A STUDENT GUIDE TO WOUND CLOSURE

For Medical Students

PREPARED BY

Leona Boyer, RVT Council of Health Science Deans Office

Surgical Skills Lab Room B514
(306) 966-8212 Health Sciences Building
leona.boyer@usask.ca University of Saskatchewan

(Revised 2012)

SOME TEXT AND DIAGRAMS COMPILED FROM:

Wound Closure Manual, Ethicon

Physician Suture Training Guide, Davis & Geck
Technique in the Use of Surgical Tools, Anderson and Romfh
Wound Closure - Materials and Techniques, Zederfeldt and Hunt
INTRODUCTION

This document is intended to provide the student with an introduction to

common suture materials, needles, and the proper techniques of suturing. The
document alone does not provide all the information needed to learn to suture
properly, but is designed to supplement practical training sessions available
through the Surgical Skills Teaching Lab. (a.k.a.) The Suture Lab

Development of good technique requires a knowledge and understanding of the

rational mechanics involved in suturing. Don't be misled by your loyalty to the
judgement of superiors. You may just end up acquiring their bad suturing
habits.

Your criteria for determining the best method should be Accuracy and
Security. These should be your prime concern when suturing, not speed and
comfort! Speed and ease of performance are by-products that will be achieved
with lots of practice. If they are your first concern, you may never be accurate
or secure.

Practice produces skill. "Practice makes perfect" deteriorates to "practice makes

imperfect" when practice becomes the repetition of mistakes or cumbersome
and inaccurate manoeuvres. Mistakes become comfortable after they have
been thoroughly practiced. Correction of poor technique always takes more
practice than learning a good method in the first place.

Note:

As class size continues to increase and consequently groups sizes as well, the
need for individual attention also increases. Extra practice sessions can be
arranged by contacting the Lab @ 966-8212 and booking a time to come to the
lab for some one-on-one teaching time.

Basics can be further developed and practised, and new suture patterns can be
learned. ‘Hand Ties’ are also taught through the lab.

Students are encouraged to visit the lab as often as is needed to get

comfortable with their suturing and hand tying skills.

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Properties of Suture

Physical Construction of Suture

Suture is any strand of material used to approximate the tissue edges and give artificial support
while the tissue heals naturally. When considering a type of suture, there are three things that
you need to consider. This information should be indicated somewhere on the packaging of
the suture:
1. Absorbable or Non-absorbable
2. Natural or Synthetic material
3. Braided or Monofilament construction

ABSORBABLE:

Absorbable sutures are designed to break down over a specific time frame and be absorbed by
the body. They are used when temporary support is required and the healing tissue will
eventually support itself. Absorption occurs in one of two ways:

- In Natural sutures: Proteolysis

- In synthetic sutures: Hydrolysis

NON-ABSORBABLE:

Non-absorbable sutures are designed to either be left permanently in the body or are to be
removed after a certain healing period. Permanently placed, non-absorbable sutures are
generally used in tissue where even though healing may occur; the new tissue may never have
the needed strength to support itself. The effective tensile strength of such sutures remains
high over time. When used to close skin, non-absorbable sutures are usually removed in 7 – 10
days, but this may vary by location and situation. NOTE: Some non-absorbable suture, like Silk
and Nylon may be significantly weakened by the body over time and therefore cannot be
considered as permanent sutures.

NATURAL:

Natural sutures are made from animal or plant materials. Their protein composition can elicit
the most pronounced tissue reaction (inflammation) of any suture material. Their useful
strength in tissue varies from a few days with Fast Catgut to several months for Silk, and can
vary with the individual.

SYNTHETIC:

Sutures can be made from synthesizing a wide variety of polymers. Synthetic materials cause
less tissue reaction than natural fibres, therefore their strength and absorption rate (for
absorbable suture) is more uniform and predictable in all individuals.

BRAIDED:

This construction involves several filaments or strands being braided or twisted together. This
results in a strong suture that is flexible and easy to handle. Multifilament or braided sutures

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pass less easily through tissue than smooth monofilaments and the resulting "tissue drag" can
cause tissue trauma. These problems are significantly reduced by using "coated" braided
materials.

The surface of a suture must be compatible with the specific tissue application and have the
desired knotting characteristics and capabilities. A rough suture surface can cause trauma and
cutting of surrounding tissues, both of which are undesirable. Therefore, selection of suture
materials should consider both the structure of the tissue and the surface of the suture. In
principle, a suture with a rough surface can be tied with fewer knots than one with a smooth
surface as knots are less likely to slip. Many of these sutures have been coated to reduce tissue
drag, thereby making them more slippery. Care must be exercised with the tying of all types of
suture to ensure proper square knots are placed.

