WOUND S U T U R I NG

S H O P: B A S IC S K IL L S
W OR K
LO PM E N T I N W O U N D
DEV E
EC HN I Q U E S
CLOSURE T
C. LORENZO, MD
WORKSHOP OBJECTIVES

• HANDLING OF BASIC SUTURING INSTRUMENTS

• TECHNIQUES IN BASIC WOUND SUTURING
• TYPES OF SUTURES
• BASIC KNOT TYING
BASIC SUTURING INSTRUMENTS
• GRASPING INSTRUMENTS NEEDLE HOLDER
• The most commonly used holder
• Available in different lengths
• Have an indentation in one jaw –a hollow oval groove so that the
surgeon can “stitch” away from him in a forward movement
• Probably the only instrument where metal is held by metal so
that wear factor is very high –this is why some have inserts
made Tungsten carbide, the hardest metal known to extend the
instrument’s usage
BASIC SUTURING INSTRUMENTS
• GRASPING INSTRUMENTS
THUMB AND TISSUE FORCEPS

• Tissue forceps with teeth or toothed dissecting forceps –

characterized by “teeth” at the end of the jaws; the surgeon uses
the teeth to grasp heavier tissues that might slip ffrom non-
toothed forceps
• Tissue forceps without teeth or non-toothed dissecting forceps or
thumb forceps –characterized by serrations at the tip, the
surgeon uses these as an extension of his fingers to grasp all
types of tissue
BASIC SUTURING INSTRUMENTS
• GRASPING INSTRUMENTS
ADSON DISSECTING FORCEPS

• Named after Dr. A.W. Adson, a famous surgeon who designed

these forceps to be used in brain or “neuro” surgery.
• Used to grasp very delicate tissues such as blood vessels or
nerves.
• Very lght, with firm jaws that widens abruptly into thumb grip
• Come with or without teeth
BASIC SUTURING INSTRUMENTS
• CUTTING OR SEPARATING INSTRUMENTS
LIGATURE SCISSORS MAYO SCISSORS METZENBAUM
SCISSORS
BASIC SUTURING INSTRUMENTS
• SURGICAL NEEDLES • Main purpose is to allow the correct passage of
sutures through the tissue
• Must cause the least possible trauma when
penetrating the tissue
• Shape must be appropriate to any particular
applcation –Lower tissue penetration force is related
to less needle bending during tissue passage
• Should have sufficient strength so it does not bend
easily but should also have sufficient ductility that
enables it to a given angle under a given amount of
pressure or load
BASIC SUTURING INSTRUMENTS
• SURGICAL NEEDLES
• Different needle points and
bodies result in different
tissue perforations.
BASIC SUTURING INSTRUMENTS
• SURGICAL NEEDLES
• Wide variety of surgical needles available and the
selection of needle to use depends on the type of tissue
to be sutured, the location and accessibility of the
tissue to be sutured, the size of the suture material and
the surgeon’s personal preference.
BASIC SUTURING INSTRUMENTS
• SURGICAL NEEDLES
NEEDLE SHAPE AND
NEEDLE ANGLE
CURVATURE
HANDLING OF SUTURING INSTRUMENTS
• GENERAL GUIDELINES
• Ring instruments must utilize the ring finger and thumb as stabilizers of the
instrument handle
• Instruments must be held in prone position
• Size of instruments must be proportionate to the tissues being handled
HANDLING OF SUTURING INSTRUMENTS
• GENERAL GUIDELINES
SUTURING
• Movement of needle has to follow the curve of the needle
• Needle must be stabilized at the center of the needle body
• Return thread has to be either 1/3 or ½ of the entire strand of suture
 BASIC WOUND SUTURING
• SIMPLE CONTINUOUS (SKIN)
• Also known as “running” suture
• Mainly used with tension-free wounds –where deeper sutures have
been placed in order to minimize wound tension
• Considered to cause less scarring due to the fact that less knots are
performed
• Disadvantage: higher risk of dehiscence if the suture breaks
• Commonly used to secure the perimeter of a split- or full thickness skin
graft
• Optimal result when performed with Non-absorbable monofilaments
• Alternative sutures: Mid-term absorbable monofilaments

(0:15-4:00)
https://www.youtube.com/watch?v=NC9XwH3aXKA
HANDLING OF SUTURING INSTRUMENTS
• SIMPLE INTERRUPTED (SKIN)
• Most common technique to close wound
• Once performed the first knot, it is positioned on one side so that
it does not lie directly on wound edge and does not disturb the
healing process
• Easy to place
• Provide great tensile strength
• Less likely to compromise blood circulation
• Need longer time to be placed
• Higher risk of causing the so-called “railroad track” scars
• Optimal result: Non-absorbable monofilaments
• Alternate suture: Mid-term absorbable monofilament

