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Development of good technique requires a knowledge and understanding of the rational mechanics involved in suturing.

When taking a bite of the tissue, the needle should be pushed through using only a wrist action, if it becomes difficult to pass through the tissue, an incorrect needle may have been selected, or the needle may be blunt.

The tension of the suture material should be maintained throughout to prevent slack sutures, and the distance between the sutures should be equal.

The use of a specific suture pattern may vary depending on the area being sutured, the length of the incision, the tension at the suture line, and the specific need for apposition, inversion, or eversion of the tissues.

Suture patterns can be broadly categorized as interrupted or continuous.

A. Interrupted Patterns

Interrupted sutures are used to relieve tension, or in areas where more strength is required. They are not as economical as a continuous suture as a knot must be tied after each suture placement, using a great deal more suture material. Should one of the sutures fail, this will not affect the rest of the sutures placed in the wound.

• Time consuming.
• Large amounts of suture materials.
• Presence of additional amounts of suture materials within the tissue.
• Ability to maintain strength and tissue position if part of suture line fails or tears.
• Provide more accurate edge to edge apposition.
• Less scar tissue formation in the healed wound

B. Continuous Patterns

Continuous patterns are the quickest type of suture pattern, used for areas of low tension such as the closure of body cavities, muscle layers, adipose tissue, and skin, and are more economical than interrupted patterns.

If pulled too tightly, however, the wound may pucker. If any part of the wound breaks down due to failure of the continuous suture, the rest of the wound may be affected and re-open along its length.

• Less time consuming.
• Fewer amounts of suture materials.
• Fewer suture materials within the tissue.
• Unable to maintain, if one knot is slipped, fail or tear out the entire suture line become loosened.
• Difficult to gain an accurate edge to edge apposition.
• More scar tissue formation.

C. Appositional Patterns

1. Simple Interrupted Suture

• A bite is taken symmetrically at an equal distance from either side of the wound and pulled tight.
• A knot is placed, and the suture material is trimmed before repeating the method until the wound is closed.
• This type of suture is useful for closure of the linea alba during abdominal surgery or other areas requiring more strength.
• Easy to apply.
• Secure anatomical closure.
• Allows adjustment of suture tension.

Usages

• Skin, subcutaneous tissue, fascia, vessels, nerves, gastrointestinal and urinary tract.

2. Simple Interrupted Intradermal Suture

• Upside down simple interrupted to ‘bury the knot’.
• These are placed in a simple interrupted pattern below the skin and the bites of the suture lie vertical to the incision.
• They are used to eliminate dead space and to relieve tension on the skin sutures.
• They are useful to reduce patient interference and to eliminate the need for suture removal in sensitive areas.
• This pattern should be used in conjunction with a buried knot(s).
• Absorbable suture material should be used.

Usages

• Intradermal or subcuticular closure.

3. Interrupted Cruciate (Cross Mattress) Suture

• An ‘X’ shape is created over the wound.
• A bite is taken from one side, passing to the other, before advancing forwards by 8–10 mm then repeating from the original bite side.
• A knot is then placed to join the suture ends, over the top of the wound.
• For this suture to be most effective, a square should be created with the corners of the suture.
• This suture is used for tension relief.
• Stronger and quicker than simple interrupted sutures, as more of the wound is closed with each suture placed.
• Prevents eversion.

Usages

• Skin.

4. Simple Continuous Suture

• Place an initial knot.
• Take a bite of 0.5–1 cm from either side of the wound.
• Pull suture material tight so wound edges are appositional.
• Repeat the suture a short distance away from the first; the bite should start from the same side each time as the original bite until the wound has been closed.
• Place a knot to secure the wound closure.
• Faster than interrupted suture patterns.
• Promotes suture economy.
• Provides a more air-tight or fluid-tight seal.
• More difficult to adjust tension.
• Can fail completely if the knot is weak or inadequate.

Usages

• Skin, subcutaneous tissue, fascia, gastrointestinal and urinary tract.

5. Continuous Intradermal Suture

• Another modification of a simple continuous and modified horizontal mattress suture.
• The suture passes horizontally through the layers of the dermis, taking a bite from alternating wound edges, and the skin is pulled closed with no sutures visible.
• This is a suture of low strength so is usually used in areas with low tension, however, in a higher tension wound, skin sutures may be used in addition.
• Intradermal sutures are more comfortable for the patient and help to prevent patient interference, they avoid tracking of infection into the wound and there is minimal scarring.
• Promotes suture economy.
• Provides good skin apposition.
• Weaker than skin sutures.
• No sutures to remove.

Usages

• Intradermal or subcutaneous closure.

6. Ford Interlocking Suture (Reverdin – Blanket Stitch – Lock Stitch)

• A modification of a simple continuous suture.
• Secure the suture material with a knot.
• A bite is taken from each side of the wound.
• Before pulling the suture tight, the material is threaded through the loop leaving an ‘L’ shaped suture.
• Repeat until the wound is closed.
• These create better skin apposition than a simple continuous suture.
• More difficult to remove.

Usages

• Skin

7. Gambee Suture

• A modified simple interrupted, but more difficult to apply.
• Helps control mucosal eversion.
• Less susceptible to bacterial ‘wicking.
• This is a specialized suture used in the repair of the intestine.
• A Modified Gambee is placed in the same way but does not penetrate the lumen of the intestine.

Usages

• Intestinal anastomosis.