MONOFILAMENT:

This type of suture construction results in a single strand or filament. The surface is very
smooth and passes easily through tissue, reducing trauma from “tissue drag”. However, they
can be difficult to handle and tie as they are less flexible than multifilament construction. Most
synthetic monofilaments also have some degree of “memory”. This memory results in a suture
that holds the shape it had in the package, making it more difficult to work with. The memory
of some sutures can be relaxed a little or a lot, depending on the product, but is not effective in
all synthetic sutures.

We can use the properties of this memory to help secure our knots by adequately tightening
each knot. The ‘memory’ will now take over and want to hold the new shape of the knot. A
poorly tightened knot will want to return to its original shape and may become loose or come
apart completely.

NOTE: With whichever type of suture you are using, remember to work WITH the suture,
not against it. Understand its properties to get the most from it. Trying to force your will
upon the suture usually results in frustration, a dislike of the suture and ultimately, poorly
tied knots.

Suture Selection

How to choose suture

Many factors contribute to the choice of materials and techniques for wound closure. The final
choice is often a compromise of several of those factors and may be combined with personal
preference based on past experience.

Some factors to consider

- How long is the suture to be wholly or partially responsible for the strength of the wound?
- How does the suture material affect the tissue and the process of healing?
- How great is the risk of infection?
- Is absolute fixation needed or is certain mobility acceptable, or even desirable?
- What dimension of suture is necessary to obtain the desired degree of fixation?
- What strength of suture is required?
- Is the material flexible enough for the given purpose and is it possible to knot it in the space
provided?
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The following recommendations are based on the properties of the suture materials and their
performance in each situation.

SKIN:
The skin is one area where the final result, based on your selection of suture and your technical
skill, will be the most evident to your patient. Make informed choices that will give the best
result possible. It will be appreciated. Stitches in tissue that was approximated too tightly and
are left in too long may result in “hatch marks” on either side of the scar. The hole made by
the stitch may rip and become larger with increased tension on the wound (i.e. swelling).
Sometimes, these resulting marks are more noticeable long term than the scar itself.

Percutaneous (Transcutaneous) Suture: (Simple, interrupted pattern)

Recommendation: SYNTHETIC, NON-ABSORBABLE, MONOFILAMENT

Example: NOVAFIL, PROLENE, SURGI-PRO, SURGILENE, DERMALON

Possible Alternative: SYNTHETIC, ABSORBABLE, MONOFILAMENT

Example: MONOCRYL, MAXON, PDS, BIO-SYN

Unsuitable: Organic or synthetic, braided absorbable materials

Example: SILK, DEXON, VICRYL

SIZE: Usually 4-0. In the Face: 5-0 or 6-0.

NEEDLE: Reverse cutting, 3/8 curve, (precision, premium or prime, reverse cutting for face)

Comments: Percutaneous sutures should be approximated to barely appose wound edges;

otherwise, postoperative swelling may cause the suture to be too tight. Tape closure of
wounds, when feasible, is biologically preferable to any suture. In some conditions, tapes do
not securely co-apt wound edges. In these cases sutures should be placed, removed early, and
replaced with tapes for continued wound support. With tape used this way, it is possible to
avoid stitch marks and abscesses without compromising wound approximation.

Intracutaneous (Subcuticular) Suture: (Buried, continuous pattern)

Recommendation: A continuous pattern using SYNTHETIC, NON-ABSORBABLE, MONOFILAMENT

(to be removed)
Example: NOVAFIL, PROLENE, SURGILENE

Common Alternative: A continuous or interrupted pattern using SYNTHETIC, ABSORBABLE

(uncoloured) MONO or MULTIFILAMENT
Example: MONOCRYL, MAXON, PDS (Monofilament);
DEXON, VICRYL (Braided)

SIZE: Suggest 4-0, 5-0, but will vary with location

NEEDLE: Reverse cutting, 3/8 curve

Comments: Intracutaneous suturing has the advantage of completely avoiding stitch marks. It
can be used where cosmetic aspects are especially important. It is an advanced pattern and can
be challenging to complete correctly. If synthetic absorbable materials are used, it is quite
common that temporary nodules appear under the scar a couple of weeks after suturing. These
disappear spontaneously in the course of months as the suture breaks down and absorbs.
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Subcutaneous Suture: (fat layer)

Recommendation: No Suture

Possible Alternative: SYNTHETIC, ABSORBABLE

Example: DEXON, VICRYL
SIZE: Varies
NEEDLE: Taper, 3/8, 1/2, 5/8 curve

Comments: The subcutaneous fat is the tissue with the least resistance to infection and so, it’s
best to avoid introduction of foreign materials, like suture. If the tissue is reasonably elastic,
good apposition is obtained spontaneously. However, do not leave a DEAD SPACE as this can
cause greater problems. This tissue must be gently approximated.

