Basic Wound Closure & Knot Tying
Basic Wound Closure &Knot TyingJoslyn Albright, MDGeneral SurgeryPGY-4 Research Resident
Objectives Provide basic information on commonlyused suture materialsReview general principles of woundclosureProvide a general overview of basicsurgical knot tying
Suture Material Generally categorized by threecharacteristics:Absorbable vs. non-absorbable Natural vs. synthetic Monofilament vs. multifilament
Absorbable Suture Degraded and eventually eliminated in one oftwo ways: Via inflammatory reaction utilizing tissue enzymesVia hydrolysisExamples: “Catgut”ChromicVicrylMonocrylPDS (polydioxanone ble
Non-absorbable Suture Not degraded, permanentExamples: Prolene (polypropylene)Ethibond (polyester/Dacron)NylonStainless steelSilk*(*not a truly permanent material; known to be brokendown over a prolonged period of time—years)
Natural Suture Biological originCause intense inflammatory reactionExamples:“Catgut” – purified collagen fibers fromintestine of healthy sheep or cows Chromic – coated “catgut” Silk
Synthetic Suture Synthetic polymersDo not cause intense inflammatory reactionExamples: VicrylMonocrylPDSProleneNylon
Monofilament Suture Grossly appears as single strand of suturematerial; all fibers run parallelMinimal tissue traumaResists harboring microorganismsTies smoothlyRequires more knots than multifilament suturePossesses memoryExamples: Monocryl, PDS, Prolene, Nylon
Multifilament Suture Fibers are twisted or braided togetherGreater resistance in tissueProvides good handling and ease of tyingFewer knots requiredExamples:Vicryl (braided) Chromic (twisted) Silk (braided)
Suture DegradationSuture Material“Catgut”Method ofDegradationProteolyticenzymesTime toDegradationDaysVicryl, MonocrylHydrolysisWeeks tomonthsPDSHydrolysisMonths
Suture Size Sized according to diameter with “0” as reference sizeNumbers alone indicate progressively larger sutures (“1”,“2”, etc)Numbers followed by a “0” indicate progressively smallersutures (“2-0”, “4-0”, etc)Smaller ------------------------------------- ��.”2”.”3”.
Needles Classifiedaccording to shape and typeof point Curvedor straight (Keith needle) Taper point, cutting, or reverse cutting
Needles Curved Designed to be heldwith a needle holderUsed for most suturing Straight Often hand heldUsed to securepercutaneously placeddevices (e.g. centraland arterial lines)
Needles Taper-point needle Round bodyUsed to suture softtissue, excluding skin(e.g. GI tract, muscle,fascia, peritoneum)
Needles Cutting needle Triangular bodySharp edge towardinner circumferenceUsed to suture skin ortough tissue
Suture Packaging
Wound Closure Basic suturing techniques:Simple sutures Mattress sutures Subcuticular sutures Goal: “approximate, not strangulate”
Simple Sutures Simple Interrupted Single stitches,individually knotted(keep all knots on oneside of wound)Used foruncomplicatedlaceration repair andwound closure
Mattress Sutures Horizontal Mattress Provides added strengthin fascial closure; alsoused in calloused skin (e.g.palms and soles) Two-step stitch: Simple stitch then,Needle reversed and 2ndsimple stitch madeadjacent to firstsame size bite as firststitch
Mattress Sutures Vertical Mattress Affords preciseapproximation of skinedges with eversionTwo-step stitch: Simple stitch made –“far, far” relative towound edge (large bite)Needle reversed and 2ndsimple stitch made insidefirst – “near, near” (smallbite)
Subcuticular Sutures Usually a runningstitch, but can beinterruptedIntradermal horizontalbitesAllow suture toremain for a longerperiod of time withoutdevelopment ofcrosshatch scarring
Steri-strips Sterile adhesive tapesAvailable in differentwidthsFrequently used withsubcuticular suturesUsed following stapleor suture removalCan be used fordelayed closure
Staples Rapid closure ofwoundEasy to applyEvert tissue whenplaced properly
Two-Hand Square Knot Easiest and mostreliableUsed to tie mostsuture materials(click image to start video)
Instrument Tie Useful when one orboth ends of suturematerial are shortCommonly usedtechnique forlaceration repair(click image to start video)
References Encyclopedia of Knots provided by Ethicon; available atwww.jnjgateway.com/public/USENG/5256ETHICON Encyclopedia of Knots.pdf(More extensive overview of knot tying with photos for those interested in surgery) Blackbourne, LH, editor. Surgical Recall. 2nd ed. Baltimore: Lippincott Williams &Wilkins; 1998 Cameron, JL, editor. Current Surgical Therapy. 7th ed. St. Louis: Mosby; 2001 Edgerton, MT. The Art of Surgical Technique. Baltimore: Williams & Wilkins; 1988 Gomella, LG, Haist, SA. Clinician’s Pocket Reference. 9th ed. New York: McGraw-HillMedical Publishing Division; 2002 (Useful book for anyone doing clinical rotations!)(Excellent resource for technical details of surgery)Special thanks to Drs. Thomas and Angelats for theirassistance in the development of this presentation.
Knot Tying. Objectives Provide basic information on commonly used suture materials Review general principles of wound closure Provide a general overview of basic surgical knot tying. Suture Material Generally categorized by three . Encyclopedia of Knots provided by Ethicon ; available at
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