Face!Mouth!&!Jaw!Surgery:!International!Trainee!Journal!of!Oral!&!Maxillofacial!Surgery.!2011;!1(2):!53D63!

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FMJS%

( ( ( EDUCATIONAL( REVIEW(

! Suturing!Part!2:!Suturing!technique!
Jake&Turnera,*& William&Rookb&
aDepartment! of! General! Surgery,! Lincoln! County!

Abstract(
This(article(provides(a(basic(understanding(of(the( techniques( involved( in( hand( tied( reef( knots,( instrument( tied( reef( knots,( hand( tied( surgeons( knots(and(tying(at(depth.(It(also(covers(the(basics( of( wound( closure( and( haemostasis( using( interrupted( suturing,( continuous( suturing,( vertical( mattress( suturing,( horizontal( mattress( suturing,( subcuticular( suturing( and( a( transfixion( suture.( Further( surgical( techniques( exist( outside( the( scope( of( this( article,( and( other( ways( of( performing( the( following( techniques( safely( also( exist( and( are( just( as( valid( as( the( techniques( discussed(here.( (

Hospital,!Lincoln,!UK! bThe!University!of!Birmingham,!Birmingham,!UK!

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*Correspondence:! Dr! Jake! Turner,! Department! of! General! Surgery,! Lincoln! County! Hospital,! Greetwell!Rd,!Lincoln,!LN25QY! ! Telephone:!+447759745652! Email:!jake.turner@doctors.org.uk! ! Keywords:!Continuous!suturing;!Hand!tied!knots;! Horizontal! mattress! suturing;! Instrument! tied! knots;! Reef! knots;! Subcuticular! suturing;! Surgeons! knots;! Transfixion! suturing;! Vertical! mattress!suturing!

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Face(Mouth(Jaw(Surg((2011;!1!(2):(53D63! ( Needles.! There! are! many! safe! and! accepted! techniques! for! knot! tying! and! suturing,! this! article! demonstrates! one! such! accepted! technique! as! recommended! by! the! Royal! College!of!Surgeons!basic!surgical!skills!course.! This! article! will! not! describe! in! detail! the! techniques! for! instrument! handling! or! specific! surgical!techniques!such!as!bowel!anastomoses,! vessel!anastomoses!or!tendon!repair.!

Introduction!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.!
! The! techniques! to! suturing! and! knot! tying! are! complex! and! require! years! of! practice! and! reflection! to! hone! and! perfect.! This! article! will! discuss! the! basic! principles! of! knot! tying! and! suturing! as! a! followDon! article! from! the! article! in! the! last! issue! of! Face! Mouth! &! Jaw! Surgery,! Suturing(Part(1:(Choice(of(Surgical(Sutures(and(( ( (

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Suturing!Part!2:!Suturing!techniques!

Middle&finger&throw&(see&figure&1&and&2)( Knot!tying!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!n!!!!!!!!!!!!!!!!!!!!!!!!!! ! Knot!tying!is!an!essential!component!of!any!safe! surgical!technique!and!if!performed!poorly!can! have! disastrous! consequences! including! haemorrhage,! wound! dehiscence! and! hernia! predisposition1.!It!is!important!to!spend!time!in! understanding! the! key! principles! of! knot! tying! and!practicing!a!safe!technique!to!ensure!a!firm! foundation!for!future!surgical!development.! The!key!principles!for!safe!knot!tying!include2:! Correct! orientation! of! throws! to! ensure! a! locking! arrangement! of! the! knot! to! avoid!subsequent!knot!slippage! Avoiding! crushing! or! damaging! the! suture! material! weakening! the! suture! used! for! the! knot! and! avoiding! subsequent!knot!breakage! Effective!bedding!of!the!knot!around/on! the! structure! being! sutured/closed! to! ensure!an!effective!seal/outcome! Minimisation! of! the! disruption! to! the! tissue! when! laying! the! knot! to! avoid! cutting! out! of! the! tissue,! or! after! completion! by! minimising! the! size! of! the!knot!present!in!situ! There! are! four! main! knots! that! should! be! mastered!to!achieve!a!basic!understanding!and! skill! set! for! any! surgical! trainee,! these! include;! the! one! handed! reef! knot,! an! instrument! tied! reef! knot,! the! surgeons! knot! and! the! one! handed!reef!knot!at!depth.!It!can!be!difficult!to! describe! the! step! by! step! technique! of! knot! tying! using! just! pros! and! a! combination! of! the! images!provided!below!as!well!as!online!media3! should! be! used! to! supplement! the! text! in! this! article!for!a!comprehensive!understanding.! ! ( The(one(handed(reef(knot( Involves! two! main! stages:! the! middle! finger! throw! and! the! index! finger! throw,! both! laying! one!half!of!the!reef!knot!in!opposite!directions,! ensuring! a! locking! knot! has! been! laid.! The! technique!for!performing!these!stages!has!been! highlighted!below:!

