Cushing pattern
http://www.youtube.com/profile?user=basel5099#p/u/4/i0hVQC2hJNA

http://www.youtube.com/profile?user=basel5099#p/u/5/OVRUymALXpQ

deep dermal layer stitch

- dr. hoshi says ok to torque if you are not in the deep fascia

- when you go into the skin, you go a few mm in, raise the needle and see that it is about a few mm from the incision

- the sutures are burried

-

For small incisions (lumpectomy), or anythning else, to prevent puckering the skin, take SMALL bites for your deep dermals!

- Also, for breasts or any place cosmetic, first do the ends first. The key when doing the deep dermals here (at the corners) is you have to have the suture coming out away from your corner. that way when you do the knot tie, it brings the two ends together and you can do your rollypolly away from the corner to really cinch them together.
lizarraga, 9/3/14


- When doing deep dermals, of course start at the ends first. Then you can do the halving just like 2 or 3 times. Then you must start the official deep dermas away from you, doing the rolly-polly stuff toward you, and doing each successive deep dermal layer moving toward you. Doing deep dermals moving away fromyou does not end well. Me, 9/9/14

- When working with a medical student, do this:

- We each get 3-0 Vicryl
- I put in the vicryl stitches at the corners
- I can do halving if I want to
- But the key is, we each start in the middle of the incision by each putting a deep dermal in the middle
- Then we each put successive deep dermals toward myself, and she toward herself
- We do the twisty thing to get the stuff to come together (9/10/14)

- When putting in deep dermals, put them deeper than you usually do. Don't turn the deep dermals into subcuticulars because then the knots stick out of the skin. (Sugg, 9/10/14)

Suturing: subcuticular suture

- first get your suture and needle

- if you're right handed, stand on the right side of the patient and suture from bottom to top (that's the most comfortable position)

- first thing you do is go from superficial to deep at the very end of the line

- then tie the knot

- once the knot is tied, cut the short end

- then put the needle in, from deep to superficial, make sure to come out in the middle and on the subcuticular layer as close up as possible.

- now you're ready for the subcuticular layers

-

continue from here!

Subcuticular suture: Benefits

The running subcuticular stitch is popular because of its excellent cosmetic appearance.

tools of the trade, p.117

Subcuticular sutures: Types of sutures to use

This type of wound closure can be performed with either absorbable or nonabsorbable suture.

We use Vicryl (polyglycolic acid) 3-0 or 4-0 absorbable sutures on a curved cutting needle, since this material incites the least inflammatory response of all the absorbable suture materials.

tools of the trade, p.117

Subcuticular sutures:  Use of steristrips

Most surgeons support a subcuticular closure with Steri-Strips placed at right angles to the incision for at least a few days following suture placement.

tools of the trade, p.117

Subcuticular sutures:  STEPS

- The suture line is begun at one end of the incision with a burried knot.

- The suture is then run continuously just below the skin surface in a horizontal mattress fashion.

- Upon reaching the end of the incision, the suture either exits the skin approximately 1cm from the end of the incision and tied to itself or the suture can be buried on itself and cut flush with the skin.

TECHNIQUE

- By following the curve of the needle with each bite, the incision can be approximated evenly with an appropriate degree of tension.

tools of the trade, p.117

Knot less subcuticular suture

In my OR case with Dr. Shaaban on 10/30/10, he showed me how to do a knot less subcuticular.

- first you make the first stitch from superior to the apex into the wound and pull it through

- then you start running the subcuticular from the subcuticular layer starting at the apex

- you run the subcuticular, trying to pull the needle through as close to the skin as possible

- then at the end, you just make one big bit out from the other apex

- then you hold both lines up

- then you put the betadine

- then you cut the suture ends on both sides

- then you place steristrips, staggered

- what a great idea!

Different ways to finish a subcuticular

The way I learned how to finish a subcuticular is:

- you take your last bite on your left side

- then you back stitch a final bite on the right side

- then you pull the string through in a special way to form several knots

- then you pull the string out

- then you make one last bite

The way Dr. Pitcher does it is:

- you end the last stitch on your right, but then you make a locked stitch at the end, and then take your big bite [10/23-24/10]

Doing a subcuticular with Dr. Choi. The first thing is where on the incision you start (the superior or inferior side). If you are right handed, you start the subcuticular on your right. (so if you are standing on the patient's right side, you will start the incision on the inferior aspect of the incision).

- Also start it on the side closes to you. So that would be top to buttom, and then bottom to top

- Then do a one handed knots with the first one being between the two fingers, holding the shorter side with your knot tying hand (for me it's my left hand)

- Go back in and come back at the apex. For this, you do a backhanded suture (so you need to set your needle pointing backward on the needle driver)

- Now make the first subcuticular stich start at the apex, and then the next stich on the other end should start at the apex too

- AT THIS TIME, YOU CAN ASK FOR A SMALLER NEEDLE DRIVER

- Now when you take bites, you want to take a bite directly across from where the last one exited from the other end

- You just have to hold the needle with the needle driver, you don't have to lock the needle inside the needle driver

- Take a bite of the skin (either take a horizontal or a vertical bite) and go in a bit. THEN, push the needle through from the end of the needle, and grab it with your needle driver in a way that you are ready to make the next bite without having to readjust your needle

- DO NOT GRAB THE NEEDLE WITH YOUR ADSONS! EVER! YOU SHOULD BE ABLE TO DRIVE AND PICK UP THE NEEDLE WITHOUT ANY ADDITIONAL HELP FROM A PICKUP!!

