Basic Surgical practice

Dr Tedla G.
Department of Surgery,Arbaminch University

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Outline
• Approach to the surgical patient
• Prophylaxis
• Tissue handling
• Suture and suture technique
• Knot Tying

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Approach to the surgical patient-Introduction

• The preoperative assessment is a vital part of the care given to patients scheduled
for both routine and emergency surgery.

• The clinical assessment:

• Standard format of history
• Physical examination
• Investigations

• The main systems under evaluation are the respiratory and cardiovascular
systems

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The respiratory system

• Symptoms like cough, shortness of breath and hemoptysis, purulent sputum and
the presence of wheeze may also indicate underlying lung disease.

• The presence of a productive cough is associated with an increase in postoperative

chest complications.

• Recent onset warrants postponement of surgery and the commencement of

appropriate treatment with antibiotics and chest physiotherapy.

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Respiratory system

• If the patient has a chronic productive cough, then elective surgery should be
postponed only if the patient has additional signs suggesting an infection.

• The functional ability questions:

• "how far can you walk before you get short of breath”?
• "what activities make you short of breath”?

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The risk factors for pulmonary complications

• Known pulmonary disease

• Abnormal pulmonary function tests (FEV1/FVC < 60%)

• Smoking

• Age > 60 years

• Obesity

• Upper abdominal and thoracic surgery and Long operation time

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Preoperative steps

• Usual history

• CXR if over age of 40 years.

• Preoperative Spirometry and arterial blood gases if necessary.

• FEV1 and FVC

• Decrease or stop smoking and increase or optimize bronchodilator therapy

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Post operative pulmonary problems

• Adult respiratory distress syndrome

• Pulmonary edema

• Fat embolism

• Atelectasis

• Pneumonia

• Aspiration
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Ways to decrease complications

• Incentive Spirometry

• Chest physiotherapy

• Postural drainage when needed

• Humidified oxygen

• Bronchodilator therapy

• Antibiotics when necessary

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The cardiovascular system

• Obtain historical information concerning previous MI, angina, cardiac

medications and arrhythmias.

• Examine patient to assess the rate and rhythm of the pulse, origin of any murmur,
peripheral edema, or CHF.

• The most accurate method of diagnosing the cause of a cardiac murmur is

Echocardiography.

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The cardiovascular system

• In general all diastolic murmurs and loud systolic murmurs which are
accompanied by a thrill are abnormal and indicate underlying structural heart
disease.

• The risk of cardiac disease can be assessed using the Goldman Index.

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 The Goldman’s index
Risk factor Score

• Third heart sound / gallop rhythm 11

• MI within 6 months 10
• >5 Ventricular ectopics per min 7
• Rhythm other than sinus 7
• Age > 70 years 5
• Emergency surgery 5
• Aortic stenosis 3
• Abdominal or thoracic operation 3
• Poor general condition 3

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• The rationale is that these indices may help identify high-risk patients
who need further preoperative assessment through a noninvasive or
invasive approach and for characterizing low-risk patients in whom
further evaluation is unlikely to be helpful

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Specific cardiac Risks

• Previous cardiac disease

• Recent MI: elevated risk
• SOB, angina, arrhythmias
• Valvular heart disease
• Goldman’s criteria for peri-op risk of MI
• Past history
• Medications

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Specific hepatic Risks

• Evidences of Hepatic dysfunction

• chronic liver disease

• liver function abnormalities: INR, bilirubin, Albumin

• ascites, encephalopathy

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Specific renal Risk

• Renal dysfunction
• serum urea, creatinine

• Timing of dialysis

• Chronic anemia

• IV contrast

• Medications : Gentamicin, Meperidine, NSAIDS

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Specific immunity risk

• Immune competence
• multi-drug testing antigen response

• Drugs: steroids, immune suppressing (transplant)

• Diabetes

• AIDS

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Specific medication Risk

• Drugs

• Steroids

• Warfarin

• Oral hypoglycaemics and insulin

• ASA

• Cardiac meds - pre/post-op

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Preoperative Care And Evaluation- Practical Summary

