BASIC SURGICAL SKILLS MANUAL

Principles and Applications

2nd Edition • Electronic Version

PHILIPPINE COLLEGE OF SURGEONS

• Committee on Surgical Training

Cenon R. Alfonso, MD - Committee Chairman

Miguel C. Mendoza, MD - Editor-in-Chief

Shirard L.C. Adiviso, MD, Jose Joey H. Bienvenida, MD,

and Renato Cirilo A. Ocampo, MD

Armando C. Crisostomo, MD - Regent-in-Charge.

PCS SCIENTIFIC PUBLICATION NO. 12

Foreword2nd Edition . . . Cenon R. Alfonso, MD, FPCS, Chairman

Committee on Surgical Training, Philippine College of Surgeons2003

Foreword1st Edition . . . Gabriel L. Martinez, MD, FPCS, Chairman,

Committee on Surgical Training, Philippine College of Surgeons1999

Message from the 2003 PCS PresidentFernando A. Lopez, MD, FPCS

Preface2nd Edition . . . Armando C. Crisostomo, MD, FPCS,

Regent-In-Charge (2003), Committee on Surgical Training,Philippine College of Surgeons

Preface1st Edition . . . Jose Y. Cueto, MD, FPCS, Regent-In-Charge

(1999), Committee on Surgical Training, Philippine College ofSurgeons

� Chapter ILearning & Assessing Psychomotor Skills inSurgeryJose Y. Cueto, Jr., MD, MHPEd, FPCS (1st edition)• Self-Assessment Questions

� Chapter IIThe Use of Simulation in Surgical TrainingShirard L.C. Adiviso, MD, MHPEd, FPCS• Self-assessment Questions

� Chapter IIISuture MaterialsJose Antonio M. Salud, MD, FPCS andJerome G. Baldonado, MD, FPCS (1st edition)Joey H. Bienvenida, MD, FPCS (2nd edition)• Self-assessment Questions

� Chapter IVSurgical NeedlesCenon R. Alfonso, MD, FPCS and

Nilo C. de los Santos, MD, FPCS (1st edition)

Renato A. Ocampo, MD, FPCS (2nd edition)

• Self-assessment Questions

Table of Contents

� Chapter V

Knot Tying

Jose Antonio M. Salud, MD, FPCS (1st edition)Miguel C. Mendoza, MD, FPCS (2nd edition)• Self-assessment Questions

� Chapter VISuturing Techniques

Cenon R. Alfonso, MD, FPCS,Shirard L.C. Adiviso, MD, MHPEd, FPCS,Jose Joey H. Bienvenida, MD, FPCS,Miguel C. Mendoza, MD, FPCS, andRenato Cirilo A. Ocampo, MD, FPCS (2nd edition)• Self-assessment Questions

� Chapter VIIClinical Applications

Cenon R. Alfonso, MD, FPCS,Jerome G. Baldonado, MD, FPCS,Alejandro C. Dizon, MD, FPCS,Rene C. Encarnacion, MD, FPCS,Eduardo S. Eseque, MD, FPCS,Gabriel L. Martinez, MD, FPCS,Paul Jesus S. Montemayor, MD, FPCS,Jose Antonio M. Salud, MD, FPCS, andJose A. Solomon, MD, FPCS.

• Plastic Closure of Skin Lacerations• Skin Closure with Skin Adhesives• Abdominal Wall Closure• Inguinal Herniorrhaphy/ Repair of the Inguinal

Floor• Appendectomy• Cholecystectomy & Surgery of the Bile Ducts• Liver Trauma• Bowel Anastomosis• Vascular Anastomosis & Repair• Application of Retention Sutures• Self-assessment Questions

Appendix A (Glossary of terms)

Appendix B (Answers to self-assessment questions)

2003 PCS Board of Regents

2003 Committee on Surgical Training

Acknowledgement

Even a full decade before the turn of the 21st

Century, the growing movement toward a paradigm

shift of surgical skills training has already begun. This

shift is from the operating-room-patient venue into the

surgical skills laboratory-simulation setting.

Because of this propensity, it will become unaccept-

able in the near future for young surgical trainees to be

allowed to “practice” and hone their basic surgical

techniques among patients in the operating room.

Furthermore, it may also come to a point that before

being allowed to do so, these trainees will be required

to pass a certification from a surgical skills laboratory.

This means that the essential principles of mastery in

psychomotor skills - repetition and feedback - have

been adequately satisfied. This likewise implies that the

trainee has progressed from being unconsciously

incompetent in surgical techniques as they started into

unconsciously competent as they ended (mastery) their

surgical skills training.

The hope is once the trainee is faced with an actual

Foreword• 2nd Edition

patient, basic surgical technique is almost second

nature.

The first step towards the above-mentioned goal is to

be able to experience an audiovisual simulation. This is

the importance of this CD version and Edition of the

Basic Surgical Skills Manual.

To all the members of the CST, Atong, Shirard, Joey,

and Ike, most specially to the Regent-in-Charge,

Armand, thank you and congratulations for all your

selfless efforts, contributions, and seemingly-endless

proddings.

An audiovisual simulation in basic surgical technique

Cenon R. Alfonso, MD, FPCS

Chairman,Committee on Surgical Training (2003)Philippine College of Surgeons

This manual was conceived in 1996 in answer to a

palpable need for a structured, problem-oriented

instructional tool for trainees and surgical practitioners.

In 1998, during the incumbency of Dr. Antonio B.

Sison, the Committee on Surgical Training (CST) through

its Chairman, Dr. Gabriel L. Martinez presented the

project proposal to the PCS Board of Regents. The

favorable action of the Board of Regents led to the

creation of the Sub-committee on Skills Improvement

under Dr. Jose Antonio M. Salud.

While diligently collecting and collating data from

the various makers of surgical needles and sutures for

inclusion in the Basic Surgical Skills manual, the CST

made representations with Johnson & Johnson Medical

Philippines through Mr. Bayani R. Santos, Jr. and Mr.

Erwin Tantoco who favorably endorsed the project.

In 1999, during the incumbency of Dr. Francisco Y.

Arcellana, the drafts of the Manual were presented to

the Board of Regents for comments and suggestions.

Once approval was obtained, the CST, and J & J

Foreword• 1st Edition

through its Franchise Manager, Ms. Ruth Nicolas,

engaged the services of Creative Powerhauz to publish

this manual.

As in any endeavor, there are unsung heroes whose

efforts were vital to the completion of this project: the

members of the 1998 and 1999 Committee on Surgical

Training, Regent-representative Dr. Jose Y. Cueto, Jr.,

contributors Drs. Nilo C. de los Santos and Paul Jesus S.

Montemayor. Special thanks to Dr. Elizabeth F.

Mabilangan-Salud and Ms. Olivia S.M. Manzano, CST

secretary.

Addressing need for problem-oriented instructional tool

Gabriel L. Martinez, MD, FPCS

Chairman,Committee on Surgical Training (1999)Philippine College of Surgeons

Clinical acumen, surgical knowledge and decision-

making, and the right attitude and motivation do not

make up a complete Surgeon.

These have to be adequately matched by a set of

fine psychomotor skills, i.e. mastery of technical compe-

tence. Training of young physicians into the Art and

Science of Surgery therefore requires not only intensive

education, but equally important, is the toning of every

muscle and discipline of each movement they create

during operations into a purposeful progress towards

the goal of every procedure they perform.

This aspect of surgical training essentially requires

two basic learning principles, namely: repetition and

feedback.

This feat of the Committee on Surgical Training is the

first step towards this end. A visual companion into the

world of Surgical Technique allows application of almost

all the senses in order to guide the young trainee in the

“HOW” of the procedures.

In the short term, the Board of Regents envisions this

project to serve as a guide to trainees. So that before a

Message from the 2003 PCS President

The backbone for all cutting specialties

certain technique is performed by simulation or in a

patient, the young trainee can view this first and then

play back for feedback.

In the long term however, this CD Edition of the

Basic Surgical Skills Manual will play as the backbone

of the National Surgical Skills Center (NSSC) that PCS

will establish for all cutting specialties.

In behalf of the Board of Regents, let me congratu-

late the Committee on Surgical Training for this project.

Allow me to extend a similar warm recognition to the

partner of PCS in this project, Johnson & Johnson

Medical Philippines.

Fernando L. Lopez, MDPresident 2003

Preface• 2nd Edition

Despite all the attention given to the development of

a strong basic theoretical foundation in surgery and the

enhancement of attitudinal competencies, the surgeons

of today continue to be judged mainly by the quality of

their technique in the performance of various surgical

procedures.

Major requirements for the accreditation of residency

training programs in surgery continue to highlight the

need for adequate operative experience in order to

ensure the competency of our trainees.

Despite the importance of the operative skill,

continuing education in this regard continues to be

wanting. Also, there is a need to standardize the

teaching of surgical technique to our students and

residents while appreciating some variation in individual

style.

With this in mind, the Surgical Training Committee of

the Philippine College of Surgeons has embarked on

this endeavor to further improve the initial landmark

publication of the Basic Surgical Skills Manual, this time

in electronic form.

Subsequently, we intend to pursue publication of the

Advanced Surgical Skills Manual, which highlights more

advanced techniques to include laparoscopic ap-

proaches.

Finally, we also plan to pursue the establishment of a

National Surgical Skills Center to be set up under the

auspices of the Philippine College of Surgeons.

All these efforts serve to demonstrate our sincere and

unwavering determination to attain our vision of being

the leading organization in uplifting the practice of

surgery in the country.

Uplifting the practice of surgery in the Philippines

Armando C. Crisostomo,

MD, MHPEd, FPCS

Regent-in-Charge (2003)Committee on Surgical TrainingPhilippine College of Surgeons

Preface• 1st Edition

As mandated by the Philippine College of Surgeons,

the PCS Committee on Surgical Training is primarily

concerned with the educational welfare of residents.

To fulfill this mandate, the project on the Surgical

Skills Improvement Program for residents was conceived.

In its original concept, there were two components:

1. Basic surgical skills (for junior residents)

• appropriate selection of needles and sutures

• suturing

• knot-tying

2. Advanced surgical skills (for senior residents)

• use of staplers and laparoscopy

• stapling techniques

• laparoscopic techniques

Why was this program envisioned? What resident

needs does it answer?

The training of young surgeons in these very basic

surgical skills started during their minor surgery sessions

in medical school. As students, they learned scrubbing,

preparation of the operative site, suturing and knot-tying.

In clinical clerkship and internship, they had opportu-

nities to perform in actual patient situations, suturing

different kinds of wounds, but many of them unsuper-

vised.

During residency, they assist numerous operations

and surgical procedures. Through constant exposure and

observation, residents get to absorb the practices, the

A foundation for learning basic surgical skills

habits and preferences of their senior residents and

consultants. As they progress to higher levels of training,

they indulge in their own series of trials and errors,

performing procedures in actual patients.

Conferences and audits have revealed the conse-

quences - leaks from repairs, blow-out of anastomoses,

disruption of abdominal closures and many others.

Undoubtedly, many of these complications are multifac-

torial, but a lot of them could be traced to deficiencies in

technical expertise.

This manual aims to provide a foundation for

learning the most basic surgical skills that all surgeons

need to master. These skills are very important compo-

nents of patient care. They are carried out regularly, in

the day-to-day activities of a surgeon. They must be

learned correctly and thoroughly because patient

outcomes are influenced by how well these skills are

performed.

Jose Y. Cueto, Jr., MD, MHPEd,

FPCSRegent-in-charge (1999)Committee on Surgical TrainingPhilippine College of Surgeons

I. Relevance and Importance

Surgeons who are involved in the training of residents are all

too familiar with complications that follow surgical procedures.

These are regularly presented in mortality-morbidity conferences

and include leaks from simple repairs, disruption of anasto-

moses, strictures and stenosis following tight suturing, partial and

complete dehiscence of abdominal wall closures and many

more.

These complications comprise the evidence of the importance

of psychomotor skills, specifically, operative skills. They constitute

a very critical part of day-to-day surgical patient care. While it is

true that most of them are multifactorial in origin, the most

important factor within the control of the surgeon is his technical

expertise. Patient outcomes are definitely influenced by how well

procedures are performed.

II. Theoretical Basis for Learning Skills

A. Fitt’s three-phase theory

Phase 1 Cognitive Phase

This phase involves the initial “intellectualization” process

necessary in learning a new task. Both the trainor and trainee try

to verbalize what needs to be learned. The trainee has to

understand the concepts and principles involved in the task

before any performance can be attempted. In surgery, the nature

of the technical skills, their indications, applications,

contraindications, complications or consequences are discussed.

In this phase, performances of trainees are prone to error.

There is, therefore, a need for the trainor to demonstrate how a

task should be accomplished.

Phase 2 Fixation or Associative Phase

This phase involves the development of correct pattern of

action and behavior. This is established thru practice with

regular feedback on the quality of performance. Incorrect

practices and steps are identified and rectified. There is gradual

elimination of error. This phase lasts a lot longer than the

cognitive phase.

Phase 3 Autonomous Phase

This phase is characterized by gradually improving speed and

accuracy of performance. The residents develop smoothness and

efficiency of movements, with minimal wasted moves, and

elimination of unnecessary steps.

During this phase, there is increasing resistance to stress and

Chapter I

Teaching and Assessing Psychomotor Skills in Surgery

Jose Y. Cueto, Jr., MD, MHPEd, FPCS

Objectives of this Chapter

After going through this chapter, the learner is expected to:

1. Understand the importance and relevance of learning and

assessing surgical skills

2. Discuss the theoretical bases for learning skills and their

educational implications

3. Formulate a system to evaluate skills

interference from other activities, and in fact, concurrent activities

may be performed.

