IV. Basic wound-closing methods: sutures and clips
6. Methods of wound closure
6.1. Suturing with simple
interrupted knotted stitches
(skin and subcutis closure)
For simple interrupted stitches, a needle holder, a
curved needle (a 1/2 circle cutting needle) and 30-35 cm of thread are needed.
The subcutaneous tissue must be stabilized by gently
grasping it with tissue forceps 0.5 cm deep on the far side of the wound. The surgeon should insert the needle to- ward him- or herself, obliquely downward, 1–2 cm deep.
Suturing should be started with the hand pronated,
and the needle should be driven following its curva- ture by progressively supinating the hand until the point of the needle appears. The needle should ex- it the tissue perpendicular to the wound. With deep stitches, it can occur that the needle should be re- leased and regrasped. The surgeon must always see the point of the needle when possible.
When the point of the needle exits the tissue, the
needle should be grasped and stabilized with the forceps, then released and regrasped with the needle holder under the forceps and removed from the tis- sues. The point of the needle must never be grasped.
The free end of the thread is held by the assistant,
and the thread is pulled out from the needle. The needle closed in the jaws of the needle holder is passed to the scrub nurse.
The distance from one suture to the next should be
approximately 1–1.5 cm. The elevation of tissues with knotted sutures by the assistant may provide help toward insertion of the next suture.
All the stitches are cut just above the knots, only af-
ter the last one has been tied.
6.2. Suturing with Donati stitches
(skin closure)
For in vitro training and non-human practice #40
linen thread or nylon thread and a skin needle (a 3/8 or 1/4 cutting needle) are used.
The stitch takes both deep and superficial bites and
is useful for closing deeper wounds. The superfi- cial bite allows for a more exact apposition of the skin edges, and the inversion of wound edges can be avoided. The wound edge is grasped and stabilized with tissue forceps on the far side, and the needle is inserted ~ 1 cm from the edge, close beside the for- ceps. The stitch is continued on the other side. The needle should exit the other skin edge at the same distance (1 cm) from the wound.
The needle should be removed from the skin and the
point is turned into the opposite direction to make a back-handed stitch (the inner curvature of the nee- dle and the point are up). The needle is then grasped with the needle holder again. During these steps, the position of the needle holder remains unchanged.
The closer wound edge is elevated with the tissue for-
ceps, and a back-handed stitch is inserted 1–2 mm from the edge. The needle should leave the tissues be- tween the cutis and subcutis. The stitch is repeated in the far side wound edge, from inside to outside.
The thread is removed from the needle. The stitch-
es must be tied just tight enough to appose the edg- es without causing ischemia, taking into account that edema will occur during the next few days. The threads are cut after complete closure of the wound, but ~ 0.5–1 cm is left above the knots.
The wound should be disinfected with povidone-io-
dine or iodine tincture and covered with a bandage.
6.3. Wound closure with metal clips
(agrafe)
Metal clips made of stainless steel or titanium can also be used for the approximation of tissues. They can be ap- plied to close skin wounds and, for example to make gas- trointestinal sutures. In the case of skin, they can be used on fields without wound tension and where wounds tend to heal quickly (e.g. after appendectomy, strumectomy or hernia repairs). Clips can be applied to close the lumen of different tissues and organs (vessels, ducts, etc.). This method is also used in video-endoscopic surgery.
1. Clips fit into the jaws of a special grasping instru-
ment designed for their handling, the Michel clip ap- plicator and remover. The clip is grasped with the
forceps-like part of the applicator. The assistant ap- proximates and lifts up the opposite wound edges with two tissue forceps. The surgeon inserts the clip with the applicator between the two tissue forceps, perpendicular to the incision, with a definite move- ment. When compressed, the toothed tips of the clip are closed with the instrument. The distance between the clips is 1–1.5 cm. Clips are removed with the other end of the instrument. It is forbidden to close wounds of the hand or the hairy skin of the head with clips.
2. Skin wounds can also be closed with a modern, clip
applicator.
3. Staplers: These approximate tissues with staples in
one or two rows. The metal clips are pressed by the apparatus into the anvil of the opposite side, where they become crooked and are closed without crush- ing the tissues.
Linear stapler: This closes tissues with double
rows of staples in a straight line; it can also cut the tissues between the two rows (gastrointestinal and lung surgery).
Circular staplers: These can be used to approximate
tubular structures (esophagus or intestinal surgery).
Staplers are suitable for making purse-string su-
tures (intestinal surgery).
Vascular staplers use special 3-row clips for the
complete occlusion of vessels.
6.4. Other wound-closing methods
1. Surgical adhesives: These are usually produced from fibrin, collagen or thrombin and induce the last phase of blood coagulation, so that a firm fibrin mesh is pro- duced. Application fields: Anastomosis, securing vas- cular and nerve sutures, fixation of skin transplants and stopping bleeding (see later).
2. Wound closure with self-adhesive strips (Steri-Strip): These can be applied if the wound edges can be eas- ily and well approximated in the case of smaller wounds not requiring suturing. They are also used to fasten subcuticular sutures.
Disadvantages: Less precision is attained than with sutur- ing; body parts with secretions (armpits, palms or soles) are difficult areas; areas with hair are not suitable for taping.