CHAPTER 23. SUTURING
Indications185
Cautions186
Contraindications186
Equipment187
Practical procedure187
Post-procedure care193
Complications196
Prior to his post as physician to the Emperor Marcus Aurelius, the Greek physician Galen (129–circa 200–216) worked for several years gaining experience in the management of trauma as physician in a gladiator school. There he described using sutures for the purposes of haemostasis and tendon repair.
Lord Joseph Lister (1827–1912) introduced sutures treated with carbolic acid to promote antisepsis, as well as pioneering the process of chromatization to prolong the tensile strength of the suture. In these times suture material was most commonly derived from violin strings, the instrument itself being referred to as the ‘kit’ (from the word ‘kitara’, what we now refer to as the guitar). The intestines of the sheep, goat or ox were used to make these strings, termed ‘kitgut’. Suture material subsequently became referred to as ‘catgut’ despite not using the intestines of the cat in their production.
INTRODUCTION
Suturing is a skill commonly required outside the operating theatre, especially in A&E for minor trauma. Prior to suturing, a careful neurovascular and motor examination is always required as well as examining the wound for debris or foreign bodies.
INDICATIONS
Tip Box
Always consider the alternatives to sutures when contemplating wound closure, including surgical staples, wound closure adhesive tape (e.g. Steri-Strips®) and dermal adhesives (cyanoacrylate skin glues, e.g. Dermabond®).
CAUTIONS
Superficial skin lacerations are commonly managed in the A&E setting. However, always seek senior or expert guidance prior to suturing if unsure.
• Injuries to extremities that occurred over 12 hours prior to presentation may, following appropriate cleaning, be left to heal by secondary intention.
• Seek a specialist referral if, on examination, there is any evidence of underlying bone fracture or neurovascular or motor deficit relating to the injury.
• Plastic surgery specialists will consider referrals or will readily give advice for any cases involving skin wounds if required.
• In general, proceed with caution in cases in which the cosmetic outcome is of greater significance to the patient:
— paediatric cases
— maxillofacial cases.
• Caution should also be used with bites, either human or animal. Closed-fist bites (e.g. sustained when the patient’s fist comes into contact with another person’s teeth) can lead to deep tendon infections, and are worth discussing with orthopaedic or hand specialists. Animal bites, if superficial, may also require a senior opinion with respect to antibiotic prophylaxis.
CONTRAINDICATIONS
• Lack of consent.
• Foreign body in the wound.
• Wound infection.
EQUIPMENT
• Sterile gloves and drapes.
• Chlorhexidine solution cleaning.
• 1 L bag of normal saline, giving set, sterile scissors and eye goggles.
• Lidocaine.
• 1 × 10 mL syringe.
• Orange needle.
• Green needle.
• Suture cutter.
• Suture pack (including toothed forceps, non-toothed forceps and needle holder).
• Gauze.
• Sterile dressing.
• Non-absorbable suture (e.g. ‘1’ silk).
— Non-absorbable sutures may be made from silk, nylon, polypropylene (Prolene) or polyester (Dacron).
— Sutures are sized by the United States Pharmacopoeia (USP) scale (Table 23.1). For example, an 11-0 suture would be appropriate for specialist ophthalmic surgery, a 4-0/5-0 suture for closing a limb wound, and a 2-0 suture for securing a central venous catheter.
| Gauge (USP scale) | Non-absorbable suture diameter (mm) |
|---|---|
| 11-0 | 0.01 |
