Suture Patterns Flashcards
Interrupted vs. continuous patterns:
How do interrupted patterns compare to continuous patterns with regard to security? Efficiency?
more secure —> failure of 1 or 2 single interrupted sutures does not usually affect the integrity of closure and it allows for adjustments of tension throughout the suture line
less efficient —> more time needed to tie individual knots
How do interrupted patterns compare to continuous patterns with respect to price of suture? Presence of foreign material in wound?
more expensive —> uses more suture material
more foreign material (suture) in the wound
How are continuous patterns done?
begin with an initial knot and continue with the pattern to the end of the incision prior to tying the final knot
- only 2 knots, but knots MUST be tied properly
What are 2 cons to using a continuous pattern over an interrupted one? 3 pros?
CONS: failure of 1 knot leads to disruption of entire suture line, less precise control of suture tension and wound approximation
PROS: time efficient/faster, less foreign material in the wound, better air and water-tight closure
How are interrupted and continous patterns started?
- begin at the end of the incision nearest to your dominant hand
- take the first bite from the top at or just beyond the corner of the incision (~1-3 mm)
How should bites be spaced from the incision edge and between sutures?
- distance from incision edge = ~3-5 mm
- distance between sutures = ~5-8 mm
What is an appositional pattern? When are they used?
bring the tissue in direct approximation of the two cutting surfaces
used when there is no excessive tension on the incision edges
What pattern enables the best anatomical approximation (and the best cosmetic results)? What does this allow?
appositional pattern
brings the edges of the incision together, resulting in the fastest healing
What are 5 examples of appositional patterns?
- simple interrupted
- simple continuous
- cruciate
- Ford interlocking
- intradermal
What type of pattern is the simple interrupted pattern? When is it used?
interrupted, appositional
when there is normal tension on the incision’s edges —> NOT recommended when there is tension
What impact does the simple interrupted pattern have on local blood supply to the incision edges? What can excessive tension lead to?
minimal impact, unless overtightened
inversion of the skin margins
What are 2 common uses of the simple interrupted pattern?
- close skin, subcutaneous layer, and body wall
- ligation of blood vessels or nerves
Simple interrupted steps:
What can happen when knots are tied too tightly?
post-operative swelling, redness, and discomfort, which can impair wound healing
What type of pattern is the simple continuous pattern? How does it affect local blood supply and apposition?
continuous, appositional
larger effect on blood supply compared to simple interrupted
provides better apposition with an air- and water-tight seal
What does excessive tension in the simple continuous pattern lead to?
puckering and tissue strangulation
What are 4 things that the simple continuous pattern is used to close?
- subcutaneous layer
- body wall
- hollow organs
- skin (less common)
What are the 5 steps to performing the simple continuous pattern?
- place a simple interrupted suture ~5 mm beyond the edge of the incision; secure the suture and cut the short end
- return to the original side of the incision and move ~5 mm down the incision
- repeat steps 1 and 2 until ~5 mm before the edge of the incision
- when taking the final bite, do not tighten the suture all the way, creating a small loop
- tie the long end of the suture to the loop and tighten
What type of pattern is the cruciate pattern? How does it compare with closure and blood supply?
interrupted, appositional
stronger closure than simple interrupted, since it covers greater distance along the incision
larger effect on blood supply compared to the simple interrupted
What does the cruciate pattern specifically help resist? When should it NOT be used?
resists tension while preventing inversion of the skin edges
concern for tension
What 3 things is the cruciate pattern best for closing?
- skin (esp mass removals)
- body wall
- gingiva
What are the 3 steps to performing the cruciate pattern?
- begin as if performing a simple interrupted, but after exiting through the opposite side of the skin DO NOT TIE THE KNOT
- take a second bite on the same side of the incision
- tie to the short end of the suture from step 1
What are 3 special considerations with the cruciate pattern?