1. With!the!ventral/palmar!surface!of!your!left! hand! facing! superiorly,! allow! the! short! end! of! the! suture! to! run! across! the! dorsum! of! your! middle,! ring! and! little! fingers! being! grasped! between! your! index! finger! and! thumb! of! your! left! hand! and! pass! the! long! end!of!the!suture!across!the!ventral!surface! of! your! middle,! ring! and! little! fingers! grasping! its! end! between! your! index! finger! and!thumb!of!your!right!hand.! 2. Flex!the!distal!interphalangeal!joint!of!your! middle! finger,! taking! the! middle! portion! of! long!end!of!the!suture!material!with!it,!until! the! distal! phalynx! of! this! finger! is! hooked! behind! the! free! portion! of! the! short! end! of! the! suture! material! (just! below! the! thumb! and!index!finger!grasp).! 3. Grasping!the!free!portion!of!the!short!end!of! the! suture! material! (just! below! the! thumb! and! index! finger)! between! the! dorsum! of! the! distal! phalynx! of! the! middle! finger! and! the!pulp!of!the!ring!finger,!extend!the!distal! interphalangeal! joint! and! release! the! thumb/index!finger!grasp!until!the!free!end! of! the! short! end! of! the! suture! material! has! been!pulled!through!the!loop!formed!in!2.! 4. Tighten! this! throw! by! repositioning! your! grip! with! your! index! finger! and! thumb! of! your! left! hand! grasping! the! free! end! of! the! short!end!of!the!suture!and!maintaining!the! initial! grip! of! your! right! hand! on! the! long! end!of!the!suture!material.!Then!move!your! left! hand! away! from! you! and! your! right! hand!towards!you.! !
( ( ( ( ( ( ( ( ( ( (

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Face!Mouth!&!Jaw!Surgery:!International!Trainee!Journal!of!Oral!&!Maxillofacial!Surgery.!2011;!1(2):!53D63!

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Figure( 1( ( Stage( 1( and( stage( 2( of( the( middle( finger(throw(

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Figure( 2( ( Stage( 3( and( 4( of( the( middle( finger( throw(

! ! ! Index&finger&throw&(see&figure&3&and&4)! 1. Start! with! the! short! end! of! the! suture! grasped! between! the! index! finger! and! thumb!of!your!left!hand!with!a!loop!running! over! the! dorsum! of! an! index! finger! extended! distal! phalynx! of! the! same! hand,! and! the! long! end! of! the! suture! grasped! between! your! index! finger! and! thumb! of! your!right!hand.! 2. Loop! the! long! end! of! the! suture! material! over! the! extended! distal! index! finger! phalynx!of!the!left!hand!by!moving!the!right! hand!away!from!you,!maintaining!the!same! grip.! 3. Flex!the!distal!interphalangeal!joint!of!your! index! finger! of! your! left! hand,! pulling! the! long! end! of! the! suture! material! under! the! short! end! of! the! suture! material,! then! extend! the! distal! interphalangeal! joint! of! your!index!finger!of!your!right!hand!so!that! it!now!lies!over!the!short!end!of!the!suture! material! with! a! loop! of! the! long! end! of! the! suture! material! over! the! index! finger! of! your!right!hand.! 4. Now! flex! the! distal! interphalangeal! joint! of! your! index! finger! of! your! left! hand! again,! hooking!the!short!end!of!the!suture!material! through! the! loop! formed! in! 3! simultaneously! releasing! the! grip! of! the! short! end! of! the! suture! material! between! the! index! finger! and! thumb! of! your! left! hand.!

