Establishing surgical access
To allow the surgeon to work freely and clearly see objects deep within the wound channel, tissues must be fixed and retracted. The choice of instrument depends directly on the tissue type:
- Skin and subcutaneous adipose tissue: retracted using toothed hooks.
- Fascia, muscle masses, pleura, and peritoneum: require more delicate handling. Blunt lamellar hooks and specialized retractors are used for them.
When working with large cavities (thoracic or abdominal), the physician must strictly ensure that mobile internal organs—such as lung tissue or intestinal loops—do not get caught under the metal blades. When concluding any cavity-related stage of the operation, the surgeon performs a mandatory revision: carefully inspecting the space to rule out leaving wipes, sponges, or surgical instruments inside.
Principles of structure joining
The fundamental principle of surgery is to suture exclusively histologically homogeneous layers. For soft tissues, suture threads or tantalum staples applied by special stapling devices are most commonly used. In addition, high-frequency currents, ultrasonic methods, and metal wire are used.
When working with bone tissue, rigid fixation structures are used: metal plates with screws, pins, and special nails.
Characteristics of suture material
The selection of threads is based on requirements for strength, material thickness, and methods of its preliminary processing. There are two major groups of threads:
- Non-absorbable. These include silk, nylon, and a number of synthetic fibers. Upon entering the body, they become encapsulated, remaining there as foreign bodies. They are chosen for areas where maximum mechanical strength is required (e.g., during aponeurosis repair in hernioplasty).
- Absorbable. These include classical catgut and modern synthetic analogues (Dexon, Vicryl). Depending on the caliber of the thread and the method of its factory processing, the material completely biodegrades in 8, 12, or 24 days.
Types of sutures and knots
The surgeon's arsenal includes several basic suture configurations: interrupted, continuous, mattress, as well as Multanovsky's locking suture (also called the blanket stitch).
The process of creating a stitch is always divided into four consecutive stages:
- Needle insertion;
- Needle exit;
- Pulling the ligature;
- Tying the knot.
Regarding thread fixation, practice distinguishes the double surgical knot, the simple knot (also known as the ladies' knot), and the square knot.
Algorithms for working with interrupted sutures
Placement technique: The surgeon grasps the wound edge with forceps. The needle is inserted at a distance of one to one and a half centimeters from the incision edge, passing through the skin and subcutaneous tissue. On the opposite side, the exit is made from the depth to the surface. If the subcutaneous tissue is too thick, closure is performed layer by layer: the deep layer is closed with catgut or fine nylon, and the superficial layer (skin) with silk.
The distance between adjacent stitches should be 1.5 cm. The knot is tightened precisely until the wound edges touch (tissues must not be crushed!), while the assistant helps approximate the edges using forceps. The formed knot must be positioned to the side of the incision line.
Removal technique: Use anatomical forceps to grasp the knot and pull it upward slightly. The white part of the thread that was inside the wound channel will appear beneath the knot. It is this white part that must be cut with scissors. Then the thread is carefully pulled out in the direction opposite to the incision. This is done so that the external part of the ligature does not pass through the wound channel and infect it.
Briefly: answers to topical questions
What types of absorbable surgical sutures exist?
There are natural and synthetic types of absorbable surgical sutures.
- Catgut — plain, chromic, and silver-coated.
- Synthetic threads — Vicryl, Dexon, Monocryl, Polysorb, Oxylon.
Their absorption time is 8–12–24 days, depending on the thread thickness and processing method.
In which surgical situations is the use of non-absorbable threads indicated?
The use of non-absorbable threads is indicated in situations where special tissue joining strength is required.
- Aponeurosis approximation — used in the surgical treatment of hernias.
- External sutures — applied to the perineal skin in case of tears or episiotomy.
Such threads (silk, nylon, Dacron) become encapsulated as foreign bodies, and when applied to the skin, they require removal on the 5th day.
What requirements apply to modern surgical suture material?
A number of strict requirements apply to modern surgical suture material.
- Surface — must be smooth and even.
- Handling properties — good gliding and elasticity.
- Mechanical properties — knot security, absence of hygroscopicity and swelling capacity.
- Biological inertness — biocompatibility with living tissues and absence of allergic effects.
- Biodegradation — the degradation time of the threads must coincide with the wound healing time.
What complications are possible if the technique of placing skin sutures is violated?
If the technique of placing skin sutures is violated and tension is incorrectly chosen, the following complications are possible:
- Edge dehiscence — occurs with insufficient thread tension.
- Tissue ischemia — develops due to excessive tension.
- Necrosis — is a consequence of severe compression of the wound edges or walls.
For prevention, sutures are tightened only until the edges touch with moderate tension.
What is the technique for layer-by-layer closure of a deep wound?
The technique for layer-by-layer closure of a deep wound consists of sequential tissue joining for precise edge adaptation.
- Deep layer — if subcutaneous tissue is thick, deep tissues are sutured first (catgut or fine nylon).
- Superficial layer — sutures are then applied to the skin (e.g., silk).
The main principle is that the wound is closed so that no "pockets" or closed spaces remain inside.
The four stages of a stitch are easy to remember by the actions: "Enter (insertion), Exit (extraction), Pull (pulling), Tie (knot)."
Class and exam questions
Where should the surgical knot be located after tying?
The knot should always be shifted to the side of the incision line. This prevents direct pressure of the knot on the approximated edges and reduces the risk of impaired blood supply in the healing zone.
Which part of the thread should be cut when removing a suture?
The thread is cut below the knot, in the area of the white part, which is extracted from the channel itself. If you cut the dyed outer part and pull, surface dirt will get inside the wound.
Why is a layered suture necessary when there is a well-developed subcutaneous fat layer?
Layer-by-layer closure eliminates "dead spaces" deep within the wound where fluid can accumulate, and ensures secure edge approximation without excessive skin tension.
What else to study on this topic
- Specifics of using surgical staplers and tantalum staples
- Specifics of the Multanovsky suture and the mattress suture
- Types of osteosynthesis instruments (plates, pins, nails)
- Physicochemical properties of absorbable sutures (Vicryl, Dexon)
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