This lecture covers the basics of suturing i.e wound healing, indications and contraindications of suturing, wound assessment, wound aftercare, suture and needle types, suturing techniques, knot types.

1. The basics of Suturing
TA Khaled H Alkhodari, M.D

2. WOUND PHYSIOLOGY AND HEALING
• The epidermis, dermis, subcutaneous layer, and deep fascia
are the tissue layers of concern in wound closure:
• The epidermis and dermis are tightly adhered and clinically
indistinguishable, and together constitute the skin. Dermal
approximation provides the strength and alignment of skin closure.
• The subcutaneous layer is mainly comprised of adipose tissue. Nerve
fibers, blood vessels, and hair follicles are located here. Although this
layer provides little strength to the repair, sutures placed in the
subcutaneous layer may decrease the tension of the wound and
improve the cosmetic result.
• The deep fascial layer is intermixed with muscle and occasionally
requires repair in deep lacerations.

3. The healing process of skin occurs in several
stages
●Coagulation begins immediately following the injury. Vasospasm as well as
platelet aggregation and fibrous clot formation occur. During the inflammatory
phase, proteolytic enzymes released by neutrophils and macrophages break
down damaged tissue.
●Epithelialization occurs in the epidermis, which is the only layer capable of
regeneration. Complete bridging of the wound occurs within 48 hours after
suturing.
●New blood vessel growth peaks four days after the injury.
●Collagen formation is necessary to restore tensile strength to the wound. The
process begins within 48 hours of the injury and peaks in the first week. Collagen
production and remodeling continue for up to 12 months.
●Wound contraction occurs three to four days following the injury, and the
process is poorly understood. The full wound thickness moves toward the center
of the wound, which may affect the final appearance of the wound.

4. Systemic disturbances can influence wound
healing
• Systemic disturbances can influence wound healing. These
host factors include renal insufficiency, diabetes mellitus,
nutritional status, obesity, chemotherapeutic agents,
corticosteroids, and anticoagulant or antiplatelet adhering
drugs.
• Disorders of collagen synthesis, such as Ehlers-Danlos
syndrome and Marfan's syndrome, can also affect wound
healing.
• In addition, patients of African or Asian ethnicity can be prone to
hypertrophic scar formation or keloids.

5. Local disturbances are more common contributors to abnormal
wound healing.
• These factors include temperature, ischemia, tissue trauma, denervation, and infection:
• Temperature, blood supply, and ischemia are interrelated. The higher the temperature
of the anatomic area, the greater is the blood supply and resultant oxygen delivery. The
skin temperature of the face can be up to 9°F warmer than that of the foot, thus
allowing for sutures to remain for shorter periods of time and also allowing for lower
infection rates. Different suturing techniques can contribute to tissue ischemia, in
particular the vertical mattress suture.
• Infection can occur in any traumatic wound, and all acute wounds are contaminated to a
certain degree. An infection occurs when there is an imbalance between host resistance
(systemic or local) and bacterial inoculum. The mechanism of injury and the time from
injury to potential repair are important considerations. Crush injuries may cause
extensive cellular necrosis and higher infection rates than shear injuries due to the
greater energy distributed over a larger area. An injury heavily contaminated with dirt,
gravel, or other debris also has a higher infection risk. The length of time between the
injury and the evaluation also affects infection risk.

6. Basic characteristics of wound healing after suturing
• A surgical wound never attains the same cutaneous tensile strength as of
normal uncut skin.
• Two weeks after suturing, 3-5% of original strength will be achieved by a surgical
wound.
• By the end of third week, 20% of the ultimate wound strength is achieved,
• By one month only 50% of wound strength is attained.

7. • All sutures are foreign bodies and produce an inflammatory response in the host
dermis.
• Peak inflammatory response is seen between second and seventh day with
abundance of polymorphonuclear leukocytes, lymphocytes, and large monocytes
in dermis.

