Suturing

Clinical Skills
Suturing

Sian Williams (Clinical Skills Manager/Tutor)

Dr Brian Jenkins (Former Clinical Skills Lead)
 Suturing
Aims & Outcomes

Aims & Outcomes

The aim of this module is to facilitate learning regarding the purpose and procedure of simple
interrupted suturing.
Learning Outcomes
At the end of the session the student should be able to:

 Define the reasons why simple suturing may be necessary

 State the common risk factors that may arise as a result of the procedure being carried out
 Recognise when simple suturing may be contraindicated
 Describe the use of analgesia during the process
 Recognise the need for asepsis during the process
 Describe the information required for the completion of patient care plan documentation
 Outline the aftercare advice required following the procedure
 Evaluate own learning and recognise how improvements can be made
 Suturing
Introduction

Introduction
Suturing is a technique used to hold wound edges in apposition until primary healing occurs, decreasing healing
time and improving cosmetic results. The aim is to avoid excess tension on the sutures, so that future wound
dehiscence is avoided. In deep wounds, this may require that the deeper tissues such as muscle and fat layers
are sutured first in order to reduce tension on the skin sutures. Before closure is attempted, the wound must be
inspected, any foreign bodies such as glass removed, and the wound thoroughly cleaned. If non-viable tissue is
present, this should also be removed prior to attempted closure.

There are many types of suture, each with different advantages and disadvantages. The technique described
here will be for simple interrupted sutures, which produce good wound closure with an adequate cosmetic result
under most circumstances.

Consent
Explain the procedure to the patient, including the reasons for it and any discomfort that may be experienced,
and obtain consent.
 Suturing
Indications, Contraindications & Risks

Suturing - Indications, Contraindications and Risks

Indications Contra-Indications Risks

•Wound closure (healing by
primary intention)
•Securing drains (e.g. chest or
ascitic drains) or lines (e.g. central
venous or arterial lines) to skin
•Lack of consent •Infection
•Foreign body in the wound •Failure of wound healing
•Wound infection •Hypertropic or keliod scarring
(more common in younger
individuals and those with
pigmented skin)
 Suturing
Local Anaesthetics

Local Anaesthetic
Local anaesthetic agents have varying onset times, duration of action and ability to penetrate tissue.
Local anaesthetics are weak bases and are most efficacious in alkaline conditions whereby the un-ionised form
crosses the neuronal membrane. Conversely, infected or inflamed tissues have an acidic environment, which
reduces the action of local anaesthetic. Furthermore, the increased vascularity of these environments gives rise to
an increased risk of systemic absorption and subsequent side-effects.

The most commonly used local anaesthetic for ward-based procedures is Lidocaine (also known as lignocaine).
 Suturing
Local Anaesthetics - Dosage

Local Anaesthetic - Dosage

The concentration of Lidocaine (mg/ml) equals the percentage concentration multiplied by 10. For example:

1% Lidocaine = 10mg/ml
2% Lidocaine = 20mg/ml

The maximum dose of Lidocaine (without vasoconstrictor agent) can be calculated as follows:

Maximum dose (mg) of Lidocaine = 3 x weight (kg), up to a maximum of 200mg (see BNF)
 Suturing
Indications, Contraindications & Risks

Local Anaesthetic - Indications, Contraindications and Risks

Indications Contra-Indications Risks

•Local anaesthesia for painful
procedures
•Complete heart block •Lidocaine toxicity
•Certain arrhythmogenic
cardiological conditions are
exacerbated by local anaesthetics
•Hypovolaemia
•Known allergy to lidocaine
•Local anaesthetic in combination
with epinephrine should NEVER be
used in digits and appendages
given the consequent risk of
ischaemic necrosis
 Suturing
Methods of Suturing

Methods of Suturing

A – Simple Interrupted
B – Simple Continuous
C – Horizontal Mattress
D – Running Subcutaneous
E – Vertical Mattress

