SUTURING
CONTENT
INTRODUCTION
DEFINITION
ARMAMENTARIUM OF SUTURING
SUTURE MATERIALS
PRINCIPLES OF SUTURING
SUTURING TECHNIQUES
SURGICAL KNOT
REMOVAL OF SUTURE
REASONS FOR FAILURE OF SUTURE
POSSIBLE COMPLICATIONS
ALTERNATIVES TO SUTURE
CONCLUSION
INTRODUCTION:
Any surgical procedure involves the creation of a wound and subsequent closure by repositioning or
reapproximating and securing the surgical flaps by suturing to allow optimum healing. A suture is a strand
or thread of material used to approximate tissues and also to ligate blood vessels. To suture is the act of
sewing or bringing tissues or flaps edges together and holding them in apposition until normal healing takes
place. Sutures also help the wound to withstand normal functional stresses and to resist wound reopening.
DEFINITION:
The act or method of joining together the two edges of a wound or incision by stitching or similar means.
ARMAMENTARIUM OF SUTURING:
Suturing either extra oral or intraoral wounds requires the following equipment.
1.Needle holder:-These are available in different types and sizes based on the region where it is used & also
based on the thickness of the suture material being used for suturing.
2.Suture materials
3.Suturing needles
4.Tissue holding forceps:-This is also available in different types Toothed
Non-toothed:-Usually the toothed Adson’s forceps is used for suturing in maxillofacial region. A non-
toothed forceps may be used for suturing fragile mucosa.
5.Suture cutting scissors.
SUTURE MATERIALS:
ABSORBABLE
o NATURAL
1. CATGUT
2. COLLAGEN
3. CARGILE-MEMBRANE
4. FASCIA LATA
o SYNTHETIC
1. POLYGLYCOLIC-ACID ( Vicry, Surgicryl, Polysorb & Dexon )
2. POLYDIOXANONE(PDSTM ll)
NON-ABSORBABLE
o NATURAL
1. Silk
2. Linen
3. Cotton
o SYNTHETIC
1. Nylon
2. Polypropylene
3. Prolene, surgilene
4.Polybutester (Novafil)
PRINCIPLES OF SUTURING
The needle should be grasped at approximately one-third the distance from the eye and two-thirds from
the point.
The needle should enter the tissues perpendicular to the tissue surface and no less than 2-3 mm from
the incision.
The needle should be passed through the tissues along its curvature.
The suture should be passed at an equal depth and distance from the incision on both sides.
The needle always passes from the thinner tissue to the thicker tissue.
Suture whenever possible, should be placed from movable to immovable tissue.
While doing suturing involving interdental papillae, the suture should pass below the imaginary line
formed by the base of the triangles formed by these interdental papillae.
The sutures should be tried only to approximate the tissue, not to blanch.
The knot should never lie on the incision line.
Sutures should be placed at a greater depth than the distance from the incision, so as to evert the
wound margins.
Use the least amount of sutures that will secure the wound excessive causes needless perforation of the
tissue and hampers the blood supply of healing wound.
Use as few knots as possible because they are the weakest part of the suture and at the same time act as
irritants.
Use the smallest suture possible to close the wound.
Sutures should be removed 7-10days post-operatively to prevent the formation of epithelial tracks.
SUTURING TECHNIQUES:
Interrupted suture
Continuous suture
Mattress suture
Figure of 8 suture
Subcuticular suture
Interrupted Suture-Sling Suture:
The suture is passed through both the edges of the wound at an equal depth and distance from the incision,
needle penetration should be 3 mm from the wound edges and the knot is tied. It is the most commonly used
suture.
Advantages: It is strong, and can be used in areas of stress. Successive sutures can be placed according to
individual requirement. Each suture is independent and the loosening of one suture will not produce
loosening of the other. A degree of eversion of the margins can be controlled. If the wound becomes infected
or there is hematoma formation, removal of a few sutures may offer a satisfactory treatment.
Continuous Over and Over Suture Initially, a simple interrupted suture is placed and the needle is then
reinserted in a continuous fashion such that the suture passes perpendicular to the incision line below and
obliquely above. The suture is ended by passing a knot over the untightened end of the suture. It provides a
rapid technique for closure and distributes the tension uniformly over the suture line. It also offers a more
water tight closure
Continuous Locking Suture:
This technique is similar to the continuous suture, but locking is provided by withdrawing the suture
through its own loop.
The suture thus passes perpendicular to the incision line. The locking prevents excessive tightening of the
suture as the wound closure progresses.
Mattress Suture:
These sutures may be horizontal or vertical. These are used in areas, where tension free flap closure
cannot be accomplished. Mattress sutures are used to resist muscle pull, evert the wound edges and to
adapt the tissue flaps tightly to the underlying structures (e.g. bone grafts, tissue grafts, dental implant,
regenerative membrane, etc.)