8. Goals ofsuturing:
• Provide an adequate tension of wound closure without dead space but loose enough to
obviate tissue ischemia and necrosis.
• Maintain hemostasis.
• Permit primary intention healing
• Reduce postoperative pain
• Provide support for tissue margins until they have healed and the support no longer
needed
• Prevent bone exposure resulting in delayed healing and unnecessary resorption
• Permit proper flap position

9. WOUND ASSESSMENT
• The management of minor lacerations begins with assessment and
preparation of the wound. Wound assessment includes:
• Determination of the mechanism of the injury
• Age of the injury
• Identification of possible contamination or foreign body
• Assessment of extent of the wound
• Assessment for neurovascular compromise or tendon injury in the surrounding
area
• Need for tetanus prophylaxis
• Identification of risk factors that might affect healing

10. INDICATIONS
• Sutures are appropriate when the depth of the wound will lead to
excess scarring if the wound edges are not properly opposed.
Typically this is true whenever the laceration extends through the
dermis.
• Clean, uninfected lacerations on any part of the body in healthy
patients may be closed primarily for up to 18 hours following the
injury without a significant increase in the risk of wound infection.
• Facial wounds may be closed primarily up to 24 hours following the
injury. In select cases, closure of facial wounds may occur up to 48
to 72 hours after injury if there are no signs of infection, the patient
has no risk factors for infection, and the wound edges can be

11. CONTRAINDICATIONS
“Concern about wound infection is the main reason not to close
a wound primarily.”
• Wounds that have been grossly contaminated with foreign debris that cannot
be completely removed, infected tissue, or noncosmetic wounds that have
come to medical attention late should be allowed to heal by granulation
(secondary intention) after appropriate cleansing.
• Animal bites, especially in noncosmetic areas (eg, hand, foot).
• Deep puncture wounds in which effective irrigation cannot occur.
• Wounds in which suturing will cause too much tension across the suture line.
In this instance, healing by secondary intention with later scar revision may
be a better approach.

12. • Wounds that are actively bleeding, especially if the source is
arterial (with the exception of scalp wounds). The clinician should
establish hemostasis so that a subcutaneous hematoma does not
collect and create a potential nidus for infection as well as impede
proper healing.
• Superficial wounds that would be expected to heal without
significant scarring, such as lacerations or abrasions that only
involve the epidermis. Suturing in these wounds will potentially
cause increased scar formation and risk for infection.
CONTRAINDICATIONS

13. WOUND PREPARATION
• Wound irrigation, foreign body removal, and necrotic tissue
debridement are the main preventative measures against tissue
infection.
• Debridement has been considered by many to be equally or more
important than irrigation in the management of the contaminated
wound.

14. WOUND PREPARATION- IRRIGATION
• Irrigation is the most important means of decreasing the incidence of wound
infection because soil or small foreign bodies that remain in a wound reduce the
inoculum of bacteria required to cause infection. However, irrigation may not be
necessary for all low-risk wounds, particularly those in well-vascularized locations.
• Irrigation is performed after adequate local anesthesia has been administered or
peripheral nerve block has been performed. Procedural or conscious sedation
should be considered for repair of wounds in areas that require the patient to be
still (eg, wounds that are near the eye or mouth) or in patients whose inability to
cooperate jeopardizes the adequacy of repair.
• Consideration must be given to the irrigation solution, pressure, and volume.
• The use of a splash shield decreases splatter and minimizes the exposure to
potentially infectious fluids.

15. WOUND PREPARATION- IRRIGATION-
Irrigation solution
• Isotonic (normal) saline is frequently used for uncomplicated
wounds, although tap water may be an acceptable alternative.
• Thus, running tap water may be an acceptable alternative to isotonic
saline, at least in healthy patients with clean wounds and in settings
where water quality is assured.
• In addition, when easily available, warmed saline may offer a comfort
advantage to room-temperature irrigation

16. • A dilute (ie, 1:10 mixture of povidone/iodine solution [Betadine]) and
isotonic saline may provide useful antiseptic activity for contaminated
wounds.
• Betadine surgical scrub solution should not be used for this purpose
because it contains ionic detergent that may be toxic to wound tissue.
• Other antiseptic solutions (eg, chlorhexidine and hydrogen peroxide)
sometimes are used to reduce bacterial contamination. However, some of
these solutions may be toxic to wound tissue, have little action against
bacteria, impede wound healing, or have other adverse effects.
• The author uses tap water irrigation for the irrigation of clean uncomplicated
wounds and uses dilute povidone/iodine for dirty or bite wounds.
WOUND PREPARATION- IRRIGATION-
Irrigation solution

17. Irrigation pressure & Volume
• Ideal irrigation pressures are unknown. However, most experts recommend
pressures of 5 to 8 lbs per square inch (PSI).
• Irrigation pressures of 5 to 8 PSI can be achieved by using a 19-gauge
syringe or catheter on a 60 cc syringe .
• Volume — The volume of irrigation solution depends upon the location
and cause of the wound. Smaller, cleaner wounds and those in highly
vascular areas usually require less volume.
• As an example, a simple 1 cm forehead laceration may be adequately cleansed
with 150 to 200 mL, whereas a 4 cm wound on the lower leg that was caused by a
fence may require 500 mL or more.

