Suture Like a Pro: A How-To Guide for Healthcare Students and Professionals

"A stitch in time saves nine."

These were the words spoken by British Prime Minister Boris Johnson, and it sent search engine mavens into a frenzy. So, they scoured Quora and google, trying to figure out what he meant.

But for those of you medical students and professional doctors, his phrase should be well known to you. Rapid response is crucial, especially when patients are in the throes of bleeding out.

So, how do you become a master suturer, in an industry where the skill is so vital - in all shades of the medical field? Well, let's sew up that confusion with this suture guide!

First, what kind of things do you need to take into account before putting a needle into the skin?

Pre-Procedure

As with any serious procedure, you will have to extract consent from the lips of any patient. This will come on the heels of an open discussion on the possible risks that could crop up as a result of suturing -- such as infection, or dead skin developing due to the pressure of the thread.

There might also be scarring, the threats of which are exacerbated by the type of suture thread used. But suturing -- in most cases -- minimizes the scar that results from the wound healing, as without suturing there can be a circular scar that's left behind.

All these factors require disclosure to the patient, before sticking the needle in.

The good news?

Proper steps at the start of an operation cut, or, at the very least, mitigate issues. And as a medical student, it can be even more difficult to get the patient to consent to you working on him or her. If that happens, swallow your pride. There will be more patients for you to work your suturing magic on. 

Should they opt-out of the suturing option, then there are alternative options that you can pull out of your playbook, such as:

• Healing by secondary intention
• Steri-strips
• Skin glue

Let's say that they say yes! Ok, they have agreed, and the moment that you have been waiting for happens. You step into the supply room, bouncing on your feet in anticipation. Only that bouncing dies immediately when you take a gander at the vast supplies that lie in front of you.

Questions flood your brain:

• Needle size?
• Suture Size?
• Absorbable, or non-absorbable.
• How should I close the wound?
• Vertical, or horizontal mattress?

The last question nods you off in a doze for just a moment. It's a lot to take in. But setting up your operation is just one part of the equation. 

Suturing Supplies

So, what equipment should you use in your inaugural suturing voyage, so that it doesn't tank like the Titanic? Here are the things that you should arm yourself with.

Sterile Gloves

Bacteria comes home to roost on our hands, and it can cause infection. Don't make your patient its house party.

Suture Kit

These convenient kits contain all of the vital tools for your operation: needle holders, forceps, and scissors. Check out our suture kits to sharpen your skills through hands-on practice!

Skin Preparation

Remove any kind of foreign body that can invade and fester the wound -- from the hair around the wound, or bacteria. Antiseptic can accomplish this, from povidone-iodine, or chlorhexidine. Just keep it out of the wound.

If high risk of infection is lurking, then you can cleanse the wound through "Irrigation": which is removing the foreign gunk by using normal saline, drinking-quality water, or cooled boiled water.

Be certain that it's low-pressure irrigation, with the use of a syringe.

Your Suture

Be sure to keep in mind the size/material/needle. For example, some non-absorbable sutures are generally not used for mouth operations, as wounds in the mouth heal much faster than in other locations.

Do you need some threads for practicing? Check out our suture threads here!

Dressing Materials

Simple wounds might not be as pesky for you, but those larger, more gnarly wounds might push back against the healing process.

So arm yourself with some dressings. They aid the wound in closing and keep out lurking bacteria.

Local Anaesthetic

Because needles hurt! You can apply this with or without the use of adrenaline.

Good Lighting

Like light bathes a mechanic as he dives into a car, and tinkers with its intricate parts, so should you be. This is a delicate process, where the smallest degree of change in the needle can affect the healing process.

Be sure that you can see what you're doing.

Some Things to Keep in Mind

Animal bites are nasty. They'll usually always require operative washout, so be sure to consult with some specialists before undergoing such an operation.

Don't be the doctor that contaminates your patient's wound.
If you're just breaking into the medical scene, try to stay clear of facial suturing. These wounds require very a fine suture which decreases any room for error.

If you suspect that nerves or tendons are damaged underneath the skin layers, then stay clear of suturing that wound, as this might stretch and put tension on the underlying damage.

You prepare your equipment, and the moment has come as you gaze down at your patient. Only, you forgot one thing, your eyes rolling back in disappointment:

You need to brush up on your suturing techniques! So, what are some basic passes and throws you can do to close up the wound?

First, what principles back up those techniques?

Suturing Principles

Because you can't master those suturing techniques if you don't know some basics first. Break out that textbook, it's time to lay the foundation for your suturing skills. 

Suture Placement

Remember bacteria? Well, that's why your grungy fingers shouldn't handle the needle (I'm sure that they're usually squeaky clean), and so there's a specific way that you need to hold the needle:

About 3/4 of the way from the tip of the needle.

To secure the needle in the holder, you need to tighten it until you hear an audible "click" -- this is the ratchet catching. Don't exhibit a death hold on the holder, should the needle snap under your anxious pressure.

