Suture Techniques
Imagine weaving through skin with the finesses of a seasoned surgeon, where each stitch carries the weight of knowledge and dedication.
Where Suture Meets Skin…
This is where the suture theory marries up with the etiquettes to allow for the different suturing techniques to be executed. Immerse yourself in this playlist of video's, starting from the basics and working your way up to more advanced technqiues.
The Fundamentals Before you Begin
There are some basic rulings that one should follow when suturing. These are outlined below.
1) Hold the needle with the needle holder at the junction between the proximal 1/3 and the distal 2/3 of the length of the needle.
2) Penetrate the skin with the needle perpendicular to the surface.
3) Glide the needle smoothly through the skin using a supinating movement of the forearm, exploiting the natural curvature of the needle.
4) Insert the needle equidistantly from edge of the wound surface to that of the exiting point.
5) Consecutive sutures should be width length apart from the preceding suture.
6) Everting the wound edges ensures that the final surface of the closed wound lays flat. As wounds heal they contract. Contraction starting from a flatter plane produces an inverted (depressed) wound.
The Surgeons Knot (Instrument Tie)
A secure way of tying sutures and ligating arteries is through the use of the surgeons knot. The standard method of tying the surgeon’s knot involves the use of a hand and a needle holder (driver). It is also possible to tie the knot using two instruments or even just your hands. The former is mainly used in microsurgery whereas the latter is used more in general surgery when suturing in deeper tissues. Regardless of how you tie it and what means you use, a properly made surgeon's knot consists of one double loop, followed by two single loops in opposite directions.
The Simple Interrupted Suture
It's simple, fast, and easy. The simple interrupted suture is the standard benchmark for skin closure. It can be utilised for simple wounds, both traumatic & surgical. It may be used alone in the context of smaller wounds under minimal to no tension, or can be used as a secondary layer to aid in epidermal approximation in the case when the dermis has been closed using another technique.
The Simple Continuous Suture
The simple continuous method is used particularly where speed is required such as a laceration on an upset child, or in cases where it is important to obtain tightness. Despite its speed, simple continuous sutures pose difficulty allowing for finer adjustments to the wound in the case where one area requires more tension than another. This is due to the tension being equally distributed along the continuous path so individual tension paths cannot be made. They can also produce unsightly cross hatch marks resulting in poorer cosmesis.
The Vertical Mattress Suture
In wounds where there is high tension between margins and where eversion is desired, the vertical mattress suture can be considered. The eversion produced by this stitch is particularly desired in body sites where the wound edges tend to invert such as the posterior neck, or wounds located on concavities. It may be easier to memorise the pattern of entry for this suture as 'far-far-near-near', with all four passes of the needle through the skin lying in one line that is perpendicular to the wound.
The Horizontal Mattress Suture
The horizontal mattress suture is commonly used for suturing the muscles and their fascia. It is not routinely used in skin closure due to the poor cosmetic outcome. However in skin types that are particularly atrophic, this technique may be helpful as the broader anchoring bites help minimise tissue tear that otherwise may be seen with other techniques such as the simple interrupted suture. Again, similar to the vertical mattress, the horizontal mattress is useful for promoting eversion, reducing tension, and eliminating dead space. Nevertheless they can lead to unsightly cross-hatching marks for the patient.
The Subcuticular Suture
These continuous sutures spread the wound tension, oppose wound edges and reduce dead space. They aren’t used to provide support as these wounds should be under minimal tension to start with. Therefore, deeper dermal sutures are usually used as a prerequisite. Artery clips or steri-strips can be used on the proximal/distal end, or you can tie both ends together after completing the suture. Leave plenty of suture length both proximally and distally so that as you progress through the subcuticular closure, you can check that it glides freely in both directions which facilitates removal when needed. As this is placed within the superficial dermis, no marks are left on the skin surface preventing cross-hatching and therefore, superior cosmesis.
Ensure to use non-dyed (clear) sutures such as PDS as this will prevent the suture appearing superficially through the dermis (especially on lighter skin tones), which can be unsettling for patients.
Self-directed Learning
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