SuturesandSuturingTechniques SanjeevDutta,M.D.

StanfordUniversity DepartmentofSurgery
I. OBJECTIVES
Bytheendofthislaboratorysessionparticipantsshouldbeableto: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Describethevariousformsofsutureconstruction,theiradvantages anddisadvantages,andtheirappropriateuse. Describethedifferenttypesofsuturematerialandtheirunique properties. Describethevarioussutureneedlesandtheconditionsfortheir use. Describevarioussuturingtechniquesandindicationsfortheiruse. Describeproperpreparationofthesurgicalfieldforsuturing. Demonstrateproperneedleloadingontoneedledriver. Demonstrateasimpleinterruptedstitch. Demonstrateasimplerunningstitch Demonstratearunningsubcuticularstitch. Demonstrateverticalandhorizontalmattressstitches.

II.

ASSUMPTIONS
Theparticipantwillhavecompletedthemoduleonknottying,and understandproperuseofforceps.

III.

SUGGESTEDREADINGS
nd 1) Giddings,FD.SurgicalKnotsandSuturing(2 edition).Giddings StudioPublishing,FortCollins:2002. 2) Galli,SKDandConstantinides,M.WoundClosureTechnique. EmedicineWebsite. www.emedicine.com/ent/topic35.htm 3) Zuber,TJ.TheMattressSutures:Vertical,Horizontal,andCorner Stitch.AmericanFamilyPhysician,Dec15,2002Vol66(12):2231 2236.

IV.

DESCRIPTIONOFLABORATORYMODULE
Inthislaboratory,participantswillfirsthearanoverviewofbasicsuturing principlesandviewanexpertvideoofsuturingtechniques. Residentswill thenrotatethroughfourstationswheretheywillperformasimple interruptedsuture,arunningsubcuticularsuture,averticalmattress suture,andahorizontalmattresssuture.

V.

DESCRIPTIONOFTECHNIQUESANDPROCEDURE
A. Techniqueforloadingofneedleontoneedledriver. a. Graspcurvedneedle2/3ofthewayfromsharpend,usingtips ofdriver. b. Holdneedleatslightangletoaxisofneedledriver. B. Techniqueforsimpleinterruptedstitch. a. Usingtoothedtissueforcepsfortraction,insertneedleintoskin edge,startingwithneedleperpendiculartoskinsurface,and comingoutinthewound. b. Insertneedleonoppositewoundedge,anequivalentdepthto theinitialplacement.Theneedleshouldtraversedownward throughtheepidermis,anddermis,andtakeasmallbitofthe subcutaneoustissue. c. Onoppositewoundedge,theneedleshouldfollowareverse path,exitingtheskinequidistanttotheoppositeside. d. Handorinstrumenttiesothattheskinedgesareapproximated withoutunduetension. e. Suturesshouldbeplaced0.5to1.0cmapart. C. Techniqueforrunningsimplestitch. a. Placesimplestitchatoneendofwound,cuttingtailend. b. Usingtoothedforcepsfortissuetraction,runsuturewithsimple stitchinacontinuousfashionfromonewoundedgetotheother. c. Eachbiteshouldbeequidistantfromtheskinedgeandevenly placed. d. Atendofstitch,leavealoopfortyingtofinishthestitch. D. Techniqueforrunninglockedstitch. a. Beginasinsimplerunningstitch. b. Asneedletipexitstheskin,placeneedlethroughpreviousloop tolockit.Proceedinthismannerforeachthrow. E. Techniqueforrunningsubcuticularstitch. a. Startbyanchoringsuturetodermiswithasimplestitch. b. Insertneedlehorizontallyintodermiswithouttraversing epidermis,startingwithneedleperpendiculartodermisand followingitscurve,andpurchasingsmallbitofdermis. c. Placeasimilarbiteontheoppositeedge,backstepping approximately1/4thedistanceofthelastbite. d. Alternatefromsidetoside,ensuringcongruenttissue approximation. e. Applyfinishingknot.

F.

Techniqueforverticalmattressstitch. a. Usingthefarfar,nearnearsystem,theneedleispassed48 mmfromtheskinedgedeepintothesubdermis,traversesthe woundandexitstheskinequidistantontheoppositewound edge. b. Theneedleispassedbackwithashallowdermalbite12mm fromthewoundedge,takingasimilarbiteontheoppositeside (nearnear). c. Thetwoendsofthesuturearethentiedonthesideofthe woundwherethesuturingbegan,withoutexcessivetension. Techniqueforhorizontalmattresssuture. a. Initiatebyinsertingsutureneedle48mmfromwoundedge, andtakeabiteoftheoppositewoundedge,exiting48mm awayfromedge. b. Advancealongwound48mmandreinsertneedleintoskinfor anidenticalbutoppositebiteofeachwoundedge. c. Tiethesutureonthesideofthewoundwherethesuturing began.

G.

VI.

COMMONERRORS
Acommonerrorthatcanoccurinanyofthesuturetechniquesdescribed istoolittleortoomuchtensiononthewoundclosure.Toolittletension resultsinpoorcosmesisandincreasedriskofinfection.Toomuch tensioncanresultinskinnecrosis. Acommonerrorintherunningsutureisripplingofthewoundclosure. Thisisoftenduetofailuretoreentertheskindirectlyacrossfromthe needleexitsite.Itisimportantthatadvancementalongthewoundoccur withthesuturebiteitselfratherthanduringcrossingtotheothersideof thewound. Anothererrorcommontomostsuturingtechniquesisfailuretoprovide eversionofskinedges. Eversioncreatesthebestsubsequentcosmesis asthewoundheals.Thiserrorusuallyoccursinthesimpleinterrupted suturebydirectingtheneedletiptowardthewoundasopposedtoslightly awayfromthewoundastheneedleenterstheskinandsubcutaneous tissue.

VII.

RECOMMENDATIONSFORPRACTICE
Assuturingskillsaresofundamentaltoallofsurgicalpractice,itwillbe importanttocontinuetopracticethesesuturingtechniquesbeyondthe surgicalskillslaboratorysession.Mostsurgicalskillslaboratorieswillmake availablesyntheticskinorpigsfeetforindependentpracticetoimproveboth techniqueandspeedofsuturing.

VIII. SUPPLIESANDSTATIONSETUP
Thislaboratorycanbeconductedusingeithersyntheticskinorpigsfeet. Whicheverisused,itwouldbeimportanttohaveatleastonesegmentof syntheticskinoronepigfootforeachresidentinthelaboratorysession. Station1:SimpleInterruptedandRunningStitch 40Vicryloncuttingneedle Syntheticskinorpigsfoot Needledriver Adsonforceps Suturescissors Station2:RunningSubcuticularStitch Asinstation1 Station3:VerticalMattressStitch 20Silkoncuttingneedle Syntheticskinorpigsfoot Needledriver Adsonforceps Suturescissors Station4:HorizontalMattressStitch Asinstation3