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To begin, let us consider the suturing of a simple laceration or incision on a flat area of the body with normal skin thickness and adequate blood supply. Sutures are usually placed 3/8 to 1/2 inch apart on an extremity, the trunk, or back. The distance between each suture should be more or less equal to the span of the suture itself. Simple sutures are used for skin edges that are not likely to turn under (invert), and are applicable to thicker areas of the body’ s surface. Around the face or in areas where unusual delicacy is required, very fine sutures of silk or nylon are placed 1/8 to 3/16 inches apart, and left in only three to five days. On larger areas of the body, the sutures are left in place approximately one week—for example, the upper extremities, chest, or abdomen. Leave sutures intact for ten days to two weeks in the lower extremities, back, or other areas where blood supply may be compromised. It is important not to tie the sutures too tight nor compress the skin edges so closely that free circulation is impaired. On the other hand, the suture should not be so loose to allow the skin edges to gape and thereby delay healing, as well as leaving open a route for infection.

During healing, sutures should be kept clean and dry. After three to four days showers are usually permitted, including shampooing of the hair after scalp injuries. Prolonged soaking, however, is inadvisable. Wet dressings should never be permitted to remain over sutures.

Silk and cotton sutures especially should be kept dry, as they may act as a “wick” to allow the entrance of germs resident on the skin surface. Nylon and subcuticular (buried) sutures are less likely to become infected. The latter type involves a special technique, comprising a back and forth sewing motion beneath the skin to “bury” the suture. This enables it to heal with scarring. Subcuticular sutures are particularly valuable in the perineum after childbirth, in the face to reduce scarring, and in children, where their removal several days later would be unduly traumatic.

Chromic, Dexon, or other absorbable material will provide a subcuticular closure with no necessity to remove sutures later. Properly done, this technique produces a very nice healed surface with minimal of scarring.

Nylon is not as suitable for subcuticular closure. When it or other nonabsorbable material is used, the ends must be left exposed outside the skin, and the suture removed after appropriate cleansing and at the proper time.

Skin edges that are prone to invert should be repaired using a vertical mattress technique. This enables the suture to encircle the deeper layers of the wound, as well as bring together (approximate) the skin edges. This is the usual method used to close abdominal incisions. Less often used in acute trauma, it is nevertheless appropriate in locations where careful attention to cosmetic results are indicated.

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It is difficult to give a brief description of proper suturing technique to enable a person to acquire this art quickly. Several generalizations, however, will be discussed to help, remembering that practice makes perfect. As mentioned already, wounds that are over eight to twelve hours old are grossly contaminated and should never be sutured. Only when ligatures are necessary to control bleeding would sutures be indicated, or after careful surgical debridement and irrigation in an operating room. The placement of sutures to close a wound must take into consideration the location of the injury, the types of suture material available, the nature of the blood supply, the general body health, and the skill of the medic. Suturing around the more delicate parts of the body, such as the face, eyelids, genitalia, and hand should be reserved for surgeons who have proven skills.

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Two Hand Square Knot

Wayne W. LaMorte, M.D., Ph.D., M.P.H.

Photography by Michael J. LaMorte

The two hand square knot is the most fundamental knot for the surgeon.
Well-constructed square knots with flat throws have less likelihood of slipping.

 

1) This shows the beginning of knot construction. Note that the short end is in the right hand, and the thumb of the left hand is beginning to create a loop by pushing the long strand to the right.
2) The right hand has brought the short end toward the surgeon and across the left hand strand to form a loop. The left thumb protrudes through the loop. Note that the left forefinger contacts the thumb, so the thumb can guide the index fingert down through the loop.
3) The left index finger has been rotated down into the loop.
4) The short strand is now placed between the thumb and forefinger in order to transport the short end up through the loop.
5) The left hand is now rotated counterclockwise to bring the thumb back up through the loop, pushing the short end up with it.
6) The short end has now emerged completely through the loop and will be re-grasped with the right hand in order to tighten the “throw” that has been created..
7) The surgeon begins to tighten the throw by pushing the long strand away… and pulling the short strand toward himself.
The throw is now snugged down. Note that tension is applied by pulling the two strands in opposite directions at an angle of 180 degrees.
9) The left forefinger now begins to form the loop for the next throw by sliding beneath the long strand and pushing it to the right.
10) The short strand is now brought to the left and beneath the long strand to form the new loop.
11) The left thumb contacts the forefinger and begins to rotate up into the loop.
12) The left thumb has now emerged from the loop, and the short strand will be pinched between the thumb and forefinger of the left hand.
13) The right hand releases the short end, and the left hand is now rotated in the opposite direction to drive the short end through the loop toward the surgeon.
14) The short end is re-grasped by the right hand and pulled away from the surgeon, and the long strand is pulled toward the surgeon.
15) Equal tension is applied to both strands as they are pulled in opposite directions to secure a flat square knot.
16) To secure the knot, a third throw will be added, using the same technique for the first throw.
17) After creating the loop, the left index finger is rotated clockwise into the loop, and the short end is placed between the thumb and index finger of the left hand.
18) The left hand is rotated back in a counterclockwise direction to pass the short end through the loop.
19) Finally, the short end has been re-grasped with the right hand and pulled toward the surgeon as the left hand pushes the long strand away to secure the third throw.
Multifilament or braided materials such as silk can usually be secured with just three throws. The throws are alternated to create successive square knots, so with three alternating throws, one essentially creates a double square knot. Slippery monofilament suture material, such as nylon or prolene, requires 5 or 6 alternating throws because it has a tendency to slip and untie itself.

