See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/380814717

Handbook of basic surgical suturing

Book · May 2024

DOI: 10.22271/ed.book.2139

CITATIONS READS

0 1,328

1 author:

Jan Mohammad Rather

Govt medical college, Handwara, J&k
15 PUBLICATIONS 7 CITATIONS

SEE PROFILE

All content following this page was uploaded by Jan Mohammad Rather on 23 May 2024.

The user has requested enhancement of the downloaded file.

 Author
Dr. Jan M. Rather

®
AkiNik Publications
New Delhi
Published By: AkiNik Publications

AkiNik Publications
169, C-11, Sector - 3,
Rohini, Delhi-110085, India
Toll Free (India) - 18001234070
Phone No.: 9711224068, 9911215212
Website: www.akinik.com
Email: [email protected]

Author: Dr. Jan M. Rather

The author/publisher has attempted to trace and acknowledge the materials

reproduced in this publication and apologize if permission and
acknowledgements to publish in this form have not been given. If any
material has not been acknowledged please write and let us know so that we
may rectify it.

© AkiNik Publications TM
Publication Year: 2023
Pages: 55
ISBN: 978-93-5570-548-8
Book DOI: https://doi.org/10.22271/ed.book.2139
Price: ` 385/-

Registration Details
 Printing Press License No.: F.1 (A-4) press 2016
 Trade Mark Registered Under
• Class 16 (Regd. No.: 5070429)
• Class 35 (Regd. No.: 5070426)
• Class 41 (Regd. No.: 5070427)
• Class 42 (Regd. No.: 5070428)
 About the Book

Sutures, needles and wound care techniques. Handbook of basic

surgical suturing talks about gives you the opportunity to understand
the basics of wound management and allows you to practice simple
suturing in preparation for your future.
This booklet was made as a complimentary guide for you.
Though it doesn't replace standard more in-depth books and other
resources.
This will serve as a handy source of information for trainees and
junior surgeons.
 Table of Contents

S. No. Topics Page No.

Unit - 1: Wound Healing and Management 01-07

1. Phases of Wound Healing 01
2. Factors that affect Wound Healing 02
3. Type of Wound Closure 02
4. Wound Assessment 03
5. Prevention of Wound Infection 06
Unit - 2: Wound Closure 08-40
1. Wound Preparation 08
A. Aseptic Technique 08
B. Local Anesthesia 09
2. Suture Materials 12
3. Characteristics of Suture Material 15
4. Needles 16
A. The Anatomy of a Needle 16
B. Types of Needles 17
5. Suturing Instruments 19
6. Suture Techniques 22
A. Simple Interrupted Suturing 22
B. Continuous Suturing 23
C. Mattress Suturing 23
D. Subcuticular Suturing 24
7. Knotting Techniques 25
A. Instrument Knot 25
B. One Handed Knot 28
C. Two Handed Knot 31
8. Wound Care 37
A. Wound Dressing 37
B. Suture Removal 38
9. Alternative Methods of Wound Closure 39
Unit - 3: Basics of Laparoscopic Suturing 41-53
References 54-55
 Unit - 1
Wound Healing and Management

1. Phases of wound healing

Wound healing involves a complicated series of event that can be
divided into three phases:
A. Inflammatory (4 days after tissue injury)
The main cells involved in this process are polymorphonuclear
leukocytes (PMNs), platelets, and macrophages. Shortly after a
wound occurs, PMNs appear and remain the predominant cell for
approximately 48 hours. The neutrophil is not crucial for normal
wound healing, but the macrophage is.
B. Proliferative (4 days to 3 weeks)

This phase begins only when the wound is covered by epithelium.

It is characterized by the production of collagen in the wound. The
wound appears less edematous and inflamed than before, but the
wound scar may be raised, red, and hard. The primary cell in this
phase is the fibroblast, which produces collagen.
C. Maturation (3 weeks to 1 year)
This phase is characterized by the maturation of collagen by
intermolecular cross linking. The wound scar gradually, flattens and
becomes less prominent and paler and suppler. This phase is a time of
great metabolic activity. Collagen is deposited in the wound, and
existing collagen is remodeled and removed; thus, there is no net
collagen gain in the wound.

Page | 1
2. Factors that affect wound healing
A. Local factors

• Wound cleaning.
• Good approximation of the edges.
• Bleeding must be controlled to prevent hematoma formation,
which predispose wound to infection.
• Infection decreases the rate of wound healing and
detrimentally affects proper granulation tissue formation,
decreases oxygen delivery, and depletes the wound of needed
nutrients.
B. Systemic factors

• Nutrition is an extremely important factor in wound healing.

• Uncontrolled diabetes mellitus or Hyperglycemia decrees
wound healing.
• Medications like, steroids.
• Chronic illness (immunodeficiency disease, cancer, uremia,
liver disease, jaundice) prevent wound healing.
• Smoking
• Immunosuppression medication like steroid and
chemotherapy impair healing.
• History of radiation, because it affects local wound healing by
causing vacuities, which leads to local hypoxia and ischemia.

3. Type of wound closure

A. Primary intention
Acute wounds can be managed in several ways. The most
common method is to primarily close the wound, resulting in healing
by primary intention. The method applies to all surgical incisions and
lacerations that are closed with sutures, staples, adhesive band, or any

Page | 2
technique by which the surgeon intentionally approximates the
epidermal edges of a wound. It also includes tissue transfer
techniques and flaps that may be used to close larger defects.
B. Secondary intention

The wound is left to close by granulation. it takes longer than the

previous method but generally it is good for infected wound where
dressing is necessarily. Classically these wounds are treated with
“wet-to-dry” dressings wherein a gauze sponge is moistened with
saline and used to pack the wound, covered with a dry dressing; the
moist sponge dries out, and when it is removed and changed once or
twice a day, gentle debridement of the wound is achieved.
C. Delayed primary closure
In delayed primary closure, sometimes called healing by tertiary
intention, the wound is initially managed as a secondary intention
wound, that is, left open with dressing changes. After sometimes,
when the wound is clean and granulation tissue is abundant, the
wound edges are actively approximated. This approach is successful
because granulation tissue, while not sterile, is extremely vascular and
as such is highly resistant to infection.
4. Wound assessment

• First step: is to control bleeding and evaluate the need for

other emergency procedures.
• Second step is to obtain a thorough history about the patient
and the events surrounding the injury.
1) About the patient
Tetanus immunization status
Tetanus is a devastating disease, causing muscle spasms that can
lead to muscle rigidity and seizures. Without adequate treatment, one
in three adults with tetanus will die. Although immunization has made
tetanus uncommon, it always lurks in the background.

