The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [642]
Absorbable sutures degrade rapidly and thus allow the deep tissues within a wound to be closed successfully. They are also useful for patients who may not remember they have had sutures or will not attend for follow-up
Sutures can be removed once healing has occurred, normally 5–10 days after injury
Suturing must be performed by an experienced practitioner
Requires local anaesthetic
Suture material is a foreign body in the wound and thus increases the risk of infection
Interrupted sutures are not recommended for fragile skin
Sutures tied too tightly can damage tissues and when too loose they may delay healing
If skin layers are not aligned then patients can be left with a scar
Forceps used to lift skin may crush the tissue
Adhesive skin closure strips
Available in a variety of widths
Useful for superficial wounds that are not subject to tension
Strips are cheap and easy to use and remove
No local anaesthetic required and tissue damage is minimal
Strips do not adhere to sweaty or hairy skin
If there is tissue oedema it makes it difficult to achieve good apposition of the wound edges
May be suitable over some joints but where skin is taut or subject to movement, they do not provide optimum closure
Tissue adhesive
Surgical ‘superglues’ are now popular for emergency settings
Good cosmetic results
Less painful than suturing
Wound complication rates are low
It is expensive
Not suitable over joints and areas of high tension
Needs second person to assist in getting skin edges aligned
Staples
Staples are made of stainless steel wire
Provide greatest tensile strength
Quick method and offers low level of tissue reactivity and better resistance to infection than sutures
Can be performed without local anaesthetic
Staples are more expensive than sutures and may be confined to wounds where needlestick injury is a high risk
Must be inserted by an experienced practitioner
Failure to align tissue edges may cause scar deformity
Only useful for superficial skin layers
From Elkin et al. (2004), Jay (1999), Richardson (2007).
Wounds may vary and therefore careful assessment is required before the method of closure is selected and attempted (Richardson 2007). Richardson (2007) lists the following guiding principles to assist with decision making.
What is the aim of the wound closure? For example, eliminating dead space where a haematoma can develop, realigning tissue correctly or holding aligned tissues until healing has occurred.
What is the history of the wound? This informs the practitioner about the depth of the wound and likelihood of infection.
What is the wound site pattern? This and biomechanical properties may rule out some methods of closure.
Removal of sutures or staples
Evidence-based approaches
Rationale
Removal of sutures is usually performed between 7 and 10 days post insertion, but this is dependent on where the wound is and whether it has healed. Routinely, every other suture or staple is removed first, with the rest removed if the incision remains securely closed. If any sign of suture line separation is evident during the removal process, the remaining sutures are left in place and reported to the medical team (Elkin et al. 2004). Note that staples have replaced clips (Pudner 2005).
Preprocedural considerations
Assess the wound, as the time period for removal of sutures depends upon the patient’s underlying pathology, condition of their skin and the wound position (Pudner 2005). Surgical notes and instructions should also be taken into account along with the skills of the practitioner (NMC 2008b). Analgesia may be offered depending on the patient and wound site.
Procedure guideline 15.2 Suture removal
Essential equipment
Sterile dressing pack containing gallipots or an indented plastic tray, low-linting swabs and/or medical foam, disposable forceps, gloves, sterile field, disposable bag
Fluids for cleaning and/or irrigation
Hypoallergenic tape
Appropriate dressing
Appropriate hand hygiene preparation
Detergent wipe for cleaning trolley
Total traceability