point has been passed, so the needle should be discarded rather than attempt to straighten it.
4. Use of Needle Holders The needle holder should be carefully selected to match the size of needle used. Needles should be held on flatted area, not at the needle point or attachment area. (Benbow, 1995) 4. Selecting the type of suture The following are the most common:

• Simple interrupted
• Vertical mattress
• Horizontal mattress
• Sub-cuticular.

Simple interrupted suture This technique is usually applied to simple wounds, both traumatic and surgical, following excision of a skin lesion, for example. The needle is placed perpendicular to the wound on the opposite side approximately 3-5mms away (depending on the size and position of the wound) from the wound edge. The needle is passed preferably in a way so that it produces a pathway, which is wider at the base of the wound than at its surface. The proximal side is dealt with a reverse fashion. This will result in a “brandy” glass shape to the suture pathway. When the wound is approximated, eversion will occur. Demonstrates that equal bites are taken on either side of the wound. (The depth of the bites is also equal) It is important to ensure that the width and depth of the ‘bites” are similar on both sides to prevent an overlap of the wound edges. Small bites will produce precise approximation of small wounds, whereas larger bites are useful for eliminating dead space and for reducing tension in larger wounds (preventing ischaemia of the wound edges). The interval between sutures will vary with the particular wound. Too many sutures will lead to ischaemia; too little may lead to a poorly approximated wound. Continuous suturing instead of placing individual simple sutures is an alternative method. However, in day-to-day closure of simple wounds it is rarely used. It can produce ugly crosshatch marks and it may be difficult in making fine adjustments. Mattress sutures There are two different types of mattress sutures: vertical and horizontal.

Completion of horizontal mattress suture Subcuticular Sutures are placed in the subdermis level in a horizontal fashion taking equal bites. The ends are knotted so that they are also lying subcutaneously. Normally the intention is to leave the suture in-situ so an absorbable suture is needed. The suture is useful where the dead space and tension is minimal. If these situations exist, deep sutures are placed before inserting the subcuticular stitch. As the stitch is placed in the subdermis, cross-hatching is prevented. Subcuticular is placed longitudinally in the subcuticular plane Advantages of interrupted sutures are:

• easier to insert
• alternate sutures can removed
• suture removal is simpler
• easier to achieve accurate alignment of the wound surfaces Castille (1991) Advantages of continuous sutures are:
• Less risk of scarring / tattooing from sutures
• Less irritation caused by suture knots.

Tissue Adhesive Histoacryl glue can be used to close minor wounds and lacerations and is particularly suitable for children, since the procedure is less traumatic and quicker than suturing. (Barnett 1998, Richardson 2004) When using glue it is important the child is told the wound may feel warm when the special glue is applied. This prepares them for the exothermic reaction during polymerisation. The wound is cleaned with prescribed solution using an aseptic technique, then dried. Wound edges should be pushed and held together with your thumb and forefinger. A very thin layer or several dabs of histocryl is then applied to the surface to close the wound. Maintain pressure around the wound until the glue hardens - around 30 seconds. Avoid placing fingers too close to the wound as accidental spillage may adhere your glove to the patient. Wounds which require expert advice:

• Lacerations with ragged edges
• Deep wounds with excessive haemorrhagia
• Wounds close to the eye
• Wounds around the mouth. Preparation for suturing: The aims of closing a wound by placing sutures are to:
  • Eliminate any dead space ( Mackay-Wiggan et Ratner 2007 )
  • Support the wound until tensile strength is recovered, to prevent wound from dehiscing
  • Allow skin edges to be accurately approximated to produce a cosmetically and functionally acceptable wound. i.e. primary intention
  • Prevent healing by secondary intention, which may result in an unacceptable scar
  • Reduce bleeding and infection. Explanation and consent Ensure patient has understood what is happening and given consent. Explain the procedure to the child and carer in language which is easily understood. Obtain consent from a guardian. Ideally the child should sit or lie on the parent’s lap.

Safe Disposal of Sharps

• The person actually suturing is responsible for the safe handling and disposal of all sharps used in the procedure.
• Prepare equipment before starting the procedure, including a sharps container.
• Sharps container should be attached to the trolley and taken to the patient being sutured.
• Take a note of all sharps used in the procedure and make sure they are all safely disposed of afterwards.
• Keep hands behind the sharps point or blade at all times.
• Dispose of used needles at the point of use. Disposal of Clinical Waste Any waste which is contaminated wholly or partly with body fluids will generally be placed in an orange plastic bag which is marked “Clinical Waste”. Waste generated during a suturing procedure is classified as clinical waste. (Benbow, 1995) Pharmacology Considerations related to Suturing Pharmacological considerations in relation to suturing focus almost exclusively on local anaesthesia and Tetanus prophylaxis. Local anaesthesia Lignocaine 1% without adrenaline is most commonly used. It temporarily inhibits nerve impulses from the sensory nerves by stabilising neuronal impulses, causing a reversible block. This endures for between 30 - 120 minutes. (Smithing 2002) Safe doses: 3mg / Kg body weight. Great care should be taken to avoid intravascular injection of Lignocaine. Any local anaesthesia should not be injected into inflamed tissue or directly into the traumatised tissue, as this can result in the Lignocaine being so rapidly absorbed that a systemic rather than a local reaction is produced. Adverse / side effects As with any drug, side effects / reactions are possible. However, allergy to commonly used local anaesthetics is extremely rare. The following are potential symptoms and side effects of toxicity , which may occur as a result of accidental intravascular injection of Lignocaine:
• Perioral tingling
• metallic taste
• restlessness
• dizzy
• slurred speech
• convulsions/coma
• bradycardia
• circulatory collapse. (Brown 1992) Tetanus Clostridium tetani gram-positive, spore-forming anaerobic bacillus causes tetanus. Once activated, it becomes highly resistant because of its ability to produce spores. Incubation ranges from two days to two weeks. It exists in soil, garden moss and animal/human excreta and enters the body through open wounds.

The bacillus attaches to cells in the CNS, causing respiratory depression in the medulla. Signs & Symptoms local joint stiffness generalised stiffness trismus seizures trismus trismus back pain difficulty swallowing tacchycardia Hypertension hyperpyrexia opisthotonus Tetanus Toxoid is used for Tetanus prophylaxis. This is normally given as an IM injection followed by 2 booster injections at 4 weeks and two years. The Tetanus status of any patient with a wound should be assessed and treated as outlined in the table below: INSERT TETANUS TABLE