Page | 3
A. Pulsatile bleeding at time of injury
Even if the patient is not bleeding at the time of your
examination, the history of bright red, pulsatile bleeding at the time of
injury implies an arterial injury. A thorough vascular exam is
required, and formal surgical wound exploration is almost always
indicated.
B. Medical illnesses
Patients with diabetes are more prone to infections and wound-
healing problems. Encourage diabetic patients to keep glucose levels
well controlled to decrease the risk of complications. Malnourished
patients and patients with human immunodeficiency infection (HIV)
or a history of cancer also have wound-healing difficulties.

C. Smoking history
Tobacco smoking dramatically decreases circulation to the skin
and slows down the wound-healing process. Medical professionals
have a duty to tell all patients not to smoke. But the patient with an
open wound should be specifically warned that smoking interferes
with and perhaps prevents the healing process. Smoking also
increases the risk for wound complications and poor cosmetic
outcome.
2) Events surrounding the injury
A. Timing of the injury
It is best to close an open wound within 6 hours of injury. Do not
close a wound after 12 hours because the risk of infection becomes
unacceptably high. Wounds on the face are exceptions to this rule.
The face has an excellent blood supply, which makes infection less
likely. In addition, cosmetic concerns are important. It is therefore
acceptable to close a wound on the face that is older than 6 hours
(perhaps up to 24 hours or at most 48 hours), as long as you can clean
it thoroughly.

Page | 4
B. Nature of the injury

• A wound caused by a clean knife has a low risk of infection

• Dirty wound carries risk for tetanus and other infection.

Wood may break off and leave pieces behind, increasing the
risk for subsequent infection if the wound is not explored and
washed out thoroughly.

• Any wound that may contain a foreign body should be

explored and the foreign body removed.

• Animal bites, especially dog bites, often penetrate more

deeply than you think. Bites on the hand should raise concern
about involvement of an underlying joint. Oral bacteria may
cause severe infections. Always consider the risk of rabies

• Human bites also are associated with specific oral bacteria

that may cause serious infections.

• If any object penetrated the patient’s clothing or shoes before

piercing the skin, the chance for infection is increased
because pieces of clothing may become embedded in the
underlying tissues. If an object penetrated the patient’s shoes,
be concerned about a possible pseudomonal infection.

• Crush injuries maybe associated with greater underlying

damage than initially appreciated.

• Gunshot wounds.

• Thermal or electrical injury.

Page | 5
 Human bites Knife wound

Dog bites Gun shot

Prevention of wound infection

• Never close infected wounds.

• For fresh wound, systematically perform wound toilet and

surgical debridement. Then close it primarily when the
wound completely clean.

• For contaminated wounds manage them with surgical toilet,

leave them open and then close them 48 hours later. This is
known as delayed primary closure.
To prevent wound infection

• Restore tissue perfusion and blood circulation as soon as

possible after injury.

Page | 6
 • Maintain the core temperature of the body within normal
range.
• Provide high-energy nutrition as soon as possible.
• Perform wound toilet and debridement as soon as possible
(within 8 hours if possible).
• Respect universal precautions to avoid transmission of
infection.
• Give antibiotic prophylaxis to victims with deep wounds and
other indications.
• Antibiotics not replacement for good debridement and wound
toilet.
• Use of topical antibiotics and washing wounds with antibiotic
solutions are not recommended.
3) An infected wound is a wound with pus.
4) A contaminated wound is a wound containing foreign or dirty
material.

Page | 7
 Unit - 2
Wound Closure

The goals of laceration repair are to achieve hemostasis, avoid

infection, restore function to the involved tissues, and achieve optimal
cosmetic results with minimal scarring.
1. Wound preparation
A. Aseptic technique
1) Actual preparation of the wound involves cleansing and
debridement.
Clean.. Clean.. Clean... very important to prevent any
infections.
2) The skin surface surrounding the wound, should be washed
and disinfected with a solution that is rapidly acting, with a
broad spectrum of antimicrobial activity.
Also, it should not delay healing or reduce tissue resistance to
infection.
3) Prior to cleansing, the area around the wound may have to be
anaesthetized to reduce the discomfort to the patient.
Although excellent as skin cleansers, these solutions are
potentially toxic to the local wound defenses and may
increase the rate of subsequent wound infection if they are
spilled into a wound in large quantities. These solutions
should be irrigated from the wound with a sterile normal
saline solution as the final step in wound cleansing

Page | 8
 Wound irrigation is a form of mechanical wound cleansing
that is known to effectively remove bacteria and other debris.

Sterile technique requires the physician to be

1) Able to open and put gloves on without contamination to the
sterile surface of the gloves
2) Able to clean and drape the wound and surrounding area.

3) Able to control the instruments and suture, such that they are
not contaminated by non-sterile surfaces
B. Local anesthesia
It is a method where there is localized loss of pain feeling and
consciousness remains intact.

Local anesthetics
Drugs which produce reversible block to the transmission of
peripheral nerve impulse.

