Suturing a Wound – Part V – the British Way

There are as many ways to suture a wound as to sew a dress.  While that may be a bit of an exaggeration, the point is, there is not a single technique for every situation and operator.

First we examine local anesthesia. 

Elaine Cole, Senior Lecturer in Emergency Care, City University London demonstrates local anesthesia using an entry point outside the wound edge.  This is certainly effective and quick, but not my favorite method, particularly not with children.  The needle used in the video looks more painful than placing three or four sutures would be.  It certainly isn’t mandatory to anesthetize the area prior to suturing, though most people prefer to be numbed.  If you’re going to bother numbing a person to prevent pain, then choosing a painless way to anesthetize seems like a good idea, too.

If time permits, I often prefer to drip the anesthetic inside a laceration, which numbs the superficial layers.  Then, if you go slowly enough, a child may not even feel it as you gradually inject the medicine a little deeper.  Numbing from the inside may require a lesser amount of anesthetic, and if you find the patient is experiencing discomfort, it is easy enough to inject a little more within the wound.

Now, on to our first video on local anesthesia:


Next, for a little suturing.

Our lecturer advises starting in the middle of the wound.  This is certainly one option, but if you don’t line it up perfectly, the rest of the sutures may be poorly positioned as well.  It is often easier to start at one end, where it is clear how the skin should be aligned.  Additionally, the ends of most wounds gape much less than the middle, making it easier to bring the edges together with little tension.

She demonstrates taking the needle into the middle of the wound, then out again the opposite side.  (Occasionally, for small wounds, you’ll be able to do this in one step.)  I usually don’t pull the suture through until I’ve done the second half of the suture, as it is VERY easy to pull it all the way out by accident. 

She also demonstrates double-throws at the beginning and end of a single knot.  It is quite useful to perform a double-throw when laying down the first throw of a knot, as this decreases slippage significantly.  Subsequent throws can be singletons.  In Part I of this series, the surgeon demonstrates greater efficiency of movement in going from one throw of the knot to the next.  She also demonstrates using the hands more than instruments, which is the opposite of what a skilled operator would do, but I agree, this is easier for amateurs.  When handling the needle, though, be very cautious about pricking either the patient or yourself. 

Knowing how many sutures to place is a skill acquired with practice.  Continuous subdividing in half may lead to more or fewer sutures than really needed.  Mentally dividing the halves of the wound into thirds may be better in some instances. 

She takes care to align her sutures to one side as she goes, but when blood is oozing and you’re continually dabbing it, the sutures may slip to one side or the other.  It is often easier to align them all to one side after they’re all in place.  The main reason to align the knots to one side is for easier removal later.  If you’re placing a long line of sutures, it is nice to leave fairly short “tails” on your sutures, or you may use up all your material before you are done.

Her comments in the final video about everting the wound edges are important.  She emphasizes improved scar appearance, but in my experience, improved wound healing is more important.  I have seen lacerations that have been neatly sutured with the edges turned in a little, and they simply do not grow together this way.

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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
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