18. SUTURE MATERIALS

19. AFTERCARE- Dressing and bathing
• Most wounds should be covered with an antibiotic ointment and a nonadhesive dressing
immediately after laceration repair.
• The dressing should be left in place for 24 hours, after which time most wounds can be
opened to air.
• Wounds closed with nonabsorbable (eg, nylon, polypropylene) suture may be gently
cleaned with mild soap and water or half-strength peroxide after 24 hours to prevent
crusting over the suture knots.
• An antibiotic ointment can be applied to the wound as well, with instructions to apply the
ointment two times per day at home until suture removal.
• In contrast, absorbable sutures rapidly break down when exposed to water and should be
kept dry.

20. AFTERCARE- Tetanus prophylaxis

21. AFTERCARE- Prophylactic antibiotics
• Proper wound preparation is the essential measure for preventing wound
infection after suturing simple lacerations.
• We recommend that healthy patients with minor wounds, other than bite
wounds, who undergo laceration repair with sutures not be prescribed
prophylactic antibiotics.
• In addition, some experts advocate prophylactic antibiotics in patients with
excessive wound contamination (eg, soil or water contamination), vascular
insufficiency (eg, devascularized wound, peripheral artery disease), or
immunocompromise.

22. AFTERCARE- Suture removal
The timing of suture removal varies with the anatomic site:
• Eyelids – Three days
• Neck – Three to four days
• Face – Five days
• Scalp – 7 to 14 days
• Trunk and upper extremities – Seven days
• Lower extremities – 8 to 10 days

23. AFTERCARE- Follow-up visits
• Most clean wounds do not need to be seen by a physician until
suture removal, unless signs of infection develop.
• Highly contaminated wounds should be seen for follow-up in 48
to 72 hours.
• It is imperative that clear discharge instructions are given to
every patient regarding signs of wound infection.

25. Ideal suture materialshould:
• Have good handling characteristics
• Not induce significant tissue reaction
• Glides through tissues easily
• Allow secure knots
• Have adequate tensile strength
• Not cut through tissue
• Be sterile, Unfriendly to bacteria
• Be non-allergenic
• Cheap

26. No suturemeetsall thesecriteriain all situations.
• Youhave to choose the most appropriate suture material from the large variety
available based on the:
• Tissue being sutured and how it heals
• Disease and patient factors
• Procedure
• Available suture materials
• Personal preference

27. When a junior surgical trainee is asked,
“Which suture would you like for skin?”
A common response is
“Whatever The Boss likes to use!”.
• This answer serves two purposes:
• It maintains the status quo
• But(more importantly) it also covers
up the fact that many of us have only a
very basic understanding of suture
materials.

28. Classification of suturematerials
• Generally categorized by three
characteristics:
• Absorbable vs. non-absorbable
• Natural vs. synthetic
• Monofilament vs. multifilament

29. Absorbable Suture
• Degraded and eventually eliminated :
• Via inflammatory reaction utilizing tissue enzymes
• Via hydrolysis
• Examples:
• Natural: Catgut-plain or chromic
• Synthetic: Polyglactin (vicryl), polyglycolic acid (dexon) Vicryl , Monocryl , PDS
• Uses :
• Internal
• Intradermal/ subcuticular
• Rarely on skin

32. Non - AbsorbableSuture
• Not degraded, permanent
• Examples:
• Natural: Silk linen
• Synthetic: Polyamide (nylon), polyester (dacron), polypropylene (prolene) ,
stainless steel
• Uses :
• Primarily Skin : Needs to be removed later
• Intradermal/ subcuticular
• Internal : Abdominal sheet , Ligature , Orthopedics