Page | 9
Categories of local anesthesia
1) Topical anesthetics

Agents applied topically to such diverse sites as skin, eye,

gingival mucosa, tympanic membrane, tracheobronchial tree, and
rectum.
Forms of topical anesthetic preparation include

• Ointment
• Spray
• Solution
• Suppository
Example of topical preparations of lidocaine

• 4% aqueous solutions for endotracheal installations

• 2% Jelly for intraurethral use
• 10% aerosol for anesthesia of gingival mucosa
2) Injectable anesthetics

• Produced by intra dermal and subcutaneous injection of local

anesthetics in the area of the intended surgery.
• Primarily useful for minor superficial procedures
• Dosage of local anesthetic required for adequate infiltration
depends on the weight of the patient, extent of the area to be
anesthetized and the expected duration of the surgical
procedures.
Table: Upper dose limits for commonly used local anesthetics agents

Plain solution (without adrenaline) With adrenaline

mg/kg mg/kg
Procaine 7 9
Lidocaine 4 7

Page | 10
 Bupivacaine 2 3
Mepivacaine 4 7
N: B1% local anesthesia is 10 mg/ml

• Addition of adrenaline reduces the peak concentration in

blood because it induced vasoconstriction
• Any local anesthetic can be employed for infiltrative
anesthesia.
The steps for direct infiltration of local anesthetic are as follows:
i) Ensure that the areas distal to wound show no neurovascular
compromise.
ii) Explain the procedure to the patient and, in children, the care
giver.
iii) Provide sedation and restraint, if needed.

iv) Cleanse the site of infiltration with povidone-iodine or other

similar antiseptic preparation and allow to air dry or dry with
sterile gauze.
v) For open wounds, put a few drops of the anesthetic material
into the wound and then rapidly place the needle into the
subcutaneous layer by inserting it through the wound margin
rather than intact skin.
vi) For intact skin, rapidly place the needle through the skin into
the subcutaneous layer.
vii) Slowly inject small volumes of the anesthetic. During
anesthetic infiltration, either slowly advance the needle or
initially insert it to the hub and infiltrate as the needle is
withdrawn.
viii) Anesthetize adjacent areas by inserting the needle through the
previously injected skin or wound until the entire region
requiring anesthesia is infiltrated.
ix) After a few minutes, lightly test the skin or wound margins

Page | 11
 for adequate anesthesia using the injection needle or other
sharp object (suture needle, Adson forceps).
3) Peripheral nerve block

Local anesthetic agent. Injected percutaneously in the area of the

nerve to be blocked. It can be divided arbitrarily into:
A. Minor nerve block

• Involves the blockade of single nerve. Example, is digital

nerve block.

B. Major nerve block

• Involve blockade of major trunks or plexus such as brachial

plexus blockade.
2. Suture materials
A. Absorbable sutures
An absorbable suture is generally defined as stitch that will lose most of
its tensile strength within 60 days after implantation. The ideal absorbable
suture has low tissue reactivity, high tensile strength, slow absorption rates,
and reliable knot security. Classically, absorbable sutures were only used for
deep sutures. However, many have advocated the use of absorbable sutures
for percutaneous closure of wounds in adults and children.

Page | 12
 Tensile
Raw strength Absorption Tissue
Suture Uses
material retention in rate reaction
vivo
For all surgical
Natural Phagocytosis
procedures
product and enzymatic High
Plain Within five to especially when
derived from degradation Tissue
catgut seven days tissues that
sheep or within 7-10 reaction
regenerate faster
cattle intima days
are involved.
Natural
product
derived from
Chromic gut is
sheep or Phagocytosis
Moderate more rapidly
Chromic cattle intima Within 21 to and enzymatic
tissue absorbed in the
catgut treated with 28 days degradation
reactivity. oral cavity.
chromium within 90days
As plain catgut.
salts to resist
body
enzymes

Synthetic material
Complete Subcutaneous,
made of within
absorption mild intracutaneous
polyglycolic acid three to
(Vicryl) occurs in tissue closures,
and coated with N- four
60 reactivity abdominal and
laurin and L- weeks
To 90 days thoracic surgeries
lysine.
This suture is
often used by
Copolymer of mild plastic surgeons
21 days 90-120
(Monocryl) glycoline and tissue for facial
maximum days
capiolactone reactivity lacerations closed
with subcuticular
running sutures
It
maintains
Complete
sat least Suture where
absorption Minimal
Synthetic 50 slightly longer
(Dexon) occurs in tissue
polyglycolic acid percent of wound support is
60 reactivity
its tensile required
To 90 days
strength
for 25

Page | 13
 days.
Pediatric
Complete cardiovascular
Polydioxa Mild
Polyester and five to six absorption surgery,
one tissue
polymer weeks within 200 ophthalmic
(PDS) reactivity
days surgery
Fascia closure

B. Non-absorbable sutures

Tensile
Raw strength Absorption Tissue
Suture Uses
material retention in rate reaction
vivo
It is rarely used
for suturing of
Lowest tensile minor wounds
Natural strength of any because stronger
Absorbed
protein raw non-absorbable synthetic
Silk slowly over Moderate
silk from suture. materials,
1-2 years
silk worm 80-100%lost typically used to
by6months tie off blood
vessels or bowel
segments
high tensile Degrades at Used for closure
Polyamide strength loses approximate of skin, surgical
Nylon low
polymer 15-20% per ly 15-20% incisions or drain
year per year age tubes
It is especially
noted for its
plasticity,
Polypropyl Synthesized Remain
high tensile allowing the
ene from encapsulated
strength more low suture to stretch
(Surgilene, polyolefin in body
than 1 year to accommodate
Prolene) plastics tissue
wound
swelling, plastic
surgery
Remain Cardiovascular
high tensile
Polybuteste Polymer of encapsulated surgery, plastic
strength more low
r (Novafil) propylene in body surgery, general
than 1year
tissue surgery
.

Page | 14
3. Characteristics of suture material
The choice of suture is determined by a balance of the various
characteristics of suture materials most appropriate for the specific
wound closure situation.