These characteristics of performance are found in specialists

and experts, marked by a high level of proficiency.

III. Educational Implications

A. Need to recognize the phases of learning skills

To make the acquisition of psychomotor skills more effective,

the trainors should understand and apply the different phases of

learning. Each resident presents with his/her own level of

knowledge and competence with regard to a particular skill. The

trainor must be able to bring the residents through the different

phases of learning.

An educational activity that addresses the cognitive phase of

skills learning is the pre-operative conference. Residents go

through details in a procedure and verbalize the steps in a

particular operation and how complications are to be avoided.

Another very important activity is the operative assist. Operations

that residents assist in are actually considered “demonstrations”

by consultants and senior residents. Needless to say, the residents

must be exposed to the correct way of performing different

operations and techniques.

The skills that residents learn take years to refine, and are

finally incorporated into the autonomous phase of behavior.

Once habits become part of autonomous behavior, it becomes

very difficult to unlearn them.

B. Need for focus and clarity

In order that lower level residents know what needs to be

learned, complex tasks must be broken down into sub-tasks. The

residents focus first on learning the simpler sub-tasks before

graduating to complex tasks. Ideally, these skills should be

learned in the laboratory using simulations, using inexpensive

materials or animals. What needs to be learned, how they are to

be learned, and how they are to be assessed become clear to the

residents.

C. Need for structure

The old method of “see one, do one” has long been proven

to be inadequate and even dangerous. Repeatedly assisting

procedures and operations do not automatically mean that

trainees will absorb only the good practices of their seniors and

superiors. In order to obtain the required level of proficiency in

surgical skills, a structured method of teaching and assessment is

needed.

Supplementary workshops that include multi-station, hands-

on and interactive format will be of great help. The residents

rotate through different stations learning about needles, sutures

and how to select and use them depending on the clinical

situation. Group discussions then follow in order to recapitulate

and emphasize the important factors in selection, principles

governing their use, and the correct steps that should be fol-

lowed.

D. Need for guidance, supervision and feedback

It is during the fixation or associative phase where residents

develop their own pattern of action and behavior. They are

exposed to different consultants and senior residents who have

their own way of performing different techniques. The residents

should be able to determine and decide which steps and tech-

niques they should adopt, and which ones to reject and avoid.

When residents in lower years are allowed to acquire “bad

habits” and incorporate them into their practice, it becomes very

difficult for them to unlearn these habits when they reach their

senior years. There must, therefore, be adequate guidance and

supervision. In addition, timely feedback should be given

regarding what needs to be corrected and how they are to be

corrected. In this way, only the proper steps are incorporated

into the autonomous phase of skills acquisition.

E. Need for simulation and practice

Before residents are allowed to operate and perform proce-

dures on actual patients, they should be given opportunities for

simulations. This allows the trainor to make sure that the trainee

has mastered the steps in a certain procedure.

During simulation and practice, the deficiencies and errors of

the residents should already be determined and corrected. This is

to make surgical training safe, and avoid unnecessary complica-

tions that may arise from operations and procedures done

incorrectly.

IV. Assessing Psychomotor Skills

A. Direct observation with the use of checklists and rating

scales

This is the most valid method of assessing how trainees

perform. However, this is time-consuming because it requires the

presence of trainors all throughout the procedure. This method is

process-oriented and assumes that the resident follows the details

described in the cognitive phase. The consultant or supervisor

assesses how residents select needles and sutures, particularly in

the way they are handled.

B. Product evaluation

This is done by inspecting a finished product or a completed

task. For example, an anastomosis is inspected by the trainor

before the abdomen is closed. This can be reserved for higher

level trainees who have already demonstrated mastery of the

process.

C. Record review

For audit purposes, the record of procedures and operations

are meticulously examined. The materials used (needles and

sutures), the steps and their sequences and the over-all operative

management are assessed. These are all correlated with the

outcomes, such as the presence/absence of complications.

However, this method relies heavily on the accuracy and com-

pleteness of the operative records.

D. Objective Structured Clinical or Practical Exam (OSCE or OSPE)

This method utilizes a number of stations where skills are

tested. Skills such as suturing fascia, muscle, skin, intestine and

blood vessels are evaluated. Every station has a rater who

observes the trainee. With the use of objective checklists and

rating scales, the performance is determined to be satisfactory or

unsatisfactory. The results are then fed back to the trainees for

them to know where they need to improve on.

The use of structured clinical or practical exams ascertain that

all residents go through the same stations and the same tasks.

This is very difficult to attain in real clinical situations where cases

differ in degree of difficulty. Even similar cases of appendicitis

present with varying technical difficulties depending on patient

habitus, position of the appendix, etc.

REFERENCES

Abbatt F and McMahon R. Teaching Health Care Workers: A Practical Guide;Macmillan Education, London, 1988

Bouhuijs P, et al. The OSCE as a part of a Systematic Skills Training Approach,Medical Teacher, Vol. 9, No. 2, 1987

Crosby J. Learning in Small Groups, Medical Teacher, Vol. 18, No. 3, 1996

Harden RM, et al. Task-based learning: an educational strategy for undergraduate,postgraduate and continuing medical education, Part I, Medical Teacher, Vol. 18,

No. 1, 1996

Morgan M and Irby D. Evaluating Clinical Competence in the Health Profession;

C.V. Mosby, Co., St. Louis, 1978

Patrick J. Training: Research and Practice; Academic Press, San Diego, CA, 1992

A. Direction:

On the blank beside each number, identify and write the

phase (Column B) in which the process in Column A takes

place according to Fitt’s three-phase theory.

Column A

___1. Performing assisted or supervised operations

___2. Enumerating the steps of an operation in a pre-

operative conference

___3. Learning through demonstration-return demonstration

with trainor

___4. Performing operations independently and smoothly

___5. Describing operative complications

Self-Assessment Questions (Chapter I)

Column B

A. Cognitive Phase

B. Fixation Phase

C. Autonomous Phase

B. Direction:

Column A contains comments from residents in-training.

Identify and write on the space before each number, the

component under which the problem falls.

Column A

___6. “I have been left on my own to learn new skills”

___7. “I did my first bowel anastomosis in a real patient

because there is no animal laboratory”

___8. “I don’t know what stage of learning I am in”

___9. “I don’t know what to learn”

___10. “No one is correcting my mistakes”

Column B

A. Knowledge of phases of learning

B. Focus and clarity

C. Structure

D. Guidance, supervision and feedback

E. Simulation and practice

C. Direction:

Identify the most valid and appropriate method of assess-

ment for the skills listed. There can be more than one correct

answer per number.

Column A

___11. Selection of needles and sutures

___12. Handling of instruments

___13. Knot-tying technique

___14. Quality of anastomosed bowel

___15. Suturing an anastomosis in an animal laboratory

Column B

A. Direct observation of actual performance

B. Product evaluation

C. Record review

D. Objective structured clinical examination

Chapter II

The Use of Simulation in Surgical Training

Shirard L.C. Adiviso, MD, MHPEd, FPCS

All surgical trainees need a core of basic surgical skills

regardless of their specialties. This requires continuous deliber-

ate practice to master it and should start early in their training.

The trainors have an important role in making this possible.

They should describe, demonstrate and arrange practice

sessions in teaching these skills.

During the last several years, medical education has swayed

away from traditional method of apprenticeship. Most of the

surgical skills were previously mastered initially with real patients

but is now transferred in “vitro” or simulated venue.

Professional and public concerns in surgical simulation has

been initiated by almost identical situation with the airline

industry with its desirable reputation for safety and its commit-

ment to lifelong training. Actual patient based learning is an

important part of advanced surgical training but acquiring

technical skills in a venue where patient safety is not at risk is

now inevitable.

Simulation (using physical models, computer program or

combination of two) provide the opportunity to achieve and

evaluate skills through repeated practice within a safe and

controlled environment.

Advantages of Simulation

1. The training design can be formulated based on the

needs of the learner and not the patient.

2. Since the venue is safe and controlled, learners are

allowed to fail and learn from such failures in a way that is

unacceptable in a true clinical scenario.

3. Simulators can offer objective evidence of performance

using their inherent tracking functions to map learner’s trajectory

in detail. Assessment forms are developed for both formative

and summative evaluations.

4. The capacity of the simulators to provide ready feedback

in digital form offers collaboration in learning.

Classification of Simulations

1. Model Based Simulation – a range of relatively inexpen-

sive models or animals are available. Basic procedural skills are

taught from simple intravenous insertion to wound suturing. The

benchtop models are limited in terms of feedback. This requires

comprehensive support from expert mentors.

Objectives of this chapter

After going through this chapter, the learner is expected to:

1. Understand the role of simulation in surgical training.

2. Conduct teaching and learning activities in basic and

advanced surgical skills using simulation.

A Simple Taxonomy of Simulators (Medical Education, 2003)

SKILL MANUAL REQUIREMENT EXAMPLES

Precision Placement Direct needle Intravenous needle insertion

Instrument to a point Lumbar puncture

Simple Manipulation Guide a catheter Angioplasty

Endoscope Colonoscopy

Ultrasound probe Bronchoscopy

Abdominal ultrasound

Complex Manipulation Perform single complex task Bowel/ vascular

anastomosis , MIST-VR,

Lap Sim

Integrated Procedure Perform multiple task of Laparoscopy procedure

entire procedure Anesthesia simulation

Figure 1- Flexible sigmoidoscopy trainer (Immersion Medical).

Figure 2 - Endoscopic surgery trainer (MIST-VR: – Minimally

Invasive Surgical Trainer – Virtual Reality

Figure 3 - Laparoscopy Simulation (LapSim Basic Skills 2.0)

Figure 4- Simulated operating theater with mannequin.

2. Computer Based Simulators (shown below)

1. Hybrid Simulation- combine physical model with comput-

ers using realistic interface like instruments and real diagnostics.

Kneebone’s 5 Stages of Training Method

1. Watching an animated graphic of procedure.- essential

points of technique are shown by animated graphics usually

with spoken commentary.

2. Watching a clinical video of the procedure- short clinical

video sequences show the techniques performed by an expert

on a real patient.

3. Watching the procedure demonstrated on a model-

demonstrated a simulated tissue model by the same expert

wherein steps can be stopped, started and replayed at will.

4. Doing the procedure on a model- learner carries out

procedure on an identical model and practices repeatedly then

reviews the techniques.

5. Doing the procedure on a patient under supervision. An

experienced colleague or mentor supervised the learner while

performing the procedure on a patient.

Kneebone’s Tips in using Simulation and Multimedia

1. Simulation offers means of detaching skills from their

clinical context and learning without the pressures of clinical

responsibility.

2. The earlier surgical skills training starts, the better.

3. To learn a new motor skill you should see it demon-

strated, then practice it repeatedly and receive feedback about

your performance.

4. Non-biological simulated tissue allows a range of basic

surgical procedure to be learned in skills workshops.

5. Clinical teaching skills are not the same as workshop

teaching skills, and new methods of learning require new ways

of teaching.

6. To teach skills to complete novices you have to start from

first principles, avoiding any assumption of previous knowledge.

7. It is easy to overestimate the knowledge and skill of any

group of learners, especially as they may be embarrassed to

admit their ignorance. Assume nothing but go right back to

basics – provided you treat the learners with respect, they will

value the experience.

8. Do not overestimate the complexity needed in basic

surgical skills teaching.

9. Ensure that you are familiar with the procedures you will

be teaching and with any models used.

10.Setting up basic surgical workshop requires thought and

planning but need not be prohibitively expensive.

11.Learners like a clear framework within which to exercise

their navigational freedom.

12.Make the teaching aim clear from the onset. Encourage

learner to repeat procedure till they become proficient.

REFERENCES

Anastakis,Dmitri et al. Assessment of Technical Skills Transfer from Bench Training to

Human Model. The American Journal of Surgery. Vol.177 Feb.1999

Cauragh,James et al. Modelling Surgical Expertise for Motor Skills Acquisition. TheAmerican Journal of Surgery. Vol 177, Apr.1999

Connor, Michael et al. A Computer Based Self-Directed Training Module for BasicSutures. Medical Teacher Vol. 20 no.3, 1998.

Kneebone, R.L. Twelve tips on Teaching Basic Surgical Skills Using Simulation and

Multimedia. Medical Teacher Vol. 21 No. 6, 1999.

Kneebone,Roger . Simulation in Surgical Training:Education Issues and Implications.

Medical Education. Vol 37. 2003

Rogers,David et al. Computer Assisted Learning Versus A Lecture and Feedback

Seminar for Teaching Basic Surgical Skills. The American Journal of Surgery. Vol 175.

June 1998

Wigton, Robert. See One, Do One, Teach One. Academic Medicine. Vol. 67 no.11, Nov. 1992.

Direction:

On the blank beside each number, identify the simulator used in

the Column B to the examples of skills in Column A.

Column A

____ 1) Intravenous needle insertion

____ 2) Colonoscopy

____ 3) Vascular anastomosis

____ 4) Laparoscopy Procedures

____ 5) Abdominal Ultrasound

Column B

A ) Simple manipulation

B ) Precision Placement

C ) Integrated Procedure

D) Complex Manipulation

Self-Assessment Questions (Chapter II)

Sutures are fibers of strands of a material used for sewing

tissues to help wound healing by surgically approximating its

edges. The material used to close blood vessels to achieve

hemostasis is called ligature.

The first suture materials were used between 2500 and 3000

BC as documented by Egyptian papyri and they consisted of

fibers of plant origin, leather, animal tendons and parchment

strips. However, it was only in 1860 when Joseph Lister intro-

duced carbolic catgut, the first suture material specifically for

surgical use. Eventually other materials were introduced for

surgical use such as linen, silk, celluloid, horsehair, wire, etc.

