simple wound closure

Question 1

what are the equipment and the PPE to take?

Answer 1

1. Hand rub
2. Gather equipment needed for suturing:
   a. Surgical mask, white plastic apron (MA)
   b. Sterile surgical gloves (check expiry)
   c. Suture, either Mersilk or Prolene (check expiry)
   d. Sharps bin
3. Check expiry date of all equipment after gathering them.
4. Don surgical mask first, the white plastic apron.
   a. Don surgical mask – blue surface is outer surface. The folds of the surgical mask should face down for liquids to drip downwards. Metal wire should be at the top. Pull to spread the mask across your face. Mould the metal wire to your nose.
5. Check expiry of the sterile surgical gloves. Open it away from the sterile field, not above the suturing set. Open the outer packaging of the sterile gloves carefully, if not it might fall out. Drop the sterile gloves into the suturing set. Discard the outer packaging.
6. Check the expiry of the suture. Open it away from the sterile field, not above the suturing set. Open the outer packaging of the suture carefully, if not it might fall out. Drop the suture into the suturing set. Discard the outer packaging.
7. Surgical hand wash all the way until elbows, DO NOT rinse in a back and forth motion, DO NOT let water drip back up to fingers, DO NOT let either hand touch each other, and DO NOT let hand touch the basin/tap head. Leave hand under running tap in the same location to rinse all soap in that location off. DO NOT rinse in a back and forth motion!!!
8. Use one bare hand to pick up one paper towel from suturing set. Avoid crossing the sterile field.
9. Dry ONE hand with ONE paper towel from suturing set in circular motions from fingers down to elbow. Discard first paper towel.
10. Repeat procedure to dry other hand. Take your time to dry your hands as it will make wearing the sterile gloves a lot easier.
11. Using bare fingertips, carefully unfold the inner paper packaging of sterile gloves carefully.
    a. Bare hands can only touch the inner surfaces of the sterile gloves.
    b. Outer surface of sterile gloves can only touch outer surface of other sterile glove.
12. Slide 1st hand into the opening of 1st sterile glove.
13. Use bare fingertips of 2nd hand to touch the inner surface of folded flap on 1st sterile glove and pull it down over the 1st hand. Does not matter if it is imperfectly worn as you cannot adjust the outer surface of 1st glove using bare fingertips of 2nd hand already. Wait until you have worn the 2nd glove, then you can start adjusting both of them to fit perfectly as the glove’s outer surfaces can touch each other.
14. Slide the gloved 1st hand under the outer surface of folded flap on 2nd sterile glove. At the same time, insert the 2nd ungloved hand into the opening of 2nd sterile glove.
15. Pull down the folded flap over the 2nd hand.
16. Adjust the gloves to fit the hands

Question 2

What else is there to do before approaching patient?

Answer 2

17. Pick up the needle-holder using dominant hand and toothed forceps using non-dominant hand.
18. Mount the suture using the needle-holder, following the 2/3-1/3 rule. Needle-holder should be 2/3 away from the sharp end and 1/3 away from the blunt end.
19. Pull out the entire suture from the paper packaging.

Question 3

How do you approach the patient?

Answer 3

20. Bring the suture over to the wound on the table. Lift the suture high enough to ensure that the dangling suture does not touch the sides of the trolley or any other contaminated areas.
21. Not sure if this is required as patient is likely under general anesthesia, but could be local anesthesia too (that’s why you must check if the wound is adequately anaesthetized): Introduce yourself, explain procedure to the patient and obtain patient consent, then get patient’s full name and NRIC.
22. Before starting the suturing, use toothed forceps to check that the ENTIRE LENGTH of the wound is adequately anesthetized by grabbing the skin up and down the length of the wound area and checking if the patient can feel anything.
23. Using the toothed forceps, hold onto the 1st leaf of the skin from which the needle is going to enter. Enter with the needle perpendicular to the skin, about 0.3-0.5cm from the wound.

Question 4

How do you suture?

