Horizontal Mattress Suture – OSCE guide

geekymedics.com/horizontal-mattress-suture

August 6, 2018

Horizontal mattress sutures are useful in wounds under tension and help to evert wound
edges when skin naturally inverts into the wound. The horizontal mattress is a square-
shaped suture with the knot lying parallel to the wound.

This guide demonstrates how to perform a horizontal mattress suture, including step-by-
step images and a video of the procedure.

Some other guides you might find useful:

Vertical mattress suture

Simple interrupted suture
Suture materials
Theatre etiquette

Equipment

Needle holder (Driver)

Hold this with your dominant hand
Put your thumb through one handle
Place your ring finger through the other handle, some people prefer avoiding this as
they feel you have greater dexterity and range of movement (this is referred to as
“palming”)

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 Needle holder closed

Needle holder open

Locking the ratchet of the needle holder

Locked ratchet

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Toothed forceps (Pickups)

Hold with your non-dominant hand
Hold like you would a pen
Be gentle with skin, do not grip it too tight or you may damage the wound edges

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 Hold the forceps with your non-dominant hand in the same way you would hold a pen

Use your thumb and index finger to grip gently with the forceps

How NOT to hold the forceps

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Scissors
Used for cutting sutures
Position your index finger at the base of the blades to make your movements more
precise
Rest the blades on your index finger of your non-dominant hand to increase accuracy
when cutting

Use the scissors to cut sutures

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 Use your index finger to increase your accuracy when using scissors

Use your index finger to increase your accuracy when using scissors

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Suture
Different suture materials are used for different wounds, anatomical layers of closure
and areas of the body
Some of this is surgeon’s preference
Please see our separate guide on suture materials for more information

Load the needle between the apex of its curvature and two-thirds from the needle tip

Ensure your needle is loaded in the tip of the needle holder

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Basic principles of wound management
All wounds should have local anaesthetic infiltration before the intervention. Take care in
cosmetically sensitive areas such as the lip as this may distort the normal anatomy.

Following this, they should be thoroughly washed and the wound bed should be examined
for internal damage. Patients should be up to date with their tetanus immunisation and
contaminated wounds warrant a course of an antibiotic such as co-amoxiclav or a suitable
alternative if allergic.

X-rays should be performed if there is suspicion of a fracture or foreign body.

Wound edges should be debrided if the wound is contaminated. If there is no damage deep
to the skin, then primary closure can be performed.

BODY AREA SIZE MATERIAL REMOVAL

TIME

Face/Lip 6-0 Monofilament, non-absorbable 3-5 days

Scalp 3-0, 4-0 Monofilament, non-absorbable 7-10 days

Chest/Abdomen/Back 3-0, 4-0 Monofilament – may be absorbable or non- 10-14 days

absorbable

Limbs 3-0 to 5- Monofilament – may be absorbable or non- 10-14 days

0 absorbable

Hands 4-0 or 5- Monofilament – usually non-absorbable 10-14 days

0

Nailbed 6-0 Braided, rapidly absorbable Absorbable

*Use intuition, some patients have much thicker skin than others and will require a larger
suture to facilitate wound closure.

Setup
This is a sterile procedure, and therefore the wound and surrounding skin must be
prepared with antiseptic solution before placing a drape around the sterile field. You must
wash your hands and wear sterile gloves, taking care not to ‘de-sterilise’ during the
procedure. Although you may not need a surgical gown, you must don gloves taking care
not to touch the external surface.

Wash the wound and debride the skin edges if ragged or dirty and if you are certain there
is no deep tissue damage you may proceed to close the skin.

Load your needle holder by placing the needle in the tip of the holder, two-thirds of the
distance from the tip to the thread.

Plan the entry and exit of your suture on either side of the wound. The suture should lie
perpendicularity across the wound.

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 Load the needle between the apex of its curvature and two-thirds from the needle tip

Ensure your needle is loaded in the tip of the needle holder

Out to In
1. Gently lift the skin with the forceps, and pierce the skin surface with the needle
perpendicular (90 degrees) to the skin at approximately 4mm from the wound edge (if the
wound is under tension a bigger needle bite may be required).

2. Supinate your wrist so that the needle passes through the dermis and rises out of the
middle of the wound.

3. Use your forceps to hold the needle whilst you release your needle holder.

4. Re-grasp the needle in the same place with your needle holder.

Gently lift the skin edge with the forceps and pierce the skin surface with the needle
perpendicular to the skin.

Supinate your wrist so the needle rises out the middle of the wound.

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 Re-grasp the needle and follow its curvature as you pull it through the skin, try not to
grasp the tip as it will blunt!

Grasp the needle with your forceps to prepare you to re-grasp with the needle holder.

