SUTURE GUIDE

How to use your tools

In your kit you will find:

- Mayo-Hagar needle holder

- Adson toothed forceps
- Iris scissors
- Scalpel holder
- Mosquito Forceps
- Scalpel blades
- Suture thread

Below you will find a step by step guide on how each tool is used.

The Mayo-Hagar needle holder

- The needle holder is held between your thumb and ring finger. Place your index finger along the needle
holder to give you more stability when suturing. This will allow for more natural movement while placing your
sutures and opening your tools. The needle holder is opened by pressing downwards and pushing either side
of the handle away from each other.

Adson toothed forceps

- The toothed forceps are used to hold the skin when taking a bite through the wound. These help to apply
more tension to the skin to make it easier for the needle to go through. The teeth inside the forceps give a
better & firmer grip.

Iris scissors

- The scissors can be used to cut the suture thread while suturing, as well as, remove any sutures in situ to
allow for future practice.

Scalpel holder

- Handling the scalpel correctly is essential. Begin by carefully opening the scalpel blade, making sure you do
not touch the blade. Using the needle holder, grip the scalpel blade about halfway. Gently slide the blade onto
the handle. You will feel a click once the blade is in place.

- To remove the blade from the scalpel, gently lift the bottom of the blade, pointing the scalpel downwards to
ensure no accidents occur. Slowly slide the blade off.

Suture thread

– The thread provided is nylon monofilament non-absorbable suture which is remarkably smooth & soft,
allowing for excellent knot security.
 How to prepare for suturing

When preparing to suture, one must keep in mind the following:

- The suture thread comes enclosed in a plastic bag. This is because, in surgery, we aim to ensure no
contamination occurs. Ideally, when scrubbed up, someone else will open the outer packaging, and you would
take packaging within. In our case, while practising, contamination is not a concern.
- Once you have opened the packaging, you will find a white packet within which holds the needle and thread.
- Once the needle is exposed, you will need to use your needle holder to grasp the needle. Aim to hold the
needle 2/3 of the length as shown in the photo below. Holding the needle at 2/3 ensures the best movement
through the skin.

You are now ready to get suturing!

Before you begin, practice pronating and supinating your hand back and forth, this will help when it comes to getting
the needle through the skin.

Once you have got the hang of it, you are now ready to take your first “bite” through the skin. Throughout the
document, we will use the term taking a “bite” of the skin to represent the action of piercing the needle through the
skin.

Using the toothed forceps, grip a piece of the skin and lift it up gently. Place the needle at a 90O angle with your hand
pronated approximately 1cm from the wound edge.

Supinate your hand while applying a small amount of pressure to the needle, so that it follows the natural curve of the
needle through the skin. Once you have gone through the first side of the wound, repeat the same movements
through the other side of the skin, about 1cm from the wound end. When preparing to take another bite next to your
previous one, make sure the space between the two bites is equal to the length of the first one.
 Get ready to suture!
Wound suturing and closure is essential for:

• Reducing dead space

• Supporting and strengthening wounds until they heal
• Approximation of skin edges to minimise scarring
• Reduce the risk of bleeding and wound infection

The suture techniques that we will teach throughout this PDF are the following:

- Hand Tie Knot

- Simple Interrupted Suture
- The Surgeon’s Knot
- Vertical Mattress Suture
- Horizontal Mattress Suture
- Continuous Suture
 Hand knot tying
Knot tying is one of the most fundamental techniques in surgery and is often incorrectly performed. It is commonly
used in all types of surgical specialities. Make sure that you understand how to hand tie first before moving on to
further techniques as this will stand by you for the rest of your surgical career. It is vital to practice regularly to ensure
you have mastered the skill.

An easy way to practice would be to use shoelaces or old suture threads from your hospital placements. You can ask a
scrub nurse for threads that are going off date before they are thrown away.

The general principles of knot tying include:

1. The knot must be firm and unable to slip

2. Must be as small as possible to minimise foreign material entering
3. Keep the material neat and undamaged
4. Try to avoid tearing the tissue while suturing

The hand tie is commonly known as thrown and laid and is the foundation of surgery. This technique is made up of 2-
knot throws. Both throws are tied with the hands over the wound and held horizontally. The one-handed knot consists
of two throws, described as the “coming down throw” and the “going up throw”, both performed alternately.

Please refer to the alphabets in each technique to match the instruction to the example photo provided.

“Coming down throw”:

(a) After taking a bite of the skin, you are ready to lay your first throw. Pull the thread through leaving the end
without the needle attached about 5 inches long. We will refer to this as the short end. First, we will perform
the down throw.
(b) Begin by facing the palm of your left hand downwards and bending your elbow about 90 degrees. Picking up
the short end, using your fourth digit “ring finger” and thumb.
(c) Turn your palm upwards so that the thread is rotated and passes over your middle and index finger as
illustrated below.
(d) With your right hand, hold the long thread (the side of the thread with the needle) and wrap it around the left
middle and index fingers, creating a loop.
(e) Flex the left middle finger under the short thread and then straighten so that the short thread is behind your
middle finger.
(f) The thread can now be released from your thumb and ring finger, then using your middle and index finger, pull
the short thread through the loop you have created.
(g) Once you’ve pulled the short thread through the loop, you can now pull the short thread down towards you
while pulling the long thread upwards away from you. Holding the knot firmly, you are now ready to try the
“going up throw”.
(a) (b)

(c) (d)

(e) (f)
 (g)

“Going up throw”:

(a) This time, pick up the short thread between your index finger and thumb.
(b) Turn your palm to face upwards, so that the thread is lying over your middle and ring finger
(c) Using your right hand again, place the long thread down over your middle and ring finger.
(d) Flex your middle finger and straighten it over the short thread again. The thread can now be released from
your left thumb and index finger, using your middle and ring finger, pull the thread through the loop you have
created.
(e) Pull the short thread upwards and the long thread towards you.
(f) Cut any excess thread.