• Aims: Psychological and Physical preparation of the patient for surgery

• Psychological: Patient information, obtaining written consent, allaying fears

• Physical: Ensure diagnosis is correct and symptoms have not changed

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Anaesthetic risk assessment
(ASA Classification)

Class Physical Status

• P1: A normal, healthy patient

• P2: A patient with mild systemic disease
• P3: A patient with severe systemic disease that limits
activity but is not life threatening
• P4: A patient with severe systemic disease that is a
constant threat to life
• P5: Moribund; Not expected to survive but is submitted
to operation in desperation
• P6: A declared brain-dead patient whose organs are
removed for donor purpose
• E: Indicates emergency surgery “ E ” used in
addition to the above “ P ” codes.

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Role of the Surgeon

Thorough History and Examination

• Focus on operative, anesthetic and patient healing factors

• Cardiovascular and Respiratory Fitness

• Pre-existing Medical Conditions which influence wound healing:

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Role of the Surgeon

• Drug therapy and allergies

• Previous Medical and Surgical/ Anaesthetic History

• Relevant advice: Lose weight, stop smoking, reduce alcohol

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Order the relevant Preoperative Tests

General Tests carried out in most patients:

• Full Blood Count

• Urinalysis

• Urea, Creatinine and Electrolytes

• Group, Cross match and Save

• Chest X Ray and ECG

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Specific Blood Tests: where indicated

• Liver Function Tests in jaundice, malignancy

• Amylase in acute abdominal pain

• Blood Glucose in established or suspected Diabetics

• Clotting Studies in liver disease, or if on anticoagulants

• Thyroid Function Tests in thyroid disease

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Pre-operative preparation-a day before

• Obtain consent for the procedure

• Discuss with patient and the family about the risks, benefits and alternatives.

• Keep NPO after mid-night for morning surgery

• Commence IV hydration with fasting

• Optimize patient medically, treat infection and Stabilize diabetes

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Pre-operative preparation- a day before
• Preoperative incentive spirometry.

• Schedule anesthetic evaluation or consultations.

• Discontinue or maintain medications

• Skin preparation/Marking for ostomies

• Bowel preparation as necessary

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Pre-operative preparation

• DVT prophylaxis where indicated

• Catheterize or insert NG tube as indicated

• Arrange intra-operative X/Rays or Frozen section as required

• Blood availability

• Wound infection prophylaxis

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Hypertension and Surgery

• Hypertension is a common disease and patients with this condition frequently

present for surgery.

• The disease is usually symptomless but if untreated, hypertension may result in

heart and failure, renal dysfunction and cerebrovascular accidents.

• Poorly controlled hypertension is indicated by diastolic blood pressure > 110 or

systolic pressure > 160.

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Hypertension and Surgery

• Severe untreated hypertension may lead to serious complications

• myocardial infarction
• left ventricular failure
• cerebral hemorrhage
• hypertensive encephalopathy
• renal failure.
• develop marked swings in blood pressure
• cardiac dysrhythmias and ischemia
• bleed more during surgery

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Emergency Surgery
• Efforts should be made to control the blood pressure before induction.

• Treat pain and anxiety with appropriate medication.

• Acute use of anti-hypertensive drugs can cause unexpected hypotension which

may result in stroke, blindness and myocardial ischemia.

• Note that a moderately low blood pressure in a normal patient (eg 90-100 systolic)
may reflect more serious hypotension in the hypertensive.

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Elective surgery
• The blood pressure should be assessed well before operation.

• An examination may reveal whether the hypertension has caused any cardiac,
renal or neurological complications.

• Electrolytes estimation, ECG and a chest X-ray are useful to help assess cardiac
and renal function.

• Patients with significant hypertension (diastolic pressures >110mmHg) should not

undergo elective surgery until their hypertension has been adequately controlled.

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Elective surgery
• Patients with well-controlled hypertension should normally continue their
medication up to, and including, the day of surgery.

