Basic surgical skills final

• Patients.
• Procedures.
• Gowning.
• Gloving.
• Skin Incisions.

• Needles.
• Suture Materials.
• Instruments
• Suturing techniques.
• Wound healing.
• Wound Closure.

• Patient & Procedure
• Hand washing
• Gowning & Gloving
• Universal precautions

• Patient
• Permission
• Preparation
• Position
• Procedure
• Post procedure
• Prescription

• “ If ” hair must be removed, clipping &
depilatory creams are better than
shaving with a razor (as shaving 
damage the skin's defences &  risk
of wound infection).
• Hair removal is better to be
accomplished immediately prior to
surgery & outside the OR.

• Supine
• Prone
• Fowler’s.
• Trendlenberg’s.
• Lateral (Sim’s).
• Lithotomy.
• Knee-chest.
• Squating.

• Has immediate & broad activity against gram+ve &
gram-ve bact., many fungi & viruses & myco-bacteria,
(although not sporicidal).
• Kills faster than chlorhexidine gluconate or povidone
iodine, but has little residual effect.
• { 1-minute scrub with alcohol = 4-7 minute scrub with
other antiseptics}.
• Not to be used on mucous membranes.
• 70% solution is most commonly used. Ethanol,
normal propyl, & isopropyl are all effective.
• Highly flammable, (must be dried completely where
electro-cautery or laser will be used).

• The povidone carrier releases its
iodine slowly.
• Iodophors are highly effective.
• Their anti-microbial action declines
rapidly upon drying, (does not have a
residual effect).
• Iodine is in-activated by organic
material so should be applied only to
clean skin.

• more effective against gram +ve than
gram -ve bacteria, with less activity
against viruses & fungi.
• It binds to the top layer of the skin  
extended effectiveness, (chemical activity
for about 5 hours).
• It does not become inactivated in the
presence of organic materials.
• It is also available as an alcohol-based
hand-rinse, combining the rapid &
effective action of alcohol with the long
action of chlorhexidine gluconate.

Duration is
not fully
established,
better to be
~ 5 minutes.

• The prep solution & paint shouldn't be allowed to
pool or accumulate under, or adjacent to the
patient (to prevent chemical burns & decrease the
risk of electrosurgical or laser burn).
• Sterile towels should be placed at the periphery of
the skin prep boundaries to prevent accumulation
of the agents.
• ECG leads, grounding pad, & tourniquet (if in the
area of the skin prep region), should be covered by
an adhesive clear plastic drape to prevent
accumulation of prep fluids & prevent chemical
burns.
• Do not wipe off prepping solution. Allow it to DRY
COMPLETELY prior to draping.

• Skin prep is begun at the incision site to the
periphery, using circular motion.
• The most important principle is to progress from
clean to dirty area.
• Areas of high microbial counts, (axilla, groin,
perineal region, anus & vagina are prepped last
with a separate sponge.
• Umbilicus is an exception. It is prepped first.
This prevents debris from umbilicus from
splashing onto the prepped abdomen.
• In abdomino-perineal & abdomino-vaginal
procedures, separate skin preps are used starting
with perineal & vaginal areas.

• Included area is from
nipple line to upper 1/3
of thighs; table level
left to table level right.

• Do not use Chlorhexidine or alcohol
solutions.
• Place drip towel or drape under buttocks
to prevent prep solution from pooling
under the patient’s coccyx.
• Ensure towel or impervious drape is
removed following completion of the
prep.

A. Prep pelvis, labia, perineum, & thighs:
– Start at the pubis to iliac crest (back & forth
strokes).
– Prep L. majora & perineum (downward
strokes).
– Use fresh sponge to prep inner thigh of first
leg starting at labia majora then laterally
(back & forth strokes). Then discard sponge
when periphery reached.
– Use fresh sponge to prep inner thigh of
second leg starting at labia majora & moving
laterally using back & forth strokes. Discard
sponge when periphery reached.

B. Vaginal prep: use a separate sponge
mounted on a forceps.
C. Prep anus last.

1) Handle drapes as little as possible.
2) Never reach across the operating table to drape the
opposite side, go around the table.
3) Hold the drapes high enough to avoid touching non-
sterile areas (take care of the overhead light).
4) Hold the drape high until it is directly over the proper
area, then drop it. NEVER adjust any drape. If the
drape is incorrectly placed, leave it & place another
drape over it.
5) Protect the gloved hands by cuffing the end of the sheet
over them. Do not let the gloved hand touch the skin of
the patient.

6) A drape should be carefully unfolded & allowed
to fall gently into position by gravity.
7) The low portion of the sheet that falls below the
safe working level shouldn’t be raised or lifted
back onto the sterile area.
8) Drape the incisional area first, then the
periphery.
9) Use non-perforating towel clamps.
10)When sterility of a drape is questionable,
consider it contaminated.

