Suture & Local vs Different Specialties

As I rotate through the different specialties during my orientation I am noticing the differences between suture & the order it’s used & what it’s used for. I also noticed the differences between when local is used & when it’s not used.

The longer I scrub & have to pull suture & put the extra suture back, the more I remember where it all is & what it’s used for. I will share what I have learned so far.

I always have my pile of suture I need & then a pile with 1 extra for each suture pulled, as well as any holds/availables. Gyne is one I have learned you grab more than one extra for! Once you use the last one you always make sure to ask for another!

GENERAL SURGERY

Inguinal Hernia Repair
Suture order:

2-0 silk K833 (x1)
The surgeon will pull out the hernia & fix it then use the 2-0 to close the hole.

0 Prolene 8412 (x3)
Once the hole is closed the surgeon will decide which mesh they would like to use, which is usually the same almost every time. Our surgeon will use 3 Prolene, unless she uses the plug, then she’ll want a 4th. It’s our job to know & ask, “Are you going to want another Prolene?” I’m working on speaking up & asking those things.

3-0 Vicryl (x2)
Once I hand this to the surgeon I start my closing count.

4-0 Monocryl Y426 (x1)
This of course is the closing suture.

TIP: Sometimes the surgeons will ask for a suture back if it’s long enough… never cut your suture from the needle until you know they’re done with it. I just leave mine. When they ask for it, you should also be able to tell which is which. Clearly, they are different colors & different sizes. Silk is black & is larger. Prolene is blue & has a lot of memory. Monocryl is a white/clear color & is very small. When I set up I always put them in order & load the first 1-2 suture. As you can see in the photo below I will load the suture & not pull it out all the way. I also will use my marker to label which is which, especially if I have to take it off the needle & use it for something else.

LOCAL: For general surgery, local is almost always used at the beginning & sometimes at the end of the surgery. For lap chole’s we use a 1:1 ratio of .50% Marcaine w/epi & 1% lidocaine w/epi. If the Marcaine has 30 & the lido has 20, they’ll give the Marcaine first so we can waste 10cc of the Marcaine to make it equal. For hernias, we will put this foam-type (Xaracoll) of Bupivacaine in the patient (I think it’s pretty new, our surgeon has only recently been using it & had a rep), so we don’t give local at the beginning or will give only a small amount.

Xaracoll – We cut them in half & the surgeon grabs them with DeBakey forceps. You have to be very careful because they crumble easily. I use my 10 blade to cut them.

OB/GYN

Local:
We do not use local for these cases since anesthesia does a spinal block at the beginning of the case. Instead of the patient coming in & us helping them move over & getting them all ticked in, etc., they will move over & sit on the edge of the bed for their spinal.

At the end of the case, they will use Exparel, which is what’s pictured below. They use these for C-sections as well. I have always used 2 syringes.

Suture:
You should always have a lot of extra suture for gyne cases. Once they are out of certain sutures, you should ask for another suture right away because they will most likely use it after the next.

Chromic is used last with these cases. For C-sections, 2-3 Chromic are used first, then two 3-0 Vicryl, last a blunt Chromic.

Ortho
Local: We do not use local at the beginning for ortho, as well. A block is done before the case.

Suture:
0 Vicryl is used first.
2-0 Vicryl is next.
Monocryl.
Then, last is Ethilon.

Draping:
This is also different. It took me a few times to get the hang of.
If there is a hand case, they will want a U-drape to wrap around the arm to prep. Once it’s prepped, they’ll want a towel under the arm to lie it on. Then they will remove that U-drape. They’ll wrap a towel around it, depending on the surgeon. They will normally want a stack of 4 towels to put under the patient’s hand.

Then, stockinette, U-drape, large drape under it, & then the extremity drape. The last large drape will be used by the tech to cover the arm. Cords are also different. There are many more cords, & they are usually placed on a mayo stand & placed over the patient.

Lights:
You should also make sure when doing a C-section or any gyne case with a large incision, that you make sure the lights are always where the surgeon is working. It took me a bit to get the hang of that & remember, as well.

ENT does not use a lot of suture, but here & there, depending on the case, Chromic will be used in the nose. I think I have only used it for a septoplasty with navigation only.