Page Contributor: Mitchell Buller

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General Principles

 

      Material selection and surgical techniques in Pediatric Surgery generally align with those of General Surgery, as identical procedures are performed in the pediatric population

      Because the pediatric population ranges from premature infants to college-age adolescents, suture and needle size varies across the pediatric population

      This section is by no means a comprehensive overview of pediatric surgery techniques, but simply serves to highlight some of the differences in suture selection and technique between the adult and pediatric populations

      While multiple surgeons with many years of experience were surveyed, these recommendations reflect their opinions and preferences and may not coincide with those of the surgeons at your institution

 

Special Considerations in the Pediatric Population

·      Suture removal in a child can be quite difficult in an uncooperative child

     o   For this reason, the use of absorbable sutures in more common

·      Children typically have less subcutaneous fat than adults, so knots in deep stiches may not bury well

 

General Closure Techniques

 

      Skin

     o   Dermis

     §  Material: vicryl or monocryl

     §  Size: 4-0 or 5-0

     §  Needle: P2 or P3

     §  Technique: simple buried

     o   Epidermis

     §  Material: dependent on closure type

          o   Monocryl: if closed using a running subcuticular stitch

          o   Chromic gut/plain gut/fast gut: if closing using simple interrupted stitches

     §  Size: 4-0 or 5-0

     §  Needle: P2 or P3

     §  Technique: depending on the size and amount of tension that will be placed on a wound, some surgeons elect to forego tying any knots in their running subcuticular stitches

               o   In this situation, the tails of the suture are left long and covered with a sterile adhesive strip


      Face: for cosmetic purposes, smaller suture with a more delicate needle is typically used

     o   Dermis: 6-0 monocryl taper

     o   Epidermis: 7-0 chromic reverse cutting


      Scalp:

     o   Deep: 3-0 monocryl taper

     §  When suturing the deep tissue of the scalp it is important to incorporate the galea (epicranial aponeurosis) into each bite, as this layer provides strength for the closure

     §  Some surgeons elect to suture the galea and dermis in two separate layers

     o   Epidermis: 4-0 plain gut P2


      Bowel

     o   Material: Vicryl or PDS

     o   Size: 5-0

     o   Needle: taper

     o   Technique: single-layer interrupted

     §  This technique theoretically allows for bowel growth and circumferential expansion over time

     §  In adult patients, continuous stitches and oversewing are more common

 

Common Procedures

 

·      Circumcision: techniques vary

     o   Freehand

     §  Foreskin excision: scalpel

     §  Closure: interrupted stitches using a 5-0 chromic gut taper

     o   Device-assisted

     §  Foreskin excision: scalpel with assistance of Gomco clamp, Mogen clamp, or Plastibell device

     §  Closure: wound heals by secondary intention without the use of suture


·      Cleft lip repair: a defect of the lip with or without involvement of the underlying alvelous

     o   Orbicularis oris: 3-0 monocryl

     §  Figure-of-8 stitches are often placed for added strength in muscle approximation

     o   Nasal sill: 5-0 plain gut

     o   White roll

     §  Deep: 6-0 monocryl and/or 7-0 PDS

     §  Superficial: 6-0 fast gut

     o   Dry vermillion: 6-0 chromic gut

     o   Wet vermillion: 5-0 chromic gut

     o   Intraoral: 4-0 chromic gut

     §  This includes areas such as the premaxilla gingivolabial sulcus and buccal sulcus


·      Cleft nasal deformity: alwaysassociated with cleft lip repair, as the cleft results in alar deformity and/or asymmetry and septal deviation

     o   Alar cinch suture: 3-0 PDS

§  This is a special technique used to mitigate any unfavorable increase in width of the nasal base

     o   Contouring: 4-0 PDS

§  These stitches are placed in an attempt to correct any misalignment or asymmetry of the ala, such as asymmetrical dimpling


·       Cleft palate repair: a defect of hard and soft palate. An important consideration in this procedure is the increased rate of degradation of absorbable sutures due to the enzymatic activity of saliva. Therefore, rapidly degrading sutures such as plain gut and fast gut are less commonly used.

     o   Mucosa: 4-0 or 5-0 vicryl taper

     §  These sutures are used for the majority of closures in this procedure, including closure of:

     o   Nasal side of uvula and velum

     o   Nasal portion of palatal repair

     o   Anterior alveolar cleft flaps

     o   Levator veli palatine (LVP) sling repair

     o   Reinforcing sutures between flaps and alveolus

     o   Remainder of soft and hard palate repair

     o   Oral side of uvula: 4-0 chromic gut


·      Nissen fundoplication: while the skin incisions are handled in the usual fashion, the “wrap” created by the fundus can be secured via multiple sutures

     o   Laparoscopic approach: 3-0 nylon taper

     o   Open approach: 3-0 Ethibond® taper

     §  Can be secured via an extracorporeal knot pusher or an intracorporeal tie, depending on surgeon preference


·      Pectus excavatum repair (Nuss procedure): techniques vary

     o   To flip the bar to a convex position after insertion, #2 vicryl sutures without needles are wrapped around the bar and clamped with needle drivers

     §  This decreases the risk of inadvertent perforation injury in the thoracic cavity

     o   To anchor the bar laterally, 1-0 or 0 PDS is used

 

Acknowledgements

We would like to thank the Kosair Children’s Hospital Pediatric Surgery team at the University of Louisville School of Medicine and the Cardinal Glennon Children’s Hospital Plastic Surgery team at the St. Louis University School of Medicine for their contributions to this material.

     

© McGeorge-Sturgill 2016