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Suturing!Part!2:!Suturing!techniques! Figure(4((Stage(4(and(5(of(the(index(finger(throw(

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5. Tighten! this! throw! by! repositioning! your! grip! with! your! index! finger! and! thumb! of! your! left! hand! grasping! the! free! end! of! the! short!end!of!the!suture!and!maintaining!the! initial! grip! of! your! right! hand! on! the! long! end!of!the!suture!material.!Then!move!your! left! hand! towards! you! and! your! right! hand! away! from! you! (note! the! opposite! orientation! to! the! middle! finger! throw,! ensuring!a!locking!reef!knot).!
( ( ( Figure( 3( ( Stage( 1,2( and( 3( of( the( index( finger( throw(

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( ( ( ( ( ( ( ( ( ( (

( Instrument(tied(reef(knot( Follows! the! same! principles! of! the! one! handed! reef! knot! with! two! main! stages! resulting! in! a! throw! in! opposite! directions! to! ensure! the! laying!of!a!locking!reef!knot.! ! ! Short& end& of& suture& material& away& from& you& (see&figure&5)! 1. With! the! instrument! in! your! right! hand! lying! over! the! long! end! of! the! suture! material! and! the! end! of! the! long! end! of! the! suture! material! grasped! between! the! index! finger! and! thumb! of! your! left! hand,! loop! the! long! end! of! the! suture! material! up! and! over! the! instrument! from!a!posterior!to!anterior!direction.! 2. Using! the! instrument,! grasp! the! tip! of! the!short!end!of!the!suture!material!and! pull! this! through! the! loop! around! the! instrument!made!in!1.!Then!tighten!this! throw! by! moving! the! instrument! and! short! end! of! the! suture! material!

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towards! you! and! the! long! end! of! the! suture! material! grasped! between! the! index! finger! and! thumb! of! your! left! hand!away!from!you.!
( Figure( 5( ( Instrument( tying( with( short( end( of( suture(material(away(from(you,(stages(1(and(2(

from!you!and!the!long!end!of!the!suture! material! grasped! between! the! index! finger! and! thumb! of! your! left! hand! towards! you! (note! the! opposite! orientation! to! the! middle! finger! throw,! ensuring!a!locking!reef!knot).!
( ( Figure( 6( ( Instrument( tying( with( short( end( of( suture(material(towards(you,(stages(1(and(2(

! & & Short&end&of&the&suture&material&towards&you& (see&figure&6)( 1. With! the! instrument! in! your! right! hand! lying! over! the! long! end! of! the! suture! material! and! the! end! of! the! long! end! of! the! suture! material! grasped! between! the! index! finger! and! thumb! of! your! left! hand,! loop! the! long! end! of! the! suture! material! up! and! over! the! instrument! from!an!anterior!to!posterior!direction.! 2. Using! the! instrument,! grasp! the! tip! of! the!short!end!of!the!suture!material!and! pull! this! through! the! loop! around! the! instrument!made!in!1.!Then!tighten!this! throw! by! moving! the! instrument! and! short! end! of! the! suture! material! away!

! ! ( The(surgeons(knot( This! technique! is! a! variation! on! the! reef! knot! where! each! throw! involves! a! repeated! loop! to! provide!extra!security.!The!same!technique!can! be! used! as! discussed! and! demonstrated! in! the! one! handed! reef! knot,! however! after! completing!a!throw,!before!tightening!it,!repeat! the!same!manoeuvre!to!lay!two!throws!back!to! back! before! tightening! and! moving! onto! the! opposite! throw,! where! again! a! second! manoeuvre!is!repeated!to!lay!two!throw!back!to! back!(see!figures!7!&!8).!This!technique!is!useful! in! providing! extra! security! especially! when! the! first!throw!is!likely!to!slip!i.e.!tying!at!depth.!

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Suturing!Part!2:!Suturing!techniques!

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Figure(7((Extra(throw(of(the(middle(finger(throw( demonstrated!

Tying(at(depth( Follow!the!same!technique!as!used!to!lay!a!one! handed! reef! knot,! but! on! completion! of! the! middle! finger! throw,! use! the! index! finger! of! your! right! hand! to! advance! the! knot! into! the! cavity!ensuring!that!is!has!been!snugged!down! (see!figure!9).!Then!on!completion!of!the!index! finger! throw,! use! the! middle! finger! of! your! left! hand! to! advance! the! knot! into! the! cavity! ensuring! that! is! has! been! snugged! down! (see! figure!10).! !
( Figure( 9( ( Snugging( down( of( the( middle( finger( throw(demonstrated(

( Figure(8((Extra(throw(of(the(index(finger(throw( demonstrated(

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( ( ( ( ( ( ( ( ( (

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Face!Mouth!&!Jaw!Surgery:!International!Trainee!Journal!of!Oral!&!Maxillofacial!Surgery.!2011;!1(2):!53D63!

