Comparative study between combined oblique and vertical everting running stitch and the conventional suturing technique

Abstract

BACKGROUND

Wound management is an essential part of emergency medicine practice. A good suture technique should deal a complex irregular traumatic wound without any complications of dehiscence/gaping, infection, delayed wound healing, frequent dressings and further stay in hospital. There is no ideal technique of suturing for any wound. In pursuit of the new techniques, we have introduced a new suturing technique called combined oblique and vertical everting running (COVER) stitch which has showed good healing with less complications.

AIM

To compare the outcomes between the COVER stitch and conventional suturing group.

METHODS

In this study, we included 40 cases which were divided into two groups. Group 1 patients were managed by COVER stitch, and group 2 patients underwent conventional suturing for their wounds. The outcomes were measured in terms of scar quality, suturing duration and length of suture material used, suturing related complications and suture removal time which were compared by t-test using χ² test.

RESULTS

Better results were seen in COVER stitch than the conventional suturing. COVER group had significantly better results in terms of time taken for suture, amount suture material used and time taken for suture removal compared to the conventional group. No wound related complications were seen in this group. Moreover, scar formed was also better in COVER group.

CONCLUSION

COVER stitch is another new technique which can be used to deal simple to complex wounds and it is an emerging idea with good healthy scars with less complications.

Key Words: Combined oblique and vertical everting running stitch; Running vertical mattress; Wound; Horizontal mattress; Vertical mattress; Everting

Core Tip: The combined oblique and vertical everting running stitch technique provides superior wound edge eversion, tension distribution, and cosmetic outcomes compared to the conventional vertical mattress suture. This hybrid approach minimizes tissue strangulation, promotes faster healing, and reduces scar prominence, making it a more effective and aesthetic alternative for skin closure in surgical and traumatic wound repair.

INTRODUCTION

A good suturing technique is one which gives good cosmetic results, good wound healing and avoids infection. Suturing technique is an art to deal with various complex wounds with various dimensions without leading to any complications and with good cosmetic scar. Several techniques have evolved which are adopted by various surgeons based on their experience. There is no ideal technique which can deal various types of wounds. Evidence of suturing dates back to 150 anno Domini when Galen of Pergamon sutured the severed tendons of gladiators using twisted intestines of sheep or goat as described by Lekic and Dodds[1]. Later as the time passed by, technique and instruments have been developed and adopted of which commonly used are interrupted vertical and horizontal mattress stitches. Several studies have been performed to compare continuous and interrupted sutures. These studies have concluded that the continuous or running stitch is better than interrupted stitch as described by Högström et al[2] and Trimbos and van Rooij[3]. In interrupted sutures, the knots are placed at each bite which results in railroad marks at both sides of the wound as described by these two studies[4,5]. The other disadvantage of interrupted sutures is that it takes longer time for closure of larger wounds. For this purpose, few surgeons suggest the use of running stitches. We have devised a new suturing technique which combines the running vertical mattress sutures with horizontal mattress which is placed in an oblique fashion. We presume that the combined oblique and vertical everting running (COVER) stitch provides excellent wound healing and acceptable scars adjacent to the wound. It also saves time required for suturing large wounds and is easy to remove. We have devised this study to compare COVER stitch against the other conventional suturing techniques in terms of providing good wound healing and amount of scarring.

First an anchoring simple stitch is applied at one end of the wound. Then a far-far stitch placement is done approximately 6-8 mm away from the wound edge taking a deep bite in the dermis. The needle is then turned in the opposite direction and a superficial near-near bite is taken. Now the oblique stitch is placed, and the far bite is taken approximately 4 mm distal to the first bite. The needle then takes the far bite from the other end of the wound followed by the near-near bites as described earlier. This is a form of combined horizontal and vertical mattress sutures. The tension is equally distributed across the wound area and knots are placed only at the ends of the wounds. The technique is described in Figure 1. The clinical wound images, before and after suturing are shown in Figure 2. This study aims to assess two aspects: First, the time taken to apply the COVER stitch compared to the conventional interrupted vertical mattress stitch in similar wounds; second, the patient satisfaction regarding scar marks after wound healing with both techniques.

Figure 1 The technique of applying the combined oblique and vertical everting running stitch and the appearance after placement of the final knot. A: Application; B: Final knot appearance and no suture marks over the wound.

Figure 2 Clinical photographs of the combined oblique and vertical everting running stitch applied on a widely retracted wound and its appearance after complete closure. A: Wound before suturing; B: Wound after suturing.

MATERIALS AND METHODS

We have devised a randomized controlled trial study the evaluate the above objectives. Forty patients between the age group of 15-50 years, meeting the inclusion criteria was included in the study. The study was conducted over a period of three months. Patients were divided into groups by allotting them in an alternative way and the surgeon and the patient were blinded. All the stitches were applied by a single surgeon under similar settings. Time duration required for complete closure of the wound was recorded in each case. The amount of suture material required was also be recorded. The course in the hospital and the post operative care was similar for both the patient groups. In the follow-up patients was reviewed on 14^th day for wound healing. The time duration required for stitch removal was also recorded for both the techniques. After removal of the stitches the scar was assessed by both the treating surgeon as well as a patient and was commonly graded between the four grades i.e., excellent, good, fair, poor based on modified Hollander score scale.

