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hi welcome to the Duke suture skills
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course my name is Michael Zen and on the
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director of the human tissue lab here at
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Duke this course will teach you the
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basics in suture technique we’ll review
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simple suture mattress suture running
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suture and some of the variations and
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proper surgical technique it’s our goal
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that by teaching you proper technique
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you’ll be the best surgical resident or
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surgeon that you can be before we get
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started I’d like to thank G in the
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office at Duke for their generous grant
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that made this video possible
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before get started showing you different
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suture techniques I want to show you a
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basic instrument I this can be used with
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any of the suture techniques that you’ll
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learn once the suture is placed you’ll
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have a short end and then a longer loop
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end your needle driver should be placed
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directly between the two and then we
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will do a surgeon’s knot you’ll wrap
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there’s a longer end twice around the
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needle driver grab the smaller end and
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pull it to the opposite side and what
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will happen when you pull it to the
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opposite side it will square the knot
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and you can see how square the knot sits
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down now because it’s a surgeon’s knot
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it’ll sit unless you pull up on it so
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don’t pull up on it place the needle
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driver between the two the short end and
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the loop end now you’re going to loop it
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around only once
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grab the short end and then bring it to
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the opposite side again squaring the
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knot and don’t pull up on the suture
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until you just get it down and then you
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can tighten it and now it’s locked in
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place I recommend at least three throws
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instrument between bring the small to
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the other side and done some suture
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material you may need four throws
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something maybe like an absorbable
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suture but this is a very basic
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technique it allows you to suture in a
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small place so if multiple people are
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working and will do one more for you
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right here you can suture notice I like
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to keep this short and very short your
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instrument doesn’t move around very much
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then keep the needle driver between the
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two grab the small end pull it to the
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opposite side square and you’re not lock
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it down with that surgeon’s knot don’t
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pull up on it now until you now grab
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this and then pull it through for the
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second time and now it locks down needle
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driver between the two wrap once pull
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through the opposite side and keep that
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knot nice and square square nuts will
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not untie also will look cosmetically
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more appealing
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the first suture we’re going to teach
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you is the simple interrupted suture
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this is the most common suture that
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you’ll be using and wound closure just a
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quick tip on handling a needle you’ll
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notice your needle has a flat portion in
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the middle this is where you grab the
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needle with your needle driver you don’t
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want to grab it at the end where the
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suture comes in or the swedge because
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it’s round and you’ll be unstable never
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grab the needle at the tip because
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you’ll dull it a simple bike will want
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to enter the skin at 90 degrees and
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we’ll go back a few millimeters from the
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skin edge and take a nice bite
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perpendicular to the skin and then on
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the opposite side the same and
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exaggerate that 90 degrees if you take
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it at 90 degrees the skin edges will
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then Evert and come together nicely here
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we’ll set up a instrument tie and you
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can see here again we do three throws
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for nylon and we’ll go ahead and clip
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this this is approximation without
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tension you want to go back a couple
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millimeters for each bite if you go back
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too far it’ll tend to invert the skin
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and we want to avoid that
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so here again exaggerate the 90 degrees
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on each side to make sure that we are
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back the same distance on each side an a
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instrument tie we do a surgeon’s knot
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for the first we cross the suture over
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lay it down nice and flat don’t pull up
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on it until we get the second suture
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down and tighten it and lock it in so
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this is the simple suture it’s something
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that you’ll need to practice a lot to
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master
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next is a simple buried suture this will
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be the main suture you’ll use when
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putting some deeper sutures in before
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putting your skin suture in it’s
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important to bury a suture that we start
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deep and go superficial and end up in
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the dermis without buttonholing the skin
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and then on the opposite side we’re
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gonna do the opposite we’re gonna go
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superficial and then deep and if you
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want your not to bury it’s important
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that both ends are on the same side of
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the loop you see here’s my loop and
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here’s the suture coming out from the
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same side and as we tie this down we’ll
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do an instrument tie but we’ll pull it
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along the length of the wound and
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that’ll help the skin adjust to come
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together and do a nice instrument tie
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and what this does is it takes the
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tension off the skin so that when you go
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to do your skin closure you really can
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work on approximation you can see here
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that helps hold that together let’s go
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ahead and do one more you’re gonna go
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from deep superficial without button
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hauling the skin and then go from
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superficial to deep make sure that
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you’re coming out on the same side of
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the loop
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and we’ll do our instrument tie and
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we’ll pull it along the length of the