• Premedication with benzodiazepines (eg diazepam 10-20mg, temazepam 20-

30mg, or lorazepam 2-4mg) two hours prior to surgery will help to allay anxiety.

• Atropine should be avoided if possible, because of its tendency to cause

tachycardia

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Diabetes and Surgery
• An estimated that nearly 50% of individuals with diabetes undergo surgery in their
lifetime.

• Diabetes has an impact on:

• Perioperative fluid and electrolyte,
• Nutritional balance;
• Cardiovascular and renal function;
• Immunity and wound healing, especially when the condition is poorly
controlled..

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Preoperative assessment of the diabetic patients

• History should include:

• Type and treatment of diabetes or insulin resistance

• Known complications and previous hospitalizations

• The course and complications, if any, of prior surgeries.

• Symptoms of ischemic cardiac, renal, and/or peripheral vascular disease, if

any.

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Preoperative assessment of the diabetic patients

• Routine physical examination:

• Complete cardiac evaluation

• Identify and treat hypertension.

• Status of the peripheral circulation/the sensory nerves.

• Neuropathy by evaluating for the presence of orthostatic hypotension.

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Preoperative assessment of the diabetic patients

• Laboratory:

• Routine screening

• Fasting sugar level and hemoglobin A1c.

• BUN and creatinine, microalbuminuria and proteinuria

• EKG

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Post-operative care

• Aims: Comfortable, pain free recovery from operation with an emphasis on early rehabilitation
and expedition of discharge.

• Immediate/ post-anesthetic recovery sites/ICU

• Intermediate recovery / regular wards

• Long term recovery / home

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Role of the surgeon

1. Monitoring
• Vital signs (Pulse, BP, Temperature, Respiratory Rate)
• Urine Output
• Level of consciousness

2. Analgesia
• Improve sleep and psychological well being- faster recovery
• Decrease psychological and physiological stress
• Reduce hospital stay and costs incurred
• Promotes easy wound healing

November 27, 2023

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Role of the Surgeon

3. Fluid Balance
• Effects of fluid balance monitored with regular FBC, U&Es
• Remember activation of Vasopressin/ ADH axis during surgery

4. Awareness of Complications

5. Mobilization
• In association with physiotherapists and nursing staff

6. Respiratory Measures

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Sample Post-operative Orders

1. Diet (NPO, sips/chips, soft)

2. Activity (Respiratory therapy, physiotherapy, occupational therapy)

3. Vitals (frequency, alerts, treatment of extremes)

4. Investigations (labs/frequency, imaging, ECG, alerts)

5. Drugs (IV, antibiotics, heparin, pain control, maintenance meds and substitutes)

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Sample Post-operative Orders

6. Drains (foley, NG, surgical drains, volumes)

7. Dressings (wounds, drain sites, dressing changes, frequency)

8. Disposition (ward, high-care, high-dependency wards, ICU)

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Post Op Complications

General Immediate ( with in first 24 hrs)

1. Primary hemorrhage
2. Reactive hemorrhage:
3. Basal Atelectasis
4. Shock
5. Blood loss
6. MI, Arrythmia,Pulmonary Embolism
7. Low Urine Output
8. Acute confusion
9. Nausea and vomiting
10. Analgesia or anaesthetic related
11. Pyrexia
12. Acute urinary retention
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Post-op complications: General Early ( 1-7 days post op)

• Secondary Hemorrhage
• Pneumonia
• Anastomotic leak
• Wound site infections
• UTI
• DVT
• Bowel Obstruction: due to fibrinous adhesions
• Paralytic Ileus

November 27, 2023 .

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 Post-operative fever

• The 5 W’s:

• Wind (Lungs),

• Wound (Infection)

• Water (UTI)

• Walk (DVT)

• Wonder drugs (Drug or other Allergies).

