Transcript
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I. TYPES OF STITCHES
1. Continuous Suture:
-the tissue is held together by a suture which runs over and over like a seam in a
shirt.
-It is an alternative to interrupted sutures in almost every part of surgery.
-it is the normal way of anastomosing (joining ) blood vessels down to 5mm.
diameter.
Advantages:
>Quicker to do than interrupted stitches.
>Uses less suture material
>Prevents high pressure leakages.
>Fewer knots to harbour infection.
Against Continuous Sutures:
>May cause narrowing of anastomoses in the short term.
>If non absorbable, do not allow for growth in children in the long term.
>May cause more damage to the tissues.
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>One failure of a knot or the suture will lead to the whole suture line giving way.
>It is less easy to stitch wound edges of unequal length.
>It is more painful to remove from skin because there is no knot to lift the suture
away from the skin when cutting.
>The whole suture line in the skin has to be removed at the same time.
>Individual sutures cannot be removed.
>More potential for contaminating the wound with the suture material on skin stitch
removal.
Types:
A. PLAIN CONTINUOUS
This is a dressmaker's running stitch.
Description:
There is a knot at the start and at the end of the suture line.
The start knot must be very secure with extra (4) throws and cut longer than usual
(10mm.).
If a double suture is used, a looped start is safe.
The end knot needs as many extra throws as the start knot.
Tie together the end of the suture and the doubled length of suture from the next to
last stitch.
The doubled length of suture forms a loop which does not tighten equally at the
knot.
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Pull on the slack arm of the loop to make the end knot tighten properly.
Bury the cut ends of the knots to prevent them sticking out of the wound when
closing the linea alba of the abdomen.
Oversew the cut ends of the start knot when closing the linea alba.
Run the ends of the end knot back into the suture line in the linea alba before
cutting them.
B.MATTRESS CONTINUOUS
>The end knot needs as many extra throws as the start knot.
>Tie together the end of the suture and the doubled length of suture from the next
to last stitch.
>The doubled length of suture forms a loop which does not tighten equally at the
knot.
>Pull on the slack arm of the loop to make the end knot tighten properly.
>Bury the cut ends of the knots to prevent them sticking out of the wound when
closing the linea alba of the abdomen.
>Oversew the cut ends of the start knot when closing the linea alba.
>Run the ends of the end knot back into the suture line in the linea alba before
cutting them.
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TYPES:
VERTICAL MATTRESS SUTURE
>Useful in reducing the dead space and to approximate the edges of relatively
deeper incisions.
>It facilitates wound eversion.
>Insert the needle approximately from the edge. Take a deeper bite.
>Exit through the opposite edge at the same width.
>Using a backhand grip take a bite closer to the edge and exit on the opposite
side at the same width.
>Tie a knot.
HORIZONTAL MATTRESS SUTURE
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>Good for wound eversion
>Good for wounds under high tension
>Insert the needle approximately from the edge.
>Exit through the opposite edge at the same width.
>Reenter the same side approximately from the exit site and come through the
edge where the first bite was started.
>Tie the knot.
(Caution: horizontal knots are known to cause tissue necrosis more often, if the
knot is tied too tight)
*corner stitch
>a common suture technique.
> It used to close wounds that are angled or Y-shaped without appreciably
compromising blood supply to the wound tip.
>a variation of the horizontal mattress stitch, and is cometimes called the "half-
buried horizontal mattress stitch">
the needle enters the skin on one side of the obtuse angle of the wound, passes
through the deep dermis of the corner flap, and is re-inserted through the dermis of
the other side of the obtuse wound angle.
>it finally re-emerges through the epidermis on the side of the obtuse angle,
adjacent to the initial entry point.
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*chest drain suture
>method for securing a chest drain with one suture.
> a modified horizontal mattress stitch.
>upon removal of the drain the suture can be used for closing the wound without
placing a new stitch and the need for local anesthetics.
C. BLANKET CONTINUOUS
Continuous blanket stitch.
This is also for skin closure.
It is a variant of the continuous plain stitch without particular advantages.
It is easy to learn.
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D. CONTINUOUS SUBCUTANEOUS SUTURE
>Useful to approximate the edges of deeper layers to reduce the dead space.
>Starting from one end of the incision, first take bites on both edges
subcutaneously. Tie a knot.
