Modified Instrument Tie for Surgical Wound Closure

Simplifying surgical technique, increasing safety, avoiding contamination, and decreasing the time to perform a procedure are desirable goals of any procedure. While the basic premise of the instrument tie remains the same under our model, we provide a number of alterations designed to ease the process of suture handling and wound closure for the clinician.

The following tying technique can be utilized for any instrument tie, superficial or deep, and eliminates the necessity of putting down and picking up instruments. Controlling the body of the needle prevents exposure to the needle tip, thereby maximizing safety. Furthermore, by maintaining the suture material in the sterile gloved left hand during the surgical tie, our method prevents potential contamination of both needle and suture with the surrounding environment. Time constraints are addressed since the instruments are never set-down and are readily accessible for use during each stitch.

Once the suture has been placed through the tissue (Figure 1-1), grasp the needle with the needle holder and pull through. Move the forceps to sit in the web between the thumb and index finger. The distal end of the forceps will be held in place by folding over the 4^th and 5^th fingers or just the 5^th finger (Figure 1-2). Pull the needle through with your needle driver. With the point of the needle pointed away from the fingers, pinch the needle in its mid portion between the thumb and index finger of the left hand (Figure 1-3). Gripping and controlling the body of the suture with needle pointed away from the fingers prevents potential exposure to the needle tip while the following steps are carried out. If the surgeon is uncomfortable gripping the needle body, one can hold the suture material just proximal to the needle swage, while still maintaining efficiency. The next steps can be done separately, but as one becomes more adept with this technique, they will become a singular fluid motion. The left hand is then used to pull the suture through the wound, bringing the hand about 8 inches above the skin surface where it is then held in this position. With the needle holder in the right hand in a closed position, place the needle holder across the suture material. As you draw the needle holder towards yourself, the suture will fold on itself (Figure 1-4). Continued traction pulls the suture through the incision, which is continued until there is about 3-4 cm of suture left on the free end at the skin’s surface. While continuing to place traction on the suture with the needle holder, pinch the suture material between your thumb and index finger (the same fingers that are holding the needle), so you are now holding the needle and suture material (Figure.1-5). Fold your 3^rd and 4^th fingers over the two-stranded loop of suture material (Figure 1-6). You now have the folded suture material in place and out of the way and the needle secured. Complete the instrument tie (Figure 1-7), and cut the suture near the knot. When this is completed, release the 3^rd and 4^th fingers and the suture material. Since you have continued to hold the needle, it is still in the correct position to be grasped by the needle holder for placement of the next suture (Figure 1-8). Release the 5th finger so the forceps, which have not been set down, are also ready for use (Figure 1-9).

Dr. Richard Asarch is the director of Asarch Center Dermatology and Laser and an Associate Clinical Professor for the Department of Dermatology at the University of Colorado Health Sciences Center. He has practiced clinical and surgical dermatology for over 35 years. Dr. Asarch earned his undergraduate and medical degrees at the University of Iowa, completed his internship at Good Samaritan Hospital in Oregon, and served as a general medical officer at McChord Air Force Base. He later served as a research fellow at the Department of Otolaryngology and Maxillofacial Surgery at the University of Iowa, which was followed by a year of general surgery residency. He completed his dermatology residency at the University of Colorado Health Sciences Center and was the first director of its dermatologic surgery program. He completed his Mohs training with Dr. Frederic Mohs in Madison, WI, and has treated over 35,000 cases utilizing the Mohs procedure. He currently practices in Englewood, CO and has 5 children and 13 grandchildren.