• The only way to learn is to go to theatre.
• Duration is not fully established, better to
be ~ 5 minutes.
• Prepare the gown & gloves before you wash.
• Put the mask & cap on BEFORE gowning up.

Universal
Precautions
include:
Washing
hands
Double
Gloves
Goggles
Masks
Caps
Face
shields
Boots
Disposal of
sharps into
sharp’s
bins
Reporting
of needle
stick
injuries

 The incision should be accomplished with
the least possible tissue damage.
 A scalpel should be used, & the fewest
possible strokes will limit tissue damage.
 Electro-cautery tends to produce much
larger zones of damage & increases
infection rates.
 Haemostasis can be obtained with well-
directed cautery & fine ligatures.

• Advantages (compared to midline inc.):
– 30 xs stronger.
– Less painful, less interference with post op.
respirations.
– Less wound eviscerations & hernias.
• Disadvantages (compared to midline inc.):
– More time consuming.
– More haemorrhage.
– More nerves are divided.
– More possibility for formation of potential spaces
& haematoma formation.
– Less exposure of the upper abdomen.

A. Pfannenstiel incision:
• Transverse incision, slightly curved (curvi-
linear fashion).
• Usually 10-15 cm long.
• At any level suitable for the surgeon, about
approximately 2–3 cm above the pubic
symphysis.
• No dissection of the SC fat from the ant
rectus fascia ( as in Kustner’s incision).
• Fascial incision should not extend beyond
the ext oblique fascia.
• No need to suture the sub cutaneous tissue.

B. Joel-Cohen incision:
• A transverse incision.
• Made in a linear fashion approximately 2–3
cm above the traditional placement of the
Pfannenstiel incision.

A. Pfannenstiel incision.
B. Joel-Cohen incision.
C. Midline vertical incision.

C. Küstner incision:
• Wrongly named (modified Pfannenstiel).
• A slightly curved transverse skin incision.
• From below the level of the ASIS, extends below the
pubic hair line.
• Superficial inferior epigastric vessels are ligated.
• The external oblique fascia is incised vertically (as
in midline incision) after separation of the SC
tissue till the umbilicus at the midline.
• More time consuming (than Pfannenstiel & low
midline incisions) due to more bleeding.
• A SC drain is strongly recommended.
• Has no advantage & of very limited use.

D.Cherney incision:
• It entails freeing of the recti (& pyramidalis) from
their tendinous insertion into the SP.
• Bleeding is negligable at this area., no need to ligate
the inferior epigastric vessels.
• It gives 25% more length compared to mid line
incision.
• Provides excellent access to the space of Retzius.
• Provides excellent access to the pelvic side walls.
• Nerve injury is more encountered (especially the
Femoral nerve when using a self retaining retractor.
• To avoid osteomyelitis, the rectus should be sutured
to the lower flap of the muscle, not the SP.

D.Maylard incision:
• A true muscle cutting-incision, all layers of the abd
wall are incised transversely.
• Provides excellent pelvic exposure.
• The skin incision is to be made 3-8 cm above the SP.
• After fascial incision (till lateral to the outer edges of
the Recti), gently identify & ligate the inferior
epigastric vessels (with permenant sutures).
• After cutting the Recti , better to suture the muscle
to the overlying fascia (to avoid their retraction).
• The peritoneum is opened transversely.

Incisions Pfannenstiel Cherney Maylard Vertical
Pelvic
exposure
++ +++ ++++ +++
Upper
abdomen
exposure
+ ++ ++++
Potential
blood loss
++ ++ +++ +
Potential
hernia
+ + ++ +++
Evisceration
risk
+ ++ +++
Speed ++ +++ + ++++

A. Layered closure.
B. Modified Smead-
Jones closure.
C. Mass closure.
D. Retention suture.

• The choice of needle to be used
depends on several factors such as:
1. requirements of the procedure;
2. nature of the tissue being sutured;
3. accessibility of the operative area;
4. gauge of suture material being used; and
5. surgeon's preference.

Surgical needles have three basic components:
the point, the body & the swage.
 The Point depends on the needle type (round or
cutting).
 The Body has flattened section where the needle can
be grasped by the needle holder. Some needles have
longitudinal ribs on the surface which reduce
rotational movement.
 The majority of surgical needles are
Eyeless (already swaged to the suture
material).

• Straight needle just becomes embedded in normal
tissues, unless they can be held up. (as skin edges).
• 3/8 curve is the most common shape.
• 1/2 or 5/8 curve needle are useful in small spaces.
• 1/4 curve or a straight needle is adequate if there
is no shortage of space. (as skin edges).
• Compound shapes include a J needle for confined
spaces (as for femoral hernia repair).
• Most surgical needles are curved.
• Few are straight.
• The curve allows the needle to pass down into the
tissues & to come out again along a curved track.

