Key Practice Points
Lacerations and wounds can be managed with a few well-chosen instruments: needle holders, tissue forceps, and scissors.
Each instrument requires special handling (described in this chapter) to close lacerations and repair wounds correctly.
Proper instrument technique reduces tissue damage and excessive scar formation.
There two basic suture types: absorbable for deep, subcutaneous closure and nonabsorbable for superficial skin closure.
In recent years, however, absorbable sutures with rapid absorbing properties have been used for superficial skin closures.
Studies have shown that there are no cosmetic differences between absorbable and nonabsorbable superficial skin closures.
Older suture types, such as silk, cause greater tissue reaction than do newer synthetic materials.
Reverse cutting needles are atraumatic and are recommended more highly than older, tapered needles.
It is not necessary to have large numbers of instruments and suture materials for emergency wound care. Wounds and lacerations can be managed with three or four well-chosen instruments and a few wound closure products. Although the type of instruments remains relatively constant, each wound has differing requirements for wound closure materials. Absorbable and nonabsorbable sutures and a variety of wound tapes, staples, and tissue adhesives can be selected according to the specific patient problem. The following are guidelines for the selection of suture materials and the choice and proper handling of instruments. Tapes, staples, and adhesives are discussed in Chapter 14 .
Basic Instruments and Handling
Most wounds can be cared for with the following set of instruments: needle holders, tissue forceps, and suture scissors. For more complex wounds that may require revision or débridement, iris (tissue) scissors, hemostats, a knife handle, and appropriate knife blades might be required. A bewildering array of instruments is currently available through the major suppliers of surgical instruments, but only the types and configurations of instruments necessary to manage wounds and lacerations are discussed here. Also, numerous disposable instrument sets meet the needs of many emergency wound care problems.
Because most lacerations are closed with relatively small suture materials, the needle holder need not be bulky or large. A 4½-inch needle holder can accommodate most curved suture needles. Occasionally, large needles are used, and a 6-inch needle holder is necessary.
Technique for Handling Needle Holder
Just as important as the choice of needle holder is the technique used for holding and arming it with the needle. Figure 8-1 shows the right way and the wrong way to hold the instrument during introduction of the needle into tissue for routine emergency laceration closure. The rings are used only to clamp and unclamp the jaws by closing and releasing the locking mechanism. When introducing the needle into the skin, better precision can be gained by grasping the needle holder close to the jaws in the manner illustrated. This precision is particularly important when closing lacerations on the face.
The needle holder is armed with the needle by closing the tip of the jaws onto the body of the needle ( Fig. 8-2 ). If the needle is pushed farther back into the jaws of the instrument, the curve is flattened, significantly weakening the needle and making it susceptible to breakage. The needle itself is grasped at right angles, approximately one third of the way down the body shaft from the end to which the suture is attached (the swage).
Grasping and controlling tissue with forceps during skin closure is essential to proper suture placement. Whenever force is applied to skin or other tissues, however, inadvertent damage to cells can occur if an improper instrument or technique is used. Forceps still are widely used and are safe when proper technique is applied. The currently recommended forceps are 43⁄4-inch forceps with small teeth. Teeth decrease the need to apply excessive force to grasp and secure tissue. The use of forceps without teeth is discouraged, because the flat surface of the jaws of the forceps tends to crush tissue more easily.
Technique for Handling Forceps
When handling tissue, the jaws of the forceps are never closed on skin itself. The epidermis and dermis are avoided in favor of the superficial fascia (subcutaneous tissue). By grasping superficial fascia gently, the wound edge is stabilized for needle placement and inadvertent damage to the dermis is avoided ( Fig. 8-3 ). Forceps also can serve as a surrogate skin hook as illustrated. The needle entry point can be immobilized and supported without closing the jaws.
Figure 8-4 illustrates the correct and incorrect methods for grasping forceps. The “pencil grasp” technique allows for better control of the forceps and tends to diminish the amount of force delivered to the tissue.
