Common suture techniques Flashcards
Suture selection is based on
tissue type.
Some tissues need support for longer than others:
* Skin, muscle, subcutaneous tissue – a few days
* Fascia – weeks
* Tendon – months
Suture patterns are classified based on 3 features:
- as interrupted or continuous
- by the way they appose tissue (e.g. appositional, everting, inverting)
- by which tissues they appose (e.g. intradermal, subcutaneous)
In most cases, right-handed surgeons place sutures from right to left and left-handed surgeons from left to right.
- When suturing skin – how far from the wound edge are the sutures placed?
sutures are placed at least the length of the skin thickness from the wound edges.
the weakest point of a suture
the knot
Offset the knot so that it does not rest on top of the incision.
Factors influencing knot security: (5)
- Type of material
- Length of the cut ends
- Structural configuration of the knot
- Number of throws used
- Experience
Square knots are usually recommended,
surgeon’s knots for areas of tension.
Describe Interrupted suture patterns. (5)
- The knot is tied after each suture
- Better drainage
- Failure of a single suture does not
cause the entire suture line to fail - Relatively time-consuming
- More foreign material (knots)
Describe Continuous suture patterns. (5)
- The suture line is begun and completed with a knot.
- Fast in comparison with interrupted sutures.
- Provide good tissue apposition, relatively air and fluid tight.
- Less foreign material
- Tearing of the suture material
results in an open wound.
identify these patterns A-D
- Simple interrupted pattern (A)
- Horizontal mattress pattern (B)
- Cruciate pattern (C)
- Vertical mattress pattern (D)
Describe the Simple interrupted pattern. (4)
- Needle inserted through tissue on one side of the wound and passed through the opposite side.
- Knot tied, ends cut
- Appositional (positioning of things side by side or close together) (unless too much tension)
- Sutures in small animals 2-3 mm away from the skin edge.
Describe the Cruciate pattern. (3)
- Two simple interrupted sutures placed parallel to each other, then tied across the incision.
- Can relieve low to moderate tension
- Almost as secure as simple interrupted, but less suture material used.
Describe Horizontal mattress pattern. (4)
- Needle inserted on the far side of the incision, passed across and exited on the near side.
- Then advanced 6-8 mm along the incision
and reintroduced through the skin exiting on the far side for the knot to be tied. - Suture should pass just below the dermis
- Used in areas of tension
Describe the Vertical mattress pattern. (4)
- Needle introduced 8-10 mm from the wound edge, passed across, exited at equal distance.
- Needle then reversed and inserted on the same side 4 mm from the wound edge, passed back across and exited at equal distance.
- Sutures generally separated by 4-5 mm
- Used in areas of tension
Compare mattress patterns.
identify
Continuous mattress pattern – everting
Describe the Simple continuous pattern. (4)
- A simple interrupted suture placed and knotted. Needle then passed through the tissue from one side to the other perpendicular to the incision.
- To end the suture – needle end of the suture tied to the last loop of suture that is exterior to the tissue.
- Frequently used to close the linea alba and
subcutaneous tissue - Care should be taken to avoid excessive tightening in some areas not to cause purse-stringlike effect (e.g. intestinal anastomosis).
Describe the Ford interlocking pattern. (4)
- Each pass is linked to the previous one through a loop of material as the suture exits the tissue.
- To end – needle reversed and introduced in the opposite direction, the loop tied to the single end.
- Might be more comfortable for right-handed surgeons to start from the left and left-handed from the right (usually the other way around!)
- May appose tissue better than simple pattern.
Describe the Intradermal pattern. (7)
- The knot is buried in the dermis.
- Suture then advanced in the dermal
tissue. - Bites parallel to the incision
- Completed with a buried knot
- May be used instead of skin sutures
to reduce scarring. - No need to remove
Describe the Subcutaneous pattern. (2)
- To eliminate dead space, provide
apposition. - When drainage might be necessary,
interrupted sutures preferred.
identify
subcutaneous pattern
Describe and name Sutures used to close hollow organs (inverting). (4)
- Simple interrupted or continuous most commonly used (appositional patterns advocated as this facilitates rapid healing).
- Lembert pattern
- Connell and Cushing patterns
- Schmieden pattern
- Two-layer closure usually not recommended nowadays for most organs
(e.g. simple continuous or Schmieden + Cushing), but can be used when closing the stomach for instance.
Describe the Lembert pattern. (5)
- Continuous variation of a vertical mattress pattern used on hollow organs.
- Serosa and muscularis penetrated 8-10 mm from the incision edge, exited 3-4 mm from the wound.
- Continued in a similar fashion on the other side.
- Repeated along the length of the incision
- Is an inverting pattern
Describe Connell and Cushing patterns. (7)
- Began with a simple interrupted or vertical mattress suture.
- Needle advanced parallel to the incision and reintroduced at a point that corresponds to the exit point on the contralateral side.
- The suture should cross the incision perpendicularly.
- Connell pattern enters the lumen (penetrates all layers)
- Cushing pattern extends only to the submucosal layer
- Continuous inverting patterns, create a watertight seal. Inversion occurs when suture tightened.
- Cushing can be used as a second layer in case of two-layer closure.
Difference between Connell and Cushing patterns.
Both are inverting patterns for hollow organ closure.
- Connell pattern enters the lumen (penetrates all layers)
- Cushing pattern extends only to the submucosal layer. Cushing can be used as a second layer in case of two-layer closure.
Describe Schmieden pattern. (3)
- Insertion of the needle is from under the wound surface passing through all the layers.
- Continuous inverting pattern
- Quick (1st layer) closure of the defect
