So I've seen many different preferences for closing a lac, withmany sutures vs. few. What is the main take on suture technique for simple interupted in the ER? It seems plastics guys use a lot of sutures, meaning they space them closer together, whereas ER docs/PAs tend to space them furter apart. In both ways the wounds look good, closed with good hemostasis/approximation.
Sutures, Many vs. Few
- Thread starter PAGuy77
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Well, there it is: good approximation, not gaping, but not so many that it resembles "railroad tracks". Both the Trott book on lacs and Roberts and Hedges procedures are good on this. "Too many" versus "too few" is quite heavily experiential.
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Much of this too depends on the situation. A dirty wound on an extremity I will use few sutures and loosely approximate (of course after thorough irrigation, etc). A cosmetic facial wound that's clean (i.e. not a dog bite) I will typically put more into. Tension and movement of the sutured area also make a difference.
Overall, I think that in the ED the enemy of good is better. I tell most people (especially families of young children that I'm fixing a facial lac) that I'm very good and if they are displeased they can always follow up with plastics for revision. That seems to go over very well, and my repairs always look fine when I'm done. Don't try to be a plastic surgeon, because you're not.
Overall, I think that in the ED the enemy of good is better. I tell most people (especially families of young children that I'm fixing a facial lac) that I'm very good and if they are displeased they can always follow up with plastics for revision. That seems to go over very well, and my repairs always look fine when I'm done. Don't try to be a plastic surgeon, because you're not.
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Hard to be specific, since there's a bit of art and a lot of opinions about suturing, but the goals are to approximate the wound edges, slightly eversion, and give the closure some temporary strength 'til the sutures come out and some healing occurs. Depends on the body part (ex. face - sutures a bit closer), but try to meet the above goals while putting in as few sutures as possible.
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I start by placing a suture at each critical point (vermilion border, wound apex, obvious skin line, etc) then interpolate, by dividing each gap with a suture, until it looks good to me.
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I find I put in far fewer sutures than most of my midlevels do (I've seen them pack 7 into a 2.5 cm lac), as I think the inflammatory response from the sutures delays healing. Usually I'll follow Wilco's principal (hardest stitch goes in first) for anything that has cosmetic importance, then put in sutures till it doesn't gape with light lateral pressure. Remember that the only thing the sutures do for healing is hold the wound edges together, so go till you've got enough sutures to do that with reasonable certainty. Anything after that is wasting your time and increasing the risk of poor healing.
Also, for the love of all that is holy, leave tails long enough to grasp through the crusting that will be there on day 3, or 5, or 7. Better yet, use absorbables.
Also, for the love of all that is holy, leave tails long enough to grasp through the crusting that will be there on day 3, or 5, or 7. Better yet, use absorbables.
