Suturing technique

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General principles

Equipment

• Dominant hand 
  • Needle-holder
  • Scissors 
• Non-dominant hand 
  • Non-toothed forceps – used to bring the needle out from the other side of the wound
  • Toothed forceps – used to manipulate skin if needed

Holding instruments

• Hold the needle-holder and scissors with thumb and ring finger in the holes, middle finger on the side and index finger on the top; hold the forceps like a pen
• Use your dominant hand to grip the needle with the needle-holder
  • Position of needle within needle-holder teeth: the needle should be grasped at a right angle, two thirds of the way from the tip, facing medially, with the needle tip pointing upwards
• Use your non-dominant hand mainly to bring the needle out from the other side of the wound using the non-toothed forceps. You can also use it to hold the needle directly if desired, or hold the toothed forceps to manipulate skin.
• The needle should be held in the needle-holder to enter skin; the non-toothed forceps should be used to bring the needle out of the centre/other side of the wound, before transferring it back to the needle-holder for more suturing. 
• When tying an instrumental knot, the needle can be held by the non-toothed forceps (in your non-dominant hand) or your non-dominant hand’s fingers directly 

Placing sutures

• Suture so the skin edges are slightly everted (it is the dermis-dermis contact that allows healing)
• Do not constrict the tissue
• In general, most sutures are placed 5mm wide from each wound edge and 5mm apart (except for face – 2-3mm wide and 3-5mm apart)
• Note, in order to ensure the final sutures are 5mm wide from each wound edge, you will need to place them a bit wider because the skin will compress when the sutures are tied 
• Where possible, enter the side of the wound opposite and farthest from you (so you are bringing the needle towards yourself)
• Deep, gaping wounds will need deep absorbable sutures placed before closing the skin

Sharp safety

• If you hold the needle directly, ensure you only hold the distal end and never bring the needle out of the skin with your fingers to avoid risk of sharp injury
• When finished, clamp the sharp part of the needle longitudinally inside the needle-holder to safely dispose of it

Techniques overview

Suture techniques

• Interrupted sutures (several individually tied sutures) – permits precise opposition of wound edges; can be used anywhere; best if you are worried about the cleanliness of the wound
  • Interrupted over-and-over suture – most commonly used 
  • Interrupted vertical mattress suture – mattress sutures are useful if wound edges are difficult to evert
  • Interrupted horizontal mattress suture 
• Continuous sutures (one continuous suture to close wound) – permits closer approximation of wound edges; prevents passage of bodily fluids (including blood); evenly distributes tension; wound must be clean and it must be easy to oppose edges; not commonly used for skin
  • Continuous over-and-over suture
  • Continuous interlocking suture
  • Continuous everting mattress suture
• Special sutures
  • Intracutaneous (subcuticular) suture – creates inconspicuous wound
  • Tendon suture
  • Cervical suture

Knot-tying techniques

• Instrument ties – most commonly used 
• Two-handed
• One-handed

Interrupted over-and-over suture

This is the most common technique for closing skin using non-absorbable sutures.

• Start in the middle of a linear wound, or at the corners of a jagged wound
• Enter the skin at a right angle, about 5mm wide of the edge of the wound, on the side farthest from you
• Then go about 5mm deep into the subcutaneous tissues before coming out of the centre of the wound (optional – usually done for the first sutures but not as the wound edges become closer together)
• If you came out of the centre, enter the subcutaneous tissues of the other side of the wound about 5mm deep
• Come out of the skin on the opposite side of the wound at a 90˚ angle about 5mm wide of the wound edge 
• Pull most of the thread through the wound, leaving enough distally to tie a knot
• Tie knot and cut ends (as below)
• Start the process again for the other sutures – place sutures about 5mm apart

Instrumental knot-tying

This is the most common knot-tying technique.

• Pull most of the thread through the wound, leaving enough distally to tie a knot
• Using your non-dominant hand, hold the needle with your fingers or with the non-toothed forceps (like when you brought it out of the wound edge)
• Twist the needle end of the suture around the shaft of the needle-holder in your dominant hand 
• 2 throws away: do this twice away from you first, then tie knot by gripping the other end of the suture with the needle holder’s teeth and pulling this through the loops. Then tighten the knot by pulling each end in opposite directions.
• 1 throw towards: repeat the process but twist the needle end of the suture in the opposite direction around the needle-holder and only once
• 1 throw away: repeat the process, twisting the needle end of the suture in the original direction around the needle-holder once
• Cut ends about 5-10mm from knot
• Ensure knots are pulled to one side of the wound rather than left overlying the centre (they may get stuck in the granulation tissue and become difficult to remove)

Removal Times