Basic surgical skills

1. BASIC SURGICAL
SKILLS, SUTURES
AND NEEDLES
SU 1 ACADEMICS
DEPARTMENT OF
GENERAL SURGERY
IGMC SHIMLA
Dr. Navam Dhiman
Junior Resident
Department of General Surgery
I.G.M.C. Shimla

2. REFERENCE
S
🠶Bailey & LoveShort Practice of
Surgery 28e
🠶www.medscape.com

3. HISTO
RY
🠶 The origins of surgery can be traced back many centuries. Through the ages,
practitioners have used a wide range of materials and techniques for closing
tissue……..
🠶 They also used adhesive linen strips, similar to modern-day Steristrips.
🠶 By 1000 BC, Indian surgeons were using horsehair, cotton and leather sutures.
🠶 In Roman times, linen and silk and metal clips called “fibulae” were commonly
used to close gladiatorial wounds.
🠶 By the end of the nineteenth century, developments in the textile industry led to
major advances, and both silk and catgut became popular as suture materials.

4. SUTURING –
GOALS
🠶 Provide adequate tension for wound closure but loose enough to prevent tissue
ischaemia & necrosis.
🠶 Protecting underlying tissues from infection or other irritating factors.
🠶 Preventing post-operative haemorrhage.
🠶 Permitting healing by primary intention.
🠶 Preventing bone exposure resulting in delayed healing & bone resorbption.
🠶 Permit proper flap position.

5. IDEAL SUTURE –
QUALITIES
🠶 Minimal tissue reaction
🠶 Smoothness - minimum tissue drag
🠶 Easily Sterilisable
🠶 Adequate tensile strength
🠶 Ease of handling - Minimum memory
🠶 Knot security
🠶 Cost effectiveness
🠶 Favourable absorption profile
🠶 Resistance to infection

6. BASIC
DEFINITIONS
🠶 Suture is a material used to approximate living tissues or sutures together.
🠶 Ligature is a suture used to encircle a blood vessel to arrest or control bleeding.
🠶 Tensile strength is the ability of the material or tissues to resist deformation or breakage.
🠶 Elasticity is the ability of the material to regain its original form or length after deformation.
🠶 Pliability is the ability to adjust knot tension & to secure knot.
🠶 Memory is the inherent capability of suture to return or maintain its original gross shape.

7. SUTURE MATERIAL –
TYPES
🠶Behavior – Tissue : Absorbable / Non-absorbable
🠶Structure : Monofilament / Multifilament
🠶Origin : Natural / Synthetic

8. SUTURE
MATERIAL
• NON ABSORBABLE
Absorbable

9. ABSORBABLE –
NATURAL
🠶Plain catgut : Light. Derived from submucosa of sheep or beef
intestine.
* Used for ligating superficial blood vessels & subcutaneous fatty
tissues.
* bailey’s doesn’t recommend the use of catgut
🠶 Chromic catgut : Yellow. Treated with chromium salt.
* It may be used in the presence of infection & in cancer cases.

10. ABSORBABLE –
SYNTHETIC
🠶 Polyglactin (Vicryl) : purple, copolymer of Lactide & Glycolide.
* Minimal tissue reaction. Used in general soft tissue approx ; Intestinal
anastomosis, Vessels ligation in all surgical specialties.
🠶 Dexon (Polyglyconic acid) : purple/cream, homo polymers of glycolide.
* Avoid in adipose tissue & losses tensile strength more rapidly than vicryl.
🠶 Others:e.g; Polyglyconate(maxon), Polydiaxone(PDS), Polyglecaprone(monocryl)

11. NON –ABSORBABLE –
NATURAL
🠶 Surgical silk: Black. Derived from the cocoon of the silk worm larvae, trigger
inflammatory reactions, undergo proteolysis & undetected by 2yrs.
* Used in ligating major blood vessels, tendon repair etc.
🠶 Surgical steel & wires : High tensile strength & Hold knots very well
* Used in orthopaedic, Neurosurg & Thoracic surgery
🠶 Others: e.g; Virgin silk, cotton, linen

12. NON –ABSORBABLE –
SYNTHETIC
🠶 Nylon : Is a polyamide polymer, Blue / White
* 81% tensile strength at 1yr & 66% at 11yrs
* Elicits minimal tissue reaction
* Has good memory
* Pliable when moist
* Premoistened form is used in cosmetic plastic surgery
* Its elasticity makes it useful for skin closure & Herniorrhapy
🠶 Others : e.g; Polypropylene (Prolene), Polyester fiber (Mersilene/Dacron/Ethibond)

13. MONOFILAMENT
🠶 Grossly appears as single strand of suture material; all fibers run parallel
Minimal tissue trauma. Resists harboring microorganisms
🠶 Ties smoothly
🠶 Requires more knots than multifilament suture
🠶 Possesses memory
🠶 Examples:
* Monocryl
* PDS, Prolene
* Nylon

14. MULTIFILAME
NT
🠶 Fibers are twisted or braided together
🠶 Greater resistance in tissue
🠶 Provides good handling and ease off tying
🠶 Fewer knots required
🠶 Examples:
* Vicryl (braided)
* Chromic (twisted)
* Silk (braided)

15. SUTURE
DEGRADATION
Suture Material Method of Absorption Time to Absorb
Catgut Proteolytic enzymatic
digestive process.
10 Days
Vicryl Hydrolysis. 60% in 2 weeks
30% in 3 weeks
PDS Slow Hydrolysis. 70% in 2 weeks
50 % in 4 weeks
14% in 8 weeks
Silk / Nylon Gradual encapsulation by
fibrous connective tissue.
year