• Absorbable sutures are generally used as deep sutures;

Absorbable vs. they do not need to be removed post-operatively.
Non-absorbable • Non-absorbable sutures are used for surface sutures;
require manual removal post-operatively.
Surgeons prefer to use the smallest size that will provide
adequate strength. The size increases as the first digit
decreases.
Tensile strength
• 3-0 is relatively a strong suture
• 6-0 is a thin comparatively weak suture.
The ability to retain length and strength after stretch, and
the ability to regain its original length after stretch. This is
important:
Plasticity and 1. To accommodate post-operative edema without cutting
elasticity into the tissue
2. To maintain epidermal approximation once the edema
has resolved.
Determined by a number of related characteristics.
1. A suture with a low coefficient of friction slides
through tissue well but the knot will unravel more
easily.
2. A suture with a high memory will spring back to its
Ease of
original position. While these sutures tend to be strong,
handling and
They maybe difficult to handle and have decreased
knot security
knot security.
• A suture with high pliability can be easily bent, and
will therefore handle well with good knot security.
• Multi filament braided sutures handle more easily and
tie well, but can potentially harbor organisms between
fibers leading to increased infection risk. They also
Multifilament vs
tend to have higher capillarity so can absorb and
Monofilament
transfer fluid more easily increasing potential for
bacteria to enter from the skin surface.

Page | 15
 • Monofilament sutures have a lower infection risk and a
lower coefficient of friction, but with a lower ease of
handling and knot security.
Refers to the degree of inflammatory response to the
suture.
Tissue reactivity
i) Higher for natural products such and silk and gut
ii) Lower for synthetic fibers such as nylon.

4. Needles
Suture needles should be handled very carefully. The needle
should only be grasped with needle-holders.

A. The anatomy of a needle

Choosing the proper needle can be confusing because of varying
nomenclature. While the basic anatomy of the needle remains the
same, the needle anatomy can be divided into the following parts:
1) The eye: is the end of the needle attached to the third.

There are three types of the needle eye:

Closed eye, French (split or spring) eye, or swaged (eyeless).

Page | 16
2) The body: is the portion that is grasped by the needle holder
during the procedure. The body of the needle should be as close
as possible to the diameter of the stitch to minimize bleeding and
leakage.
The curvature of the needle body may come in a variety of
shapes. Each shape gives the needle different characteristics.
i) Straight needle
ii) Half-curved needle
iii) Curved needle (The curvature maybe 1/4, 3/8, 1/2 or 5/8
circle).
iv) Compound curved needle
3) The needle point: extends from the extreme tip to the maximum
cross section of body. Each needle point is designed and
produced to the required degree of sharpness to smoothly
penetrate specific types of tissue.
B. Types of needles

• Cutting needles
• Conventional cutting needles
• Reverse cutting needles
• Side cutting needles
• Taper point needles
• Taper cut surgical needles
• Blunt point needles
Page | 17
Page | 18
5. Suturing instruments
1) Needle holder: used to grab on to the suture needle

2) Forceps: used to hold the tissues gently and to grab the

needle

Page | 19
 3) Suture scissors: used to cut the stitch from the rest of the
suture material

How to hold the instruments?

Whenever you use sharp instruments, you face the risk of
accidentally sticking yourself. Needle sticks are especially hazardous
because of the risk of serious infection (hepatitis, human
immunodeficiency virus). To prevent needle sticks, get to the habit of
using the instruments correctly.
Never handle the suture needle with your fingers.
1) Needle holder

Place your thumb and ring finger in the holes. When using the
needle holder, be sure to grab the needle until you hear the clasp
engage, ensuring that the needle is securely held. You grab the needle
at its half-way point, with the tip pointing upward. Try not to grab the
tip; it will become blunt if grabbed by the needle holder. Then it will
be difficult to pass the tip through the skin.

Page | 20
2) Forceps

Hold the forceps like a writing pensil. The forceps are used to
support the skin edges when you place the sutures. Be careful not to
grab the skin too hard, or you will leave marks that can lead to
scarring.
Ideally, you should grab the dermis or subcutaneous tissue - not
the skin- with the forceps, but this technique takes practice. For
suturing skin, try to use forceps with teeth, which are little pointed
edges at the end of the forceps.

3) Scissors

Place your thumb and ring finger in the holes. It is best to cut with
the tips of the scissors so that you do not accidentally injure any
surrounding structures or tissue (which may happen if you cut with
the center part of the scissors).

Page | 21
6. Suture techniques
Principles

• The wound edges must not only be aligned but also everted.
Eversion ensures that dermal elements of the skin are apposed
which is vital for wound healing.

• In most body areas except the face, sutures should be placed

3 to 4 mm apart from the wound margin and 5 to 10 mm apart
from each other.

• With simple sutures the knots of the sutures are to be placed

away from the opposed edges of the wound.

• Skin handling must be atraumatic as much as possible.

Techniques
A. Simple interrupted suturing

• The simplest way to close skin wounds.

• Insert the needle at 90° to the skin
• It should be 3-5 mm away from the margin and 3-5 mm away
from the each other.
• Equal amount of tissue should be opposed on both sides.
• All knots should be placed on the same side with wound
edges everte

Page | 22
B. Continuous suturing
• Commonly applied in case of peritoneum and sheath closure.
• Hemostatic.
• It may cause overlapping of edges.
• Wound dehisces if one stitch is dissolved early or if it breaks.
• It is contraindicated if the skin wound is contaminated
because of high risk of infection.

