Sutures, ligatures and knots

Alison Carter
Christopher J Skilbeck
Abstract
The choice of suture material and the technique for wound closure is a topic
that may create some anxiety for the junior surgeon. It may also be that pa-
tients judgement of a procedures outcome is disproportionately based on
the wound itself. This article discusses various commonly used suture ma-
terials, the needles used to place them and the techniques employed in
tying them. It also highlights important alternatives to traditional suturing.
Keywords Ligation; suture; suture techniques
Background
The junior surgeon must have a clear understanding of the
principles underlying choice of suture material, and of the tech-
nique for wound closure, not least because often it is the stage of
the operation that the SHO (or ST/CT/FY) gets to do. The nal
result, as far as the patient is concerned, may be judged on the
wound itself. This is not as absurd as it rst sounds e it seems
not unreasonable that a surgeon who is proud of their work and
appreciates the detail of accurate wound closure will have
applied this level of care to the whole venture.
As with all aspects of operating, it is self-evident that practice
makes perfect, and it is essential to start obtaining experience in
wound closure from the earliest point possible in a surgical
career. This article will discuss commonly used suture materials,
the needles used to place them and the techniques employed in
tying them. Specic examples will be given from the Ethicon
range, which is commonly used within the NHS; however, in
places the appropriate proper name, will also be used, and a
broad category assigned (e.g. monolament, absorbable, syn-
thetic) e these should be used for examination purposes.
The ideal suture
The perfect suture is unobtainable. However, the characteristics
by which it is judged are highlighted in Box 1. Synthetic materials
have taken over the market as they have more predictable
characteristics and avoid the concerns of using animal-derived
materials, both cultural and infection-related.
Suture materials
Sutures may be made from naturally occurring or synthetic -
bres, and are classied as absorbable or non-absorbable. Non-
absorbable sutures remain in the body life-long, although some,
and silk in particular, are subject to degradation, resulting in loss
of effective tensile strength between 3 and 6 months. Absorbable
sutures vary in their rate of absorption. This is classied by the
breaking strength of a knotted bre. It is given as a specic
number of days and an approximate percentage of tensile
strength remaining. For example, it may be as little as 5 days/
50% (e.g. polyglactin 910 e vicryl rapide) and as much as 42
days/35% (e.g. polydioxanone e PDS II).
Recently, sutures impregnated with antimicrobial agents have
been made available. These Plus sutures have been shown in a
recent meta-analysis of 13 randomized controlled trials to afford
a statistically signicant reduction in surgical site infections in
selected patient populations.
Each of these different characteristics has advantages and
disadvantages, and no suture material will be perfect for every
situation. A selection of commonly used sutures and their uses is
shown in Table 1.
Sizes
The size of suture used is determined by the tissue being opposed.
The nomenclature of suture sizes is interesting, and requires some
explanation. It is derived from the United States Pharmacopeia
(USP). Originally, sutures were manufactured in sizes ranging
from6 to 1, with the larger number representing a larger suture. As
techniques improved, manufacture of progressively smaller su-
tures was possible. Asize 0 is smaller thana 1, whilst 00 (or 2e0) is
smaller still. This continues down to size 11e0 suture, such as
used in ophthalmic surgery.
Needles
The majority of surgical needles are pre-loaded with suture (i.e.
swaged). The alternative to swaged needles is eyed. In these, the
suture has to be threaded on by the scrub nurse. In the United
Kingdom these are rarely used outside specic indications.
The surgeon has an extensive array of needles to choose from.
The point may be cutting, tapered or blunt (Table 2). Cutting
needles aid the passage through tough tissues, such as fascia or
skin. Taper point needles minimize trauma to the tissues they
pass through and are typically used for suturing bowel or vessels.
Blunt tip needles are intended to minimize the risk of sharp
injury to the operator and are preferred by some for this reason
for closing fascia such as the abdominal wall; however,
perceived increases in safety must be offset against the greater
force required to drive these needles through tough fascia.
The needle should be typically mounted in the needle-holder
one third from the swaged end, to provide optimal control whilst
preventing bending.
Characteristics of an ideal suture
C
Good handling
C
Minimal tissue reaction
C
Secure knotting
C
Predictable tensile strength
C
Sterile
C
Non-allergenic
C
Inexpensive
Box 1
Alison Carter BMedSci(Hons) BMBS MRCS is a Core Surgical Trainee at Guys
and St. Thomas Hospital, UK. Conicts of interest: none declared.
