Surgery Spotlight: Suture Skills Video-Surgery Spotlight: Suture Skills Video

Surgery Spotlight: Suture Skills Video

Video Transcription

Hi, welcome to the Duke Suture Skills course. My name is Michael Zenn, and I'm the director of the Human Tissue Lab here at Duke.  This course will teach you the basics in suture technique. We'll review simple suture, mattress suture, running suture, and some of the variations and proper surgical technique.  It's our goal that by teaching you proper technique, you'll be the best surgical resident or surgeon that you can be.  Before we get started, I'd like to thank the GME office at Duke for their generous grant that made this video possible.  Before we get started showing you different suture techniques, I want to show you a basic instrument tie. This can be used with any of the suture techniques that you'll learn.  Once the suture is placed, you'll have a short end and then a longer loop end. Your needle driver should be placed directly between the two, and then we will do a surgeon's knot.  You'll wrap the longer end twice around the needle driver, grab the smaller end, and pull it to the opposite side.  What will happen when you pull it to the opposite side, it will square the knot. You can see how square the knot sits down.  Because it's a surgeon's knot, it'll sit unless you pull up on it. Don't pull up on it. Place the needle driver between the two, the short end and the loop end.  Now you're going to loop it around only once. Grab the short end and then bring it to the opposite side, again, squaring the knot.  Don't pull up on the suture until you just get it down, and then you can tighten it. Now it's locked in place.  I recommend at least three throws, instrument between, bring the small to the other side, and done.  Some suture material, you may need four throws, something maybe like an absorbable suture. This is a very basic technique. It allows you to suture in a small place.  If multiple people are working, we'll do one more for you right here. You can suture. Notice I like to keep the short end very short.  Your instrument doesn't move around very much then. Keep the needle driver between the two. Grab the small end, pull it to the opposite side, squaring your knot.  Lock it down with that surgeon's knot. Don't pull up on it now until you now grab this end and pull it through for the second time, and now it locks down.  Needle driver between the two, wrap once, pull to the opposite side, and keep that knot nice and square. The square knots will not untie, also will look cosmetically more appealing.  The first suture we're going to teach you is the simple interrupted suture. This is the most common suture that you'll be using in wound closure.  Just a quick tip on handling the needle. You'll notice your needle has a flat portion in the middle. This is where you grab the needle with your needle driver.  You don't want to grab it at the end where the suture comes in, or the swedge, because it's round and you'll be unstable. Never grab the needle at the tip because you'll dull it.  A simple bite, we'll want to enter the skin at 90 degrees, and we'll go back a few millimeters  from the skin edge and take a nice bite perpendicular to the skin, and then on the opposite side, the same, and exaggerate that 90 degrees.  If you take it at 90 degrees, the skin edges will then evert and come together nicely. We'll set up a instrument tie, and you can see here, again, we do three throws for nylon,  and we'll go ahead and clip this. This is approximation without tension. You want to go back a couple millimeters for each bite.  If you go back too far, it'll tend to invert the skin, and we want to avoid that. So here again, exaggerate at 90 degrees on each side, make sure that we are back the  same distance on each side. An instrument tie, we do a surgeon's knot for the first, we cross the suture over, lay  it down nice and flat, don't pull up on it until we get the second suture down, and tighten it and lock it in. So this is the simple suture.  It's something that you'll need to practice a lot to master.  Next is a simple buried suture. This will be the main suture you'll use when putting some deeper sutures in before putting your skin suture in.  It's important to bury a suture that we start deep and go superficial and end up in the dermis without buttonholing the skin, and then on the opposite side, we're going to  do the opposite. We're going to go superficial and then deep, and if you want your knot to bury, it's important  that both ends are on the same side of the loop, and you see here's my loop, and here's the suture coming out from the same side.  As we tie this down, we'll do an instrument tie, but we'll pull it along the length of the wound, and that'll help the skin edges to come together.  We'll do a nice instrument tie, and what this does is it takes the tension off the skin so that when you go to do your skin closure, you really can work on approximation.  You can see here that that helps hold that together. Let's go ahead and do one more. You're going to go from deep to superficial without buttonholing the skin, and then go  from superficial to deep. Make sure that you're coming out on the same side of the loop, and we'll do our instrument  tie, and we'll pull it along the length of the wound so it'll allow it to bury. Back to the other side, and back to the other side.  That is our simple interrupted buried suture.  Next is the vertical mattress suture. Vertical mattress suture is a very useful suture, especially when wounds are hard to  close if they're under a lot of tension, or maybe there's a lot of swelling, or you anticipate swelling.  It's especially valuable when skin is you want to keep rolling in and you want to evert them.  