Students at this stage of training are expected to demonstrate, a degree of competence in the procedural steps required to
carry out simple interrupted suturing only.
 Suturing
Equipment

Equipment

Needle holder
Scissors
Toothed forceps
Non-toothed forceps
Suture pack
Cleaning solutions e.g Saline, Povidone iodine, Betadine or Chlorhexadine (check for
allergies).
Sterile drape, fenestrated
Local anaesthetic solution eg Lidocaine Hydrochloride (Check BNF: Usually 1% or 2%
solution: (to max of 200mg)
 Suturing
Procedure (1 of 19)

Procedure

 Prepare the
equipment on a
clean, sterile
surface.
 Suturing
Procedure (2 of 19)

Procedure
 Position the wound on a stable surface, ensuring that lighting is optimal.
 Wash hands and put on sterile gloves.
 Inspect the wound, removing any dirt or foreign objects, and debriding as necessary.
Thoroughly clean around the wound with antiseptic solution if required, but only ever use
normal saline to irrigate the wound bed.
 Isolate the area with a sterile drape. When suturing, ensure that hands, instruments or
suture remain within this area.
 Before suturing, infiltrate with 1% Lidocaine through the wound, beneath the skin, from the
ends of the wound and round the wound edges. Try to avoid injecting excessive volumes
(which will distort the anatomy).
 Suturing
Procedure (3 of 19)

Procedure

 Small toothed forceps should be

used to grasp the skin edges
during suturing. Forceps with
teeth provide a secure grasp with
minimal pressure, thereby
avoiding crushing of the skin
edge. The forceps should be held
in the first three fingers as one
would hold a pen, using the first
three fingers.
 Suturing
Procedure (4 of 19)

Procedure

 The needle holder should be

held in a way that is
comfortable and affords
maximum control. Most
surgeons grasp the needle
holder by partially inserting
the thumb and ring finger into
the loops of the handle. Note
that the index finger provides
additional control and
stability.
 Suturing
Procedure (5 of 19)

Procedure

 Small toothed forceps should

be used to grasp the skin
edges during suturing.
Forceps with teeth provide a
secure grasp with minimal
pressure, thereby avoiding
crushing of the skin edge. The
forceps should be held in the
first three fingers as one
would hold a pen, using the
first three fingers.
 Suturing
Procedure (6 of 19)

Procedure

 Placement of the 1st

suture is begun by
grasping and slightly
everting the skin edge.
The right hand is rotated
into pronation so that the
needle will pierce the skin
at a 90o angle.

Note that the trailing suture is

placed away from the surgeon
to avoid tangling.
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Procedure (7 of 19)

Procedure

 The needle is driven through the full thickness of the skin by rotating the needle
holder (supinating). By keeping the shaft of the needle perpendicular to the skin
surface at all times, one takes advantage of the needle's curvature in traversing the
skin as atraumatically as possible.
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Procedure (8 of 19)

Procedure

 Grasp the needle with forceps or

needle holder. Pronation in the
previous step makes it possible
to complete passage of the
needle with a smooth, natural
supination which rotates the
needle upwards and away from
the surgeon. Again, this
minimizes trauma to the tissues.
 Remount needle.
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Procedure (9 of 19)

Procedure

 Again, the right hand

is supinated in order
to rotate the needle
through the full
thickness of the skin,
keeping the shaft at a
right angle to the skin
surface.
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Procedure (10 of 19)

Procedure

 The needle is
regrasped...
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Procedure (11 of 19)

Procedure

 The suture material is drawn

through the skin, leaving 3
cm. protruding from the far
skin surface. The forceps are
then dropped so the left hand
can grasp the long end in
preparation for an instrument
tie.
 The needle holder is
positioned between the
strands over the wound.
 Suturing
Procedure (12 of 19)

Procedure

 The long strand is

wrapped twice around
the needle holder.
 The needle holder is
then rotated away from
the surgeon to grasp
the short end of the
suture.
 Suturing
Procedure (13 of 19)