•Needles are made from stainless steel alloys,
selected to hold a very sharp point for one
use only.
•They are designed to bend, rather than to
break, when over stressed.
• The strength of the needle is designed to
match the use to which it is put.

Needle length, not chord
length (bite width), is the
measurement supplied on
suture packages
Chord length: the linear distance from the point
of the curved needle to the swage (bite width).
Needle length: The distance measured along the
needle from the point to the swage.

Radius: This is the distance from the body of the
needle to the centre of the circle along which the
needle curves (bite depth).
Diameter: The gauge or thickness of the needle
wire.
The needle should be
long enough to:
Pass through the tissue.
 Show at the far side of the
wound to be grasped by the
needle holder or dissecting
forceps.

• Size originally scaled from 0-3.
• As technology advanced & sutures became smaller,
extra 0’s were added.
• Scale now ranges from 3 (largest) to 12/0 (smallest)
Size Uses
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels
4/0 Mucosa, neck, hands, limbs, tendons, blood vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
0 and larger
Abdominal wall, fascia, drain sites, arterial lines,
orthopaedics

(1) Round-bodied needles
• Designed to separate tissue fibers rather than cut
them.
• Used either for soft tissue or in situations where easy
splitting of tissue fibers is possible.
• After the passage of the needle, the tissue closes
tightly round the suture material, thereby forming a
leak-proof suture line which is particularly vital in
intestinal & cardiovascular surgery.

(1) Round-bodied needles
Needle type Description Typical application
Intestinal
The hole made by this needle is
no larger than the diameter of the
needle.
The hole is then filled by the material,
which reduces the risk of leakage.
Gastrointestinal tract;
biliary tract;
dura;
peritoneum;
urogenital tract;
vessels; nerve.
Heavy
In some situations where particularly
strong needles are required, a heavy
wire diameter needle would be
appropriate.
Muscle;
subcutaneous fat;
fascia;
pedicles.
Blunt
Taper-point
Where needle-stick injury is a major
concern, particularly in the presence of
blood borne viruses,
the blunt taper-point needle virtually
eliminates accidental glove puncture.
Uterus;
pedicles;
muscle;
fascia.
Blunt-point
This needle has been designed for
suturing extremely friable vascular
tissue.
Liver;
spleen;
kidney;
incompetent uterine cx.

(2) Cutting needles
• They are required where tough or dense tissue
needs to be sutured.
(3) In addition, there are surgical needles for
special areas,
such as microsurgery, opthalmics & endoscopic
surgery.

(2) Cutting needles
Needle type Description Typical application
Tapercut™
This needle combines the initial
penetration of a cutting needle with
the minimized trauma of a round-
bodied needle.
The cutting tip is limited to the
point of the needle, which then
tapers out to merge smoothly into a
round cross-section.
Fascia;
ligament;
uterus;
scar tissue.
Cutting
This needle has a triangular cross-
section with the apex on the inside
of the needle curvature. The
effective cutting edges are restricted
to the front section of the needle.
Skin;
ligament;
nasal cavity;
tendon;
oral.
Reverse
cutting
The body of this needle is triangular
in cross-section with the apex on the
outside of the needle curvature.
Skin; fascia;
ligament; tendon;
oral; nasal cavity.

 Tapered Needle
• Gradually taper to the point & cross-section
reveals a round, smooth shaft.
• Used for tissue that is easily penetrated (as
bowel or blood vessels).
 Cutting
• Triangular tip with the apex forming a
cutting edge.
• Used for tough tissues, (as skin)
(NB: use of a tapered needle with skin causes
excess trauma because of difficulty in
penetration).
 Reverse cutting needle
• Similar to conventional cutting needle except
the cutting edge faces down instead of up.
• This may decrease the likelihood of sutures
pulling through soft tissue.

Round-bodied needle
Cutting needle

W9890
needle
• Thread (suture material):
• 75 cm thread length,
• 3/0 thread diameter (size).
• Coated Vicryl (polyglactin , braided, absorbable,
synthetic).
• Needle =
• Cutting (reverse cutting).
• 30 mm long,
• 3/8 circle

Code J345
• Thread (suture material):
• 90 cm thread length,
• 2/0 thread diameter (size).
• Coated Vicryl (polyglactin , braided, absorbable,
synthetic.
• Needle =
• Rounded (taper end).
• 36 mm long,
• half circle

The ideal suture has the following criteria :
1. Sterile
2. All-purpose (composed of material that can be
used in any surgical procedure).
3. Causes minimal tissue injury or tissue
reaction (ie, non-electrolytic, non-capillary,
non-allergenic, non-carcinogenic).
4. Easy to handle.
5. Holds securely when knotted (ie, no fraying or
cutting).
6. High tensile strength.
7. Favourable absorption profile.
8. Resistant to infection.

