The document outlines basic surgical skills related to wound healing and suturing techniques, including types of wound healing (primary, secondary, and delayed primary closure) and various suture materials. It details the properties and handling of sutures, types of needles, and proper techniques for suturing, including the simple interrupted stitch and suture removal guidelines. Additionally, it emphasizes the importance of selecting appropriate suturing methods and materials based on wound type and tissue characteristics.

1. BASIC SURGICAL SKILL
dr. Jeffrey Ariesta Putra D.MAS, Sp.B, FICS, FMAS

2. Overview
01
02
03
TYPE OF WOUND HEALING
Suture Material
Needle
THE INSTRUMENTS
Simple Interrupted Suture
Suture Removal
BASIC SUTURING TECHNIQUE

3. WOUND HEALING

4. 3 PHASES OF WOUND HEALING
Inflammatory (Reactive) Proliferative (Reparative) Maturational (Remodeling)
The 3 phases often overlap

5. WOUND HEALING
PRIMARY INTENTION SECONDARY INTENTION
Wound closed by suturing,
skin grafting or flap closure
Clean incised wound/
surgical wound
Highly contaminated wound
or tissue loss
Wound is left open to heal
Closed by reepithelization
• Optimum closure method
• wound heals in minimum time with
no separation of its edges
• minimal scar formation
More complicated and prolonged than
healing by primary intention

6. • contaminated and infected wounds with extensive tissue loss and a high risk of infection
(eg. trauma following RTA, penetrating injury)
• Steps taken include:
– Debridement of nonviable tissues
– 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
TERTIARY INTENTION/ DELAYED PRIMARY CLOSURE
Contaminated wound Treated by repeated
debridement
Wound is closed by suturing
skin or grafting or flap

7. THE INSTRUMENTS

8. Small toothed forceps (Addison forceps) grasp the skin edges during suturing
Hold in the first three fingers in a similar way to a pen
FORCEPS & NEEDLE-HOLDER
Grasp the needle-holder by partially inserting the thumb and ring finger into
the loops of the handle
The free index finger provides additional control and stability

9. The main types of needle include:
Reverse cutting needle
Similar to a conventional cutting needle except
the cutting edge faces down instead of up
Cutting
Used for tough tissue, such as skin (use of a
tapered needle with skin causes excess trauma
because of difficulty in penetration)
NEEDLE
Tapered
Used for tissue that is easy to penetrate, such as
bowel or blood vessels

10. NEEDLE
 Most sutures with the suture material swaged onto the base of the
needle
 Shapes vary from a quarter circle to five-eighths of a circle, depending
on how confined the operating field is
 Choice of needle should ‘alter the tissue to be sutured as little as
possible’ and is dependent on:
– The tissue being sutured
– Ease of access to the tissue
– Individual preference

11. PROPERTIES OF SUTURE MATERIAL
Handling of a suture
 Memory
Tendency to stay in one position
Leads to difficulty in tying sutures and knot unravelling
 Elasticity
Ability to return to its original length after stretching
High elasticity sutures should be used in oedematous tissue
 Knot strength
Force required for a knot to slip
Important to consider when ligating
 Tensile strength
Force necessary to break a suture
Important to consider in areas of tension (linea alba)
 Tissue reaction
Undesirable since inflammation worsens the scar
Maximal between Day 3&7

12. • Consists of a single smooth strand
• Less traumatic, less friction
• Associated with lower rates of
infection
• More likely to slip
• Preferred for skin closure because
they provide a better cosmetic result
SUTURE MATERIAL
• Consists of multiple fibres woven together
• Easier to handle and tie and knots are
less likely to slip
Monofilament Multifilament

13. SUTURE MATERIAL
Catgut
• Consists of processed collagen from animal intestines
• Broken down after 7 days
Chromic catgut
• Consists of intestinal collagen treated with chromium
• Loses tensile strength after 2-3 weeks and is broken
down after 3 months
 Degraded non-enzymatically by hydrolysis when water
penetrates the suture filaments and attacks the polymer
chain
 Tend to evoke less tissue reaction than those occurring
naturally
Subclassified according to degradation time
Natural Synthetic

14. Size originally scaled from 0-3
As technology advanced and sutures became smaller, extra 0s were added
Scale now ranges from 3 (largest) to 12/0 (smallest)
SIZE OF SUTURE MATERIAL
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,

15. SUTURE MATERIAL SUMMARY
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

16. BASIC SUTURING
TECHNIQUE

17. ARMING THE NEEDLE-HOLDER
 Open the suture packet with one tear to reveal the needle
 Grasp the needle two-thirds the distance from its
pointed end

18. SIMPLE INTERRUPTED STITCH
 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
1
2

19. SIMPLE INTERRUPTED STITCH
 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
3
4

20. SIMPLE INTERRUPTED STITCH
 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
5
6

21. SIMPLE INTERRUPTED STITCH
 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
7
8

22. SIMPLE INTERRUPTED STITCH
 Supinate the needle-holder to rotate the needle 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
9
10

23. SIMPLE INTERRUPTED STITCH
 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
11
12

24. SIMPLE INTERRUPTED STITCH
 Now draw the short end back through the loop towards yourself
 Now tighten the first throw
13
14

25. SIMPLE INTERRUPTED STITCH
 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
15
16

26. SIMPLE INTERRUPTED STITCH
 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
17
18

27. SIMPLE INTERRUPTED STITCH
 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 as shown
 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)
19
20

28. SUTURE REMOVAL
Sutures should be removed:
 Face: 3-4 days
 Scalp: 5 days
 Trunk: 7 days
 Limb: 7-10 days
 Foot: 10-14 days

29. SUTURE REMOVAL
Steps involved in removal:
 Reassure patient that the procedure is not painful
 Cleanse the skin with hydrogen peroxide
 Grasp one of the suture ‘tails’ with forceps and elevate Slip the tip of
the scissors under the suture and cut close to the skin edge (to
minimise the length of contaminated suture that will be pulled
through the wound)
 Gently pull the knot with the forceps and reinforce the wound Proxi-
Strips if required

30. SUMMARY
Types of wound healing
• Primary intention
• Secondary intention
• Delayed primary closure
Suture material
Properties
• Natural or synthetic
• Non-absorbable or absorbable
• Monofilament or multifilament
Size
• Ranges from 3 – 12/0

31. SURGERY IS AN ART

32. Ethicon
– Knot Manual http://www.jnjgateway.com/public/useng/5256ethicon_encyclopedia_of_knots.pdf
– Wound Closure Manual http://www.jnjgateway.com/public/useng/ethicon_wcm_feb2004.pdf
Student BMJ
– Taylor B and Bayat A, (May 2022, June 2022 & July 2022), Basic plastic surgery techniques and
principles.
Boston University School of Medicine
– http://www.bumc.bu.edu/departments/pagemain.asp?page=5734&departmentid=69
REFERENCES

33. THANK YOU
ANY QUESTION?