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Figure( 10( ( Snugging( down( of( the( index( finger( throw(demonstrated(

Each! suture! should! be! placed! at! right! angles! to! the! wound,! avoiding! placing! too! much! tension! through! the! suture,! which! would! otherwise! impede! healing! or!cut!out!through!the!tissue.! The! angle! of! penetration! with! the! needle! should! be! at! 90! degrees! to! the! skin! edge,! guiding! the! needle! through! the!tissue!following!the!natural!angle!of! the!needle!body.! Appose! the! wound! edges! accurately! to! ensure! accurate! closure! and! minimise! the! scar! formation.! Eversion! and! inversion! of! wound! edges! and! their! benefits! are! discussed! in! mattress! suturing.!

! Suturing!technique!!!!!!!!!!!!!!!!!!!!!!!!!i!
! When! closing! a! wound! the! choice! of! suture! material! and! needle! rely! on! a! thorough! understanding! of! the! available! options! and! the! required! physical! properties! and! performance! of! the! chosen! suture! and! needle.! A! review! of! these!options!and!the!characteristics!of!each!are! highlighted! in! the! previous! article! Suturing( Part(1:(Choice(of(Surgical(Sutures(and(Needles.! The! key! principles! for! safe! and! effective! suturing!include:! Ensuring! the! length! of! the! wound! is! at! least!3!times!the!width!of!the!wound!to! ensure! too! much! tension! is! not! placed! through!the!sutures.! Aim! to! take! bites! of! tissue! of! equal! size! to!the!depth!of!the!wound!being!closed.! The! distance! between! sutures! in! nonD continuous! closure! should! also! equal! this!size!in!depth!and!bite.!

! There! are! 6! types! of! suturing! technique! that! will! be! discussed! in! this! article,! they! include;! interrupted! suturing,! continuous! suturing,! vertical! mattress! suturing,! horizontal! mattress! suturing,! subcuticular! suturing! and! a! transfixion!suture.! ! ( Interrupted(suturing( Separate! bites! of! tissue! and! closure! using! individual! reef! knots! are! used.! It! is! the! commonest! choice! of! suturing! technique! used! for! wound! closure,! providing! an! equal! tension! across! the! wound! and! a! secure! closure! and! apposition! of! the! wound! edges.! Note! that! all! knots! must! be! placed! to! the! side! of! the! wound! to!avoid!seeding!infection!into!the!wound!edge! and!that!the!tails!of!the!sutures!should!be!cut!to! about! 5mm! to! allow! sufficient! grasping! for! suture!removal.! !
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Suturing!Part!2:!Suturing!techniques! Figure( 12( ( Commencing( and( completing( a( continuous(closure(

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Figure( 11( ( Commencing( and( completing( an( interrupted(suture(closure(

! ! ( Continuous(suturing( Commence! the! closure! with! an! initial! interrupted! suture! at! one! end! of! the! wound,! cutting! only! the! short! end! of! the! suture.! Then! continue!to!take!bites!of!the!wound!working!to! the!far!end!where!a!further!reef!knot!is!used!to! secure! the! closure! (see! figure! 12).! This! type! of! closure!is!useful!for!quick!closures!and!wounds! that! may! need! to! be! opened! quickly/easily! i.e.! high! risk! of! bleeding! or! infection.! The! risks! of! this! closure! is! that! if! one! knot! fails! then! the! whole! wound! dehisces,! and! it! can! be! easy! to! apply! too! much! tension! through! the! whole! closure! encouraging! poor! wound! healing! and! cutting!out!of!the!tissue.! !
( ( ( ( (

! ! ( Mattress(suturing( There! are! two! types! of! mattress! sutures;! vertical! mattress! and! horizontal! mattress,! both! useful! to! ensure! eversion! and! accurate! vertical! apposition! of! a! wound! edge! that! would! otherwise! invert! easily! and! heal! with! poor! aesthetics!(back!of!neck,!palm!of!hand!and!sites! of!skin!laxity)!as!well!as!provide!tension!across! both!superficial!and!deep!tissue!planes!negating! the! need! for! a! 2! stage! closure.! Eversion! of! a! wound! edge! can! results! in! a! raised! scar! that! after! suture! removal! will! flatten! opposed! to! widening! as! would! occur! with! accurately! opposed! wound! edges! in! other! closure! techniques4.! The! risks! of! a! mattress! suture! are! that! it! can! dig! in! to! the! skin! leaving! railroad! markings! and! it! can! be! unforgiving! if! vertical!

