TEHNIK MENJAHIT dan MENGENAL PERALATAN BEDAH DASAR
Menjahit & Mengenal Peralatan Bedah Dasar
Video Menjahit & Mengenal Peralatan Bedah Dasar (6 Menit)
Suturing is the act of using a needle to thread ligature material through tissue, either as a secure method to surround a blood vessel, or to approximate cut tissues next to each other to facilitate healing.
During surgery, we use sutures to close the tissues.
In the case of lacerations or trauma, we use sutures to restore the normal anatomy.
There is an entire science involved in knowing when to suture something and when to not suture something, what type of suture to use, and what diameter to use. For today’s lesson, I’m going to ignore that science and just focus on the basic techniques.
Occasionally, suturing is done with you holding the needle in your hand, but usually, you will hold it with a needle holder or needle driver.
The needle holder has jaws to grip the needle. If you look closely at the inner surface of the jaws, you’ll see a fine grid that helps hold the needle in any position you put it. In contrast, a straight clamp usually has parallel grooves within its jaws. You can use a straight clamp for suturing, but it doesn’t work as well as a needle driver because the needles tend to slip within the jaws.
At the opposite end of the needle driver are rings for your fingers and a ratcheting lock, with three positions.
Grasp the needle holder with your 4th digit inserted into one ring, just to the first joint. Place the tip of your thumb into the other ring, and place your index finger on the body of the instrument. In this position, you will have the greatest control. Later, with more experience, you may find leaving your thumb out of the ring is smoother for you.
Sutures come in a variety of lengths, thicknesses, composition, and packaging, but they all have in common the ability for an unsterile person to open them for access by a sterile person. They also all have in common a method of visualizing the butt end of the needle so it can be grasped by a needle holder before removing it from the sterile package.
In this example, the clear wrapper is peeled open using two hands, exposing the sterile suture package that can be lifted out in a sterile fashion.
If you hold the sterile pack in your left hand so you can read the lable, you’ll see a notch in the upper right hand corner. Tear open the package at the notch and you will see the butt end of the needle. Grasp the butt end with a needle holder and pull it straight out of the package. The suture material will deploy behind it. Don’t hit anyone with an overly enthusiastic pull.
Load the needle in the needle holder so that the needle is grasped two-thirds the way back from the needle tip. If you are further back, the needle will tend to bend and break during use. If you are too close to the tip, it will restrict your suturing range.
The needle should be loaded at a right angle to the needle holder’s axis. During surgery, there may be times when you change that basic orientation, but always start off with the needle loaded at right angles, two-thirds of the way back from the tip.
Hold the forceps in your other hand as though it were a pencil. You can use the forceps to stabilize tissue you are about to sew, grasp tissue, grasp a needle, or as a pusher to let you see underneath structures.
Remember that every time you pinch tissue with your forceps, you are traumatizing that tissue, so it is best to use the forceps sparingly as a grasping instrument, and more often as a pusher or stabilizer, without crushing the tissue.
When passing the needle through tissue, try to follow the curve of the needle. Don’t just ram the needle straight through. If the tissue is thin enough, you will be successful in getting the needle through it, but you will traumatize the tissue, tearing it in order to force the needle through. If the tissue is thick, the needle won’t slide through and you may end up breaking or bending the needle. Use a simple supination motion of your wrist to push the needle through its natural, curved path.
Once the needle is through the tissue, it is often best to release the needle holder, pronate your wrist, come over to grasp the exposed needle, and then continue the same curve of the needle. If you don’t reposition your wrist, it will be difficult for you to complete the curve of the needle. If you grab the exposed needle with your forceps, it will be very difficult to follow the curve of the needle. More likely, you will end up just yanking the needle out…not good for the tissue. In some situations, particularly tissue that is on tension from retraction, you may need to grasp the exposed needle with your forceps to hold on to it long enough for you to come over with the needle holder to complete the needle’s circular path.
There is a difference between closing an incision that is oriented side-to side in front of you versus up and down in front of you. The important thing is to make sure your needle holder is oriented in line with the incision. That’s easy if the incision is vertical in front of you. But if the incision is transverse in front of you, you’ll need to swing your elbow out over the patient in order to get your needle holder to line up with the line of the incision.
When sewing two edges together, make sure that the needle’s path through one edge is duplicated by a mirror image path on the other side. If you don’t get them to match, the edges will be uneven, slowing healing and sometimes resulting in a weaker scar and unsightly scar.
A simple stitch is when you make a single pass through the tissues to bring them together or to secure them. When first learning, practice this stitch because it is basic to all the other more complex stitches.
After the simple stitch is completed, the loose ends are tied using a square knot or surgeon’s knot. During surgery, 3 to 5 throws are generally employed, depending on the tissue and the suture material.
When multiple interrupted sutures are placed, they are should be an even distance apart and usually an even distance back from the cut edge. For example, a common placement for sutures is 1/2 cm apart and 1/2 cm back from the cut edge. An important exception to that rule is when closing the fascia, which is the main strength of the wound. Fascial sutures should probably not be lined up perfectly, so as to avoid uniform perforations that could act like a postage stamp tearing out of it’s roll. Many surgeons prefer that some of the sutures be placed closer to the cut edge of the fascia and other sutures be placed further away, more evenly distributing and stresses that might be applied to the repair.
Another commonly used technique of suturing during surgery is a running stitch. With this method, after completing one pass of the needle through the tissue, you move down a centimeter on the tissues and pass the needle through again, without stopping to tie the suture. This method has the advantage of speed, effectiveness, even distribution of tension, and decreased suture bulk, but it sometimes distorts the tissue through its obliquely applied forces. Further, should the suture break anywhere along its length, there is a tendency for the entire suture line to give way.
Practice suturing now, with single stitches. If you have time after mastering single sutures, try suturing a continuous line of sutures.
Now that you’ve mastered the basics, you will need to practice these techniques a lot, so they are very natural for you and you don’t have to think much about the mechanics of suturing.
Borrow an old needle holder or straight hemostat and some surplus suturing materials from the surgical suite and carry them around in your lab coat pocket. Practice opening and closing the needle holder and practice grasping small objects with it. For the last century, medical students during their “down” times have practiced sewing two raised edges of their pant-legs together. When you’re finished, just cut out the sutures.