Suture Patterns Flashcards
There are a ____ of suture patterns that can be used to close a surgical incision
variety
It is important to be able to perform the ____ patterns and be familiar with their ___ properties, so you can decide when their use is appropriate.
basic, basic
Important to chose a pattern that will ___ the incision and provide _____ _____ support with minimal ____ reaction
close, maximum, mechanical, tissue
There are often ____ appropriate patterns to close a specific incision.
One may be appropriate for __ species, but not another. _____ patient factor may influence pattern selection. _____ preference plays a major role in the ___ pattern selection.
several, one, Individual, Personal, final
List the different suture patterns
Interrupted vs. Continuous
Appositional vs. Inverting vs. Everting
Simple vs. Tension
What suture pattern is this?
interrupted
What suture pattern is this?
continuous
What suture pattern is this?
interrupted vs. continuous
Interrupted Patterns
Series of _____ sutures
More ____ than a continuous pattern b/c if 1 or 2 single interrupted sutures are compromised, does not usually affect the ___ of closure
Allows for adjustments of ___ throughout the suture line
Uses ___ suture material = ___ to the practice; charging ___ ____ of suture in some hospitals; suture is very ______. Increased amount of _____ material (____) in the wound
Less ___ = efficient! BUT, in this case, ____ time needed to tie the individual knots.
individual, secure, integrity, tension, more, costly, per packet, expensive, foreign, suture, time, More
Continuous Patterns
Begin with an initial ___ and continue with the pattern to the ___ of the incision [prior to tying the ___ knot] Only ___ knots, but knots MUST be tired _____.
Less precise control of suture _____ and wound _______.
Tension is adjusted after ___ bite and difficult to adjust at the ____.
Failure of the ___ leads to disruption of the suture line
Time ___ and _____ pattern to perform
_____ foreign material (suture) in the wound
Provides better __ and ____-tight closure
knot, end, final, two, properly, tension, approximation, each, end, knot, efficient, faster, Less, air, water
Suture Placement
Start
Interrupted patterns
- End of the incision nearest to your dominant hand [R vs. L handed surgeon]
- Top of incision [if vertical]
- At or just beyond the corner of the incision (~1-3mm)
Continuous patterns
- At or just beyond the corner of the incisions (~1-3mm)
Bites
- Distance from incision edge = ~3-5mm
- Distance between sutures = ~5-8mm
Tags
Appositional patterns
Used when there is no ______ tension on the incision edges.
Enables the best anatomical _____
Brings the ____ of the incision together.
Results in the ____ healing
Gives the best ____ result
Examples:?
excessive, approximation, edges, fastest, cosmetic, Simple Interrupted
Simple Continuous
Cruciate
Ford Interlocking
Intradermal
Simple Interrupted Pattern
Pattern classification – ?
Often used when ____ tension on the incision’s edges. Local tension is managed by adjusting tension on the _____ sutures
Not recommended if there is ____
_____ impact of the local blood supply to the incision edges, unless _______.
Excessive tension causes _____ of the skin margins
Uses:?
interrupted and appositional, normal, individual, tension, Minimal, overtightened, inversion, Close skin, subcutaneous layer, body wall, etc.
Ligate blood vessels or nerves
How to perform an interrupted pattern
Don’t tie the knot too tightly! Remember that in the living animal, minimal tension must be placed on the
skin otherwise post-operative swelling, redness and discomfort may occur, which can impede wound healing.
Simple continuous pattern
Pattern classification – ?
Larger effect on the _____ _____ when compared to the simple interrupted
Placed more ____ and provides better _____; provides ___ and ____-tight seal
Excessive tension can cause _____ and tissue ______
Avoid suture failure b/c you only have ____ knots.
