What are the steps in suture placement?

Updated: Mar 05, 2020
  • Author: Desiree Ratner, MD; Chief Editor: Dirk M Elston, MD  more...
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A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of the distance from the tip of the needle, depending on the surgeon’s preference. The needle holder is tightened by squeezing it until the first ratchet catches. The needle holder should not be tightened excessively, because damage to both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular to the needle holder (see the image below).

Needle is placed vertically and longitudinally per Needle is placed vertically and longitudinally perpendicular to needle holder.

Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin, or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth finger into the loops and placing the index finger on the fulcrum of the needle holder to provide stability (see the first image below). Alternatively, the needle holder may be held in the palm to increase dexterity (see the second image below).

Needle holder is held through loops between thumb Needle holder is held through loops between thumb and fourth finger, and index finger rests on fulcrum of instrument.
Needle holder is held in palm, allowing greater de Needle holder is held in palm, allowing greater dexterity.

The tissue must be stabilized to allow suture placement. Depending on the surgeon’s preference, toothed or untoothed forceps or skin hooks may be used to grasp the tissue gently. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis.

Forceps are necessary for grasping the needle as it exits the tissue after a pass. Before removal of the needle holder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation.

The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge, depending on skin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the two sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.

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