• Absorbable - Progressive loss of mass and/or volume of
suture material; does not correlate with initial tensile strength.
• Breaking strength - Limit of tensile strength at which suture
failure occurs.
• Capillarity - Extent to which absorbed fluid is transferred
along the suture.
• Elasticity - Measure of the ability of the material to regain its
original form and length after deformation.
• Fluid absorption - Ability to take up fluid after immersion.
• Knot-pull tensile strength - Breaking strength of knotted
suture material (10-40% weaker after deformation by knot
placement).

• Knot strength - Amount of force necessary to cause a knot to
slip (related to the coefficient of static friction and plasticity of
a given material).
• Memory - Inherent capability of suture to return to or
maintain its original gross shape (related to elasticity,
plasticity, and diameter).
• Non-absorbable - Surgical suture material that is relatively
unaffected by the biological activities of the body tissues and is
therefore permanent unless removed.
• Plasticity - Measure of the ability to deform without breaking
and to maintain a new form after relief of the deforming force.
• Pliability - Ease of handling of suture material; ability to
adjust knot tension and to secure knots (related to suture
material, filament type, and diameter).

• Straight-pull tensile strength - Linear breaking strength
of suture material.
• Suture pullout value - The application of force to a loop of
suture located where tissue failure occurs, which measures
the strength of a particular tissue; variable depending on
anatomic site and histological composition (fat, 0.2 kg;
muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg).
• Tensile strength - Measure of a material or tissue's ability
to resist deformation and breakage.
• Wound breaking strength - Limit of tensile strength of a
healing wound at which separation of the wound edges occurs.

• Absorbable sutures or Non-absorbable sutures.
• Monofilament sutures or Multifilament sutures.
• Of Biological (natural) source or Man-made
(synthetic) source.

Absorbable sutures:
• Offer temporary wound support, then are gradually absorbed.
• Composed of biodegradable materials which can be:
 Naturally occurring (degraded enzymatically).
1. Catgut
• Consists of processed collagen from animal intestines.
• Broken down after 7 ds.
2. Chromic catgut
• Consists of intestinal collagen treated with chromium.
• Loses tensile strength after 2-3 ws & is broken down after 3 ms.
 Synthetic
• Degraded (non-enzymatically) by hydrolysis when water
penetrates the suture filaments & attacks the polymer chain.
• Tend to evoke less tissue reaction.
• Sub-classified according to degradation time.
The ideal suture should disappear immediately after its
work is complete, but such a suture does not yet exist.

Non-absorbable sutures
• Do not absorb, but some, especially those
of biological origin, lose strength without any
change in the mass of the suture material.
• Others gradually fragment over time.
• Other non-absorbables, especially those of
synthetic origin, never lose tensile strength or
change in mass.

Mersilk
Natural
Nurolon
Ethibond
Braided
Ethilon
Prolene
Monofilament
Synthetic
Non-absorbable
Catgut
Natural
Vicryl rapide
Synthetic
Short term
Braided vicryl
Braided
Monocryl
Monofilament
Medium term
Panacryl
Braided
PDS II
Monofilament
Long term
Absorbable

Monofilament suture (Ethilon or Prolene)
• Made of a single smooth strand.
• Less traumatic as they glide through tissues with less friction.
• May be associated with lower rates of infection (resists
harbouring micro-organisms).
• Ties down smoothly, but more likely to slip (should be
secured with 5 or 6 ‘throws’ in contrast to 3 throws with
multifilament)
• Preferred for skin closure because they provide a better
cosmetic result.
Multifilament suture (Mersilk or Mersilene)
• Consists of several filaments twisted together.
• Gives good handling and tying qualities.

based on the origin of the raw material; suture material is either:
Biological or natural source (Mersilk, cotton & steel)
• They tend to create greater tissue reaction than man-made
sutures;
• Result can be localised irritation or even rejection.
• Factors present in the patient (as infection & general health) can
affect the rate at which enzymes attack & break down absorbable
natural sutures.
Man-made or synthetic source (Prolene, Ethilon,
Nurolon)
• Very predictable and elicit minimal tissue reaction.

Name Ab Filament. So.
 Gut  Mono N
 Silk  Braided N
 Cotton  Braided N
 Steel  Mono N
 Monocryl (poliglecaprone)  Mono S
 Maxon (polyglycolide-trimethylene carbonate)  Mono S
 PDS (polydioxanone)  Mono S
 Vicryl (polyglactin)  Braided S
Dexon (polyglycolic acid)  Braided S
 Prolene (polypropylene)  Mono S
 Novafil (polybutester)  Mono S
 PTFE (polytetrafluoroethylene)  Mono S
 Nylon  Mono or Braided S
Steel  Mono or Braided S
 Polyester  Braided S

• Needle Holder
• Forceps
• Blade / Scalpel
• Scissors
• Other instruments

• Notice the Ratchet.
• Notice the course inner
tip.
• How to manipulate it:
– Thumb – to unlock
– 3rd finger (middle finger)
– 1st finger (index)
• Use distal phalanges.
T3
1

• Open ′suture packet with one tear to reveal ′needle.
• Grasp ′needle with ′needle holder at ′ junction of
′upper 1/3 & ′lower 2/3 (two-thirds ′distance from its
pointed end).
• Avoid grasping ′needle at its proximal or distal ends.
• Correct movement is supination of ′wrist.
• Suture needle size & material vary in size dependant
on properties & usage.