Uses:?
continuous and appositional, blood supply , rapidly, apposition, air, water, puckering, strangulation, two, Close subcutaneous layer, body wall, hollow organ
incisions, and skin [less common - b/c other suture patterns tend to be a little bit better]
How to perform a simple continuous pattern
Step 1: Start by placing a simple interrupted suture ~5mm beyond the end of the incision. Secure suture with a knot and cut the short end of the suture
Do NOT cut the end of the suture attached to the needle
Step 2:Return to the original side of the incision [initial side] and move ~5mm down the incision
Step 3: Repeat steps #1 and #2 until the end of the incision [stop ~5mm before the end of the incision]
Step 4: When taking the final bite, do not tighten the suture all the way
This will create a small loop
Step 5: Tie the long end of the suture [end with the needle attached] to the loop previously created
Cruciate pattern
Pattern classification – ?
_____ closure than simple interrupted, since it covers greater ____ along the incision
_____ effect on the blood supply when compared to the simple interrupted b/c you are taking bites _____ together.
Helps resist _____ while preventing ______ of the skin edges
Should NOT be used when there is a concern for _____.
Uses:?
interrupted and appositional, Stronger, distance, Larger, closer, tension, inversion, tension, Close skin and body wall
How to perform a cruciate pattern
How to perform a cruciate pattern:
Step 1. Begin as if performing a simple interrupted, but after exiting through the opposite side of the skin – DO NOT TIE A KNOT
Step 2. Take a second bite on the same side of the incision [keep the bites equidistant from the incisions, so there’s a symmetrical “X” after the knot is tied]
Step 3. Tie to the “short end” of the suture from Step #1
Recommendations:
Place each bite a distance from the surgical incision edge
that is equal to the thickness of the tissue [usually 3 – 5mm]
Space sutures approximately twice the distance apart
[usually 6 – 8 mm]
Leave the loop loose enough to accommodate
post-operative swelling
How to Perform a Cruciate PATTERN Continued…
Ford interlocking pattern
Pattern classification – ?
Some _____ in the event of knot failure; be careful with knots in general
Effect on the blood supply is ____ to the simple continuous pattern
May cause pressure _____ and/or become ____ when placed under tension
Suture pattern is commonly used in ____, but can be used to close ___ in small animals
DO NOT ?
continuous and appositional, security, similar, necrosis, buried, bovine, skin, tighten too much [especially in small animals with more delicate skin]
The Ford Interlocking pattern is very similar to the _____ ________ pattern, however before taking the next bite, the needle is passed through the _____ suture loop
Ford Interlocking pattern is ended by forming a _____ loop at the end of the incision, which is used to knot the free end of suture.
simple continuous , previous, separate
What suture pattern is this?
Ford interlocking
How to perform a ford interlocking pattern
Step 1: Place a simple interrupted suture and knot it
Only cut the end of the suture material that is NOT attached to the needle
The suture will be the anchor for the rest of the suture line
Step 2: Lay the excess suture on the side of the incision closest to you [this will create a loop that the needle will pass through]
Step 3: Take the next bite [approx. 5 mm away from initial bite] and bring the needle up through the loop
Step 4: Continue down the incision in this manner
Step 5: After taking the final bite, take an additional bite through the skin
Bring the needle through the outside of the loop; tie free end with the end still attached to the needle
Rosen said she loves this pattern
Intradermal pattern
Pattern classification – ?
______ the skin edges and diminishes _____ on the skin closure
With good apposition there will be _____ scarring.
Modified _____ ______ that runs _______ though the dermis
Suture material remains ______ –> will never be seen on the ____
Needle never exits the ____; _______ impact on local blood supply
continuous and appositional, Opposes, tension, minimal, simple continuous, horizontally, buried, outside, skin, Minimal
intradermal pattern
Burying the knot - beginning of suture
Step 1: Begin inside the incision. Take a bite in the subcutaneous or intradermal layer from “deep to superficial” on the side of the incision closest to you
Step 2: Cross over to the opposite side of the incision and take a bite in the subcutaneous layer from “superficial to deep”
Step 3: Tie a knot – Make sure to tighten the knot parallel to the incision
Make sure knot is buried and not laying on top of the suture
Cut the end of the suture not attached to the needle
Step 4: The first bite taken after burying the knot should typically be taken deep to superficial, on either side of the incision to allow the knot to be buried further
Burying the knot - end of suture
Step 1: Stop the suture pattern approx. 1cm from the end of the incision.