34. Classification of suturematerials
/Chromic

36. Natural Vs. Synthetic
• Natural
• Made of biologic fibers
• Are absorbable or nonabsorbable types
• Tend to induce more tissue reaction than synthetic materials
• Common examples include surgical gut (catgut) and silk
• Synthetic
• Made of man-made materials
• Are absorbable or nonabsorbable types
• Tend to be less reactive than natural materials
• common examples include polydioxanone (PDS) and nylon

38. Monofilament Vs MultifilamentSuture:
Monofilament
• Grossly appears as single strand of suture material; all fibers run
parallel
• Has minimal tissue drag so minimal tissue trauma
• Resists harboring microorganisms
• Ties smoothly, Requires more knots than multifilament suture
• Significantly weakened by kinking or if crushed by instruments
• Monocryl, PDS, Prolene, Nylon

40. Monofilament Vs MultifilamentSuture:
Multifilament
• Fibers are twisted or braided together
• Greater resistance in tissue
• Provides good handling and ease of tying
• Fewer knots required
• Examples: Vicryl (braided), Chromic (twisted), Silk
• Can form nidus for calculi formation in bladder and biliary system if persist for significant duration
• Should NOT be placed in infected or contaminated areas
• bacteria can reside between individual fibers of the strand
• isolated from immune system and antibiotics
• results in persistence of infection as long as suture present

42. SUTURE SIZE

43. 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 Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

44. Suture Size
• The selected size and tensile strength should approximate the tissue
being sutured.
• The goal is to select the smallest suture that will support the
incision
• Too fine → breaks before tissue heals resulting in dehiscence
• Too large → more foreign material in wound causing more tissue reaction and slower
wound healing

45. • The gauge or caliber are usually expressed using the
US Pharmacopoeia
• sizes (USP).

47. Diameters/sizes available
Catgutisavailableinvarioussizes,rangingfrom(0000)to(3)inorderofincreasing diameters
Old gauge Diameter in
m.m.
8|0 0.05
7|0 0.07
6|0 0.1
5|0 0.15
4|0 0.2
3|0 0.3
2|0 0.35
0 0.4
1 0.5
2 0.6
3 0.7
4 0.8
Dr Raed Ziara

49. Suture indications by location
1. Mucosal Lacerations (mouth, Tongue or genitalia)
1. Absorbable Suture: 3-0 or 4-0
2. Scalp, Torso (chest, back, Abdomen), Extremities
1. Superficial Nonabsorbable Suture: 4-O or 5-O
2. Deep Absorbable Suture: 3-O or 4-O
3. Face, Eyebrow, Nose, Lip
1. Superficial Nonabsorbable Suture: 6-O
2. Deep Absorbable Suture: 5-O
4. Ear, Eyelid
1. Superficial Nonabsorbable Suture: 6-O
5. Hand
1. Superficial Nonabsorbable Suture: 5-O
2. Deep Absorbable Suture: 5-O
6. Foot or sole
1. Superficial Nonabsorbable Suture: 3-O or 4-O
2. Deep Absorbable Suture: 4-O
7. Penis
1. Superficial Nonabsorbable Suture: 5-O or 6-O

50. Knot tensile strength
• is measured by the force, in pounds, which the suture
strand can withstand before it breaks when knotted.
• The accepted rule is that the tensile strength of the suture
need never exceed the tensile strength of the tissue.

51. Specific suture materials
For each suture that you use, you need to know:
• Absorbable or nonabsorbable
• If absorbable, how rapidly
• Monofilament or multifilament (braided)
• Amount of tissue reaction that it stimulates
• Knot security and ease of handling
• Unique properties of that material

52. Absorbable suture : Plain catGut
• Suture Types : multifilament Raw material : Derived from sheep intestinal
submucosa and bovine intestinal serosa , treated with chromic salt
• Tensile strength , retention in vivo lost within 7–10 days
• Absorption rate: Phagocytosis and enzymatic degradation within 7–10 day
• Tissue reaction : High
• Contraindications :Not advised for use in tissues which require prolonged
approximation
Frequent uses : Ligate superficial vessels, suture subcutaneous tissues

