Suturing Instruments

The surgical needle holder used in suturing lacerations should have several features. 5 First, it should hold the needle securely to direct it through the tissue. Second, it should release the needle easily to allow the suture to be tied. And third, it should have a design that can readily grasp the suture end to be used for the instrument tie.

The appropriate needle holder should hold the needle firmly without crushing it. The jaws of the needle holder may be flat or scored ("teeth"). Teeth may limit twisting and rotation of the needle, allowing it to be directed through tissue more accurately. However, teeth may damage needles and monofilament synthetic sutures, reducing their breaking strength. Smooth-face needle-holder jaws with rounded edges do not cause structural damage to either monofilament suture or needles. However, their smooth jaw surfaces provide limited resistance to twisting or rotation of the needle. Needle-holder jaw faces can be textured with tungsten carbide particles to create a fine granular surface, making them an attractive alternative to either smooth jaws or those with teeth. The textured face provides more needle-holding security than smooth jaws but significantly less than jaws with teeth. The needle-holder jaw should grasp only the needle body; clamping the needle point damages the cutting edge and dulls the needle. The suture needle should be aligned perpendicularly to the long axis of the needle holder and grasped between the jaws about 2 mm from the their tips. As noted above, the needle should be grasped 1.5 mm beyond the depth of the channel or swage hole, a site that provides optimal resistance to bending.

The finger holes of the needle holder are used for directing the needle and latching and unlatching the jaws. The needle holder can be grasped by either the thenar grip or the thumb-ring finger grip; each has its advantages. Both grips, however, do not place the index or middle finger through the ringlet holes; instead, the index finger is placed along the side of the needle-holder arms and the middle finger is pressed against the outside curve of the bottom ringlet for more control as the suture is placed. When placing a suture, the hypothenar side of the hand holding the needle holder can be placed against the patient's skin in order to brace the hand against sudden movement. This is particularly useful when placing a suture in a child or a moving patient.

With the thenar grip, the thenar eminence and skin overlying the first metacarpophalangeal joint are pressed against one ringlet, while the long, ring, and small fingers encircle the other ringlet. This position aligns the needle holder in the same direction as the longitudinal axis of the wrist and forearm, allowing the hand and needle holder to be positioned comfortably into recessed cavities (e.g., the oral cavity). In addition, the needle can be released and regrasped by the needle holder without changing positions. The needle can be redirected in preparation for the next stitch by spinning the needle holder clockwise in the palm. The disadvantage of this grip is the lack of precision when releasing the needle; when the thenar eminence applies pressure to the ringlet, it disengages the ratchet mechanism uncontrollably, causing inadvertent movement of the needle.

In the thumb-ring finger grip, the tip of the thumb is positioned in one ringlet, while the tip of the ring finger is placed in the other ringlet. The greatest advantage of this grip is its controlled disengagement of the ratchet mechanism, permitting precise manipulation of the needle. This advantage must be weighed against the relatively larger size of the physician's hand and needle holder; the palm is separated from the needle holder, making it more difficult to position the needle holder in recessed cavities (e.g., the mouth).

To align skin edges, a skin hook is preferred over forceps with teeth; hooks do not crush tissue, as do forceps. When forceps are used, they should pick up and elevate the skin as opposed to grasping the epidermis between the teeth. Conversely, the dermis can be grasped with the forceps, again, avoiding grasping the epidermis.

Because the ratchet mechanism of most needle holders is designed for right-handed individuals, most physicians prefer to hold the needle holder with the right hand, allowing them to hold skin hook or tissue forceps with the left hand. Before passing the needle through tissue, lay the free end of the suture away from the wound. The curved suture needle is passed through the tissue by starting with the hand prone and then twisting the wrist to a supine alignment, driving the needle through in one motion. For small lacerations being closed with only percutaneous sutures, this one motion can drive the needle from one side, across the wound, and out the other side without the need to release the needle. For larger lacerations, those with gaps, or those where approximating the layers is important, the needle is released after the point comes out in the wound, regrasped, and repositioned for placement through the other side.

Percutaneous sutures should be placed to achieve eversion of the edges. To accomplish this, the needle should enter the skin at a 90° angle. The curving motion of the needle and wrist movement then drives the needle first downward and then across the wound. The needle point should also exit the opposite side at 90°. It is desirable for the depth of the suture to be wider than the width (from entry to exit). Sutures placed in this manner (similar to the shape of an Erlenmeyer flask) will encompass a portion of tissue that will evert when the knot is tied (Fig, 3Z-12). Percutaneous sutures should also match opposing layers; the exit at one side of the wound should be at the same level as the entrance on the opposite side.

An adequate number of sutures should be placed so that the wound edges are closed without gaping. The general rule that the space between individual sutures should be roughly equal to the length of each bite (distance from needle entry point to the wound edge) can really be used only in straight wounds with sharp edges (e.g., surgical incisions). Experience and practice are the most useful guides to placement and spacing of percutaneous sutures in traumatic wounds.

Bleeding should be controlled before wound closure. Most bleeding stops after gentle compression with gauze sponges applied to the wound surface, using aseptic technique. Persistent bleeding should be controlled as noted in Chap.36.

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