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Complications: General Late (>7 days)

• Obstruction: due to fibrous adhesions

• Incisional Hernia
• Hypertrophic scar
• Persistent Sinus
• Recurrence of Malignancy

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Days 0 to 2

• Mild fever (T<38) (Common)

• Tissue damage and necrosis at operation site
• Hematoma

• Persistent Fever (T> 38)

• Atelectasis:
• Specific infections related to the surgery
• Biliary infection in post biliary surgery
• UTI post urological surgery
• Blood Transfusion/ Drug Reaction:

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Days 3-5

• Bronchopneumonia

• Sepsis

• Wound infection

• Drip site infection/ phlebitis

• Abscess formation (e.g. subphrenic or pelvic)

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Days 5-7

• DVT

• Specific complications related to surgery

• bowel anastomosis breakdown
• fistula formation

• AFTER THE FIRST WEEK (less likely related to the specific operation)
• Wound infection
• Distant sites of sepsis
• DVT

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Post Op Complications

• Wound should be examined daily

• Seroma

• Hematoma

• Infection

• Non-healing

• Dehiscence

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Post operative check list

• Post-operative day number 1

• Assess the patient’s level of pain, lungs, cardiac status, flatulence and bowel movement.

• Examine the distention, tenderness, bowel sounds, wound discharge, bleeding from incision.

• Discontinue IV infusion when taking adequate PO fluids. Discontinue Foley catheter.

• Ambulate as tolerated, incentive spirometry, hematocrit.

• Post operative pain control

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Post operative check list

• Post-operative day number 2

• If passing gas or if bowel movement, advance to regular diet unless bowel resection

• Milder analgesia

• Remove drains if dry

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Post operative check list

• Post-operative day number 3-7

• Check pathology result

• Remove stitches

• Consider discharge home with appropriate medication

• Write discharge note

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 ANTIBIOTICS IN SURGERY,
PROPHYLACTIC & THERAPEUTIC

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Antibiotics
• Used to kill or inhibit the growth of bacteria
• Classified as bactericidal or bacteriostatic
• Kill bacteria directly or Prevent cell division
• Classified by target specificity: Narrow-spectrum vs Broad range
• Most modified chemically from original compounds found in nature,
some isolated & produced from living organisms

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FOUR MAIN TARGETS OF ANTIBIOTICS
IN BACTERIA

• Cell Wall Synthesis

• Protein Synthesis

• Nucleic Acid Synthesis

• Cell Membrane Function

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PROPHYLAXIS
 From Latin, from Ancient Greek (pró, “before”) + (phúlaxis, “a
watching, guarding”).
 Maneuvers to diminish the presence of exogenous (surgeon & OR
env’t) & endogenous (pt) microbes are termed prophylaxis, & consist
of the use of :.
Mechanical,
Chemical &
Antimicrobial modalities, or
A combination of these methods.

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Prophylactic antibiotic treatment

-is the use of antibiotic before/during/after

diagnostic/therapeutic/surgical procedure to prevent infectious
complications

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Antibiotic Prophylaxis……..
• Prevent infection of a surgical incision.
• Preop antibiotic prophylaxis is proved to reduce the risk of SSIs
• Only the incision itself is protected, & only while it is open & thus
vulnerable to inoculation.
• If it is not administered properly, is ineffective & may be harmful.
• Doesn’t prevent postop nosocomial infections

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Antibiotic Prophylaxis……..

• Indicated for most clean-contaminated & contaminated (or potentially

contaminated) operations.
• A clean-contaminated operation in w/c antibiotic prophylaxis is not
indicated is elective laparoscopic cholecystectomy.
• biliary surgery; High risk conferred by: Age >70 yrs, Diabetes
mellitus, or A recently instrumented biliary tract (e.g., biliary stent).

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Four Principles Guide The Administration Of
Antimicrobial Agent For Prophylaxis:

 Safety

 An appropriate narrow spectrum

 Little or no reliance on the agent for therapy of infection.

 Adminster within 1hr before surgery & for a defined brief period

thereafter (no >24 hrs, 48hrs for cardiac surgery, & ideally, a single dose)

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Antibiotic Prophylaxis
1st -generation cephalosporin is preferred in almost all
circumstances.

Clindamycin used for Penicillin-allergic pts.