53. Absorbable suture : chromicGut
• Suture Types : multifilament Raw material : Derived from sheep
intestinal submucosa and bovine intestinal serosa Tensile strength ,
retention in vivo Lost within 21–28 days
• Absorption rate: Phagocytosis (within 90 days)
• Tissue reaction : Moderate
• Contraindications :Not advised for use in tissues which require
prolonged approximation
Frequent uses : Ligate superficial vessels, suture subcutaneous
tissues

54. • treated with a chromium salt solution to resist body
enzymes, prolonging absorption time over 90 days.
• Chromic gut minimize tissue irritation, causing less
reaction than plain surgical gut

55. Absorbable suture : (Vicryl)
• Suture Types : Braided multifilament Raw material : Polyglactin
• Tensile strength , retention in vivo Approximately 60% remains at
2 weeks , Approximately 30% remains at 3 weeks
• Absorption rate: Hydrolysis minimal until 5–6 weeks. Complete
absorption 60–90 days
• Tissue reaction : Mild
• Contraindications :Not advised for use in tissues which require
prolonged approximation under stress
• Frequent uses : General surgical use where absorbable sutures
required, e.g. gut anastomoses, vascular ligatures. Has become the
‘workhorse’ suture for many applications in most general surgical
practices, also for subcuticular wound closures. Ophthalmic surgery

56. Polyglactin 910 (Vicryl)
• significant tissue drag
• may cut delicate tissues
• available with coating
• decreases drag
• poorer knot security (need extra throws)
• good knot security
• 3 throws can achieve a secure knot (one extra if coated)
• 4-5 throws at start and 5-6 throws at end of continuous suture patterns
• comparison with chromic gut:
• stronger
• more predictable loss of tensile strength
• much less reactive
• more rapid and complete removal from the body
• can be used to close tissue layers that regain sufficient strength within 7-14
days

57. • Suture Name - Vicryl
• Construction - Braided
• Absorption - 56-70 Days
• Color - Violet or White
• Additional Info - One of the most common sutures used in all
surgical services to appoximate soft tissue.

58. COATED VICRYL*RAPIDE
POLYGLACTIN 910SUTURE
• Coated VICRYL RAPIDE suture is the fastest-absorbing
synthetic suture
• Elicits a lower tissue reaction than chromic gut suture.
• indicated only for use in superficial soft tissue approximation
of the skin and mucosa short-term wound support (7 to 10
days)
• retain approximately 50% of the original tensile strength at 5
days post implantation.
• All of the original tensile strength is lost by approximately 10
to 14 days.
• Absorption is essentially complete by 42 days.

59. Absorbable suture : Polydioxanone
(PDS II)
• Suture Types : Monofilament Raw material : Polyester polymer
• Tensile strength , retention in vivo Approximately 70% remains at 2
weeks , Approximately 50% remains at 4 weeks, 14% remains at 8weeks
• Absorption rate: Hydrolysis minimal at 90 days , Complete absorption at
180 days
• Tissue reaction : Mild
• Contraindications :Not for use in association with heart valves or synthetic
grafts, Frequent uses : Uses as for other absorbable sutures, in particular
where slightly longer wound support is required , it is commonly used to
approximate fascia in open abdominal cases.

60. Polydioxanone (PDS)
• Construction - Monofilament
• Absorption - 183 - 238 days
• Color - Clear or Violet
• Additional Info - PDS is a long lasting absorbable monofilament suture for soft
tissue approximation, it is commonly used to approximate fascia in open abdominal
cases.

61. Absorbable suture :Polyglycolicacid
(Dexon)
• Suture Types : Braided multifilament Raw material : polyglycolic
• acid.
• Tensile strength , retention in vivo : Approximately 40% remains at 1
week , Approximately 20% ,remains at 3 weeks
• Absorption rate: Hydrolysis minimal at 2 weeks, significant at 4
• weeks. Completeabsorption 60–90 days
• Tissue reaction : Minimal
• Contraindications :Not advised for use in tissues which require
• prolonged approximation under stress
• Frequent uses : as other absorbable
• How supplied :with needles & without needles

62. Absorbable suture : (monocryl)
• Suture Types : Monofilament Raw material : glycolite and
caprolactone
• Tensile strength : loses tensile strength quickly (50 % within 7 days)
• Absorption rate: 90–120 days
• Tissue reaction : Minimal
• Contraindications :Not advised for use in tissues which require
prolonged approximation under stress
• Frequent uses : used for soft tissue suturing when prolonged wound
support is not necessary (eg. subcutaneous and intradermallayers)

63. • Construction - Monofilament
• Strength - 50%-70% 1 week, 20% - 40% @ 2
weeks
• Absorption - 91-119 Days
• Color - Violet or Undyed Clear
• Additional Info - One of the most common
sutures used in all surgical services for skin
closure, used commonly in cosmetic surgery
for general soft tissue closure.

