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Suturing - How to Suture a Wound

 

No matter if you practice in family medicine, emergency medicine, a surgical subspecialty, or urgent care, there is a common procedure that a provider must know how to complete efficiently.  This is knowing how to suture a wound. 

Today we will be discussing everything from:

  • Suture selection
  • Duration that sutures should remain in tissue
  • Suturing basics. 

So, let’s dive in!

Suture Size Selection

The first thing that a provider must decide when beginning to suture a wound is the type and size of the suture that would work best, or what your preference may be.  You might hear a colleague or preceptor rattle off “give me a 4-0 Vicryl on a PS-2”, but what does this even mean?

The number, “4-0” refers to the size of the suture fiber. Vicryl is the type of suture, and PS-2 is the type of needle that the suture is attached to.

4-0 Vicryl Suture

When to Use Smaller Sized Sutures (10-0, 9-0 and 8-0)

Next, for the size, the larger the number, the smaller the size of the fiber.  Sutures that are 10-0, 9-0, and 8-0 are typically used in the most delicate surgeries. Commonly these are used in ophthalmic surgeries and for repairing small damaged nerves as well as in lacerations of the hand.

When to use 7-0 and 6-0

Sutures that are sized 7-0 and 6-0 are often used for repairing small vessels and arteries or for delicate facial plastic surgery.  Other common uses may include vascular graft sewing, such as in a carotid endarterectomy.

When to use 5-0 and 4-0; and 3-0 and 2-0

5-0 and 4-0 sutures can be used in larger vessel repairs such as in an abdominal aortic aneurysm repair or skin closure. 

Sutures sized 3-0 and 2-0 are used in skin closure when there is a lot of tension on the tissue, closure of muscle layers, or repair of the bowel in surgery.

Suture Material Selection - Absorbable

The material in which the suture is comprised matters regarding if the suture will dissolve or not.  Some dissolvable sutures include:

  • Vicryl Rapide
    • 2 weeks
  • Undyed Monocryl
    • 3 weeks
  • Dyed Monocryl
    • 4 weeks
  • Coated Vicryl
    • 5 weeks
  • PDS
    • 9 weeks
  • Panacryl
    • 70 weeks

The rate in which a suture dissolves is dependent upon the suture type, size, and location in the body where the suture is placed. Additionally, some characteristics within the patient can affect how fast the suture will dissolve as well.  If a patient is febrile, has an infection, protein deficiency, or if the suture is under high tension, the suture may dissolve faster.

Non-absorbable

Additionally, there are non-absorbable sutures as well, in which these often lie on the skin and must be removed.  If they are within the body, “buried”, they will be retained in the tissue. Uses for non-absorbable sutures include:

  • Interrupted skin suturing when sutures will be removed later
    • 4-0 Nylon
  • Securing drains to the skin
    • 2-0 Silk
  • Repairing sutures for blood vessels
    • 6-0 Prolene
  • Vessel graft sutures for AAA, Femoral-Popliteal graft, or Carotid Artery grafts
    • 5-0, 6-0 Prolene or Gortex
  • Bowel repair sutures
    • 3-0 Silk
  • Achilles tendon repair
    • #5 Ethibond or Fiberwire

Braided Sutures vs. Non-braided or monofilament

The last two qualities to consider when choosing a suture is whether you would like the suture to be braided, and what type of needle that you would like to use.  Braided sutures have strands that are woven together, such as Silk, Vicryl, and Ethibond. Non-braided or monofilament sutures have a single strand, and can include Monocryl, PDS, and Ethicon Nylon.

So, which do you choose?  It is typically provider preference.  Non-braided sutures cause less reactivity in the body, and are also not as prone to infection due to the lack of rough surface for bacteria to adhere to.  Braided sutures have less of a tendency to loosen at the surgical knot surface, are stronger, and also provide a better grip on the tissue being sutured.

 

Needle Type - Tapered vs Cutting

As for the needle, tapered needles are used inside of the body, such as on bowel, fascia, or muscle where the tissue is more easily pierced.  Options can include TP, CTX, CT, SH, CV, or BV.

Cutting needles are used for skin and very tough tissue, such as on bone and tissue.  Cutting needle options may include FSLX, FSL, FS, PS, or P3.

 

How long do my sutures need to stay in for?

A common question after you suture a wound for a patient is, “how long do these need to be in for?"  Well, if you choose an absorbable suture, they will dissolve on their own without removal.  However, if a non-absorbable suture is chosen, then the length of time in which the suture needs to remain in depends on the location.

Timing of Suture or Staple Removal
Am Fam Physician. 2017;95(10):628-636. Copyright © 2017 American Academy of Family Physicians

 

As you can see in the above table, sutures that are in the face can be removed after 3 to 5 days, whereas sutures that are in thicker areas of skin, such as the palms or soles of the feet should remain in 14 to 21 days before removal.

 

How to suture a wound

Lastly, we will go over briefly one way how to suture a wound as well as suturing basics.  Below is a detailed description of a simple interrupted suture placement or instrument knot tie.

Instrument Tie Part 1

Instrument Tie Part 2

 

Photo Description of how to tie a suture

Instrument Tie Steps

Finally, I have attached a link here to a how to suture video.  If you have any questions about suturing, feel free to reach out to us at Medgeeks!

Sources

  • Am Fam Physician. 2017;95(10):628-636. Copyright © 2017 American Academy of Family Physicians
  • Pfenninger and Fowler’s Procedures for Primary Care
  • Family Practice Notebook
  • Surgical Instruments and Suture Material Lecture. Southern Illinois University School of Medicine Physician Assistant Program

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