16. SUTURE
SIZE
🠶Sized according to diameter with “0” as reference size
Numbers alone indicate progressively larger sutures
(“1”,“2”, etc.)
🠶 Numbers followed by a “0” indicate progressively
smaller sutures (“2-0”, “4-0”, etc.)
🠶Smaller [Thick]< --------------------------> [Thin] Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

17. NEEDLE –
ANATOMY

18. NEEDLE POINT -
GEOMETRY
Taper-Point
(Round)
•Suited to soft tissue
•Dilates rather than cuts
Reverse cutting
•Very sharp
•Ideal for skin
•Cuts rather than dilates
Conventional
Cutting
•Very sharp
•Cuts rather than dilates
•Creates weakness allowing suture tearout
Taper-cutting
•Ideal in tough or calcified tissues
•Mainly used in Cardiac & Vascular procedures.

19. NEEDLE
SHAPES
Eye
Microsurgery
Nasal cavity
Nerve
Skin
Tendon
Dura
Eye
Fascia
Nerve
Eye (Anterior
segment)
Muscle
Eye
Skin
Peritoneum
Laparoscopy
Cardiovascular
Oral
Pelvis
Urogenital tract

20. IDEAL SUTURE –
NEEDLE
🠶High quality stainless steel
🠶Smallest diameter possible
🠶 Stable in the grasp of needle holder
🠶 Sharp enough to penetrate tissues with minimal resistance & trauma
🠶Sterile & corrosive resistant

21. USE OF NEEDLE
HOLDERS
Loading
Needle
Needle
passing
through skin

22. TECHNIQU
E
🠶 Needle should be grasped with the needle holder approx. 1/3 distance from the
eye & 2/3 from the point.
🠶 Needle should be placed perpendicular to surface being entered & pushed
through tissues following curvature of the needle & rotating the wrist.
🠶 Needle enters 2-3mm away from the margin of the flap & exists at the same
distance on the opposite side.
🠶 The two ends of the suture are then tied in a knot & cut 0.8cm above the knot.
🠶 Knot should never lie on incision line.
🠶 Never close under tension.

23. THE SUTURE
PACKAGING
STRAND
SIZE
MATERIAL
STRAND
LENGTH
PRODUCT
CODE
NEEDLE CODE
WITH LIFE
SIZE PICTURE
OF NEEDLE
NEEDLE
LENGTH
COLOUR
POINT TYPE
NEEDLE
CIRCLE

24. SUTURE
TECHNIQUES
🠶 Simple sutures
🠶 Mattress sutures
🠶 Subcuticular sutures

25. SIMPLE –
INTERRUPTED
🠶 Suturing is passed through both edges
at an equal depth & distance from the
incision & knot is tied.
🠶 Common & Stronger.
🠶 Each suture is independent & loosening
of one suture will not produce loosening
of other.

26. SIMPLE –
CONTINUOUS
🠶 Useful in pediatrics
🠶 Rapid
🠶 Easy removal
🠶 Provides effective hemostasis
🠶 Distributed tension evenly along length
🠶 Can also be locked with each stitch

27. MATTRESS–
VERTICAL
🠶 It has a far – far- near – near order of
bites.
🠶 The knot is perpendicular to the wound
edge.
🠶 Useful in maximising wound eversion ,
reducing dead space and minimising the
tension across the wound.

28. MATTRESS –
HORIZONTAL
🠶 Used for high – tension wounds or
wounds with fragile skin.
🠶 The knot is parallel adjacent to the
wound edge.
🠶 Useful in maximising wound eversion ,
reducing dead space and minimising the
tension across the wound.

30. SUTURE
REMOVAL
🠶 Face: 2- 3 days
🠶 Scalp: 5 days
🠶 Trunk: 7 days
🠶 Arm or leg: 7-10 days
🠶 Foot: 10-14 days

31. RECENT
ADVANCES
Staples
🠶 Formed from high quality
stainless steel
Tapes - Steristrips
Use of tissue adhesive adjunct
(benzoin)
🠶 Suitable for skin closure
Adhesives
A sterile, liquid topical skin adhesive
Reacts with moisture on skin surface
to form a strong, flexible bond
Only for approx. skin edges of wounds Rarely used for primary closure

32. SURGICAL
KNOTS

33. SQUARE ORREEF
KNOT
🠶 Square knot formed by wrapping the suture
around the needle holder once in opposite
directions b/w ties.
🠶 3 ties are recommended.
🠶 The two-hand square knot is the easiest and
most reliable for tying most suture materials.
🠶 It may be used to tie surgical gut, virgin silk,
surgical cotton and surgical stainless steel.

34. SURGEON’S OR FRICTION
KNOT
🠶 It is formed by 2 throws of suture around the
needle holder on the first tie & one throw in
the opposite direction on the 2nd tie.
🠶 The surgeon's
recommended for
or friction knot is
tying braided synthetic
absorbable suture, VICRYL*/ ETHIBOND*
polyester suture, ETHILON* nylon suture,
MERSILENE* polyester fiber suture,
NUROLON* nylon.

35. GRANNY’S OR SLIP
KNOT
🠶 Granny’s knot involve a tie in one direction
followed by a tie in the same direction & third
tie in the opposite direction to square the knot
& hold it permanently.
🠶 It has the tendency to slip when subjected to
increasing pressure.
🠶 It is not recommended.