 If gram-ve/anaerobic coverage is required,

A 2nd -gen cephalosporin or The combination of a 1st -gen agent

plus metronidazole is the 1st -choice regimen of most experts.

Vancomycin only in institutions in w/c the incidence of MRSA

infection is high (>20% of all SSIs).
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Antibiotic Prophylaxis……..

• The optimal time is within 1hr before incision

• 2 hrs for vancomycin or a fluoroquinolone

• If given sooner/after the incision is closed its ineffective

• Most inappropriately timed first doses of prophylactic antibiotic

occur too early;

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Antibiotic Prophylaxis……..

• Antibiotics with short (t1/2< 2 hrs; e.g., cefazolin or cefoxitin)

• should be redosed every 3 to 4hrs during surgery if the operation is

prolonged or bloody.

• Single-dose prophylaxis (with intraop redosing, if indicated) is

equivalent to multiple doses for the prevention of SSI.

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Empirical Therapy
when the risk of a surgical infection is high, e.g ruptured appendicits
significant contamination during surgery. e. g inadequate bowel prep or
considerable spillage of colon contents).
In critically ill pt & severe sepsis/septic shock.
A short course of drug (3 to 5 days),
should be curtailed as soon as possible based on microbiologic data.

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Therapeutic antibiotic tx.
• De-escalation therapy:. initial antimicrobial selection is broad,
with a later narrowing of agents based on pt response & culture results.
• Initial drug selection based on initial evidence (Gram +ve vs. Gram-ve
microbes, yeast), coupled with institutional & unit-specific drug
sensitivity patterns.
• Antimicrobial coverage chosen should be adequate, since delay in
appropriate antibiotic tx is associated with significant increases in
mortality.
• Within 48 - 72 hrs, culture & sensitivity reports will allow refinement
of the antibiotic regimen to select the most efficacious agent.
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Therapeutic antibiotic tx…….
Therapy for monomicrobial infections follows standard guidelines:
3 to 5 days for UTIs
7 to 10 days for pneumonia,
7 to 14 days for sepsis
6 to 12wks for Osteomyelitis, endocarditis, or prosthetic infections for.

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Therapeutic antibiotic Treatment

• The least toxic, least expensive agent to w/c the organism is most
sensitive should be selected.

• Consider 2 or more agents in Serious or recrudescent infection,

particularly if a MDR.

• Commonly an agent may be administered IV for 1 to 2 wks, ff which

the tx course is completed with an oral drug.

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When to discontinue antibiotics
• The absence of an elevated WBC count,
• lack of band forms of PMNs on peripheral smear
• lack of fever.
• In the presence of one or more of these indicators, search for extra-
abdominal source of infection or A residual or ongoing source of
intra-abd infection (e.g., abscess or leaking anastomosis)

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Misuse of antimicrobial agents

Financial impact on health care costs,

ADR due to drug toxicity and allergy,
New infections such as C. difficile colitis, &
Development of MDR among nosocomial pathogens.

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Tissue handling

• Proper surgical technique and tissue handling is important to prevent

wound infection, promote wound healing and ensure likelihood
satisfactory outcome to the surgical practice.

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• Accurate tissue apposition enhances healingand promotesrapid return
to normal function
• Retraction and dissection of tissues can produce pockets known as
dead space
• Dead space can delay healing and serve as site for bacterial growth
and contamination
• Placement of drains to prevent fluid accumulation

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Suture Materials and
Suture Technique

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 Introduction
• Suture is surgical technique to close a
wound by joining the edges.
• Suture (n) a piece of material used to
close a wound or connect tissues, e.g.
catgut, thread, or wire.

• Suturing is the most versatile, least

expensive and most widely used
technique of securing tissue during an
operative procedure.

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• Suture is made of a variety of materials with a variety of properties.

• Suture materials can be categorized in a number of ways, based on

the following different characteristics.

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 Absorbable vs. nonabsorbable
Braided vs. monofilament
Synthetic vs. biological(Natural)
Suture size
Needle shape (straight; circle; )
Needle size
Needle point (cutting vs.
tapered(round))
Single vs. double needle (single-ended
vs. double-ended)

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 • It may be synthetic or
biological, absorbable or
non-absorbable and
constructed with a single
or multiple filaments.

