hi welcome to the Duke suture skills course my name is Michael Zen and on the director of the human tissue lab here at Duke this course will teach you the basics in suture technique we'll review simple suture mattress suture running suture and some of the variations and proper surgical technique it's our goal that by teaching you proper technique you'll be the best surgical resident or surgeon that you can be before we get started I'd like to thank G in the office at Duke for their generous grant that made this video possible before get started showing you different suture techniques I want to show you a basic instrument I this can be used with any of the suture techniques that you'll learn once the suture is placed you'll have a short end and then a longer loop end your needle driver should be placed directly between the two and then we will do a surgeon's knot you'll wrap there's a longer end twice around the needle driver grab the smaller end and pull it to the opposite side and what will happen when you pull it to the opposite side it will square the knot and you can see how square the knot sits down now because it's a surgeon's knot it'll sit unless you pull up on it so don't pull up on it place the needle driver between the two the short end and the loop end now you're going to loop it around only once grab the short end and then bring it to the opposite side again squaring the knot and don't pull up on the suture until you just get it down and then you can tighten it and now it's locked in place I recommend at least three throws instrument between bring the small to the other side and done some suture material you may need four throws something maybe like an absorbable suture but this is a very basic technique it allows you to suture in a small place so if multiple people are working and will do one more for you right here you can suture notice I like to keep this short and very short your instrument doesn't move around very much then keep the needle driver between the two grab the small end pull it to the opposite side square and you're not lock it down with that surgeon's knot don't pull up on it now until you now grab this and then pull it through for the second time and now it locks down needle driver between the two wrap once pull through the opposite side and keep that knot nice and square square nuts will not untie also will look cosmetically more appealing the first suture we're going to teach you is the simple interrupted suture this is the most common suture that you'll be using and wound closure just a quick tip on handling a needle you'll notice your needle has a flat portion in the middle this is where you grab the needle with your needle driver you don't want to grab it at the end where the suture comes in or the swedge because it's round and you'll be unstable never grab the needle at the tip because you'll dull it a simple bike will want to enter the skin at 90 degrees and we'll go back a few millimeters from the skin edge and take a nice bite perpendicular to the skin and then on the opposite side the same and exaggerate that 90 degrees if you take it at 90 degrees the skin edges will then Evert and come together nicely here we'll set up a instrument tie and you can see here again we do three throws for nylon and we'll go ahead and clip this this is approximation without tension you want to go back a couple millimeters for each bite if you go back too far it'll tend to invert the skin and we want to avoid that so here again exaggerate the 90 degrees on each side to make sure that we are back the same distance on each side an a instrument tie we do a surgeon's knot for the first we cross the suture over lay it down nice and flat don't pull up on it until we get the second suture down and tighten it and lock it in so this is the simple suture it's something that you'll need to practice a lot to master next is a simple buried suture this will be the main suture you'll use when putting some deeper sutures in before putting your skin suture in it's important to bury a suture that we start deep and go superficial and end up in the dermis without buttonholing the skin and then on the opposite side we're gonna do the opposite we're gonna go superficial and then deep and if you want your not to bury it's important that both ends are on the same side of the loop you see here's my loop and here's the suture coming out from the same side and as we tie this down we'll do an instrument tie but we'll pull it along the length of the wound and that'll help the skin adjust to come together and do a nice instrument tie and what this does is it takes the tension off the skin so that when you go to do your skin closure you really can work on approximation you can see here that helps hold that together let's go ahead and do one more you're gonna go from deep superficial without button hauling the skin and then go from superficial to deep make sure that you're coming out on the same side of the loop and we'll do our instrument tie and we'll pull it along the length of the wounds so it'll allow it to bury come back to the other side and back to the other side that is our simple interrupted buried suture next is the vertical mattress suture Furcal mattress suture is a very useful suture especially when wounds are hard to close if they're under a lot of tension or maybe there's a lot of swelling or you anticipate swelling it's especially valuable when skin is just want to keep rolling in and you want to even some we'll call this the far far near near stitch and this is the configuration of your suturing we're gonna enter far from the wound travel under the skin come out far and then come back and go near near essentially you're taking this part of the skin and closing it to this part of the skin and that's the power of the suture simple suture is really relying on that much smaller area so we'll start far and travel under the skin and the same thing on the other side and we'll turn our needle around and now we'll go near and near and what you'll see when we tie this down is that this approximates an averse to skin edges and we can make it just as tight as we want we have our granny knot that'll hold it and we'll square our knots so I'll show you that one more time it's a vertical mattress suture far far near there and as you tie it down decide how much tension you need do you hurt your skin edges and hold things together and that's your vertical mattress our next suture is the horizontal mattress suture it's configuration is horizontal as opposed to our vertical mattress you can think of this as two simple sutures so in some of that since it's a simple suture it just saves you some time it's important here that you stay close to the skin edge and you are the same distance on both sides you'll take your bite on one side and then the other side and then you'll turn it around and you'll go back so you'll end up on the same side and there you can see our mattress the advantage of this is speed compared to doing simple suture it doesn't you've ER it as effectively sometimes as a vertical mattress here you see the way I've placed it it's reverting nicely so that's one example of a horizontal technique a variant of this is the figure-of-eight suture the figure-of-eight suture is the same distribution you take your simple bite in your simple bite but rather than turning the needle around you move on and take your next simple bite and simple bite what that does when you tie this it'll make a small little eight and that's why it's called a figure of eight