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Bruising results when the skin or underlying tissue has been traumatized. A kick, a blow, or a fall may not break the skin, yet result in trauma to the underlying blood vessels. When one of these vessels, small or large, is injured, bleeding occurs beneath the skin. The black and blue discoloration that often results from such injuries are called a bruise (ecchymosis). Applying ice packs immediately after such injury is helpful to reduce the bleeding, as well as relieve pain. Under NO circumstances should heat be applied to a bruise in the acute stage. Even in the healing phase, one should use heating measures with considerable caution.

Deep bruises in a muscle may produce swelling and considerable pain, but are located beneath the fascial planes and therefore show no visible discoloration. These also should be treated with ice. In the acute injury, some pressure is advisable to reduce the amount of bleeding.

When the skin surface is broken, several other reactions take place. First, there is a loss of blood, with the amount and rate of flow depending on the vessels that have been severed. Since the face and scalp are extremely rich in blood vessels, bleeding is often brisk. Yet because of its visible location, prompt pressure can reduce the blood loss.

A knowledge of appropriate pressure points, where arteries to the extremities come close to the surface, can prepare one to reduce blood flow in a very severe arterial injury. Pressure under the armpit, in the groin, or behind the knee may be life saving when a large artery has been ruptured. More commonly, however, the application of direct pressure over the wound will reduce the amount of blood flow. With the normal clotting mechanism inherent in body tissues, the bleeding will then stop, allowing coagulation or clot formation to secure the area.

The second problem that results when the skin is broken is that germs find entrance. Depending upon the amount of contamination, the wound may require thorough cleansing before any closure or bandaging is attempted. Thorough irrigation with water is the most effective, provided that the water is clean. Done early after an acute injury this constitutes the most important aspect of care, since infection is easier to prevent than to treat.

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Unforeseen events occur in the lives of individuals every day. When these affect our health and cause bodily harm or injury, we usually call them accidents. Cases of extreme urgency, constituting a threat to life or limb, we term emergencies. Most hospitals are equipped with special facilities ranging from first aid stations to comprehensive trauma units. These emergency rooms are deluged with people having minor problems that have assumed the sense of urgency. However, many of these could well be taken care of at home. Some of the more common health hazards and problems will be discussed in this category in future blog posts.

It is well to remember the Boy Scout motto “be prepared” in obtaining necessary knowledge before the crisis. A calm, cool head combined with a knowledge of what to do in an emergency may prove the difference between life and death as crises erupt in the home. The words of Rudyard Kipling expressed it well, “If you can keep your head when all about you are losing theirs and blaming it on you… then you will be a man, my son.” These poetic expressions apply to every nurse, homemaker, and lifesaver who can render first aid in an emergency, and do the right thing, at the right time, in the right place, in the right way. Such individuals are at a premium in our turbulent society.

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Although the complexities of coronary bypass surgery are beyond the scope of this book, a few comments are in order. Briefly stated, this recent surgical advance is a procedure involving the removal of one or both of the major veins (saphenous vein) in the leg and its careful transplantation in the chest. After appropriate cardiac catheterization to determine the adequacy of the coronary circulation, the vein is placed between a hole made in the aorta as it leaves the heart and the more distant part of the coronary artery. With its 5-10% risk to life, the exorbitant cost ($30-50 thousand), and the lack of long-term statistics as to its effectiveness (at best 2 years), this operation should be regarded as a last resort.

Reconditioning programs are springing up around the country and offering a superior alternative to many bypass candidates. The combination of a low fat diet free of cholesterol and progressive exercise in a center with preventive capabilities will often minimize the necessity for cardiac drugs, while relieving chest pain and similar cardiac symptoms. Nevertheless, a few individuals with disease of all three coronary vessels or underlying impairment of the heart valves may need and profit from this operation. In such cases, it is my recommendation that a medical center experienced in heart surgery be selected with much prayer and care.

Following the bypass operation, cardiac rehabilitation should begin in a lifestyle conditioning center where both diet and lectures are calculated to prevent recurrence. As rapidly as possible this will recondition the patient for a return to normal living. Otherwise, the temporary relief obtained by a revascularization procedure may be short-lived as the new vessels plug themselves with cholesterol once again. One can easily see how every aspect of coronary heart disease from the cradle to the rocking chair will benefit from preventive measures.

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