2. Layered Closure and Intro to Suturing

Question 1

what are the surgical layers of closure?

Answer 1

(Reverse of surgical layers of dissection)

• Bone
• Periosteum
• Deep fascia
• Superficial fascia
• Skin

Question 2

what hardware might you find in the 5th dissection layer?

Answer 2

Recall: 5th layer of closure is BONE

• nothing (triple arthrodesis)
• K-wires
• steinman pins
• cerclage wire
• screws
• plates
• staples
• external fixation
• etc

Question 3

what would you use for closure of the JOINT CAPSULE?

which layer is this in?

Answer 3

• Use:
  
  • usually a larger, absorbable suture w/
    
    • (2-0 or 3-0 vicryl)
  • interrupted cruciate-style suture
• Joint capsule is found in the periosteum (4th layer)

Question 4

what would you use for closure of the PERIOSTEUM?

which layer is this in?

Answer 4

• Use:
  
  • usually larger, absorbable suture w/ interrupted, cruciate-style (same as joint capsule), OR
    
    • (2-0 or 3-0 vicryl)
  • running (locking vs non-locking) w/ larger absorbable suture
    
    • (2-0 or 3-0 vicryl)
• Periosteum is found in the 4th layer

Question 5

list the ABSORBABLE SUTURE material?

Answer 5

• Natural
  
  • Pig collagen, sheep intestine, cow intestine, or cat gut
  • May be chromic
• Synthetic
  
  • Vicryl (Polyglactin 910) - Vicryl Rapid, Vicryl Plus, Triclosan
  • Dexon (Polyglyolic acid)
  • PDS (Polydiaxonone)
  • Maxon (Polyglyconate)
  • Monocril (Poliglecaprone)

Question 6

list the NON-ABSORBABLE suture materials

Answer 6

• Natural
  
  • Silk
  • Cotton/Linen
• Synthetic
  
  • Nylon (Ethilon, Surgilon)
  • Polypropylene (Prolene, Surgilene)
  • Polyester (Ethibond, Dacron)
  • Fiberwire (Polyethylene multifilament core w/ braided polyester jacket)
  • Stainless steel

Question 7

list the NATURAL suture materials

Answer 7

• Absorbable
  
  • Pig collagen, sheep intestine, cow intestine, or cat gut
  • May be chromic
• Non-absorbable
  
  • Silk
  • Cotton/Linen

Question 8

list the SYNTHETIC suture materials

Answer 8

• Absorbable
  
  • Vicryl (Polyglactin 910) - Vicryl Rapid, Vicryl Plus, Triclosan
  • Dexon (Polyglyolic acid)
  • PDS (Polydiaxonone)
  • Maxon (Polyglyconate)
  • Monocril (Poliglecaprone)
• Non-absorbable
  
  • Nylon (Ethilon, Surgilon)
  • Polypropylene (Prolene, Surgilene)
  • Polyester (Ethibond, Dacron)
  • Fiberwire (Polyethylene multifilament core w/ braided polyester jacket)
  • Stainless steel

Question 9

list the MONOFILAMENT suture materials

Answer 9

• Absorbable
  
  • PDS
  • Maxon
  • Monocril
• Non-absorbable
  
  • Nylon (both)
  • Polypropylene
  • Stainless steel (both)

Question 10

list the BRAIDED/ MULTIFILAMENT suture materials

Answer 10

• Absorbable
  
  • Vicryl
  • Dexon
• Non-absorbable
  
  • Nylon (both)
  • Polyester
  • Fiberwire
  • Stainless steel (both)

Question 11

Per Prism pg 79, what should you use for CAPSULE CLOSURE

(in general)

Answer 11

2-0 or 3-0 Vicryl

with cruciate stitch

Question 12

Per Prism pg 79, what should you use for

SUBCUTANEOUS TISSUE CLOSURE?

Answer 12

3-0 or 4-0 Vicryl

Question 13

Per Prism pg 79, what should you use to close SKIN?

Answer 13

4-0 Nylon or Prolene

Question 14

When can skin sutures be removed? Why?