• Use ′non dominant hand,
• Hold in ′first three fingers (similar way to a
pen holding)
• Notice ′tip:
– Toothed
– Non Toothed
Toothed forceps
Non-toothed forceps

Russian forceps
Singley forceps
Micro-surgery forceps (micro-forceps)
Bipolar /
Diathermy
forceps
Adson forceps
DeBakey forceps

• Use needle holder
to insert the blade
& slide it on the
handle

• For small No. Scalpel (as No. 11):
hold like a pencil.
• The tripod grip:
three parts of ′tripod are:
′side of ′middle finger, & ′tips of
′index & thumb.
• The tripod grip enables ′surgeon to:
1. Flex & extend ′digits, so that ′scalpel
moves in & out during delicate
dissections.
2. Rotate ′handle of ′scalpel with ′thumb,
so ′scalpel can cut small diameter
curves.

• For larger No. Scalpel (as No. 22):
hold like a table knife.
• ′handle rests in ′ palm of ′ hand.
• ′digits & hand are largely on top of
′scalpel (unlike with ′pen grip).
This means that ′scalpel can be held
close to ′surface of ′tissues when
cutting, without ′digits & ′hand
getting in ′way as in ′pencil grip.
• This allows ′curved part of ′blade to
cut ′skin, rather than ′point of ′blade
tending to just scratch ′skin (with the
tripod grip).

The grip is quite gentle.
1. For tough tissues, (such as skin on ′back), grip
more firmly & place your index finger on ′top of
′handle rather than on ′side  This will increase
′downward pressure of ′blade on ′tissue.
2. For more delicate tissues, hold ′handle between
′thumb on one side & ′four fingertips on ′other.
1 2

•DO NOT hold ′scalpel in ′fist or like
a dagger.
•DO NOT dissect with ′handle of
′scalpel. (You will be concentrating
on ′site of dissection & may
accidentally cut your assistant) .
•DO NOT hold ′scalpel in your hand
while using another instrument
(You may accidentally cut ′patient as
you concentrate on ′dissection area).
X

•ALWAYS pass ′scalpel to someone else handle
first.
•PREFERABLY, place ′scalpel in a dish for ′scrub
nurse to pick out.
•DO NOT throw ′scalpel down on ′bench (or on
′patient).

• ′part of ′blade that does ′cutting is ′curve (& not ′tip).
• Scratching with ′tip of ′blade is a beginner's error.
• Go slowly & gently at first with repeated strokes in
′same place, until you see how much ′blade is cutting
′tissue.
• Press harder at ′beginnings & ends of ′incision.
• Blade should be perpendicular to ′tissues to avoid
slicing; Slicing will de-vascularise ′thinner side of
′incision.

• Two (main) types (dissecting & suture
cutting).
• Thumb & ring finger into rings.
• Index to stabilise from top.
• Use tips of phalanges.
• Use other hand / fingers to stabilise.

• Haemostats / Artery Forceps
– Use to clamp blood vessels
– Jaws may be curved or straight.

Kelly Clamp
Mosquito Clamp
Kocher Clamp
Allis Clamp
Babcock Clamp

• Retractors
– An instrument used to retract deep
tissues in abdomen or chest cavity
– Lip may be curved or smooth

Army-Navy
Brisky-
Navratil
Rt-angle retractor
Auvard
Richardson

• Practice handling instruments.
• Be comfortable with needle holder &
forceps.
• Transfer needle from one to the other.
• Practice reversing the needle.

Standard position on needle in needleholder

• Make a 5 cm incision into the skin
model.
• Make a clean cut.

• Watch the video
• Practice tying interrupted sutures.

