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Development of good technique requires a knowledge and understanding of the rational mechanics involved in suturing.

When taking a bite of the tissue, the needle should be pushed through using only a wrist action, if it becomes difficult to pass through the tissue, an incorrect needle may have been selected, or the needle may be blunt.

The tension of the suture material should be maintained throughout to prevent slack sutures, and the distance between the sutures should be equal.

The use of a specific suture pattern may vary depending on the area being sutured, the length of the incision, the tension at the suture line, and the specific need for apposition, inversion, or eversion of the tissues.

Suture patterns can be broadly categorized as interrupted or continuous.

D. Inverting Patterns

1. Cushing Suture

• A type of variation on continuous horizontal mattress sutures.
• Suture passed through the submucosa but not mucosa.
• This technique is often used to close the incisions in hollow organs such as the stomach, urinary bladder, and uterus.
• The suture penetrates into the submucosa without penetrating the organ lumen.
• The suture runs from both sides of the incision, parallel to each other.

Usages

• Closing hollow viscera like bladder, stomach, or uterus.

2. Connell Suture

• Similar to Cushing except for complete penetration into the lumen of the viscera.
• This technique is often used to close the incisions in hollow organs such as the stomach, urinary bladder, and uterus.
• The suture penetrates into the submucosa and mucosa.
• The Connell suture technique is almost identical to the Cushing suture technique. These two suture techniques are separated according to the tissue they penetrate during suture passage.
• Connell suture technique is used to pass through the lumen.

Usages

• First layer of hollow viscera closure (stomach, bladder, or uterus).

3. Lembert Suture

• This is similar to the vertical mattress suture and is used to repair hollow organs.
• As the holding layer of an organ is the submucosa, the needle should penetrate only to this depth and never into the lumen (Penetration of submucosa but not mucosa).
• As the suture is tightened it inverts the tissues.

Usages

• Closing hollow viscera like bladder, stomach, or uterus.
• Fascial imbrication.

4. Halsted Suture

• The technique is essentially the same as for a vertical mattress suture except that two sutures are placed in a parallel fashion before they are tied.
• This produces an interrupted pattern in which the edges of the wound are inverted.

Usages

• Second layer of closure for hollow viscera.

5. Parker Kerr Suture

• A combination of a Cushing and a Lembert suture pattern.
• Two-layer closure is historically utilized to aseptically invert a transected, clamped viscus.
• A single layer of Cushings sewn over a clamp and tightened as the clamp is removed.
• Followed by an inverting seromuscular pattern (Oversewn with Lembert).

Usages

• Closure of hollow viscera stumps.

6. Purse String Suture

• Circular variation of Lembert.
• A bite is taken at regular intervals around the perimeter of an opening so that when pulled tight, it can be made smaller or closed completely.
• This technique may be used to close visceral stumps and to secure percutaneous tubes into a viscus such as may be seen in gastrostomy and cystostomy procedures.
• Useful for areas such as the rectum (to correct a prolapse).

Usages

• Closure of hollow viscera stumps or securing of tubes and catheters.