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Tensile Strength Retention
• Since different tissue types and wound closures require different
durations of suture strength, suture materials with various absorption
rates and tensile strengths have been engineered.

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• Nonabsorbable sutures permanently retain their tensile strength,
although not all nonabsorbable sutures are completely “permanent.”

• The ideal suture is easily handled by the surgeon, easy to tie, and
retains strength for the required period of time.

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Tissue Reaction
• Some suture materials evoke more of an inflammatory tissue reaction
than do others.

• The biological materials, such as silk or collagen (gut), are more

reactive than synthetic types.

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 • Braided sutures possibly induce more
scarring when placed superficially and
have a greater risk for wound
infection by harboring organisms
within the interstices of the braids.

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Suture Size
• Suture size is quantified by the 0-gauge system.
• The more 0s a suture has, the smaller is its diameter.
• 1–0 is the largest, followed by 2–0 or 00, 3–0 or 000, etc.

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• The opposite is true for sutures described by whole numbers: number
2 suture is larger than number 1 suture, which is larger than 0 suture.

• The smallest possible suture that provides the desired tensile strength
appropriate for a specific tissue type should be used.

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Surgical Needle Anatomy
Swage (Suture attachment end)
• Most needles are crimped (folded)
around the suture, while some have
an eye for threading the suture
through.

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• The swage can be designed to pull off from the suture (pop-off) or to
be cut away.

• A swage and overall needle diameter equal to or smaller than the

suture reduces leaking in a vessel anastomosis.

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Body
• The body can be straight
or curved.
• The curve can be from
1/4 to 5/8 of a circle in
circumference.

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 • A 3/8 curve is often
used for microsurgery
and skin closure, and
5/8 for confined spaces
such as the pelvis and
rectum.

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Point
The point can be;
• Cutting (sharp edge toward the inner
concave curvature),
• Reverse cutting (sharp edge toward
the outer convex curvature),
• Tapered (round tapering to a point),
or

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• Blunt.
• A cutting point provides good cosmetic results in skin and is effective
for penetrating tissues with high resistance (e.g., dermis, tendons,
and sternum).

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 • A reverse cutting needle reduces the tendency of the
knot to tear through tissue (fascia, ligament, tendon,
and eye).
• A taper needle is best for anastomoses (biliary, vessel,
nerve) and for minimizing leaks.
• Blunt-tip needles are usually reserved for friable tissue
and are sometimes selected by surgeons for increased
safety when operating on patients with
communicable diseases.

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Suture technique
Choice among these materials depends on:
• Availability
• Individual preference in handling
• Security of knots
• Behaviour of the material in the presence of infection
• Cost.

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• If you want a suture to last, for example when closing the abdominal
wall or ligating a major vessel, use one made of non-absorbable
material.

• Use absorbable material in the urinary tract to avoid the encrustation

and stone formation associated with non-absorbable suture.

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• All varieties of suture material may be used in the skin, but a reactive
suture such as silk should be removed within a few days.

• In skin wounds, remove sutures early to reduce visible markings.

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• Because of the ease of tying, braided suture may be easier to use for
interrupted stitches.

• Absorbable and non-absorbable monofilament suture is convenient

for continuous running stitches.

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 • The commercial suture package is marked with the
needle shape and size, the suture material and the
suture thickness.
• Suture is graded according to size.
• The most popular grading system rates the suture
material downward from a very heavy 2 to a very fine
ophthalmic suture of 10/0.
• Most common operations can be completed with
suture material between sizes 4/0 and 1.

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 • Different materials have different strength
characteristics.
• The strength of all sutures increases with their size.

• Suture can be purchased in reels and packaged and

sterilized on site as a less expensive alternative to
packages from the manufacturer.

