What are the best suturing techniques to use for wound closure, and can videos be used to learn them?

Optimal Suturing Techniques for Wound Closure

Use continuous subcuticular sutures with slowly absorbable monofilament material (4-0 poliglecaprone or polyglactin) as your primary technique for skin closure, as this reduces wound dehiscence by 92% compared to interrupted sutures while causing less pain and eliminating the need for suture removal. 1, 2

Core Technical Approach

Continuous suturing is superior to interrupted techniques for the following reasons:

• Dramatically reduces superficial wound dehiscence (RR 0.08; 95% CI 0.02-0.35), meaning only 3.7% of patients experience this complication overall, with 22 of 23 cases occurring in the interrupted suture group 1, 2
• Decreases postoperative pain for up to 10 days (RR 0.76; 95% CI 0.66-0.88) and reduces analgesic requirements (RR 0.70; 95% CI 0.59-0.84) 1
• Eliminates suture removal (RR 0.56; 95% CI 0.32-0.98), which is a significant patient benefit 1
• Distributes tension evenly across the entire wound length, preventing focal points of stress that lead to tissue ischemia 1
• Improves sexual function at 3 months postpartum in obstetric wounds 1

Step-by-Step Technique for Layered Wound Closure

Layer 1: Deep Tissue and Fascia

1. Anchor your suture above the apex of the wound in the deepest layer 1
2. Use continuous, non-locking sutures in a running fashion to close deep layers 1
3. Maintain a 4:1 suture-to-wound length ratio to minimize incisional hernia and complications 2
4. Reapproximate muscles in the axial plane, parallel to muscle fibers, using the same continuous technique 1

Layer 2: Skin Closure

1. Transition to subcuticular plane at the level of the hymenal ring (for perineal wounds) or dermal-epidermal junction 1
2. Run continuous, non-locking, subcuticular sutures back toward the starting point 1, 2
3. Keep sutures in the deep dermal layer to avoid nerve endings on the skin surface, which causes pain 1
4. Never lock your sutures, as this creates excessive tension leading to tissue edema and necrosis 1

Material Selection

Choose slowly absorbable monofilament sutures that retain 50-75% of their original tensile strength after 1 week in situ 1, 2:

• 4-0 poliglecaprone (preferred) 1, 2
• 4-0 polyglactin (alternative) 1, 2

This extended support period is the primary reason continuous sutures outperform interrupted techniques, as the wound receives mechanical support beyond the typical 7-9 day period when non-absorbable sutures would be removed 1

When to Use Alternative Techniques

Interrupted Sutures

Reserve interrupted sutures for situations requiring precise wound edge approximation in irregular wounds or when you need the ability to selectively remove individual sutures 3, 4

Vertical Mattress Sutures

Use vertical mattress technique when you need 3, 4:

• Excellent wound edge eversion
• Closure of dead space
• Maximum mechanical strength (though this requires 7.25 N pulling force versus 5.69 N for simple sutures) 5

Pulley Sutures

Consider pulley or modified pulley sutures for high-tension wounds, as they require significantly less pulling force (3.46 N and 4.52 N respectively) compared to other techniques 5

Contaminated or High-Risk Wounds

Use triclosan-coated antimicrobial sutures in contaminated wounds or when infection risk is elevated, as they reduce surgical site infection by 28% (OR 0.72; 95% CI 0.59-0.88) 2, 6

Critical Pitfalls to Avoid

• Never use rapidly absorbable sutures for fascial closure, as they dramatically increase incisional hernia rates 2
• Never pull continuous sutures too tightly, as this strangulates wound edges and causes ischemia 2
• Never use tissue adhesives alone in high-tension areas, as they have a 3.35-fold higher risk of dehiscence (95% CI 1.53-7.33) compared to sutures 2, 7
• Never remove non-absorbable sutures before 7-9 days for most surgical wounds, as premature removal causes dehiscence 1, 2
• Avoid transcutaneous interrupted sutures when subcuticular continuous sutures are feasible, as they damage nerve endings and cause more pain 1

Alternative: Skin Adhesive Option

Consider leaving skin unsutured or using skin adhesive after closing deeper layers, as this results in no difference in pain but significantly shorter procedure duration (P=0.001) 1. However, recognize that you need to treat 43 patients with sutures instead of adhesive to prevent one additional dehiscence 2, 7.

Video Learning Resources

While the provided evidence does not specifically address video-based learning of suturing techniques, the technical steps outlined above can be effectively learned through video demonstration, particularly for visualizing:

• Hand positioning for continuous suturing
• Needle angle and depth for subcuticular placement
• Tension management throughout the suture line
• Transition points between tissue layers 1

Master the continuous subcuticular technique first, as it provides the best outcomes across multiple metrics and is applicable to the majority of wound closures you will encounter in practice 1, 2.