The needle should always extend out from the holder at a 90-degree angle. This is vital! Why?

Because a faulty placement of the needle can have dire consequences for your patient, resulting in a bent needle that makes skin penetration difficult.

Many hold the needle holder in varying ways, although the method that gifts you with the most dexterity is by "palming" the holder. This permits you to angle the holder much more efficiently, gifting you relief from pain during suturing, which requires complicated needle angles.

Alternatively, you can use the loops at the end of the holder, but it will put more strain on your wrist joints.

Skin Penetration

90 degrees. That's the golden number when it comes to entering the tissue. This has a couple of benefits:

• Cuts down on the size of the entry wound
• Encourages skin eversion of the skin edges

The entry into the side of the wound and the other side of the wound should mirror the other side. If it enters 90 degrees, then it should also exit and reenter at 90 degrees.

When Tying Knots

Use clockwise and counterclockwise motions when tying a knot. It doesn't matter which one you choose to use first, as long as they do one thing:

Alternate!

So if you want to start with counter-clockwise action on your first pass, then on your second you'll want to use which?

That's right, clockwise. This helps secure the knot in place, preventing any slip-ups that might rip apart the beautiful suturing job that you're about to do.

But other factors can tear apart your piece of work, and surgeons will scream their heads off at you. That's if you allow your nervous energy to pull that knot a little too tight. That does one thing:

Kill the skin.

The key is to tie the knots only as far as the flaps of the skin close. If they are too tight, then blood flow won't reach the affected area. One other danger can throw off a seemingly perfect suturing job:

"Granny knots".

Other than the loving memories of our past that the word granny conjures, it can also bring forth complications for your suturing operation. How can you avoid them?

Always be sure to properly square up your knots. You accomplish this with ties that are perfectly parallel to the other. By doing this, you have just crafted the knot that's much stronger than its granny counterpart, and much less likely to slip.

It Goes Without Saying

But do try and cut down on rubbing your hands over the edges of the wound. The wound will tempt you to try and lift the flap of skin so that you can spot your entry and exit points. But that is why you have been gifted with forceps.

So, use them to hook the skin, allowing for better sightlines of your needle entries. Just remember that constricted skin is damaged skin. So don't vice-grip the skin with your forceps. It'll do more damage than good.

Concerning Wound Edges

When closing up the wound, check to be sure that the edges are everted. This gifts the patient with a more appealing scar.

So, you have some basic tips for the trade. But you need your playbook! After all, football coaches can tell you how to move, plant hit, but that won't tell you how each play is run.

So, let's give you that suturing playbook, that can get you started.

Techniques

Some simple know-how has been established, but now we will dive into the strategies that you can use in your suturing ventures.

So, break out those notepads, because this is the bread and butter of your future suturing career! But first, there's one thing that you need to know. As I said, this is a playbook, not a textbook. So, these aren't techniques that are a given in every situation.

The use of a particular technique should be determined based on a few things:

1. The case
2. Your knowledge of sutures
3. The materials available

Some may prefer to use one technique for every instance, just because of their comfort level. But, it may not be the most efficient suture technique for the given case.

For example, if it's a long-running wound, and time is of the essence, then a running stitch might be the go-to play call. But if it's a large wound that has a lot of tension on the edges, then a running suture might not be best.

So, you have your toolkit, now it's time for perfecting your suturing technique.

Simple Interrupted

This is one of the most common go-to's for doctors when approaching an operation, as it's a base technique that lays the groundwork for all other techniques.

"Interrupted" simply means that there is a break in between each knot. So, instead of having one thread of suture thread run all along the length of the wound, you have multiple knots that close it off.

The great advantage of this method is that it's extremely adaptable to the wound. You can adjust the position of the knots, as you move down the length of the cut.

What if one of the knots fails? well, much like the Titanic, there's a backup system -- the other knots. The wound can remain closed, especially after a period of healing, as long as the other knots hold.

It's easy to do, it's fast, and it's adaptable.

So, how is it done?

Step 1

You will want to expose the skin to the ride side of the wound, with your forceps. Don't grip too hard with the forceps, you only need some space to operate. 

Step 2

Next -- with forceps holding the ride side of the skin -- puncture the right side with the needle (taking a bite). The entry point should be 1 centimeter away from the wound. 

Step 3

Now, make a parallel "bite" on the opposite flap of skin, from the inside to the outside. Again, remember, it must be perpendicular to the skin!

Holding the needle with the needle holder, pull the needle so that all of the thread -- minus about 3-5 centimeters, on the right side -- is on the left side of the wound.

Step 4

Now come the "throws". Go ahead and release the needle from the holder. With your left hand, grab the thread on the left side and "throw" it around the needle holder three times. Just remember this: throw it counterclockwise! You can do it clockwise, but when you throw it again, you want to alternate in the other direction.

