Running Subcuticular Suture Technique

Posted on February 20, 2012

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Suturing  is an important part of several clerkships, and whether or not you’re going to be a surgeon, I believe it’s just proper form for a physician to be able to suture half-decently.  Unfortunately, for some of us the opportunity to practice doesn’t present itself often, and we may be rusty when we’re called upon to close someone in the OR.

I’m feeling that way now – 3 weeks into a surgical rotation (OB/GYN) and we’ve either been rushing to close and move to the next case or stapling, and I’ve barely thrown a stitch.  Additionally, I haven’t been in the OR since last summer, so I’m feeling like I’ve suffered some skill atrophy.  Impulse struck when I saw a lonely pig’s foot at the grocery store, and I decided I was going to practice (plus I needed something to do during the commercial breaks while watching The Walking Dead last night).

When I first saw a subcuticular (or intradermal) suture, I thought it was just about the coolest damn thing you could do to a wound – close it in a way that was nearly invisible and provides an excellent cosmetic result.  Unfortunately, it was hard to learn because the experienced surgeons I operated with moved so fast.  I also found that video tutorials on YouTube weren’t all that helpful either.  So, this will also be my attempt at a well-written picture-guided tutorial.

As a disclaimer, I’ve seen this done several ways, and the surgeons you work with may have their own preferences, but this technique does seem to get the job done nicely.  Click any of the pictures below to enlarge.

Step 1:  Throw your anchor knot.  Start to the right or left of the apex, and take a bite in and out through the dermis (deep to superficial).  Pull the suture through and tie it down with a one-handed or instrument tie.

This knot is actually a bit far from the apex, but that's okay.

Step 2:  Take a deep to superficial bite at the apex, exiting just below the epidermis.  This is your target exit depth for the remainder of the suture.  Pull this through, and it will “dunk” or subvert the first knot.

Step 3:  Begin taking horizontal bites.  Using your tissue forceps, turn one side of the wound up and expose the dermal/epidermal junction.  Be sure you are working in a plane parallel with the skin.  You should begin each bite exactly opposite where you exited with the previous bite.  Continue taking bites in this fashion until you’re near the opposite apex.

Pulling the suture across helps you visualize where you'll take your next bite.

Step 4:  When you take your last horizontal bite, leave some slack in the suture, pull the distal material through, and “sinch” down making this your new loop.  This is the most difficult part to explain without actually seeing it done, but there’s only one way do this part correctly without pulling the needle through.

Step 5:  Use this new loop as a tail to tie with and throw down 3 or 4 knots.  Alternatively, you can repeat this “sinching” process 3 times and then pass the needle/needle driver through the last loop.

Step 6:  Take one final bite, underneath the knot, in line with the longitudinal axis of the wound, exiting distal to the apex.  Pull the suture taught and cut directly on the skin, allowing the tail to retract slightly once cut.

Cut the tail directly on the skin.

The finished product. If my patient were alive, this would heal nicely.

I hope that this tutorial will come in handy for some of you who anticipate having to do this in the OR on an upcoming rotation, or if you’re just not comfortable asking for further instruction and want to practice at home or just run through it mentally so it’ll go more smoothly the next time ’round.

Let me know if you do find this helpful and maybe I’ll be able to do something similar with other techniques.  Suggestions are welcome.

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