Synthetic materials were first used in the 1930’s with the

introduction of polyvinyl alcohol. As the 20th century comes to a

close, manufacturers of sutures have reached a stage of signifi-

cant refinement in suture materials such that certain suture

materials are used only for specific surgical procedures.

Suture materials come in different sizes, corresponding to the

diameter of the suture and these sizes are stated in a numerical

fashion. The greater the number of 0’s, the smaller the size the

suture strand is. Thus, a 6-0 suture is smaller than the diameter

of a 2-0 suture.

Suture materials are

generally classified as

being absorbable or

non-absorbable. (Refer

to Table A: Classifica-

tion of Suture Materials.)

Absorbable sutures are those sutures which are broken down or

degraded by hydrolysis or digested by enzymatic processes.

Non-absorbable sutures, on the other hand, are those which

are not arrested by either enzymes or tissue fluids.

The most frequently used absorbable non-absorbable suture

materials are the following:

Absorbable Sutures

1. Plain Catgut

Plain catgut is derived

from the collagen of small

intestine, either the serosal

layer of cattle or the

submucosal layer of sheep.

In tissues, plain catgut

loses much of its tensile

strength at the end of one

week. It is absorbed shortly there after and thus, is recom-

mended for use in situations in which a suture is needed only

during the first week of healing as in soft tissues like subcutane-

ous tissue and ligature purposes.

Chapter III

Suture Materials

Jose Antonio M. Salud, MD, FPCS and Jerome G. Baldonado, MD, FPCS

Jose Joey Bienvenida, MD, FPCS

Objectives of this Chapter:

After going through this material, the learner is expected to:

1. Analyze the different types of sutures and their character-

istics.

2. Discuss the newer “suture materials” and their characteris-

tics.

3. Discuss guidelines in choosing a suture material based on

its biological behavior and mechanical performance.

Table A – Classification of Suture Materials

Based on Origin

Suture Material Origin

Natural

Animal

Catgut Submucosa of sheep intestine or serosa of beef intestine

Silk Raw silk spun by silkworm

Vegetable

Cotton Cotton Plant

Mineral

Steel Specially Formulated iron-chromium-nickel-molybdenum alloy

Silver Silver

Synthetic

Polyglactin 9101

Copolymer of glycolide and lactide with polyglactin 370 and calcium

stearate, if coated

Polyglycolic Acid Homopolymer of glycolid

Poliglecaprone 25 Copolymer of glycolide and epsilon-caprolactone

Polyglyconate Copolymer of glycolide and trimethylene carbonate

Polydioxanone Polyester of poly (p-dioxanone)

Poly (L-lactide/glycolide) Copolymer of lactide and glycode with caprolactone and glycolide

coating

Nylon Polyamide polymer

Polyester Fiber Polymer of polyethylene terephthalate (may be coated)

Polypropylene Polymer of propylene

Poly (hexafluoropropylene-VDF) Polymer blend of poly (vinylidene fluoride) and poly (vinylidene

fluoride-cohexafluoropropylene)

Based on BEHAVIOR

Absorbable Non-Absorbable

Catgut Cotton

Polyglactin 910 Steel

Silk

Polyglycolic Acid Silver

Poliglecaprone 25 Nylon

Polyglyconate Polyester Fiber

Polydioxanone Polypropylene

Poly (L-lactide/glycolide) Poly (hexafluoropropylene-VDF)

Based on STRUCTURE

Monofilament Multifilament (Braided)

2. Chromic Catgut

This suture material is

actually similar to plain

catgut except that it is

treated with chromate

compounds, which results

in a stronger and more

slowly absorbed suture.

Thus, the loss of tensile

strength takes a little longer, about double the time it takes for

plain sutures to lose their own. However, the absorption of

chromic is dependent on environmental factors in the tissues.

When used to suture the stomach, the presence of acid hastens

the absorption. This should not be used when extended approxi-

mation of tissues under stress is required, as in fascia. Both

plain and chromic catgut sutures may stimulate a considerable

inflammatory reaction during the absorptive phase and should,

thus not be used in areas such as the peritoneum.

3. Polyglactin

This is a synthetic

braided suture whose raw

material is a copolymer

of glycolide and lactide.

Most absorbable in

synthetic sutures,

polyglactin included, are

hydrolyzed during

absorption rather than being broken down enzymatically (as

with the natural absorbable sutures). In hydrolization, water

gradually penetrates the suture filaments causing the breakdown

of the suture’s polymer chain which results in lesser degree of

tissue reaction following tissue implantation. 75% of the strength

of this suture is retained at 14 days, and about 50% is retained

at 21 days. 100% loss in tensile strength is noted by the 32nd

day. Absorption is complete at about the 56th or the 70th day.

4. Polyglycolic Acid

This synthetic braided

suture is reduced by

the hydrolysis to

glycolic acid. Like most

synthetic sutures, the

inflammatory reaction

that results from its

breakdown is only

minimal. Its tensile strength is completely lost by the 30th day.

Complete absorption occurs about the 90th day.

5. Polydioxanone

This is a synthetic

monofilament absorb-

able suture composed of

the polyester of p-dioxa-

none. It takes longer for

its tensile strength to be

reduced as well as for its

absorption to be com-

pared with the two

previously mentioned suture materials. In vivo studies have

shown its tensile strength to be at about 70% at 14 days and

50% is retained at 28 days. Absorption starts close to the 90th

day and is complete at 6 months time.

6. Poliglecaprone

This is a mono-

filament suture whose

tensile strength in the first

week is high but rapidly

reduces soon after.

Studies have shown its

tensile strength to be

about 70% at the end of

the first week but is down to 30-40% by the end of the 2nd

week. It is thus recommended for use in situations wherein the

surgeon requires a high initial tensile strength as in subcuticular

wound closures. Absorption is complete in 90-120 days.

Non-absorbable sutures

1. Silk

By far, still the most

commonly used suture

material, silk is a

protein filament

produced by silk-

worms. As with most

braided sutures, silk

holds knots well.

However, silk loses its

tensile strength when exposed to moisture and should be used

dry. Silk loses much, if not all of its tensile strength within a year.

Although classified as a non-absorbable suture, silk can actually

be absorbed slowly but the absorption rate is variable.

2. Cotton

This is a commonly

used braided non-

absorbable suture much

like silk. It stimulates an

inflammatory reaction

greater than that of silk

and other sutures is that

this material is relatively

cheaper.

3. Nylon

This particular non-

absorbable suture comes

in a monofilament and

braided form. This suture

is characterized by its

high tensile strength and

extremely low tissue

reaction. The loss in

tensile strength is in the range of 15-20% per year by hydrolysis.

As with most monofilament sutures, nylon sutures require more

throws to securely hold the knots in place. The braided variety,

on the other hand is very similar in characteristic to silk but has

considerably less tissue reaction.

4. Polypropylene

Polypropylene is a

non-absorbable synthetic

monofilament suture.

This suture’s tensile

strength retention is

indefinite and is a suture

that is encapsulated by tissues when implanted

thus resisting tissue degradation. Because of these characteris-

tics, it is a suture that is widely used in virtually all specialties.

5. Polyester

This suture was the

first synthetic suture

material shown to last

indefinitely in tissues.

Like polypropylene,

poly-esters sutures are

encapsulated by

tissues and thus resist

tissue degradation.

6. Wire/Stainless

Steel/Titanium

A very strong suture

material that produces

little loss of tensile

strength, wire has

been used for many

years and is a popular

suture for a variety of

operations (thoraco-

cardiovascular, orthopedics, neurosurgery). Tissue reaction is

minimal. However, it is difficult to handle and may be easily

palpated by the patient.

Table B – Suture Materials and Characteristics

T A B L E O N S U T U R E C H A R A C T E R I S T I C S

Tissue Number of Absorbability Absorption Inflammatory Knot Securityof Origin strands Rate reaction (minimum #

of knots)

Plain Catgut Collagen of Monofilament Absorbed by Complete ++ 2small bowel of Enzymatic within 70 dayscattle & sheep Proteolysis

Chromic Catgut Collagen of Monofilament Absorbed by Over 90 days ++ 2small bowel of Enzymaticcattle & sheep Proteolysis

Polyglactin Copolymer of Multifilament & Absorbed by Complete in + 2/5lactide & Monofilament Hydrolysis 56-70 daysglycolide coated (size 10-0with polyglactin only)370 & calciumstearate

Polyglycolic acid Glycolic acid Multifilament Absorbed by Complete + 2polymer Hydrolysis in 90 days

Poliglecaprone Copolymer of Monofilament Absorbed by Complete -/+ 5glycolide and Hydrolysis in 91-119epsilon- dayscaprolactone

Polydioxanone Polyester Monofilament Absorbed by Complete -/+ 5polymer Hydrolysis in 180 days

Silk Silkworm Multifilament Non- N/A + 2absorbable

Cotton Cotton Plant Multifilament Non- N/A ++ 2absorbable

Nylon Long-chain Monofilament Non- N/A -/+ 2/5polymers of absorbablenylon

Polypropylene Crystalline Monofilament Non- N/A -/+ 5stereoisomer of absorbablepolypropylene

Polyester Polymer of Multifilament Non- N/A -/+ 2polyethylene absorbableterephthalate

Wire/Stainless 316L stainless Multi- & Non- N/A -/+Steel/Titanium steel Monofilament absorbable

MESH

Surgical mesh materials are more commonly used to repair

fascial defects. Its use in inguinal herniorrhaphies was even

made more popular in the advent of laparoscopic herniorrhaphy

techniques. Meshes may be non-absorbable or absorbable.

Non-absorbable Meshes

Most common types of materials used in non-absorbable

meshes are polypropylene, polyester (macroporous structures)

and polytetrafluroethylene (PTFE) (microporous structures).

Polypropylene may be monofilament or multifilament. Both

exhibit high burst strength. It is knitted in such fashion as to

interconnect each monofilament fiber and provide unidirectional

elasticity. This mesh is porous.

Absorbable Meshes

Polyglycolic acid and Polyglactin inert knit meshes are

stretchable. This mesh is mainly used to support the small

intestine and to set as a sling to protect the area from radiation

associated small bowel injury. It has 3 days tensible strength

retention and is absorbed within 60-90 days.

Surgical Staplers

Modern

surgical

stapling

devices and

techniques

were first

developed in

the Soviet

Union in the

1950’s

through the

work of the Scientific Research Institute for Experimental Surgical

Apparatus and Instruments in Moscow.

These instruments have wide application in various fields of

surgery facilitating ligation and division, resection, anastomosis

and skin and fascial closure. These staplers significantly reduce

operating time, time under anesthesia, blood loss, tissue

manipulation and trauma thus facilitating postoperative healing.

Edema and inflammation associated with manual suturing is

significantly reduced with the use of staplers and anastomoses

appear to function sooner as compared with manual suturing

techniques. The stainless steel staples that are used are virtually

inert producing minimal tissue inflammation and minimal tissue

compression. However, with the use for staplers for skin repairs,

the closure may be less meticulous. Another disadvantage of

staplers is that it may interfere with computed tomography and

magnetic resonance imaging.

Skin Adhesives

Designed to close skin wounds and lacerations, tissue

adhesives is a non-pigmented medical grade adhesive made of

n-butyl-cyanoacrylase. Applied to wound edges, to hold them

together and may provide wound healing similar to skin sutures.

The newest “suture material” available in the market today is

called topical skin adhesives, as exemplified by DERMABOND(r).

This is a non-absorbable sterile violet-colored liquid (2-

octylcyanoacrylate) that is used primarily for easy approximation

of skin edges.

Cyanoacrylate adhesives were first described in 1949 and

there first reported used as clinical adhesives was for 10 years

later. However, the use of these initial cyanoacrylates

(butylcyanocrylate) was limited due to certain physical properties.

Octylcyanoacrylate is a new-generation medical-grade

adhesive that has addressed these limitations. It is simply

applied over the apposed wound edges and allowed to set

within 45-90 seconds after application. An adhesive waterproof

film is then formed over the wound. It does not require applica-

tion of local anesthetics nor is there a need to use instruments

and sutures.

Octylcyanoacrylate tissue adhesive can replace skin sutures

on virtually all facial lacerations and properly selected extremity

and torso lacerations. It is not recommended for use on hands

and over joints since repetitive movements and washing the

adhesives may peel off with the top layer of epidermis in only a

few days, before complete healing has occurred. It is ideal for

use in children and in case where rapid skin closure essential.

After 5-10 days, the adhesive film sloughs off as the skin starts

to re-epithelialize. it has been deemed an effective and reliable

method of skin closure for many wounds, yielding similar

cosmetics results to closure with subcuticular sutures and is a

faster method of skin closure than suture.

Furthermore, cyanoacrylate adhesives also have antimicro-

bial properties against gram-positive organism and may

decrease wound

infections. However,

they have a lower

tensile strength than

sutures.

Guidelines in Choosing a Suture Material

• TABLE C

IDEAL SUTURE CHARACTERISTICS

1. High tensile strength

2. Sterile

3. Ease and security of knotting

4. Ease of handling

5. Inert (The ideal suture material would cause the least

tissue reactivity.)

6. Non-toxic, non-allergenic (both the suture and its

components when metabolized by the body)

7. Small size

8. Predictable performance

9. Smooth surface avoiding necrotic tissue, clots and

bacteria to adhere

10.Should keep its physical characteristics as long as

necessary

11.Cost effective

The selection of suture materials is generally based on its

biological interaction with the wound and its mechanical

characteristics. Whatever suture material is used for a particular

procedure, the following guidelines should be considered:

1. Select the finest suture consistent with the tissues to be

approximated.