64. Non absorbable suture

65. Non -Absorbable suture :(SILK)
• Suture Types : Braided multifilament Raw material : Natural protein
Raw silk from silkworm
• Tensile strength : Loses 20% when wet; 80–100% lost by 6 months.
• Absorption rate: Fibrous encapsulation in body at 2–3 weeks
Absorbed slowly over 1–2 years
• Tissue reaction : Moderate to high
• Contraindications :Risk of infection and tissue reaction makes silk
unsuitable for routine skin closure
• Frequent uses : become uncommonly used ,, For securing drains
externall

66. SILK
• Category: Natural Nonabsorbable Suture (braided)
• Indications:
• Skin closure
• Eye and lip skin surgery, Intraoral surgery
• Advantages: Best handling and tying of any Suture Material
• Disadvantages: Least tensile strength of any Suture Material
• High tissue reactivity (similar to Catgut Suture)
• Increases risk of infection due to high capillarity

67. Non -Absorbable suture :
Nylon (Ethilon orDermalon)
• Suture Types : Mono/multifilament Raw material : Polyamide
polymer Tensile strength : Loses 15–20% per year
• Absorption rate: Degrades at approximately 15–20% per year
• Tissue reaction : Low
• Contraindications : NONE
• Frequent uses : General surgical use, e.g. skin closure, abdominal wall
mass closure, hernia repair, plastic surgery, neurosurgery, microsurgery,
ophthalmic surgery

68. Non -Absorbable suture:
Polypropylene (Prolene)
• Suture Types : Mono/multifilament Raw material : Polyamide
polymer Tensile strength : infinte
• Absorption rate: capsulated within body tissue and doesn’t absorbe
• Tissue reaction : Low
• Contraindications : NONE
• Frequent uses : Cardiovascular surgery & anastomosis , plastic
surgery, ophthalmic surgery, general surgical subcuticular skin closure

69. Reading the sutureLabel

71. SUTURE NEEDLE

72. Suture Needles
• Along with selecting the correct suture it is important as well to select an appropriate Needle.
• The two factors in selecting a needle are size and if a cuttingor tapered needle is needed.
• While there are exceptions, much of the time you will find tapered needles are used inside the
body such as on bowel, fascia, or muscle where the tissue is more easily pierced.
• Cutting needles are used for skin and very tough tissue such as bone and tendon.
• Beyond choosing a cutting or tapered needle one only needs to select an appropriate size. There
are hundreds of sizes and types of needles

73. • Every needle has three parts:
• 1. Attachment end
• 2. Body
• 3. Point
Anatomy of aNeedle

75. The surgical needle has a basic design composed of three parts :
• The eye :which is swaged and permits the suture and needle to act as a single unit to
decrease trauma
• The body (grasping area) : which is the widest point of the needle. The body comes in
number of shapes (round, oval, rectangular, trapezoid, or side flattened)
• The point : which runs from the tip to the maximum cross- sectional area of the body.
The point also comes in a number of different shapes (conventional cutting, reverse
cutting, side cutting, taper cut, taper, blunt )

76. Needle point
(conventional cutting, reverse cutting,taper cut, taper, blunt)
(Taper cut, taper ) have a round body with a sharp pointed tip

78. Surgical Needles –Types
Round Bodied &Blunt
• Pierces and spreads the tissue without cutting.
• Used in easily penetrated tissues like Peritoneum, abdominal viscera.
• Used in internal anstomosis to prevent leakage.
• Blunt needles are used to dissect through friable tissue – liver & kidney

79. Round Body Needle

80. Surgical Needles –Types
Conventional Cutting
• Has three cutting edges
• For use to cut through tough difficult to penetrate tissue
• Can be used skin sutures

81. Surgical Needles –Types
Reverse Cutting
• Ideal for tough tissue like skin, tendon sheath or oral mucosa.
• Has more strength than conventional cutting needles.
• Has reduced risk of cutting out tissue.
• Used in ophthalmic and cosmetic surgery- minimal trauma.