Some will call this the far, far, near, near stitch, and this is the configuration of your suturing.  We're going to enter far from the wound, travel under the skin, come out far, and then come back and go near, near.  Essentially, you're taking this part of the skin and closing it to this part of the skin, and that's the power of the suture.  A simple suture is really relying on a much smaller area. So we'll start far and travel under the skin, and the same thing on the other side.  We'll turn our needle around, and now we'll go near and near. What you'll see when we tie this down is that this approximates and everts the skin edges,  and we can make it just as tight as we want. We have our granny knot, and that will hold it, and we'll square our knots. So I'll show you that one more time.  It's a vertical mattress suture, far, far, near, near. As you tie it down, decide how much tension you need to evert your skin edges and hold  things together, and that's your vertical mattress.  Our next suture is the horizontal mattress suture. Its configuration is horizontal as opposed to our vertical mattress. You can think of this as two simple sutures.  So in some of that sense, it's a simple suture, it just saves you some time. It's important here that you stay close to the skin edge, and that you're the same distance  on both sides. You'll take your bite on one side, and then the other side, and then you'll turn it around, and you'll go back, so you'll end up on the same side.  And there you can see our mattress. The advantage of this is speed compared to doing simple suture. It doesn't evert as effectively sometimes as a vertical mattress.  Here you see the way I've placed it, it's everting nicely. So that's one example of a horizontal technique. A variant of this is the figure of eight suture.  The figure of eight suture is the same distribution. You take your simple bite, and your simple bite, but rather than turning the needle around,  you move on and take your next simple bite, and simple bite. What that does, when you tie this, it'll make a small little eight, and that's why it's called a figure of eight suture.  The advantage of this again is speed. Instead of doing two simple sutures and tying two simple sutures, you'll see this sometimes  in some deeper closures, like fascial closures, because again you're grabbing a bunch of tissue to a bunch of tissue, and therefore it'll be more secure.  The final variant of the horizontal mattress is called a half-buried mattress, and we use this a lot in plastic surgery.  If there's an area where you don't want suture holes, you can actually start your horizontal mattress on one side.  On the opposite side, stay within the dermis in a horizontal fashion, in a subcuticular fashion.  Then come back on the other side, again out like you would in a normal horizontal mattress.  So effectively, it's your horizontal mattress, but half of it is buried, hence the name the half-buried horizontal mattress.  When you tie this here, it'll secure the skin, and you'll only have suture marks on one side.  You'll see we'll do this at times when we have a hair-bearing area and a non-hair-bearing area, and we want to hide the suture marks, or if it's a very end or tip of a flap, and  we're afraid that putting sutures in the tip is going to interrupt the blood supply. So our three variants of a horizontal, the straight horizontal mattress, the figure  of eight, and the half-buried horizontal mattress.  Our next stitch is a simple running suture. This will be the most common suture you'll use to close incisions.  It's a simple suture, so again, 90 degrees and 90 degrees, same bites on both sides, and you'll start with an instrument tie, and try to save length on your suture here.  You also want to measure the length of your wound, and make sure you're not working with such a long suture that it becomes unruly.  So you'll advance on the wounds in symmetric fashion, again, trying to take 90-degree bites  each time, trying to move along at the same pace and same amount each time, almost mimicking a sewing machine.  If you move along the same distance each time and take the same bites on each side, you have a beautiful cosmetic closure. People will ask, well, how much do you move along?  My answer is, as long as it's the same on both sides, it'll end up looking very nice. So be consistent in your bites.  Notice I'm exaggerating my 90 degrees, because I want this to evert. If I go too far back on the skin, or I take too shallow a bite, I'll end up inverting  the skin, and it won't heal correctly. Notice also I'm just pulling up enough on the suture, just so that the skin edges touch.  Pulling up on the suture very hard is just ischemic and can cause bad scarring. I'll end it with a simple little bite at the end, make sure we have enough tension along  the incision, and then do our instrument tie at the end. And this is a simple running closure.  A variation of the simple running suture is the simple running locking suture. We start off the same, simple bites, and a nice instrument tie, and this is a very helpful  suture when you're sewing under some tension, and especially when you don't have an assistant who can help hold the suture for you and follow you.  So take your simple bites again, 90 degrees, 90 degrees, evert the skin edges, but before you pull up, you'll make sure and actually lock the suture.  And take your simple bite, and simple bite, and again, before pulling up the last little bit, you'll lock your suture.  And you can go on from here, and the beauty of this is that, you'll see, although it's loose here, it is locking back here.  