Suture patterns Flashcards
What are the 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
What is tissue bite?
the distance between the incision/wound and the suture
How are patterns classified?
simple versus mattress interrupted versus continuous appositional versus inverting versus everting partial versus full-thickness 1 layer versus 2 - layer
What is a mattress ligature?
include tissue that isn’t in your bite
What is this?
Simple suture
What is this?
Mattress suture
What is this?
Mattress ligature
What are the benefits of interrupted sutures?
if 1 knot fails, the whole line won’t fail More accurate approximation You can adjust tension at each suture
What are the benefits of continuous suture?
quicker less suture material in wound more even distribution of tensionmore air-tight and water-tight cheaper - economic use and shorter anaesthetic
What does an appositional suture do?
it brings tissues into close approximation
What does an inverting suture do?
turns tissue edges towards the patient, away from the surgeon or into a hollow cavity
What does an everting suture do?
turns tissue edges outward away from the patient, towards the patient. rarely used
What are two appositional (approximating sutures)?
Bennett and de Hoff
Why do appositional suturing?
easy accurate wall layer alignment quicker mucosa regeneration less inflammation and fibrous scar tissue
What is an example of an inverting suture pattern?
Lembert
What are the advantages of an inverting suture pattern?
greater bursting strength similar tensile strength reduced risk of adhesions necrosis of tissue cuff *luminal compromise possible*
What are examples of an everting suture?
Travers and Knowles
What are the benefits/disadvantages of everting sutures?
ease of placement increased tensile strength endothelial contraction reduces thrombosis BUT…. prolonged inflammation and vascular compromise increased incidence adhesions increased risk of stenosis increased risk of leakage
What are the advantages of a partial thickness suture?
not exposed to luminal contents reduces wicking from lumen
What are the advantages of a full thickness suture?
better apposition suture holding layer engaged
What is the most important layer in a suture?
submucosa - as this keeps the tensile strength
What are the advantages of a two layer closure?
more accurate apposition more watertight ? easier in some tissues stronger?
What is this?
one layer closure
What is this?
two layer closure
What is this?
1 layer, partial thickness
What is this?
1 layer, full thickness
What is this?
2 layers, partial thickness
What is this?
2 layers, full thickness and partial thickness
What are the features of a simple interrupted suture? Examples?
secure anatomical closure precise adjustment of tension possible easily applied (inversion if tight) EXAMPLES - skin, GIT, fascia
What are the features of an intradermal/subcuticular suture?
upside down simple interrupted (i.e. buried knot) EXAMPLE - intradermal/subcuticular closure
What is this?
intradermal/subcuticular suture
What is this?
Simple interrupted - layer apposition good
What is this?
Poth and Gold crushing (an approximating suture) More tissue necrosis Poorer apposition of layers
What is this?
a (modified) Gambee (an approximating suture) BUT: difficult to place risk of not engaging submucosa inverting?
What is this suture? What are its features? Examples?
CRUCIATE MATTRESS (figure of 8) FEATURES: stronger than simple interrupted resists tension prevents eversion quicker than simple interrupted ?poorer apposition placed too close EXAMPLES: Skin?, tail/digit amputation
What is this suture? What are its features? Examples?
HORIZONTAL MATTRESS FEATURES: appositional to everting strangulate tissue edge ischaemia EXAMPLES: skin, muscle, tendon
What is this suture? What are its features? Examples?
HALF-BURIED HORIZONTAL MATTRESS FEATURES: composite of: horizontal mattress and subdermal/subarticular, avoids trauma to tip of flap EXAMPLES: skin closure
What is this suture? What are its features? Examples?
VERTICAL MATTRESS FEATURES: appositional to everting resists tension
EXAMPLES: skin (tension relieving)
What is another name for a mayo mattress?
“vest over pants”
What are the features of a mayo mattress and what are examples?
FEATURES: will overlap or tighten tissue planes EXAMPLES: imbrication of fascia lata, hernia closure
List the appositional mattress patterns
cruciate mattress (figure of 8) horizontal mattress half-buried horizontal mattress vertical mattress mayo mattress (vest over pants)
List examples of APPOSITIONAL CONTINUOUS PATTERNS
simple continuous running suture (baseball stitch) subcutaneous or subcuticular Ford interlocking (Blanket stitch)
What is this? Features? Examples?
