SELF/Perioperative Nursing/Suturing and Suture Removal

   ⚠️In Development: Module actively being built.

▼This page is a part of the Perioperative Nursing Curriculum by ECSACONM and SELFPlease see the Intuitive Foundation Terms of Use and do not edit without permission.

By the end of this module, learners will be able to perform basic suturing techniques and safely remove sutures when indicated. They will understand appropriate instrument handling, suture selection, and skin closure principles, as well as how to assess wound healing and ensure patient comfort during suture removal.

• Describe the indications and contraindications for suturing based on wound type and patient factors.
• Identify the essential instruments and materials required for suturing and explain how their organization supports sterility and patient comfort.
• Differentiate between common suture materials and needle types, including their appropriate uses and tissue reactions.
• Explain how wound type, anatomical location, and healing stage determine the choice of closure technique.
• Identify the normal and abnormal signs of wound healing and describe the required elements of accurate documentation.
• Describe the process and timing of safe suture removal, including the correct instruments and reinforcement methods.

Suturing is indicated in a variety of wound types, including clean surgical incisions, sharp lacerations, and avulsion injuries where viable tissue remains attached. Before suturing, the nurse should assess for contraindications:

• Heavily contaminated or infected wounds
• Deep puncture wounds or presence of foreign bodies
• Animal or human bites without proper debridement
• Devitalized or crushed tissue with poor perfusion
• Delayed presentation (>12–18 hrs; >24 hrs on face)
• Uncontrolled diabetes or severe vascular disease
• Immunocompromised patients or systemic sepsis
• Clotting disorders / anticoagulant therapy
• Allergy to local anesthetics

Patient history must be reviewed for bleeding tendencies, prior wound healing complications, and current medications such as anticoagulants that may affect closure and healing. Understanding these details helps nurses prepare the surgical team with correct materials and anticipate complications.

The wound bed must be thoroughly irrigated and debrided before any suturing begins. A wound that appears clean may still harbor debris, so meticulous inspection with good lighting and proper positioning of the patient is essential. Once cleaned, wound edges should be gently handled with toothed tissue forceps (such as Adson forceps) to avoid crushing tissue. Nurses must understand that approximation, not strangulation, of the wound edges promotes optimal healing. Leaving dead space, overly tight sutures, or irregular edge alignment all predispose to infection, poor cosmetic outcome, or dehiscence.

Proper wound assessment includes identifying the wound’s anatomical location, depth, and orientation in relation to underlying structures. For instance, wounds across joints require careful planning to prevent undue tension during movement, while wounds on the face demand precise edge alignment to minimize scarring. Nurses should anticipate and communicate these nuances to the provider, ensuring that closure technique and suture material are tailored to the wound’s characteristics. The ability to recognize when sutures are inappropriate—such as in grossly contaminated wounds—enables nurses to guide decisions toward alternative management like delayed primary closure.

Finally, nurses must recognize the importance of timing in suture removal and inform patients when removal is anticipated. For example, facial sutures may require removal after 3–5 days due to rapid healing and risk of track marks, while sutures on the trunk may remain for 10–14 days. This knowledge helps the perioperative nurse plan postoperative teaching and set realistic expectations for the patient about follow-up care.

Suture materials fall into two categories: absorbable and non-absorbable. Absorbable sutures, such as Vicryl or Chromic Gut, are commonly used for deep tissue or subcutaneous closure where removal is not feasible. Vicryl maintains tensile strength for about 2–3 weeks and causes minimal tissue reaction, while the cheaper Chromic Gut loses strength more quickly, and can trigger more inflammation. Non-absorbable sutures, such as Nylon or Prolene, are typically reserved for skin closure where removal is planned. Nylon retains strength indefinitely but can provoke mild tissue reactivity, whereas Prolene is less reactive and preferred in patients prone to scarring.

The structural configuration of sutures—braided versus monofilament—also influences outcomes. Braided sutures like silk or Vicryl offer superior knot security but may harbor microorganisms due to their multifilament surface. Monofilament sutures such as Prolene or Nylon glide more easily through tissue, reduce infection risk, but may be less secure if knots are not tied properly. Braided sutures are most often selected for elective procedures such as bowel anastomosis or fascial closure where knot security is critical, while monofilament sutures are preferred for skin closure or contaminated traumatic wounds.