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Absorbable suture
• A suture that degrades and loses its tensile strength
within 60 days is generally considered to be
absorbable.
• Polyglycolic acid is the most popular suture material
because it is absorbable and has long lasting tensile
strength. It is an appropriate suture for abdominal
closure.
• The absorption time for this suture is considered to be
60 – 90 days.

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• Catgut is pliable, is easy to handle and inexpensive.
• Chromic catgut lasts for 2–3 weeks and is used for ligatures and
tissue suture. Do not use it for closing fascial layers of abdominal
wounds, or in situations where prolonged support is needed.

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Techniques
• There are many ways to secure tissue during an operative procedure
and to repair discontinuity in the skin: tape, glue, staples and suture.
• The aim of all these techniques is to approximate the wound edges
without gaps and without tension.
• Staples are an expensive alternative and glue may not be widely
available.
• Suturing is the most versatile, least expensive and most widely used
technique.

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Suturing techniques include:
• Interrupted simple
• Continuous simple
• Vertical mattress
• Horizontal mattress
• Subcuticular
• Purse string
• Retention/tension.

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• The size of the bite, and the interval between bites, should be
consistent and will depend on the thickness of the tissue being
approximated.

• Use the minimal size and amount of suture material required to close
the wound.

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• Leave skin sutures in place for an average of 7 days.
• In locations where healing is slow and cosmesis is less important (the
back and legs), leave sutures for 10–14 days.
• In locations where cosmesis is important (the face), sutures can be
removed after 3 days but the wound should be reinforced with skin
tapes.

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• Use the needle driver to hold the needle, grasping the needle with
the tip of the driver, between half and two thirds of the way along the
needle.

• If the needle is held less than half way along, it will be difficult to take
proper bites and to use the angle of the needle.

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• Holding the needle too close to the end where the suture is attached
may result in a flattening of the needle and a lack of control.

• Hold the needle driver so that your fingers are free of the rings and so
that you can rotate your wrist and/or the driver.

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• Pass the needle tip through the skin at 90 degrees.
• Use the curve of the needle by turning the needle through the tissue;
do not try to push it as you would a straight needle.
• Close deep wounds in layers with either absorbable or monofilament
nonabsorbable sutures (Figure 4.6).

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 Interrupted sutures
• Most commonly used to repair
lacerations.
• Permit good eversion of the wound
edges, as well as apposition; entering
the tissue close to the wound edge will
increase control over the position of
the edge
• Use only when there is minimal skin
tension

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 • Ensure that bites are of equal
volume
• If the wound is unequal, bring the
thicker side to meet the thinner to
avoid putting extra tension on the
thinner side

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 • The needle should pass
through tissue at 90
degrees and exit at the
same angle
• Use non-absorbable suture
and remove it at an
appropriate time.

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Continuous/running sutures
• Less time-consuming than interrupted sutures;
fewer knots are tied and less suture is used
• Less precision in approximating edges of the
wound
• Poorer cosmetic result than other options

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 • Inclusion cysts and
epithelialization of the suture
track are potential complications
• Suture passes at 90 degrees to
the line of the incision and
crosses internally under the top
of the incision at 45–60 degrees.

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 Mattress sutures
• Provide a relief of wound tension and precise
apposition of the wound edges
• More complex and therefore more time-consuming
to put in.
Vertical mattress technique
• Vertical mattress sutures are best for allowing
eversion of wound edges and perfect apposition and
to relieve tension from the skin edges (Figures 4.7 and
4.8).

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 • Start the first bite wide of the incision and pass to the
same position on the other side of the wound.
• The second step is a similar bite which starts on the
side of the incision where the needle has just exited
the skin.
• Pass the needle through the skin between the exit
point and the wound edge, in line with the original
entry point.

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• From this point, take a small bite; the final exit point is in a similar
• position on the other side of the wound.
• Tie the knot so that it does not lie over the incision line.
• This suture approximates the subcutaneous tissue and the skin edge.

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 Horizontal mattress technique
Horizontal mattress sutures
reinforce the subcutaneous tissue
and provide more strength and
support along the length of the
wound; this keeps tension off the
scar (Figures 4.9 and 4.10).

