TRAINING AND EDUCATION

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Suture Techniques and Videos

Suturing is a kind of skin stitching which is done to accelerate wound healing. It is done by using a sterilized needle and thread. Suturing techniques are useful in stitching up deep wounds that thwart off the risk of infection creeping in.

There are different types of suture materials and needles. The choice of needles and sutures are determined by lesion location, skin thickness, etc. However, the basic suture practice, including needle driving, needle holding as well as knot placement remains same.

Suture Placement

The needle is held by a needle holder. The angle and distance from needle tip varies based on the surgeon’s preference. The needle holder should be tightened, but not excessively to prevent damage to both the holder and needle. The needle is held in vertical position and it is longitudinally perpendicular to the holder. Incorrect placement of the needle in its holder may cause problems. The problems include difficult skin penetration, bent needle, and improper entry in skin tissue.
The tissue has to be sterilized to let suture placement be proper. Based on the preference of the surgeon, skin hooks, forceps can be used to hold the tissue gently. The tissue that is being sutured should not be subjected to excessive stress to diminish risk of tissue strangulation.
Forceps are required for needle grasping when it exits tissue post a pass. Prior to removing the needle holder, holding and stabilizing the needle will be required. This maneuver reduces risk of losing a needle in the dermis. This is required when small needles are deployed in the back and big needle bites are required for apt tissue approximation.
The needle has to penetrate skin at 90° angle as it reduces entry wound size and promotes skin edge eversion. This needle has to be inserted 1-3 mm away from skin edge, but this can vary on skin thickness. The angle and depth of the suture varies on the specific suturing technique. Both sides of the suture should be like mirror images. The needle must exit the skin while being perpendicular to the surface of the skin.

Knot Tying

After the suture is placed well, it has to be secured with a knot. As it is, the instrument tie is deployed the most in cutaneous surgery and square knot is typically used.
At first, the needle holder tip is rotated clockwise by the suture’s long end for two complete turns. Its tip is deployed to hold the short end of the suture. The suture’s short end is pulled through a loop on its long end by crossing hands. This ensures two ends of suture remain on opposite sides. The needle holder is then rotated once counterclockwise around the suture’s long end. This short end is held with the needle holder tip and then gets pulled though loop once more.
The suture has to be tightened adequately to approximate wound edges minus constricting the tissue. Often leaving a suture loop after its 2nd row is prudent. This reserve loop lets the stitch expand slightly and thwarts tissue strangulation. The surgeon may add one additional row.
Using successive ties is necessary. A tie has to be laid down parallel to the one preceding it.

Placement of various specific Suture Types

Simple Interrupted Suture

The most versatile and commonly done suture is known as simple interrupted suture. This suture is done by inserting the needle in a perpendicular position to epidermis, passing through it and dermis and then exiting perpendicular to epidermis on the wound’s other side. The sides of stitch have to be symmetrically positioned in terms of width and depth.
This suture has a flask-shaped configuration overall. The stitch has to be broader at the base compared to the superficial portion at the epidermal side. If the stitch covers a bigger tissue volume at the base rather than the apex, the compression will press the tissue upward and enable wound edge eversion. This reduces risk of depressed scar getting created as the wound squeezes while healing is in progress.
As a matter of fact, tissue bites need to be evenly placed to ensure wound edges meet at the exactly same level. This brings down the risks of wound-edge height mismatch. The size of bite derived from wind sides can be kept different by altering the distance of the needle insertion zone from the wound edge, distance of the needle exit zone from the wound edge. The bite depth taken is also a factor here.
Using varying sized needle bites on the wound’s each side can rectify preexisting asymmetry in the height and thickness of the edge. Small bites can be deployed to cope with wound edges. Large bites are ideal to diminish wound tension.

Simple Running Suture

A continuous or simple running suture is basically simple interrupted sutures done in series. It is initiated by making a simple interrupted stitch and it is tied. Then a range of simple sutures is put in succession, but the suture material is not tied or cut post every pass. The sutures have to be evenly spaced so that tension gets distributed evenly along the line of suture. The stitch line is wrapped up by tying knot after the final pass at suture line’s end. The knot gets tied between suture material’s tail end where it actually exits the wound and last suture’s loop.

Running Locked Suture

A simple running suture can either be locked or it can be left unlocked. The first knot of any running locked suture gets tied as a traditional running suture. This may be locked by passing the needle though one loop preceding it as every stitch is positioned. This suture is alternatively named as the baseball stitch since the ultimate appearance of running locked suture line looks like it.

Vertical Mattress Suture

The vertical mattress suture is basically a variant of the simple interrupted suture. It comprises of one simple interrupted stitch which is put deep and wide into wound edge and another superficial interrupted stitch which is positioned closer to the edge of the wound in the opposite direction. The stitch’s width has to be increased in proportionately to the wound tension amount. So, if the tension is higher, the stitch has to be broader.

