What is the optimal tension for deep sutures?

Optimal Tension for Deep Sutures

Deep sutures should be placed with moderate tension that ensures adequate tissue approximation while avoiding excessive compression that could lead to tissue ischemia and necrosis. 1

Principles of Deep Suture Tension

Optimal Tension Guidelines

• Moderate tension: Deep sutures should be tight enough to approximate tissues but not so tight as to cause tissue compression and damage
• Even distribution: Tension should be distributed evenly along the wound edges 1
• Avoid tissue strangulation: Excessive tightness can damage blood supply to wound edges, leading to:
  • Tissue devitalization
  • Wound edge separation
  • Increased risk of infection
  • Delayed healing

Scientific Rationale

The 2023 World Society of Emergency Surgery guidelines emphasize that with excessive tension:

1. Soft tissue compression can occur when combined with increased intra-abdominal pressure 1
2. This compression results in slackening and separation of wound edges
3. A separation of wound edges greater than 10-12mm during early postoperative period strongly correlates with incisional hernia development 1

Technical Considerations

Suture Placement Technique

• Small bite technique is recommended for fascial closure:
  • Approximately 5mm from wound edge
  • Approximately 5mm between stitches
  • This allows for adequate distribution of tension on incision edges 1
  • Includes only aponeurosis (not fat or muscle)

Suture Material Selection

• Monofilament sutures are recommended for deep tissue closure 1
• Slowly absorbable materials are preferred for deep fascial closure 1
• For delicate structures like bile ducts, 5-0 or 6-0 fine suture needles should be used 1

Common Pitfalls to Avoid

1. Excessive tension:

   • Causes tissue ischemia
   • Leads to wound dehiscence
   • Increases risk of surgical site infection

2. Insufficient tension:

   • Results in inadequate tissue approximation
   • Allows dead space formation
   • May lead to seroma or hematoma formation

3. Uneven tension distribution:

   • Creates stress points along the wound
   • Leads to irregular scarring
   • Increases risk of partial dehiscence

Special Considerations

• For large defects, tension should be placed on deep and superficial fascia rather than dermis 2
• Buried sutures should be placed beside the wound without tying until surface approximation is achieved 3
• The anastomotic stoma should be tight enough to prevent leakage but not so tight as to damage blood supply 1

The ideal suture technique follows principles of "single-layer stitching, uniform margins, appropriate density, moderate knotting strength, and anastomosis without tension" 1, ensuring wound edges are properly approximated while maintaining adequate blood supply to promote optimal healing.