Statistical analysis

Analysis was done at the 15^th day after stitch removal. Unpaired t test was used and the significance was checked using χ² test. The statistical difference between the variables would indicate whether COVER stitch is truly better in comparison with the standard interrupted vertical mattress sutures for wound closure. SPSS software was used for statistical analysis.

RESULTS

In group 1 (COVER stitch), out of 20 cases, there were 12 males and 8 females. In group 2 (conventional suturing), out of 20 cases, there were 13 males and 7 females. There was no statistically significant difference between the groups with regards to wound size (P = 1.0000) (Figure 3A). The most common site of wound was the anterolateral part of leg. The average age group was 30.9 years and there was no significant difference between the groups (P > 0.05).

Figure 3 Statistical analysis. A: Wound size between the two groups are totally different showing no significance (P = 0.909); B: The time needed to suture the wound is less in group 1 compared to the group 2 (P < 0.001); C: The length of the suture needed in the combined oblique and vertical everting running stitch group was less compared to conventional suturing group (P < 0.001); D: Group 1 shows significant results than group 2 in terms of wound size to suturing time ratio (P < 0.001); E: The wound size to suturing length ratio was observed as less in combined oblique and vertical everting running stitch group and high in conventional suturing group in terms of (P < 0.001); F: The suture removal time was recorded less in combined oblique and vertical everting running stitch group than in conventional group (P < 0.001); G: There are better results seen in group 1 than in group 2 in terms of wound size to removal time ratio (P < 0.001); H: In combined oblique and vertical everting running stitch group, according to modified Hollander score scale there are 10 cases which showed excellent outcome whereas in conventional group, there are 5 cases which showed excellent outcome (P < 0.005); I: In group 1, 1 case had superficial infection, whereas in group 2, 3 cases resulted in wound dehiscence (P < 0.005). SCAR: In combined oblique and vertical everting running stitch group, according to modified Hollander score scale there are 10 cases which showed excellent outcome whereas in conventional group, there are 5 cases which showed excellent outcome (P < 0.005).

In comparison the average time for wound closure in group 1 was 5.2 minutes, while in group 2 the average closure duration was 10.55 minutes (Figure 3B and Table 1). The difference between the groups was statistically significant. The average length of the suture material required in group 1 was 19.2 cm, and in group 2 it was 29.2 cm. There was a significant difference between the groups in terms of suture length used (P < 0.005) (Figure 3C and Table 1). The wound sizes were different for each patient as they were randomly allotted in either group, so the length of the suture material, time needed to suture and suture removal time varies based on the wound size. Hence, we have analyzed based on ratios between the wound size and the other objectives. Similarly, the wound size to suturing time ratio in group 1 was 2.375, while in group 2 it was 13.4, which was again significant (P < 0.001). The mean of COVER stitch minus conventional suturing equals 1.3985, 95% confidence interval of this difference falls from 1.1252 to 1.6718 (Figure 3D and Table 1). The wound size to suture length ratio shows significant changes in group 1 (Figure 3E). Group 1 fared better than group 2 with regards to suture removal time also, with the difference being significant (P < 0.001) (Figure 3F and Table 1). The wound size to removal time ratio shows better results with group 1 (Figure 3G and Table 1).

Table 1 Comparison of surgical-related indicators between two groups.

Characteristic	Group	mean ± SD	P value
Time duration (minute)	Group 1	5.20 ± 2.608	< 0.001
	Group 2	10.55 ± 4.828
Suturing length (cm)	Group 1	19.20 ± 4.175	< 0.001
	Group 2	29.20 ± 4.336
Wound size to suturing time ratio	Group 1	2.74 ± 0.571	< 0.001
	Group 2	1.34 ± 0.197
Suturing removal time (minute)	Group 1	2.65 ± 0.875	< 0.001
	Group 2	4.70 ± 1.174
Wound size/removal time	Group 1	4.99 ± 0.895	< 0.001
	Group 2	2.76 ± 0.471

Out of 20 cases in group 1, one case landed in superficial infection which eventually head with antibiotics. In group 2, three cases led into dehiscence which were managed by secondary suturing. In group 1 (COVER stitch), modified Hollander score scale was considered and 10 cases showed excellent outcome, 8 cases showed good, and 2 cases showed fair outcomes. In group 2 (conventional suturing), 5 cases showed excellent outcome, 10 cases showed good, 2 cases showed fair, 3 cases showed poor outcome which landed into wound dehiscence and managed by secondary grafting (Figure 3H and I).

