Suture patterns Flashcards
rules for wound closure
Close tissue in the same number of layers as incised Appositional pattern unless good reason not to Choose the simplest pattern Avoid closure under tension Careful suturing more important than pattern choice
Classification of patterns
Simple vs mattress Interrupted vs continuous Appositional vs inverting vs everting Partial vs full-thickness 1-layer vs 2-layer
simple vs mattress
simple - on surface suture material runs across the wound mattres - on surface suture material is along side the wound
Interrupted vs Continuous - Interrupted
• If 1 knot fails, all line won’t fail • More accurate approximation • Adjust tension at each suture
Interrupted vs Continuous - Continuous
Quicker Less suture material in wound More even distribution of tension More air-tight & water-tight Cheaper - economical use
appositional closure
Easy to perform Accurate alignment of wall layers Quicker regeneration of mucosa Less inflammation & fibrous scar tissue
inverting closure
Greater bursting strength (24h) Similar tensile strength Reduced risk of adhesions Necrosis of tissue cuff Luminal compromise possible
everting closure
Ease of placement Increased tensile strength Endothelial contact reduces thrombosis Prolonged inflammation & vascular compromise Increased incidence of adhesions Increased risk of stenosis + leakage
Partial thickness pros
Not exposed to luminal contents Reduces wicking from lumen
Full thickness pros
Better apposition Suture holding layer engaged
simple interrupted - features
Secure anatomical closure Precise adjustment of tension possible Easily applied (Inversion if tight)
simple interrupted - examples of when to use
Skin, GI tract, fascia
Approximating sutures
Simple interrupted - Layer apposition good Poth & Gold crushing - buried suture, More tissue necrosis, Poorer apposition of layers (modified) Gambee (1951) - Difficult to place, Risk of not engaging submucosa
cruciate mattress - features
Stronger than simple interrupted
Resists tension
Prevents eversion
Quicker than simple interrupted
cruciate mattress - examples of use
skin?, tail, digit amp
Horizontal mattress - features + examples of use
Features - Appositional to everting, Strangulate tissue, Edge ischaemia
Examples - Skin, muscle, tendon
vertical mattress - features + examples of use
Appositional to everting
Resists tension
Skin (tension relieving)
Vertical vs Horizontal mattress - which cuts off blood flow to the skin more
horizontal
simple continous - features
Series of linked “interrupted” sutures
Suture line advances on one side of the wound
Good for areas under low tension
simple continous - examples of use
subcutis, fascia, vessels, GI tract
running suture - features
Series of linked “interrupted” sutures
Suture line advances on both sides of the wound
rapid closure at the expense of accuracy of approximation
Ford interlocking (Blanket stitch)
Greater security than simple continuous
Better apposition than simple continuous
More difficult to place & finish
used in skin
inverting patterns
Cushing
• Connell
• Lembert
• Halsted
• Czerny
• Parker-Kerr
• Purse-string
everting pattern
Horizontal mattress
Lembert (interrupted) - features
Variation of the vertical mattress, i.e. upside down
Tissue bites perpendicular to wound edge
Lembert (interrupted) - example of use
Hollow viscus (second layer)
Lembert (continuous) - Dupuytren’s - pic only
Halsted
Modification of the Lembert
Two interrupted Lemberts as a mattress suture
Examples - Hollow viscus
cushing - features
Variation of the continuous horizontal mattress (i.e. upside down)
Tissue bites parallel to wound edge
Penetrates submucosa but not lumen
Less inversion
cushing - examples of use
hollow viscus
connell
like cushing but penetrates the lumen
hollow viscus
czerny
simple continuous partial thickeness
hollow viscus
Parker-Kerr oversew
1st layer: Cushing
2nd layer: Lembert
Example - Closure of visceral stump e.g. pyometra
purse-string
circular lembert
stump inversion, feeding tubes
continous horizontal mattress
appositional to everting
cardiac surgery, oversewn with SC
suture patterns that relieve tension
- Vertical mattress
- Horizontal mattress
- Far-near-near-far
- Far-far-near-near
- Echelon sutures
- Quills, bolsters, stents & pledgets
far-near-near-far - pic only
tension on outside of the loop
far-far-near-near - pic only
Simple interrupted echelon suture
Alternating simple interrupted sutures
Narrow bite - apposition
Wide bite - tension
Can use with quills/stents
quills + horizontal mattress
distribute tension - incr contact surface
everting
Quills + Vertical mattress
distribute + relieve tension