Christopher J Skilbeck BSc FRCS(ORL-HNS) is the ENT/Skull Base Fellow at
Addenbrookes Hospital, Cambridge, UK. Conicts of interest: none
declared.
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SURGERY 32:3 117 2014 Elsevier Ltd. All rights reserved.
The correct conduct of passing the suture back to the scrub
nurse with the point protected in the needle-holder should be
second-nature to both the senior and aspiring surgeon alike.
Suture placement
Once the correct suture material has been chosen, the surgeon
must employ a sound technique when placing the suture. As a
general rule the tissues should be handled as little as possible. If
forceps are required they should be as ne as is practicable. The
needle should be inserted perpendicular to the material being
sutured and driven through tissues to follow the natural curve of
the needle to prevent tearing. Skin should be opposed accurately,
with mild eversion of the edges to promote healing. In most
circumstances, accurate apposition will require the needle to be
passed through each edge of tissue separately, rather than a
through and through stitch.
The depth of suture should be equal on both sides of the wound
and all dead space should be eliminated. It is for this reason that
deeper wounds need layered closure. The wound should be closed
without tension and the principle of halving a wound is often
applied in order to achieve equal suture placement (Figure 1).
Continuous sutures should be placed in a similar fashion,
although the principle of halving is not applicable, and the sur-
geon will probably nd it easier to suture towards themselves.
They should continue to observe a 90-degree angle of entry
through the skin. An assistant is required to follow the surgeon,
by applying tension to the loose end of the suture. A variation of
this technique is a blanket stitch where the appropriate tension is
maintained by way of passing the needle through the loop
created by the previous stitch. This can then be carefully snug-
ged down and the next stitch placed.
A mattress suture involves two passes of the needle through
each side of the wound. The rst pass is as previously described
for interrupted suturing. Subsequently the needle is reversed and
the second pass returns the needle to the original side of the
wound. It may either be closer to the wound edge and therefore
more supercial (vertical mattress) or in the same depth plane
but further along the wound edge (horizontal mattress). Vertical
mattress sutures are useful for wound eversion, whereas a
variation of the horizontal mattress is utilized for closing a corner
when, for example, a V-shaped advancement ap has been
created.
Subcuticular suturing involves a continuous suture placed to
approximate the skin layer of a wound. It may be performed
using either absorbable or non-absorbable suture material. The
technique of passing the suture in the subcuticular plane from
side to side can give an aesthetic closure. Care should be taken to
keep bites of equal size as otherwise the wound closure can be
susceptible to puckering. Fixation of the initial and nal suture
varies, and most surgeons will develop their own technique e it
will depend on whether the suture is absorbable or not.
Knot tying
There is variety in the manner of tying surgical knots. For the
most part, the surgeons knot will prove acceptable (Figure 2).
This is based on the reef knot which consists of alternate left-
over-right, right-over-left throws. The surgeons knot involves a
double-throw in the rst instance, followed by a further two
throws in the opposite direction. Some suture materials (partic-
ularly stiff monolaments) need additional throws as they tend
to unravel. Five or six is usually all that is necessary in those
situations. Any more should be avoided as the knots themselves
provide an environment for microbes to reside and those that are
absorbable may provoke a foreign body reaction.
When tying the knot, the surgeon should take care to lay each
throw down by pulling in directly opposing directions e this
Commonly used sutures and their uses
Suture Material Synthetic/Natural Monolament/Braided Properties
Absorbable
Catgut Puried animal intestine Natural Monolament Marked inammatory response
Absorbed by proteolytic digestion
NOT used in UK
Monocryl Polyglicaprone 25 Synthetic Monolament Used for subcuticular closure
Vicryl Polyglactin 910 Synthetic Braided Absorbed by hydrolysis. Handles well
Vicryl Rapide Polyglactin 910 Synthetic Braided Rapid absorption
PDS II Polydioxanone Synthetic Monolament Slow absorption
Non-absorbable
Silk Natural silk Natural Braided Optimal handling characteristics
Marked inammatory reaction
Degrades without absorption
Mersilene Polyester Synthetic Braided/monolament High tensile strength
Ethilon Nylon-polyamide Synthetic Monolament Minimal tissue reaction
Prolene Polypropylene Synthetic Monolament Used for vascular anastomosis
Steel wire Stainless steel Synthetic Monolament Very high tensile strength. Used for closing
sternotomy incisions
Adapted from Andrews (see Further Reading)
Table 1
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SURGERY 32:3 118 2014 Elsevier Ltd. All rights reserved.
ensures the suture material lies at. Subsequent throws should be
laid down with the hands pulling in alternating directions. The
suture should be cut to leave an appropriate length e usually
around 5 mm. When tying non-absorbable suture for skin closure,
an appropriate length should be left to facilitate easy removal.
