Figure 1
How to perform a subcutaneous purse string suture
While the sheath is in place, the first stitch is perfomed starting in front of the entry site, in direction of primary puncture and exiting behind the entry site (Note scar from original fistula surgery).
Then a second stitch is performed on the opposite side of the sheath, starting behind the entry point exiting in front of the cutaneous puncture site
The purse string is then completed and the sheath is ready to be retrieved
After forming a knot the sheath is removed
After removing the sheath the puncture side is compressed by one finger and the knot is closed followed by additional knots and conter-knots.
The string is kept under tension for a couple of seconds testing whether bleeding control is complete and no subcutaneous hematoma is formed
The string is cut and after checking again whether no more bleeding occurs
A transparent stripe is used to cover to the wound and the patient will be discharged. Normally we ask the patient to stay in the hospital for another 30 minutes to make sure that no late hematoma will occur.