C. Mattress suturing
• This is a double stitch, which aims to close the deep part of
the wound, to obliterate dead space and slightly invert the
edges.
• It also aims to relieve tension from the edges of the wound.
• Starting from one edge of the needle passes through the other
edge, and is then returned to the starting side through separate
bite
• It is most useful where skin is loose or hemostasis is required.
• If the entry and exit holes lie parallel to the edges, these are
called horizontal mattress stitches
• If the entry and exit holes are perpendicular to the edges,
these are vertical mattress stitches

Page | 23
 Vertical

Horizontal

D. Subcuticular suturing
• Easy to remove
• Cosmetically better
• The suture material can be absorbable or non-absorbable
• Enter the skin about 1 cm from the end of the incision using
preferably a straight needle. Pass the needle through sub
cuticular layer and dermis along the wound in regular step-
wise fashion

Page | 24
7. Knotting techniques
A. Instrument knot

i) Short purple strand lies freely. Long white end of strand held
between thumb and index finger of left hand. Loop formed by
placing needle holder on side of strand away from the
operator.

ii) Needle holder in right hand grasps short purple end of strand.

Page | 25
iii) White strand is drawn toward operator with left hand and
looped around needle holder held in right hand. Loop is
formed by placing needle holder on side of strand toward the
operator.

iv) First half hitch completed by pulling needle holder toward

operator with right hand and drawing white strand away from
operator. Needle holder is released from purple strand.

Page | 26
v) With end of the strand grasped by the needle holder, purple
strand is drawn through loop in the white strand away from
the operator.

vi) Square knot completed by horizontal tension applied with left

hand holding white strand toward operator and purple strand
in needle holder away from operator. Final tension should be
as nearly horizontal as possible.

Page | 27
Hand knot
B. One handed knot

i) White strand held between thumb and index finger of left

hand with loop over extended index finger. Purple strand held
between thumb and index finger of right hand.

ii) Purple strand brought over white strand on left index finger
by moving right hand away from operator.

Page | 28
iii) With purple strand supported in right hand, the distal phalanx
of left index finger passes under the white strand to place it
over tip of left index finger. Then the white strand is pulled
through loop in preparation for applying tension.
iv) The first half hitch is completed by advancing tension in the
horizontal plane with the left hand drawn toward and right
hand away from the operator.

v) White strand looped around three fingers of left hand with

distal end held between thumb and index finger.

Page | 29
vi) Purple strand held in right hand brought toward the operator
to cross over the white strand. Continue hand motion by
flexing distal phalanx of left middle finger to bring it beneath
white strand.

vii) As the middle finger is extended and the left hand pronated,
the white strand is brought beneath the purple strand.

Page | 30
 viii) Horizontal tension applied with the left hand away and right
hand toward the operator. This completes the second half
hitch of the square knot. Final tension should be as nearly
horizontal as possible.
C. Two handed knot

i) White strand placed over extended index finger of left hand

acting as bridge, and held in palm of left hand. Purple strand
held in right hand.

Page | 31
ii) Purple strand held in right hand brought between left thumb
and index finger.

iii) Left hand turned inward by pronation, and thumb swung

under white strand to form the first loop.

Page | 32
iv) Purple strand crossed over white and held between thumb and
index finger of left hand.

v) Right hand releases purple strand. Then left hand supinated,

with thumb and index finger still grasping purple strand, to
bring purple strand through the white loop. Re grasp purple
strand with right hand.

Page | 33
vi) Purple strand released by left hand and grasped by right.
Horizontal tension is applied with left hand toward and right
hand away from operator. This completes first half hitch.

vii) Left index finger released from white strand and left hand
again supinated to loop white strand over left thumb. Purple
strand held in right hand is angled slightly to the left.

Page | 34
viii) Purple strand brought toward the operator with the right hand
and placed between left thumb and index finger. Purple strand
crosses over white strand.

ix) By further supinating left hand, white strand slides onto left
index finger to form a loop as purple strand is grasped
between left index finger and thumb.

Page | 35
x) The final tension on the final throw should be as nearly
horizontal as possible.

xi) Left hand rotated inward by pronation with thumb carrying

purple strand through loop of white strand. Purple strand is
grasped between right thumb and index finger.
xii) Horizontal tension applied with left hand away from and right
hand toward the operator. This completes the second half
hitch.

Page | 36
8. Wound care
A. Wound dressing
Aim of wound dressing
Covering the wound surface and moisturizing it facilitates healing
and re-epithelization of the edges and prevent infection by the low pH
created on the wound surface to be occlusive dressings.
Layers of dressings
Typically, dressings usually have three layers:
1) Contact layer- The layer in contact with the wound surface.
2) Absorbing layer- To absorb the exudates from the wound.
3) Binding layer- The outermost layer which holds the dressing
together (bandage).
Types of wound dressing
Name Indications Advantages Disadvantages
Sticks to the wound.
Easily available,
Non- Painful during change.
Most wound cheap. Good
reabsorbable Can damage epithelium.
types absorbing
(gauze) Not truly occlusive.
capacity.
Require frequent change
Occlusive
Superficial Non-absorbent, hence not
dressing.
Films wounds and useful inexudative
Impermeable to
surgical sites wounds
bacteria
Exudative Form an Need exudates to
Foams,
wounds and ‘autolytic’ layer function, hence not
colloids
cavities to remove debris suitable for dry wounds
Hydrophilic Form an Cannot be used in sites of
Highly exudative
(alginate ‘autolytic’ layer anaerobic infection/dry
wounds
dressings) to remove debris wounds
Can cause maceration of
Dry and necrotic Moisture peri-wound skin. Very
Hydrogels
wounds contributing minimal absorptive
capacity.

Page | 37
B. Suture removal
Eyelids: 3 days
Neck: 3 to 4 days
Face: 5 days
Scalp: 7 to 14 days
Trunk and upper extremities: 7 to 10 days
Lower extremities: 8 to 10 days
Over joints: 10-14 day

Steps of suture removal

Step 1: Cleanse the area with an antiseptic material. Hydrogen
peroxide can be used to remove dried serum encrusted around the
sutures.
Step 2: Pick up one end of the suture with thumb forceps (A), and
cut as close to the skin as possible where the suture enters the skin
(B).
Step 3: Gently pull the suture strand out through the side opposite
the knot with the forceps (C). To prevent risk of infection, the suture
should be removed without pulling any portion that has been outside
the skin back through the skin.

