Basic and special suturing techniques in
surgery
István Gál MD
Department of Surgical Research and
Techniques
Semmelweis University
Tissue approximation
• The surgical hand-made suture is one type of tissue
approximation
• If we perform the hand-made suture, the tissues are
approximated by stitches and the threads are knotted
• Accurate tissue approximation is essential for operative
surgical repair of defects. Aside from gentle handling of
tissues and careful dissection, the approximation must be
achieved without compromise of the integrity of the blood
supply essential to the healing process
Surgical sutures
Classification of suture types General rules of the stitches:
• According to layer: • not too close to the margin of the wound
one layer(if we approximate only one • stitches should be placed in the same
layer of tissues), two or more layers distance
• knots should be placed out of the wound
• According to depth: line
one or two lines (rarely more lines) • no wrinkles or gaps
• avoid the overturn of the edges of the
wound (exception purse-string ligature)
• According to length:
• no too strong pull of the threads to
interrupted or continuous suture line avoid the ischaemia of the tissues
Right keeping of the needle driver, grasping of the
needle and the stitch
Errors of the stitches
dead space insuffitient depth
no exact parity of the knot in the wound-line
wound margins
Basic surgical sutures
Simple interrupted suture (skin, fascia,muscle)
• Knot tying is performed after every single stitch. The tightness of the stitches
should be equal.
• Advantage: if one or two stitches get loose, the margins of the wound stay
together
• Disadvantage: time consumption, because of the more frequent knot tying
Basic surgical sutures
Vertical mattress suture (skin)
• This is the most frequent suture of the skin. Also known as Donati ‘s type suture.
We start with the stitch longer distance from the edges of the skin in the deeper
tissues, than the one we performed in the case of a simple interrupted suture.
Following this stitch we come back and conduct the needle into the edges of the
skin. This will result an exact parity of the skin margins. The thread is placed
vertical to the wound.
Basic surgical sutures
Vertical mattress suture (Allgöwer)
• This is a special form of the vertical mattress suture. The suture is similar as the
Donati’s suture. The difference is that the thread stays in the deep side of the
wound and doesn’t come out to the surface of the skin and runs intracutaneous.
Basic surgical sutures
Horizontal mattress suture
• This is a double stitch, as presented previously, but in this case the stitch comes
back about 1 cm from the starting point and the thread runs parallel in the same
layer.
Basic surgical sutures
Simple running suture (peritoneum, mucosa,
gastrointestinal tract)
• This type of sutures are used generally for the tension free tissues. Advantage : we
can perform it quickly, knot tying is necessary only at the start and at the end of
the suture line. Tenson is divided equally between the stitches, if the thread is
conducted right. Disadvantage: if one loop gets loose, or in the case of wound
infection and the suture must be removed, we have to take into consideration the
full dehiscence of the wound
Basic surgical suture
Halted running suture
• This form of running suture is similar to the previously presented, with the
difference that the thread must be passed under the thread on the opposite side
before the next stitch. In such manner we can avoid the looseness of the suture.
Basic surgical sutures
Intracutaneous running suture
• This type of suture result a very good scar and aesthetic outcome. We can use it
for the closing of the wounds of the skin. The thread runs in the dermis
approximately parallel with the surface of the skin. The thread is on the surface of
the skin at the fore- part and at the end of the wound, which is stuck or knotted
itself.
Basic surgical sutures
Pure-string ligature (tobacco bag suture)
• This is a special form of the running sutures which is frequently used in the gastro-
intestinal tract surgery. We use it e.g. in open appendectomy in the daily surgical
practice. The stump of the appendix following appendectomy is handled by
tobacco bag suture. If we pull and tie the circular form placed suture, the opening
will be closed.
Tissue approximation in more layers
cross section of an abdominal wall incision
Knot tying with hands
Classical surgical knot tying Knot tying „ Viennese” technique
Knot tying with instrument
Other methods of tissue approximations
Special suturing technique
Microsurgery
Special suturing techniques
Laparoscopic surgery
Setup for suturing in endoscopic surgery. The optical port is positioned
between the instrument ports.The triadic relationship between the two
instruments and suture lines is important
Needle deflection and alignment for tissue
penetration
Steps of the intracorporeal knot tying
Steps of intracorporeal knot tying
Steps of intracorporeal knot tying
Steps of intracorporeal knot tying
Steps of intracorporeal knot tying
Steps of intracorporeal knot tying
How can we use it in the clinical practice?