Step 2: With the needle pointing towards you, take a perpendicular bite in the subcutaneous or intradermal layer superficial to deep on the far side [away from you]
Step 3: Cross over to the opposite side of incision and take a bit deep to superficial on the near side [closest to you]
This will form the deep loop [purple stand]
Step 4: Take a third bite superficial to deep on
the far side [away from you]
Seen as the blue strand in the image
Step 5: Tie a knot with the deep loop [purple]
and deep suture [pink strand]
Remember to tighten the knot parallel to the incision
Make sure the knot is buried and not laying on top
of the suture
Why is it important to bury the knot?
Avoid having the knots protruding through the edges of the skin incision
Do not want the patient to lick or chew at the knots –> falls apart
Prevents access of dirt and bacteria from the environment to the deeper layers –> a lotf of antibiotics for a really long time
Intradermal suture pattern
How to perform an intradermal pattern
Step 1: Begin with a buried knot (below the skin but above the subcutis)
Step 2: Take a horizontal needle bite is taken, entering the dermis [just below the skin, but above the subcutaneous tissue] along the cut edge of the skin
Advance along the incision [parallel], exiting approx. 4mm on the same side of the incision
Step 3: Cross the incision and take another similar bite on the opposite side of the incision
Bite should be parallel to where the previous bite exited the dermis
Step 4: Continue pattern along the entire incision
Step 5: End with a buried knot
overlapping suture would help prevent separation
Intradermal pattern recommendations
Bites are placed within the dermis as _____ to the skin’s _____ as possible
Successive bites should _____ at least _____ for the best apposition
Tension is adjusted after ___ bite; Difficult to readjust once the pattern is ______
Knots are buried beneath the skin’s surface at the ______ of ____ of the incision
Tissue forceps need ____ pressure to adequately _____ the skin while placing the bites
- Can result in significant ?
- Using the ____ and ____ finger to stabilize the skin during needle placement is helpful [tissue forceps are palmed – readily available for needle extraction from the issue]
close, surface, backtrack, halfway, each, completed, beginning, end, excess, stabilize, post-operative bruising, thumb, index
Inverting patterns
Turns the incision edges ____ [ ____ from the surgeon]
Used in ____ lumen-_____ organs
Inverting patterns ______ the size of the _____ organs’ lumen [avoid this pattern if the lumen is already _____]
______-_____ apposition helps provide a water-tight seal
________ the exposed suture and decreases the risk of ______
Avoid when _____ the skin [will ____ healing]
Examples:?
inward, away, larger, hollow, decrease, hollow, small, Serosa-serosa, Minimizes, adhesions, closing, delay, Lembert
Cushing
Purse String
**Suturing hollow organs
________ ______ is the holding layer; need it for the tight seal we are looking for.
Examples of hollow organs:?
Complications:?
Tunica submucosa
Bladder
Gallbladder
Stomach
Intestines
Uterus
Esophagus
- Dehiscence –> leak in incision –> septic peritonitis –> emergency
- Calculi/stone formation –> more so when dealing with bladder and gallblade; careful with what suture we are choosing because some can serve a annitis aka place where bacteria congregrate, reproduce, multiply.
- Adhesions –> do not want other organs becoming friends with nearby organs. omentum loves to adhere to other things
small intestines; lumen is small so do not use inverting; use simple continuous or interrupted
bladder, gallbladder = appositional inverting patterns
Single-Layer Closure
Partial thickness vs. full thickness
Simple interrupted or simple continuous are common
Double-Layer Closure
Inner [1st layer]
Outer [2nd layer]
What you may see some surgeons do:
Stomach –?
Urinary Bladder?
Intestines?
2 layer
1 layer = mucosa nd submucosa
second layer = serosa and muscularis
2 layer closure
1st layer = appositional pattern
2nd layer = inverting pattern
1 layer closure = inverting pattern
2 layer closure = similar to the stomach closure
returns back to 100% strength in short periods of time, so controversy on these patterns
1 layer closure = appositional pattern
Lembert Pattern
Pattern classification – ?
