Suture Patterns

-Interrupted or Continuous

-Way they Appose Tissue

-Tissues they primarily Appose

Suture Patterns Classification (3)

-Appositional

-Everting

-Inverting

Suture Pattern can be classified by the Way they appose Tissue

Subcutaneous or Subcuticular

Suture Pattern can be classified by Tissues they primarily appose

Subcutaneous suture

Suture that are placed to eliminate dead space & provide some apposition of skin so that less tension is placed on skin sutures

-Simple continuous

-Drainage

Subcutaneous Sutures - are generally placed in this manner

-However, during this instance, Simple Interrupted Sutures are preferable

Subcuticular or Intradermal Closures

may be used in place of skin sutures to reduce scarring or eliminate the need for suture removal (e.g. Fractious Patient)

-Burying the knot in Dermis

-Buried Knot

Subcuticular or Intradermal Closures

-Suture line is begun by

-Suture line is completed completed with a

Interrupted Suture Pattern

-Time consuming

-Large amounts of Suture materials

-Presence of additional amount of suture materials within the tissue

-Ability to maintain strength & tissue position if part of suture line fails or tears

-Provide more accurate edge to edge apposition

-Less scar tissue formation in the healed wound

1 Simple Interrupted Pattern

2 Cruciate Pattern

3 Horizontal Mattress Pattern

5 Vertical Mattress Pattern

6 Halstead Pattern

7 Gambee Pattern

Interrupted Suture Patterns (7)

Simple Interrupted Pattern

Suture made by inserting the needle through tissue on one side of an incision or wound, passing it to the opposite side, and tying

False, It SHOULD BE offset

True or False. A Simple Interrupted Patterns knot should NOT be offset so that it does rest on top of the incision, and the ends of the suture are cut

True.

True or False. In a Simple Interrupted Pattern, in Skin sutures, the Ends are left long enough to allow them to be grasped during removal

2-3 mm away

In Simple Interrupted Patterns, the sutures should be placed approx. how many mm away from the skin edge?

-R-L

-L-R

(in horizontal fashion)

In Simple Interrupted Patterns, the direction in which

-Right-handed

-Left-handed

Surgeons place the sutures

Disruption of a single suture DOES NOT cause the entire suture line to fail

Primary advantage of Simple Interrupted Patterns

False, Simple Interrupted Patterns take more time & result in more foreign materials (knots) in the wound

True or False. Continuous patterns take more time & result in more foreign materials (knots) in the wound than Simple interrupted sutures

Cruciate Pattern

When two simple interrupted sutures are placed parallel to each other and then tied across the incision to create an "X"

True

True or False. Cruciate sutures are appositional & can relieve low to moderate tension across an incision

!!!

[!!!] Less suture material is used to close a skin incision with cruciate sutures than simple interrupted, yet cruciate sutures still afford the security of an interrupted pattern

Horizontal Mattress Pattern

are placed by inserting the needle on the far side of the incision, passing it across the incision, and exiting it on the near side, as described for a simple interrupted suture

[!!!]

[!!!] Horizontal Mattress Pattern

-The needle is then advanced 6 to 8 mm along the incision & reintroduced through the skin on the near side

-It then crosses the incision, exiting from the skin on the far side, and the knot is tied

4-5 mm

Horizontal Mattress Sutures are generally separated by how many mm?

-tension

-tissue eversion

Horizontal Mattress Pattern

-are used primarily in areas of ____

-however, often cause this

Vertical Mattress Pattern

-The needle is introduced approx. 8-10 mm from the incision edge on one side, passed across the incision line, & exited at an equal distance on the opposite side

-The needle is reversed & inserted through the skin on the same side & exited on the far side, each bite approx 4 mm from the skin edge, & the knot is tied

Vertical

(Horizontal, Vertical) Mattress Pattern are stronger when used in areas of tension, & are preferred when addressing tension in skin closure, as there is less disruption to blood supply of the wound edges

Eversion of skin margin

Vertical mattress is relatively time consuming but ____ is less of a problem than with horizontal mattress sutures

False, BOTH

True or False. Only Vertical Mattress Patterns can be bolstered using rubber stents & buttons

Halstead Pattern

Interrupted mattress pattern that is a modification of a continuous Lembert pattern

infrequent

Halstead Pattern is a/n (frequent, infrequent) technique used in veterinary medicine, but does provide exact skin approximation