- place each bite a distance from the surgical incision edge that is equal to the thickness of the tissue (~3-5 mm)
- space sutures approximately twice the distance apart (~6-8 mm)
- leave the loop loose enough to accommodate post-operative swelling
What type of pattern is the Ford interlocking pattern? What effect does it have on blood supply?
continuous, appositional
larger effect, like the simple continuous pattern
What can happen when the Ford interlocking pattern is put under tension?
pressure necrosis and/or become buried
In which animals is the Ford interlocking most commonly used? Can it be used on other animals?
bovine, sheep, goats
yes, close to the skin in small animals
- too much tightening can be detrimental in animals with delicate skin
How does the Ford interlocking pattern compare to the simple continuous pattern with regards to pattern and ending?
- Ford interlocking is similar to the simple continuous, but before taking the next bite, the needle is passed through the previous suture loop
- Ford interlocking is ended by forming a separate loop a the end of the incision, which is used to knot the free end of suture
What are the 5 steps to performing the Ford interlocking pattern?
- place a simple interrupted suture and knot it and cut the end of sutre not attached to the needle
- lay the excess suture on the side of the incision closest to you to create a loop that the needle will pass through
- take the next bite ~5 mm away from the initial bite and bring the needle up through the loop
- continue down the incision in this manner
- after taking the final bite, take an additional bite through the skin and bring the needle through the outside of the loop and tie the free end with the end still attached to the needle
What type of pattern is the intradermal pattern? Why is it considered the best cosmetic pattern?
continuous, appositional
apposes the skin edges and diminishes tension on the skin closure —> good apposition = minimal scarring
Where is the intradermal pattern performed? What is its effect on local blood supply?
modified simple continuous that runs horizontally through the dermis —> suture material remains buried, needle never exits the skin
minimal impact
What are the 4 steps to burying the knot at the beginning of the intradermal pattern?
- 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
- cross over to the opposite side of the incision and take a bite in the subcutaneous layer from SUPERFICIAL to DEEP
- tie a knot - make sure to tighten the knot parallel to the incision and make sure the knot is buried and not laying on top of the suture; cut the short end of the suture
- take the first bite after burying the knot DEEP to SUPERFICIAL to bury the knot further
What are the 5 steps to burying the knot at the end of the intradermal pattern?
- stop suture pattern ~1 mm from the end of the incision
- with the needle pointing towards you, take a perpendicular bite in the subcutaneous or intradermal layer SUPERFICIAL to DEEP on the far side
- cross over to the opposite side of the incision and take a bite DEEP to SUPERFICIAL on the near side, forming a deep loop
- take a third bite SUPERFICIAL to DEEP on the far side
- tie a knot with the deep loop formed in step 3 and the deep suture
What are the main 2 reasons that we bury the knots in the intradermal pattern?
- avoid having knots protruding through the edges of the skin incision to keep the patient from licking or chewing
- prevents dirt and bacteria from the environment from accessing deeper layers of the skin
What are the 5 steps to performing an intradermal pattern?
- begin with a buried knot
- take a horizontal bite entering the dermis (just below the skin, but above the subcutis) along the cut edge and advance parallel to the incision, exiting ~4 mm on the same side
- cross the incision and take another similar bite on the opposite side of the incision
- continue pattern along the entire incision
- end with a buried knot
What are 5 important recommendations for performing the intradermal pattern?
- bites should be placed within the dermis as close to the skin surface as possible
- successive bites should backtrack at least halfway for the best apposition
- tension should be adjusted after each bite (difficult to do this once the pattern is completed)
- knots are buried beneath the skin surface at the beginning and end of the incision
- tissue forceps need excess pressure to adequately stabilize the skin while placing bites —> significant post-op bruising, can use thumb and index finger while palming forceps
What are inverting patterns? What are the most commonly used on?
patterns that turn the incision edge inward (away from surgeon)
larger lumen-hollow organs
What are 3 reasons that inverting patterns are used on larger lumen hollow organs? Why is it avoided on the skin?