Needle selection is equally important. Cutting and reverse cutting needles are commonly used for skin closure, as their triangular tips allow clean penetration without excessive tissue trauma. Tapered needles, on the other hand, are reserved for delicate tissues like bowel or muscle. Needle size and suture gauge must be matched to the wound: finer gauges (5-0, 6-0) for facial or hand wounds, and thicker gauges (2-0, 3-0) for trunk or scalp closures. Nurses should prepare an array of options in advance to ensure procedural flow. A curved needle facilitates access to confined areas, while straight needles may be useful for surface-level wounds in accessible regions. By recognizing these principles, nurses not only assist providers but also anticipate potential difficulties, ensuring smooth procedural execution.

Essential suturing supplies must be collected in a structured manner to preserve sterility and efficiency. Instruments should be arranged on the Mayo stand or sterile tray in the order of anticipated use: needle holder in the center position for immediate access, followed by Adson or toothed tissue forceps on the right side, and Metzenbaum scissors or suture scissors on the left. Sterile gloves, a surgical mask, and gown should be donned prior to preparing the sterile field. Drapes must be placed to isolate the wound and create a defined sterile working zone.

Antiseptic solution, such as povidone-iodine or chlorhexidine, must be placed within reach of the circulating nurse, who will assist in preparing the skin before incision or suturing begins - see Skin Preparation and Draping - ECSACONM. Gauze swabs should be stacked neatly on the sterile field to facilitate quick access during hemostasis or cleaning. Local anesthetic with syringe and appropriately sized needle should be prepared, labeled, and checked for expiration. The sharps container must be within arm’s length of the procedure field to ensure safe disposal of needles and blades.

Suture materials should be laid out in a logical sequence on the back table: absorbable sutures in one section, non-absorbable sutures in another, and labeled clearly for the provider’s selection. Sterile field trays or packs should include surgical drapes, sterile towels, and marking pens if required for incision planning. Nurses should also confirm the presence of a wound assessment chart for documentation of wound characteristics, closure method, and number of sutures placed.

This structured organization allows the nurse to anticipate needs and maintain sterility throughout the procedure. A disorganized field increases the risk of contamination, delays during suturing, and unnecessary patient discomfort. Each supply serves a distinct role, and their systematic arrangement reduces error and supports precise wound closure.

Self-Assessment

Please complete the following: Quiz 1: Suturing and Suture Removal - ECSACONM

Closure technique selection is guided by wound type, tissue tension, and anatomical location. The simple interrupted suture is the most versatile method, used for irregular wounds or when precise tension adjustment is needed at each stitch. The continuous (running) suture is placed rapidly and distributes tension evenly across long, straight wounds, though failure of one segment can compromise the entire line. The vertical mattress suture provides strong eversion and reinforcement in high-tension areas such as joints, while the horizontal mattress suture is especially useful for fragile or thin skin where tension must be spread broadly. The blanket (over-and-over) suture offers extra reinforcement along straight incisions, commonly in trunk or extremity wounds. Finally, the subcuticular suture is placed within the dermis for cosmetic closure, typically on the face or other visible areas, where minimizing scarring is the priority.

Clean surgical incisions with well-approximated edges are generally closed immediately with simple interrupted, continuous, or subcuticular techniques depending on cosmetic need. Contaminated wounds, such as traumatic lacerations from dirty environments, may require irrigation, debridement, and sometimes delayed closure to reduce infection risk. Traumatic wounds with tissue loss, irregular edges, or crush injury may need reinforced mattress sutures to counteract high tension and poor perfusion. In cases of surgical incisions under tension (e.g., abdominal wall), closure should include methods that distribute force evenly, such as continuous sutures or vertical mattress sutures for added reinforcement.

Each wound must be assessed for depth, edge viability, tissue loss, and the presence of dead space. A shallow, linear wound with viable edges can be closed with simple interrupted sutures. A deep wound with a cavity requires closure of the deeper layers using absorbable sutures, followed by an appropriate skin closure technique to reduce tension. Irregular wounds may need staggered simple interrupted sutures to ensure edge alignment. The nurse should anticipate these needs and prepare a range of sutures and needle types so that the provider can adapt closure to the wound’s complexity without delay.