REMEMBER: With all stitches, the first knot is placed to approximate the tissue correctly, do
not over-tighten and cause strangulation of the tissue. Each subsequent knot however must be
tightened adequately to the previous knot to ensure the overall integrity of the knots. Some
monofilaments may cause the first knot to over tighten, so remember to allow for this.

SUTURE SIZING

Suture is available from an "8" (Heaviest) to "11 - 0" (Finest). The very largest sizes are not
commonly used in humans, but are designed for veterinary use.

The important factor in deciding suture size is the relationship between the tensile strength of
the suture (how much tension can it withstand before if breaks), and the tissue to be sutured.
Tensile strength of the wound need only match or slightly exceed the holding power of the
tissue to be sutured.

For example, you don't need a rope to tie your shoes... it might work, but its overkill. A
shoelace would do. Finer diameter sutures make smaller knots, provide less tissue reaction,
and result in minimal scar formation. Finer stands are very flexible, easy to handle, but do
require gentle tying. Closely placed, fine sutures create a stronger suture line than widely
spaced, heavy sutures.

Tissue drag is also closely related to gauge; the finer the gauge, the less tissue trauma is
caused by the passage of the suture. Braided sutures will have greater tissue drag than
monofilaments of the same size. Suture strength is related to the size of the suture, but also
can vary with the type of suture material chosen and the type of suture construction. ie: Not all
types of size 4-0 sutures are equal in strength.

Larger ------------------------------------------------------------------------------------------------------------------>>>> Smaller

8 7 6 5 4 3 2 1 0 2-0 3-0 4-0 5-0 6-0 7-0 8-0 9-0 10-0 11-0
Greatest tensile strength ----------------------------------------------------------------------------->>>> Weaker tensile strength

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Common Sutures

ABSORBABLE COMPOSITION CONSTRUCTION

SHORT Term:
Plain Gut Natural - made from cattle intestine Multi – 3- 4 strands only
Fast Absorbing Gut Natural – breaks down 50% faster than plain gut

Chromic Gut Natural - made from cattle intestine Multi - “ “

Treated with chromic salts to delay absorption rate

CAPROSYN+ Synthetic – Polyglytone 6211 Mono

(newest –potential gut replacement)

VICRYL Rapide Synthetic – Polyglactin Braided

Medium Term:
DEXON+ Synthetic - Polyglycolic Acid Braided
VICRYL* Synthetic - Polyglactin 910 Braided
POLYSORB+ Synthetic – Lactomer Braided

MONOCRYL* Synthetic - Poliglecaprone 25 Mono

BIO-SYN+ Synthetic – Glycomer 631 Mono

Longer Term:
PDS* Synthetic - Polydioxinone Mono
MAXON+ Synthetic - Polyglyconate Mono

NON-ABSORBABLE COMPOSITION CONSTRUCTION

SILK Natural Braided

ETHIBOND*/TI_CRON^/SURGIDAC+ Synthetic - Coated Polyester Braided

ETHILON*/DERMALON^ Synthetic - Nylon Mono

NUROLON*/SURGILON^ Synthetic - Nylon Braided

PROLENE*/SURGILENE+/SURGIPRO+ Synthetic - Polypropylene Mono

NOVAFIL+ Synthetic - Polybutester Mono

Stainless STEEL Natural Mono

FLEXON+ Natural - Coated Steel Braided

Trademark information

* ETHICON Trademark
+ USSC, SYNATURE, COVIDIEN Trademark

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SUTURE

ABSORBABLE NON-ABSORBABLE

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NEEDLES

3 Components: - Point
- Body
- Attachment: Swaged or Eyed (Closed or French)
Point:
CUTTING:

- REVERSE cutting, 3rd cutting edge on OUTSIDE curve

May have regular or premium cutting edge

- CONVENTIONAL cutting, 3rd cutting edge on INSIDE curve

- SIDECUTTING, SPATULA, DIAMONDPOINT, LANCET

Specialty cutting needles with different cutting patterns

- TAPERCUT: small reverse cutting tip with round body – not common

NON-CUTTING:

- TAPERPOINT or ROUND, non-cutting, round body with sharp tip

- BLUNT, taper body with rounded, blunted tip

Body: (curvature)

- Straight: not commonly used; not useful in area with limited access

- Curved:
¼ circle 3/8 circle ½ circle 5/8 circle

Attachment:
Suture swaged on: Closed Eye: French Eye:

Atraumatic Traumatic

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Needle Points and Body Shapes

Point/ Body Shape Applications

Ligament
Nasal cavity
Oral cavity
Skin
Tendon

Fascia
Ligament
Nasal cavity
Oral mucosa
Skin - most commonly used
Tendon sheath

Eye

Skin (plastic or cosmetic)

These are becoming more widely used, but do
cost more than standard cutting needles These
drive with more ease and with less trauma than
standard cutting needles. Look for a ‘P’ in the
needle code. eg. P-12 or PC-3

