Simple Suturing: Procedure Demonstration

00:01 All right. So we're back now and we're sterile.

00:05 And so we're actually going to begin the procedure.

00:08 So the first thing that we're going to do is we're going to want to clean the wound.

00:13 So we can actually, um, anesthetize the wound so we can get started with suturing. So you want to either use iodine or chlorhexidine or patient today has an iodine allergy. So we're going to actually use chlorhexidine.

00:28 We're going to make sure that we're cleaning all the outer edges of the wound.

00:35 Okay. Then you're going to throw this away.

00:38 You want to make sure that you keep your sterile field clean and not put anything dirty. You want to make sure that you have a waste basket near that is for biohazard trash when you're performing this procedure.

00:49 You also notice that I am not wearing my white jacket because typically that would get dirty. Um, if it's going to be really messy, I would use my surgical gown.

01:02 But most of the time you can just have your scrubs on.

01:06 So the next thing I want to do is anesthetize the wound.

01:09 You want to think about what you're numbing the wound with.

01:12 So this is actually going to be a forearm that we're going to be doing today.

01:17 So we could use lidocaine with epinephrine in it.

01:21 But if this was, um, either an ear wound laceration lip laceration I laceration, or the tip of the nose or digit, we would not want to use epinephrine.

01:35 We would want to stay with plain lidocaine.

01:39 So typically you're already going to have.

01:42 And I have this already drawn up.

01:44 Um, five cc's of lidocaine.

01:47 And so you're going to start at the edge of the wound and inject.

01:51 So you're going to come back here and you're going to inject in.

01:54 So we can do a block. So typically you're going to angle the needle where you can push some in here. And you want to push about a CC, and then you're going to come back and you're going to go to the other side and you're going to push about a CC in.

02:13 Keep in mind that you're talking to the patient about this may feel uncomfortable.

02:16 They may feel pressure.

02:18 They may also feel, um, pain and burning with lidocaine.

02:24 That is normal. You want to come to the other side and you want to go in, and you want to make sure that you're withdrawing to make sure you're not in a vessel, and then you want to inject in another CC as you're slowly pulling out, but not to pull out completely so that you can go to the other side and anesthetize so that we have a block completely around, you're going to see some bulging, but that's okay. This is just to demonstrate what you would do.

02:57 Now that we have that you want the patient to.

03:02 And I'm putting that back on my sterile field because I did not use all of that.

03:06 So for some reason, when we get ready to start the procedure, the patient is not fully anesthetized.

03:12 Then we would be able to put a little bit more, which does happen sometimes because patients eat up the lidocaine at different rates due to different conditions, different medications and things that are going on with the patient.

03:27 I also sometimes will anesthetize a patient and go see another one, particularly in primary care, give them a few minutes to numb up and then come back in and sterile up again and do the procedure.

03:39 So these forceps actually have grippers on them, which would serve as a poking mechanism.

03:45 We want to tell the patient that they are going to feel pressure but should not feel pain. So we're going to pinch and we're going to ask them, do they feel any pain with that? Or they just feel the pressure.

03:58 They're just feeling the pressure. So next we're going to irrigate.

04:02 This is not going to go as well as it would on a person because this is a mannequin.

04:06 But you want to make sure that you're irrigating the wound and that nothing is in the wound. And we don't see anything in the wound here, so that's completely clean.

04:18 And then the next step that we're going to do is get ready to suture.

04:23 So you're going to open up your sutures.

04:31 Sometimes this can be a little tricky with gloves on.

04:34 And you can see that you have the hook here.

04:39 And so I'm just going to grab this hook using my needle driver.

04:43 You want to make sure you have a good portion of the needle driver there.

04:47 And this is a pretty long string.

04:49 So you want to make sure that you're staying on your sterile field.

04:52 Both this is sterile as well as this sterile.

04:57 And you're going to take your forceps.

05:00 And you're going to go particular pin perpendicular to the wound about 2 to 3in.

05:08 And you're going to come to the other side about 2 to 3in.

05:14 And then you're going to grab the other end of the needle.

05:29 You want to leave yourself a little tail.

05:31 You want to make sure that your suture material is laid there to the side.

05:36 You want to grip the suture and you're going to wrap it around your needle driver twice, and then you're going to pull taut.

05:44 That's one throw. You're going to do it again.

05:52 That's two throws. You're going to do it one more time.

05:58 And that's three throws.

06:01 Then you're going to lay your needle driver here on the sterile field.

06:05 And you're going to take your ribbon and cut a little in there a little in here.

06:11 And then you're going to use your driver again and you're going to pick it up.

06:18 And if you have trouble positioning it, you can take your forceps so that you can get a better handle on it.

06:24 And then we're going to go in and do the same thing if you need to.

06:27 You can use your grips to give you better positioning.

06:31 Make sure that you want the sutures to be close to one another.

06:39 And you're going to come through again. And you're going to use that needle driver.

06:43 Sometimes when you're new, depending on how deep the wound is or just being new, sometimes you can come into the middle of the wound.

06:56 With your needle driver and then go back to the other side.

06:59 If you feel more comfortable doing that as well, that's acceptable. And then that's the first throw.