- decrease the size of the organ’s lumen, so it cannot be used on organs with small lumens
- serosa-serosa apposition helps provide a water-tight seal
- minimizes the exposed suture and decreases adhesion risk
- delays healing
What are 3 examples of inverting patters?
- Lembert
- Cushing
- purse string
What is the holding layer of hollow organs when they are being sutured? What are some examples of these hollow organs?
tunica submucosa
- bladder
- gallbladder
- stomach
- intestines
- uterus
- esophagus
What are 3 common complications when suturing hollow organs?
- dehiscence - leakage, can lead to peritonitis
- calculi/stone formation
- adhesions - omentum!
How do surgeons typically do single-layer and double-layer closures of hollow organs?
SINGLE: partial thickness vs. full thickness; simple interrupted or simple continuous most common
DOUBLE: 1st layer = inner; 2nd layer = outer
What is a common way for surgeons to close the stomach, bladder, and intestines?
STOMACH: 1st layer = appositional pattern; 2nd layer = inverting pattern
BLADDER: one layer closure = inverting pattern; 2 layer closure like stomach
INTESTINES: 1 layer closure = appositional pattern
What type of pattern is the Lambert pattern?
partial thickness (doesn’t go into lumen), continuous, inverting
What are 2 major uses of the Lembert pattern?
- GI surgery
- large-lumened hollow organs - colon, bladder, stomach, rumen
(single or double layers - can be 1st or 2nd layer)
What are the 5 steps of performing a Lembert pattern?
- create a partial thickness simple secured knot across the ~3 mm away from the end of the incision
- insert the needle perpendicular to the incision through the serosa and muscularis layer ~8-10 mm from the incision (FAR) and surface on the same side of the incision ~4 mm from the edge (FAR)
- cross over to the opposite side and insert the needle through the serosa and muscularis ~4 mm from the edge (NEAR) and resurface ~8-10 mm from the incision (FAR)
- return to the original side and repeat ~3 mm down from previous bites until the end is reached
- perform a secure knot across the incision, ~3 mm from the end of the incision on either side and tie the long end of the suture to the loop created
How do the bites of the Lembert pattern run? What layers does it penetrate?
perpendicular
serosa, muscularis, submucosa
(NOT MUCOSA)
How does bite length affect inversion in the Lembert pattern? When should tension be adjusted?
farther bites from incision edge = more tissue inversion
with each bite - difficult to readjust once the pattern is complete
What type of pattern is the Cushing pattern? How should the pattern be started?
partial thickness (penetrates submucosa, NOT the lumen), continuous inverting
RIGHT side if right-handed
LEFT side if left-handed
In what 2 situations is it common to use the Cushing pattern?
- hollow viscera - bladder, stomach, uterus
- 2-layer closure
What are the 6 steps to performing the Cushing pattern?
- create a partial thickness simple secured knot across the incision ~3 mm from the end of the incision
- insert the needle parallel to the incision through the muscular and submucosal layers ~5-8 mm (needle should resurface on the same side of the incision
- cross over to the other side, inserting the needle parallel to the incision through the muscular and submucosal layer ~5-8 mm from the incision (needle should resurface on the same side of the incision
- return to the original side and repeat with bites ~3 mm from each other and carry on until the end of the incision is reached
- perform a secure knot across the incision ~ 3mm from the end and tie the long end of the suture to the loop created
What type of pattern is the Connel pattern? How is it used if it is a part of a 2 layer closure?
full-thickness (lumen-penetrating), continuous, inverting
can only be used at the 1st (inner) layer, commonly followed by a Cushing or Lembert pattern
When is the Connel pattern most commonly used?
hollow viscera - bladder, stomach, uterus
Cushing vs. Connel patterns:
What type of pattern is the purse string pattern?
partial thickness (non-penetrating), continuous, inverting
In what 4 common situations that the purse string pattern is used?
- hollow organ viscera
- temporarily close the anus during perineal surgical procedures
- maintain rectal prolapse reduction
- close defect in hollow organ wall
Purse string pattern:
What are the 4 steps to perform a purse string pattern?