Page | 38
9. Alternative methods of wound closure
A. Wound closure tapes (Steri-Strips)

1) Composed of strips of reinforced microporous surgical

adhesive tape.
2) Used to provide extra support to a suture line, either when
running subcuticular sutures are used or after sutures are
removed.
3) The tapes may reduce spreading of the scar if they are kept in
place for several weeks after suture removal.
4) Often, used in conjunction with a tissue adhesive. Because
they tend to fall off, and mainly in low-tension wounds and
rarely for primary wound closure.

B. Staples

Used in surgical wounds in the, including wounds on the scalp or

the trunk.
Advantages: Quick placement, minimal tissue reaction, low risk
of infection, and strong wound closure.
Disadvantages: Less precise wound edge alignment and higher
cost.

Page | 39
C. Tissue adhesive glues

• Super glues that contain acrylates

• May be applied to superficial wounds to block pinpoint skin
hemorrhages and to precisely coapt wound edges.
• Because of their bacteriostatic effects and easy application,
they have gained increasing popularity.
• The most commonly used adhesive, 2-octylcyanoacrylate
(Dermabond), has also been used as a skin bolster for
suturing thin, atrophic skin.
Advantages: Rapid wound closure, painless application, reduced
risk of needle sticks, absence of suture marks, and elimination of any
need for removal.
Disadvantages: Increased cost and less tensile strength (in
comparison with sutures)

Page | 40
 Unit - 3
Basics of Laparoscopic Suturing

During General Surgery training, suturing and knot-tying for open

surgery is relatively easy and one of the initial skills to be acquired
and mastered. In contrast, similar skills in Minimally Invasive
Surgery (MIS) are more challenging to acquire and takes time to
achieve proficiency. Competence and confidence in laparoscopic
suturing allow the surgeon to venture into complex procedures and is
an indispensable skill for dealing with intraoperative events.
In open surgery, one has the advantage of binocular vision
providing depth perception; however, in MIS, the surgeon encounters
various hindrances: indirect visualization, loss of freedom of
movement, fixed-port positions, and limited working space. These
eliminate three-dimensional view (unless using a 3D video system),
restriction of instrument movements and movement about the target,
and restricted movement within the workspace. Ergonomics
contributes to setting a comfortable and efficient posture for
executing the skill; cognizance of elements like azimuth angle,
elevation angle, manipulation angle, and triangulation are beneficial.
Effect of stress, pressure, and fatigue during MIS procedures
contribute to the adverse performance of fine movements in this skill.
Thus, endo-laparoscopic suturing is associated with a longer and
steeper learning curve compared to that in open surgery.
Aside from the knot-tying skill and the type of knot thrown, the
braiding, the material, and the size of the suture used influence the
security of the knot. The monofilament sutures have a risk of slippage
and are less pliable compared to braided sutures. The hydrophilic
material (catgut, Dacron, polyglactin, and lactomer) swells on contact

Page | 41
with water and theoretically results in a more secure or tighter
properly thrown knot. Among sutures of similar material, the larger
sized will allow more force to be applied before breaking thus the
tightness of a knot using 2-0 suture is double that of one with 3-0
suture.
Equipment and Instruments
• Laparoscope camera with monitor display and light source
• Laparoscopic needle driver set
• Laparoscopic grasper and forceps laparoscopic scissors
• Knot pusher for extracorporeal suturing
• Trocars-5, 10, 12 mm ports-metallic or plastic
• Sutures
• Mayo scissors
• Artery forceps
• Measuring tape
There are different types of needle holders available. Generally,
needle holders have jaws that are more powerful and sturdier than
other laparoscopic forceps and graspers. They have serrations for
better needle grip, a catch for locking and unlocking, and they can be
straight or curved and fits in the 5 mm trocars.
General principles
Setting the scene: It is a crucial and important step in suturing. It
should be like an orchestra and the surgeon needs to put himself in the
best ergonomically available condition concerning position, angle,
height, choice and placement of instrumentation, light source, choice
of suture, and type of knotting among others. A good camera with
adequate lighting and a high-definition display can make all the
difference that is required for a smooth surgery.
The thickness of the abdominal wall, the position, and the angle
of the port placement are vital. Too far or too near will make it

Page | 42
difficult to maneuver. If the angle of the port is not in the same
direction as the region of surgery then it will cause the surgeon to
work against the abdominal wall, especially if it is an obese patient.
Position of the surgeon: The camera should be positioned
between the two instrument ports; this setup matches the normal
relationship between the eyes and two hands as in open surgery
(Fig. 1a). The surgeon should be in a relaxed stance with the table
height matched adequately so that he/she does not have to slouch or
strain. The monitor should also be placed at an eye level to prevent
neck strain, this is especially important in lengthy surgeries and high-
volume centers.

Hand-eye coordination: Movements made during laparoscopic

surgery should be slow and steady compared to open surgery and the
movements have to be limited to the field of vision. This is especially
true when one is dealing with sutures and instruments like scissors
and cautery. Eliminating unnecessary movements and taking
choreographed actions during the procedure will help the surgeon and
the OR team for more focused and productive output. A formal
training course can help to learn these ergonomic skills for better
productivity. A high level of concentration is integral to perform even
simple needle-driving maneuvers.