07:08 This is going to be the second throw.

07:10 And this is going to be the third throw.

07:15 Oops. Good job. Sometimes this will break on you.

07:20 If it does, that's okay.

07:21 You just need to go back in and put another suture in.

07:25 Also, the polyproline is a little bit harder to use for suturing just because it's more like fish and twine. So sometimes it can move around a lot more.

07:37 This is silk. We're actually using a 4.0 because that would be appropriate for this area. So again you're going to put the needle perpendicular.

07:50 You're going to pull across.

07:53 You're going to pull it out.

08:00 You're going to leave yourself a little tail. You're going to make sure that your suture is on the sterile field. You're going to wrap around twice.

08:12 And do the square knot.

08:14 And actually what it looks like underneath is a square.

08:18 So when you're going in like this, it actually creates a square.

08:22 So you're actually encapsulating the epidermis, the dermis and the subcutaneous tissue with the muscle as the bottom layer to create this great healing medium. And then you're going to clip your sutures again.

08:39 And you want to make sure that they're all staying to the same side.

08:42 That can be something you can do after you're finished.

08:44 If it's not that's not a problem.

08:47 But you want them all to the same side.

08:53 Then we're going to pick up our needle again.

08:56 We're going to go back in about the same way and do another suture.

09:02 And you're going to continue doing this until you have fully closed the entire wound.

09:15 You wrap it around the needle driver twice.

09:18 Pull wrap around the needle driver twice and pull.

09:24 You want to make sure that you're pulling the skin taunt, because if you're not pulling it taunt, you're not going to get clear edges, but you don't want to pull it too tight.

09:36 So things that you don't want to see are ripples in the skin or blanching.

09:41 If you see blanching, this means you're actually cutting off circulation and the tissue will not be viable.

09:47 Remember, again, this was a clean cut and we didn't have to clean it up.

09:52 But if you've got areas that have skin that looks like it's not vitalized with blood very well or mangled too much, then you actually want to make sure that you take your surgical scissors like this.

10:07 These are very sharp, and you actually cut a clear border to be able to close the wound.

10:16 Going back in again. And as you can see, I'm keeping the sutures about the same distance apart so that we don't have what we talked about earlier, which is some dehiscing.

10:28 And that's where the skin actually opens up.

10:30 We don't want that to happen.

10:34 When you get closer to the end of your suture, you're going to have less space between you and the needle.

10:41 So you want to make sure that you're watching that so that you don't get nicked with the needle. So if you're getting too tight and you're not finished with your suturing, it would be better to open a new set of sutures than risk a needle stick.

11:00 Again, you'll cut your.

11:05 Strings. Okay. We're going to do this again.

11:14 And it's okay that you're not fast.

11:16 This is not a speed race.

11:29 Okay. And you want to make sure you leave enough tail for you. So it's okay that you're having to cut off because you'd rather have more tail than not enough tail and actually pull back through and actually have to do the suture again, because that's going to make the skin more fragile.

11:53 And we don't want that.

11:59 And sometimes like that the little tail stayed in.

12:03 So you just have to see which side.

12:08 And it'll pull on out.

12:17 Okay. I think we're only going to need 1 or 2 more sutures here.

12:21 And then this wound will be closed.

12:30 The forceps with a little bit of teeth are going to be more helpful to you, particularly for you to grab up skin to force it through the needle if you need to or force against. They'll also be helpful if you were picking up debris out of the wound.

12:52 Which we would have done when we were cleaning the wound. Want to make sure it's snug but not too snug? Remember about your blanching, and remember that you're going to need to do three throws in order to ensure.

13:15 That the wound will stay closed.

13:18 All right, we got one more and we'll be finished.

13:28 Another thing that I didn't talk about, but you want to make a parent is you wouldn't want to do this procedure by yourself just because there are times where you might not have something on your sterile field that you may need, your medical assistant can be there and either open it up so it falls on your sterile tray. Sometimes you may not have enough lidocaine, and you might have to, um, get some more lidocaine that you don't have sterile. So they have to drop the needle and the syringe on your sterile field.

14:03 And then they have to hold the bottle for you to be able to draw more up.

14:07 So you need to be thinking about those things.

14:10 That's why it's always good to have an assistant or something unexpected happens that you don't expect somebody has a reaction to the medication.

14:20 Maybe they've never had lidocaine before and you didn't know that was going to happen.

14:26 Okay. And so you're going to go and take off these extra strings here.

14:35 And all of the knots are lined up on the same side.

14:39 So that's great. So now it would be ready to bandage at this point.

14:44 You could become unsterile.

14:46 Um, and a lot of times your medical assistant may end up dressing the wound for you.

14:51 Just make sure to apply antibiotic cream and make sure you put a occlusive dressing over the area, and that they keep it on for at least 24 hours to 48 hours, um, before they remove it.

15:04 And then they want to come back in 3 to 5 days if it's on the face, because this was a forearm, they'd come back in 7 to 10 days to have the suture removed. The other thing that you want to make sure is where all your sharps are before you leave. You want to make sure you dispose of those, even though you may not clean up the rest of the materials you want to make sure that's done.