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SUTURING

Suturing overview

  • Suturing is one of the many techniques used to close wounds

    • Other techniques include surgical staples, Steristrips, cyanoacrylate glue​

  • It is used to approximate body tissues together to allow healing by:

    • Reducing dead space​

    • Support and strengthen wounds

    • Haemostasing wounds

    • Reducing risk of infection

  • Inadequate or improper wound closure will lead to dehiscence, poor wound healing and/or pathological scarring​

  • Suture is foreign body: use minimal size, amount of suture necessary to close wound

Suturing overview

Instruments

  • Suture (see below)

  • Needle holder

    • Various designs and sizes available​ - Halsey or Mayo-Hegar needle holders are most suitable for skin closure

    • Non-ratcheted needle holders are also available for precision control - Gillies needle holder

    • Some are designed scissors - Gillies or Olsen-Hegar needle holder

    • Hold this with thumb and ring finger in holes, middle finger above the ring finger (but outside the holes) and index finger as close to the hinge as comfortably possible for maximum control

  • Forceps

    • Generally available as toothed or non-toothed​

      • Toothed forceps preferable for skin closure​

    • Hold this like chopsticks, not pliers

  • Scissors

    • For cutting sutures​​​

    • Hold as per needle holders

Instruments

Sutures

  • Medical device generally involveing use of a needle with an attached length of thread

  • Available in different shapes, sizes and thread materials

  • Needles

    • Shapes - Straight, 1/4 circle, 3/8 circle, 1/2 circle, 5/8 circle, J-shaped​

    • Design - round-bodied, cutting, reverse cutting, taper, trocar point, spatula point

    • Some sutures available with needles on both ends

  • Thread, can be classified according to:

    • Natural vs synthetic

      • Natural - Silk​

      • Synthetic - Vicryl (polyglactin 910), Vicryl Rapide (polyglactin 910)​, Monocryl (poliglecaprone 25), PDS (polydioxanone)

    • Braided vs monofilament

      • Monofilament sutures glide  easier but may consequently have less grip on tissues

      • Braided​ - Vicryl (polyglactin 910), Vicryl Rapide (polyglactin 910)​, Ethibond (Polyethylene terephthalate), Silk

      • Monofilament - Monocryl (poliglecaprone 25), PDS (polydioxanone)

    • Absorbability​

      • Occurs by hydrolysis

      • Absorbable - Vicryl (polyglactin 910), Vicryl Rapide (polyglactin 910)​, Monocryl (poliglecaprone 25), PDS (polydioxanone)

      • Non-absorbable - Ethilon (nylon), Prolene (polypropylene), Silk

    • Sizes​

      • Originally produced in sizes 1 to 6 (1 is smallest)

      • Eventually refinement in manufacture of much finer sutures enabled size 0 and smaller (00 or 2-0, 000 or 3-0, etc)

      • Sutures thicker than 0 now not often used

      • Therefore, parodoxically 3-0 is finer than 2-0

      • Sutures up to 12-0 available for supramicrosurgery

      • Microsurgery usually requires 8-0 to 10-0 sutures

      • Skin closure usually uses 4-0 or 5-0 sutures

Sutures

Simple interrupted sutures

  • Most commonly used technique

  • Interrupted - individual sutures are not commected

  • Easy to place with high tensile strength

  • Individual sutures can be removed without affecting other sutures in closure

  • Requires relatively longer time to place

  • Procedure:

    • Start in the middle of the wound, place sutures at either 1cm intervals or by dividing into further halves until wound is approximated without tension​

    • Ensure bites are equal volume

      • If wound edge is unequal, bring thicker side to meet thinner side to avoid putting extra tension on thinner side

    • Ensure good eversion and approximation of wound edges

    • Perform instrument or handtied surgical knot, leaving knot on side of wound

    • Cut suture ends to length less than or equal to distance between sutures

    • Repeat until wound closed securely with minimal tension

Simple interrupted sutures
Screenshot 2020-06-01 at 1.24.17 pm.png

Continuous subcuticular sutures

  • Continuous low-strength suture used to approximate wound edges while keeping sutures buried

  • Nearly always requires absorbable sutures

  • Less time-consuming than interrupted sutures

  • Good technique required to achieve good approximation​​

  • Procedure:

    • Start either with deep dermal suture (see below) or from approximately 1cm from the wound edge

    • Make a throw to the apex of the wound

    • Make subsequent throws entering, traversing and exiting at the plane of dermis-epidermis junction from one side of the wound to the other until the opposite apex

    • End the suture with a deep dermal suture (using an Aberdeen knot) or by passing the needle from the apex to 1cm away to the wound edge

    • Bury all knots and suture ends

Deep dermal sutures

  • Most commonly used technique

  • Interrupted - individual sutures are not commected

  • Easy to place with high tensile strength

  • Individual sutures can be removed without affecting other sutures in closure

  • Requires relatively longer time to place

  • Procedure:

    • Start in the middle of the wound, place sutures at either 1cm intervals or by dividing into further halves until wound is approximated without tension​

    • Ensure good eversion and approximation of wound edges

    • Perform instrument or handtied surgical knot, leaving knot on side of wound

    • Cut suture ends to length less than or equal to distance between sutures

Screenshot 2020-06-01 at 1.24.00 pm.png
Continuous subcuticular sutures
Deep dermal sutures
Screenshot 2020-06-01 at 7.44.23 pm.png

Mattress sutures

  • Provides relief of wound tension

  • Provides precise wound edge apposition

  • More complex, therefore more time-consuming

  • Vertical and horizontal types

  • Horizontal mattresses can be placed interrupted or continuous

Mattress sutures
Screenshot 2020-06-01 at 7.56.19 pm.png

Tips and tricks

  • Size of suture “bite” and interval between bites should be equal in length, proportional to thickness of tissue being approximated

  • Avoid pinching skin with forceps if possible to minimise tissue injury

  • Ensure needle penetrates skin perpendicular to surface of skin

Tips and tricks

References

  1. Emergency and Essential Surgical Care (EESC) program. World Health Organisation. Link: https://www.who.int/surgery/publications/s16383e.pdf

References
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