Halstead Pattern

The needle enters & exits perpendicular to & an on the same side of the incision. The needle then crosses over the wound and is passed in and out the skin in a similar fashion. The needle is advanced down the incision, and this pattern is repeated in reverse, back across the incision, and the knot is tied

Gambee Pattern

Interrupted pattern used in intestinal surgery to reduce mucosal eversion

Gambee Pattern

-The suture is introduced the same as a simple interrupted suture from the serosa through the muscularis and mucosa to the lumen

-The needle is then returned from the lumen through the mucosa to the muscularis before it crosses the incision

-After crossing the incision, it is introduced in the muscularis and is continued through the mucosa to the lumen

-The needle is then reintroduced through the mucosa & muscularis to exit from the serosal surface, and the suture is tied

mucosal inversion, wicking of material

Gambee sutures reduce _____ and may reduce ______ from the intestinal lumen to the exterior

-Less

-Fewer

-Fewer

-True

-Difficult

-More

Continuous Suture Pattern

-(More, Less) Time Consuming

-(More, Fewer) amounts of suture materials

-(More, Fewer) materials within the tissue

-True or False. Unable to maintain, if one knot is slipped, fail or tear out the entire suture line become loosened

-(Easy, Difficult) to gain accurate edge to edge apposition

-(More, Less) Scar Tissue Formation

1 Simple Continuous Pattern

2 Ford Interlocking Pattern

3 Lembert Pattern

4 Connell & Cushing Pattern

Continuous Suture Pattern (4)

Simple Continuous Pattern

Consists of a series of simple interrupted sutures with a knot on either end; the suture is continuous between the knots

Simple Continuous Pattern

To begin a simple continuous suture line, a simple interrupted suture is placed and knotted, but only the end that is not attached to the needle is cut. The needle is then passed through the tissue from one side to the other, perpendicular to the incision. The suture is advanced above the incision line at a diagonal.

Ford Interlocking Pattern

A modification of a Simple continuous pattern in which each passage through the tissue is partly locked

Ford Interlocking Pattern

-Each pass through the tissue is linked to the previous passage as the suture exits the tissue through a created loop of material

The needle is reversed & introduced in the opposite direction from that used previously

How to terminate a Ford Interlocking Pattern

tied to the single end

The loop of the suture formed on the opposiite side is [Ford Interlocking Pattern]

Locked Suture Patterns

[Ford Interlocking Pattern]

(Locked Suture Pattern, Simple Interrupted Pattern) which of these may be placed quickly & may appose tissue better

Ford Interlocking Pattern

This pattern also provides greater stability than a simple continuous pattern in the event of a partial break along the line

Lembert Pattern

-variation of a vertical mattress pattern applied in a continuous fashion. It is an inverting pattern that is often used to close hollow viscera

close hollow viscera

Lembert Pattern is used often to

8 - 10 mm

Lembert Pattern: The needle penetrates the serosa & muscularis approx. ____ mm from the incision edge & exits near the wound margin on the same side

3-4 mm, 8-10mm

Lembert Pattern: After passing over the incision, the needle penetrates approx. ____ from the wound margin and exits ____mm away from the incision

Connell & Cushing Patterns

The are inverting patterns that are used to close hollow organs

Connell & Cushing Pattern

A watertight seal is created by the inversion; however appositional patterns are advocated for visceral closure in small animals, as this facilitates rapid intestinal healing

-Connell

-Cushing

-enters the lumen

-extends ONLY to the submucosal layer

inverts

In a Connell & Cushing Patterns, when it is tightened, the incision _____

Parker-Kerr suture

a modification of the Cushing and Lembert patterns that has been described for closing the stump of hollow viscera. It is seldom used it causes excessive tissue inversion

1 Three-Loop Pulley Suture

2 Bunnell Suture

3 Far-Near-Near-Far Suture

Tendon Sutures (3)

-Kessler locking-loop

-Bunnel-Mayer

-Krackow

Other tendon sutures

Three-Loop Pulley Suture

Considered to be biomechanically superior to other tendon patterns as it is more resistant to gap formation during tensile loading

Bunnell Suture

Not commonly used bc it is difficult to place & may damage the tendon's microcirculation. Ischemia resulting from the suture may cause the suture to pull out or may result in death of the tendon ends. The resultant gaps must then be filled with fibrous tissue

