Episiotomy and Epistorrhaphy

Episiotomy:

surgical incision of the perineum, between the area between the vagina and the rectum, that to widen the vaginal opening during childbirth.

Episiorrhaphy:

suture of the perineum following an episiotomy.

This surgical repair pioneered by Fielding Ould around 1742.

Continuous and interrupted absorbable sutures have been used for repair of episiotomy and second degree perineal tears following childbirth. However, continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

Moreover, the continuous technique can be used for all layers (vagina, perineal muscles and skin) where as the interrupted sutures can be used for perineal skin only.

Continuous Lock Sutures

• A continuous lock pattern, also called a “blanket stitch” or Ford interlocking suture.
• A progressive series of sutures inserted uninterruptedly in the skin like a simple continuous suture, partially locking each passage through the tissue.
• This type of suture is indicated when speed as well as some suture security are needed for closure.
• Following the placement of each suture, the needle passes above the unused suture material to lock the suture in place as it is tightened.
• Sutures should be removed 7 to 10 days after surgery.
• Suture placement is more rapid than for interrupted suture pattern and pattern has greater stability than other continuous patterns in the event of a partial break along the suture line.
• The pattern requires an increased amount of suture material and does not readily allow tension adjustment after placement.
• It is more difficult to remove than a simple continuous suture.

Interrupted Sutures:

• The most commonly used and versatile suture in cutaneous surgery is the simple interrupted suture.
•  This suture is placed by inserting the needle perpendicular to the epidermis, traversing the epidermis and the full thickness of the dermis, and exiting perpendicular to the epidermis on the opposite side of the wound.
• The 2 sides of the stitch should be symmetrically placed in terms of depth and width.
• In general, the suture should have a flask-shaped configuration, that is, the stitch should be wider at its base (dermal side) than at its superficial portion (epidermal side).
• If the stitch encompasses a greater volume of tissue at the base than at its apex, the resulting compression at the base forces the tissue upward and promotes eversion of the wound edges. This maneuver decreases the likelihood of creating a depressed scar as the wound retracts during healing.

Medscape. 2010. Suturing Techniques. Retrieved January 2, 2010 from http://emedicine.medscape.com/article/1128240-overview

Sutures

 

1. Suture Characteristics
   1. Tensile Strength
      1. Related to suture size (see below)
      2. Related to weight required to break a suture
   2. Knot strength
      1. Force required for a knot to slip

   

   1.  Configuration
      1. Monofilament (less risk of infection)
      2. Braided multifilament (easier to handle and tie)
   2. Elasticity
      1. Degree suture stretches and return to original length
   3. Memory or suture stiffness
      1. High memory: Suture stiff, difficult handling, unties
   4. Tissue reactivity (inflammatory response to suture)
      1. Reaction peaks in first 2 to 7 days

 

1. Needles
   1. Curvature
      1. Straight needle
      2. Curved 2/8 of circle
      3. Curved 3/8 of circle (preferred needle in most cases)
      4. Curved 4/8 of circle
      5. Curved 5/8 of circle
      6. 
2. Needle Tip
   1. Tapered (used in vascular sutures)

    

     3.  Suture types recommended for skin closure

   1. 1. Deep (dermal or buried) Absorbable Sutures
         1. Polyglecaprone 25 (Monocryl)
         2. Polydioxanone (PDS)
         3. Polyglactin-910 (Vicryl)
         4. Polyglycolic acid (Dexon)
      2. Superficial, monofilament Nonabsorbable Sutures
         1. Nylon (Ethilon)
         2. Polypropylene (Prolene)
   2. Conventional cutting needle
   3. Reverse cutting needle (preferred in most cases)

 

1.  Suture indications by location (see suture types above)
   1. Mucosal Lacerations (mouth, Tongue or genitalia)
      1. Absorbable Suture: 3-0 or 4-0
   2. Scalp, Torso (chest, back, abdomen), Extremities
      1. Superficial Nonabsorbable Suture: 4-O or 5-O
      2. Deep Absorbable Suture: 3-O or 4-O
   3. Face, Eyebrow, Nose, Lip
      1. Superficial Nonabsorbable Suture: 6-O
      2. Deep Absorbable Suture: 5-O
   4. Ear, Eyelid
      1. Superficial Nonabsorbable Suture: 6-O
   5. Hand
      1. Superficial Nonabsorbable Suture: 5-O
      2. Deep Absorbable Suture: 5-O
   6. Foot or sole
      1. Superficial Nonabsorbable Suture: 3-O or 4-O
      2. Deep Absorbable Suture: 4-O
   7. Penis
      1. Superficial Nonabsorbable Suture: 5-O or 6-O

 

1. Suture removal timing
   1. Scalp: 6-8 days
   2. Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
      1. Follow with papertape or steristrips
   3. Ear: 10-14 days
   4. Chest and abdomen: 8-10 days
   5. Back: 12-14 days
   6. Extremities: 12-14 days
   7. Hand: 10-14 days
   8. Foot and sole: 12-14 days
   9. Penis: 8-10 days
   10. Condition delaying Wound Healing: 14 to 21 days
       1. Chronic Corticosteroid use
       2. Diabetes Mellitus

1. References
   1. Howell (1997) Emerg Med Clin North Am 15(2):417
   2. Moy (1991) Am Fam Physician 44(6):2123