What suturing techniques are used in different clinical situations?

Suturing Techniques for Different Clinical Situations

Continuous subcuticular suturing is the preferred technique for most wound closures as it reduces wound dehiscence, distributes tension more evenly, and provides better cosmetic outcomes compared to interrupted sutures. 1

Skin Closure Techniques

Continuous Subcuticular Technique

• Best for: Most skin closures, especially when cosmesis is important
• Benefits:
  • Less pain for up to 10 days postpartum 1
  • Reduced need for analgesia 1
  • Reduced need for suture removal 1
  • Lower risk of wound dehiscence 1, 2
  • Better distribution of tension across the suture line 1
  • Improved postpartum sexual function at 3 months (in obstetric cases) 1
• Technique:
  • Use 4-0 or 5-0 slowly absorbable monofilament sutures (e.g., poliglecaprone) 1
  • Place stitches 5mm from wound edge and 5mm apart ("small bite" technique) 1
  • Non-locking technique preferred to avoid tissue edema and necrosis 1

Interrupted Sutures

• Best for:
  • High-tension wounds
  • Contaminated wounds where partial wound breakdown may occur
  • Facial wounds requiring precise edge alignment
• Technique:
  • Use non-absorbable monofilament sutures (e.g., polypropylene, nylon) for facial wounds 3, 4
  • Remove facial sutures after 5-7 days to prevent permanent suture marks 5

Specific Clinical Situations

Abdominal/Laparotomy Closure

• Recommended approach:
  • Use slowly absorbable sutures rather than rapidly absorbable ones 1
  • Employ "small bite" technique (5mm from edge, 5mm between stitches) 1
  • Maintain suture length to wound length ratio of 4:1 or higher 1
  • Use monofilament sutures rather than multifilament 1

Perineal Laceration/Episiotomy Repair

• Second-degree lacerations:
  • Close in layers: vaginal epithelium → perineal muscles → perineal skin
  • Use continuous non-locking technique for all layers 1
  • Anchor suture above apex of laceration in vaginal epithelium 1
  • Use crown stitch to reapproximate bulbo-cavernosus muscles 1
  • Finish with subcuticular stitch from inferior perineal margin to hymen 1

Obstetrical Anal Sphincter Injuries

• Sequential closure from deep to superficial:
  1. Anorectal mucosa: 3-0 or 4-0 delayed absorbable sutures (continuous or interrupted) 1
  2. Internal anal sphincter: End-to-end repair with mattress or interrupted sutures 1
  3. External anal sphincter: Either end-to-end or overlapping technique 1
  4. Rectovaginal fascia, perineal body, skin, and vaginal tissues 1

Diaphragmatic Hernia Repair

• Technique:
  • Use interrupted non-absorbable 2-0 or 1-0 monofilament or braided sutures in two layers 1
  • For defects >3cm, reinforce with mesh to prevent recurrence 1
  • Consider biosynthetic, biologic, or composite meshes due to lower recurrence rates 1

Facial Wounds

• Technique:
  • Use 5-0 or 6-0 monofilament sutures 3, 4
  • Consider absorbable sutures for children to avoid the trauma of suture removal 3
  • Remove sutures after 5-7 days to minimize scarring 5

Suture Material Selection

Absorbable vs. Non-absorbable

• Slowly absorbable sutures:

  • Recommended for most wound closures 1
  • Retain 50-75% tensile strength after 1 week 1
  • Provide extended wound support without requiring removal 1, 2
  • Examples: polyglactin (Vicryl), poliglecaprone (Monocryl), polydioxanone (PDS)

• Non-absorbable sutures:

  • Best for facial wounds and high-tension areas 3, 4
  • Require removal (5-7 days for face, 7-14 days for other areas) 5
  • Examples: polypropylene (Prolene), nylon (Ethilon)

Monofilament vs. Multifilament

• Monofilament sutures:
  • Recommended for most wound closures 1
  • Cause less bacterial seeding and lower infection risk 1
  • Smoother passage through tissues

Common Pitfalls and Caveats

1. Excessive tension:

   • Can lead to tissue ischemia, necrosis, and wound dehiscence
   • Use "small bite" technique and maintain proper SL/WL ratio in abdominal closures 1

2. Inappropriate suture removal timing:

   • Too early: risk of wound dehiscence
   • Too late: permanent suture marks, increased scarring, higher infection risk 5

3. Incorrect suture selection:

   • Avoid rapidly absorbable sutures for laparotomy closure 1
   • Don't use multifilament sutures in contaminated wounds due to higher infection risk 1

4. Improper technique in specialized areas:

   • Diaphragmatic repairs require specific techniques to prevent recurrence 1
   • Anal sphincter injuries need proper identification and repair of both internal and external sphincters 1

By selecting the appropriate suturing technique and material for each clinical situation, you can optimize wound healing, minimize complications, and improve cosmetic outcomes.