Suturing Techniques

CHAPTER 1

Hi everyone. My name is Deanna Rothman. I'm a general surgery resident at Massachusetts General Hospital. And welcome to our suturing techniques. We're gonna start off by going through some of the things you can find in a typical suturing kit.

The first thing is your suture pad. Suture pads are usually made out of foam or rubber and are a great place to practice your suturing. I have an example incision in this one here. Next, I'll go through some of the basic instruments that you commonly find. First, your scalpels. So there's several different kinds of scalpels you can encounter. First is the 10 blade. As you can see, it has a rounded belly, that's the sharp knife, and it's also pretty thick. This with the 10 blade in comparison to the 15 blade. Also has a rounded belly, but it's a little bit smaller. This one's usually used for skin incisions that are slightly smaller, so the port site, whereas the 10 blade is used for larger skin incisions. And lastly, we have our 11 blade. As you can see, the 11 blade is shaped a little bit differently. It has a pointed tip and you actually use it with the tip first aiming away from yourself. So this one's also used for finer skin incisions. Next, let's talk about our needle driver. So this is your needle driver. You can tell it's your needle driver because it has a blunt end, a serrated inside and the axis is pretty close to the tip as you can see here. A needle driver is different from, for example, this kind of snap, which is called a Mosquito or a Jake. Because this one has a rounded tip, serrated edges, and a slightly longer end with the axis slightly farther away from the tip. That's how you know this is not your needle driver, but this one instead is. Next, You'll commonly find some scissors. So there is a right way to hold the scissors, believe it or not. And what you'd like to do is have the screw side facing up towards the sky. And that way if you push down on your thumb, it'll cut down every time. Next is your Adsons or your forceps. You ideally wanna use your Adsons like if they're a pencil. So you wanna be holding them straight up like this. The ones with teeth are the ones you wanna use on the skin because it's actually less traumatic. So you wanna make sure you have Adsons with teeth and you hold them like a pencil to be able to lift up the skin. And those are our most common instruments in our suture kit.

Now before we get started on suturing, I'm gonna show you how to load your needle driver. So we have our needle driver and our 2-0 silk suture. So when you load your needle driver, you ideally want to grab the needle with just the tip of your needle driver as you can see there. And you wanna have it at a slight angle. So the needle tip is pointing back at me, but it's slightly at an angle, about 45 degrees upwards from the horizontal. You also ideally want to have your needle loaded about 2/3 of the way from the tip of the needle, so mostly towards the back, ideally like this. And this will help give you the most dexterity and flexibility as you're taking your bites. So now that you're ready, now you're ready to start suturing.

CHAPTER 2

So we're gonna start with our simple interrupted stitch. So we have our incision and our suturing pad. And ideally, these are used to close superficial incisions, usually in just a simple interrupted way. So I'll show you what I mean by that. When we start sewing, we always sew from right to left. So I'm gonna grab the right side of my incision and lift it up with my Adson forceps, like I mentioned, holding it like a pencil. Then you're gonna, with your needle, try to get really perpendicular to that skin. So you wanna be going in at a 90-degree angle with your needle and enter the skin. And you wanna come out with your needle in the middle of your incision. Sometimes, if your incision is close together, you can actually take this in one bite and go through and through. But usually I think it's a little bit easier to actually reload your needle and then get ready to start over again. Now, with my Adsons again, I'm gonna hold up the left side of my incision, really show myself the area I wanna go in, enter in the center of my incision, and come out on the other side. Here, you wanna be thinking that you wanna be symmetric. Meaning that you wanna have the same amount of distance from your incision on one side as the other. And you also want it to be about equal in terms of the length down the incision that you're going. So now that I've taken my bite, I'm gonna pull my needle through and get ready to tie. For this one, I'm going to instrument tie. So I want the end of my suture to be pretty short and make it a little bit easier. One instrument tie, I'm gonna leave my needle down and out of the way and I'm gonna take my needle driver, start at the center of my incision, and then wrap the string twice around my needle driver. And I'm gonna grab the tip of that other suture, my other end, and pull through forming my first knot. Then I'm gonna go back to the middle, wrap it around once this time, grab that end again and pull through. That's gonna be my second knot. Because this a silk, I need at least three knots. So I'm gonna go back to the middle, loop around, grab my suture again and make my last knot. That's a simple interrupted. If you have a longer incision like I do here, I would probably do a couple of simple interrupted or do a running whip stitch, which we'll go through next.

