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SUTURE PATTERNS AND CLINICAL APPLICATIONS

or the sewing course for surgeons

Susanne Lauer

Purpose

Provide strength during lag phase Promote tissue apposition primary wound healing (fast) water-tight seal to hollow organs

Classification

How performed (placed)


Interrupted

(single sutures) Continuous (sutures linked)

How tissues are affected


Appositional Inverting Everting

How much tissue suture spans


Simple
Mattress

Advantages and Disadvantages


Interrupted 1. If one fails, remainder unaffected
2. More knot tying -> more sx time 3. More suture material implanted 4. More knots -> more irritation

Continuous 1. Failure of one portion -> failure of entire suture line 2. Quicker
3. Less suture material 4. Less knots -> less irritation

Appositional Sutures
Allows healing of like tissue layers More physiologic Early strength (functional fibrin adhesions) Maintains lumen Equal seal of hollow organs compared to inverting and everting patterns

Appositional Suture patterns


Simple Interrupted Gambee Interrupted Intradermal or Subcuticular Interrupted Cruciate or Cross Mattress Simple Continuous Continuous intradermal or subcuticular Ford Interlocking

Appositional Suture Patterns

Simple Interrupted

Gambee

Interrupted Subcuticular

Appositional AppositionalSuture SuturePatterns Patterns

Interrupted Cruciate

Simple Continuous

Continuous Intradermal

Ford Interlocking

Inverting and Everting Patterns


Non physiologic healing More scar tissue, More reaction, due to microabscesses Inverting -> less peritoneal adhesions As single layer, not stronger than other patterns Compromises lumen size Good water-tight seal

Inverting Suture Patterns


Lembert Halsted Cushing Connell Parker Kerr Purse String

Inverting Suture Patterns

Connell

Cushing

Inverting Suture Patterns

Interrupted

Lembert

Continuous

Inverting Suture Patterns

Halsted

Inverting Suture Patterns

Parker-Kerr

Purse String

Simple versus Mattress Sutures


Simple 1. Not appropriate for tension will cut through tissue 2. Best apposition Mattress 1. Spread over larger area -> relief of tension 2. Tissue eversion or inversion

Suture Pattern Terminology


Suturing or Sewing Suture not Stitch Bite = span of tissue that suture encompasses on either side of incision Bite is often referred to for:

Distance Orientation Spacing Placement

in relation to incision

order, technique

Suture Pattern Terminology


Short

end (tag) = end of suture Long end (tag) = end with needle

Knots
Weakest point of suture Each phase of knot = throw Need at least 2 throws for knot

Square Knot

Knot must be tied as square to be secure Need to interchange the strand that goes over the top (left over right / right over left) If same strand over the top -> granny knot

Slip Knot

Can be created during either throw of a square knot If knot not tied flat Not secure But, can be advantageous when tension present (needs additional secure throws)

Surgeons Knot

Indication: moderate tension across incision First throw with two passes, followed by second throw with a single pass Subsequent knots are standard (single pass) Do NOT use, if not needed -> too much irritation bulky!

How many knots to be safe?


Interrupted sutures: 4 throws Continuous sutures: 5 throws

Further increase in throws -> does not increase strength If knot weak -> increase diameter of suture material

Knot placement

Standard -> superficial

Knot placement

Interrupted

Buried knot
Indication:
Subcutaneous

tissue On deep surface Knot not exposed


Continuous

Suture Placement and Knot Tying

Suture placement Hand placement


In

flat tissue planes Large straight needles

Needle holder placement


Difficult

access areas Smaller needles

Knot tying By hand or using the needle holder

Knot Tying with Needle Holder

Downloaded from: Small Animal Surgery, 3/e (on 22 February 2010 05:20 PM) 2007 Elsevier

Mattress Sutures
Interrupted Vertical mattress Interrupted horizontal mattress Quilled Near and far Stent Continuous horizontal mattress Locking Loop

Tension Suture Patterns

Interrupted vertical mattress

Interrupted horizontal mattress

Tension Suture Patterns

Quilled

Far to near

Kessy, 3y, F, Rottweiler


Bred 71 d ago 1st litter HBC 2y prior (pelvic fract.) Greenish fluid from vulva 8h ago No pup yet Strong contractions

Kessy, 3y, F, Rottweiler


Abd radiographs: 7 pups, one fetus in vaginal canal; malunion of pelvic fractures CBC, chemistry unremarkable

Dystocia, Cesarian Section

Dystocia, Cesarian Section

How to close ???

Uterine closure
1-2layer 3-0, 4-0 absorbable taper-point Simple contin +/- Cushings or Lembert

Abdominal closure

How to close ???

Abdominal closure

External Rectus sheath!!!!!!! Absorbable simple interrupted or continuous (depending on experience)

Interrupted/Continuous Advantages ?

Interrupted
Tension

precisely adjustable

Continuous
Speed More

air & watertight seal

Interrupted/Continuous Disadvantages?

Interrupted
More

foreign material Poor suture economy Time consuming

Continuous
Suture

breakage = Disaster Less precision

Deadspace and Approximation

Subcutaneous

Subcuticular

Burying the knot

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