1) Horizontal Mattress Suture:
The needle is passed from one edge of the incision to another and again from the latter edge to the first
edge in a horizontal manner and a knot is tied. The distance of needle penetration from the incision line
and the depth of penetration of the needle is the same for each entry point, but horizontal distance of
the points of penetration on the same side of the flap differs (needle penetration through the surgical
flap should be at least 8 mm away from the flap edges). This suture provides a broad contact of the
wound margins, e.g. closure of extraction socket wounds.
2) Vertical Mattress Suture:
It is similar to the horizontal mattress, except that, all factors remaining constant, the depth of penetration
varies, i.e. when the needle is brought back from the second flap to the first, the depth of penetration is more
superficial. It is used for closing deep wounds.
Figure of 8 Suture:
The figure of 8 suture can be used for the extraction socket closure as well as for adaptation of the
gingival papilla around the tooth.
Subcuticular Sutures:
The subcuticular layer of tough connective tissue if sutured will hold the skin edges in close
approximation when cosmetic results are desired. Continuous short lateral stitches are taken beneath
the epithelial layer of the skin. The ends of the suture come out at each end of the incision and are
knotted. This type of suturing leaves a cosmetic scar.
SURGICAL KNOT:
1. Surgical Knot Tying Surgical knot tying is vital to the art of suturing.
2. It is essential for knot security and to prevent untimely knot untying, that the appropriate surgical knot
be used for the specific suture material being secured.
3. Knot security can be assessed by measuring the force required to slip or break a knotted loop of suture
material.
A knot can be tied using an instrument, like the needle holder or with the hand.
Secure/Square Knot Standard square or reef knotting method:
1. It is a special knotting technique, once tied, the knots are secure.
2. The first throw is placed in precise position for the knot, using a double loop.
3. The second throw is tied using horizontal tension. Additional two throws are desirable. Totally
there should be four throws and the ends should be cut long.
Surgeon’s Knot:
1. It is formed by two throws of the suture around the needle holder on the first tie and one throw in
the opposite direction in the second tie.
2. Synthetic resorbable and non resorbable suture materials can be used to prevent untimely knot
untying.
s
Granny’s Knot or Slip Knot:
1. When using silk, chromic catgut or plain catgut suture material, a slip (Granny’s) knot can be
used.
2. It involves a tie in one direction followed by a second tie in the same direction and a third tie in
the opposite direction to square the knot and hold it securely.
REMOVAL OF SUTURE:
The suture is grasped with an instrument and lifted above the epithelial surface. The scissors are then
passed through one loop and transected close to the surface. The suture is then pulled out.
Skin sutures are usually removed after a period of 7–10 days depending upon the area, and mucosal
sutures are removed between 5 and 7 days.
REASONS FOR FAILURE OF SUTURE:
Breakage
Cuts out
Knot slips
Extruded suture
Resorbs too rapidly
Removed too early
POSSIBLE COMPLICATIONS:
If sutures are tied too tightly, or if their tension is increased due to tissue swelling, there can be mechanical
damage to the tissues as well as compromise of the blood supply.
This in turn can cause the edges to undergo localized necrosis or atrophy, leading to increased scarring or
possible wound dehiscence.
ALTERNATIVES TO SUTURE:
LIGATING CLIPS:
These can be resorbable or non resorbable. Ligating clips are made from stainless steel, tantalum or
titanium or polydioxanone. They are designed for the ligation of tubular structures.
SURGICAL STAPLES:
Surgical staples can be used for skin closure and closure of the abdominal layers. Skin staples are
made up of stainless steel, and are placed uniformly to span the incision line. They have minimal tissue
reaction. They can be used for routine skin closure anywhere in the body. Their use is contraindicated
when it is not possible to maintain at least 5 mm distance from the stapled skin to the underlying bone
and blood vessels.
TISSUE ADHESIVES:
After tight closure of the subcutaneous tissues, the skin layer can be closed with the help of tissue
adhesive like N-butyl-cyanoacrylate, which on tissue contact polymerizes into a hard substance that
keeps the wound margins together.
DERMABOND TOPICAL SKIN ADHESIVE:
It is a 2-octyl cyanoacrylate with a long carbon side chain structure that is combined with plasticizer-
nontoxic, flexible, transparent bond. It has three dimensional strength and is 3–4 times stronger than
N-butylcyanoacrylate. This adhesive is applied to the dry skin over the wound by a proper technique in
multiple thin layers (at least three). It sets within three minutes and offers sutureless skin
approximation. It has no length restrictions and wounds do not need to be linear. It provides a
waterproof clear dressing resulting in excellent cosmetic result.
CONCLUSION:
A suture is a strand or thread of material used to approximate tissues and also to ligate blood vessels. To
suture is the act of sewing or bringing tissues or flaps edges together and holding them in apposition until
normal healing takes place. Sutures also help the wound to withstand normal functional stresses and to resist
wound reopening.