Knowledge of the skin and underlying structures directly influences closure choice. Wounds over joints such as elbows and knees must withstand movement and tension; vertical or horizontal mattress sutures are appropriate here to provide eversion and strength. Scalp wounds often need layered closure with absorbable sutures in the galea and simple interrupted sutures in the skin. Facial wounds, where cosmetic outcome is a priority, require fine 5-0 or 6-0 sutures with either simple interrupted or subcuticular techniques. Abdominal incisions should be supported with continuous sutures to maintain even distribution of tension and reduce the risk of dehiscence. Each location presents unique biomechanical demands, and the nurse should be prepared with the appropriate suture material and instruments for that anatomical site.

Knowledge of skin anatomy and underlying structures informs closure decisions:

• Wounds over joints (knee, elbow): must accommodate frequent movement and tension, making reinforced closures like the vertical mattress or horizontal mattress sutures preferable to prevent dehiscence. The nurse should prepare skin hooks or small joint retractors to keep edges visible during placement.
• Scalp wounds: often require deep tissue support with absorbable sutures placed in layers, followed by skin closure using simple interrupted sutures for strong approximation. Small self-retaining scalp retractors or handheld skin hooks should be available to expose the wound edges clearly.
• Facial wounds: benefit from delicate cosmetic repair with continuous (running) sutures or simple interrupted sutures in fine gauge (5-0 or 6-0) to minimize scarring. Fine skin hooks are particularly important for precise edge handling without crushing fragile facial tissue.
• Lacerations across skin creases or tension lines: should be carefully aligned and closed with simple interrupted sutures to distribute tension evenly and preserve natural contours. Adson toothed forceps should be ready to gently handle edges in these delicate areas.
• Long, straight wounds in low-tension areas (forearm, trunk): may be efficiently managed with a continuous (running) closure or, if extra reinforcement is needed, a blanket (over-and-over) suture. The nurse should prepare small retractors to hold edges open for accurate placement along the wound length.
• Deep wounds with dead space (thigh laceration, abdominal wall): require absorbable sutures placed in the subcutaneous layer to eliminate space and reduce tension, followed by skin closure using simple interrupted or vertical mattress sutures for added strength. Handheld retractors are essential for deep exposure, while skin hooks keep superficial edges aligned.

Understanding the phases of wound healing is critical. The inflammatory phase (days 0–3) is when infection risk is highest, making proper edge approximation and sterility crucial. The proliferative phase (days 4–21) relies on good perfusion and tension-free closure to support granulation and collagen deposition. The remodeling phase (weeks to months) determines final scar quality, so cosmetic techniques such as subcuticular closure are particularly important in visible areas. During closure, the nurse must assist by maintaining clear visualization of the wound edges, passing instruments in the correct orientation, and handling tissue gently with forceps or retractors to avoid crushing - more detail can be found in the Surgical Assistance - ECSACONM module.

Immediately after wound closure, the nurse must complete a detailed entry in the wound assessment chart. This includes the number of sutures placed, the type and gauge of suture used, and the specific closure technique performed. The wound location should be recorded using clear anatomical landmarks, and any intraoperative challenges—such as friable tissue, bleeding, or need for tension relief—must be noted. Each dressing applied should be described by type (e.g., non-adherent gauze with transparent film, pressure dressing), and the exact time of application should be documented.

At each dressing change, the wound must be inspected under bright light before cleansing. Normal findings within the first 24–48 hours are mild edge erythema up to 2–3 mm, minimal clear or serosanguineous drainage, swelling that does not increase, and pain that begins to decrease after the second day. Concerning signs include erythema extending more than 5–10 mm from the wound, redness that expands beyond previously marked margins, thick yellow or green drainage, foul odor, fever above 38 °C, tense swelling, gaping wound edges, dusky or black discoloration, and red streaks extending from the incision. To assess thoroughly, the nurse should measure the width of erythema in millimeters, mark and date the perimeter, palpate for warmth, induration, or fluctuance, and gently check for drainage type and amount using standardized descriptors: none, scant, small, moderate, or large. Any gap should be measured in millimeters, and the condition of the edges described precisely (well-approximated, separated, ischemic).

Analgesia must be managed proactively. Patients should be offered simple oral agents such as acetaminophen or NSAIDs unless contraindicated, and their effectiveness should be reassessed. The wound site should be protected from unnecessary strain: extremity wounds may be supported with slings or elevated to reduce edema, while abdominal wounds may require support when coughing or mobilizing. Before discharge, the nurse must provide both verbal and written instructions. Patients should be taught to observe for warning signs—spreading redness, thick drainage, increased pain after day two, gaping sutures, or fever—and told to return immediately if these occur. Dressing change instructions should specify frequency, hand hygiene steps, and exact materials required.