- ALSO, TAKE SMALL BITES AS YOU GO. THE BIGGER BITES YOU TAKE, THE MORE CHANCE YOU HAVE THAT THE WOUND WILL NOT CLOSE WELL AND YOU WILL HAVE TISSUE STICKING OUT AND SUCH

- At the end, you go up to the apex on one side, then you come from the apex on the other end, and then you do those circle loops and then you take one last bite and then you are don!!!

dr. ch

Dr. ke had a way of finishing the subcuticular but fuckin' can't remember what he did

Simple interruped sutures: Benefits

Simple interrupted sutures are commonly used because it gives a good cosmetic result provided the knots are tied snugly but not tight and that massive bites are avoided.

tools of the trade, p.115

Simple interrupted sutures: STEPS, and technique

STEPS

- In this stitch, the needle enters the skin at right angles to the incision and passes subcutaneously to the opposite edge and exits exactly opposite its entrance.

TECHNIQUE

- the knots are tied snugly but not tight

- massive bites are avoided

tools of the trade, p.115

INSTRUMENT TIE
- twirl it toward where the suture is
- Don't position yourself in an awkward position when you about to twirl

source: Lizarraga, 9/3/14

Suturing: Figure of eight

CHEN'S FIGURE OF 8

- On a baby, he did figure of 8 of subcuaneous fascia + dermis using 3-0 PDS

- Take a bite on the right side (down to up)(bit far away horizontal bite and depth of the wound

- Finish the bite on the left side same way

- Then take the next bite the same plane as the first bite on the right but this time it is a smaller bite and IT IS JUST UNDER THE SKIN!

- Finish on the left side, small bite again, again depth is JUST UNDER THE SKIN.

- That is how I remember it

- This is a burried figure of 8.

- Learned 8/2014 fromn Dr. chen

ADULT

- Well, I saw him do a figure of 8 on an adult

- This time, it was the usual figure of 8

- It's like doing deep dermals but times two and the depth is the whole subcutaneous layer (down to above the muscle) and you definitely are not just under the skin but a little lower than tha.

http://www.youtube.com/watch?v=IHj6nLALvMA

http://www.youtube.com/watch?v=IHj6nLALvMA&p=A89603BAE2778037&playnext=1&index=3

http://www.medicalvideos.us/play.php?vid=2043

Modified Figure of 8 images

http://www.springerlink.com/content/r43gw86600270283//fulltext.html#Fig1

Today was a great day. I learned a cool way to do a figure of 8 from Dr. Katz

- I am so happy I learned how to do this.

- So what I am doing is this

- First, you figure of 8 , between figure of 8's, you travel only 1cm, so don't travel so much! He said.

- But within a figure of 8 itself, you can travel a bit longer thn that

- First, you take a top to bottom bite on your right side

- Then, on the left, you travel about 1cm or more and you take your bottom-to-top bite there

- Then, on the right, you take you across bite

- Then, your final bite on the right actually goes superior to the previous one on the left, effectively forming an X.

- It's pretty cool and now I've learned something new. So happy about it!

I learned this from Dr. Katz during a donor nephrectomy case as we were closing the fascia! Pretty cooll!!

6/11/15

Suturing: Suture Material Choice: Emergency Department

Wound Closure

Choosing a suture material

Skin closure: use nylon ETHILON or PROLENE or SILK

Skin or mucosal closure in children: use VICRYL RAPIDE

Tendon repair: use ETHILON or PROLENE

Mucous membrane: use SURGICAL GUT OR CHROMIC GUT

Deep suture: use VICRYL, MONOCRYL, DEXON

Deep closure under significant tension: PDS, MAXON

Suturing: Suture Material Choice: Operating room

Suturing: Suture Material Choice: Operating room

My questions

- surgical intern pocket guide said silks absorb in 2 years. the surgical skills ppt said that silk is non-absorbable. which is it?

During most of your intern year, you will have little autonomy in terms of choosing suture material (it will be up to the attending). The attending or resident's choice is always the right one.

Nevertheless, one day someone will ask you what you want, and it is worthwhile to know the basic choices.