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• The two sutures are aligned beside one another. The first stitch is
aligned across the wound; the second begins on the side that the first
ends.
• Tie the knot on the side of the original entry point.

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 • Continuous subcuticular sutures
• -Excellent cosmetic result
• -Use fine, absorbable braided or
monofilament suture
• -Do not require removal if
absorbable sutures are used.

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 •- Useful in wounds with strong
skin tension, especially for
patients who are prone to keloid
formation
•Anchor the suture in the wound
and, from the apex, take bites
below the dermal-epidermal
border
-Start the next stitch directly
opposite the one that precedes it
(Figure 4.11).
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 •Purse string sutures

A circular pattern that draws

together the tissue in the
path of the suture when the
ends are brought together
and tied (Figure 4.12).

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Retention sutures technique
• Insert retention sutures through the entire thickness of the abdominal
wall leaving them untied at first.
• Sutures may be simple (through-and-throughough) or mattress in
type.
• Insert a continuous peritoneal suture and continue to close the
wound in layers.

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 -When skin closure is complete, tie
each suture after threading it through
a short length of plastic or rubber
tubing (Figures 4.13–4.16). -Do not
tie the sutures under tension to avoid
compromising blood supply to the
healing tissues.
-Leave the sutures in place for at
least 14 days.

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 Knot Tying

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Knot Tying
• Knot is the intertwining of the ends of a suture , so that the ends will
not slip or become separated.
• a way of joining or securing lengths of suture , or other strands by
tying the material together or around itself.

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 -There are many knot tying
variations and techniques, all
with the intention of completing
a secure, square knot.

-A complete square knot consists

of two sequential throws that lie
in opposite directions.
-This is necessary to create a
knot that will not slip (Figure
4.17).
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 -A surgeon’s knot is a variation
in which a double throw is
followed by a single
throw to increase the friction
on the suture material and to
decrease the initial slip until a
full square knot has been
completed. (Figure 4.18).

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 • Use a minimum of two complete square knots on any
substantive vessel and more when using
monofilament suture.

• If the suture material is slippery, more knot throws

will be required to ensure that the suture does not
come undone or slip.
• When using a relatively “non-slippery” material such
as silk, as few as three throws may be sufficient to
ensure a secure knot.

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 • Cut sutures of slippery materials longer than those of
“non-slippery” materials.

• There is a balance between the need for security of

the knot and the desire to leave as little foreign
material in the wound as possible.

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 Techniques
• There are three basic techniques of knot tying.
• 1 Instrument tie
• This is the most straightforward and the most
commonly used technique; take care to ensure that
the knots are tied correctly
• You must cross your hands to produce a square knot;
to prevent slipping, use a surgeon’s knot on the first
throw only.

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 -Do not use instrument ties if the patient’s life
depends on the security of the knot (Figure
4.19).

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 • 2. One handed knot

• Use the one handed technique to place deep seated

knots and when one limb of the suture is immobilized
by a needle or instrument.
• Hand tying has the advantage of tactile sensations
lost when using instruments; if you place the first
throw of the knot twice, it will slide into place, but
will have enough friction to hold while the next throw
is placed.

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• -This is an alternative to the surgeon’s knot, but must be followed
with a square knot
• -To attain a square knot, the limbs of the suture must be crossed
even when the knot is placed deeply (Figure 4.20).

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• 3.Two handed knot
• -The two handed knot is the most secure.
• Both limbs of the suture are moved during its placement.
• A surgeon’s knot is easily formed using a two handed technique
(Figure 4.21).

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 • With practice, the feel of knot tying will begin to seem
automatic.
• As with learning any motor skill, we develop “muscle
memory”.

• Our brain teaches our hands how to tie the knots, and
eventually our hands tie knots so well, we are no
longer consciously completing each step.

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Suture removal
• The timing of suture removal varies with the anatomic site :
• Neck - 3 to 4 days
• Face and scalp - 5 days
• Eyelids - 3 days
• Trunk and upper extremities - 7 days
• Lower extremities - 10-14 days

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