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.

>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.

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.

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

>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 "halfburied 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.

*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.

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

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

>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

>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 knots are 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 of dressing 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

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 other light 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.

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 or makeup 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)

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.

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 varying lenghts 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 nonabsorbable 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

6. Polydioxnone - a monofilament suture extruded from the polyester -particularly useful in tissues where both an absorbable suture and extended support 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

-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.

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. The most 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.

>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 nonadherent 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 24 hours 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.

>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

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.

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.

>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. Nondissolvable 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.

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, contact the hospital or your doctor.