Answer 4

24. Exit 1st leaf of skin from approximately centre-depth of the wound.
    a. If you accidentally exit too deep into wound during the exam, just go with the flow and enter the opposite side of the wound at the same depth.
25. After the needle has COMPLETELY exited the 1st leaf of skin, use the needle-holder or your fingers to pull the rest of the string through whilst leaving a little bit of string leftover on this side. BE VERY CAREFUL NOT TO POKE YOURSELF.
    b. You cannot use the toothed forceps to pull the needle and remaining string through as it was not designed for this purpose.
26. Mount the suture using the needle-holder again, following the 1/3-2/3 position.
27. Using the toothed forceps, hold onto the 2nd leaf of the skin from which the needle is going to enter. Enter with the needle perpendicular to the wound, at the same depth of the wound.
28. Exit 2nd leaf of skin about 0.3-0.5cm from the wound also.
29. After the needle has COMPLETELY exited the 2nd leaf of skin, use the needle-holder or your fingers to pull the rest of the string through whilst leaving a little bit of string leftover on this side. BE VERY CAREFUL NOT TO POKE YOURSELF.
30. Form the 1st Surgeon’s knot by holding needle-holder further away from body and making two loops around the needle-holder, then grabbing the TIP of the leftover end of the string with the needle-holder, and pulling it through.
    a. Always grab the TIP of the leftover end to make pulling through smooth and simple without any knots in-between.
    b. To make this knot neat, pull it toward the side it is going to.
31. Form the 2nd square knot by holding needle-holder closer to body and making one loop around the needle-holder, then grabbing the TIP of the leftover end of the string with the needle-holder, and pulling it through.
    a. Always grab the TIP of the leftover end to make pulling through smooth and simple without any knots in-between.
    b. To make this knot neat, pull it toward the side it is going to.
32. Form the 3rd square knot by holding needle-holder further away from body and making one loop around the needle-holder, then grabbing the TIP of the leftover end of the string with the needle-holder, and pulling it through.
    a. Always grab the TIP of the leftover end to make pulling through smooth and simple without any knots in-between.
    b. To make this knot neat, pull it toward the side it is going to.
33. Form the 4th square knot by holding needle-holder closer to body and making one loop around the needle-holder, then grabbing the TIP of the leftover end of the string with the needle-holder, and pulling it through.
    a. Always grab the TIP of the leftover end to make pulling through smooth and simple without any knots in-between.
    b. To make this knot neat, pull it toward the side it is going to.
    c. End with the needle-holder CLOSER to your body.
34. Note: In real life Mersilk = 4 knots, but Prolene = 6 knots.
35. Cut the leftover strings away to leave 0.5cm tails on the interrupted suture.
36. Repeat this process for 2 other interrupted sutures, positioning them 1cm away from each other.
37. After completion of 2 more interrupted sutures, discard the leftover suture into the sharps bin immediately, if not you will FAIL, even if you run out of time!
38. Pull all the sutures to one side of the wound to make it neat (it is in the rubrics)!

Question 5

How do remove the PPE?

Answer 5

40. Remove sterile surgical gloves using aseptic technique – outside of glove can only touch outside of other glove. Pinch wrist part of 1st glove and pull it down, turning 1st glove inside-out along the way to trap any pathogens. Ball up 1st glove in 2nd-gloved hand. Use exposed finger to insert under the cuff of 2nd glove and pull down to remove 2nd glove inside-out. Discard both gloves.
41. Hand rub
42. Remove white plastic apron using aseptic technique – pull to break top loop of apron first then break bottom strap. (FOR APRON: It is top then bottom, NOT THE SAME AS YELLOW GOWN SEQUENCE OF REMOVAL). Ball up apron slowly using inner surface (do not fling it out as there may be fluids). Discard white plastic apron.
43. Hand rub
44. Remove the surgical mask using aseptic technique – ensure you do not cup/touch the front surface of the surgical mask – remove both ear straps at the same time to prevent it from brushing your clothes. Discard the surgical mask.
45. Medical hand wash
46. Thank the patient