So next we're gonna do the simple running, which is also called the simple continuous, or whip stitch. So this is a continuation of your simple interrupted stitch. We have our simple interrupted and instead of cutting our suture, we're actually gonna use it to continue down the length of our incision. So just like we did with our simple interrupted, we're gonna grab our right end of our incision, just a little bit of distance from my last bite, start 90 degrees on the right side of my incision, go to the center, regrab my needle making sure to use our Adsons to really expose that area for ourselves and then go again on the other side to come through on the left side of my incision. And that's my first bite. As you're going through this whip stitch, what you wanna be thinking about is symmetry. So you wanna make sure you're traveling the same distance down the incision. And also that your bites are equally distanced from the center of the incision. The distance between your bites usually depends on the length of the incision and also the tensile strength of the tissue itself. So it kind of varies. And usually you can continue this for as long as your incision requires. So when you reach the end of your incision and it's time to end your whip stitch, there is a specific way that you're supposed to end and close your stitch. So, if this is my last bite, I'm gonna pull my needle through, but I'm gonna leave a little bit of a loop this time. And I wanna use that loop like I did use the end of this string for my instrument tie. So I'm gonna start at the middle of my incision, loop my longer string with my needle around twice, and I'm gonna grab the tip of that loop and pull through. And that's my first throw. So now for my second one, once again to the middle of the incision, wrap around once, grab the tip of that loop, and pull through. And middle of the incision, wrap around once, tip of the loop, pull through. And that's your running whip stitch. So lastly, you wanna make sure to cut your ends, and your incision is closed.

CHAPTER 3

Well now we're gonna move on to our vertical mattress and horizontal mattress. These sutures are usually used for larger tensile strength tissues. So for example, after fasciotomy, and you have to bring the edges of that swollen tissue together, this is usually the kind of suture we'd use. So I'm gonna go through each kind of stitch and how you can tell them apart.

So first, I'm gonna go through the horizontal mattress. For the horizontal mattress, we're gonna start it on the right side of our incision and we're take a full-thickness bite. So going into the epidermis and coming out in the subcutaneous tissues of the incision. We're then gonna do the same thing on the left, going from the center of our incision and coming out perpendicular to the incision on the other side of the incision itself. But now, you actually wanna move down on the left side of your incision, rotating your needle to be backhanded, and you're gonna travel along the length of the incision and go this time from the left side to the right side of your incision, coming out in the middle. And once again, I'm gonna regrab my needle, backhanded. And this time, I'm gonna go into - from the center of my incision to the right side along the same line from where I came initially. And so with this stitch, you wanna make sure to be symmetric with the distance that you travel on each side and also the distance away from the center of the incision. Now when you tie down your horizontal mattress stitch, the edges should evert nicely and should get a little bit of puckering, which is what you expect. As you can see here.

Now that's a little bit different from your vertical mattress, and I'll show you how that one looks next. So with your vertical mattress, the mnemonic I usually like to remember is far far, near near. So you're gonna start on your right side, a good amount away from the center of your incision. So let's say this, this one about two centimeters. Exactly as far as you go will depend on the tensile strength of your tissue. I'm gonna start far, again, full-thickness bite. I'm then gonna regrab, give myself a little bit of slack, and once again, go full thickness from the center of my incision, out pretty far again on the edge, about two centimeters. Exactly the distance will depend on the tensile strength of the tissue that you're working on. Now, once again, we're gonna flip our needle to be backhanded. And this time, we're gonna go near, near. So we're gonna go along the same line of our incision instead of traveling down. And we're just gonna go slightly closer to the center of the incision coming outta the center. But this time, I started on my left side, and now working towards my right side. And then I'll tie this down. Just like the horizontal mattress, you'll get some eversion of the edges of the tissue and a little bit of puckering, which is expected As you see here. So now you have your horizontal mattress and your vertical mattress. So the way to tell them apart is that the horizontal mattress is horizontal in relationship to the center of the incision. And same thing with your vertical. The vertical is vertical in relation to the central of the incision. And so that's how you can tell. And now you have your vertical and horizontal sutures.