____ thickness [non-_______ pattern]
Can be _____ or ____
Can be used in a _____- or ____-layer closure
If used in a double layer closure can be used as a ?
Uses:?
continuous and inverting
continuous and inverting
penetrating
continuous, interrupted
single, double, 1st or 2nd layer
Commonly used in GI surgery
Large lumened hollow organs
Colon
Bladder
Stomach
Rumen
How to perform a lembert pattern
Step 1: Create a partial thickness simple secured knot across the incision, approximately 3mm away from the end of the incision on either side
Step 2: Insert needle perpendicular to the incision through the serosa and muscularis layer approximately 8-10mm from the incision (“far); needle should surface on the same side of the incision approximately 4mm from the edge (“near”)
Step 3: Cross over to the opposite side of the incision; insert needle perpendicular to the incision through the serosa and muscularis layer approximately 4mm from the edge (“near”); needle should surface on the same side of the incision approximately 8-10mm from the incision (“far”)
Step 4: Return to the original side of the incision and repeat step #2 and #3, approximately 3mm down from previous bites
Step 5: Carry on this fashion until the end of the incision is reached
Step 6: For the final knot, perform a secure knot across the incision, approximately 3mm away from the end of the incision on either side
Tie the long end of the suture to the loop created
General recs for lembert pattern
1. Bites run ______
2. Penetrates the ?
3. Does NOT penetrate the mucosa of the ?
4. The farther the bites are placed from the incision’s edge, the more ?
5. Tension is adjusted with ____ bite, as it’s difficult to _____ once the pattern is completed
perpendicular
serosa, muscularis, and submucosa
hollow organ
tissue inverted
each
readjust
Cushing pattern
Pattern classification – ?
_____ thickness [non-penetrating pattern]
Penetrates the _____, but NOT the organs’ ____
It’s important to start the pattern on the ____ side if RIGHT handed, _____ side if LEFT handed
Commonly used with a __-layer closure
Uses:?
bites happening in a ______ fashion = main difference
continuous and inverting
Partial
submucosa
lumen
RIGHT, LEFT
2
Hollow viscera
Urinary Bladder
Stomach
Uterus
parallel
How to perfrom a cushing pattern
Step 1: Create a partial thickness simple secured knot across the incision, approximately 3mm away from the end of the incision on either side
Step 2: Insert the needle parallel to the incision through the muscular and submucosal layers approximately 5-8mm; needle should surface on the same side of the incision
Step 3: Cross over to the opposite side of the incision; insert needle parallel to the incision through the muscular and submucosal layer approximately; needle should surface on the same side of the incision
Step 4: Return to the original side of the incision and repeat step #2 and #3, approximately 3mm down from previous bites
Step 5: Carry on this fashion until the end of the incision is reached
Step 6: For the final knot, perform a secure knot across the incision, approximately 3mm away from the end of the incision on either side
Tie the long end of the suture to the loop created
Connell pattern
Pattern classification – ?
____ thickness [penetrating] pattern
Similar to the _____ pattern, except bites _____ the lumen
If used with a __-layer closure, this pattern can only be used as the ________ layer
Commonly followed by a ____ or ____ pattern
Uses:?
continuous and inverting
Full
Cushing, penetrate
2, 1st [inner]
Cushing, Lembert
Hollow viscera
Urinary Bladder
Stomach
Uterus
Cushing partial thickness
Connel full thickness
Pure String Pattern
Pattern classification – ?
______ thickness [non-penetrating pattern]
Commonly used on _____ organ viscera
Temporarily close the ___ during perineal surgical procedures
Maintain ____ _____ reduction
Close _____ in hollow organ wall?
continuous and inverting
Partial
hollow
anus
rectal prolapse
defect
Pure string pattern
How to perform a pure string pattern
Take a several millimeter long bite into the tissue
Distance from edge will depend on how much tissue you want to invert or evert
Continue the pattern by taking bites every 3mm, until the entire circumference is sutured
Tighten suture allowing the tissue to cinch down
Tie knot
Finger trap pattern
Used to secure tubes to the patient
Example – secure Feeding tube; keep ucath in place
How to perform:
Step 1: Place a purse string suture around the base of the tube and leave long suture ends. Tighten pattern and tie a secure square knot.