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wounds so it’ll allow it to bury come
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back to the other side and back to the
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other side that is our simple
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interrupted buried suture
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next is the vertical mattress suture
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Furcal mattress suture is a very useful
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suture
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especially when wounds are hard to close
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if they’re under a lot of tension or
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maybe there’s a lot of swelling or you
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anticipate swelling
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it’s especially valuable when skin is
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just want to keep rolling in and you
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want to even some we’ll call this the
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far far near near stitch and this is the
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configuration of your suturing we’re
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gonna enter far from the wound travel
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under the skin come out far and then
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come back and go near near essentially
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you’re taking this part of the skin and
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closing it to this part of the skin and
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that’s the power of the suture simple
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suture is really relying on that much
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smaller area so we’ll start far and
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travel under the skin and the same thing
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on the other side and we’ll turn our
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needle around and now we’ll go near and
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near and what you’ll see when we tie
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this down is that this approximates an
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averse to skin edges and we can make it
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just as tight as we want we have our
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granny knot that’ll hold it and we’ll
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square our knots
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so I’ll show you that one more time it’s
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a vertical mattress suture
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far far near there
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and as you tie it down decide how much
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tension you need do you hurt your skin
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edges and hold things together
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and that’s your vertical mattress
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our next suture is the horizontal
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mattress suture it’s configuration is
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horizontal as opposed to our vertical
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mattress you can think of this as two
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simple sutures so in some of that since
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it’s a simple suture it just saves you
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some time it’s important here that you
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stay close to the skin edge and you are
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the same distance on both sides you’ll
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take your bite on one side and then the
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other side and then you’ll turn it
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around and you’ll go back so you’ll end
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up on the same side and there you can
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see our mattress the advantage of this
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is speed compared to doing simple suture
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it doesn’t you’ve ER it as effectively
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sometimes as a vertical mattress here
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you see the way I’ve placed it it’s
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reverting nicely so that’s one example
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of a horizontal technique a variant of
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this is the figure-of-eight suture the
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figure-of-eight suture is the same
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distribution
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you take your simple bite in your simple
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bite but rather than turning the needle
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around you move on and take your next
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simple bite and simple bite what that
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does when you tie this it’ll make a
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small little eight and that’s why it’s
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called a figure of eight suture the
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advantage of this again is speed instead
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of doing two simple sutures and tying
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two simple sutures you’ll see that
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sometimes in some deeper closures like
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fascial closures because again you’re
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grabbing a bunch of tissue to a bunch of
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tissue and therefore it’ll be more
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secure the final variant of the
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horizontal mattress is called a
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half-buried mattress and we use this a
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lot in plastic surgery if there’s an
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area where you don’t want suture holes
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you can actually start your horizontal
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mattress on one side on the opposite
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side stay within the dermis in a
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horizontal fashion in a sub-q ticular
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fashion and then come back on the other
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side again out like you wouldn’t a
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normal horizontal mattress so
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effectively it’s your horizontal
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mattress but half of it is buried tends
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to name the half bare
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horizontal mattress and when you tie
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this here it’ll secure the skin and you
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only have suture marks on one side
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you’ll see we’ll do this at times when
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we have a hair bearing area and an on
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hand bearing area we want to hide the
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suture marks or if it’s a very end or
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tip of a flap and we’re afraid that
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putting sutures in the tip is gonna
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interrupt the blood supply so our three
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variants of a horizontal the straight
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horizontal mattress the figure of eight
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and the half-buried horizontal mattress
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our next stitch is a simple running
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suture this will be the most common
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suture you’ll use to close incisions
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it’s a simple suture so again 90 degrees
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and 90 degrees same bites on both sides
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and you’ll start with an instrument
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tying and try to save length on your
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suture here you also want to measure the
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length of your wound and not make sure
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you’re not working with such a long
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suture that it becomes unruly you’ll
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take you’ll advance on the wound in
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symmetric fashion again trying to take
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90 degree bites each time try to move
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along at the same pace and same amount
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each time almost mimicking a sewing
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machine
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if you move along the same distance each
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time and take the same bites on each
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side have a beautiful cosmetic closure
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people will ask well how much do you
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move along my answer is as long as it’s
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the same on both sides it’ll end up
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looking very nice so be consistent in
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your bites notice I’m exaggerating my 90
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degrees because I want this to e vert I
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if I go too far back on the skin or I
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take too shallow a bite I’ll end up
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inverting the skin and it won’t heal
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correctly notice also I’m just pulling
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up enough on the suture just so that the
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skin edges touch pulling up on the
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suture very hard it’s just ischemic and