Laparoscopic surgery is being increasingly used and knot
tying via laparoscopic instruments represents a challenge for
even the experienced surgeons manual dexterity. Knots can be
classied as extracorporeal (i.e. being tied outside the body and
pushed through a port via a knot pusher) or intracorporeal (i.e.
being tied within the abdominal cavity using laparoscopic in-
struments). Practice once again is the key to success, and uti-
lizing a laparoscopic training box early in your career is advised.
Classication of needle points
Needle point (symbol used
on packaging)
Advantages and disadvantages
Conventional cutting
needle (:)
Has three cutting edges that are sharpened to pass through dense, irregular and relatively thick
connective tissue. The third cutting edge is on the inside concave curvature of the needle towards
the surgical wound and, because it is sharp, care must be taken in some tissues (e.g. tendons, buccal
mucosa) to avoid cutting through more tissue than is desired.
Reverse-cutting needle (7) Has three cutting edges, but the third edge is on the outer convex curvature of the needle. The hole
left by the needle produces a wide wall of tissue against which the suture is to be tied, thereby
reducing the risk of a cut-out.
Round-body taper
point needle (C)
This pierces and spreads the tissue without cutting it. The needle tapers to a point and is used in
tissue that can be easily penetrated (e.g. peritoneum, bowel, myocardium). It is preferred when the
smallest possible hole in the tissue and minimum tissue cutting are desired, so is conventionally
used for anastomoses.
Taper-cutting needle (Y) Combines the features of the reverse-cutting edge tip and round-body needles. The point readily
penetrates tough tissue, whilst the tapered round-body prevents cutting into the surrounding tissue.
Widely used on sclerotic or calcied vessels or for tendon repairs.
Blunt-point needle (B) Has a tapered body with a rounded, blunt-point that dissects through friable tissue rather than
cutting it. Mainly used for suturing the liver and kidney.
Table 2
Wound halving
A simple way of correcting wound inequalities is to place the first stitch half
way along each side, then place the next stitches half way along each half
wound. Continue until there are no gaps in the wound edge. This is useful
for subcutaneous tissue as well as skin. This is only possible for interrupted
stitches.
Figure 1 Halving a wound. The rst suture should be placed at the
midpoint of the wound. Subsequent sutures should further halve the
wound in turn. This ensures that any inequalities in the lengths of the
wound edges are spread along the whole wound.
Surgeons knot
Figure 2 Surgeons knot. A modied reef knot with a double throw in the
rst instance.
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Alternative methods of wound closure
Staples may be used as a means of rapid closure of skin instead of
interrupted sutures. These metallic clips are usually made from
titanium (allowing MRI scanning) and produce a minimal tissue
reaction. When applying the stapler the surgeon should have the
help of an assistant to maintain tension along the wound to
ensure careful approximation of both edges. Like closure with
sutures, it is usual to place skin staples working from the distal
wound end and come towards oneself.
Skin staples require a specialized device for their removal.
Care should be taken on removing the staples as they constitute a
potential sharp.
Tissue adhesive (Dermabond) may be used for closure of
skin wounds. It is most appropriate for wounds that are already
in close approximation. It is also extremely useful for small
traumatic wounds in children.
Adhesive tapes (Steri-Strips) are often used alone and in
combination with sutures. The wound edges should be carefully
opposed and the tapes applied perpendicular to the wound. They
are increasingly used as commonplace after subcuticular sutur-
ing to aid good apposition of the tissues. Adhesive tape is
particularly useful in the closure of supercial lacerations and
wounds in children. Local anaesthetic is not required and the
removal is less traumatic. A
FURTHER READING
Andrews S. MRCS core modules: essential revision notes. PasTest, 2002.
Edminston Jr CE, Daoud FC, Leaper D. Is there an evidence-based argu-
ment for embracing an antimicrobial (triclosan)-coated suture technology
to reduce the risk of surgical-site infections?: a meta-analysis. Surgery
2013; 154: 89e100.
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SURGERY 32:3 120 2014 Elsevier Ltd. All rights reserved.