2. The suture material should have adequate tensile strength

and maintain it until its purposed is served.

3. Choose a suture that would produce the least tissue

reaction.

4. Select sutures with the least risk for bacterial proliferation.

5. Select sutures that are pliable, easy to handle and able to

maintain knot security .

These principles are important to remember in the choice of

sutures based on their physical properties:

1. Sutures should be at least as strong as normal tissues

through which they are placed.

2. Suture strength must be maintained until the wound gains

maximum strength.

3. Tissue reaction to sutures should not prolong the healing

process.

To apply these principles, one must have information

regarding the normal strength of tissues, the rate at which

injured tissues regain strength, the strength of different sutures,

the rate at which sutures lose strength and the interaction

between sutures and tissues.

• TABLE D

HIERARCHY OF BIOLOGICAL INERTNESS

(from highest to lowest)

Highest Plain Cutgut

Reactivity Chromic catgut

Linen-Cotton

Silk

Braided Uncoated polyester

Braided Uncoated Polyamide

Braided Coated Polyamide

Synthetic Absorbable

Monofilament Polyamide

Monofilament Polyester

Polypropylene

Lowest Steel

Reactivity Titanium

Normal Strength of Tissue

Experimental data regarding human tissue strength are

limited. However, a number of papers in the literatures provide

data about other animal tissues. Tissue strength is determined in

several ways:

1. Tensile strength - refers to load applied per unit of cross

section area in lbs/in2 or kg/cm2

2. Breaking strength - measurement of force required to

break a wound without regard to its dimension

3. Bust strength - amount of pressure necessary to rupture a

viscus

Tensile strength is the preferred measurement for homog-

enous materials (ex.,. sutures). For heterogeneous materials (ex.,

skin), the breaking strength is more practical to use. For hallow

organs (ex., intestines), burst strength is the more appropriate

measure. From the meager data available, it can be shown that

that regardless of the species, the relative strength of tissues to

each other are similar. Animal studies show that the stress

needed for a suture to pull out from the following tissues are:

a. Skin -- 0.9 lbs.

b. Fat -- 0.44 lbs.

c. Fascia -- 8.3 lbs.

d. Muscle -- 2.8 lbs.

e. Peritoneum -- 1.9 lbs.

f. Viscera

-- 2.19 lbs. (stomach)

-- 3.7 lbs. (rectum)

Above the limits of the strength of the tissue, no advantages

gained by using a larger or stronger suture to hold the wound

edges together. These data on relative strength are useful only if

considered in relation to the rate at which wounds in these

tissues regain strength.

Variations in Healing Rate

A wound rarely, if ever, attains the same strength as unin-

jured tissue. The gain in strength varies from tissue to tissue.

Skin -- 70% strength at 3-4 months.

Fascia -- 50% of original strength at 50 days; 80% at 1 year.

Muscle -- 80% strength at 10-14 days.

Viscera -- 80% at 14-21 days.

REFERENCES

Edlich RF, Woods JA, Duke DB. Scientific Basis of Wound Closure Techniques.

Dannenmiller Memorial Educational Foundation, San Antonio, Texas.

Ethicon Wound Closure Manual, Ethicon, Inc., 1994

Maw JL, Quinn JV, Wells GA, Ducic Y, Odell PF, Lamothe A, Brownrigg PJ and

Suctliffe T. A Prospective Comparison Of Octylcyanoacrilate Tissue Adhesive &

Sutures for the Closure of Head and Neck Incisions; Journal of Otolaryngology, 1997,

Vol.26, 1;26-30

Quinn J, Wells G, Sutcliffe T, Jarmuske M, Maw J, Steill I and Johns P. A Randomized

Trial Comparing Octylcyanoacrylate Tissue Adhesive and Sutures in the Management

of Lacerations; JAMA, 1997, Vol. 277, 19:1527-1530

Sabiston DC, Jr. Textbook of Surgery, The Biological Basis of Modern Surgical

Practice, 15th ed., WB Saunders Co., 1997

Wound Closure In the Operating Theatre, B Braun Melsungen AG

Zinner MJ, Schwartz SI, Ellis H, Ashley SW & McFadden DW. Maingot’s Abdominal

Operations, 10th ed., 1997

1. Which of the following sutures are considered non-absorb-

able?

a. Polyester

b. Polydioxanone

c. Polyglactin

d. Polyglycolic acid

e. Poliglecaprone

2. Which of the following suture material has an indefinite

tensile strength?

a. Nylon

b. Silk

c. Polyester

d. Polypropylene

e. Polyglactin

3. Which of the following is a characteristic of skin adhesives?

a. Interferes with MR imaging

b. Consumes more time compared to sutures

c. Yields similar cosmetic results as with subcuticular sutures

d. Is used for joints lacerations

e. Produces pain on application

Self-Assessment Questions (Chapter III)

4. Which of the following sutures loses tensile strength the

longest?

a. Chromic catgut

b. Polyglactin

c. Polyglycolic acid

d. Polydioxanone

e. Poliglecaprone

5. Which suture material is most suitable in closing the fascia of

the abdominal wall?

a. Plain catgut

b. Chromic catgut

c. Polydioxanone

d. Poliglecaprone

e. Staplers

6. Which of the following suture materials exhibits the highest

inflammatory tissue reaction?

a. Polypropylene

b. Polyglactin

c. Chromic

d. Silk

e. Polyester

7. Based on their physical properties, what suture will be good

choice to approximate fascia after a contaminated operation?

a. Plain catgut

b. Polypropylene

c. Silk

d. Chromic catgut

e. Cotton

8. The following statements regarding the physical properties of

sutures and tissues are true EXCEPT?

a. Above the limits of normal tissue strength, there is no

advantage with the use of a larger or stronger suture

b. A suture should hold injured tissues in apposition until

the healing process to withstand stress without mechanical

support

c. Foreign bodies like sutures cane lead to the development

or persistence of local infection and therefore, should not stay

longer than their supported use

d. From the practical stand point, tensile strength is more

important than breaking strength

e. All of the above

Objectives of this Chapter

After going through this chapter, the learner should be able to:

1. Analyze the factors involved in needle selection.

2. Describe the characteristic of the surgical needle.

3. Identify the common types and code names of the locally

available needles.

Factors in the Selection of Needles

When considering the ideal surgical needle for a given

application, the type of tissues being approximated should be

considered: they should be altered as minimally as possible by

the needle. The only purpose of the needle is to introduce the

suture into the tissues. The needle should also be large enough

and of appropriate size, shape and design in order to provide

precise and efficient suturing. There are five basic requirements

that must be met in proper needle selection. The needle must

be:

1. Able to carry suture material through tissues with minimal

trauma.

2. Sharp to overcome tissue resistance.

3. Rigid to resist bending but flexible to prevent breaking .

4. Sterile and corrosion-resistant to prevent introduction of

microorganisms or foreign bodies into the surgical site, and

5. Of appropriate size, shape and design.

The surgical needle has evolved with the history of surgery

itself. The first needles were either closed-eyed or the so-called

French-eye needles requiring the scrub nurse to thread the

suture into the eye of the needle. The double strand of the

suture that results from threading and the increase in diameter

of the needle because of the presence of the eye, causes

additional trauma to tissues and in anastomotic procedures,

may lead to leakages.

Moreover, threading is time consuming and the needles are

difficult to prepare during surgery. A weak point is created near

the eye that could lead to needle breaks and even to rusting.

During operations in deep confined areas, eyed needles may

become unthreaded. Theoretically, it is more difficult to retrieve

them when accidentally dropped inside body cavities without the

suture. Because of these, there was a gradual reluctance both in

the use and manufacture of eyed surgical needles and favor

shifted towards swaged surgical needles.

Anatomy of the Surgical

Needle

Regardless of its intended

use, every surgical needle has

three basic components:

1. The point

2. The body

3. The attachment end

(swaged or eyed)

Chapter IV

Surgical Needles

Cenon R. Alfonso, MD, FPCS & Nilo C. de los Santos, MD, FPCS

Renato Cirilo A. Ocampo, MD, FPCS

A. Needle Point

The point extends from the extreme tip of the needle to the

maximum cross section of the body. Each specific point is

designed and produced to the required degree of sharpness to

smoothly penetrate the type of

tissue to be sutured.

1. Tapered

The body of the needle

tapers to a sharp point at the

tip. The taper point needle is

often preferred where the

smallest possible hole in the

tissue and minimal tissue trauma is desired. This is particularly

indicated in intestinal anastomosis. It is also ideal for approxi-

mation of the peritoneum, fascia and subcutaneous tissues.

Examples are needles code-

named CT-1 and SH.

2. Blunt

A rounded blunt point that

does not cut through tissues is

used for penetrating friable,

parenchymal and vascular

tissues like the liver, spleen or

kidneys. An example is the BP-

1 needle.

3. Reverse Cutting

These needles have a cutting

edge in the outer convex

curvature of the needle. This

cutting edge may extend from

the point of the needle down to

the swaged area. The cutting edge may also extend only down

to 1/3 of the distance to the swaged area. This type is most

useful in plastic surgical procedures. These types of needles are

coded PS- 2 and OS-8. The latter type is also indicated in the

closure of skin and various plastic surgery applications and

other orthopedic procedures.

4. Taper Cut (Trocar point)

This is a blend of the

combined features of the

reverse cutting and the taper

point needles. Three cutting

edges extend approximately 1/

32 inches back from the point.

All three edges of the point are sharpened to provide uniform

cutting action. It easily penetrates dense tough tissues. This type

is used for sclerotic or calcified tissues and for heavy fibrous

tissue such as the fascia. A typical example is V-40.

5. Conventional Cutting Edge

The cutting sharp edge is in

the concave curvature of the

needle. This is ordinarily used

in common plastic surgery

procedures and in closure of

superficial wounds and

incisions. An example is the

PC-5 needle.

B. Needle Body

The portion between the point and the swage of a needle is

called its body. This is the grasping area of the needle holder.

C. Attachment End

1. Swaged

This is the area in which the suture is

attached to the needle. It is of specific

importance to the needle-suture

relationship.The ideal swage area

diameter is a one-to-one suture-

needle ratio so that the more exact the

sizes correspond to each other, the

lesser the damage to the tissues. On

the other hand, the bigger the ratio,

the greater unnecessary tissue damage is produced. In cases of

bowel anastomosis, this ratio is most crucial in preventing

needle puncture leaks. Suture attachments to the needle are

most commonly done in two ways:

Channeled Needles

A channel is developed in the swage area and the suture is

placed or clipped in the channel. Pressure is applied to close the

channel around the suture in order to hold it tightly.

Drilled Needles

Mechanically drilled. A hole is drilled into the swage area of

the needle and the end of the suture is placed inside the hole.

The hole is then crimped a little in order to secure the suture

end.

Laser-drilled Needles

A feature provided where the swage area is laser-drilled to

achieve the closest one-to-one needle-suture ratio. Laser-drilled

needles are currently available among cardiovascular products.

It has the advantage of a tapered swage which in turn provides a

smoother transition from needle to suture. In addition, a laser-

drilled needle allows the so-called extended side flattening, a

design that adds strength and resistance to bending.

2. Closed Eye

Similar to a household sewing needle, the

shape of the closed eye may be round,

oblong or square.

3. French Eye

These needles have a slit from inside

the eye to the end of the needle with ridges

that catch and hold the suture in place.

4. Control Release Needle Suture

These needle sutures allows easy

detachment of the needle from the

suture when desired by the surgeon.

This allows rapid placement of

sutures in succession, reducing

operative time.

D. Chord Length

The chord length is defined as the straight line distance from

the point of a curved needle to the swage. This varies from 2

mm. to more than 5 cm. Length is a determining factor in the

width of the bite taken by the needle. Chord length comparison

between the CT-1 needle and the TP-1 needle will make the

biggest difference in the width of the bite.

E. Needle Diameter

This refers to the gauge or thickness of the needle wire.

Needle diameter varies from 30 microns to 56 mil (.056 inch).

The diameter equals the size of the needle tract.

F. Needle Radius

If the curvature of

the needle were to con-

tinue to make a full circle,

the radius of the curvature

is the distance from the

center of the circle to the

body of the needle. This

varies from 1 mm. to 1 1/8

inches. The curved needle

is always thought of as part of a circle.

G. Needle Shape

Needles are available in various shapes to accommodate the

desired “turnout” from different tissues. The shape of the needle

remains consistent regardless of size. For example, although a

TF needle is significantly smaller in size than an XLH, they are

both 1/2 circle needles. The following are the usual needle

shapes used:

1/4 circle (TG)

3/8 circle (P)

1/2 circle (CT)

5/8 circle (UR)

straight or Keith needle

TG Needle: Their use is often limited to ophthalmic and

microsurgical procedures. Size and depth of the area to be

sutured are small and shallow.

P Needle: This is the most commonly used curved needle.

It can be easily manipulated in relatively large and superfi-

cial wounds such as closure of the dermis with slight

pronation of the wrist. Because of a large arc of manipula-

tion required, 3/8 circle needles are awkward to use in

deep cavities such as the pelvis or in small, cramped areas

with difficult access.

CT Needle: it is relatively easy to use in confined areas and

difficult to reach locations though it requires more pronation

and supination movements of the wrist than a 3/8 circle needle.

UR Needle:

the tip of a 1/2

circle needle

such as the CT-

1 can become

obscured by

other tissue

deep in the

pelvic cavity.

When this

occurs, the

surgeon may

have difficulty locating the point of the needle in order to pull it

through the tissues. A 5/8 circle needle such as the UR-4 is most

advantageous in these situations.

H. Needle Length

This is the distance between the point and the swage

measured along the body of the needle.