>Burry the knot. But do not cut the needle end of the suture.
>Take small bites one side and the other alternatively in a continuous manner.
>At the end of the incision tie a knot between the loose end and the loop of the last
bite. Cut the free ends close to the knot and burry it.
>The superficial layer can be closed with simple interrupted sutures or continuous
cutaneous suture.
2. INTERRUPTED SUTURES
- individual stitches, each tied separately compared to a conituous suture
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SIMPLE INTERRUPTED SUTURES
>Most commonly used suture
>Start by inserting the needle perpendicular to the skin. Go through enough of
subcutaneous tissue.
>Exit through the opposite edge of the incision at the same angle.
>Tie both ends together.
>Caution: Tie the knot only sufficiently tight. Too tight a knot would cause tissue
necrosis. Too loose would hamper the healing.
3. DEEP BURRIED SUTURE
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>It is most useful to reduce the dead space of deeper incisions. It approximates the
tissues better. >That way it reduces the tension on the cutaneous sutures.
>Take a backhanded bite of deeper layer of subcutaneous tissue
>Exit out of relatively superficial part of the subcutaneous tissue.
>Enter the superficial layer of subcutaneous tissue of the opposite edge.
>Exit from the deeper layer of the subcutaneous tissue.
>Pull the tissues close.
>Tie the knot. Cut the loose ends close to the knot.
>Burry the knot
4. CONTINUOUS LOCKED SUTURE
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>This is a variation of continuous suture.
>It provides beeter strength to the wound.
>Useful for incisions with moderate tension
>Has the disadvantage of tissue necrosis in poorly vascularized areas or if the knotsare too tight.
>Just like continuous suture, first place a simple suture. Do not cut the needle end
of the suture.
>After each stitch is placed, as in continuous suture, the needle is passed through
the loop of the preceding suture. Gentle torsion is made before the next loop is
placed.
>Final knot is made just like in continuous suture between the free end and the
loop of the preceding suture.
GENERAL INCISION CARE
Guidelines for home care of an incision vary somewhat depending on the material
that was used for closure, the location and size of the incision, and the nature of the
operation. The following section is a general description of the major aspects of
incision care.
Patients should ask their doctor for specific information about caring for their
incision:
>the type of closure used
>whether another appointment will be needed to remove any sutures or staples
>the length of time that the incision should be kept covered, and the type ofdressing that should be used
>whether the incision must be kept dry, and for how long
>any specific signs or symptoms that should be reported to the doctor
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Most hospitals and surgery clinics provide patients with written handouts or
checklists about incision care; however, it is always helpful to go over the
information in the handout with the doctor or nurse, and to ask any further
questions that may arise.
a. BATHING AND SHOWERING. Incisions should be kept dry for several days after
surgery, with the exception of incisions closed with tissue glue. Incisions closed with
nonabsorbable sutures or staples must be kept dry until the doctor removes the
sutures or staples, usually about seven to 10 days after surgery. Incisions closed
with Steri-strips should be kept dry for about four to five days. If the incision gets
wet accidentally, it must be dried at once. Patients with incisions on the face,
hands, or arms may be able to take showers or tub baths as long as they are able to
hold the affected area outside the water. Patients with incisions in other parts of the
body can usually take sponge baths.
It is usually safe to allow incisions closed with tissue glue to get wet during
showering or bathing. The patient should, however, dry the area around the incision
carefully after washing.
b. PHYSICAL ACTIVITY AND EXERCISE. Patients should avoid any activity that is
likely to pull on the edges of the incision or put pressure on it. Walking and otherlight activities are encouraged, as they help to restore normal energy levels and
digestive functions. Patients should not, however, participate in sports, engage in
sexual activity, or lift heavy objects until they have had a postoperative checkup.
c. MEDICATIONS. Patients are asked to avoid aspirin or over-the-counter
medications containing aspirin for a week to 10 days after surgery, because aspirin
interferes with blood clotting and makes it easier for bruises to form in the skin near
the incision. The doctor will usually prescribe codeine or another non-aspirin
medication for pain control.
Patients with medications prescribed for other conditions or disorders should ask
the doctor before starting to take them again.