CHAPTER 4

So before we move on to practice other suturing techniques, let's see what they look like at the level of the skin. So first, we're gonna be starting with our laparoscopic port site closures. For these closures, there's two main ways that we usually close them. Your incisions from the level of the skin looking down will usually be about one centimeter in size. The first step we're gonna do is a U-stitch. For a U-stitch, you stay in the level of the dermis and basically travel along the length of your incision. So what that looks like is you'll start by taking a bite on one side of your apex, travel inside the dermis, and then come out at the other side of your apex. You're then gonna go in directly across from where your first stitch came out, traveling in the level of the dermis, and then ending up on the same side where your first bite came in. And that's where your knot will be. Now what that looks like as a cross section of the skin - so this is your epidermis, your dermis layer here, and your subcutaneous fat. So your stitch will only stay in the level of the dermis, and your knot will also be in the level of the dermis. The other main way to close a laparoscopic port site is called a deep dermal. For the deep dermal, you're gonna go deep to superficial and superficial to deep. So what that means is you start in the subcutaneous fat, come up to the level of the dermis, then go directly across from where that bite was, go to the dermis, and then end up again in the subcutaneous fat. And so your knot will be deep. And now what that looks like as a cross-section, you're gonna start in the subcutaneous fat, go up into the dermis, cross your incision to the other side, still in the level of the dermis, and then go down into the subcutaneous fat. And that's where your knot will be. Deep inside of the tissue. So these are our main two ways that we close laparoscopic port sites. So now let's go practice them together.

So like what we just demonstrated on the board, we're now gonna be actually practicing our laparoscopic port closures. So as you can see, I have two small, about centimeter-sized incisions to be practicing on. And we're gonna be doing both our U-stitch and our deep dermals. As I mentioned, you wanna stay in the dermis the entire time. So I'm gonna grab my incision at the opposite apex from where I'm originally gonna go in. I'm gonna go in right at that dermis. Travel along the length of my laparoscopic port site and come out at the other side. You can see, and the whole time, I'm staying in that dermis layer. And now, I wanna come back around and basically end up exactly where I started. So to do that, I'm actually gonna rotate my body, go once again at the dermis and usually wanna go in exactly where your last stitch came out. Going in at the dermis, traveling along the length of the incision at the dermis, and then coming out at the other apex. And once you do that, you can tie. You can either instrument tie or hand tie these. I usually prefer hand tie because I feel I can get a slightly tighter closure. And there you go. Now you have your U-stitch.

So next, we'll run through the deep dermal. For the deep dermal, you're gonna go deep to superficial, superficial to deep, as I mentioned. So, I'm gonna lift up the skin really showing me that subcutaneous fat where I'm gonna enter. And that dermis. I'm gonna go into the subcutaneous fat and out really at the edge of the dermis, not through the epidermis. And that's one bite. And then to get the other side, I'm once again gonna rotate my body really using my a since to expose that dermis for me, go into the dermis, and out in the sub-q, directly across from where my last bite was. And now you can tie. And just like that, our lap sites are closed. Now we've gone through the U-stitch and the deep dermal, which are both ways to close our laparoscopic port sites.

CHAPTER 5

So next, we'll be practicing our subcuticular stitch. The key of this stitch is that there will be no knots outside of the skin, leaving a very nice aesthetic closure. So for your subcuticular, it's usually for longer incisions, usually in finer, more delicate areas. So to start your subcuticular stitch, you're gonna do a deep dermal. So as I mentioned before, you start deep in the subcutaneous fat, come out to the dermis, and cross over into the dermis, and then tie your knot once again in the subcutaneous fat. And as you see, I'm starting at one apex that's usually farthest from me if I'm sewing vertically, and then working my way towards myself. Instead of cutting one of the ends, I'm gonna go behind my knot with my needle and come out in the apex of my incision in the dermis. So I'm never ever going outside of the epidermis. My next bite will then be in the layer of the dermis on either side of my incision. So I'm gonna start on my right side. I'm gonna go into my dermis, follow the curve of my needle, and then come out back in the dermis farther along the length of my incision. Instead of traveling between bites, I'm gonna travel only within bites. So my next bite will be exactly across from when my first bite came out. So I'm gonna take another bite, always in the dermis and then coming out and crossing exactly where my last one came out. And I'm gonna keep doing that along the length of my incision. It is important to make sure to go in with your next bite, exactly where you came out on the last one to keep a nice tight closure. And once you get to the other apex, we'll be doing something called an Aberdeen hitch, which I'll show you shortly. But basically, it helps you dip your knot down and dunk it underneath the skin. So at the end, you have a nice tight closure without any knots outside. So now let's practice that together.