Needle Arming

The needle should be grasped in the area about 1/4 to 1/2

the distance from the swaged area to the point. It should be held

on securely at the tip of the needle holder’s jaws. There are

various types of holders to accommodate different needles and

for different locations and tissues. The following factors must

influence the needle holder’s choice:

1. Security of the needle in the holder

2. appropriate size for specific needles

3. appropriate length for specific procedures

Single Versus Double Armed Suture

Commonly used sutures have one swaged-to-suture strand.

Situations do arise wherein there is a need to place a suture at a

midpoint and suturing must continue on both sides. The typical

examples are vascular anastomoses. In such situations, it is ideal

to use a double-armed suture. This is a suture strand with a

needle swaged at each end. If the strand is divided into halves,

this results into two single-armed sutures that can be used

individually. An example is the CT-1, CP-1 double armed needle

suture combination for episiotomy repair.

Characteristics of Surgical Needles and their Clinical Impor-

tance

Trauma to the tissue edges that are sutured together during

surgical procedures, among other factors, theoretically spells an

integral part of the outcome of wound healing. The relation-

ship is, in fact, indirectly proportional. The greater the trauma

induced, the poorer the outcome. If it were an intestinal anasto-

mosis, for example, excessively traumatized ends may result to a

poorer blood supply, affecting the integrity of the intestinal

layers, and complete apposition. Subsequent wound healing

processes therefore are compromised. It appears that the choice

of needle, suture material, as well as the technique of apposing

and handling tissues together are important factors in order to

achieve the best outcome with the least tissue damage. There-

fore, surgical needle design, characteristics and usage play

significant roles in the art and science of surgery.

Sharpness and Pointedness

Sharpness, in contrast to “pointedness,” refers to the condi-

tion of the blade of cutting surgical needles. This is obviously

not applicable among needles that are not flattened at the distal

body and point. (Needles that are round may either be pointed

or blunt at the opposite end of the swage). But cutting needles

can become blunted both at their point and at the flattened

body mainly due to repeated usage or friction against hard

tissue and foreign bodies. There are round needles that are

created with blunted points for the purpose of passing sutures

through solid organs like the liver and spleen. But it is desirable

to always use sharp cutting needles when indicated.

Sharp cutting needles create clean, minute lacerations

through tissues and cut muscle fibers. Pointed round needles,

however, just create puncture wounds and merely split muscle

fibers rather than cut them. Minute lacerated wounds created by

using cutting needles may completely tear at their corners when

subjected to tension. Literally, they tend to extend easily to a

rent. Punctured wounds by nature are not prone to renting and

are easily plugged. Thus, among hollow organs like viscus and

blood vessels, pointed round needles are favored.

On the other hand, tough tissues like the epidermis and the

subcuticular layers are difficult to traverse with pointed needles.

Thus, the cutting action of a flattened needle is desirable. These

tissues are not prone to lacerations or renting due to its fibrous

content.

Atraumatic Needles

This is a misnomer. All needles cause some form of trauma

to sutured tissues. So-called atraumatic needles cause the least

injury. This is so because of the following characteristics:

1. Small diameter,

2. The size of the swage is the same as the size of the body,

3. The suture material is of the same diameter as the

needle, and

4. There is no eye. With the smooth passage of the needle

and the suture through the tissue, the injury to the edges are

minimized.

Rigidity versus Flexibility

Rigidity of surgical needles is dependent on the diameter,

composition of the metal alloy used and the temperature by

which they were set (tempered). This is, therefore, affected by its

frequency of being subjected to autoclaving. Rigid needles are

necessary in suturing bones, cartilage and very tough fascia.

Hernia needles, sternal needles and needles used to wire bones

together are some examples. Rigid needles tend to break when

too much shearing pressure is applied unlike flexible needles.

Flexible needles, however, tend to withstand a greater shearing

force or even bending but generally not in acute angles.

Rust-free and Corrosion-free Needle Material

Stainless steel needles are generally rust- and corrosion-free.

Most surgical needles are no longer made of lesser quality. Their

flexibility, inertness and smoothness are other characteristics

that are most desirable in surgical needles for medical grade

usage. Other metal alloys are even better but their cost is

prohibitive.

Needle Weakpoints

Eyed needles break most frequently at the junction of the

swage and the body. This is so because of the tension created

by the angle of the needle against the suture. In the process of

passing a curved needle through tough tissues, the straight

portion of the eyed needle may be pulled by the surgeon at an

acute angle against the tissue. In other situations, the surgeon

may load the needle at this weak point and apply the drive force

through the tissue.

Another weak point, particularly among atraumatic round

needles, is the junction of the body and the point. The surgeon

may force the body of the curved needle through the tissues at

Self-Assessment Questions (Chapter IV)

1. Which of the following needles are most applicable when

suturing deep in the pelvic cavity?

a. 1/4 circle

b. 3/8 circle

c. 1/2 circle

d. 5/8 circle

e. straight needle

2. For suturing liver lacerations, the surgical needle to use is:

a. CT series

b. SH series

c. BP series

d. TP series

e. V-4 needles

3. The surgical needle for microsurgical procedures is:

a. UR-4 d. V-4

b. PS-1 e. CT-1

c. XLH

4. Surgical needles most commonly used for bowel anastomosis

is:

a. Reverse cutting

b. Circle tapered

c. Cutting tapered

d. Rounded blunt

e. Conventional cutting

5. The needle to use in the primary repair of a complete but

clean traumatic transection of the ureter is:

a. MO d. X-1

b. PS e. RB-1

the same angle as the point rather than smoothly glide the body

according to its curvature. By its structure, the tapered point and

the full diameter body creates a weak point at their junction

considering the tension these two areas will undergo at different

angles. Besides, the force exerted by the needle holder at the

body will exacerbate the above situation.

REFERENCEEthicon Wound Closure Manual, Ethicon, Inc., 1994

Objectives of this Chapter

Proper knot tying is one of the essentials in the performance

of a good surgical procedure. The art and science of surgery

requires that knots be tied not only with dexterity and speed, but

they should be placed with the right amount of tension for

proper approximation of tissues and ligation of blood vessels.

At the end of this chapter, the learner should be able to:

1. Discuss the general principles of knot tying

2. Describe the common techniques of knot tying which can

be applied to the different types of surgical procedures.

3. Perform the common techniques of knot tying which can

be applied to the different types of surgical procedures.

General Principles of Knot Tying

In knot tying, general principles to be adhered to are the

following:

1. When handling sutures, one must take care to avoid

damage to the suture material.

2. In tying any knot, friction between strands must be

avoided to prevent weakening of the integrity of the suture.

3. Sutures should be tied with appropriate tension to

prevent tissue strangulation or gaping of edges.

4. The completed knot must be secure.

5. For monofilament sutures, at least 5 throws are required

to securely hold the knots in place as less than this may result in

a tendency for the knots to loosen. Additional throws do not

add to the strength of a properly tied knot.

6. For braided sutures, two throws are required to securely

hold the knot.

7. Sutures must be cut to their proper length.

Chapter V

Knot Tying

Jose Antonio M. Salud, MD, FPCS

Miguel C. Mendoza, MD, FPCS

Knot Tying Techniques

Square Knot (Two-Hand Technique)

4. Purple strand crossed

over white and held

between thumb and index

finger of left hand.

3. Left hand turned

inward by pronation, and

thumb swung under white

strand to form the first

loop.

2. Purple strand held in

right hand brought

between left thumb and

index finger.

1. White strand placed

over extended index

finger of left hand acting

as brdige, and held in

palm of left hand. Purple

strand held in right hand.

12. The final tension on

the final throw should be

as nearly horizontal as

possible.

11. Horinzontal tension

applied with left hand

away from and right

hand toward the opera-

tor. This completes the

second half hitch.

10. 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.

9. 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.

7. Left index finger

released from white

strand and left hand

again supinated to loop

white strand over the left

thumb. Purple strand held

in right hand is angled

slightly to the left.

6. 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.

5. 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. Regrasp purple

strand with right hand.

8. Purple strand brought

toward the operator with

the right hand and

placed between left

thumb and index finger.

Purple strand crosses over

white strand.

Knot Tying Techniques

Square Knot (Two-Hand Technique)

Click here for video on Square Knot (two-hand technique)

Square Knot (One-Hand Technique)

This is an alternative to the two-hand technique of knot tying.

4. 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.

5. 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. Regrasp purple

strand with right hand.

3. 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.

1. White strand held

between thumb and

index finger of left hand

with loop over extended

index finger. Purple

strand between thumb

and index finger of right

hand.

2. Purple strand brought

over white strand on left

index finger by moving

right hand away from

operator.

6. Purple strand releases

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.

Click here for video on Square Knot (one-hand technique)

8. 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.

7. Purple strand brought

toward the operator with

the right hand and

placed between left

thumb and index finger.

Purple strand crosses over

white strand.

5. The loop is slid onto

the thumb of the left

hand by pronating the

pinched thumb and index

finger of left hand

beneath the loop.

6. Purple strand drawn

left with right hand and

again grasped between

thumb and index finger

of left hand.

7. Left hand rotated by

supination extending left

index finger to again pass

purple strand through

forming a double loop.

8. Horizontal tension is

applied with left hand

toward and right hand

away from the operator.

This double loop must be

placed in precise position

for the final knot.

Surgeon’s or Friction Knot

1. White strand placed

over extended index

finger of left hand and

held in palm of left hand.

Purple strand held

between thumb and

index finger of right

hand.

2. Purple strand crossed

over white strand by

movin right hand away

from operator at an

angle to the left. Thumb

and index finger of left

hand pinched to form

loop in the white strand

over index finger.

3. Left hand turned

inward by pronation, and

loop of white strand

slipped onto left thumb.

Purple strand grasped

between thumb and

index finger of left hand.

Release right hand.

4. Left hand rotated by

supination extending left

index finger to pass

purple strand through

loop. Regrasp purple

strand with right hand.

9. With thumb swung

under white strand,

purple strand is grasped

between thumb and index

finger of left hand and

held over white strand

with right hand.

10. Purple strand

released. Left hand

supinates to regrasp

purple strand with index

finger beneath the loop

of the white strand.

11. Purple strand rotated

beneath the white strand

by supinating pinched

thumb and index finger

of left hand to draw

purple strand through

the loop. Right hand

regrasps purple strand to

complete the second

throw square.

12. Hands continue to

apply horizontal tension

with left hand away from

and right hand toward the

operator. Final tension on

final throw should be as

nearly horizontal as

possible.

Click here for video on Surgeon’s or Friction Knot

5. Purple strand looped

over and under white

strand with right hand.

6. Purple strand looped

around white strand to

form second loop. This

throw is advanced into the

depths of the cavity.

7. Horizontal tension

applied to pushing down

on purple strand with

right index finger while

maintaining counter

tension on white strand

with left index finger.

Final tension should be

as nearly horizontal as

possible.

Deep Tie

In tying knots deep within a body cavity, this is the recommended technique of knot tying.

1. Strand looped around

hook in plastic cup on

Practice Board with index

finger of right hand which

holds purple strand in

palm of hand. White

strand held in left hand.

2. Purple strand held in

right hand brought

between left thumb and

index finger. Left hand

turned inward by prona-

tion, and thumb swung

under white strand to

form the first loop.

3. By placing index finger

of left hand on white

strand, advance the loop

into the cavity.

4. Horintal tension

applied by pusing down

on white strand with left

index finger while

maintaining counter-

tension with index finger

of right hand on purple

strand.

Ligation around a Hemostatic Clamp

Illustrated below is one of the methods for ligating blood vessels around a hemostatic clamp.

1. When sufficient tissue

has been cleared away to

permit easy passage of

the suture ligature, the

white strand held in the

right hand is passed

behind the clamp.

2. Left hand grasps free

end of the strand and

gently advances it behind

clamp until both ends are

of equal length.

3. To prepare for placing

the knot square, the white

strand is transfered to the

right hand and the purple

strand to the left hand,

thus crossing the white

strand over the purple.

4. As the first throw of

the knot is completed the

assistant removes the

clamp. This maneuver

permits any tissue that

may have been bunched

in the clamp to be

securely crushed by the first throw. The second throw of the

square knot is then completed with either a two-hand or one-

hand technique as previously illustrated.

6. Square knot com-

pleted by horizontal

tension applied with left

hand holding white

strand toward operator

and purple strand in

needleholder away from

operator. Final tension

should be as nearly

horizontal as possible.

5. With end of the strand

grasped by the

needleholder, pugple

strand is drawn through

loop in the white strand

away from the operator.

4. White strand is drawn

toward operator with left

hand and looped around

needleholder held in

right hand. Loop is

formed by placing

needleholder on side of

strand toward the

operator.

1. Short purple strand lies

freely. Long white end of

strand held between

thumb and index finger of

left hand. Loop formed by

placing needholder on

side of strand away from

the operator.

2. Needleholder in right

hand grasps short purple

end of strand.

3. First half hitch com-

pleted by pulling

needleholder toward

operator with right hand

and drawing white strand

away from operator.

Needleholder is released

from purple strand.

Instrument Tie

This is particularly useful when tying knots for suture materials where ends are short.

Click here for video on Instrument Tie technique (Square Knot)

Click here for video on Instrument Tie technique (Surgeon’s Knot)

Cutting Sutures

When knots have been tied, they are now ready to be cut.

This entails running the tip of the scissors lightly down the suture

strand to the knot. Most sutures are cut close to the knot,

approximately 1-2 mm. from the knot to decrease tissue reaction

and minimize the amount of foreign material left in the wound.