( 0 -3:10)
https://www.youtube.com/watch?v=CqrhxLZKxx8
HANDLING OF SUTURING INSTRUMENTS
••MATTRESS SUTURE (SKIN)
Used when the wound edges are not close enough to each other to allow tension-free healing
• Larger amount of tissue is incorporated within the suture passage, tension is well held under the skin
edges
• Disadvantage: surface scarring due to increased tension across the wound and also to the fact that the
suture enters the skin 4 times on each stitch
• this effect can be avoided by early removal of the sutures once the tissue as recovered enough
strength to be held together without any extra support 5-7days
• If left longer, it is highly recommended to use bolster in order to minimize suture strangulation of
the tissue
• Used in cases were eversion of the wound edges is desired in order to counteract against the roll-under
effect that might happen secondary to tissue contraction during healing
HANDLING OF SUTURING INSTRUMENTS
••MATTRESS SUTURE (SKIN)
Used in areas where the wound edges tend to invert (e.g. wound on a concave surface)
• Use of this sutures is limited in areas where cosmetic result is important
VERTICAL MATTRESS HORIZONTAL MATTRESS
• Optimal result: Non-absorbable monofilament • Optimal result: Non-absorbable monofilament

1:00 – 0:25 – 5:
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HANDLING OF SUTURING INSTRUMENTS
••CONTINUOUS SUBCUTICULAR (ABSORBABLE)
Performed with absorbable sutures
• Advantage: no need for second visit to extract
the suture
• Some would avoid this this technique in order
to reduce to a minimum the amount of foreign
material remaining in the wound
• Used only where there is an absence of tension
at the skin level
• Optimal result: mid-term absorbable
monofilaments

https://www.youtube.com/watch?v=-rvJZ3jR7AU
TYPES OF SUTURE
• NATURAL ABSORBABLE SUTURES
CATGUT CHROMIC
• Brown twisted threat made of collagen derived
from serosal layer of bovine intestine treated with
chromic salts
• Tensile strength retention rate ranges 21-28days
• Absorption is by enzymatic degradation within
90days
TYPES OF SUTURE
• NATURAL ABSORBABLE SUTURES
CATGUT PLAIN
• Yellowish, twisted thread structure made of
collagen derived from serosal layer of bovine
intestine
• Tensule strength is lost within 7-10days
• Absorption by enzymatic degradation within
70days
TYPES OF SUTURE
• SYNTHETIC ABSORBABLE SUTURES
BRAIDED MULTIFILAMENT
• Most common braided sutures are made of pure
Polyglycolic acid, an inert material tht has an
innate bacteriostatic effect, a very high breaking
resistance and short absoption time
• Absorbed by hydrolysis in presence of tissue fluids
lasting from 42-90days
TYPES OF SUTURE
• SYNTHETIC ABSORBABLE SUTURES
MONOFILAMENT
• Most recommended surgical suture because it is
flexible and easy to handle
• Smootger than any other absorbable suture and
creates no tissue drag and no room for infection
• Free of capillary effect –therefore can be used in
infected areas
• Absorbed through hydrolysis
TYPES OF SUTURE
• NATURAL NON-ABSORBABLE SUTURES
SILK
• Made of natural silk filaments braided and coated
with wax and silicone
• Inert wax coating creates very good tissue
compatibility and decreases suture’s capillarity to a
minimum
• Loses its tensile strenth in one year
TYPES OF SUTURE
• NATURAL NON-ABSORBABLE SUTURES
POLYESTER
• Non-absorbable monofilamaent suture made of
uncoated polyester
• Very good tissue compatibility because the thread
is biochemically and physiologically inert
• Used in skin, plastic and reconstructive surgery
TYPES OF SUTURE
• NATURAL NON-ABSORBABLE SUTURES
POLYAMIDE
• Monofilament suture made of Polyamide and
usually of black or blue color
• Pseudo non-absorbable suture which loses tensile
strength 15-20% per year and will be fully
absorbed in 2 to 3 years
• Mainly used for plastic and reconstructive
surgeries
TYPES OF SUTURE
• NATURAL NON-ABSORBABLE SUTURES
POLYPROPYLENE
• Monofilament suture, uncoated and usually of blue
color
• Suitable for the parachute technique which
surgeons use for cardiovascular surgery
• Uniform surface that allows effortless passage
through
BASIC KNOT TYING
• ONE-HAND TIE (0:18 – 3:32)
HTTPS://WWW.YOUTUBE.COM/WATCH?V=UFJBTBJEU4Y

• TWO-HAND TIE (0:29 – 4:40)

HTTPS://WWW.YOUTUBE.COM/WATCH?V=O8OQXTGAS7O
• INSTRUMENT TIE (0:30 – 4:10)
HTTPS://WWW.YOUTUBE.COM/WATCH?V=VSCCS37TSLW
THANK YOU!