General Principles
Many
varieties of suture material and needles are available. The choice of
sutures and needles is determined by the location of the lesion, the
thickness of the skin in that location, and the amount of tension
exerted on the wound. Regardless of the specific suture and needle
chosen, the basic techniques of needle holding, needle driving, and knot
placement remain the same.
Suture placement
A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of the distance from the tip of the needle, depending on the surgeon’s preference. The needle holder is tightened by squeezing it until the first ratchet catches. The needle holder should not be tightened excessively, because damage to both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular to the needle holder (see the image below).
Needle is placed vertically and longitudinally perpendicular to needle holder. Incorrect
placement of the needle in the needle holder may result in a bent
needle, difficult penetration of the skin, or an undesirable angle of
entry into the tissue. The needle holder is held by placing the thumb
and the fourth finger into the loops and placing the index finger on the
fulcrum of the needle holder to provide stability (see the first image
below). Alternatively, the needle holder may be held in the palm to
increase dexterity (see the second image below).
Needle holder is held through loops between thumb and fourth finger, and index finger rests on fulcrum of instrument. Needle holder is held in palm, allowing greater dexterity. The tissue must be stabilized to allow suture placement. Depending on the surgeon’s preference, toothed or untoothed forceps or skin hooks may be used to grasp the tissue gently. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis.
Forceps are necessary for grasping the needle as it exits the tissue after a pass. Before removal of the needle holder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation.
The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge, depending on skin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the two sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.
First, the tip of the needle holder is rotated clockwise around the long end of the suture for two complete turns (see the image below). The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, so that the two ends of the suture are on opposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end of the suture. The short end is then grasped with the needle holder tip and pulled through the loop again.
Knot tying. The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increases with increased wound edema. Depending on the surgeon’s preference, one or two additional throws may be added.
Properly squaring successive ties is important. In other words, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and is inherently weaker than a properly squared knot. When the desired number of throws is completed, the suture material may be cut (if interrupted stitches are used), or the next suture may be placed.
Needle holder is held through loops between thumb and fourth finger, and index finger rests on fulcrum of instrument. Needle holder is held in palm, allowing greater dexterity. The tissue must be stabilized to allow suture placement. Depending on the surgeon’s preference, toothed or untoothed forceps or skin hooks may be used to grasp the tissue gently. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis.
Forceps are necessary for grasping the needle as it exits the tissue after a pass. Before removal of the needle holder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation.
The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge, depending on skin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the two sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.
Knot tying
Once the suture is satisfactorily placed, it must be secured with a knot.[35] The instrument tie is used most commonly in cutaneous surgery. The square knot is traditionally used.First, the tip of the needle holder is rotated clockwise around the long end of the suture for two complete turns (see the image below). The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, so that the two ends of the suture are on opposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end of the suture. The short end is then grasped with the needle holder tip and pulled through the loop again.
Knot tying. The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increases with increased wound edema. Depending on the surgeon’s preference, one or two additional throws may be added.
Properly squaring successive ties is important. In other words, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and is inherently weaker than a properly squared knot. When the desired number of throws is completed, the suture material may be cut (if interrupted stitches are used), or the next suture may be placed.
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