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d. SUN EXPOSURE. As an incision heals, the new skin that is formed over the cut is
very sensitive to sunlight and will burn more easily than normal skin. Sunburn in
turn will lead to worse scarring. Patients should keep the incision area covered for
three to nine months from direct sun exposure in order to prevent burning and
severe scarring.
SPECIAL CONSIDERATIONS FOR FACIAL INCISIONS. Patients who have had facial
surgery are usually given very detailed instructions about incision care because the
skin of the face is relatively thin, and incisions in this area can be easily stretched
out of alignment. In addition, patients should not apply any cosmetic creams ormakeup after surgery without the surgeon's approval because of the risk of
infection or allergic reaction.
GENERAL HYGIENE. Infection is the most common complication of surgical
procedures. It can be serious; of the 300,000 patients whose incisions become
infected each year in the United States, about 10,000 will die. It is important,
therefore, to minimize the risk of an infection when caring for an incision at home.
Patients should observe the following precautions about general cleanliness and
personal habits:
wash hands carefully after using the toilet and after touching or handling trash or
garbage; pets and pet equipment; dirty laundry or soiled incision dressings; and
anything else that is dirty or has been used outdoor
ask family members, close friends, and others who touch the patient to wash their
hands first
avoid contact with family members and others who are sick or recovering from a
contagious illness
stop smoking (smoking slows down the healing process)
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Risks
Some patients are more likely to develop infections or to have their incision split
open, which is known as dehiscence. Risk factors for infection or dehiscence
include:
>obesity
>diabetes
>malnutrition
>a weakened immune system
>taking corticosteroid medications prescribed for another disorder or condition
>a history of heavy smoking
>Warning signs
Patients who notice any of the following signs or symptoms should call their doctor:
fever of 100.5F (38C) or higher
severe pain in the area of the incision
intense redness in the area of the incision
bruising
bleeding or increased drainage of tissue fluid
Normal results
As an incision heals, it is normal to experience some redness, swelling, itching,
minor skin irritation or oozing of tissue fluid, or small lumps in the skin near the
incision. At first, the skin over the incision will feel thick and hard. After a period of
two to six months, the swelling and irritation will go down and the scar tissue will
soften and begin to blend into the surrounding tissue.
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II. TYPES OF SUTURES
>Absorbable Sutures
-are sterile strands prepared from collagen derived from healthy mammals or
from a synthetic polymer.
-capable of being absorbed by being resistance to absorption
1. Surgical Gut
-collagen derived from submucosa of sheep intestine of the serosa of beef
intestine
-digested by tissue thus no permanent foreign body remains
2. Plain Surgical Gut
- used to ligate small vessels and to suture subcutaneous fat
-losses tensile strength relatively quickly, usually in five to ten days and is
digested within 70 days because collagen strands are not treated to resist
absorption
3. Chromic Surgical Gut
- treated un a chromium salt to resist absorption by tissues for varyinglenghts of time
depending on strength of solution, duration and method of process.
-it is used for ligation of larger vessels and for suture of tissues in which non-
absorbable materials are not usually recommended because they may act as nidus
for stone formation, as in the urinary and biliary tracts.
4. Collagen sutures
- are extruded for a homogenous dispersion of pure collagen fibrils from
tendons of beek.
- used primarily in opthalmic surgery
5. Synthetic Absorbable Polymers
-are used for ligating or suturing except in tissues where extended
approximation of tissues under stress is required
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6. Polydioxnone
- a monofilament suture extruded from the polyester
-particularly useful in tissues where both an absorbable suture and extendedsupport are desirable
7. Polyglycolic 9/0
- are controlled combination of glycolide and lactide resulting in a copolymer
with a molecular structure that maintains tensile strength longer than a surgical gut
Available in 2 forms:
- uncoated monofilament
-coated filament
8. Polyglycolic acid
-is a homopolymer which loses tensile strength more rapidly and absorbs
within 30 days
>Non-absorbable
1. Surgical silk
- an animal product made from the fiber spun by the silkworm larvae in
making cocoons.
