Healthcare and Medicine Reference
Insert the needle into the open surface of the wound at a similar
distance from the skin edge to before.
Supinate your dominant hand, taking a path through the proxi-
mal skin edge with the needle emerging an equal distance from
the wound edge as taken in step 2 (Figure 21.5b). NB avoid
trapping excessive subcuticular tissue within the suture, as this
will prevent accurate apposition of wound edges and will ulti-
mately necrose, increasing infection risk.
Without moving the forceps, release the needle holder, then
remount the needle on the side that has emerged from the
Pull the majority of the suture through the wound, leaving a
length of suture about 3-5 cm on the distal side of the wound
edge (Figure 21.5c).
Now the suture must be tied to secure it as described below.
Figure 21.4 Administering local anaesthetic.
Knot tying: knot over forceps method
Position the needle holder parallel to the wound, raised a few
Your toothed forceps are held with your non-dominant hand,
in between thumb and index fi nger, as a pincer grip, as you would
Pick up the needle with the forceps and mount it on the needle
centimetres above it.
With the longer length of suture (needle end) on the proxi-
mal side of the wound, wind this twice clockwise around the
needle holder (do this holding the suture and not the needle)
Grasp the short end of the suture with the needle holder, pulling
holder, approximately two-thirds of the way along its length from
its tip, holding it at 90° to the needle holder.
NB suturing should be performed without handling the sharp
with your hands, thus reducing the risk of injury - 'no-touch
If the wound is deep, absorbable sutures can be placed through
it through the two loops just created, so that the short end now
lies on the proximal side of the wound and the long length on the
distal side (i.e. cross hands). This 'tie' or 'throw' should lie fl ush
against the skin (Figure 21.5e,f).
The knot should be pulled so that the wound edges just
the fascia before closing skin to eliminate potential spaces.
This can be done with the same suture technique as described
The placement of the fi rst suture is the most important; as a
Now secure the knot as follows.
Wind the long length of suture once
anticlockwise around the
needle holder. Again grasp the short end of the thread with the
needle holder, pulling it through the single loop just created
(again crossing hands).This throw should also lie fl at, thus creat-
ing a 'squared' knot. This resembles a reef knot. If it resembles a
slipknot, it has been done incorrectly (Figure 21.5g,h).
Finally wind the suture once
rule it should be at the middle of the wound, ensuring accurate
With a simple straight wound, it is easiest to position yourself so
that it runs horizontally to your eye line.
With the forceps, pick up the distal wound edge and evert it,
clockwise around the needle holder
pulling the short end through the loop to lock the knot.
Cut the two ends of thread 5 mm away from the knot.
holding it slightly raised.
With your dominant hand pronated, pierce the skin a reasonable
distance from the wound edge; this should be equal to the depth
of the bite required (approximately 2-10 mm, depending on the
site, size and depth of wound and delicacy of suture material)
and enter the skin at 90° (Figure 21.5a).
Supinate your dominant hand forming an arc; the needle should
Repeat your interrupted suturing until the wound is adequately
opposed. Ensure that the wound edges are opposed correctly, everted
and not overlapping. Failure to do so will prevent adequate healing.
To ensure the knots do not scar, ensure removal at appropriate time
periods. For example:
appear in the centre of the wound at an equal depth to the dis-
tance in step 2 (Figure 21.5b).
Ensuring the majority of the needle is visible in the base of the
hands 10 days
wound, release the needle from the needle holder.
Remount the needle on your needle holder.
scalp 5 days
other 7-10 days.
Only once the needle is remounted may you release the distal
skin edge from your forceps.
Pick up the proximal skin edge with your forceps and evert it.
(Ideally the path taken by the suture through the proximal wound
edge should mirror that of the path you have just taken through
the distal wound edge.)