• Grasp the skin edge with the
forceps and slightly evert the
skin edge
• Then pronate the needle-
holder so that the needle will
pierce the skin at 90o
• Ensure the trailing suture
material is out of the way to
avoid tangling
 Drive the needle through the
full thickness of the skin by
supinating the needle-holder
 Keeping the shaft of the
needle perpendicular to the
skin allows the curvature of
the needle to traverse the skin
as atraumatically as possible

• Release the needle and
pronate the needle-holder
• Regrasp the needle proximal
to its pointed end
• Maintain tension with the
forceps to prevent the needle
from retracting
• Again, supinate the needle-
holder to rotate the needle
upwards and through the
tissue

• Regrasp the needle in order to
rearm the needle-holder (due
to HIV risks it is better to use
the forceps to do this)
 Grasp and slightly evert the
opposing skin edge with the
forceps
 Pronate the needle-holder

• Again, supinate the needle-
holder to rotate the needle
through the skin, keeping the
shaft 90° to the skin surface
• After releasing the needle,
pronate the needle-holder
before regrasping the needle…

• …and again supinate the
needle-holder to rotate the
needle through the skin
 Pull the suture material through
the skin until 2-3 cm is left
protruding
 Discard the forceps and use your
free hand to grasp the long end in
preparation for an instrument tie
 Place the needle-holder between
the strands

• Wrap the long strand around
the needle-holder to form the
loop for the first throw of a
square knot
• Rotate the needle-holder away
yourself and grasp the short
end of the suture

• Now draw the short end back
through the loop towards
yourself
• Now tighten the first throw

• The throw should be tightened
just enough to approximate
the skin edges but not enough
to strangulate the tissue
• To begin the second throw of
the square knot, wrap the long
strand around the needle-
holder by bringing the long
strand towards yourself

• Rotate the needle-holder
towards yourself to retrieve
the short end
• Grasp the short end and draw
it through the loop by pulling
it away from yourself

• Finally, tighten the second
throw securely against the
first
• Ensure the knot is to one side
of the wound to avoid
involvement in the clot
 In one hand hold the scissors
 With the other hand maintain
tension on the suture material
 Slide the tips of the scissors down
the strands to the point where they
will be cut
 Cut the suture material leaving 4-
5mm tails (important for removal of
external non-absorbable sutures)

• Watch the video.
• Practice tying Continuous sutures.
• Tie Knot at one end.
• Cut only one strand.
• Continue suturing along wound.
• Secure suture at other end with reef
knot.

• Mattress sutures are either:
Vertical, or Horizontal.
• They can evert or invert wound edges.

• Sutures should be removed:
 Face: 3-4 days
 Scalp: 5 days
 Trunk: 7 days
 Limb: 7-10 days
 Foot: 10-14 days
• Steps involved in removal:
– Reassure patient that ′procedure is not painful.
– Clean ′skin with hydrogen peroxide.
– Grasp one of ′suture ‘tails’ with forceps & elevate.
– Slip ′tip of ′scissors under ′suture & cut close to ′skin edge
(to minimise ′the length of contaminated suture that will be
pulled through ′wound).
– Gently pull ′knot with ′forceps & reinforce ′wound Proxi-
Strips if required.

1) Clean.
2) Clean, contaminated.
3) Contaminated.
4) Infected.
1) Clean:
• Uninfected operative wound in which no
inflammation is encountered & NO systemic tracts are
entered (resp., GIT)
• Closed by primary intention & is usually not drained.

2) Clean, contaminated:
• Operative wound in which systemic tract (s) are
entered under controlled conditions and without
contamination.
3) Contaminated: Includes:
• Open traumatic wounds (open fractures, penetrating
wounds)
• Operative procedures involving:
 Spillage from the GI, GU or biliary tracts.
 A break in aseptic technique (open cardiac
massage).
− Microorganisms multiply rapidly that a contaminated
wound can become infected within 6 hours.

4) Infected
o Heavily contaminated/infected wound prior to
operation.
o Includes:
• Perforated viscera.
• Abscesses.
• Wounds with undetected foreign body/necrotic
tissue.

1. Primary intention.
2. Second (secondary)
intention.
3. Delayed primary closure.

• Involves closure of a wound within
hours of its creation.
• It is the optimum closure; the wound
heals in minimum time with no
separation of its edges & minimal scar
formation.
• Thus, a wound closed surgically with
sutures or by other means heals soon
after creation .

• Occurs when the wound fails to heal by primary
intention due to:
– Infection
– Excessive trauma
– Tissue loss.
• More complicated & prolonged than healing by
primary intention.
• ↑↑ formation of granulation tissue :
– Contains myo-fibroblasts which lead to gradual but
marked wound contraction.
– May protrude above the wound surface, prevent
epithelialisation & thus require treatment.
– Imprecise approximation of
tissue (leaving dead space).

• Used in management of contaminated & infected
wounds with extensive tissue loss & high risk of
infection (eg. trauma following RTA, penetrating
injury).
• Steps taken include:
– Debridement of non-viable tissues (usually under
sedation).
– Leaving wound open with gauze packing inserted.
– Wound approximation within 3-5 days if no
infection is evident.
– If infection is present, the wound is allowed to
heal by secondary intention.

There are 3 phases for wound healing:
1. Inflammatory phase.
2. Proliferative phase.
3. Remodeling phase.

