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Vertical Mattress Stitch……………………………….page 2 Simple Interrupted Suture…………………………….page 5 Instrument Tie - Square Knot…….…………………page 12
D. Ph. and these are responsible for ensuring eversion of the wound edges when the suture is tied.Vertical Mattress Stitch Wayne W... e. Path of the vertical mattress stitch: The vertical mattress stitch consists of “far-far” and “near-near” components. M.g. Photography and Editing by Michael J.P. LaMorte. These are about 4 mm from the wound edge. The “near-near” components are bites that are taken very close to the wound edge. in the palm of the hand. M.. 2 . and Christine Hamori.D. M. The “far-far” component is similar to the two bites for a simple interrupted stitch. LaMorte The vertical mattress stitch is particularly useful in situations in which the skin edges have a tendency to invert or turn down into the wound.D.H.
The first “near-near” component is placed by reversing the placement of the needle in the needle holder and “backhanding” the needle so that the bite is taken away from the surgeon. The second “far” bite is being placed in the proximal wound edge. The first “near” bite has been taken.about 4 mm from the wound edge. and the needle holder is about to regrasp the needle to complete the bite. and the needle emerges about 4 mm from the wound edge.The first “far” bite is just like the beginning of a simple interrupted stitch . 3 .
4 .The needle has been regrasped. After second and third throws are added to secure the knot. bringing the throw down just tight enough to approximate the wound edges. The first loop of the square knot is formed by wrapping the long strand around the needle holder… … and the short strand is grasped and pulled back through the loop toward the surgeon. Both the short and long strands emerge from the skin surface furthest away from the surgeon. and now the second “near” bite is being taken on the wound edge furthest away from the surgeon. the next stitch will be placed about 4-5 mm to the right of the first stitch. and the needle holder is being positioned to begin an instrument tie.
Supination and pronation are required to manipulate the curved needles used in surgery.. M. but with the hand pronated. Forceps with teeth provide a secure grasp with minimal pressure.D.Simple Interrupted Suture Wayne W.H. 5 . Ph.D. M. thereby avoiding crushing of the skin edge. LaMorte. Note that the index finger provides additional control and stability. such as the Addison forceps shown here. using the first three fingers. This illustrates the same grasp.P. Most surgeons grasp the needle holder by partially inserting the thumb and ring finger into the loops of the handle.. The forceps should be held in the first three fingers as one would hold a pen. Photography by Michael J. should be used to grasp the skin edges during suturing. LaMorte Small toothed forceps. The needle holder should be held in a way that is comfortable and affords maximum control.
6 . Note that the trailing suture is placed away from the surgeon to avoid tangling.ethiconinc. The right hand is rotated into pronation so that the needle will pierce the skin at a 90o angle. (Drawing from Ethicon website: http://www.As a rule. since this will damage the suture. Placement of the 1st suture is begun by grasping and slightly everting the skin edge. the needle should be grasped at its center or perhaps 50-60% back from the pointed end. The needle should be grasped 1-2 mm from the tip of the needle holder.com/wound_management/procedure/wound/ ) One should avoid grasping the suture material or the distal end of the needle with the needle holder.
7 . natural supination which rotates the needle upwards and away from the surgeon. Note that the forceps maintain their grasp. this minimizes trauma to the tissues. Again.The needle is driven through the full thickness of the skin by rotating the needle holder (supinating). thereby preventing the needle from retracting. it is probably advisable to train yourself to use the forceps for this instead of fingers. Pronation in the previous step makes it possible to complete passage of the needle with a smooth. given the risks of HIV and hepatitis. By keeping the shaft of the needle perpendicular to the skin surface at all times. However. The needle has been released and is about to be regrasped. one takes advantage of the needle’s curvature in traversing the skin as atraumatically as possible. Here the needle is being regrasped in preparation for passage through the opposite skin edge. This was traditionally done by grasping the needle with the non-dominant hand. The right hand has been fully pronated in preparation for regrasping the needle.
Again. keeping the shaft at a right angle to the skin surface.The skin edge closest to the surgeon has been grasped and everted slightly. while the right hand is pronated to “cock” the needle and position it for passage through the skin. 8 . the right hand is supinated in order to rotate the needle through the full thickness of the skin. the right hand is pronated before the needle is regrasped… … and the right hand is then supinated in order to rotate the needle through the skin atraumatically. After releasing the needle.
Note that the needle holder is positioned between the strands over the wound. The needle holder is then rotated away from the surgeon to grasp the short end of the suture. leaving 2-3 cm. 9 . protruding from the far skin surface. The short end is grasped and drawn back through the loop toward the surgeon. The long strand is being wrapped around the needle holder to form the loop for the first throw of a square knot.The suture material is drawn through the skin. The forceps are then dropped or “palmed” so the left hand can grasp the long end in preparation for an instrument tie.
The throw is tightened… … creating a flat throw which will be tightened just enough to approximate the skin edges. Remember: approximate. The needle holder is then rotated toward the surgeon to retrieve the short end. do not strangulate. The second throw of the square knot is initiated with the needle holder pointed to the left as the long strand is wrapped around it by bringing the long strand toward the surgeon. … 10 .
The second throw is then brought down and tightened securely against the first throw. such as nylon. pulling it away from the surgeon. one would place 5 or 6 throws of alternating construction in order to minimize the likelihood of knot slippage. The next suture will then be placed about 4 mm away from the first one. such as a knuckle. For example. The distance between stitches will depend on how easily the wound edges can be approximated and how much tension or motion is likely to be exerted across the wound during healing. 11 . If a slippery monofilament material.… and the short end is drawn through the loop that has been created. were being used. such as silk. With a braided material. a wound on a flexion surface. might require closer sutures than a wound in the scalp. The suture will then be cut leaving 3-4 mm tails. a third throw (replicating the first) would be placed to secure the knot.
away from the surgeon. The left hand has brought the long end away from the surgeon to begin to form a loop. and the tip of the needle holder is being rotated away from the surgeon to grasp the tip of the short end. M.H..P. Note that the short end is beneath the tubing.D. Well-constructed square knots with flat throws have less likelihood of slipping. 2) The needle holder is held above the tubing pointing from right to left. Ph. 3) The long strand has now been looped around the needle holder.Square Knot Wayne W.Instrument Tie .D. The instrument tie is commonly used for closure of superficial lacerations because it conserves suture material and can be done quickly. 12 . LaMorte. M. 1) This shows the beginning of knot construction. LaMorte The square knot is the most fundamental knot for the surgeon. Photography by Michael J..
and it will be pulled back through the loop toward the surgeon. 13 . 5) As the short end is pulled toward the surgeon. Note that the short end is now toward the surgeon. 7) The left hand initiates creation of the 2nd loop by bringing the long strand toward the surgeon. 6) The throw is tightened by pulling with equal tension in both directions. grasps the short strand. the long end is pushed away. which now protrudes through the loop.4) The needle holder. and the needle holder again is pointing to the left.
such as nylon or prolene. which will be pulled back through the loop. 9) The tip of needle holder has now been rotated toward the surgeon. For monofilament material.. 11) The second throw is tightened by pulling with equal tension in opposite directions. The tip of the needle holder will now be rotated toward the surgeon to grasp the short end. 3 throws are generally sufficient. and grasps the short end. alternating between the first and second throws. For braided suture material. 10) The needle holder has now pulled the short end back through the loop away from the surgeon. and the left hand pulls the long strand toward the surgeon. Additional throws are added.8) The left hand brings the long strand toward the surgeon across the needle holder to form a loop. 14 . 5 or 6 alternating throws are required to prevent knot failure. such as silk.
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