HISTORY

The original absorbable suture materials were plain and chromic “cat gut,” which actually consisted of collagen derived from the submucosa of animal intestines.

surgical skills ppt, CODA

WHEN TO USE ABSORBABLE SUTURES

- in most situations, choose an absorbable suture

- definitely absorbable if infection is present

- What are they

- Now there are many synthetic absorbable materials made from polymers (Vicryl and Monocryl). These materials are broken down non-enzymatically by hydrolysis (surgical skills ppt)

WHEN TO USE NON-ABSORBABLE SUTURES

- If scarring poses a problem, a non-absorbable monofilament suture is used

- For fascial cover, use nonabsorbable suture with high tensile strength

- for vascular anastomosis, or other situations in which strength is necessary over long periods of time, use nonabsorbable suture with high tensile strength

- What are they

- Non-absorbable sutures are made of materials that are not readily broken down by the body’s enzymes or by hydrolysis.
- There are naturally occurring non-absorbable materials (e.g., silk, cotton, and steel) and synthetic non-absorbable materials (e.g., nylon and Prolene, Mersilene).

ABSORBABLE SUTURE MATERIAL

                             Tensile         Absorption   Reaction

                             strength        Rate

Plain                             0% 7-10days     70 days          moderate

Chromic                         0% 21-28days   90 days          moderate

Vicryl (polygalactin)         65%-2wks         70 days            mild

PDS (monofilament)          85%-wks        210 days          slight

Silk (braided)                  0%-1 year      2 years            moderate

NONABSORBABLE SUTURE MATERIAL

                             Tensile                        Reaction

                             strength

Cotton                          50% decrease at 6months      minimal

Steel                            Indefinite                             minimal

Ethilon (nylon)                decrease 15% year               low

Nurolon                         decrease 15%                      very low

Mersilene (braided polyester)  indefinite                       minimal

Ethibond (braided polyester)   indefinite                       minimal

Prolene (monofilament)          indefinite                       minimal

surgical intern pocket guide p.70

CHROMIC

Chromic gut is collagen treated with chromium salts to delay break down. Chromic gut typically loses its strength after 2-3 weeks is completely digested after about 3 months.

surgical skills pt CODA

NYLON

- monofilament

SILK

- multifilament

Suture needles

Increasing sizes (8/2/18)

- SH

- MO6

- CT2

- CT1

Needles are stainless steel Point type

1) Taper

- Sharp to penetrate tissue

2) Cutting

- Cut through tissue without damaging surrounding tissues

3) Blunt

- Blunt nosed – reduce needlesticks

Magnified ends of each needle type

(slide 2 of surgical skills ppt)

surgical skills pptt in CODA

Suturing: Suture size - which is larger?

Suture size is stated numerically; as the number of 0's in the suture size increases, the diameter of the strand decreases.

For example, size 5-0, or 00000, is smaller in diameter than size 4-0, or 0000.

surgical skills ppt, CODA

Use "absorbable braided suture" to close the subcutaneous layer of a laceration. MCQ. [schartz qb, p.80, q17][absite clinical management]

#17. Once the wound described above has been irrigated and debrided, which suture should be used to close the subcutaneous layer?

.

a. biologic absorbable monofilament (plain gut)

b. synthetic absorbable monofilament

c. absorbable braided

d. none of the above

.

.

.

.

.

- The answer is C.

- In general, the smallest suture required to hold the various layers of the wound in approximation should be selected in order to minimize suture-related inflammation.

- Nonabsorbable or slowly absorbing monofilament sutures are most suitable for approximating deep fascial layers, particularly in the abdominal wall.

- Subcutaneous tissues should be closed with braided absorbabe sutures, with care to avoid placement of sutures in fat.

- Although traditional teaching in wound closure has emphasized multiple-layer closures, additional layers o suture closure are associated iwth increased risk of wound infection, especially when placed in fat.

- Drains may be placed in areas at risk of forming fluid collections.

DURATION OF SUTURES
- -Chromic gatgut - strength for 14 days; absorbs in 70 days
- monocryl - strength for 7 days; absorbs in 90 days
- vicryl - lasts 2 weeks; absorbs in 70 days
- PDS - strength 2-8 weeks; absorbs in 200 days


SOURCES
https://en.wikipedia.org/wiki/Suture_materials_comparison_chart
https://en.wikipedia.org/wiki/Vicryl
https://en.wikipedia.org/wiki/Monocryl

At the end of a case, you will close an incision

- you do your subcuticular

- then you clean the area

- then you get cover it up with gauze and tegaderm

- because you want the area to be sterile for at least 24 hours; so keep your sterile field until the dressing is on

3/17/11

Continuous everting Mattress
http://www.youtube.com/profile?user=basel5099#p/u/6/uo3gDnZD-PQ

Vertical Mattress Pattern
http://www.youtube.com/profile?user=basel5099#p/u/8/37gnHI_MU2Y

Horizontal mattress pattern
http://www.youtube.com/profile?user=basel5099#p/u/9/bnryDfLWIBY

Lesson: 5/8/18:
- He taught me a trick to tying prolene sutures
- You do your first throw like normal, leave the end suture long

- Pull up on the needle suture instead of pushing down on the knot
- Then do your second throw in the same direction while pulling up still on the needle suture
- This seemed to be a cool trick to not make an air knot and not struggle with the prolene suture

- The trick is to make sure you leave the tail end of the suture long when you start it