injuries poisoning
How To Repair a Laceration With Simple Interrupted Sutures
Step by Step Description of Interrupted Sutures
(See How To Cleanse, Irrigate, Debride, and Dress Wounds for step-by-step descriptions of wound preparation, anesthesia, and dressing.) Cleanse, anesthetize, irrigate, and debride the wound as necessary. Place a sterile fenestrated drape over the wound. Place additional drapes nearby as needed to provide a large enough sterile work area. Hold the needle driver in your dominant hand, with your index finger extended along the side. This grip gives the most control. Some experts recommend not putting your fingers in the finger holes of the needle driver while placing sutures; doing so can make it harder to insert the needle perpendicular to the skin. However, you may place your fingers in the holes when releasing the needle from the driver and also when you tie knots using the instrument (instrument tie). Hold the tissue forceps in your nondominant hand, as you would a pencil. Do not close the tips of the forceps tightly on the skin, because this can damage tissues.Use only toothed forceps or a tissue hook when handling tissue to help prevent crushing the tissue. Hold suture scissors with your index finger extended toward the tip for better control. In general, place the first suture in the middle of the wound. Load the needle driver: Grasp the needle at a 90-degree angle with the very tip of the driver. Grasp the needle at the junction of the proximal and middle third of the needle. Use the tip of the forceps as a hook (or use a tissue hook) to gently lift the tissue and evert the wound edges as needed while the sutures are being placed.Proper wound edge eversion during this step is essential to optimal approximation of the dermis, which ultimately helps maximize the strength and minimize scarring of the healed wound. Place sutures by gently supinating your wrist so that the needle follows its curvature through the skin. The needle should enter and exit the skin at a 90-degree angle (see figure Simple Cutaneous Suture ). Match the bite depth and the bite width on both sides of the laceration. The bite depth should be greater than the bite width. Push the needle through both wound edges if this can be done with little resistance. If resistance is significant—or if you are placing a suture across a relatively wide space (as may occur with the first few sutures of an interrupted suture closure)—pull out the needle through the center of the laceration after it passes through the first wound edge and then reattach it to the needle driver. Continue the suture with a second bite passing it into the opposite side of the wound. Gently pull the suture through the path of the needle and leave some (eg, 2 to 3 cm) of the free end of the suture material exposed. Release the needle from the driver, and allow the needle to rest on the sterile drape. Tie the suture using an instrument tie as described below. Repeating these steps, place all subsequent sutures in the middle of each open section, until there are no remaining gaps in the wound. Spacing between sutures is typically equal to the distance from needle entry to wound margin (see figure Suture Spacing ). The suture begins and ends equidistant from the wound margins. Points A and B are at the same depth. The suture is farther from the wound edge when the wound is deep. The skin edges should be everted by making the width of the bite greater at the deepest part of the wound than at the surface. Spacing between sutures is typically equal to the distance from needle entry to wound margin. Sutures should enter and exit at an equal distance from the wound margin. Hold the tip of the needle driver above and between the entry and exit sites of the suture. Use your nondominant hand to manually hold the long end of the suture (the needle-end). Be mindful of where the needle is lying and be careful to not allow the needle to stick your hand. To lay down the first throw of the knot, wrap the needle-end (long end) of the suture OVER the end of the needle driver twice. Wrapping twice forms the base of the surgeon’s knot, which prevents the first throw from loosening. Next, rotate the driver 90 degrees and with it grasp the free (short) end of the suture. Pull your hands in opposite directions to lay down the first throw securely but not tightly; tight sutures risk cutting into the skin and causing ischemia as wound edema develops over the next several hours. On the second and subsequent throws of the knot, wrap the needle-end of the suture OVER the needle driver only once. Grasp the free end of the suture with the driver and pull in opposite directions to tighten the knot. These subsequent throws may be pulled tightly. Note that the suture is always drawn OVER the needle driver, and that your hands move in alternating directions across the laceration with each throw. Adhering to this method assures that all knots are square knots. Place a total of about 4 throws. After the final throw, cut the suture with a scissors, leaving tails about 1 cm long. 