And so when you're under a lot of tension, especially, it'll hold for itself. Now sometimes I'll do a running stitch, and I don't plan on doing a running locking, but  at some point in the middle of the suture, it starts loosening on me, and then you can just throw in one of these locking sutures. Always keep it nice and tight.  So it's not a suture necessarily that you'll use primarily, because I think for scarring purposes you prefer a regular suture, and I will say also, as you become more and more  expert at suturing, you'll be able to control your simple suture much better, each time locking the suture.  And we're going to end this with a simple stitch, and again, when we tie this, we want to make sure we have good tension on the rest of the suture.  And that is our running locking suture.  Our next stitch is a running subcuticular suture. Out of all the sutures we're teaching you, this is probably the hardest to master.  This is probably for the most cosmetic closure, as you're running within the dermis deeply, so there's no sutures on the outside at all.  So you won't see any of the railroad tracking that you would see from any of the other outside sutures. This is an absorbable suture, and we will start by burying the knot.  So I'll go deep in the corner, away from the skin, maybe just the very deepest part of the dermis, and we'll do our instrument tie, and this allows the knot to be buried.  So we can suture over it. This is important because we don't want knots coming up to the skin. They can stick out.  It's called spitting, and patients do not like it when the knots spit. Now the knot is deep, so we're going to go deep, and then we're going to come superficial,  and that brings us right up to the corner, and this is where we're going to start our subcuticular run.  When you start or get close to a corner, I definitely recommend smaller bites to start. As you can see, I'm just within the dermis, a horizontal bite, and I'm going to advance  a little bit on the other side and take another small bite, again, stay well within the dermis. Now with this stitch, I'm always asked is, how much do you advance each time?  What I like to do is to see here with my suture where the next bite should be, and that's where I'm going to put it. So in some sense, it depends on how much tension there is.  On this wound, there's not a lot of tension. Now we're going to start to take regular bites on each side.  I'm trying to take the same depth and the same amount of tissue each time as we begin to advance.  Keep pulling everything up and keeping tension, and notice I'm not pulling up very tight either. We're just getting the skin to approximate, no button-holing of the skin.  This is just pure horizontal dermis. Wants to come right there. We're going to get a good bite of the dermis. Wants to come right there.  Just like when we started, as you begin to approach the corner, you want to stop taking such big bites and start going to some smaller bites because you really want the skin edges  to be well-approximated at the corner and not create any dog ears. We also want a barrier knot. So if we're on a barrier knot, we have to start thinking about now about getting deep  with both of the two ends that are going to get tied. So at this point here, I'm superficial, and I'm going to go superficial on this side and then head deep.  That'll get me down to sort of where we started, down deep. And I'm going to take one more bite that's deep, and I'm going to tie that, and that'll help to bury the knot.  And now what I'm going to do to help bury the knot as well is to cut the short end here right on the edge of the knot, and I'll take the needle and bury that knot further.  So I'm going to pick up here and see where that knot's going, and I can come out through the skin nearby and just simply pull up on this.  I can just cut it flush with the skin, and that helps to duck our knot from our suture. That concludes this course.  We at Duke feel strongly that excellent surgeons begin with excellent basic technique, and I hope you've learned some of that during this video.  Come back often as you begin to perfect your own technique. If you'd like to learn more about Duke Plastic Surgery or the Human Tissue Lab here at Duke,  visit us on the web at plastic.surgery.duke.edu.

Video Summary

The Duke Suture Skills course, led by Michael Zenn, aims to teach essential suture techniques for surgical residents and surgeons. The course covers various sutures, including simple, mattress, running, and their variations, emphasizing proper surgical and instrument tie techniques. Beginning with a basic instrument tie, participants learn to create and square knots without loosening them. Participants then explore different sutures: the simple interrupted suture for wound closure, simple buried sutures for tension relief, vertical mattress sutures for wounds under tension, horizontal mattress along with its variations, and more. Emphasizing the importance of 90-degree skin entry for neat edges, each technique is meticulously demonstrated for effectiveness and cosmetic appeal. The course concludes with the running subcuticular suture, noted for its cosmetic advantage as it leaves no external marks. The course is backed by Duke’s GME office and aims to instill fundamental skills for future skilled surgery.

Asset Caption

In this video, Michael Zenn, MD, demonstrates proper methods for multiple suture types. Simple interrupted suture, simple buried suture, vertical mattress suture, horizontal mattress (figure-of-8 & half buried) suture, simple running suture, simple running locking suture and subcuticular running suture are all covered and explained in close-up examples provided by the Director of the Human Tissue Lab at Duke University.

Surgeon Michael R. Zenn, MD This product is not certified for CME.

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