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can cause bad scarring I’ll end it with
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a simple little bite at the end make
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sure we have enough tension along the
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incision and then do our instrument tie
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at the end
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and this is a simple running closure
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a variation of the simple
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suture is the simple running locking
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suture we start off the same with simple
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bites and a nice instrument tie
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and this is a very helpful suture when
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you’re sewing under some tension
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especially when you don’t have an
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assistant who can help hold the suture
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for you and follow you you’ll take your
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simple bites again 90 degrees 90 degrees
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you’ve hurt the skin edges but before
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you pull up you’ll make sure and
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actually lock the suture and take your
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simple bite and simple bite and again
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before pulling up the last little bit
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you’ll lock your suture and you can go
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on from here and the beauty of this is
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that you see although it’s loose here it
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is locking back here and so when you’re
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under a lot of tension especially it’ll
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hold for itself
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now sometimes I’ll do a running stitch
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and I don’t plan on doing a running
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locking but at some point in the middle
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of the suture it starts loosening on me
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and then you can just throw in one of
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these locking sutures I always keep it
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nice and tight
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so it’s not a suture necessarily that
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you’ll use primarily because I think for
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scoring purposes you prefer a regular
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suture and I will say also as you become
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more and more expert at suturing you’ll
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be able to control your simple suits
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you’re much better each time locking the
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suture and we’re going to end this with
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a simple stitch
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and again when we tie this we want to
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main to make sure we have good tension
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on the rest of the suture
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and that is our running walking suture
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our next stitch is a running
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subcuticular sutures how do all those
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sutures were teaching you this is
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probably the hardest to master this is
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probably for the most cosmetic closure
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as they’re running within the dermis
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deeply so there’s no sutures on the
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outside at all so you won’t see any of
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the railroad tracking that you would see
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from any other outside sutures this is a
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absorb assuit sure and we will start by
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burying the knot so I’ll go deep in the
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corner away from the skin maybe just a
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very deepest part of the dermis and
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we’ll do our instrument tie and this
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allows the knot to be buried so we can
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suture over it this is important because
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we don’t want knots coming up to the
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skin they can stick out it’s called
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spitting patients do not like it when
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the knots bit now with knot is deep so
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we’re gonna go deep and we’re gonna come
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superficial and that brings us right up
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to the corner and this is where we’re
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gonna start our so particularly run when
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you start to get close to a corner
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definitely recommend smaller bites to
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start see I’m just within the dermis
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horizontal bites need to advance a
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little bit on the other side and take
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another small bite against a wall within
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the dermis
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now with this stitch Simoes asked us how
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much do you advance each time what I
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like to do is to see here with my suture
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where the next bite should be and that’s
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where I’m going to put it so in some
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sense it depends on how much tension
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there is on this wound there’s not a lot
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of tension now we’re gonna start to take
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regular bites on each side I’m trying to
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take the same depth and the same amount
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of tissue each time as we begin to
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advance
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keep pulling everything up and keeping
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tension
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notice I’m not pulling up very tight
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either just getting the skin to
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approximate no buttonholing of the skin
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this is just pure horizontal dermis
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wants to come right there
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can get a good play the dermis
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wants to come right there
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and just like when we started as you
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begin to approach the corner you want to
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stop taking such big bites and start
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going to some smaller bites because you
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really want these skin edges to be well
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approximated at the corner and not
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create any dog ears we also want to bury
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our knot so if we’re on a berry or not
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we have to start thinking about now
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about getting deep with both of the two
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ends that are gonna get tied so at this
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point here I’m superficial and I’m gonna
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go superficial on this side and then
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head deep that’ll get me down just sort
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of where we started down deep and I’m
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going to take one more bite that’s deep
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now I want to tie that and that’ll help
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to bury the knot
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and now what I’m gonna do to help bury
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the knot as well is to cut the short end
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here right on the edge of the knot and
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now take the needle and very that not
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further so I’m gonna pick up here and
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see where that knots going I can come
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out through the skin nearby and just
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simply pull up on this I can just cut it
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flush with the skin that helps the duck
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are not from our suture
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that concludes this course we at Duke
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feel strongly that excellent surgeons
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begin with excellent basic technique and
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I hope you’ve learned some of that
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during this video come back often as you
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begin to perfect your own technique if
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you’d like to learn more about Duke
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Plastic Surgery or the human tissue lab
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here at Duke visit us on the web at
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Plastic Surgery duke.edu