Suturing Techniques

SIMPLE INTERRUPTED SUTURES

REQUIREMENTS: 

• Needle holder 

Needle holders should be held with your dominant hand

 

 

 

• Toothed forceps 

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

Be gentle when using toothed forceps to manipulate skin, do not grip it too tightly or you may damage the wound's edges

 

• Scissors (to cut the sutures) 

• Written Informed Consent 

PROCEDURE: 

1. Load your needle holder by placing the needle in the tip of the holder. Needle should be held at the junction of 2/3rd distance from tip

Plan the entry and exit of your suture on either side of the wound such that on a cross-sectional view, the final suture, once tied, should appear square

2. First suture should always be in the centre of the wound

OUT-TO-IN 

3. Gently lift the skin with the forceps and pierce the skin surface with the needle perpendicular (90°) to the skin at approximately 4mm from the wound edge

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

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

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

IN-TO-OUT 

7. Lift the opposing skin edge gently with your forceps

8. This time the needle has to travel perpendicularly through the dermis from inside to outside. Use the curvature of the needle and supinate your wrist to move the needle through the skin

 9. As a guide, forceps may be kept near the exit point as follows: 

10. 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, pulling the suture through as you go. You should now have a suture crossing perpendicularly to the wound, approximately 4mm from the wound edge

 

KNOT TIE 

11. Put down the forceps. 

12. Pull the suture through so that there is approximately 3cm of length on the opposing side

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

14. Loop the suture away from you around the needle holder twice, then grasp the suture end with your needle holder

Tip: To remember which direction to loop in, place the needle holder in between the two limbs of the suture. Then, loop the suture material such that it lies over the needle holder first

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

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

17. Now loop the suture back towards you around the needle holder once and grasp the suture end with your needle holder. Take care not to pull the suture upwards (so that the surgical knot remains tight

 

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

19. 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

20. Once the knot is tied, use the needle holder to pull the knot to one side so it is not overlying the wound

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

VERTICAL MATTRESS SUTURE

 PROCEDURE:  

Steps 1-10 as above but take a bigger 'bite' of skin either side, meaning you enter and exit the skin approximately at 5-8mm from the wound edge. (Till A and B step in the figure)

11. Now re-load the needle facing the opposite direction (away from you). The aim is the throw another suture across the wound directly above or superficial to your original throw, taking smaller bites of the skin edge to evert the wound edges. You need to bring your suture back to the side of original entry so that you can tie your knot away from the wound

12. 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

13. 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

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

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

16. Lift the opposing skin edge gently with your forceps

17. 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 needle through the skin back to where you started

18. 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. Finally, pull the suture through

KNOT TIE: Similar to above

VIDEO LINK FOR ALL SUTURE TECHNIQUES:
https://www.youtube.com/watch?v=TFwFMav_cpE&feature=youtu.be

 

Time line:
0:48 - Instrument tie and Simple interrupted sutures
04:37 - Simple buried suture (subcutaneous interrupted)
06:17 - Vertical Mattress suture
08:07 - Horizontal Mattress suture, Figure of 8 suture, Half- buried Horizontal mattress suture
10:53 - Simple Running (or Continuous) suture
12:55 - Simple Running (or Continuous) suture with interlocking
15:05 - Subcuticular running (or Continuous) suture

VIDEO LINK for simple interrupted sutures: 

For Right-Handed: https://youtu.be/z8oWv-nVO6g  

For left-handed: https://youtu.be/iuxOv3Y0OX4

 

VIDEO LINK for vertical mattress: https://lacerationrepair.com/techniques/basic-suturing-techniques/vertical-mattress-sutures/  

 

Written by our guest author Akanksha Barnwal

Illustrations by Anveshi Nayan
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