Re-grasp the needle with your needle holder.

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In to Out
5. Lift the opposing skin edge gently with your forceps.

6. This time the needle has to travel perpendicular through the dermis from inside to
outside. Use the curvature of the needle and supinate your wrist to move the needle
through the skin. Equal needles bites of depth and distance from the wound should be
taken to allow wound edges to oppose equally and neatly.

7. Again, use your forceps to grasp the needle and pull it through the skin. You should
continue to follow the curvature of the needle as it travels through the skin. Pull the suture
through.

You should now have a suture crossing perpendicular to the wound, approximately 4mm
from the wound edge.

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If the wound is under tension, you can take a bigger ‘bite’ of skin either side, meaning you
enter and exit the skin between 5-8mm from the wound edge.

Lift the opposing skin edge gently with your forceps

Use the curvature of the needle and supinate your wrist to move the needle through
the skin

You can use the forceps to create counter-traction as you push the needle through
the skin

Pull the suture through the skin

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8. Now re-load the needle facing the opposite direction (away from you). The aim is the
throw another suture across the wound 8-10mm distal and parallel to you first suture. You
need to bring your suture back to the side of original entry so that you can tie your knot
away from and parallel to the wound.

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9. Again, you can remove your fingers from the needle holder handle if you find this
increases your dexterity. Gently lift the skin with the forceps, and pierce the skin surface
with the needle perpendicular to the skin.

10. Because your needle is loaded facing away from you, you will need to pronate your
wrist so that the needle passes through the dermis and rises out of the wound.

11. Use your forceps to hold the needle whilst you release with your needle holder.

12. Re-grasp the needle in the same place with your needle holder.

13. Lift the opposing skin edge gently with your forceps.

14. This time the needle needs to travel perpendicular through the dermis from inside to
outside. Use the curvature of the needle and pronate your wrist to move the needle through
the skin back to where you started.

15. Again, use your forceps to grasp the needle and pull it through the skin. You should
continue to follow the curvature of the needle as it travels through the skin. Pull the suture
through.

Re-load the needle facing the opposite direction.

Pierce the skin surface and pronate your wrist so that the needle passes through the
dermis and rises out of the centre of the wound.

Hold the needle with your forceps whilst you release your needle holder.

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Pull the suture through the skin, following the curvature of the needle.

Re-grasp the needle in the same place with your needle holder.

Lift the opposing skin edge gently with your forceps.

Use the curvature of the needle and pronate your wrist to move the needle through
the skin back to where you started.

Re-grasp the needle.

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 Pull the suture through the skin.

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Knot tie
16. Drop the forceps (gracefully).

17. Pull the suture through so there is approximately 3cm length on the opposing side.

18. Hold the suture in your non-dominant hand, and the needle holder in your dominant
hand.

19. Loop the suture away from you around the needle holder twice, then grasp the suture
end with your needle holder. Pull the needle holder towards you and push your non-
dominant hand away to lay the first knot.

20. Let go of the suture with your needle holder but keep hold of it in your non-dominant
hand.

21. Now loop the suture back towards you around the needle holder once and grasp the
suture end with your needle holder. Push the needle holder away from you and bring your
non-dominant hand towards you to lay the second knot.

22. Finally, loop the suture away from you around the needle holder once, then grasp the
suture end with your needle holder. Pull the needle holder towards you and push your non-
dominant hand away to lay the final knot.

23. The knot will lie on one side of the wound because you have both suture ends coming
from the same side.

24. Now cut the suture between 5-6mm in length. If it is too short the knot will come
undone. If it is too long, the suture material will become trapped within other knots and they
will come undone.

You must not pull the suture too tight or you risk crushing skin and causing tissue
ischaemia. For this reason, this knot can be used temporarily to reduce or stop bleeding
(e.g. in large scalp lacerations).

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Loop the suture away from you around the needle holder twice.

Grasp the suture end.

Pull the needle holder towards you and push your non-dominant hand away to lay the
first knot.

Pull the needle holder towards you and push your non-dominant hand away to lay the
first knot.

Now loop the suture back towards you around the needle holder once and grasp the
suture end with your needle holder.

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 Push the needle holder away from you and bring your non-dominant hand towards
you to lay the second knot.

Finally, loop the suture away from you around the needle holder once, then grasp the
suture end with your needle holder.

Pull the needle holder towards you and push your non-dominant hand away to lay the
final knot.

Trim the suture.

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Overview
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 Throw your first suture across the wound (OUT to IN, then IN to OUT).

The aim is the throw another suture across the wound 8-10mm distal and parallel to
you first suture

Pull the suture through

Perform knot tie

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REVIEWED BY

Mr Ahmed Ali-Khan

Consultant Plastic Surgeon

LASE Medical Limited

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