WOUND CLOSURE BY SUTURE
Dr. Anand Shandilya*
Consultant Pediatrician, Mumbai *
Indications:
  1. Incised wounds
  2. CLWs (Contused and Lacerated Wounds)

Contraindications:
  1. Contaminated wounds
  2. Infected wounds
  3. Penetrating/Puncture/Stab wounds (Deep to seemingly innocuous skin puncture wounds, vital structures may de damaged. Avoid skin closure till this is ruled out. Also avoid pulling out the weapon/instrument responsible for the puncture, especially over the chest, abdomen or in the vicinity of major vessels. This may eliminate the plugging effect that the instrument may have over a vascular injury).

General Principles:
  1. Healing takes place best if skin edges are accurately apposed to each other, without tension.
  2. Skin edges should be slightly everted for best results. Inversion of skin edges will not result in a fine scar.
  3. All wounds should be as clean as possible before suturing. Cleaning adequately is often best achieved under the effect of local anaesthesia.
  4. Any dead space in the depths of the wound should be eliminated using deep sutures.
  5. Sutures should be fine, equally placed and close together.
  6. Sutures should be removed as soon as possible. Those on the face can be removed by the 5 th day; those on the scalp may be removed after 7-8 days, while those on the trunk or extremities can be removed after 10 days.
  7. After removal of sutures, further wound support can be given using strips of adhesive tape applied in strips, perpendicular to the wound axis.

Materials required:
  1. Sterile gauze pieces
  2. Povidone iodine solution
  3. Normal saline
  4. Tincture Benzoin
  5. Adhesive tape (Micropore/Transpore)
  6. Sterile plastic sheet/sterile drapes
  7. 2% lignocaine solution
  8. Sterile water for injection
  9. Suture material

Instruments required:
  1. Needle holder
  2. Fine (Adson's) Toothed Forceps
  3. Tissue cutting scissors
  4. Suture cutting scissors
  5. Fine haemostat
  6. Disposable syringes/fine needles (no. 25/26)

Procedure:
  1. Cleaning the wound: Irrigate the wound using saline and povidone iodine solution, using either a wet gauze piece, or a syringe. Let the irrigating fluid flush away small particulate foreign bodies from the raw surfaces.
  2. Isolate the wound from surrounding areas using sterile towels or plastic sheets.
  3. Infiltrate local anaesthesia in the wound edges and in the skin surronding the wound. The recommended dose of lignocaine for infiltration is 2 mg/kg body weight. 1% lignocaine (2% lignocaine solution double-diluted using water for injection) contains 10 mg of lignocaine per ml. of solution. Wait for a few minutes and confirm that the anaesthesia is effective.
  4. Complete cleaning the wound. Explore to gauge the depth of the wound, check for damaged deeper structures. Check for devitalized or crushed tissues; these may be trimmed using scissors. Remove any contaminating particles, foreign bodies, etc. Decide whether deep sutures are necessary to close fascia or muscles in the depth of thee wound.
  5. If an obvious bleeding vessel is identified, it may be held in a hemostat and ligated. Most small bleeding vessels can be included in the stitch.
  6. Proceed to suture the deeper layers using absorbable suture material. 30 or 40 catgut or vicryl are suitable.
  7. Skin is sutured using non-absorbable suture material. Nylon or silk are suitable.
  8. Check for satisfactory skin apposition, clean with povidone iodine, and cover wound with a dry sterile gauze held in place by adhesive strips.
  9. Check wound after 4-5 days and remove sutures when appropriate.

Sutureless Wound Closure using Adhesive skin-closure Strips

Indications:

Superficial wounds involving skin, especially on face, digits

Contraindications:
  1. Deep wounds
  2. Infected wounds
  3. Actively bleeding wounds

Materials required:
  1. Dressing materials as above
  2. Pre-packed sterile skin closure strips (Ethistrips / Steri-strips)

Instruments required:
  1. Fine forceps
  2. Scissors

Procedure:
  1. Lean wound as described earlier
  2. Dry area around wound completely
  3. Hair growth around skin edges may need trimming
  4. Apply tincture benzoin solution around the skin edges. Take care to ensure that this solution does not enter the wound. Wait until dry.
  5. Prepare adhesive skin strips by cutting to adequate size.
  6. Hold skin edges in apposition using forceps and apply tape at a perpendicular axis to the wound.
  7. Use multiple adhesive strips to ensure tension-free skin approximation.
  8. Cover with sterile gauze and strap in place.
  9. Inspect wound after 2-3 days to ensure continued adherence of skin strips
  10. Remove after 10 days.

Precautions:
  1. If skin strips do not adhere well, check for factors which may be responsible: inadequate skin cleansing, presence of greasy residue on skin, bleeding from the wound, hair growth, tension at the skin edges.
  2. When used for wounds on digits, avoid encircling the digit around its full circumference to prevent a tourniquet effect on a digit which may develop oedema due to inflammation, induced by trauma.
How to Cite URL :
Shandilya A D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=499
Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.