Sterile Suture Techniques

Sutures are the most functional way of closing a wound or incision to promote rapid healing, prevent

infection, and preserve function of bodily tissues. Sutures are also helpful in allowing wounds to heal

with the least amount of scar and deformity to an area. By bringing the edges of an incision/wound

together, suturing helps fibrin - a component of blood coagulation - to form a framework for molecules

that will eventually fill the wound. This process expedites clotting and helps establish a barrier to

bacterial invasion quicker than a natural healing process. Because of this, suturing is a very important

process that requires knowledge of not only wound healing, but also suture materials to help expedite the

healing process. Many different types of suture materials and suture needles are available for commercial

use, and knowledge of these different types of material and proper suturing techniques is essential for the

healing process. Information on these different types of needles and suture available can be found below,

along with instructions for practicing the simple suture technique, square knot tying, and suture removal.

Materials □ Suture material and suture needle (see below for determining size and material necessary)

□ Needle holders

□ Standard suture scissors

□ Gloves

□ Materials to practice suturing (Ex: Banana, peach, suture board, etc.)

Determining Correct Suture Needle Size and Suture Material

Needles ◘ Needles are made of steel alloy (Surgalloy) with a

NuCoat coating so they stay sharp for multiple passes

though tissue

◘ The appropriate needle choice for any situation is the

needle that will cause the least possible amount of

trauma to the tissue being sutured

◘ Different needle points are used for different tissues

◘ Use the two tables provided below to determine which

needle point geometry would be best for use in a specific

tissue

Monofilament

Multifilament (Braided)

Suture Material ◘ A suture is a thread used for uniting wound edges.

◘ Suture materials can come in pre-packaged, sterilized units

with the needle tip attached or on a spool of suture material

from which the needle must be tied on to the sutures.

◘ Suture material packaging always contains information

pertaining to the size of the strand, material, needle size and

shape (if pre-attached), and other necessary information

◘ Qualities of suture material:

□ Adequate tensile strength

□ Flexibility and elasticity

□ Easy to handle

□ Knotable

□ Easily sterlisable

◘ Characteristics of suture according to behavior in tissue:

□ Absorbable – suture that is absorbed or digested by

the body cells and tissue fluids in which they are

embedded and after the healing process.

Ex: catgut, collagen

□ Non-absorbable – suture materials that cannot be

absorbed by the body cells or fluids. They are removed

after healing is complete.

Ex: silk, stainless steel, nylon

◘ Characteristics of suture according to structure

□ Monofilament – single thread, no capillary action, less

infection risk, smooth tissue passage, higher tensile

strength, has memory, more throws required

□ Multifilament (Braided) – multiple threads braided

together, has capillary action, increased infection risk,

less smooth passage, less tensile strength, better

handling, better knot security

Simple Suturing Technique

1. Begin by making sure all materials are accounted for. Set

suture tools to one side and put on the gloves.

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2. To open the suture material package, find the end that is

slightly separated. Grab one flap in each hand and slowly

pull apart to open the package.

NOTE: The inside of the package is sterile, whereas the

outside of the package is not. In a real life sterile

situation, you should have someone else open the

package for you but for learning purposes in a non-

sterile environment, opening the package yourself is

okay

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3. After opening the suture packaging, grab the needle portion

with needle holders and pull out the suture material from the

package.

NOTE: In the end, you should have an empty outer

package, an empty inner package, and your suture

material ready to use on your practice suture surface.

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4. Begin by holding the needle about ¾ from the end with the

needle holders

CAUTION: Although you may use your fingers to

handle the needle in order to correctly position it within

the needle holders, be careful not to stab yourself with

the needle as it could cause bodily harm and will also

desterilize the needle.

5. Place the needle roughly ¼ inch away from the right side of

the incision mark on the practice board. Push the needle

down into the board and follow the natural curve of the

needle so that it circles out of the left side of the incision at

roughly ¼ inch away from the incision mark as well

NOTE: These instructions are written for a right-handed

person. Those who hold needle holders in their left hand

should reverse the left and right sides of the directions

given

NOTE: Sutures placed too close to the incision site will

be more likely to break, especially in thinner epithelium

linings. However, sutures placed too far away from the

incision site will not be effective at helping the incision

to heal properly.

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6. Once the needle has been pushed through to the other side of

the incision site, release the needle holders from the right

side of the needle and use them to grab the tip of the needle

and pull it completely through to the left side of the incision

until the suture material itself begins to come through

CAUTION: Be gentle when pushing the needle through

your patient’s skin. Bruising can occur from improper

suture technique. Also, be careful to not accidently grasp

your patient’s skin with the needle holders during this

process.

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7. At this point, you may release the needle from the needle

holders and grab the suture material itself with your hand to

pull it through the site until there is roughly 1 inch of

material still sticking out of the right side of the board

Tying a Square Knot

1. To begin tying a square knot, grab the left side of the suture

material with your left hand and the needle holders in your

right hand. Wrap the suture material from your left hand

clockwise around the needle holders one time.

1/4 inch

1 inch

2. Once wrapped around, use the needle holders to grab the end

of the suture material on the right side of the incision site.

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3. Crisscross your hands so that the suture material from the

right side is brought over to the left, and vice versa. This

creates the first loop of the square knot.

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4. Repeat this process again by using your left hand to wrap the

suture on the right side of the incision around the needle

holders, then grab the tip of the suture on the left side of the

incision and crisscross hands again. This will form a square

knot.

NOTE: The suture material is not found to be extremely

tight over the incision. Although sutures must be tight

enough to hold the incision site together, they must also

be loose enough to allow for inflammation after surgery.

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5. Repeat steps 8-11 to create a second square knot on top of

your first knot. This will provide insurance that the sutures

will remain intact and not come out

6. After completing the two knots, hold the two ends of the

suture up and use suture scissors to cut the ends.

NOTE: For absorbable sutures, it is best to cut the

sutures short so that there is less irritation where the

sutures have been placed inside of the body. For sutures

that must be removed, it is better you leave longer suture

ends so that the sutures may be easily found again when

being taken out, especially should hair begin to grow

back over time in the area sutures are being placed.

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7. Repeat this process multiple times to close the incision site.

NOTE: Sutures should be places roughly ¼ to ½ inches

apart to make sure the incision site is fully closed.

However, the less sutures the better as sutures will also

cause trauma to the already sore incision site.

Simple Suturing Removal

1. To remove simple sutures, gently pull up on the laces of the

suture so that it is slightly pulled away from the original

incision site. Use suture scissors to cut the suture material

NOTE: Although unlikely, the suture material may be

slightly stuck in the now healed incision site. Gentle

tugging on the suture should release the sutures from the

incision site. Should small amounts of bleeding occur,

use gauze to clean the site so no infection may occur.

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2. Repeat this process to remove all sutures from the healed

incision site.

CAUTION: Be careful when removing sutures from

your patient so as not to cut their skin, especially on live

animals that may try to move around. Remember to be

gentle as the area may still be sore after surgery.

1/4 to ½

inch

Square Knot Picture Source: http://www.surgery.vcu.edu/images/clerk_knots.gif