suture the advantage of this again is speed instead of doing two simple sutures and tying two simple sutures you'll see that sometimes in some deeper closures like fascial closures because again you're grabbing a bunch of tissue to a bunch of tissue and therefore it'll be more secure the final variant of the horizontal mattress is called a half-buried mattress and we use this a lot in plastic surgery if there's an area where you don't want suture holes you can actually start your horizontal mattress on one side on the opposite side stay within the dermis in a horizontal fashion in a sub-q ticular fashion and then come back on the other side again out like you wouldn't a normal horizontal mattress so effectively it's your horizontal mattress but half of it is buried tends to name the half bare horizontal mattress and when you tie this here it'll secure the skin and you only have suture marks on one side you'll see we'll do this at times when we have a hair bearing area and an on hand bearing area we want to hide the suture marks or if it's a very end or tip of a flap and we're afraid that putting sutures in the tip is gonna interrupt the blood supply so our three variants of a horizontal the straight horizontal mattress the figure of eight and the half-buried horizontal mattress our next stitch is a simple running suture this will be the most common suture you'll use to close incisions it's a simple suture so again 90 degrees and 90 degrees same bites on both sides and you'll start with an instrument tying and try to save length on your suture here you also want to measure the length of your wound and not make sure you're not working with such a long suture that it becomes unruly you'll take you'll advance on the wound in symmetric fashion again trying to take 90 degree bites each time try to move along at the same pace and same amount each time almost mimicking a sewing machine if you move along the same distance each time and take the same bites on each side have a beautiful cosmetic closure people will ask well how much do you move along my answer is as long as it's the same on both sides it'll end up looking very nice so be consistent in your bites notice I'm exaggerating my 90 degrees because I want this to e vert I if I go too far back on the skin or I take too shallow a bite I'll end up inverting the skin and it won't heal correctly notice also I'm just pulling up enough on the suture just so that the skin edges touch pulling up on the suture very hard it's just ischemic and can cause bad scarring I'll end it with a simple little bite at the end make sure we have enough tension along the incision and then do our instrument tie at the end and this is a simple running closure a variation of the simple suture is the simple running locking suture we start off the same with simple bites and a nice instrument tie and this is a very helpful suture when you're sewing under some tension especially when you don't have an assistant who can help hold the suture for you and follow you you'll take your simple bites again 90 degrees 90 degrees you've hurt the skin edges but before you pull up you'll make sure and actually lock the suture and take your simple bite and simple bite and again before pulling up the last little bit you'll lock your suture and you can go on from here and the beauty of this is that you see although it's loose here it is locking back here and so when you're under a lot of tension especially it'll hold for itself now sometimes I'll do a running stitch and I don't plan on doing a running locking but at some point in the middle of the suture it starts loosening on me and then you can just throw in one of these locking sutures I always keep it nice and tight so it's not a suture necessarily that you'll use primarily because I think for scoring purposes you prefer a regular suture and I will say also as you become more and more expert at suturing you'll be able to control your simple suits you're much better each time locking the suture and we're going to end this with a simple stitch and again when we tie this we want to main to make sure we have good tension on the rest of the suture and that is our running walking suture our next stitch is a running subcuticular sutures how do all those sutures were teaching you this is probably the hardest to master this is probably for the most cosmetic closure as they're running within the dermis deeply so there's no sutures on the outside at all so you won't see any of the railroad tracking that you would see from any other outside sutures this is a absorb assuit sure and we will start by burying the knot so I'll go deep in the corner away from the skin maybe just a very deepest part of the dermis and we'll do our instrument tie and this allows the knot to be buried so we can suture over it this is important because we don't want knots coming up to the skin they can stick out it's called spitting patients do not like it when the knots bit now with knot is deep so we're gonna go deep and we're gonna come superficial and that brings us right up to the corner and this is where we're gonna start our so particularly run when you start to get close to a corner definitely recommend smaller bites to start see I'm just within the dermis horizontal bites need to advance a little bit on the other side and take another small bite against a wall within the dermis now with this stitch Simoes asked us how much do you advance each time what I like to do is to see here with my suture where the next bite should be and that's where I'm going to put it so in some sense it depends on how much tension there is on this wound there's not a lot of tension now we're gonna start to take regular bites on each side I'm trying to take the same depth and the same amount of tissue each time as we begin to advance keep pulling everything up and keeping tension notice I'm not pulling up very tight either just getting the skin to approximate no buttonholing of the skin this is just pure horizontal dermis wants to come right there can get a good play the dermis wants to come right there and just like when we started as you begin to approach the corner you want to stop taking such big bites and start going to some smaller bites because you really want these skin edges to be well approximated at the corner and not create any dog ears we also want to bury our knot so if we're on a berry or not we have to start thinking about now about getting deep with both of the two ends that are gonna get tied so at this point here I'm superficial and I'm gonna go superficial on this side and then head deep that'll get me down just sort of where we started down deep and I'm going to take one more bite that's deep now I want to tie that and that'll help to bury the knot and now what I'm gonna do to help bury the knot as well is to cut the short end here right on the edge of the knot and now take the needle and very that not further so I'm gonna pick up here and see where that knots going I can come out through the skin nearby and just simply pull up on this I can just cut it flush with the skin that helps the duck are not from our suture that concludes this course we at Duke feel strongly that excellent surgeons begin with excellent basic technique and I hope you've learned some of that during this video come back often as you begin to perfect your own technique if you'd like to learn more about Duke Plastic Surgery or the human tissue lab here at Duke visit us on the web at Plastic Surgery duke.edu

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