This is true particularly for braided sutures. For monofilament

sutures, it is advised to cut a little longer from the knot, approxi-

mately 3-4 mm. as these type of sutures may loosen after knot

tying. For sutures applied to the skin, the sutures are cut even

longer away from the knot. The reason for this is to make it

easier for the surgeon to remove the sutures at a later time.

REFERENCES

Knot Tying Manual, ETHICON, 1996

Ochsner, A and DeBakey ME. Christopher’s Minor Surgery, 8th

ed., WB Saunders

Co.

Self-Assessment Questions (Chapter V)

1. In knot tying, which among the following sutures will require

more throws to maintain the knots in place?

a. Silk

b. Polyester

c. Nylon

d. Wire

2. Why are more throws required for maintaining knots when

tying monofilament sutures?

a. They are more difficult to handle

b. The knots have a tendency to loosen

c. More tension is required to maintain monofilament

sutures

d. None of the above

A granny knot is not recommended. However, it may be

inadvertently tied by inccorectly crossing the strands of a knot. It

is shown only to warn against its use. It has the tendency to slip

when subject to increasing pressure.

Granny Knot

Chapter VI

Suturing Techniques

Cenon R. Alfonso, MD, FPCS; Shirard L.C. Adiviso, MD, MHPEd, FPCS; Jose Joey H. Bienvenida, MD, FPCS;

Miguel C. Mendoza, MD, FPCS; and Renato Cirilo A. Ocampo, MD, FPCS

Objectives of this Chapter

Suturing is one of the basic skills essential for a surgeon to

master. The dexterity, proper application of the use of the needle

holder and suture, and the correct suturing technique depending

on the tissues to be approximated are skills that should be

second nature to the surgeon. There are numerous techniques in

suturing. At the end of this chapter, the learner should be able to

1. Describe the different suturing techniques and their

application to different surgical procedures for tissue approxima-

tion.

2. Perform the various suturing techniques for their applica-

tion to different surgical procedures for tissue approximation.

Different Suturing Techniques

INTERRUPTED SUTURES

Interrupted sutures use a number of strands to close the

wound. Each strand is tied and cut after insertion. This provides a

more secure closure, because if one suture breaks, the remaining

sutures will hold the wound edges in approximation. Interrupted

sutures may be used if a wound is infected, because microorgan-

isms may be less likely to travel along a series of interrupted

stitches.

Simple Interrupted

Each stitch is tied independently of other stitches.

Simple Interrupted

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Horizontal Mattress Suture

A horizontal mattress suture starts some distance from the wound

edge, also passes under the wound to emerge on the opposite

side at the same distance from the edge. Then, coming from the

same side of the wound at some distance from where it emerged,

it passes back deeply under the wound to exit on the opposite side

at the same distance from the edge, where it is tied. The horizontal

mattress provides coaptation in an everted fashion. It is used for

closure of deeper tissues such as fascia.

Interrupted Vertical Mattress

Interrupted Horizontal Mattress

Click here for video of Vertical Mattress

Click here for video on Horizontal Mattress

Vertical Mattress

A vertical mattress suture starts some distance from the

wound edge, passes deeply under the wound and emerges on

the opposite side at the same distance from the edge. It then

returns taking a more superficial bite from each wound edge. It

is tied on one side of the wound and does not appear to cross

it. The vertical mattress suture gives a good approximation of

the skin edge and therefore results in a cosmetically acceptable

scar. It is frequently used for fine skin closure. The vertical

mattress consists of a “far-far, near-near” component. The

vertical mattress is also known as the Stewart suture.

Subdermal Interrupted

This technique is used to close wounds where cosmetic

aspects are especially important. It carries the advantages of

completely avoiding stitch marks. This may be done in inter-

rupted or continuous fashion. It can only, however, be recom-

mended in wounds with low degree of contamination.

Figure of Eight Mattress Suture

A figure of eight mattress suture starts at some distance from

the wound edge, goes deeply under the wound to come out of the

opposite side at some distance from the edge. It goes back to the

opposite side where it re-enters the wound in the same manner as

the first component but at some distance from it. The suture is

subsequently tied. This provides an everted type of approximation

of tissues and is used primarily for the deeper planes.

Click here for video on Subdermal Interrupted

Click here for video on Figure of Eight

Figure of Eight Mattress

Subdermal Interrupted

Continuous Interlocking

This involves passing each stitch in continuous fashion

through the loop of the previous stitch.

Subcuticular

Click here for video on Simple Continuous Interlocking

This technique is used to close wounds where cosmetic

aspects are especially important. It carries the advantages of

completely avoiding stitch marks. This may be done in inter-

rupted or continuous fashion. It can only, however, be recom-

mended in wounds with low degree of contamination.

Click here for video on Subcuticular

Continuous Interlocking

Subcuticular

CONTINUOUS SUTURES

Also referred to as running stitches, continuous sutures are a

series of stitches taken with one strand of material. The strand may

be tied to itself at each end, or looped, with both cut ends of the

strand tied together. A continuous suture line can be placed rap-

idly. It derives its strength from tension distributed evenly along the

full length of the suture strand. However, care must be taken to

apply firm tension, rather than tight tension, to avoid tissue stran-

gulation. Overtensioning and instrument damage should be

avoided to prevent suture breakage which could disrupt the entire

line of a continuous suture.

Continuous suturing leaves less foreign body mass in the

wound. In the presence of infection, it may be desirable to use a

monofilament suture material because it has no interstices which

can harbor microorganisms. This is especially critical as a

continuous suture line can transmit infection along the entire

length of the strand. A continuous one layer mass closure may

be used on peritoneum and/or fascial layers of the abdominal

wall to provide a temporary seal during the healing process.

Simple Continuous (Over and Over running stitch)

This involves making more than one stitch with a single

suture strand before the knot is tied.

Over-and-Over Running Stitch

Technique

1. The needle is inserted from the outside and 2.5 mm

lateral to incision.

2. It is directed downward toward the cut edge of incision to

penetrate first the serosa and then the muscularis down to, but

not through, the submucosal layer.

3. It is directed superficially so that it emerges from the

viscus wall through muscularis and serosa close to the edge of

incision.

4. It is reinserted close to the incision’s edge passing

laterally through serosa and muscularis down to, but not

through muscularis and serosa. At no time it penetrates the

lumen.

5. The sutures are non absorbable and are placed 3 to 5

mm apart.

INTERRUPTED LEMBERT

This is the most important fundamental suture in gastrointes-

tinal surgery. It is used chiefly to approximate outer layer in any

multiple layer closure of an anastomosis or opening in the

gastrointestinal tract or hallow viscus.

Click here for video on Lembert Stitch

Lembert Stitch

Note: This procedure approximates the serosa while mucous

membrane is inverted and fibromuscular layer is well grasped.

Objection: Takes more time for placing and tying and must be

positioned closer together to ensure water tight closure.

CONNELL SUTURING

Used to approximate first layer in the repair of an incision or

first layer of closure of the anterior wall of the gastrointestinal

anastomosis and the first layer in closure of an open end of a

resected gut. Suture to be used should be of catgut or synthetic

absorbable kind and is always reinforced by an outer layer of

non-absorbable suture that buries it and does not penetrate all

the layers of the GIT wall into the lumen.

Technique

1. The suture is passed 4 to 5 mm from end parallel to its

wound edge.

2. It pierces all layers of the gut wall with an “in and out on

the same side” or “loop on the mucosa” type of stitch.

3. The suture is tied after the first stitch is taken, the knot

being placed either within or without the gastrointestinal wall,

depending upon the site of origin of suture.

4. After the knot is tied, the needle is passed from without to

the inside of the intestinal wall. It then is advanced about .3 cm

and is reinserted from within to the outside of the gut wall, after

which it is brought across the incision to penetrate the opposite

wall from without inward and so forth.

5. The suture is tied again at the far end.

Click here for video on Connel Suturing

Connell Suturing

Note: It is important to remember that the suture crosses the

incision only from the outside of one wall to penetrate the

outside of the opposite wall. It penetrates from the inside to the

outside only on the same side on which the previous stitch

ended.

Advantage: This is hemostatic and compresses all layers of the

gut wall.

Technique

1. This enters the serosal surface of the efferent bowel 6 to 8

mm from its cut edge, penetrate through the mucosa and

immediately reenter the mucosa and exit to serosa on the same

side 2 to 3 mm from the edge.

2. They then cross to the efferent bowel and enter its serosal

surface 2 to 3 mm from the edge and penetrate through the

mucosa, immediately reenter the mucosa 5 to 6 mm from the

edge, exit through the serosa on the same side and tied on the

serosal surface of the bowel.

GAMBEE SINGLE LAYER

This is an interrupted inverting suturing of full thickness of

bowel wall using single row of non absorbable sutures. This

technique is used in repairing small and large intestine and

anastomosing gallbladder to jejunum and duodenal operation.

Gambee Single Layer

Note:

1. Valuable in anastomosing bowel ends that are uneven in

diameter.

2. Single row of sutures results in narrow flange of turned

tissue so there is little likelihood of obstruction and of impair-

ment of the blood supply to the anastomatic area.

3. Simplicity and ease of performance.

PURSE STRING

This suturing technique is intended to close an opening, whether

actual or potential, of a hollow organ, around a tube (as in jejun-

ostomy feeding tube insertion), or around another tubular organ

(as in the inversion of the vermiform appendix in auto-appendec-

tomy), or simply to close a round-configurated defect (as in closing

a small colonic perforation). As the name implies, in the purse-

string suturing technique, as the suture is tightened, the tissue

involved will create an enclosure that is similar to a purse that is

being tied up in its neck using a string. The technique is perform

on the bowel wall by suturing the sero-muscular layer around the

defect at equidistant points of about 2-3 millimeters apart, form-

ing a circle around the centrally located opening of the bowel wall

so that the point of exit is almost approximating the point of entry.

When the suture ends are knotted, this should create the effect of

circumferential tightening closure around the defect until all the

edges approximate centrally into a closed purse. Other clinical

uses may require a double purse-string suturing technique wherein

a smaller purse is created within a bigger purse so that the bigger

purse, when tightened after the smaller purse, inverts the closure

done by the smaller one. This is intended to decrease the prob-

ability of leak in and around the closure.

SMEAD JONES SUTURING (Far-Far-Near-Near)

REFERENCE

Chassin, Jameson , Operative Strategy in General Surgery, Sprigler- Verlag NewYork (1994) PP 845-856Click here for video on Purse String

Click here for video on Smead Jones

Purse String

Smead Jones Suturing

This technique is most useful for closing the midline abdomi-

nal wall incision. Using a 1-0 Polydioxanone suture (PDS), encom-

pass 3 cm of the tissue on each side of the linea alba then take a

small bite at the linea alba about 5mm in width on each side. This

results in a small loop within a large loop. The purpose of the

small loop is simply to orient the linea alba so its remains in

apposition rather one side moving on top of the other. Place the

small loop 5-10mm below the main body of the suture to help

eliminate the gap between adjacent sutures. Insert the next suture

no more than 2 cm below the first. Large, curved Ferguson needles

are used for this procedure.

Column A

___1. This suturing technique is intended to close an opening of

a hollow organ around a tube

___2. This suturing technique is used for fine skin closure

producing everted edges. It consists “far-far, near-near” compo-

nent.

___3. This technique is an interrupted inverting suturing of the full

thickness of bowel wall using only a single row of non absorb-

able sutures in bowel anastomosis.

___4. This suturing technique is used chiefly to approximate the

outer seromuscular layer in any multiple layer closure of an

anastomosis or opening in the gastrointestinal tract.

___5. This suturing technique is usually used to approximate first

layer of closure of the anterior wall of the gastrointestinal

anastomosis.

___6. This suturing technique avoids any stitch marks on the skin

and is usually is used to close wounds where cosmetic aspects

are especially important.

___7. This technique is usually used as an internal retention

suturing technique as an added strength to hold the abdominal

together and consists of a “far-far-near-near” component.

___8. This suturing technique involves passing each stitch in

continuous fashion through the loop of the previous stitch. It is

usually used for hemostatic purposes.

Column B

A. Vertical Mattress

B. Gambee

C. Continuous Interlocking

D. Purse String

E. Subcuticular

F. Smead Jones

G. Connel

H. Lembert

Self-Assessment Questions (Chapter VI)

Direction:

On the blank beside each number in Column A, identify and write the letter from column B that corresponds to column A.

Objectives of this Chapter

After going through this chapter, the learner is expected to:

1. Select the appropriate suture materials/needles to be used

in commonly performed general surgical procedures.

2. Apply the principles behind the rational use of these

suture materials/needles in the different surgical procedures.

3. Identify the alternative suture materials and techniques for

the said procedures.

Plastic Closure of Skin Lacerations

Listed below is the recommended manner of plastic repair for

lacerations in various locations:

When repairing skin lacerations, the skin edges must first be

freshened to achieve a sharp, smooth border. The thinner the

skin, the finer the sutures to be used, e.g., eyelid, use 6-0 or 7-

0 nylon, polypropylene or silk.The same sutures are recom-

mended for other facial lacerations without tension. Facial

lacerations with tension should be closed with 5-0.

For skin lacerations with subcutaneous tissue involvement

that is less than 0.5 cm. deep, subdermal stitches using 5-0 or

6-0 polyglactin, poliglecaprone or polydioxanone are recom-

mended. Thereafter, the skin should be closed as above.

For skin lacerations with subcutaneous tissue involvement

greater than 0.5 cm. deep, the subcutaneous tissue should first

be closed with absorbable sutures. In the absence of tension,

Chapter VII

Clinical Applications

Cenon R. Alfonso, MD, FPCS; Jerome G. Baldonado, MD, FPCS; Alejandro C. Dizon, MD, FPCS; Rene C. Encarnacion, MD,

FPCS; Eduardo S. Eseque, MD, FPCS; Gabriel L. Martinez, MD, FPCS; Paul Jesus S. Montemayor, MD, FPCS; Jose Antonio M.

