Suturing 101: It's All About the Knots

Earlier this week, I began exploring the basics of suturing, types of needles and "thread".  Now that you know the basics of selecting your suture materials, grab a needle holder, some scissors, a pack of whatever suture material you can find and a banana (or a pig's foot but my guess is you don't have one lying around your house) and let's tie some knots.

Suturing Instruments

There are a few things you will need to begin suturing besides the packet of suture itself.  First, you will need a needle holder used to grasp the suturing needle and place it in the skin.  Secondly, you will need forceps to help grab the needle on the opposite side of the skin.  Finally, suture scissors will be necessary to cut the suture.  Most hospitals and clinics provide sterile suturing packets containing all of these instruments prepackaged. 

The suturing needle should be held in the needle holder at it's midpoint, where the curve is relatively flat to prevent the needle from bending as it passes through tissue.  There is some special technique to handling the needle holder so be sure to watch the video at the end of this post for instruction. 

Before You Suture

Always, always, always thoroughly cleanse any laceration before suturing.  Check for foreign bodies and other complications such as tendon involvement.  If you suspect bony involvement or a foreign body, order an X-Ray of the area before closing it with sutures.  Even seemingly simple wounds can present complications so you must be thorough in your exam before suturing.  And, of course, prepare the laceration in sterile fashion.

Suture Placement

Before you start suturing a laceration, you need to know where your sutures will go.  On nearly all areas of the body except the face, sutures should be placed 3-4 mm from the wound edges with 5-10 mm between each suture.  On the face, sutures should be made smaller and closer together.  Sutures on the face are placed 2-3 mm from the wound edge and 3-5 mm apart.

You should start placing your suture on the wound edge farthest from you, sewing toward yourself.  This makes the process easier from a biomechanics standpoint.  Make sure you pull both edges of the wound together to meet so they can heal properly.  Avoid creating inversion where one edge of the wound curls under as this will delay healing.  If you pull the wound edges together properly, the layers of skin on each side of the wound, dermis and epidermis, will align facilitating quick healing. 

Let's Tie Some Knots!

Enough background information.  Time to place some sutures and tie some knots.  The most basic type of suture is the simple interrupted suture.  This technique is commonly used on the skin and is likely what you will use most as a nurse practitioner.  Here are the steps to placing simple interrupted sutures:

  1. Insert the needle at a 90 degree angle to the skin.  Turn your wrist guiding the needle through the tissue.
  2. Pull the needle out through the other side of the skin at an equal distance from the wound edge.  Leave a few inches of suture "thread" at the wound edge where the needle entered the skin.
  3. Tie a knot by loosely wrapping the long end of the suture "thread" twice around the lower third of your needle holder.  Then, grasp the short end of the "thread" pulling it through the two loops of suture tying a knot.  Repeat twice more, this time wrapping the long end of the suture around only once.

Suture Removal

Sutures should be removed in a timely manner to prevent infection ad suture marks.  In general, sutures on the face should be removed in 5-7 days, 7 days on the neck, 7 days on the scalp, 10-14 days on the trunk and upper extremities and 14-21 days on the lower extremities.  If sutures are removed too early, wound edges may spread resulting in increased scarring. 

Ok, let's be honest.  Even after reading the above instructions for placing simple interrupted sutures, if you have never placed sutures before you still probably have no idea what you are doing.  Fortunately, I found this video demonstration:

The best thing you can do to perfect suturing technique is to practice.  Cut a slit into a banana peel and borrow some sutures from your nurse practitioner school, clinic or hospital.  If you don't have access to extra suturing material, you can buy a practice suturing kit on Amazon.  The more you practice, the more comfortable you will feel suturing in the real world.  

 

Comments

Link to practice suturing kit on Amazon not working.

For myself, I found this one: https://www.theapprenticedoctor.com/suture-kit/

Viktor Velychko

 

Hi Austin,

The answer is not all.  Many nurse practitioners have the opportunity to learn to suture in their NP program particularly in their clinical hours.  Some do not.  If you are an NP and did not learn to suture, you may still learn how on the job.  Just make sure someone experienced can teach you and supervise you as you learn.

Erin Tolbert

Are all Nurse Practitioners taught how to suture as apart of their education?

Austin