The timing of suture removal must be clearly communicated and written on the patient’s chart: 3–5 days for face, 7–10 days for scalp and upper extremities, 10–14 days for trunk, and 14–21 days for lower extremities or high-tension areas. Patients must be informed of their scheduled removal date before discharge. Escalation criteria must also be documented: purulent drainage, rapidly expanding erythema, fluctuance, wound separation greater than 5 mm, dusky or necrotic skin edges, or systemic fever require immediate provider notification. If such signs are detected, the nurse should document findings in precise terms, note actions taken (e.g., wound culture, removal of alternate sutures for drainage, application of a new dressing), and clearly state “provider notified” in the chart.

Suture removal begins with preparation of the sterile field and the appropriate instruments. The nurse should prepare the following instruments for the procedure:

• Adson toothed forceps – to gently lift each knot without crushing tissue
• Fine suture removal scissors – positioned to cut sutures at the correct angle, close to the skin
• Sterile gauze – for blotting, cleansing, and maintaining a clear field
• Antiseptic solution – to cleanse the skin before and after suture removal
• Adhesive strips (e.g., Steri-Strips) – to reinforce wound edges after sutures are removed

Good lighting and proper patient positioning are essential, and the instruments must be arranged in a logical order so the procedure can be carried out smoothly without breaking sterility or causing discomfort.

Assessment of the wound must occur before the first suture is removed. The nurse should look for edge approximation, erythema, drainage, swelling, or separation that could indicate poor healing or infection. If dehiscence, spreading redness, or purulent drainage is seen, removal should be delayed and the provider notified. When removal is appropriate, the knot should be elevated carefully with the Adson forceps, and the scissors placed directly under the knot to cut on the side closest to the skin. This ensures that only the buried portion of the suture passes through tissue, reducing contamination and trauma.

Removal should proceed gradually and with inspection between each step. In long incisions, every other suture may be removed first to check whether the wound remains closed without gaping. If the wound edges hold, the remaining sutures can then be removed in sequence. Throughout the process, gauze should be used to wipe away any exudate and maintain a clear field of view, while skin hooks or small retractors may be needed in deeper or curved areas to keep edges visible and accessible. Adhesive strips should be applied immediately after removal in areas where tension persists, supporting the wound until full epithelialization occurs.

Following removal, the wound must be examined carefully under light for signs of dehiscence, ischemia, or infection. The nurse should document the number of sutures removed, the condition of the wound edges, the presence or absence of drainage, the use of adhesive strips, and the patient’s tolerance of the procedure. Patients should be instructed to avoid stress on the site for the next 24–48 hours, to keep the area clean and dry, and to return promptly if they notice redness, drainage, swelling, or wound separation.

In low-resource environments, nurses may need to improvise when sterile instruments or sutures are limited. Where multiple sizes of sutures are unavailable, selecting a mid-range size such as 3-0 Nylon can provide versatility for many wound types. If specialized forceps are lacking, standard dissecting forceps may be sterilized and used with care to avoid tissue trauma. When absorbable sutures are scarce, careful planning of follow-up becomes even more important to ensure timely removal of non-absorbable sutures. When staffing shortages occur, one nurse may need to manage both supply preparation and instrument passing. In this case, organizing the sterile field meticulously becomes even more crucial. Instruments should be grouped in the exact order of use, and wound assessment charts should be prepared in advance to save time. Patient teaching can be adapted to emphasize self-care, especially if follow-up opportunities are limited, with clear written instructions on signs of infection and when to seek urgent care.

Self-Assessment

Please complete the following: Quiz 2: Suturing and Suture Removal - ECSACONM

Cumulative Test

Please complete the following: Module Test: Suturing and Suture Removal - ECSACONM

Developer Instructions

In a brief paragraph or two, describe your simulator. What does it look like? What does it do? What are the layers or elements? Work on this section after completing Simulation requirements

• Simulator Build Instructions - to be created after completing Simulator Build specifications
• Simulator Practice Instructions - to be created after completing Simulator Build specifications

• Link: [Description]
• Link: [Description]

• Link
• Link

Developer Instructions

Include any research or sources you used to develop this module that may be helpful to learners. You may also add evidence demonstrating the module’s impact or effectiveness.

• Link: [Description]

• Link: [Description]