Suture Workshop

Jack W. Hutter DPM, C. ped, FACFAS,
FAPWCA, Diplomate, ABPFAS

The earliest reports of surgical suture date to
3000 BC Egypt
Oldest known example of suturing is on a
mummy from 1100 BC
The Indian sage Sushruta described wound
suture and materials in 500 BC
Hippocrates described suture techniques
Galen described gut suture taken from sheep
intestine
Lister developed techniques for sterilization of
gut suture
The modern era of suture begins in 1931 with
polyvinyl alcohol synthetic absorbable suture
Polyester in the 1950’s, polyglycolic in the 1970’s
Today most suture is made of a synthetic
polymer

The type of suture technique and
material chosen can either compliment
or hinder the surgical result
Improper suture placement tissue
handling can lead to painful, noticeable
scarring, adhesions, dehiscence, tissue
strangulation, hematoma
With some specific exceptions, nondissolvable
suture is used to close skin,
dissolvable all else

Needle holder, forceps or Adson, Adson-
Brown pick-ups, suture with needle
Needles are either cutting or reverse
cutting, cutting sharp on the inner curve,
reverse on the outer curve
Reverse cutting needles reduce the
chances of the needle and suture cutting
cross-ways through tissue
Suture diameter and needle size vary
depending upon the task

The needle holder is held with the tip of the
thumb and the 2 nd , 3 rd or 4 th finger
Grasp the needle with the holder at the swage
(widest point, usually 1/3 distance from the
suture ) of the needle
The needle is fragile, easily bent or broken
Stabilize the tissue edge with the pick-ups
Penetrate at a 90 degree angle
Grasp the passed through portion of the needle
with the holder before releasing the pick-ups
Pull the needle and suture through the tissue
Repeat the process or tie off

Placement points for needle penetration
should be directly opposite and symmetric
depending upon the technique
When closing skin, the suture should not be
more than 3mm from the incision
Wound edge inversion is to be avoided,
strive for slightly everted edges
Sutures placed too tightly will create a
larger scar, tissue strangulation, and are
harder and more painful to remove

Should not be too tight to avoid tissue
constriction
Should be at least a square knot, created by two
clockwise twists of the needle holder around the
suture and grasping the loose end of the suture,
then a counterclockwise twist
A “granny knot” will slip
A third clockwise twist creates an even stronger
“locked” knot
Strangulation occurs with the third twist if the
second is not securely tightened
Leave adequate suture length after each knot for
easier and less painful removal

Simple interrupted
Simple running ( continuous )
Continuous with lock
Running intra-cuticular
Vertical mattress
Vertical mattress with pulley
Horizontal mattress
Simple or continuous subcutaneous
Other methods of closure
Modified Bunnell suture for tendon repair
Ligature

Location of the incision
Skin thickness
How much tension is on the incision,
potential for swelling
Creation of dead space
Cosmetic result ( reduced scarring )

Linear
-Straight, uncomplicated, no
angular correction
Curvi-linear ( semi-elliptical )
-Used to accommodate tissue
irregularity, angular correction
Converging semi-ellipitical
-Excision of lesion, tissue
redundancy
Lazy “S”
-Used where a large amount of
exposure is desired, reduced
tension on skin edge
” V- Y”Advancement
-Lengthens skin contracture
Teardrop
-Derotational incision

SIMPLE INTERRUPTED
PRO
-Easily placed
-Good wound edge strength
-Less tissue strangulation
CON
-Minimal edge eversion
-Time consuming to place
-Noticeable train – track scar
possible if left in too long
or too tight

SIMPLE CONTINUOUS ( RUNNING )
PRO
-Less knots, thus quicker to
place and less scarring
-Good for long incisions
CON
-Tissue strangulation if too
tight, with dehiscence
-Avoid if tissue is hypovascular

SIMPLE CONTINUOUS LOCKED
PRO
-Increased strength, used in
cases where there is great
tension on the incision
anticipated
-Reduced slippage of the suture
line
-Quickly placed as is similar to
the simple continuous except
with a doubling back under
the suture loop
CON
-Micro vascular impairment
-Increased risk of dehiscence

CONTINUOUS ( RUNNING ) INTRACUTICULAR
PRO
-Usually done with dissolving material,
doesn’t need to be removed
-Improved cosmetic result if done
properly
-Placed within the epidermis, results in
less scaring and no RR tracks
CON
-Less eversion of edges if done
improperly, resulting scar will be
more noticeable
-Time consuming
-Too much material, will contribute to
scar hypertrophy from increased
tissue reaction
-Increased skin tension can lead to
gapping

VERTICAL MATTRESS
PRO
-Good edge eversion
-Dead space closure
-Quickly done
-Less strangulation if
combined with intermittent
simple interrupted sutures
CON
-Strangulation if excessive
swelling
-RR tracks due to four access
points

VERTICAL MATTRESS WITH CINCH ( PULLEY )
Same PRO’s and CON’s as
with vertical mattress
except allows for even
greater closure strength,
but also increased risk of
strangulation depending
upon the amount of
swelling

HORIZONTAL MATTRESS
PRO
-Good if high wound tension,
swelling
-Good edge eversion
CON
-If placed too tightly, there is
increased risk of
strangulation and
dehiscence
-More painful to remove due
to double stranded throw

SIMPLE INTERRUPTED AND CONTINUOUS SUBCUTANEOUS
PRO
-Layer closure of subcutaneous
tissue
-Usually dissolvable suture
material
- Interrupted for small space,
continuous for larger
-Closes dead space
-Reduces tension on skin
incision
CON
-Strangulation if too tight
-Increased suture reaction,
dehiscence, “ spitting of knot”

Steri-strips
-Good as a bolster when combined with other suture
methods
-Reduced scarring
Staple
-Not used in foot surgery very much
Adhesives
-Dermabond
-Similar to superglue ( cyanoacrylate )
-Not as strong as suture, used as a skin bolster
combined with traditional suture
-Little scarring
-Rapid healing
-No suture removal

Used in tendon repair,
“Z” -plasty tendon
lengthening
A combination of
horizontal and vertical
mattress
Number of suture throws
increases strength

In foot surgery, primarily vascular
Venous, arterial bleeders
Instrument or hand tie, square knot
Bovie electrocoagulation

Thank you