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apposition! of! the! tissues! is! not! achieved! accurately.! A! vertical! mattress! is! achieved! with! a! deep! pass! through! both! wound! edges! followed! by! a! superficial! pass! directly! above! and! reversed! to! the! deep! pass! (see!figure!13).!! A!horizontal!mattress!is!achieved!with!a! pass! through! both! wound! edges! followed! by! a! pass! perpendicular! and! reversed!to!the!original!pass!(see!figure! 14).! !
( Figure( 13( ( Commencing( and( completing( a( vertical(mattress(suture( Figure( 14( Z( Commencing( and( completing( a( horizontal(mattress(suture(

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( ( ( ( (

! ! ( Subcuticular(suturing( This!form!of!closure!is!often!used!for!superficial! wound! closure! when! the! original! injury! to! the! tissue! was! clean! and! an! aesthetic! closure! is! preferable!(i.e.!post!operative!wound!closure!in! a! sterile! theatre).! It! is! traditionally! undertaken! with! an! absorbable! monofilament! suture! such! as! monocryl! where! the! knots! are! buried! in! the! tissue.! However,! nonDabsorbable! suture! closure! can! be! undertaken! with! beads! used! to! secure! the! ends! of! the! suture! material.! This! paper! will! demonstrate! the! absorbable! suture! closure! technique! where! the! first! reef! knot! is! applied!to!the!base!of!the!wound!near!the!apex! of! the! incision,! and! bites! of! subcuticular! tissue! are! taken! from! alternating! sides! of! the! wound! in! a! continuous! manner! pulling! the! wound! together! carefully! (see! figure! 15).! The!

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Suturing!Part!2:!Suturing!techniques! Figure(16((Tying(an(Aberdeen(knot(to(finish(the( subcuticular(closure(

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subcuticular!closure!is!then!completed!by!tying! and!burying!a!surgical!knot!at!the!distal!end!of! the!wound!(i.e.!Aberdeen!knot)!(see!figure!16).! For! further! information! regarding! Aberdeen! knots! please! refer! to! the! basic! surgical! skills! handbook.! !
( Figure( 15( ( Starting( the( subcuticular( closure( with( a( reef( knot( at( the( apex( and( taking( subcuticular(bites((

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( ( ( ( ( ( ( ( ( ( (

! ! ! Transfixion(suture( Transfixion! sutures! are! used! to! tie! off! structures! that! if! the! suture! were! to! slip,! potentially! catastrophic! consequences! could! occur!(i.e.!arteries,!appendicular!stumps!etc.).!A! haemostat! or! other! such! surgical! clamp! is! placed!across!the!structure!in!question,!a!stitch! is! placed! through! the! structure! 1/3! of! the! way! along! it! below! the! clamp,! and! one! throw! of! a! reef! knot! is! tied! around! the! smaller! side! of! the! structure!(see!figure!17).!Then!pass!the!free!end! of! the! suture! to! the! other! side! of! the! structure! where! another! throw! of! a! reef! knot! is! tied! whilst!the!assistant!releases!the!clamp,!allowing! the!structure!to!bunch!up.!A!further!two!throws! (i.e.! a! full! reef! knot)! is! performed! securing! the! stitch!in!place!(see!figure!18).!

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Figure( 17( ( Commencing( a( transfixion( suture( with( the( first( throw( of( the( reef( knot( being( laid( down( and( the( short( end( of( the( suture( material( passed(around(the(ligated(structure! Figure( 18( ( Tying( the( second( throw( of( the( reef( knot.( This( would( then( be( followed( by( a( further( two( throws( to( secure( the( transfixion( suture( in( place(

Conclusion!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.!!!!!!!!!!!!!! References!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.!!!!!!!!!!
! This! article! should! provide! a! basic! understanding! to! the! techniques! involved! in! hand! tying! of! basic! surgical! knots! and! performing! basic! surgical! would! closure! and! haemostasis.! Further! surgical! techniques! exist! outside!the!scope!of!this!article,!and!other!ways! of! performing! the! above! techniques! safely! also! exist! and! are! just! as! valid! as! the! techniques! discussed! here.! It! is! recommended! that! you! build!on!and!refine!the!basic!skills!as!outlined!in! this!article!using!different!resources!such!as!the! basic! surgical! skills! handbook! and! utilise! any! opportunity!to!practice!these!skills!during!your! clinical!practice.!
(

!
1. Kant! YL,! William! BL.! Scientific! Basis! for! the! Selection! of! Surgical! Sutures! and! Needles! (2005).! Intercollegiate! Basic! Surgical! Skills! Course! Handbook:! Participant! Handbook! (4th! edition).! Surgical! Knot! Tying! D! One! Hand.( http://www.youtube.com/watch?v=sHBlx1 UdNYw&feature=related!! Sissenger! T.! Suture! patterns.! The! Queenss! Veterinary! School! Hospital,! Department! of! Veterinary! Medicine,! University! of! Cambridge.!!

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