Salud, MD, FPCS; and Jose A. Solomon, MD, FPCS.

use polyglactin, poliglecaprone or polydioxanone 5-0. Thereaf-

ter, the skin should be closed as mentioned above.

If the muscle is involved, repair the muscle using absorbable

sutures, 4-0 or 5-0 polyglactin, poliglecaprone or

polydioxanone after which the steps as mentioned earlier are

followed.

The preferred needles for the above procedures would either

be P-1, P-3, PC-5 or FS-2 needles.

Skin Closure with Skin Adhesives

(Octylcyanoacrylate/Strips)

Prior to repairing wounds that may be closed with skin

adhesives, it is first necessary to assess whether deep suturing or

debridement is necessary. Skin adhesives are used only for the

most superficial layer of the skin and so it is necessary to suture

deeper structures if they are involved. After this has been done,

the wound edges are manually approximated together with

fingers or forceps. If Octylcyanoacrylate is to be used, this is

applied on the wound using an applicator tip. The wound

edges are held together for about 30 to 45 seconds to allow for

complete polymerization. A film will be noted over the wound.

No dressings are necessary. The said adhesive film will slough

or fall off within 5-10 days as the skin re-epithelializes.

For skin strips, after deeper structures have been repaired,

the wound edges are approximated again with the fingers or

forceps and the strips are simply applied over the wound edges

to apposition. The strips may then be removed in 5-7 days.

Abdominal Wall Closure

In closing the abdominal wall, it is not necessary to close the

peritoneum as closure of this layer does not contribute to wound

strength. Still, some surgeons prefer to do so since this is

considered to aid in reducing the formation of adhesions.

However, the use of highly reactive sutures or sutures that are

applied too tightly may result in formation of significant adhe-

sions between the peritoneum and the underlying structures.

Furthermore, healing of the peritoneum is complete within seven

to fourteen days post-operatively. Thus, if the peritoneum is to be

closed, it is best to use sutures that result in minimal tissue

reaction while maintaining tensile strength for at least 14 days.

Polyglactin and polyglycolic acid sutures are thus recommended

using a 1/2 circle round needle.

The fascia is considered the most important layer in closing

an abdominal surgical wound. It is the major supportive

structure of the body and is the strongest tissue in the abdomi-

nal wall and thus, carries the brunt of the stress on the abdomi-

nal wound. Breakdown of this layer may result in the develop-

ment of incisional or ventral hernias especially in malnourished,

obese or immunocompromised patients.

The known critical healing period of fascia is somewhere

between the 14th and 21st post-operative days. A suture must

therefore maintain immediate and extended wound support to

prevent breakdown of this layer. In this regard, the best suture

materials would be those that maintain a long tensile strength

such as polypropylene, nylon, polyester, silk or cotton, 2-0 or 0

on a 1/2 circle needle. Since absorbable sutures like polyglactin

and polydioxanone can maintain tensile strength of about 40%-

50% at 3 weeks, they may also be used. However, in the

presence of infection or contamination, the sutures that elicit

minimal inflammation are best.

Inguinal Herniorrhaphy/Repair of the Inguinal Floor

Inguinal hernia repair is classified as a clean wound. The

incision is usually short and the precise anatomical repair is done

in a deep confined space. In repairing the inguinal floor, precise

tension on the fascial edges requires a technique where each

suture exists independent of the others. For this reason, the

majority of hernia repairs are performed using a simple

interrupted suture line. There are, however, some repair tech-

niques that utilize a continuous suture line. Since knot-tying is

extensive, and knot security is important in the interrupted

technique, a braided suture is used while monofilaments are

used for the continuous technique. The repair requires a strong

suture of adequate diameter to keep the tissues together without

breaking or cutting through. While the transversalis fascia is

relatively easy to penetrate, its analogues like the iliopubic tract

or Cooper’s ligament are tough tissues. In the face of tough

tissues in tight working areas, there is the tendency for a needle

to shift in the needle holder; worse, it can bend, perforate or

lacerate vital and vulnerable structures. For a precise anatomical

repair, the choice of the suture and the needle is vital.

The ideal suture is a non-absorbable braided (or monofila-

ment), 0 or 2-0 with permanent strength and low reactivity

(polyester or polypropylene) together with a very sharp tapered,

heavy-bodied atraumatic (channeled or drilled) needle, prefer-

ably 1/2 to 5/8 circle with a relatively short to medium chord

length.

The acceptable alternative is a silk suture threaded through a

sharp, tapered, heavy-bodied, eyed needle at 1/2 circle with a

relatively short to medium chord length.

Appendectomy

During an appendectomy, the mesoappendix is serially

clamped, cut down to the base and ligated using silk/cotton 2-0

or 3-0 sutures.

The base of the appendix is suture ligated using 2-0 silk/

cotton in a round 1/2 circle intestinal needle especially if the

Click here for video on Abdominal Wall Closure

Click here for video on Subcuticular Skin

base is wide. A free tie of 2-0 is often times used to reinforce

ligation of the base before the appendix is divided. It is always

safer to doubly ligate the base to reduce the possibility of stump

blowout. An alternative step is to apply purse-string sutures

using 2-0 or 3-0 silk/cotton in a 1/2 circle intestinal needle to

bury the appendiceal stump. However, no clear advantage has

been noted with the use of purse-string sutures.

Another alternative suture material is the braided absorbable

variety (polyglactin/polyglycolic) 2-0 or 3-0. Since it has a high

breaking force, maintains its tensile strength up to 14 days and is

only absorbed after 45 days, it can be used to ligate the appen-

diceal stump without the fear of stump blow-out. The wound

would have long healed before they are absorbed. One clear

disadvantage is the cost of the suture material.

Cholecystectomy and Surgery of the Bile Ducts

After identifying the cystic duct and artery during a cholecys-

tectomy, these structures are individually ligated with non-

absorbable 2-0 sutures (silk/cotton). Sometimes the cystic duct

can be ligated with a transfixing suture using 2-0 or 3-0 silk/

cotton utilizing a full curved round intestinal needle. Braided

suture materials are used in ligating vessels, the cystic duct and

bile ducts because they require minimal knots without easily

slipping as compared to monofilaments. Although tissue reaction

is greater, it is clinically insignificant if applied outside the wall of

a hollow structure or viscus. Hence, non-absorbable braided

suture materials are appropriate in this setting. It does not readily

slip and is cost-effective. Another alternative method of securing

the cystic duct stump is by using liga clips as in laparoscopic

surgery. Doubly ligating or clipping the cystic duct stump is

suggested to prevent unnecessary leaks.

When closing a choledochotomy, it is advisable to use a 3-0,

4-0 or 5-0 absorbable monofilament suture such as

poliglecaprone or polydioxanone, using a 1/2 curved tapered

needle. This is preferable over non-absorbable because they do

not act as a nidus to stone formation and they produce less

trauma to the bile duct wall since it smoothly slides inside the

needle tract during suturing. Its disadvantages are that it

requires more knots to secure the closure and are relatively more

expensive.

The best alternative suture material is the braided absorb-

able variety which requires less knots to secure the choledochos-

tomy (polyglactin or polyglycolic).

Liver Trauma

Simple suturing techniques of traumatic liver injuries are

applicable only to type I and II injuries. More complex liver

trauma management is beyond the scope of this manual. The

majority of simple liver injuries usually resolve spontaneously. If

bleeding fails to stop with other maneuvers (e.g., packing or

electro-cautery), the cut edges of the lacerated liver parenchyma

may need to be sutured.

Liver parenchyma is very vascular and friable. Tensile strength

is not a concern in this situation because what is required is just

to approximate the edges for hemostasis. Long tensile strength

retention and absorption time is likewise not a requirement.

For this reason, an appropriate and ideal suture for this

situation is chromic catgut suture. Chromic suture has a smooth

surface thereby inciting less trauma as it passes through liver

tissue. The suture is retained long enough for the purpose of

maintaining hemostasis. The suture is best swaged on a long,

blunt-tipped liver needle (BP-1) which is best when passed

through the vascular liver tissue.

Chromic 2-0 horizontal mattress sutures are applied on both

edges of the cut surface with or without interposition of a hemo-

static material or omental pedicle. The knots are tied gently with

Click here for video on Double Ligation of the Appendix

Click here for video on Ligation of the Cystic Duct

Click here for video on Suture of the CBD

a minimum of tension just to approximate the edges, taking

care in avoiding cutting through the friable liver tissue. Applica-

tions of deep suture bites are likewise avoided to prevent

necrosis of normal liver tissue.

The alternative suture would be an absorbable suture like

polyglactin.

Bowel Anastomosis

Leakage of intestinal contents or its frank breakdown after a

bowel anastomosis carries severe consequences. A critical factor

that determines anastomotic integrity is the application of proper

suturing technique and material. However, it must be empha-

sized that half of the procedure is accomplished before the

actual resection and anastomosis, i.e., during the preparation

of the segments that are to be resected and the bowel ends that

are to be joined together.

Another unique feature of the procedure is that of tissue

inversion. The repair is reinforced by the proper approximation

and healing of the seromuscular layer of each bowel end.

Inversion therefore provides a serosa-to-serosa apposition over a

mucosa-submucosal repair.

All the layers of the bowel wall are characteristically soft with

minimal to moderate dense fibrous support. As such it is easy to

penetrate. Using taper point or round point needles is appropri-

ate. Anything sharper than a taper or round needle may be more

traumatic or more risky than is desirable. Moreover, the depth of

the bite in bowel anastomosis need not be very deep and the

working space inside the abdominal cavity may be somewhat

confined. A 1/2 circle needle is standard for this repair. Bowels

are lumenous structures with fluid and gaseous contents and its

repair is ideally done without tension which seldom offers

resistance. Therefore, the diameter of the needle must be thin to

keep it water-tight but at the same time relatively strong and

stable given the necessary thin wire diameter. The average

thickness of bowel walls that are to be anastomosed only require

medium chord length. And in order to create the least puncture

injury to the bowel walls, atraumatic needles, i.e., those with a

swage attachment rather than eyed, are desirable.

Healing time is relatively fast with the anastomosis assuming

tensile strength in about 7-14 days. The serosal layer heals faster

than the submucosa but it is the latter, being the most fibrous

among the 4 layers that gives the anastomosis its required

strength. The submucosal repair therefore, is the most important

for the surgeon. Consequently, the suture material that is ideal

for bowel anastomosis must therefore retain tensile strength

beyond the healing time of the slowest healing tissue - the

submucosa. Absorbable suture materials are commonly used

but non-absorbables are also popular particularly among single

layer technique of repair.

It is not uncommon for the prolonged presence of a suture in

the mucosa to provoke significant foreign body reaction and

granuloma formation. This has great significance in the gastric

mucosa as it may lead to post-operative anastomotic ulcer

formation. Hence, for the inner layer in gastric or duodenal

anastomosis, short term absorbable suture materials are pre-

ferred. A popular compromise in single layer closure technique is

a longer term absorbable suture material such as polyglactin,

polyglycolic and polydioxanone.

In a double layer anastomosis, non-absorbables are com-

monly used in the seromuscular inverting stitch while virtually any

absorbable material like poliglecaprone is acceptable in the

mucosal and submucosal layers. The rationale here is the

required prolonged reinforcement of the seromuscular repair for

the slower healing submucosal layer and for the quickly ab-

sorbed inner suture.

There are, however, suturing techniques that accomplish

bowel anastomosis using single layer repair. These are mostly

applied in esophageal and rectal anastomoses where the

procedures are performed in very limited and confined spaces

and where the margins of resection are too short to adequately

permit an inversion technique. The anastomoses in such cases

may be commonly performed with a running stitch, although an

interrupted technique is also popular for facilitating a precise re-

approximation. Here, both braided and monofilament materials

are utilized depending on the technique, i.e., monofilament for

running, continuous stitch and braided for interrupted. Keep in

mind that a continuous non-absorbable suture would, in

essence, serve as a purse-string that would permanently limit the

size of the lumen as opposed to employing the interrupted

technique using absorbables.

In considering the size of the suture material, there has to be

a reasonable balance between the required tensile strength and

tissue reaction due to the foreign body. Suture material strength

is a function of the size. But bowel anastomosis is best done

without tension. The bowel walls are neither thick nor fibrous

where stress and strain to suture material is minimal. But if the

suture is too “fine,” there is always the possibility of “cutting

through” the tissues with the slightest strain. Therefore, 3-0 is the

standard while 2-0 is acceptable as well as 4-0.

Finally, a material that elicits the least amount of tissue

reaction is desirable in order to minimize incidence of adhesions

between the site of repair and other peritoneal surfaces as well

as to eliminate granuloma formation within and without the

bowel.

Vascular Anastomosis and Repair

Vascular suturing has specific demands different from other

suturing techniques. Suturing and repair of vessels demand

precision in the approximation of the cut edges to maintain

integrity of the lumen and prevent dehiscence/breakdown which

has more disastrous consequences. Tensile strength retention and

absorption rate are very critical in determining the choice of

suture. Blood vessels are subjected to a tremendous amount of

pressure per square millimeter and for this reason, sutures have

to be strong and absorbed/broken down only after a long time.

Given also the special situation of anastomosing blood vessels to

synthetic grafts, one must remember that only one side of the

repair will undergo biologic wound healing and repair. It has also

been noted that using absorbable sutures or sutures that are

easily broken down (including silk), leads to a higher incidence of

vascular anastomotic breakdown or pseudo-aneurysm formation.