Procedure

 The short end is

grasped and drawn
back through the
loop toward the
surgeon and
tightened...
 Suturing
Procedure (14 of 19)

Procedure

 ...creating a flat throw

which will be tightened
just enough to
approximate the skin
edges. Remember:
approximate; do not
strangulate.
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Procedure (15 of 19)

Procedure

 The second throw of the square knot is

initiated with the needle holder in
front as the long strand is wrapped
around it by bringing the long strand
toward the surgeon.
 The needle holder is then rotated
toward the surgeon to retrieve the
short end, and the short end is drawn
through the loop that has been
created, pulling it away from you
 Suturing
Procedure (16 of 19)

Procedure

 The second throw is

then brought down
and tightened
securely against the
first throw.
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Procedure (17 of 19)

Procedure

 With a braided material,

such as silk, a third throw
(replicating the first)
would be placed to secure
the knot...
 Suturing
Procedure (18 of 19)

Procedure

 ...If a slippery monofilament

material, such as nylon, were
being used, one would place
5 or 6 throws of alternating
construction in order to
minimize the likelihood of
knot slippage.
 Suturing
Procedure (19 of 19)

Procedure

 Depending on the use to which it is

put, the suture should be cut with
the scissors between 0.5 and 1 cm.
of suture from the knot.
 The whole procedure is repeated
for every stitch, with sutures
placed approximately 1 cm. apart,
finishing so that all the knots are
over the same side of the wound.
 Suturing
Tips

Tips
The technique described uses instruments to suture (rather than hands). It is a good principle
to avoid direct contact with the hands, even though they are gloved and sterile. For those less
dexterous and who find it difficult to tie good quality knots with instruments, a hand may be
used to help tie the knots.

When tying knots, always keep an eye on the end of the thread. It is the easiest thing in the
world for the thread to spring outside of the sterile area. When you are practising this in the
laboratory, use a coloured surround to simulate the sterile area. Also use gloves, as you would
when managing a patient. The sooner you get used to tying knots when wearing gloves, the
more comfortable you will feel when suturing a real wound.
 Suturing
Checklist (1 of 2)

Checklist
 Wash hands and dry
 Put on gloves (The smallest that fit comfortably)
 Put on appropriate personal protective equipment; apron and face protection
 Inject local anaesthetic
 Select material of choice (see separate sheet)
 Gather needle holder, scissors, forceps
 Grasp needle of suture in holders 1/3 of the way along its length
 Insert 5mm from edge of the wound at right angles to the skin edge, until it emerges from
inside wound
 Remount Needle
 Re-insert under opposite wound edge, so that exit point is again 5mm from wound edge (on
opposite side)
 Pull suture through until a 3cm tail remains at initial entry site
 Tie with surgical knot effectively using needle holders
 Drop needle and forceps
 Suturing
Checklist (2 of 2)

Checklist
 Take long thread
 Place needle holder behind thread
 Wrap thread round needle holder twice
 Grab short end with needle holder and pull through.
 Take long thread
 Place needle holder in front of thread
 Wrap thread round once
 Grab short end with needle holder and pull through
 Take long thread
 Place needle holder behind thread
 Wrap thread round once
 Grab short end with needle holder and pull through
 Cut suture leaving tails of 5mm
 Dispose of needle and gloves appropriately
 Suturing
Helpful Links

References and Helpful Links

Patel, N. and Knight, D. 2009. Clinical Practical Procedures for Junior Doctors. Churchill
Livingstone: Elsevier

Dornan, T. and O’Neill, P. 2006. Core Clinical Skills for OSCEs in Medicine. Churchill Livingstone:
Elsevier

Stoneham, M. and Westbrook, J. 2007. Invasive Medical Skills: A Multimedia Approach.

Blackwell Publishing

Athreya, B.H. 2010 Handbook of Clinical Skills: A Practical Manual. World Scientific

Thomas, J. Monaghan, T. 2007. Oxford Handbook of Clinical Examination and Practical Skills.
Oxford Medicine Online
Revised Sian Williams 17 01 14