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Practical suturing techniques animated demonstrations

Equipment needed

• Sterile gloves

• Sterile antiseptic skin preparation (povidone-iodine or chlorhexidine)

• Sterile saline

• Surgical drape

• Surgical swabs, gauze

• Sterile syringe(s) and needle(s)

• Local anaesthetic

• Suture materials

• Needle driver

• Forceps

• Haemostat

• Scissors

• Scalpel

• Wound dressing.

Contraindications

In general, there are no absolute contraindications for suturing, but delayed closure may be a better option for contaminated wounds or when there has been a long interval since the time of injury.

• Interrupted suture - when used for skin closure, interrupted sutures are appropriate only where the wound edges are under low tension. If tissues are under higher tension, then additional strength is required and you will need to use a deeper layer of absorbable sutures to the dermis. Once you have brought together the wound using this method, you can use interrupted sutures to close the skin.

• Vertical mattress suture - compared with the simple interrupted suture, the vertical mattress is stronger and less likely to pull through or cause ischaemia of the wound edges. However, skin-edge necrosis will still occur if there is excess tension and other techniques may be needed, such as absorbable deep suture and/or undermining of the skin edge. The choice depends on clinical judgment. Ask for help if uncertain.

• Horizontal mattress suture - avoid in more aesthetically important areas. Suitable for wounds under some tension but skin-edge necrosis will still occur if there is excess tension, and other techniques such as absorbable deep suture and/or undermining of the skin edge may be needed. The choice depends on clinical judgment. Ask for help if uncertain.

• Continuous subcuticular suture - continuous subcuticular closure is not indicated for traumatic wounds where the skin edges are irregular, unequal lengths, or ragged and traumatised. It is not indicated where the risk of wound infection is significant (for example when a wound is contaminated) as the continuous thread means that infection will lead to complete wound dehiscence.

• Continuous suture - do not use for skin closure (used for connective tissue closure) or if there is any risk of wound infection.

Indications

• Restoring functional integrity of skin or other tissues

• Minimising scarring

• Controlling haemorrhage.

Interrupted suture:

Indicated for simple wound closure when wound edges are under low tension. In the operating theatre, they are also used to bring together deeper tissues such as muscle layers, mesentery, and fascia. If tissues are under higher tension, additional strength is required, and you will need to use a deeper layer of absorbable sutures to the dermis. Once you have brought together the wound using this method, you can use interrupted sutures to close the skin.

Vertical mattress suture:

Indicated for simple closure of wounds, including contaminated wounds following trauma. They are particularly useful when the wound requires more tension to bring together the skin edges or for thin skin where this technique helps evert the skin edge effectively. In the operating theatre, they may also be used for hand-sewn bowel anastomoses. Compared with the simple interrupted suture, the vertical mattress is stronger and less likely to pull through or cause ischaemia of the wound edges.

Horizontal mattress suture:

Horizontal mattress sutures are particularly useful when the wound is under some tension and in an area that is considered relatively less important aesthetically. This technique disperses the tension on each suture and allows for reliable eversion of the wound edge, which promotes healing.

Continuous subcuticular suture:

The continuous subcuticular suture is used to repair a straight, clean wound, which can be closed without tension. Its main use is for operative wounds, where there has been no contamination. When performed correctly, this technique results in an excellent cosmetic result, as the skin integrity is maintained and the suture is buried, invisible beneath the skin.

Continuous suture:

A continuous suture is commonly used for closing connective tissue layers. It is quick and easy, and distributes tension evenly. Examples of use of continuous suture are linea alba closure after laparotomy or closure of the external oblique aponeurosis in hernia repair or open appendicectomy. Delicate vascular anastomoses are also constructed using continuous suture techniques.

Complications

• Infection

• Haematoma

• Wound dehiscence

• Scarring.

Aftercare

Removal of sutures:

Non-absorbable sutures are removed after:

• Face and scalp - 5 days

• Limbs - 7 to 10 days

• Trunk and back - 10 to 14 days.

When there is additional tension in the repair due to swelling or skin loss, the mattress sutures should be left for slightly longer until adequate healing has occurred.