Answer 14

• 10-14 days
• Because at this point, the TENSILE STRENGTH of the wound equals the tensile strength of the suture

Question 15

INTERRUPTED suture:

define, pros, cons

Answer 15

define: the individual stitches are not connected.

• MC used technique in wound closure
• Pros:
  
  • easy to place
  • high tensile strength
  • individual sutures can be removed (e.g in cases of infection) w/o jeopardising the closure.
• Cons:
  
  • require a relatively long time to be placed
  • as each suture requires its own knot, are at a greater risk of inducing infection.

Question 16

RUNNING suture:

define, pros, cons

Answer 16

Define: the stitches are continuous and connected along the wound.

• Pros:
  
  • tends to be faster, particularly for long wounds.
• Cons
  
  • wound is at greater risk of dehiscence if the suture material breaks

Question 17

what are the questions you should consider when deciding between

interrupted and running suture techniques?

Answer 17

• how many knots do you want to throw?
• how long is the incision?
• what type of movement will take place along the incision?
• do you have to take out the sutures?
  
  • absorbable/ non-absorbable;

Question 18

what are the 4 primary types of interrupted suture

Answer 18

• simple
• horizontal mattress
• cruciate (aka figure of 8)
• vertical mattress

Question 19

what type of suture material would you use for ACHILLES repair?

Answer 19

usually a 1-0 vicryl

Question 20

what type of suture material would you use for SKIN CLOSURE?

Answer 20

3-0 or 4-0 vicryl

Question 21

what techinque and suture material(s)

should be used for closing 3rd layer (DEEP FASCIA)?

Answer 21

• usually interrupted cruciate-style with 2-0 or 3-0 vicryl, OR
• running (locking vs. non-locking) with 2-0 or 3-0 vicryl

Question 22

what techinque and suture material(s)

should be used for closing 2nd layer (SUPERFICIAL FASCIA)?

Answer 22

Usually a buried, interrupted, smaller diameter ABSORBABLE suture technique

(usually 3-0 or 4-0 vicryl)

may also be running

Question 23

what techinque and suture material(s)

should be used for closing 1st layer (SKIN)?

Answer 23

• interrupted suture technique with non-absorbable suture
• running subcuticular w/ either absorbable or non-absorbable
• skin staples
• dermabond (MC skin glue)

Question 24

describe the RUNNING SUBCUTICULAR suture technique

Answer 24

(running technique of skin)

• non-absorbable suture w/ a “bridge”
• absorbable suture w/o a bridge

Other

• W/IN THE DERMIS and closes skin
• knot the ends or leave unknotted
• re-enforce with simple sutures at the ends

Question 25

list some names of sutures we didn't learn but may later in trauma/ recon classes?

Answer 25

* apical stitch * allgower-donati technique * trauma stitch * far-near-near-far technique (*holds a lot more tension than other techniques)*

Question 26

what are the 4 appropriate places for a suture needle to be?

Answer 26

1. suture pack 2. IN the needle driver 3. sharps container 4. bury the needle into the "skin" of practice board In essence, the needle point cannot be exposed

Question 27

home base is the half-way point between what?

Answer 27

* part 1: throwing your suture * part 2: tying a surgeon's knot

Question 28

describe the steps of the SURGEON'S KNOT

Answer 28

* Step 1: cross your hands --\> **slip** knot or **simple** knot * (*with one loop or two loops)* * Step 2: uncross your hands --\> **square** knot * *(with one loop initially is a square knot; two loops is a surgeon's or friction knot)* * Step 3: cross your hands --\> **surgeon's** knot Essentially lying 3 knots on top of each other

Question 29

what is the problem with the SIMPLE /SLIP knot?

Answer 29

not very stable, loose

Question 30

how can you maintain tension until you complete the square knot?

Answer 30

square knot is the functional unit; you need to generate a square knot so it will not loosen \*you can increase the number of "throws" or "loops" to generate tension

Question 31

what are the 3 different techniques to creating a surgeon's knot?

Answer 31

* with an instrument * with ONE-HAND technique * with TWO-HAND technique