-gives good support to wound during ambulatiob and generally promotes
wound healing a little more rapidly than a surgical gut
2. Virgin silk suture
-consists of several natural silk filaments drawn together and twisted to form
8-0 and 9-0 strands for tissue approximation of delicate strucures primarily in
ophthalmic surgery
3. Surgical cotton suture
-is made from individual. long-staple cotton fibers that are combed, aligned
and twisted into a smooth multifilament strand
3. Surgical linen
- spun from long-staple, flax fibers and then twisted into tight strands and
thread from smooth passage through tissue
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-used almost exclusively in GI surgery
4. Surgical stainless steel
-drawn from 316L-88 (L for low carbon) iron alloy wire
-used in surgical stainless steel implants and prostheses
-synthetic non-absorbable sutures are used to replace silk because they have
higher tensile strength and elicit less reaction
5. Surgical nylon
- a polymide polymer derived by chemical synthesis from coal, air and water
6. Polymer Fiber
-is a polymer of terephthalic acid and polyethylene such as silicon, mersilene,
person and others
7. Polypropylene
- is a long-chain plastic plymer extruded into a blue dyed monofilament
suture strand.
-is an acceptable substitute for stainless steel in situations where strength
and reactivity are required and the suture must be left in place for prolonged
healing
8. Wire
-a surgical steel wire of heavy gauge with pointed ends; used in the reduction
and fixation of bone fragments by passing it through the cancellous portion of the
bone and spanning the fracture site.
9. Dacron
-polyethylene terephthalate, a polyester synthetic material used widely for
vascular prostheses.
10. Silver Wire Clips
-used to prevent a blood vessel from bleeding into the brain or a clip may be
used in a vasectomy to pinch together the sides of the vas deferens.
11. Silkworm gut
-this is made from the fluid secreted by the silkworm when they are ready to
form their cocoons. The disadvantage is that they must be soaked in normal saline
for about 10 minutes before use to make them pliable.
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12.Mesh
-a woven fabric used for chest wall reconstruction, strengthening tissues,
provide support for internal organs, and to treat surgical or traumatic wounds. The
fabric is usually made of Gore-Tex, Teflon, polypropylene or some other
polymer, although a titanium mesh has been used in some back surgeries. Themost common types of surgical mesh are hernia mesh, stress urinary incontinence
slings and mesh for treating prolapse.
13. Tantalum
-A rare metallic element, atomic number 73, atomic weight 180.948, symbol
Ta. It is a noncorrosive and malleable metal that has been used for plates or disks
to replace cranial defects, for wire sutures, and for making prosthetic devices
III. SUTURE SIZES:
- The size of suture material is measured by its width or diameter and is vital
to proper wound closure. As a guide the following are specific areas of their usage:
>1-0 and 2-0: Used for high stress areas requiring strong retention, i.e. - deep
fascia repair
>3-0: Used in areas requiring good retention, i.e. - scalp, torso, and hands
>4-0: Used in areas requiring minimal retention, i.e. extremities. Is the most
common size utilized for superficial wound closure.
>5-0: Used for areas involving the face, nose, ears, eyebrows, and eyelids.
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>6-0: Used on areas requiring little or no retention. Primarily used for cosmetic
effects.
IV. FOLLOW-UP CARE
Following the placement of the sutures cleanse the suture site with normal saline.
Apply a small amount of Bacitracin and cover with an appropriate size sterile non-
adherent dressing.
Depending on nature and extent of the wound, antibiotic therapy or Tetanus Toxoid
way be indicated.
Attending MO will provide orders and instructions regarding dressing changes,
suture removal, and further follow-up care.
Inform the patient theta the suture site needs to be checked in approximately 24hours for signs of infection or complications.
V. SUTURE REMOVAL
TIME FRAME FOR REMOVING SUTURES: Times will vary according to the location and
depth of the wound. However, the average time frame is 7-10 days after
application. The following general rules can be sued in deciding when to remove
sutures:
>FACE: 4-5 days.
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>BODY & SCALP: 7 days.
>SOLES, PALMS, BACK OR OVER JOINTS: 10 days
REMEMBER:
Any suture with pus or signs of infections should be removed immediately.
Once MO determines that the sutures should be removed, a suture removal kit,
consisting of scissors and a pair of tweezers is utilized to remove the sutures.
Using the tweezers, grasp the knot and snip the suture below the knot with the
scissors as close as possible to the skin.
Pull the suture line through the tissue and place on a 4x4.
Once all sutures have been removed count the sutures.
The number of sutures needs to match the number indicated in the patient's health
record.
