09.01-02 Suturing Techniques
Inserting each suture correctly is the key to good wound closure. Here you will learn how to place a suture and how to avoid damage to the wound edges.
You should be familiar with how to use the needle holder and suture needle to insert a suture with minimal tissue damage.
This module covers simple interrupted, continuous, subcuticular, mattress and pulley sutures and has plenty of tips on how to overcome common problems.
In this module
09.01 General Principles
Suture material is a foreign body implanted into human tissues and it elicits a foreign body tissue reaction. There are key principles to follow in order to minimise trauma when suturing:
Always handle tissues gently. Rough handling causes microscopic damage to the wound edges. This leads to ischaemia, poor healing and an unsightly scar.
Avoid touching the wound edge whenever possible.
09.01.01 Choosing Your Suture
Your choice of suture will depend on the area of the body, the patient's age and health and the type of closure.
In general, monofilament sutures elicit less tissue reaction than braided (multifilament) sutures, and non-absorbable sutures elicit less tissue reaction than absorbable sutures.
For more detailed information on sutures and their properties, go to the Needles and sutures module.
09.01.02 Mounting the Needle in the Needle Holder
Mounting the needle correctly in the needle holder is essential to good suturing technique. Grasp the needle on the central flat section, about two thirds of the way from the point, with the tip of the needle holder’s jaws. If the needle is too near the hinge, the jaws will get in the way.
Angle the needle slightly forward in the instrument's jaws. This conforms to the natural direction of your hand when inserting a suture and is more comfortable.
Squeeze the handles together to engage the ratchet and lock the needle in position. To release, squeeze the handles again and then separate fractionally.
09.01.03 Inserting the Suture
Always insert and remove a curved needle along the path of its curvature to ensure minimal trauma.
Consider the needle's path as a circle that begins before the needle touches the skin and continues after leaving it.
The needle should follow this curved path as it enters and passes through tissue. Continue the circular path as you remove the needle.
Ensure that the needle takes an adequate bite on each side of the wound, passing through all layers of the skin and bringing the edges together without tension.
It is usually best to pass the needle through each edge of the wound separately, repositioning the needle in the needle holder before taking the second bite.
An experienced surgeon using an adequate needle in a small wound can take both sides in a single bite.
09.01.04 Eversion
When suturing the edges of a wound together, it is important to evert the skin edges—that is, to get the underlying dermis from both sides of the wound to touch. For the wound to heal, the dermal elements must meet and heal together.
If the edges are inverted (that is, the epidermis turns in and touches the epidermis of the other side), the wound will not heal as quickly as you would like and a depressed and ugly scar may form.
Avoid inverting the edges by ensuring that your needle tip is directed slightly away from the wound as it enters the skin and subcutaneous tissue.
Aim to evert the wound edges slightly by taking a larger bite of the deeper part of the tissue. As the needle emerges, support the skin next to it with dissecting forceps.
Allow for postoperative swelling of the wound edge and do not tie the sutures tightly.
09.02 Things to Avoid
Many people experience difficulties when they are learning to close wounds. This section provides examples of common problems with suturing in general, together with advice on how to solve them.
09.02.01 Failure to Evert Edges
Failure to evert the wound may lead to an ugly depressed scar.
09.02.02 Mounting the Needle Incorrectly
Holding the needle too near its tip prevents you from taking a satisfactory bite because the needle holder's jaws will get in the way.
Holding it too near the swaged end may cause the needle to buckle or snap.
09.02.03 Superficial Bites
Avoid taking small, superficial bites - this leads to dead space within the wound. Dead space permits the accumulation of blood or serum which can act as a focus for infection and result in delayed healing.
09.02.04 Incorrect Needle Path
A curved needle being forced along a straight path can cause a lot of harm. A strong needle will cause tissue damage, while a weak needle will buckle.
Consider the needle's path as a circle that begins before the needle touches the skin and continues after leaving it.