Step 2: Bring suture ends behind the tube and cross [making an “X”]. Bring suture ends towards the front of the tube and tie a square or surgeon’s knot
Step 3: Repeat for a total of 4 knots and secure the final knot with additional throws
Finger trap pattern
Everting patterns
Turns the incision edges ____ [ _____ from the surgeon]
Used for suturing incision _____ under ____
Can lead to _____ _____
______ indicated
outside, towards
edges, tension
delayed healing
Rarely
Tension-relieving patterns
Tension refers to the tendency of the incision to ?
If there is too much tension, the suture may ?
Used to _____ tension on the suture line
Can also be used in tissues with ____ healing time
Examples:?
open up, break or pull through the tissue
decrease, slow
Mattress Patterns
Walking Sutures
Near-Far Patterns [Surgeon’s Stitch]
Vertical Mattress pattern
Pattern classification – ?
______ commonly used
____ effect on the blood supply compared to the horizontal mattress pattern, but more than the ____ _____ pattern
Less _____ noted than the horizontal mattress pattern
Uses:?
interrupted and tension relieving pattern
Stents, Less, simple interrupted, eversion
Closure of high tension areas [commonly used for skin closure]
Vertical Mattress Pattern
How to perform a vertical mattress pattern
Step 1: Take the first bite ~8mm away from the edge of the incision on the far side (“far”)
Step 2: Pass through the incision line and bring the needle up to an equal distance on the near side (“far”)
Step 3: Turn the needle around and insert the needle on the same side, but at a point ~4mm from the incision end (“near”)
Do NOT advance down the incision
Step 4: Pass through the incision line and bring the needle up to an equal distance on the far side (“near”)
Step 5: Tie a knot with the two ends, after applying appropriate tension
Horizontal mattress pattern
Pattern classification – ?
_____ commonly used
Can become an _____ pattern, depending on how ____ the suture are
_______ impact on the local blood supply compared to the vertical mattress pattern
Can easily impact local blood supply if ____
Use with caution!
Uses:?
interrupted and tension relieving pattern
Stents
eversion, tight
Greater, overtightened
Closure of high tension areas [commonly used for skin closure]
Horizontal mattress pattern
How to perform a horizontal mattress pattern
Step 1: Take the first bite ~3-5mm from the edge of the incision on the far side and cross below the incision to exit ~3-5mm through the skin on the opposite side [near side]
Step 2: Stay on the same side of the incision and move ~6-8mm down the incision
Step 3: Turn the needle around and reinsert the needle on the same side
Step 4: Pass through the incision line and bring the needle up to an equal distance on the far side
Draw the suture material moderately tight, so that the edges appose
Step 5: Repeat the process for the next suture, which should be ~4-5mm away
Step 6: Tie a knot with the two ends, after applying appropriate tension
Near Far-Far Near PatternFar Near-Near Far Pattern
Name describes ?
Variation of _____ mattress
Most appropriate pattern for ?
Resists tension without causing ______ stress directly on the incision/wound edges
Uses:?
how the bites of the suture pattern should be performed
vertical
closing incisions and wounds with considerable tension
excessive
Closure of high tension areas [commonly used for skin closure]
Near Far-Far Near Pattern
Step 1: Take the first bite ~4mm away from the edge of the incision on the far side (“near”)
Step 2: Pass through the incision line and bring the needle up ~8mm on the near side (“far”)
Step 3: Without moving down the incision, go back to the original side of the incision. Insert the needle ~8mm away the edge of the incision on the far side (“far”)
Step 4: Pass through the incision line and bring the needle up~4mm on the near side (“near”)
Step 5: Tie a knot
Ensure knot does not cross over the short strand [knot should sit adjacent to the short strand
