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Where Suture Meets Skin
Where Suture Meets Skin
This is where the suture theory marries up with the etiquettes to allow for the different suturing techniques to be executed. Immerse yourself in this playlist of video's, starting from the basics and working your way up to more advanced technqiues.
This is where the suture theory marries up with the etiquettes to allow for the different suturing techniques to be executed. Immerse yourself in this playlist of video's, starting from the basics and working your way up to more advanced technqiues.
The fundamentals before you begin...
The fundamentals before you begin...
There are some basic rulings that one should follow when suturing. These are outline below.
There are some basic rulings that one should follow when suturing. These are outline below.
1) When holding the needle with the needle holder (driver), it should be done so at the junction between the proximal 1/3 and the distal 2/3 of the length of the needle
2) The needle should penetrate the skin at a right angle to its surface.
3) The needle should move smoothly through the skin using both a supinating movement of the forearm, and the natural curvature of the needle.
4) Generally, the insertion distance from the edge of the wound surface should match that of the exiting distance as well.
5) The distance between consecutive sutures should be similar in width of the preceding suture.
6) The final surface of the closed wound should lay flat which is achieved through slight eversion (convex) of the wound edges. As wounds heal they contract, so contraction starting from a flatter plane produces an inverted (depressed) wound. Therefore, the act of eversion allows the final wound to lay flat.
A secure way of tying sutures and ligating arteries is through the use of the surgeons knot. The standard method of tying the surgeon’s knot involves the use of a hand and a needle holder (driver). It is also possible to tie the knot using two instruments or even just your hands. The former is mainly used in microsurgery whereas the latter is used more in general surgery when suturing in deeper tissues. Regardless of how you tie it and what means you use, a properly made surgeon's knot consists of one double loop, followed by two single loops in opposite directions.
It's basic, fast, and easy. The simple interrupted suture is the standard benchmark for skin closure. It can be utilised for simple wounds, both traumatic & surgical. It may be used alone in the context of smaller wounds under minimal to no tension, or can be used as a secondary layer to aid in epidermal approximation in the case when the dermis has be closed using another technique.
The simple continuous method is used particularly where speed is required, for example a laceration on a screaming childs head, or in cases where its important to obtain tightness. Despite it being quicker, simple continuous sutures pose more difficulty making finer adjustments to the wound in the case where one area requires more tension than another. This is because the tension is equally distributed along that continous path so individual tension paths cannot be made. They can also produce unsightly cross hatch marks for the patient.
In wounds where there is high tension between margins and where eversion is desired, the vertical mattress suture can be considered. This eversion is particularly desired in body sites where the wound edges tend to invert such as the posterior neck, or wounds located on concavities. It may be easier to memorise the pattern of entry for this suture as 'far-far-near-near', with all four passes of the needle through the skin lying in one line that is perpendicular to the wound.
The horizontal mattress suture is used more commonly for suturing the muscles and their fascia. It is not used in skin closure routinely due to poor cosmesis. However in skin types that are particularly atrophic, this technique may be helpful as the broader anchoring bites help minimise tissue tear that otherwise may be seen with other techniques like the simple interrupted suture. Again, similar to the vertical mattress, the horizontal mattress is useful for promoting eversion, reducing tension, and eliminating dead space. Nevertheless they can lead to unsightly cross-hatching marks for the patient.
These continuous sutures spread the wound tension, oppose the wound edges and reduce dead space. It isn't used to provide support as these wounds should be under minimal tension to start with. Therefore, deeper dermal sutures are usually used as a prerequisite. Artery clips or steri-strips can be used on the proximal/distal end, or you can tie both ends together after completing the suture. Please ensure you leave plenty of suture length both proximally and distally. This is because as you progress through the subcuticular closure, you can check that it freely glides in both directions which facilitates removal when needed. Due to the placement of this suture within the superficial dermis, no marks are left on the skin surface which prevents cross-hatching and therefore, superior cosmesis. Be mindful to use non-dyed (clear) sutures such as PDS as this will ensure you cannot see the suture (especially on lighter skin tones), which can be unsettling for patients.
Self-directed Learning
Self-directed Learning
Make use of your clinical skills resource centre & PRACTISE! They will usually allow students to loan out suture kits so you can practise in your own time & in your own place.
More techniques coming soon!
More techniques coming soon!
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