VI. WOUND HEALING
The process by which your surgical wound heals is a complex process that involves
three main steps.
Inflammation - this lasts for a short time as the blood flow is increased to your
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wound.
Proliferation - new blood vessels grow to bring nutrients to the wound and remove
dead tissue.
Maturation - new skin seals the wound and forms a scar.
The skin edges usually form a seal within a day or two of the operation. This time
varies from person to person and from operation to operation. Closing your wound
surgically (see Stitches, clips and staples) encourages your wound to heal faster.
Dressings
Not all surgical wounds need dressings. The purpose of a dressing is to:
absorb any leakage or smell from the wound
provide ideal conditions for healing
prevent infection
protect the area until the wound is healed
prevent stitches or clips catching on clothing
Some wounds don't have a dressing, for example, if they become infected at the
time of surgery.
CLIENT TEACHING:
Most surgical wounds heal without causing any problems.
Wound infections are one of the most common complications after surgery. This
means that bacteria have started to grow in your wound. If you develop an
infection, you will usually be treated with a course of antibiotics but occasionally
further surgery is needed.
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You're more likely to develop an infection if you:
smoke
have diabetes
have a condition or treatment that affects your immune system, such as leukaemia
or chemotherapy
1. Observe for signs of infection
become more painful
look red, inflamed or swollen
leak or weep liquid, pus or blood
smell unpleasant
If you're concerned about your wound or if you develop a high temperature, or
notice any of these symptoms, contact the hospital or doctor's surgery where the
operation was performed. Wound infections can be treated successfully if they are
diagnosed early.
2. Caring for your healing surgical wound
There are a number of things that you can do to look after your wound, lower your
risk of infection, and encourage healing.
Changing the dressing
>The original dressing can be left in place for up to five days (or as advised by your
doctor) providing that it's dry and not soaked with blood, and that there are no
signs of infection.
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>Before you remove the dressing, wash your hands with soap and water and then
carefully take the dressing off. Don't touch the healing wound with your fingers.
>Your healing wound can then usually be left without a dressing. However, some
people like to continue wearing a dressing over the area for protection, especially if
clothing is going to rub against it.
>The hospital may supply a replacement dressing for you to use at home. Apply the
dressing carefully and don't touch the inside of the dressing. Don't use antiseptic
cream under the dressing.
3. Taking care of stitches
Dissolvable stitches will usually disappear in around one to three weeks, but this
can take up to six weeks, depending on the type of stitches you have. Non-
dissolvable stitches are usually removed after seven to 10 days, depending on the
type of operation you have.
During this time you may see small pieces of the stitch material poking out of the
healing scar. Don't be tempted to pull on these. If there are loose ends which are
catching on clothing, trim the stitch carefully with a clean pair of scissors. Otherwise
wait until they are removed or fall out on their own. If the stitches cause you pain or
discomfort, contact your doctor or hospital for advice.
4. Eating and drinking properly
Your body needs energy to heal quickly so it's important that you eat well. Your
body will use a lot of energy, vitamins and protein when healing so make sure that
you eat a balanced diet. You should also make sure that you drink plenty of water. If
you're dehydrated, your wound may take longer to heal.
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It's important that you lose any excess weight before your operation, as being
overweight can increase the time it takes for your wound to heal.
5. Bathing and showering
It's usually possible for you to have a bath or a shower about 24 hours after surgery.
Your nurse at the hospital will advise you if this isn't the case following your
particular operation.
Some general points to remember are as follows.
>Showering is preferable to bathing, so that your wound doesn't soak in water.
>Remove any dressing before you have a bath or shower, unless your doctor gives
you different advice. Some dressings are waterproof and can be left in place.
>Don't use any soap, shower gel, body lotion, talcum powder or other bathing
products directly over your healing wound.
>You can let the shower water gently splash on to your healing wound. However,
don't rub the area, as this might be painful and could delay the healing process.
>Only have a bath if your wound can be kept out of the water. Don't soak the area
as this might soften the scar tissue and re-open your wound.
>Dry the surrounding area carefully by patting it gently with a clean towel but allow
your wound to air dry.
I>f you had surgery on your face, don't wear make-up over the scar until it has fully
healed.
>Once you get home, if you have any concerns about your surgical wound, contactthe hospital or your doctor.
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