- take a several mm long bite into the tissue (distance from the edge will depend on how much tissue needs to be inverted or everted)
- continue the pattern by taking bites every 3 mm until the entire circumference is sutured
3 tighten suture allowing the tissue to cinch down - tie a knot
What is the finger trap pattern used for? What are the 3 steps?
secure tubes to the patient (feeding tube, urinary catheter)
- place a purse string suture around the base of the tube and leave LONG suture ends - tighten pattern and tie a secure square knot
- bring suture ends behind the tube and cross them making an X, then bring the suture towards the front and tie a square or surgeons knot
- repeat for a total of 4 knots and secure the final knot with additional throws
What do everting patterns do? When are they used? Why are they rarely indicted?
turn incision edges outward (toward the surgeon)
- suturing incision edges under tension (AKA tension-relieving patterns)
- tissue with slow healing time
can lead to delayed healing
What is tension? What happens when there is a lot of tension?
tendency of the incision to open up
suture may break or pull through the tissue
(use everting patterns!)
What are the 3 common everting patterns?
- mattress patterns
- walking sutures
- near-far patterns (surgeon’s stitch)
What type of pattern is the vertical mattress pattern? How does it compare to the horizontal mattress pattern?
interrupted, tension-relieving (everting)
- less effect on blood supply (more than the simple interrupted!)
- less eversion
When is the vertical mattress pattern typically used?
closure of high tension areas - commonly used for skin closure
What are the 5 steps to performing a vertical mattress pattern?
- take first bite ~8 mm away from the edge of the incision of the far side (FAR)
- pass through the incision line and bring the needle up to an equal distance on the near side (FAR)
- turn the needle around and insert the needle on the SAME side, but ~4 mm from the incision end (NEAR)
- pass through the incision line and bring the needle up an equal distance on the far side (NEAR)
5, tie a knot with the two ends after applying tension
What type of pattern is the horizontal mattress pattern? How does it compare to the vertical mattress pattern?
interrupted, tension-relieving (everting depending on the tightness of suture)
- greater impact on local blood supply, especially with overtightening
- use with caution!
When is the horizontal mattress pattern used?
closure of high tension areas - commonly used for skin closure
What are the 6 steps of performing a horizontal mattress pattern?
- 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 (near) side - stay on the same side of the incision and move ~6-8mm down the incision
- turn the needle around and reinsert the needle on the same side
- pass through the incision line and bring the needle up to an equal distance on the far side
- repeat the process for the next suture, which should be
~4-5mm away - tie a knot with the two ends, after applying appropriate tension
Vertical vs horizontal mattress pattern:
What are the near-far patterns?
interrupted, tension relieving patterns named after how the bites of the suture pattern should be performed
(near far-far near or far near-near far)
- variation os the vertical mattress pattern
What are the near-far patterns the most appropriate to use for? Why?
closing incisions and wounds with considerable tension (commonly skin closure)
resists tension without causing excessive stress directly on the incision/wound edges
What are the 5 steps of the near far-far near pattern?
- take the first bite ~4mm away from the edge of the incision on the far side (“near”)
- pass through the incision line and bring the needle up ~8mm on the near side (“far”)
- without moving down the incision, go back to the original side of the incision and insert the needle ~8mm away from the edge of the incision on the far side (“far”)
- pass through the incision line and bring the needle up ~4mm on the near side (“near”)
- tie a knot - ensure it doesn’t cross over the short strand (knot should sit adjacent to the short strand)
What are the 5 steps of the far near-near far pattern?
- take the first bite ~8mm away from the edge of the incision on the far side (“far”)
- pass through the incision line and bring the needle up ~4mm on the near side (“near”)
- without moving down the incision, go back to the original side of the incision and Insert the needle ~4mm away from the edge of the incision on the far side (“near”)
- pass through the incision line and bring the needle up ~8mm on the near side (“far”)
- tie a knot - ensure it doesn’t cross over the short strand (knot should sit adjacent to the short strand)