So now, as I demonstrated on the board, we're gonna do our running subcuticular stitch. To show you what that looks like, as you recall, we're gonna start from one side of the incision and sew it towards ourselves if it's vertical. If it was horizontal, we'd be sewing from right to left. So kind of like how we play tennis. So for this one, I'm gonna make the incision vertical. So I'm gonna be sewing towards myself. I'm gonna start at the apex farthest away from me. And I'm gonna start with a deep dermal stitch. So as in our deep dermal, I'm gonna start in the sub-q tissues and come out in the dermis. I'm gonna do the same thing on the other side. For this ditch to start out your running sub-q, you wanna make sure to start close to the apex, but not necessarily right in your apex because it'll make it a little bit harder to take the stitch. So now that you have your deep dermal, you can tie this off and get started. Typically, for this type of stitch we would be using a Monocryl, usually like a 4-0. So something monofilament and absorbable. For in this case, I'm using the silk just so you can better visualize my stitches. So now that we have our deep dermal, we're gonna go underneath our knot and come back to the apex of our incision. You can see I'm using my left hand to really expose that dermis for myself. And you wanna be in the dermis of your apex, right there. So now, you wanna start your subcuticular stitch. You can start on either side of the incision. I wanna start on the left-hand side. I'm gonna go in my dermis, follow the curve on the needle along my dermis, along the length of my incision and come out down the length of my incision. As you can see, I'm really using my left hand to expose that dermis for me. Now I'm gonna go to the other side and I usually like to use my suture to kind of be a marker of where my last stitch came out. And that should be where I should be going in with my next stitch. So I'm gonna go into the dermis, travel along the length of the incision, and come out in the dermis. And you're gonna keep doing that along the length of your incision. As I mentioned, your left hand is really important here. You wanna make sure to be lifting straight up to form a tract for your needle to be following you. On the other hand, you do not wanna be pulling it over like this, which I see a lot of people do. because you can end up actually buttonholing the skin and going through the epidermis. So you wanna make sure to be pulling straight up. As I mentioned, your last bite should end where your new bite begins. And you really don't wanna be traveling between your bites, just within your bite. And if you do that, your incision should come together really nicely. So as you get towards the end of your incision, there's a pretty unique way to end the subcutaneous stitch, which I'll show you in a second called the Aberdeen hitch. It's a little bit different from other closures, so I'll show it to you now. So I'll probably take one more bite after this one. And your last bite should come towards the apex. And as you take that last bite, and come out on the dermis, you wanna make sure to leave a little bit of a loop. There's my loop. So now for the Aberdeen hitch, one hand is gonna be on the needle and not let go of the needle, at least for the first part, and the other hand's gonna be on the loop. So what my loop hand is gonna do is gonna take the string with the needle, I'm never letting go of the needle, and bringing it through the loop. And as I'm doing so, I'm kind of cinching down on the lower part of the string to bring that loop down. So I'm gonna show you again, you wanna do this three times. So I'm bringing the string through the loop and then pulling on that string to cinch it down. And one last time. Now, after three throws, you then want to take your needle and bring it through the loop, bringing that loop all the way down. That's gonna form a knot. Next, you're gonna take your needle again. Go into the incision somewhere beyond, so inside of the incision, beyond the knot, and come out somewhere beyond your apex through the epidermis. And you can see that's actually gonna dip your knot down so there's nothing outside of the skin. The last step is to cut the suture at the level of the skin. So now, you have no sutures left on the outside of the skin, and you have a clean incision site that you've now just closed with your subcutaneous stitch.