(a) (b)
(c) (d)

(e) (f)

Well done! You’ve officially completed the Hand Tie Knot.

It’s important to notice that your hands are changing direction with every throw, moving towards and away from you.
This is to ensure that the knot is laid down correctly and won’t come loose. If using a braided thread, it is usually
sufficient to perform three alternating throws, though, with smooth monofilament thread, it can easily slip, therefore
completing six throws is required.
 Simple interrupted suture
The simple interrupted suture is a commonly used technique in wound closure. This technique has the advantage of
being easy to place and has high tensile strength. Another advantage of this suture is that individual sutures can be
removed without causing a risk to the closure.

(a) Start by taking a bite of the skin, pulling the thread towards you, leaving the short end furthest away from
you.
(b) Next, hold the needle holder horizontally over the wound.
(c) Wrap the long end of the thread over and around the needle holder once.
(d) Grasp the short end of the thread using the needle holder.
(e) Complete the first throw by pulling the short end down towards yourself, through the loop you have created.
As you pull the short end down, ensure the long thread is pulled away from you, so that your hands are
crossing positions.
(f) Once again, place the needle holder over the wound and form a loop around the tool.
(g) Using the needle holder, grasp the short end again, but this time pull it away from you, through the loop you
have created.
(h) Your knot should now be securely laid, simply cut any excess thread.

Well done! You have now completed the Simple Interrupted suture!

(a) (b)

(c) (d)
(e) (f)

(g) (h)
 The surgeon’s knot
The surgeon’s knot is very similar to the simple interrupted suture; however instead of wrapping the thread around
the needle holder once, you will wrap it around twice. The rest of the surgeon’s knots remains the same as the simple
interrupted suture. The double wrapping around the needle holder for the first throw allows for a more secure first
knot.

(a) Start by taking a bite of the skin, pulling the thread towards you, leaving the short end furthest away from
you.
(b) Next, hold the needle holder horizontally over the wound.
(c) Wrap the long end of the thread up, over and around the needle holder twice.
(d) Grasp the short end of the thread using the needle holder.
(e) Complete the first throw by pulling the short end down towards yourself, through the loop you have created.
As you pull the short end down, ensure the long thread is pulled away from you, so that your hands are
crossing positions.
(f) Once again, place the needle holder over the wound and form a loop around the tool.
(g) Using the needle holder, grasp the short end again, but this time pull it away from you, through the loop you
have created.
(h) Your knot should now be securely laid, simply cut any excess thread.

Well done! You have now completed the Surgeon’s knot.

(a) (b)

(c) (d)
(e) (f)

(g) (h)
 Vertical Mattress Suture
(a) Begin by taking a large bite through the skin, aiming for about 1cm meter on both sides.
(b) Using your forceps, rotate your needle so that you are ready to make a reverse bite.
(c) A reverse bite is a bite made in the opposite direction as the first one as shown in the example photo.
(d) For the reverse bite, you will need to make it more superficial to the wound edge, 2mm either side; this helps
to ensure the edges of the skin evert.
(e) Once you’ve ensured even distance on either side of the wound, you can now complete the vertical mattress
suture by performing a surgeon’s knot.

(a) (b)

(c) (d)
Well done! You have now completed the Vertical Mattress Suture.
 Horizontal Mattress Suture
(a) Begin by taking a large bite through the skin, aiming for about 1cm meter on both sides.
(b) Once you have completed the first bite, rotate your needle using your forceps to position the needle for a
reverse bite.
(c) About 1cm next to your previous bite, perform a reverse bite.
(d) As you can tell from the example photo, the thread should almost resemble a square.

You can complete the horizontal mattress suture by performing the surgeon’s knot on the two threads.

(a) (b)

(c) (d)

Well done! You have now completed the Horizontal Mattress Suture.
 Continuous Suture
(a) To start the continuous suture, we will begin by taking a bite through the skin and performing a surgeon’s knot.
(b) Once you’ve completed the surgeon’s knot, cut the short end of thread leaving a 3-4mm tail.
(c) You can now begin to place your second stitch about 3mm away from the first one.
(d) Now take another bite next to the previous one.
(e) Ensure to pull and apply tension with each suture.
(f) Once you have completed the second suture, you can continue performing as many sutures as necessary
depending on the size of the wound.
(g) Take a reverse bite through the wound but do not pull the thread all the way through.
(h) To complete the continuous suture, perform a surgeon’s knot using the loop you created.

Well done you have just mastered the Continuous Suture.

(a) (b)

(c) (d)
(e) (f)

(g) (h)
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