The ideal suture for this situation is a suture that is inert, non-

traumatic, will retain its tensile strength for a long time and will

not easily be broken down or absorbed. Polypropylene has been

found to conform to most of these requirements. It is monofila-

ment, non- absorbable and incites very minimal inflammatory

reaction. This is best used with a 1/2 circle, tapered BV-1 or RB-

1 needle.

Vessels may be sutured in a running, continuous fashion,

for which a double-armed suture is best or in an interrupted

manner, especially for smaller vessels. Continuous suture

technique for very small vessels may have a purse-string effect

which may narrow the lumen further.

An alternate suture for use in vascular surgery is braided

polyester.

Application of Retention Sutures

These are utilized as reinforcing sutures to relieve pressure

on the suture line and to prevent postoperative wound disrup-

tion in abdominal wound closures in particularly vulner-

able patients, as in the elderly and immunocompromised

patients.

Retention sutures utilize strong and large suture materials, in

particular, non-absorbable sutures. Absorbable sutures need not

be used as these sutures will eventually be removed in a couple

of weeks. Sutures that may be used for this particular procedure

include nylon, polypropylene or silk 2, 1 or 0. Even stainless

steel or wire may be used. These same suture materials may be

used even in the presence of infection as they produce the least

inflammatory reaction. The best needle to use would be a large

cutting-edge needle, so as to penetrate the layers of the abdomi-

nal wall with ease. Retention sutures should be applied prior to

closing any layer of the abdominal wall and must be applied

under direct vision to prevent bowel injury. After all retention

sutures have been applied and after all the layers of the ab-

dominal wall have been closed, they are all individually tied. To

prevent tying the retention sutures too tightly, rubber bridges are

applied. These rubber bridges may be in the form of cut strips of

drainage tubes or catheters.

REFERENCES

Abrahamson J. Hernias. In: Zinner MJ, Schwartz SI, Ellis H, et al (eds), Maingot’sAbdominalOperations, 10th ed., Stamford, Conn.: Appleton & Lange, 1997

Brooks DC, Zinner, MJ. Surgery of the Small and Large Bowel. In: Zinner MJ,Schwartz SI, Ellis H, et al (eds), Maingot’s Abdominal Operations, 10th ed.,Stamford, Conn.: Appleton & Lange; 1997

Feliciano DV, Moore EE and Mattox KL. TRAUMA, 3rd ed., Stamford, Conn,:Appleton & Lange, 1996

Rout WR. Gastrointestinal Suturing. In: Zuidema GD, Ritchie WP, Jr. (eds),Shackelford’s Surgery of the Alimentary Tract, 4th ed., Philadelphia, PA: WBSaunders; 1996

Rout WR. Closure of Wound. In: Zuidema GD, Ritchie WP, Jr. (eds), Shackelford’sSurgery of the Alimentary Tract, 4th ed., Philadelphia, PA: WB Saunders; 1996

Rutherford RB. Atlas of Vascular Surgery: Basic Techniques and Exposures; WBSaunders Co., 1993

Singer AJ, Hollander JE and Quinn JV. Evaluation and Management of TraumaticLacerations; The New England Journal of Medicine, 1997, 337:1142-1148

Wilson RF and Walt AJ. Management of Trauma: Pitfalls and Practice, 2nd ed.,Williams & Wilkins, 1996

Zollinger RM, Jr., Zollinger RM. Atlas of Surgical Operations, 7th ed., New York:Macmillan, 1988

1. Which suture is best to ligate the cystic duct during a

cholecystectomy?

a. Nylon 3-0

b. Silk 2-0

c. Polyglactin 2-0

d. Cotton 4-0

e. Chromic 2-0

2. After insertion of a T-tube, repair of the CBD around the

tube

is best with which suture?

a. Silk 4-0 interrupted

b. Cotton 4-0 continuous

c. Polyglactin 4-0 simple, interrupted

d. Polypropylene 5-0 simple, interrupted

e. Polyglycolic acid 3-0 continuous

3. The use of absorbable sutures is advocated when applying

sutures in the biliary tree because?

a. It evokes less inflammation than non-absorbable sutures

does

b. Non-absorbable sutures become nidus for later stone

formation

c. Strictures are less common with the use of absorbable

sutures

d. Leaks are less likely to occur with absorbable sutures

e. Absorbable sutures are easier to handle

4. During a retrograde appendectomy, ligature of the base is

performed using which suture?

a. Silk 2-0

b. Polypropylene 2-0

c. Polyglactin 3-0

d. Chromic 2-0

e. Polyester 2-0

5. The following suture materials may be used in closing the

inner layer of a two-layer inverting bowel anastomosis, except:

a. Chromic catgut

b. Polyglycolic

Self-Assessment Questions (Chapter VII)

c. Plain catgut

d. Polyglactin

e. Polypropylene

6. The most frequently used suture material for single-layer

bowel anastomosis is:

a. Polypropylene

b. Braided silk

c. Cotton

d. Surgical gut

e. Polydioxanone

7. A 13-year old boy sustained a 2 cm. by 8 mm. deep

laceration on the left upper eyelid after being accidentally hit by

a baseball bat. The wound is clean with relatively smooth edges.

What would you do?

a. Close the wound with interrupted silk 6-0

b. Cut clean the edges and close with interrupted nylon 7-0

c. Cut clean the edges, suture the subcutaneous tissue with

6-0 polyglactin then close the skin with interrupted silk 6-0

d. Deep bite skin closure (together with subcutaneous tissue)

using 5-0 nylon

e. Debride and if available, use skin adhesives

8. During an inguinal herniorrhaphy, the suture of choice in

repairing the floor of the canal is?

a. Silk 2-0 interrupted

b. Chromic 0 interrupted

c. Nylon 0 continuous

d. Polyglactin 0 interrupted

e. Interrupted polypropylene 0

9. A completely transected axillary artery is best repaired end-to-

end using which double-armed suture?

a. Nylon 6-0 interrupted

b. Polypropylene 5-0 interrupted

c. Nylon 5-0 interrupted

d. Polypropylene 5-0 continuous

e. Polyester 5-0 continuous

Glossary of Terms

absorbable sutures

sutures which are broken down and absorbed by either hydrolysis

or digested by enzymatic processes

blunt point

a type of needle wherein the tip is rounded and will not cut through

tissues

braided

sutures with intertwining threads

breaking strength

measurement of force required to break a wound without regard

to its dimension

burst strength

amount of pressure neecessary to rupture a viscus

catgut

a type of absorbable suture derived from the bowel of either sheep

or cattle

chord length

the straight line distance from the point of a curved needle to the

swage

chromic

an absorbable suture treated with chromate compounds

continuous

a type of suture technique wherein sutures are placed into tissues

without interruption

conventional cutting edge

a type of needle with two cutting edges and in addition, have a

third cutting edge on the inside concave curvature of the needle

cotton

a non-absorbable braided suture

hydrolysis

a type of chemical process that results in suture breakdown of

synthetic absorbable sutures

in vivo tensile strength

amount of tension or pull which a suture can withstand before it

breaks, inside the tissue

knot tensile strength

the force which the suture strand can withstand before it breaks

during knot tying

knot tying

the process of securing sutures using instruments or done manually

ligature

any suture material used to tie vessels or structures

monofilament

synthetic sutures that are single and untwisted

needle body

the portion between the point and the swage of the needle

needle diameter

the gauge or thickness of the needle wire

needle length

the distance measured along the needle itself from point to end

needle radius

Appendix A

polyglyconate

a synthetic absorbable monofilament suture marketed as Maxon(r)

polypropylene

a non-absorbable synthetic monofilament suture marketed as

Prolene(r), Premilene(r), or Surgidac(r)

reverse cutting

like a conventional cutting needle except that its third cutting edge

is at the outer convex curvature of the needle

silk

the most commonly used non-absorbable braided suture; a protein

filament produced by silkworms

swage

the area in which the suture is attached to the needle resulting in

the needle and suture becoming a continuous unit

tapered needles

the type of needle wherein the body of the needle gradually tapers

to a sharp point at the tip

tensile strength

the load applied per unit of cross-section area measured in lbs/

in2 or kg/cm2

wire/steel

non-absorbable metal suture used primarily for fixing bony

structures

if the curvature of the needle were to make a full circle, this would

be the distance from the center of the circle to the body of the

needle

non-absorbable sutures

type of sutures that are not broken down by chemical processes in

tissues

nylon

a synthetic non-absorbable type of suture in monofilament and

braided forms marketed as Ethilon(r)or Nurolon*

plain catgut

simplest form of absorbable catgut suture

polydioxanone

a synthetic monofilament absorbable suture marketed as PDS(r)II

polyester

the first synthetic braided non-absorbable suture marketed as

Mersilene(r), Miralene(r), Ethibond(r), or Surgidac(r)

poliglecaprone

a synthetic monofilament absorbable suture marketed as Monocryl(r)

polyglactin

a synthetic braided absorbable suture marketed as Coated Vicryl(r)

polyglycolic

a synthetic braided absorbable suture marketed as Dexon(r)

CHAPTER I

1. B 9. B

2. A 10. D

3. B 11. A, D

4. C 12. A, D

5. A 13. A, D

6. C 14. B

7. E 15. A, D

8. A

CHAPTER II

1. B

2. A

3. D

4. C

5. A

CHAPTER III CHAPTER IV

1. A 1. D

2. D 2. C

3. C 3. D

4. D 4. B

5. C 5. E

6. C

7. B

8. D

Appendix B

Answers to Self-Assessment Questions

CHAPTER V

1. C

2. B

CHAPTER VI

1. D

2. A

3. B

4. H

5. G

6. E

7. F

8. C

CHAPTER VII

1. B

2. C

3. B

4. A

5. C

6. B

7. C

8. E

9. D

2003 Board of Regentsof the Philippine College of Surgeons

President: Fernando L. Lopez, MD

Vice-President: Edgardo R. Cortez, MD

Treasurer: Arturo S. de la Peña, MD

Secretary: Leonardo L. Cua, MD

Members: Josefina R. Almonte, MD Maximo B. Nadala, MD Armando C. Crisostomo, MD

Gerardo A. Directo, MD Rodolfo L. Nitollama, MD Rey Melchor F. Santos, MD

Maximo Dy-R. Elgar, MD Stephen S. Siguan, MD Jose C. Gonzales, MD

Maximo H. Simbulan, Jr., MD Vedasto B. Lim, MD

2003 Committeeon Surgical Training of thePhilippine College of Surgeons

Chairman: Cenon R. Alfonso, MD

Members: Shirard L.C. Adiviso, MD, MHPEd

Jose Joey H. Bienvenida, MD

Miguel C. Mendoza, MD

Renato Cirilo A. Ocampo, MD

Secretary: Annette G. Tolentino

Regent-in-charge:Armando C. Crisostomo, MD, MHPEd

Sitting (Left to right): Cenon R. Alfonso, MD,

Armando C. Crisostomo, MD, Annette G. Tolentino

Standing ( Left to Right): Miguel C. Mendoza, MD,

Renato A. Ocampo, MD, Shirard L.C. Adiviso, MD,

Joey H. Bienvenida, MD

Acknowledgement

The Committee on Surgical Training of the Philippine College of Surgeons would

like to express its sincerest gratitude to Ms. Annette G. Tolentino, Executive Secretary

of the Philippine College of Surgeons and to Ms.Ruth Nicolas, Franchise Manager,

Ethicon Division, of Johnson and Johnson Medical, Philippines, for their unwavering

and dedicated support to the completion of this 2003 Basic Surgical Skills, Electronic

Version. Also, the committee would like to acknowledge the expertise of Mr. Juanito

R. Gatus of Priority One Corporate and Marketing Communications, for the layout

and graphics; and Mr. Alain Espina, for the development of the CD.

2003 Board of Regentsof the Philippine College of Surgeons

President: Fernando L. Lopez, MD

Vice-President: Edgardo R. Cortez, MD

Treasurer: Arturo S. de la Peña, MD

Secretary: Leonardo L. Cua, MD

Members: Josefina R. Almonte, MD Maximo B. Nadala, MD Armando C. Crisostomo, MD

Gerardo A. Directo, MD Rodolfo L. Nitollama, MD Rey Melchor F. Santos, MD

Maximo Dy-R. Elgar, MD Stephen S. Siguan, MD Jose C. Gonzales, MD

Maximo H. Simbulan, Jr., MD Vedasto B. Lim, MD

2003 Committeeon Surgical Training of thePhilippine College of Surgeons

Chairman: Cenon R. Alfonso, MD

Members: Shirard L.C. Adiviso, MD, MHPEd

Jose Joey H. Bienvenida, MD

Miguel C. Mendoza, MD

Renato Cirilo A. Ocampo, MD

Secretary: Annette G. Tolentino

Regent-in-charge:Armando C. Crisostomo, MD, MHPEd

Sitting (Left to right): Cenon R. Alfonso, MD,

Armando C. Crisostomo, MD, Annette G. Tolentino

Standing ( Left to Right): Miguel C. Mendoza, MD,

Renato A. Ocampo, MD, Shirard L.C. Adiviso, MD,

Joey H. Bienvenida, MD

Acknowledgement

The Committee on Surgical Training of the Philippine College of Surgeons would

like to express its sincerest gratitude to Ms. Annette G. Tolentino, Executive Secretary

of the Philippine College of Surgeons and to Ms.Ruth Nicolas, Franchise Manager,

Ethicon Division, of Johnson and Johnson Medical, Philippines, for their unwavering

and dedicated support to the completion of this 2003 Basic Surgical Skills, Electronic

Version. Also, the committee would like to acknowledge the expertise of Mr. Juanito

R. Gatus of Priority One Corporate and Marketing Communications, for the layout

and graphics; and Mr. Alain Espina, for the development of the CD.