DISCUSSION

In the management of primary wound closure, suturing remains the standard of care. The choice between absorbable and non-absorbable sutures is largely dictated by the wound depth and anatomical location. Non-absorbable sutures are commonly employed for superficial closures, while absorbable sutures are more suitable for layered closures in deeper wounds. The latter not only provide strength to the closure but also reduce tension on the wound edges, promoting improved apposition.

Azmat and Council[6] suggested that, in deeper or more complex wounds mattress suturing techniques offer enhanced tensile strength and better edge approximation. Vertical and horizontal mattress sutures are particularly effective in minimizing tension by engaging deeper dermal layers. The vertical mattress suture is advantageous in areas prone to wound edge inversion, such as the posterior neck or concave anatomical sites, as described by Zuber[7]. However, care must be taken to avoid excessive tension on the knot, which may lead to edge eversion and increased scarring. Similarly, horizontal mattress sutures, while useful for hemostasis in vascular-rich areas like the scalp or thin-skinned regions such as the eyelid and web spaces, also carry a risk.

Further refinement in suturing techniques has led to the development of hybrid suture techniques. Krunic et al[8] demonstrated that combining simple running and vertical mattress sutures results in a quicker closure process and reduces discomfort during suture removal. This approach achieves a balance between wound edge eversion and coaptation, mitigating the risk of inversion or over-eversion. He also says that vertical mattress sutures produce eversion of the wound edges producing a better, cosmetically acceptable scar, but includes the risk of wound hyper eversion if tied too tightly, longer time to perform the stitch, and difficulties with grasping the externalized loops during suture removal. In comparison to Krunic et al’s technique[8], COVER avoids the sutures running across the wound edges and provides eversion of the margins at every stich point. Previously, Stiff and Snow[9] had described a similar running vertical mattress technique as an efficient and easy-to-master method that ensures consistent skin edge eversion and excellent wound approximation. The difference between this suturing and COVER stitch is that, the former does not exert the amount of tension required to evert the skin edges and is not suitable for large retracted wounds as highlighted by the authors themselves. On the other hand, in COVER stitch, since both ends of the vertical mattress stitch emerge at each bite point, it can resist wound retraction and gaping to a significant extent and the stich can be locked at any given point based of the wound demands.

In terms of procedural efficiency, Saranya et al[10] found that vertical mattress sutures allow for faster skin closure than subcuticular methods, although the latter may be associated with improved cosmetic results in some cases. Luo et al[11] further concluded that continuous suturing techniques provide superior outcomes in both healing and cosmetic appearance compared to intermittent methods. Building upon these findings, Ahuja et al[12] proposed a continuous, knot-free, buried vertical mattress suture technique. This method effectively combines tension-free closure with optimal eversion, while avoiding surface track marks. This is a fully buried technique of closure of the dermal layers. It does not involve the closure of the epidermis, and it is not suitable for widely retracted wounds.

Högström et al[13] suggested that the tension of the sutures over the skin margins does matter because it causes neutrophil accumulation and increased in myeloperoxidase activity which in turn decreases the breaking strength. Accordingly, continuous sutures which reduce the tension on the wound margins and reduce the myeloperoxidase activity provide better chances of healing in widely retracted wound margins. Overall, current evidence underscores the importance of tailoring the suture technique to adapt to the specific anatomical and mechanical demands of the wound site. Innovations in suture design and technique continue to evolve, with an increasing emphasis on optimizing cosmetic outcomes and minimizing postoperative complications.

COVER stitch is new procedure which can be an alternative to many other conventional suturing techniques in all kinds of wounds where skin edges can be approximated with no defect. It is a simple procedure and can be learnt easily and it saves time in patient with multiple lacerations as the time needed to suture is less. The removal time is also less comparatively causing less pain and anxiety to the patients. The suturing material length needed is also less as it saves resources in low-tier hospitals, primary health centres, low economic hospital settings, causing less number of sutures needed, decreasing the cost burden on hospitals and patients. As the technique is easy, even non-doctor or paramedic or a nurse can deal with the wounds in emergency conditions. We advocate that the COVER stitch is an excellent technique to provide good wound healing with everted margins and cause minimal scarring. This stitch would prove to be another good tool in the armamentarium of skin sutures and can provide quick and good suturing of wounds. Meanwhile, this study also has some limitations. The sample size of this study is very small. This classification system requires large group studies to assess its validity and reliability.

CONCLUSION

This study demonstrates that the COVER stitch technique is significantly more efficient than conventional suturing, with reduced suturing time, suture material usage, and removal time (P < 0.005). While both groups had similar demographics and wound sizes, the COVER stitch group showed better wound size-to-time and wound size-to-material ratios, as well as fewer complications. Clinically, the COVER stitch resulted in more excellent outcomes and no poor results, compared to three cases of wound dehiscence in the conventional group. These findings suggest that the COVER stitch is a good alternative, efficient, and effective method for skin closure, with the potential to improve healing and reduce scarring. Further studies are warranted to validate these results on a larger scale.