SIMPLE CONTINUOUS FEATURES: series of linked interrupted sutures, suture line advances on one side of the wound, good for areas under low tension EXAMPLES: subcutis, fascia, vessels, GIT
What is this? Features? Examples?
RUNNING SUTURE (BASEBALL STITCH) FEATURES: series of linked ‘interrupted’ sutures, suture lines advance on both sides of the wound rapid closure at the expense of accuracy of approximation
What are subcutaneous and subcuticular stitches?
SUBCUTANEOUS: modification of simple continuous (perpendicular bite) SUBCUTICULAR: modification of a continuous horizontal mattress (parallel bites) Accurate apposition - facilitates or obviates skin closure
What is this?
Subcutaneous suture (perpendicular bite)
What is this?
Subcuticuar suture (parallel bite)
What is this? Features? Example?
Ford interlocking (blanket stitch) FEATURES: greater security than simple continuous, better apposition than simple continuous, more difficult to place and finish EXAMPLE: skin
How are non-appositional patterns classified?
Inverting or everting
What are some examples of inverting patterns (i.e. non-appositional inverting patterns)?
Cushing
Connell
Lembert
Halsted
Czrny
Parker-Kerr
Purse-string
What are some examples of everting patterns (i.e. non-appositional inverting patterns)?
Horizontal mattress (don’t pull too tight!)
What is this? Features? Example?
Lembert (interrupted)
FEATURES: variation of the vertical mattress (i.e. upside down), tissue bites are PERPENDICULAR to the wound edge, can be interrupted or continuous
EXAMPLE: hollow viscus (second layer)
What is this?
Lembert (continuous) - Dupuytren’s (looks similar but fewer knots so less suture material needed)
What is this? Features? Example?
HALSTED FEATURES: modification of Lembert, two interrupted Lemberts as a mattress suture
EXAMPLE: hollow viscus
What is this? Features? Example?
CUSHING
FEATURES: variation of the continuous horizontal mattress (upside down), tissue bites PARALLEL to wound edge, penetrates submucosa but not lumen (partial thickness), less inversion
EXAMPLES: hollow viscus
What is this? Features? Example?
CONNELL FEATURES: like a Cushing but penetrates the lumen EXAMPLE: hollow viscus (first layer)
What is this? Features? Example?
CZERNY (or CZERNY-LEMBERT) FEATURES: generally simple continuous partial thickness, 1st layer: appostional (simple continuous, running), inverting (cushing, connell) 2nd layer: Lembert EXAMPLE: hollow viscus
What is this?
PARKER-KERR OVERSEW FEAUTRES: 1st layer - Cushing 2nd layer - Lembert EXAMPLE: closure of visceral stump (e.g. pyometra)
What is this?
PURSE-STRING FEATURES: circular Lembert (do a running stitch around the top of the tube and then pull tight) EXAMPLES: stump inversion, feeding tubes n.b. this is one on the more common sutures.
What is this? Features? Examples?
CONTINUOUS HORIZONTAL MATTRESS FEATURES: appositional to everting EXAMPLES: cardiac surgery, oversewn with SC
What are 2 solutions to tension?
Remove tension - reconstructive techniques Fight tension - tension-relieving sutures
What suture patterns are tension-relieving?
vertical mattress horizontal mattress far-near-near-far far-far-near-near Echelon sutures Quils, bolsters, stents and pledgets
What is this?
Far-near-near-far
What is this?
far-far-near-near
What is this? Features? Example?
SIMPLE INTERRUPTED ECHELON SUTURES FEATURES: alternating simple interrupted sutures, narrow bite - apposition, wide bite - tension, can use with quills/stents
What is this? Features? Examples?
Quills + horizontal mattress sutures FEAUTRES: quills or bolsters, distribute tension, everting EXAMPLE: relief of tension
What is this? Features? Example?
QUILLS + VERTICAL MATTRESS FEATURES: distribute tension EXAMPLES: relief of tension, with SI
What are the 2 most useful patterns?
Simple interrupted
Simple continuous