1. Inflammatory:
•Begins immediately & completed by
Day 3-7.
•Initially, haemostasis occurs,
•Then the wound is prepared for
repair by:
» Extra-vasation of tissue fluid, cells &
fibroblasts.
» Increasing blood supply to the wound.
» Debridement of tissue debris by
proteolytic enzymes.
• No increase in tensile strength of tissue & wound healing is
dependent on approximation of edges by closure material.

2.Proliferative:
• Starts from Day 3 onwards.
• Fibroblasts form a collagen matrix (granulation
tissue).
• This collagen matrix:
 Determines the tensile strength &
pliability of the healing wound.
 Becomes vascular, supplying the
nutrients & oxygen necessary for
wound healing.
• Tensile strength increases until
wound is able to withstand normal
stress.

• Wound contraction also occurs:
–Wound edges pull together in order to close the wound,
–If successful, it results in a smaller wound with less need for
repair by scar formation.
–Beneficial in areas such as the buttocks or trochanter.
–Harmful in areas such as the hand, neck & face (can cause
disfigurement & excessive scarring).
–Skin grafting reduces contraction in undesirable locations.

3. Remodelling:
• May continue for a year or longer
• Following completion of collagen
deposition, vascularity decreases &
any surface scar becomes paler.
• Resulting scar size is dependent
upon the initial volume of
granulation tissue.
 The percentage recovery of the tensile strength of the wound is:
– About 20% after 2 weeks

The timetable for wound healing is quite variable, eg:
 Chronic wounds can stall in the inflammatory phase
because of poor perfusion, poor nutrition, or a
numerous other factors causing excessive build-up of
exudates at the wound base. These wounds tend to
remain unhealed unless active and aggressive means
are undertaken to correct the cause while providing
proper wound care.

 Healing may become exaggerated in Keloids &
hypertrophic scar formation. Excessive type III
collagen formation in the proliferative phase causes
overgrowth of scar tissue in these wounds. Individuals
with darkly pigmented skin are genetically prone to
keloid formation. Certain body areas, as the sternum &
shoulder, are more prone to hypertrophic scar
formation.
 Phases can also be blunted as in the foetus, which has a
decreased inflammatory phase & heals without scar.

N.B.: Collagen types & locations are as follows:
Type I
Located in all connective tissue except hyaline
cartilage & basement membranes
Type II Located in hyaline cartilage
Type III
Located in distensible connective tissue (blood
vessels)
Type IV Located in basement membranes
Type V Located in all tissues
Type VI Located in all tissues
Type VII Located in the dermal-epidermal junction
Type VIII Located in the Descemet membrane
Type IX Located in hyaline cartilage
Type X Located in hypertrophic cartilage & hyaline cartilage

• Creating conditions that allow for proper wound
healing can make all the difference in various
wounds (from an unnoticeable wound after plastic
surgery to an amputation or even death in a patient
with severe vascular disease or burn).
1. Perfusion: Tissues cannot heal without the cells,
oxygen, & nutrients. This is particularly important
in wound healing of patients with diabetes or
paraplegia, patients who smoke, & patients who
have been exposed to radiation.

2. Infection: Infection is defined as: having
quantitative bacterial counts of 105 colony forming
units per gram of tissue. Infected wounds do not
heal because of decreased epithelialization and
increased collagen breakdown.
3. Nutrition: Albumin is a good marker of overall
long-term nutritional status over the last month;,
it should be > 3.5 g/dL to optimize wound healing.
Pre-albumin offers a more recent nutritional
status picture & should be maintained > 17 g/dL.
Caloric needs of severely injured patient can
exceed 35 kcal/kg/d & 0.8-2 g/kg/d of protein, &
should be continually assessed & adjusted.

4. Steroids: Corticosteroids can blunt the response of
macrophages, the most essential cell in wound
healing. Vit. A, IGF, & oxandrolone (anabolic
steroid) can be given to reverse the effects of
corticosteroids on wound healing.
5. Dressing: The wound should be kept moist (but
not wet). Desiccated (dead) tissue must be sharply
debrided. There is no substitute for frequent
dressing changes in a grossly contaminated or
recently debrided infected wound. With the advent
of negative pressure wound dressing, wound
healing for even chronic wounds can be greatly
increased.

Recently, many new technologies are
available for sealing tissues that supplement
or replace traditional methods of wound
closure.
Alternative technologies include (for ex.):
 Taping systems,
 Synthetic super glues,
 Energy-based modalities capable of melding
tissues together.

• Absorbable sutures : wound heals quickly &
needs minimal temporary support. (They
alleviate tension on wound edges).
• Non-absorbable sutures: offer longer
mechanical support.
• Mono-filaments have less drag through the
tissues & less tendency for infection.

Disadvantages :
 Additional injuries to the tissue & the
 Introduction of foreign material,
(which may interact with tissue & slow
down the wound healing process).
 Furthermore, sutures are not
watertight.

