Bovis ISSN 2398-2993

Surgery: suture patterns - overview

Synonym(s): simple, interrupted, everting, inverting, apposing, continuous, Ford interlocking, vertical, horizontal mattress, cruciate, subcuticular, intra-dermal, staple, Aberdeen knot, sliding knot, Connell, Cushing, Lembert, Gambee, purse-string, Parker-Kerr, Halstead, Far-Near-Near-Far (Pulley), Far-Far-Near-Near, stent, quilled, Krackow, three-loop-pulley, ligatures.

Contributor(s): Vetstream Ltd , Paul Wood

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Introduction

  • Probably as many different suture patterns as there are suture materials. Patterns consist of two basic types:
    • Interrupted -  each stitch is cut and tied as a separate entity.
      • Advantages:
        • Allows precise adjustment of tension along the length of the wound.
        • Failure of a single knot may not cause wound to break down.
        • Suitable for all tissue types.
      • Disadvantages:
        • Time consuming to place.
        • More knots, therefore more suture material left in wound.
    • Continuous - knots are placed only at the beginning and end of a running line of continuous stitches.
      • Advantages:
        • Less time consuming than interrupted sutures patterns.
        • Less suture material left in the wound.
        • Relatively fluid and airtight.
      • Disadvantages:
        • Failure of securing or finishing knot likely to lead to unraveling of entire suture line.
  • Suture patterns can also be classified as evertinginverting and apposing:
    • Everting tends to turn the tissue edges outward.
    • Inverting sutures tend to turn the tissue inward.
    • Apposing sutures bring the tissue edges into direct contact without eversion or inversion.
  • Another differentiation in suture patterns is whether they are a simple or mattress (tension) suture:
    • Mattress patterns:
      • Close an incision under tension better than simple patterns.
      • May slow down healing by compressing tissue on each side of the incision, compromising local blood supply.
      • Designed to withstand more tension by spreading the tension over a wider area.
      • May be appositional, inverting, or everting depending on whether suture material is placed full or partial thickness within the skin edge.

Suture knots

  • There are some guiding principles of knot formation that should be followed:
    • Knots should be as small as possible to minimize foreign body reactions.
    • After the first loop is tied in a knot traction should be maintained to avoid loosening.
    • Extra knots do not add strength to an accurately tied knot.
  • Useful knots to learn:
    • Aberdeen knot: the Aberdeen knot has been shown to be stronger and more secure than a surgeon's knot for ending a suture line. The Aberdeen knot is also of a smaller volume than a standard surgeon's knot. An Aberdeen knot tied with 3 throws and 2 turns has been shown to provide the maximum level of security.
    • Sliding knot: useful for placing a ligature deep in a body cavity, it should always be covered with a square knot for security to prevent the knot loosening.

Skin Closure

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Muscle and fascia closing

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Hollow organ closure

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Tension sutures

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Tendon repair (anastomosis)

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Special Suture and Ligature Patterns

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Further Reading

Publications

Refereed papers

  • Recent references from VetMedResource and PubMed.
  • Duffy D J, Main R P, Moore G E, Breur G J, Millard R P (2015) Ex vivo biomechanical comparison of barbed suture and standard polypropylene suture for acute tendon laceration in a canine model. Vet Comp Orthop Traumatol 28 (4), 263-269 PubMed.
  • Wilson L, Banks T, Luckman P, Smith B (2014) Biomechanical evaluation of double Krackow sutures versus the three-loop pulley suture in a canine gastrocnemius tendon avulsion model. Aust Vet J 92 (11), 427-432 PubMed.
  • Moores A P, Owen M R, Tarlton J F (2004) The three-loop pulley suture versus two locking-loop sutures for the repair of canine achilles tendons. Vet Surg 33 (2), 131-137 PubMed
  • Weisman D L, Smeak  D D, Birchard S J, Zweigart S L (1999) Comparison of a continuous suture pattern with a simple interrupted pattern for enteric closure in dogs and cats: 83 cases (1991-1997). J Am Vet Med Assoc 214 (10),1507–1510.
  • Bellah J R (1994) Surgical stapling of the spleen, pancreas, liver, and urogenital tract. Vet Clin N Am: Small An Prac 24,375-393.
  • Kirpensteijn J, Fingland R B & Boyer J E (1993) Comparison of stainless steel fascial staples and polypropylene suture material for closure of the linea alba in dogs. Vet Surg 22,464-472.
  • Pavletic M M (1990) Surgical stapling devices in small animal surgery. Compend Contin Educ Pract Vet 12 (12),1724-1741.
  • Court M H & Bellenger C R (1989) Comparison of adhesive polyurethane membrane and polypropylene sutures for closure of skin incisions in cats. Vet Surg 18, 211-215.
  • Smeak D D & Wendelburg K L (1989) Choosing suture materials for use in contaminated or infected wounds. Compend Contin Educ Pract Vet 11 (4), 467-476.

Other sources of information

  • Bojrab M J (1988) Suture Use Manual. Copyright, Pitman-Moore Inc. pp 1-23.
  • Suture materials. (1987) In: Fundamental techniques in Veterinary Surgery.Eds C D Knecht et al. W B Saunders Co, Philadelphia. pp 39-71.
  • Boothe H W (1985) Suture materials and tissue adhesives. In: Textbook of Small Animal Surgery. Ed D H Slatter. W B Saunders Co. Philadelphia. pp 334-344.


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