Eye (primary application)

Microsurgery
Ophthalmic (reconstructive)

bronchus oral cavity perichondrium

calcified tissue tendon periosteum
fascia trachea pharynx
ligament uterus ovary
nasal cavity vessels (sclerotic)
Note: Not for skin

aponeurosis pleura
biliary tract subcutaneous fat
dura urogenital tract vessels
fascia gastrointestinal tract
muscle myocardium
nerve peritoneum

blunt dissection fascia

intestine kidney
liver spleen
cervix (ligating incompetent cervix)

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Tissue Handling

Minimal trauma to tissues is fundamentally important for optimal wound healing. This requires
that:
- Tissues are handled carefully using delicate instruments
- Tissues are not strangulated and made ischemic by sutures
- Wound edges are loosely co-apted since there is always some postoperative swelling
- Dead space is avoided

Suturing Techniques

When suturing skin, wound edge eversion and matching of the epidermis is critical to minimize scar
formation. Eversion of wound edges allows for dermis to dermis approximation which is optimal for
wound healing. Interrupted or continuous suture patterns may be used. There are several methods of
stitch placement as shown on the next page. There are pros and cons that go along with each pattern.
Often patterns that are designed to give a better result are more complex and will require more practice.
However, if not done correctly, the result may look worse than one done with a simple interrupted pattern
The pattern selected is often a matter of the surgeon's expertise and preference which is fine as long as
the fundamental principles stated above are respected. Always do the simplest stitch that you do well.
This will help to ensure that you get good, consistent results.

Interrupted suture patterns are those where each stitch is placed and tied individually. Each is
independent of the others. On the skin, if excessive swelling occurs anywhere along the stitch line,
individual stitches can be removed to avoid problems that can occur when stitches are tied too tightly.
The removal of one doesn’t affect or compromise the rest of the stitches.

Continuous suture patterns depend on ‘one knot’ for integrity which may be a disadvantage. On the
other hand, continuous patterns deposit less foreign material in the tissues and are generally placed
quicker than multiple, interrupted sutures. They are generally better suited to sub-layers and not for
percutaneous closures. A large bulk of material is contributed by knots when using interrupted sutures.

Knots and Knot Security

The knot is always the weakest point of a suture loop. A knot consists of at least two throws laid on top
of each other and tightened. The square knot and the surgeon's knot are the most often used. Knots
have a tendency to loosen; therefore the importance of correct tying technique must be emphasized.
Tumbled knots, slip knots and half hitches give very poor efficiency compared to a correct knot. If
tumbled knots are used intentionally to tighten the first throw of a knot, a complement of two throws (one
square knot) is necessary to hold the slipped knot in place. Multifilament sutures require a minimum of
three throws to create two full square knots. Monofilament sutures, which are typically stiffer and
more slippery, require at least four throws to create three full square knots. Additional throws on
either type may be warranted to ensure the integrity of the knot. More knots are not necessarily better as
it will increase the bulk of material in a wound.
Remember, you need to lay your knots correctly. The better the knot, the fewer you will need.

Correct Square Knot Tumbled (Slipped) Knot

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SUTURE PATTERNS

Simple Interrupted Horizontal Mattress Vertical Mattress

Mattress Pattern Advantages:
Edge eversion, Tension Relief

Simple Continuous Locking Continuous Subcuticular Continuous

Advantage: (Intracutaneous)
watertight/airtight closure Advantage: No external marks

Suture Ligature
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Techniques to Help Ensure Good Wound Edge Eversion

Needle Entry Angle:


The needle must enter and exit the tissue at a
minimum of 90o.


This will ensure that the edges have been
approximated correctly and will not cause the edges
to invert, which is not desirable.


If the needle is driven at an entry angle of 45o, or less,
it will cause the edges to invert. If you want to drive at
this angle, you must manipulate the tissue to achieve a
90o drive.

Needles driven at an angle greater than 90o

will help to obtain good wound edge eversion.

This can be difficult to achieve and requires

practice.
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Sutures should be DEEPER than they are WIDE:

CORRECT – will help to create Eversion

These bites are wider than they are deep.

INCORRECT – will cause Inversion

EQUAL BITES: The “bite” that is taken on one side of the wound, must be equal
to the bite taken on the second side. If not, the edges may overlap.

EQUAL DEPTHS: The depth that the needle passes through the tissue should
be equal on both sides.

PERPENDICULAR: The needle should pass through the tissue perpendicular to

the incision. This will help to restore the anatomy correctly. Oblique stitches
will result in uneven closing and may leave a “dog ear” at the end of the
incision.

Remember:
EQUAL BITES, EQUAL DEPTHS, PERPENDICULAR, SQUARE KNOTS!
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