Modified Bunnell Suture Pattern

May be used to appose severed tendons

Far-Near-Near-Far Suture

-may be used in flat tendons

-minimally disrupts blood flow & provides good resistance to tension bc all suture passes are in the same vertical plane

skip

skip 70-75

False

True or False. The Important factor in ALWAYS the Pattern type

-Appropriate Suture Material Type & Size

-Knots are tied securely

-Correct tissues have been engaged

Important Factors in choosing appropriate suture pattern is NOT always the pattern type but the ff: [AKC]

1. Most materials should have 4 throws (2 square knots), and some may require more (eg Polydioxanone)

2. It is worth remembering that a continuous line should end with one more throw than it started with

3. Make sure to tighten your knots appropirately

4 Use a sliding or surgeon's knot only when the tissues are under tension, otherwise use a normal square knot

5 Appositional patterns will provide the best anatomical reconstruction in most cases, and should be preferable to everting or inverting patterns

6 Tension relieving sutures should never to be applied on a routine basis. Most tissues (esp skin) should be closed wo significant tension or neeed for tension reliveing suture patterns

Golden Rules Worth remembering in choosing Appropriate suture (6)

equal to the distance from neede entry to wound margin

Spacing bw sutures is typically

at an equal distance from the wound margin, where X=X=X

Although not an absolute formula, in geenral, sutures should enter & exit ___

[!!!]

[!!!]

-Suture should be DEEPER than they are wide

!!!

[!!!]

EQUAL BITES

EQUAL DEPTHS

PERPENDICULAR

SQUARE KNOTS

Cut

Once the knot has been securely tied, the ends must be ___

both tips of the scissors are visible

Before cutting, this must be observed in order to avoid cutting tissue beyond the suture

Cutting sutures

entails running the tip of the scissors lightly down the suture strand to the knot

Surgical gut, 1/4" (6mm), 1/8" (3mm)

The ends of ______ are left relatively long, approx. ____ from the knot. Other materials are cut closer to the knot, approx. ___ , to decrease tissue reaction and minimize the amount of foreign material left in the wound.

twist or angle the blades of the scissors prior to cutting

To ensure that the actual knot is NOT cut, this is done

!!!

[!!!] Make certain to remove the cut ends of the suture from the operative site

When the wound has healed so that it no longer needs the support of non-absorbable suture material

When is skin sutures removed

Rate of Healing & Nature of Wound

Length of time the Sutures remain in place depends on (2)

before the epithelium has migrated into deeper parts of the dermis

Sutures should be removed before ___

10-14

Sutures should be removed before the epithelium has migrated into deeper parts of the dermis, generally bw ____ days post op, BUT this may VARY

Clean or Aseptic Technique

Sutures should be removed using what technique

1: Cleanse the area w an antiseptic. Hydrogen peroxide can be used to remove dried serum encrusted around the sutures

2 Pick up one end of the suture w thumb forceps or thumb and index finger, & cut as close to the skin as possible where the suture enters the skin

3 Gently pull the suture strand out through the side opposite the knot w the forceps. To prevent risk of infection, the suture should be removed without pulling any portion that has been outside the skin back through the skin

3 Steps in Cleaning Sutures

Hemostasis

a complex process that involved platelet activation & circulating clotting factors

-allows appropriate visualization of tissue during the procedure

-prevents life-threatening hemorrhage

In surgery, obtaining hemostasis ___ (2)

applying pressure to bleeding points w gauze sponges

Low pressure hemorrhage from small vessels can be controlled by

Small hemostatic forceps (mosquito forceps)

may also be used to control bleeding from small vessels

!!!

[!!!] The vessel is grasped & clamped w the forceps for several minutes until coagulation occurs

Ligature

may be placed to ensure the bleeding is stopped

-Ligated

-Double Ligature

-Larger vessels must be

-are recommended for larger vessels, particularly arteries

Transfixation ligatures

may be indicated for larger arteries to prevent the ligature from slipping off the vessel end

Using the smallest suture possible for vesse ligation

Improves knot security

True

A Surgeon's throw should NOT be used for vessel ligation, although other friction knots would be appropriate

Miller's knot, Constrictor's knot, Strangle knot

Friction knot examples appropriate for Vessel ligation