1. Cyano-acrylate:
• An acrylic resin which rapidly polymerises in the presence of
water forming long, strong chains.
• It can induce inflammatory reaction if implanted
subcutaneously, thus, placement of SC suture aids in everting
skin edges &  chances of deposition of cyanoacrylate into the
SC tissues.
• 2-octyl cyanoacrylate is the only FDA approved cyano-
acrylate. (In addition, in Jan. 2001 FDA granted approval for its
use as a barrier against common bacterial microbes including
certain staphylococci, pseudomonads, & E. coli.)
• SurgiSeal, Octylseal, FloraSeal, Dermabond,
Surgi-Lock & Nexaband, LiquiBand.

2. Fibrin-based tissue adhesives:
• These are biological sealants based on natural adhesion
promoters like pooled blood or autologous sources (as fibrin,
platelet gels, modified collagen, and recombinant proteins).
• Used for haemostasis & can seal tissues.
• Although they do not have adequate tensile strength to close
skin, they can be used to fixate skin grafts or seal CSF
leaks.
• Baxter (Tisseel) & Haemacure (Hemaseel) are FDA-
approved fibrin tissue adhesives made from pooled
blood sources.

• Provide a fast method for wound closure.
• Associated with decreased wound infection rates.
• Composed of stainless steel, which are less reactive than
traditional suturing material.
• They are more expensive than traditional sutures.
• Require great care in placement, especially in ensuring the
eversion of wound edges.
• However, with proper placement, resultant scar formation is
cosmetically equivalent to that of other techniques.

• These tapes can be used either with sutures or alone.
• Some skin adhesives (eg, Mastisol, tincture of Benzoin) aid in
tape adherence.
• The porous paper tapes (eg, Steri-Strips) are used to ensure
proper wound apposition & to provide additional suture
reinforcement.
• Newer products (such as the ClozeX adhesive strip) allows for
rapid & effective wound closure that results in adequate
cosmosis.
• Wound closure with adhesive strips can be significantly
cheaper than suturing or using a tissue adhesive.
• However, adhesive strips are not appropriate for many types
of lacerations.

♠ Totally non-invasive, atraumatic, & promotes faster & more
natural wound healing.
♠ Painless removal from the skin wound without special
instruments after 7 - 8 days.
♠ May be used for surgical incisions & lacerations up to 47 cm.
♠ It combines a zipper & two multilayered adhesive support
strips.
♠ After surgery, the strips are adhered to both sides of the
surgical incision.
•
♠ As the zipper is closed, it draws the edges of the wound
together, securing atraumatic closure of the wound.

• The slider of the slide fastener contains a contact electrode for
electro-coagulation fitted with a cutting edge.
• As the slide fastener is opened, the slider simultaneously
effects the incision by means of the cutting edge of the
electrode, severing both the flexible sheet & the skin beneath.
• For closing the incision, the stringer tapes of the slide fastener
interlock by the action of the slider, thereby bringing both the
edges of the flexible sheet & the wound beneath into
apposition.
• As the slider is drawn forwards closing the stringer tapes,
electrical energy is applied by the electrode at the union site of
the wound edges, which have previously been brought into
apposition by the mechanical action of the slide fastener, thus
ensuring that the edges become adhered in full depth as a
result of electrical coagulation.

• Wound closure techniques based on energy
methods such as ultrasound & radio frequency are
under research.
• It is established that heating the edges of a cut or
wound to a temperature around 60 °C, (using e. g.
an appropriate laser beam), leads to a closure of
the incision.

Nanotech Wound Closure: (light activated tissue repair)
PTB [Photochemical Tissue Bonding] process is a new technique used
to repair wounded skin.
A light-sensitive dye is applied to the tissue surfaces,
The surfaces are placed in contact
The dye-stained area is exposed to visible radiation (green light) that
does not cause thermal damage for 2-3 minutes.
An immediate, water-tight strong bond is produced without additional
glues or proteins.
The bond prevents inflammation or risk of infection, & speeds up the
formation of scar tissue
The process uses a hand-held laser device.
Advantages over sutures & staples for tissue repair.
*PTB does not stimulate inflammation or cause additional damage to
tissue, thus reducing fibrosis & scarring.
* Very small structures that require time-consuming microsurgery
can be rapidly joined with less damage using PTB.
* Soft, delicate, difficult-to-suture tissues can be joined with PTB
* An immediate, water-tight seal is formed.

Dermaclose RC®
The DermaClose™ RC is a device used to facilitate rapid wound
closure.
This device automatically expands skin adjacent to a full thickness
wound facilitating delayed primary closure or significant reduction
in wound size.

• To reduce risk of hypertrophic scars &
Keloid formation.

http://medkaau.com/bssc/index.html

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