Standard 6-inch, single blunt-tip, double-sharp suture scissors are most useful for cutting sutures, adhesive tape, sponges, and other dressing materials. Because of their size and bulk, these scissors are durable and practical. Curved and straight, 4-inch iris, or tissue, scissors are used to assist in débridement and wound revision. These scissors are extremely sharp and provide excellent precision in cutting tissue for whatever task. They are delicate, however, and are not recommended for cutting sutures. Occasionally, when small sutures have been used in the face area, iris scissors can be used for suture removal.
Technique for Scissor Tip Control
Whenever scissor tip control is essential, for example, when cutting close to the knots of deep or dermal closures with absorbable sutures, the technique illustrated in Figure 8-5 is recommended. The tips of the scissors are brought gently down to the knot. Just before cutting, the tips are rotated slightly to avoid cutting the knot itself.
Hemostats have three functions in emergency wound care. Originally, hemostats were designed to clamp small blood vessels for hemorrhage control. Another use is to grasp and secure superficial fascia during undermining and débriding wounds. Finally, this instrument is an excellent tool for exposing, exploring, and visualizing the deeper areas of a wound. Two types of hemostats are commonly used in wound care. For general use, the standard hemostat is recommended. Finer work in small wounds is often best served by the 5-inch curved mosquito hemostat with fine serrated jaws.
Knife Handles and Blades
The choice of scalpels can be limited to three blade configurations, no. 10, no. 15, and no. 11. For safety, the retractable scalpel is recommended ( Fig. 8-6 ). The no. 10 blade is not usually needed in emergency wound care but occasionally is helpful for larger excisions during wound revision. Commonly used and quite versatile is the no. 15 blade, which is small and well suited for precise débridement and wound revision. This blade is also preferred for foreign-body excision and the intricate work necessary around eyes, lips, ears, and fingertips. The no. 11 blade is configured ideally for incision and drainage of superficial abscesses. It also can be used to help remove small sutures such as might be placed in the face.
Several criteria must be met before a particular suture can be used to close a laceration. A good suture must have appropriate tensile strength to resist breakage, good knot security to prevent unraveling, pliability and workability in handling, low tissue reactivity, and the ability to resist bacterial infection. Currently, there are two main classes of suture materials: absorbable and nonabsorbable. Tables 8-1 and 8-2 summarize the characteristics of suture types. In general, absorbable sutures are placed deep for closure of dead space in large wounds or to reduce closure tension. Nonabsorbable sutures are used most commonly for percutaneous or skin closure. However, there has been a growing trend toward using alternatives for skin, superficial closure (including staples), wound adhesives (see Chapter 14 ), and absorbable sutures. Table 8-3 lists recommendations for suture and closure materials by anatomic site.
|Absorbable Suture Materials||Structure||Tissue Reaction||Tensile Strength||Half- Life (Days)||Uses and Comments|
|Gut||Natural||++++||++||5-7||For mucosal closures, rarely used|
|Rapid absorbing gut||Natural||+++||++||7-10||Skin closure (face), mucosa|
|Chromic gut||Natural||++++||++||10-14||For oral mucosa, perineal, and scrotal closures; can be annoying to patients because of stiffness|
|Polyglycolic acid (Dexon)||Braided||++||+++||25||For subcutaneous closure; coated version easier to use but requires more knots (Dexon Plus)|
|Polyglactin 910 (Vicryl)||Braided||++||++++||28||For subcutaneous closure; do not use dyed suture on face|
|Polyglactin 910 (irradiated, Vicryl Rapide)||Braided||++||+++||5-7||Scalp, mucosa, child hand andface|
|Polyglyconate (Maxon)||Monofilament||+||+++++||28-36||For subcutaneous closure; less reactive and stronger than polyglycolic acid and polyglactin 910|
|Poliglecaprone 25 (Monocryl)||Monofilament||+||++++||7-10||Deep (subcutaneous) closures|
|Polydioxanone closures (PDS)||Monofilament||+||++++||36-53||For subcutaneous that need high degree of security; stiffer and more difficult to handle than polyglycolic acid or polyglyconate|