Half-Buried Vertical Mattress Suture

The half-buried vertical mattress suture can be defined as slightly modified version of the vertical mattress suture which discards two entry points from 4, and so leads to diminished scarring. Its positioning is like that of the vertical mattress suture barring that in it the needle penetrates skin to dermis’s deep part on the wound’s one side and then it takes a deep bite in opposite side in the dermis without exiting the skin. Then it crosses back to the first side and then exits the skin. So, eventually the Entry and exit points are placed on the wound’s one side in this suture style.

Pulley Suture

The pulley style suture is an alteration of the vertical mattress suture, as it is. In this style, a vertical mattress suture gets positioned and the knot is kept untied. The suture is then looped through the external loop on the incision’s other side. It is then pulled across and the knot is tied. This new loop works as pulley by directing the tension away from other strands.

Horizontal Mattress Suture

The horizontal mattress suture is made by entering the needle in skin approximately 5mm to 1 cm from the edge of the wound. The suture is made to pass through deep in dermis to the suture line’s opposite side and then exits the skin at the same distance from the edge of the wound. The needle enters the skin again on the suture line’s side just 1 cm from the exit point. The stitch is then made to pass deep to the wound’s opposite side. Then it exits the skin and the knot is tied.

Half-Buried Horizontal Suture

The Half-buried horizontal suture is also called three-point corner stitch and tip stitch. It starts on the wound’s side where the flap would be attached. The suture is then made to pass through wound edge’s dermis to flap tip’s dermis. The needle is made to pass through the flap tip’s dermal plane and it then exits the flap tip. Next, it reenters the skin where the flap would be attached. The needle is kept perpendicular as it exits the skin and knot is thereafter tied.

Dermal-Subdermal Sutures

A dermal-subdermal suture involves inserting the needle to the epidermis’s parallel at the dermis junction and subcutis. The needle then curves upward and it exits in the papillary dermis, parallel to the epidermis once more. Next, the needle is inserted in the papillary dermis parallel to the epidermis, on the wound’s opposite edge. It curves down through the reticular dermis, exits at the wound base between the subcutis and dermis, parallel to the epidermis.
The knot is basically tied at the wound base to reduce the risk of tissue reaction and knot extrusion. If the suture is positioned in a more superficial manner in the dermis about 2-4 mm distance from the wound edge, then eversion is increased.

Buried Horizontal Mattress Suture

The buried horizontal mattress suture is a type of purse-string suture. This type of suture has to be placed in deep or mid part of the dermis so that skin is not torn. If the suture is made very tight, it may actually choke the approximated tissue.

Running Horizontal Mattress Sutures

In this style, a simple suture is made and the knot is not cut but tied. A horizontal mattress suture series is placed in a continuous manner. The final loop is tied to the suture material’s free end.

Running Subcuticular Sutures

A running subcuticular suture can be described as buried form of the running horizontal mattress suture. This is placed by making horizontal bites throughout the papillary dermis on the wound’s alternating sides. The suture marks are not visible and this suture may be kept in place for some weeks.

Running Subcutaneous Suture

The running subcutaneous suture starts with the creation of simple interrupted subcutaneous suture which is not cut but tied. The suture is then looped through subcutaneous tissue and passed successively through the wound’s opposite sides. Its knot is tied at the wound’s opposite side by tying suture material’s long end to the last pass’s loop.

Variants of Tip Sutures

The Modified half-buried horizontal mattress suture is a style of suture in which an extra vertical mattress suture is positioned superficially to a half-buried horizontal mattress suture. Instead of forceps a small skin hook is deployed in it to evade the flap’s trauma.
The deep tip stitch is actually a fully buried variant of three-corner stitch. The suture is positioned into the wound edge’s deep dermis to which flap is attached. The flap is then passed through the flap tip’s dermis and pushed into deep dermis of wound edge at the opposite side.

Substitute Options of Wound Closure

Wound closure tapes : The Wound closure tapes are made of microporous reinforced surgical adhesive tape strips. They are used to give better support to suture line after removal of sutures or when subcuticular sutures are used. The usage of these tapes may diminish scar spreading if they are put on for several weeks post suture removal. As they can fall off, they are not used for primary wound closure.
Staples : Stainless steel staples for wound stitching are also used. It is used for wounds in the scalp or trunk. The benefits are quick placement, strong wound closure and reduced infection risk.
Tissue adhesive : These have bacteriostatic effects and can be applied easily. In certain medical procedures, application of Tissue adhesives has shown better results than typical sutures. The benefits of applying Tissue adhesives are rapid wound closure, absence of suture marks, painless application.
Barbed Suture : It is used mostly in cutaneous surgery. It does not have suture knots which is an advantage. This reduces infection risk. Barbed sutures have been deployed in the minimally invasive procedures. However, their efficacy may not be risk free.

These are the many techniques of sutures used to sew wounds and a simple explanation of how it is done!

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