83. Shapes
Needle BodyCurvatures
Straight
1/4 Circle 1/2 Circle
3/8 Circle 5/8 Circle

84. SurgicalNeedles
• Preferred when tissue is easily accessible
• Designed to be finger held on or near the surface
• Useful for skin closure, Micro surgery- Nerve and vessel repair

85. Needle BodyCurvatures
• The curvature of the needle determines the depth of its bite.
• Curved needles are used due to quick needle turnout from tissue.

86. Surgical Needles –Shape
I/4 Circle
• Has shallow curvature
• Typically used on easily accessible convex surfaces
• Ophthalmic and Microsurgical procedures

87. Surgical Needles –Shape
3/8 Circle
• Most commonly used curved needle
• Can easily be manipulated in large and superficial wounds
• But are awkward or impossible to use in deep cavities due to large arc
of manipulation needed- eg. pelvis

88. Surgical Needles –Shape
1/2 Circle
• For use in confined locations
• Requires more pronation and supination of wrists

89. Surgical Needles –Shape
5/8 Circle
• Ideal for deep, confined holes
• Can be used by rotating the wrist with little or no lateral movement.

90. SUTURE TECHNIQUES

91. Suture techniques
Common suture stitching techniques include:
1. Simple Interrupted Stitch
2. Running Stitch
3. Horizontal mattress
4. Vertical mattress
5. Continuous locking
6. Subcuticular

94. Simple InterruptedStitch

95. Surgicaltechniques
• Continuous (Running stitch)
• Stitches made in succession
without knotting each stitch

97. Surgicaltechniques
• Horizontal mattress
stitch?
• Simple stitch is made, the
needle is reversed, and
the same size bite is
taken again—oriented
parallel to wound

98. vertical mattressstitch
• Far-far, near-near stitch
– Simple stitch is made, the
needle is reversed, and a
small bite is taken from each
wound edge; the knot ends
up on one side of the wound

99. Subcuticularstitch
• Stitch (usually running) placed just underneath the
epidermis, can be either absorbable or nonabsorbable
(pull-out stitch if nonabsorbable)

100. Pursestringsuture
• Stitch that encircles a tube perforating a hollow viscus
(e.g., gastrostomy tube), allowing the hole to be drawn
tight and thus preventing leakage

101. Retentionsuture
• Large suture that is full thickness through the entire
abdominal wall except the peritoneum; used to buttress an
abdominal wound at risk for dehiscence

102. Knot tying
• Safe knot tying is
fundamental to good
surgical practice and
one of the first
challenges faced by the
basic surgical trainee

103. Principles of knottying
• Tie knot firmly so it does not slip.
• Carry the knot down to the tissues with the tip of the index
fingers and make sure that the strands of the ligature are
flat by drawing then in opposite directions. This prevents
twisting and the knot slipping.
• Do not use undue force otherwise the knot will cut through
the tissue or fracture.
• Tie knots in anticipation of postoperative tissue swelling to
prevent necrosis.

104. Principles of knottying
• Do not clamp the knot to complete your tie. This will
weaken the suture, particularly monofilament sutures.
• Avoid friction or sawing between strands when tying as
the suture may weaken.
• The knot should be as small as possible to exclude
foreign material.
• Do not add extra knots ‘to make sure’.

105. Basic knotting techniques
• The one-handed reef knot
• Instrument tying
• The surgeon’s knot
• The slip or granny knot
• The Aberdeen knot.

106. Guidelines for obtaining a finescar
• Try to place the incision in Langer’s contour lines.
• Use atraumatic techniques and avoid tension
• Sutures can be removed earlier than these times for
cosmetic reasons.
• If removed early additional support to the wound can be
facilitated with Steri-strip adhesive skin strips. These may
also be used as an alternative to skin sutures, particularly
in children.

107. Skin clips
• are an alternative to skin sutures.
• They have low infection rates and similar cosmetic
results.
• More expensive.
• Easier
• Faster

108. The skin s t a p l e r
-the simplest of the stapling devices to master.
- easy to apply and remove.
- saving a significant amount of time.
- closing long or multiple skin incisions .