How to suture a wound

Rationale and key points

This How to module explores how to suture a wound using several common techniques. The use of different suture techniques depends on various factors, including the type of wound, its location, skin thickness, wound tension and cosmetic considerations.

• Nurses should have a comprehensive understanding of the relevant anatomy and underlying structures, and the expertise to determine that suturing, rather than other methods of wound closure, is appropriate in each case.
• Nurses should work within their scope of practice and to agreed departmental protocols.
• Nurses should audit and reflect on their practice to ensure that their suturing skills are maintained and improved.
• Nurses should be aware of local procedures in the event of needle-stick injury.

Keywords

clinical procedures, clinical skills, suturing, suturing techniques, tissue viability, wound care, wound closure, wound management

Learning objectives

After reading this module you should be able to:

• List the equipment required to suture a wound.
• Demonstrate the preparation of a laceration for closure.
• Understand the principles of wound management.
• Demonstrate how to suture a wound using several common techniques.
• Describe common factors that can contribute to wound infection and/or delayed healing.

Procedure
Figure 1 Figure 2 The procedure for how to suture a wound and the information in this section, is supported by a video available at: https://rcni.com/how-to-suture. Figures 1-8 are stills from the video. Simple interrupted suture The needle should never be handled directly. Using non-toothed forceps, position the needle correctly in the needle holder by grasping the needle at the junction of the proximal and middle thirds. Hold the needle at a 90-degree angle to the needle holder (Figure 1). The most common technique for holding the needle holder is to place the thumb and middle finger through the finger holes with the index finger extended and resting on the shank of the device (Figure 2). This forms a triangle, which aids stability.	Figure 3 Using toothed forceps, gently grip and evert (turn outwards) one edge of the wound margin (Figure 3). Avoid using excessive pressure to prevent further trauma to the wound. Insert the needle through the everted wound edge. The needle should enter the skin at an angle of 90 degrees and should then be advanced so that the tip of the needle exits into the centre of the wound through the deep dermis or subcutaneous fat layers. The force used to push the needle into the skin should not be excessive. The technique involves ‘locking’ the wrist in a neutral position and allowing the supination movement of the elbow to provide the required energy. This allows the needle to remain at a 90-degree angle to the margin of the wound.
Figure 4 Once the needle is pulled through into the centre of the wound, remount the needle in the needle holder. The opposite margin of the wound should then be gently gripped with the toothed tissue forceps and slightly everted. Guide the needle tip through the deep dermal or subcutaneous layer so that the tip of the needle exits through the skin at a point that is equidistant to the entry (Figure 4). Grasp the needle using the toothed forceps and pull it through the wound until 3-4cm of suture material remains at the entry point. By ensuring that the entry and exit points are equidistant from the wound margin, equal tension is then applied to the wound margins. This minimises tissue tension, wound dehiscence and infection, and improves cosmetic appearance (Miller et al 2015). Infection can result from dehiscence or from inadequate vascularisation when there is too much tension on the wound margins.	Figure 5 Tie the suture with a knot to ensure that slippage does not occur. There can be three to five throws on a knot to ensure a secure tie, depending on clinician preference. The video shows a five-throw technique. For a five-throw knot, hold the needle holder at a vertical height slightly above and away from the wound margins. Wrap the longer stretch of suture material with the attached needle twice around the closed needle holder. Advance the needle holder to grip the shorter loose tail of the suture. Pull the longer length of the suture along the length of the needle holder and off the tip that is gripping the tail. Partially complete the knot by pulling one tail of the suture at 180 degrees to the other along the line of the wound and then at 90 degrees to the wound margin (Figure 5). This should appose the margins of the wound.
Figure 6 Perform the second set of throws in a similar manner (Figure 6). Bear in mind that if the initial throws were clockwise around the needle holder, then the second set of throws should be wrapped anticlockwise. Take care to ensure that the throws are not pulled too tight, since they lock the tension of the knot and could cause tissue damage through ischaemia (Singer et al 1997).	Figure 7 Figure 8 Perform the final throw with a single wrap that follows the direction of the first throw (Figure 7). This completes the knot. Pull the knot to one side of the wound so that it does not sit over the wound edges (Figure 8), since this could compromise the integrity of the healing process through friction (Armitage and Lockwood 2011).
Using scissors, cut the suture material leaving two short tails. When cutting the tails, the appropriate length is determined by wound location and ease of removal.	Figure 9 Simple interrupted sutures should be placed evenly along the length of the wound so that both margins of the wound oppose without leaving any open spaces (Figure 9a). If the clinician is not satisfied with a suture or its placement, the suture should be removed and replaced accordingly.

Learning points

1. A good understanding of anatomy and underlying structures is required to determine whether suturing is appropriate.
2. Wounds should be assessed, cleaned and debrided before suturing. Ensure the patient has been given adequate local anaesthesia.
3. Non-toothed forceps should be used to position the needle correctly in the needle holder. Needles should never be handled directly.
4. The needle should enter the skin at an angle of 90 degrees and should then be advanced so that the tip of the needle exits into the centre of the wound. The force used to push the needle into the skin should not be excessive.