Sutures are applied with a view to maintaining the coaptation of divided structures. This is necessary to facilitate repair and restore function. Suturing serves the additional purpose of checking hemorrhage from the smaller vessels. Various materials are used, some quite commonly, others rarely and for a certain purpose; catgut, silk, silkworm-gut, silver wire, kangaroo tendon, and horsehair. The three first named will meet all the requirements of the emergency surgeon.
No material is available which does not have a certain strength and which cannot be made aseptic. For emergency work, these materials must be already prepared. The creation of a proper suture from the raw material is a matter of time and care. The general practitioner will do better to buy his sutures put up in form available for immediate use, being first assured that they come from a reliable source and are put up in a manner to keep them sterile.
<Callout type="important" title="Selection of Sutures">Catgut is the ideal material for buried sutures. It has ample strength and can resist absorption in certain tissues for a certain time, but occasionally becomes practically unabsorbable and acts as a foreign body.</Callout>
Sutures may be applied using various methods: interrupted subere, continuous suture, quilled, quilted (Fig. 16), twisted, and button sutures.
The continuous suture is used in aseptic wounds only. Therefane, accidental wounds will only, on rare occasions, permit its employment. It has the advantage of being very rapidly applied, but is less sure than the interrupted suture. A little practice is essential, for it is more difficult to do well.
This is the mode of making the continuous suture: Commence by passing the suture at the upper angle of the wound. Make three successive knots. Two are sufficient for catgut. The short thread is caught in forceps and retained till the suture is completed, at which time it is cut off close to the knot (Fig. 12).
The needle traverses successively and obliquely, first the one lip of the wound and then the other; each time the assistant seizes the thread at the point of emergence, and holds it tightly until the surgeon makes a new point of emergence, when the assistant takes a new hold. In this manner, the tension of the suture is made absolutely uniform.
The mode of arrest of the continuous suture (Fig. 12). In making the terminal knot, the suture must not be allowed to relax. To accomplish this, the surgeon slips the index finger in the last loop instead of pulling the thread all the way through, as was done with all the others. Traction with this finger holds the line of suture tight while the terminal thread on the one side is knotted three times with this loop on the other side (Figs. 12, 13).
If the continuous suture is long, its stability is insured by crossing the threads at the middle of the line of suture (Fig. 14). The suture is thus interrupted at its middle in this manner: the needle is simply passed back under the last loop, at the time care being taken that the suture does not slip. The succeeding steps are the same as before (Figs. 15, 16).
The suture is completed, the loose ends are cut off close to the knot.
<Callout type="tip" title="Continuous Suture Technique">Practice is essential for a successful continuous suture; it requires uniform tension and careful handling of the thread.</Callout>
The interrupted suture is generally employed in suturing the skin, and may be of silk, silkworm-gut, silver, etc. It must not be absorbable. These sutures may be placed deeply or superficially, in the one case where there is much tension, in the other for mere approximation. The deep sutures are placed two or three centimeters apart.
The needle is entered one centimeter from the edge and emerges the same distance from the other side. The thread is concealed through most of its extent (Fig. 17). None is tied until all are passed. The lips of the wound are brought together as the knots are tied (Fig. 18).
A few superficial catgut sutures may be necessary if the edges do not completely approximate, They are passed through the thickness of the skin alone and very close to the edge of the wound (Fig. 19). No knot should be drawn too tight; it may interrupt the circulation and defeat repair. The knot should be made to one side of, and not over, the wound (Fig. 20).
<Callout type="warning" title="Suturing Technique">Avoid drawing knots directly over the wound as it can interfere with healing.</Callout>
Tf all goes well, the sutures may be removed toward the eighth day. Remaining too long, they favor infection.
Method of Removing Sutures.—Seize the loop with a dissecting forceps held in the left hand. With a pointed scissors divide the thread close to the skin, being careful not to cut between the knot and the forceps, else an effort will be trying to pull the knot through the skin.
Suppose, in spite of care, infection occurs. The temperature reaches 100 1/2° on the following day. On the second day following, it is little higher. Upon removal of the dressing, the skin around the wound is found to be reddened and swollen. Remove two or three of the middle sutures at once Secure drainage and use a wet dressing. This will usually check the infective process and pass formation.
<Callout type="risk" title="Infection Risk">If infection sets in, it can lead to serious complications such as sepsis and delayed healing.</Callout>
The subcutaneous suture is of great service in aseptic operative wounds, wherever it is especially desired to prevent a scar. It is made in this manner: Introduce a small needle threaded with catgut, one-fourth inch above the upper angle of the wound, and let it penetrate the skin and emerge exactly at the upper angle. It next penetrates the face of the skin incision, taking bite first on one side and then on the other exactly opposite (Fig. 21). At the end, the needle traverses the skin at the lower angle of the wound in the same manner as it entered at the upper angle; the sutures are then tightened (Fig. 22) until the edges of the wound are exactly coapted. The ends are secured from slipping either by knots or by pasting them down with collodion or adhesive plaster. If the thread is not absorbed, it may be removed about the sixth day by clipping one end close to the skin and then gently drawing it from the other end.
Cannaday (J. A. M. A., Jan. 4, 1998) uses pagenstecher linen and after starting the suture secures the loose end by a half bow knot. The terminal thread is secured in the same way and slipping or loosening is thus prevented.
Key Takeaways
- Catgut, silk, silkworm-gut, silver wire, kangaroo tendon, and horsehair are used for suturing wounds.
- The continuous suture is more rapid but less sure than the interrupted suture; practice is essential.
- Sutures must be aseptic to prevent infection in emergency situations.
Practical Tips
- Always ensure that your sutures are from a reliable source and sterile before use.
- Practice the technique of continuous suturing to achieve uniform tension and avoid mistakes.
- Use interrupted sutures for deep wounds where there is much tension, ensuring proper approximation.
Warnings & Risks
- Drawing knots directly over the wound can interfere with healing and should be avoided.
- Infection can occur if sutures are not properly managed; secure drainage and use wet dressings to prevent it.
- Avoid using absorbable sutures in wounds where there is pus, as this can lead to complications.
Modern Application
While the techniques described here are rooted in historical practices, many of the principles still apply today. Modern medical advancements have improved sterilization methods and materials, but the importance of aseptic technique remains critical for preventing infection. Understanding these foundational skills is invaluable for anyone preparing for emergency situations where immediate medical care may not be available.
Frequently Asked Questions
Q: What are the key differences between catgut and silk sutures?
Catgut is ideal for buried sutures as it can resist absorption, while silk sutures are non-absorbable and used in large wounds where tissues tend to spread apart.
Q: How should one handle a continuous suture if infection occurs?
If infection sets in, remove two or three of the middle sutures at once, secure drainage, and use wet dressings to check the infective process and prevent further complications.
Q: What is the purpose of using subcutaneous sutures?
Subcutaneous sutures are used to prevent scars in aseptic operative wounds where a clean appearance is desired.