Page | 43
Needle tip and suture materials
Different types of needles:
• Straight needle
• Ski needle
• curved needle
The straight needle is easier to insert and remove from the trocars
but is not used frequently. Also, the different angles to be achieved by
the straight needle is difficult to achieve comparatively. Ski needles
are easier to go through the trocars on the comparison. Straightening
the curved needle using the needle drivers/forceps before removal is
another tip for easy extraction.
A needle tip with taper cut penetrates tissues more readily than
blunt tip needles hence lesser trauma. Needle size of 2-0 and 3-0 is
optimal for laparoscopic use as it allows easy passage and removal in
the trocars.
While using just the one 10 mm camera port with a combination
of 5 mm ports during surgery, inserting a needle can be done through
the 10 mm camera trocar and after suturing, it can be extracted
through the 5 mm trocar after straightening the needle. Before
inserting the suture, the direction of the 10 mm trocar should be static
after confirming the visual field of the camera to a safe area so that
even though it is a blind insertion of the needle, it will land safely in
the operative field.
Coloured sutures are preferred over colourless sutures for better
visibility. Traditionally divided into two groups: absorbable and
nonabsorbable; braided and monofilament. A suture that swells in
contact with water increases its capacity of tying and tightening and
can be considered safer, whereas monofilament sutures have a higher
risk of slippage when compared to braided sutures. The tightness of a
suture knot of a 2/0 thread is double than a 3/0 thread

Page | 44
 Insertion and retrieval of the needle: It should be done only
under direct laparoscopic vision. The suture thread should be grasped
some 2-3 cm behind the needle while transferring it in or out through
the trocars.
While extracting the needle through metal trocars, there is a
chance of the needle to get caught in the diaphragm of the trocar on
its exit, which can then snap and/or break the needle. The diaphragm
should be kept open manually while extracting the needle. Some may
prefer to straighten the needle for easy extraction.
Loading the needle: Loading depends upon the conditions and
also the proximity or otherwise of a smooth serosal surface. There are
two processes for loading the needle.

Page | 45
 • The dangling pirouette technique.
• The deposit-pick-up technique.
This can be achieved in three ways:
1. First, the thread around 2-3 cm from the needle is held using
the dominant hand. Next using the nondominant hand grasp
the needle about one-third from the tip. Now the dominant
hand is repositioned at two-third from the needle tip the sweet
spot.
2. Lightly grasp the needle at the distal one-third with the
nondominant hand. With the dominant hand gently pull the
thread 2-3 cm from the needle towards you or away from you
so that angle from the needle can be modified. Now with the
dominant hand reposition the grip on the needle at the sweet
spot.
3. After laying the suture on a safe surface, using the dominant
handgrip the needle lightly at the sweet spot and gently brush
with the concavity of the needle on the tissue forward for
backward within the 3 o’clock direction till the correct
position is attained. The nondominant hand can be used to
assist as well.
Loading the needle during laparoscopy is an important skill to
master. It should be learned by all surgeons who are interested in
pursuing the minimally invasive approach. Suturing and needle
handling are crucial. A trainee has to understand and learn how the
needle driver works laparoscopically and how to move the needle and
the needle drivers effectively through the tissues without causing
unnecessary trauma.
The ideal length of a suture for intracorporeal suturing is 10 cm;
this length makes the knot-tying maneuver easier. For a continuous
suture, the thread should be about 15 cm long, this allows the surgeon
a way to accomplish the final knot with enough suture thread in hand.

Page | 46
Techniques of knot tying
In the intracorporeal technique, the knot is made inside the
abdominal cavity using two instruments, these can be two needle
holders or forceps.
In the extracorporeal technique, the knot is made completely
outside the abdominal cavity and then it is pushed inside the abdomen
with a knot pusher.
Intracorporeal knot tying
The advantage of intracorporeal suturing [3] are:
• The amount of suture that is being drawn through the tissue is
limited thus reducing trauma and cut through, and,
• The suture material that is being used can be finer.
Hence, delicate structures like bile ducts and intestines can be
sutured using this technique.
Before throwing the knots, it should be checked that the distal end
of the suture is no longer than 2-3 cm and in vision so it can be
grasped easily. The number of throws depends on the suture used.
Roser technique
Hold the needle with its concavity bent downwards with the
nondominant hand. In this way, the curved and rigid structure of the
needle allows the forming of the “C-loop” for the needle holder of the
dominant hand to twirl on it. This makes it easy to perform the spirals
around the needle holder before grasping the distal end of the suture.
To complete the knot, the needle is dropped in a safe place and
the nondominant hand grasps the thread close to the knot to tighten it
by moving the hands in opposite directions. Repositioning of the
instruments to hold the suture closer to the knot should be done to
stay within the visual field to avoid injury to adjacent structures.
The first knot placed is a double spiral/throw. This is followed by
again holding the needle with concavity down and repeating the
above process to throw single knots and tightening it.

Page | 47
Szabo technique
The C-loop can also be made with the suture instead of the needle
concavity around which the twirls can be made for the knots. The C-
loop can be made by just pulling the suture slightly forward or
outward with the dominant hand while the distal end is being held by
the dominant hand before throwing the spirals.
Alternative method
Grasping the suture thread 1/2 cm distal to the needle with the
dominant hand, then one has just to rotate the instrument to wind the

Page | 48
thread around the needle holder. Then forceps are used to grasp the
needle end with the other hand while the dominant hand catches the
distal end of the suture. The knot is accomplished by pulling on both
ends.
Suture designs
A thread furnished with absorbable terminal clips for anchoring.
The clip anchored to the suture thread end functions as an initial knot
and a second clip can be applied at the proximal end after suturing is
complete to avoid the need for tying knots.
Another is barbed sutures which prevent it from slipping back
through the tissues and avoids the need to make knots to secure it in
place.

When using a braided thread, a preformed loop can be created

simply by piercing the distal end of the suture with the needle, exactly
at its middle. Then the needle is pulled through this newly formed
loop, to stabilize the suture and continue for continuous suturing.

Extracorporeal knot tying

It is important to learn at least one knotting technique and use it
when required. The advantage of extracorporeal suturing is the ability
to use familiar knotting as in open surgeries which can then be
secured using a knot pusher. However, it is not preferred for suturing
delicate structures. Extracorporeal slip knots can only be used for
free-ending structures, like the appendix, peritoneal tear in TEP, and
for ligating transected duct/vessel.
It is of two types:
1) Extracorporeal slip knot
2) Extracorporeal surgeon’s knot
There are a lot of methods to make a preformed loop for a slip
knot, here a couple of them are described. The length of the suture has
to be 45 cm for the creation of the loop for the slip knot.