Now, with your right hand, grab the small length of thread on the right side with the needle holder. With your left hand, pull the long thread.

Voila! You have a knot!

Simply repeat steps 5-6 to tie off another beautiful knot. Remember that you need to alternate your throws!

Move down the wound about one centimeter, and repeat the process. Do this until the wound is sealed.

A little tip: Keep all your knots on the same side of the wound. So, if your first knot is on the left side, then keep all of your successive knots on that side.

Vertical Mattress

But sometimes the reliable simply interrupted method can't be the bind for some larger wounds. It can be hard to pull the epidermis shut for those knots. For this challenge, we will reach into our playbook for the Vertical Mattress!

Mimicking the shape of a square, this technique spreads out the tension more evenly, which allows larger wounds to close more effectively without compromising the skin, or the knot.

As a general rule, the wider the gap of the wound, the greater the length of the stitch will be.

For this one, some different rules will have to be followed. This is a wild one!

Step 1

Previously, our bites are about 1 centimeter from the wound. For this doozy, we will take our bite approximately 2 centimeters from the wound -- double it up!

Step 2

Take your outward bite 2 centimeters away from the wound site, mirroring what you side in step 1. This will take you out onto the left side. 

Step 3

Here is the trick: Using the forceps, you need to whip the needle around 180 degrees. This will have the needle facing directly at the entry point on the opposite side.

Step 4

Now, cut the distance in half. You will make your next bite, on the left side, on the same line as your first two. Only this time, it will be 1 centimeter from the wound.

Step 5

Traveling under, you will take your outward bite at 1 centimeter from the wound -- again, mirroring step 4.

Tie it off, and bravo!

You have crafted your first vertical mattress tie!

Horizontal Mattress

Another useful ally in your battle against gaping wounds is the Horizontal Mattress. But it's not only for those wounds.

You can also use this technique on more sensitive areas, like the palms or the soles of the feet. If you're short on time -- as ERs often are -- then you can use this proven technique as an anchor suture.

- At the beginning
- To anchor the middle
- At the end

In between, you can use simple interrupting to finish off your winning suture job!

How is it done?

Step 1

Take your first bite, we'll say on the right side. As always, keep the needle 90 degrees to the wound. 

Step 2

Take your outward bite, bringing your needle out of the skin on the left side. Ensure that you are maintaining that clean, 90-degree angle. 

Step 3

Now, move about 2 centimeters down on the left side (same side), and take your inward bite, towards the right side (this will leave a line, between the two points on the left side.

Step 4

Come out on the right side, tie it off, and there you have it!

You have just executed your first horizontal mattress!

Running Simple

But perhaps you have a long cut that slices down a long length? Well, tying off individual knots may take a little time. For this dilemma, we have the running simple!

The beauty of this knot is that it's simple to execute, and it gifts you superb tension control, meaning that tension is spread out evenly, all along the length of the stitch.

If the skin is too taught, and not cooperating, then you need to remember the beauty of the art of suturing, it can allow for combinations!

A nice running suture can easily be complemented by a strong horizontal mattress to anchor the middle, providing a little extra insurance for your running suture.

So, how can you etch out your perfect running stitch?

Pretty simply, if you remember the simple interrupted. It's the same steps. The only difference?

You don't cut the thread after you tie off your first knot. Instead, you will use that long strand to take bites on the left, and right side -- interchangeably -- as you work your way down the wound.

The bottom, with the wound, perfectly sealed up, you'll simply tie it off. And there you have it!

Wipe that sweat off, you did good! But what about after the deed is done? What are some crucial things to remind your patient of?

Post-Procedure

The care of the wound, and the sutures, will be just as vital as the operation towards speeding the patient along to recovery. After any operation, check to see if a dressing is required.

Remind them not to go on any luxurious Disney cruises or sun-bathed outings to Cabo. The wound must keep clean, and dry, for a minimum of 48 hours.

Now, your patient will have burning questions about when they can ditch their unsightly sutures, and bound out into the world stitchless.

Here are some basic suture removal timeframes. Note, that these are only guidelines!

• Face: 5 -7 days
• Hand/foot: 10-14 days
• Trunk/Breast: 7-14 days

Take antibiotics into consideration, to battle any threat of infection.

The best thing is to not have them make any decisions on their own, so ensure that you're open and accessible to them, or that information is readily available.

And with them walking out the door, you can heave a sigh of relief. You did it!

Transform Yourself Into A Suture Master

"A stitch in time saves nine".

Suturing is a valuable skill that can not only bring save patients' lives but also make you an amazing first responder to accidents. This makes it a crucial tool for doctors, but also for humble citizens. With our suturing book called "Suture Like a Surgeon", you can take your learning into your own hands! 

So, you now have the knowledge, but knowledge is honed by constantly brushing up on it! You happen to be in luck there, as well. Pick up some of the best quality suture kits here, so that you can become a suturing maven!