Page | 49
 Tayside knot:
Step 1: A single hitch (Half knot) is taken first

Step 2. Four and a half rounds are taken behind the first half knot
over long standing limb of thread.
Step 3: A locking hitch is made by passing tail through the second
and third loop. Figure 10. Tay side knot.

Page | 50
Laparoscopic meltzer slip knot
Step A: Two-half knot is taken first.
Step B: Three rounds are taken in front of the first double half
knot over both the limb of the loop.
Step C: Stack the knot and trim the short end. Slide the knot into
place with knot pusher under tension.

• Also, there are commercially available Endoloops which can

be used, but with added cost.
Once this preformed loop/Endoloop is inside the abdominal
cavity, the structure to be ligated is placed through the loop and the
loop is tightened with the knot pusher, and the excess suture cut.
For structures which are not blind-ended (e.g., vessels or cystic
duct) the following methods can be used.
• A suture thread is passed under the structure and both ends
are taken out. A loop as described above is tied and is then
pushed down with knot pusher and tightened.
• Also, instead an extracorporeal surgeon’s knot can be made
and pushed in followed by square knots to secure. This can be
used in all instances of laparoscopic suturing however due to
the long length of suture chances of cut through and
inadvertent injury is higher. For extracorporeal suturing, the
suture length has to be at least 75 cm.
• The granny knot and square knot can be converted into a slip
knot by applying tension on the suture ends as demonstrated.

Page | 51
 And then this can be slipped down using graspers/knot pusher
to tighten the knot. This is easier when using monofilament
sutures.

There are other options available for stitching apart from the
sutures. They are:
• Liga clips and Hemolok clips: They can be used for clipping
small and medium-sized vessels/ducts and replaces the need
to place sutures and saves time.
• However, they require specific instruments for their
deployment.
• Tackers: They are absorbable or nonabsorbable. They are
used to fix the mesh in situ and for the closure of the
peritoneum.
• But since they are driven into tissues they are associated with
some pain postoperatively, can lead to bleeding if it punctures
vessels and if used in the path of the nerves then chronic pain.
• Hence should be used with good anatomical knowledge.

Page | 52
• Stapling devices: They can also be used laparoscopically
with good outcomes. They can be used for gastrointestinal
resection/anastomosis and bile duct resection. Stapling
devices borrow the same principle as used in open surgery,
but are technically more demanding, with the limited space
available and different angles to fire the staples at. They are
available as straight and circular devices for anastomotic
purposes. The circular device is more complex to use. It is
used for endo-laparoscopic anastomosis of the esophagus,
rectum, and gastric cuff in bypass surgery. For intra-
abdominal insertion of laparoscopic stapling devices, a 12
mm port is required.
• Tissue glue: Tissue adhesives are also being used in certain
conditions like for fixation of hernia mesh in TEP and TAPP.
The advantage being that it does not cause chronic pain and
can be used on and near the triangle of pain for better fixation
when compared to tackers. It is also being used in
combination with other techniques as an aid that provides a
hemostatic or hydrostatic seal.

Page | 53
 References

1. Sarabahi S, Tiwari VK (eds). Principles and Practice of Wound

Care. 1sted. 2012
2. Choudhury Dhiraj. General Surgical Operations. 1sted. 2008
3. Ethicon, Wound_Closure_Manual, Ethicon US, LLC. 2010-2016,
available from:
http://www.uphs.upenn.edu/surgery/Education/facilities/measey/
Wound_Closure_Manual.pdf
4. Glenn E. Talboy, Annesley W. Copel and, Gregory J. Gallina.
Wound and wound healing. Peter
5. F. Lawrence. Essential of general surgery. Philadelphia:
Lippincott williams and wilkings; 1994. P130-144.
6. WILLIAMS, Norman S.; BULSTRODE, C.; CONNELL, O.
Bailey. Love’s short practice of surgery. 26th International
Student Edition, 2008.
7. Edgerton M: The Art of Surgical Technique. Baltimore, Williams
& Wilkins, 1988.
8. McCarthy JG: Introduction to plastic surgery. In McCarthy JG
(ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, pp 48-
54.
9. Md, Nadine B. Semer. Practical plastic surgery for non-
surgeons. Place of publication not-identified: I Universe Com,
2007. Web.
10. "Violence and Injury Prevention." World Health Organization.
World Health Organization, n.d. Web. 24 Feb. 2017.
11. Tadesse, Kedir, wondimu, Anderson, Yerdaw. “Essential Surgical
Skills”. Ethiopia Public Health Training Initiative. (2007).
Page | 54
12. Hsu DC. Subcutaneous infiltration of local anesthetics [Internet].
Up to date. Up to date; 2017 [cited 2017Feb24]. Available from:
https://www.uptodate.com/contents/subcutaneous-infiltration-of-
local-anesthetics
13. Closure of minor skin wounds with sutures [Internet]. Closure of
minor skin wounds with sutures. [cited 2017 Feb23]. Available
from: https://www.uptodate.com/contents/closure-of-minor-skin-
wounds-with-sutures#H18
14. Dunn D. Wound closure manual. Ethicon, inc Johnson & Johnson
Company. 2007.
15. H. Cyanoacrylate for Intraoral Wound Closure: A Possibility?
[Internet]. International Journal of Biomaterials. Hindawi
Publishing Corporation; 2015 [cited 2017 Feb 28]. Available
from: https://www.hindawi.com/journals/ijbm/2015/165428/
16. Best M. Alternative Methods of Wound Closure. Alternative
Methods of Wound Closure 1970.
http://benangjahitbedah.blogspot.com/2015/02/alternative-
methods-of-wound-closure.html?m=1 (accessed February 28,
2017).

Page | 55

View publication stats