Basic Surgical Skills

- Suture Material And Needle

- Basic Surgical Instrument/ Tourniquet, Drain, Diathermy
- Suturing Technique

What is a Suture and Needle?

- Suture is described as any strand of material used to ligate blood vessels or
approximate tissues.
- It is also used as a verb to indicate application of stitches.
- Needle is
a sharp instrument used for suturing, for puncturing, or for the guiding of ligatures.
- Suture material generally consists of a needle with an attached length of thread.

History of Suture Material

- The earliest reports of surgical suture date to 3000 BC in ancient Egypt

- The oldest sutures was found on the body of a twenty first dynasty mummy about
1100 BC. A physician, Sushruta details wound sutures and the materials used in a text
written in 500 B.C. The text describes many different types of needles – triangular,
round-bodied, curved, and straight needles. Different types of suture materials
included hemp, hair, flax, and bark fiber. He listed detailed account of how to perform
repair of anal fistula, tonsillectomy, amputation and rhinoplasty.

- Between 50,000 and 30,000 B.C. eyed needles were invented.

- 30 A.D., Aurelius Cornelius Celsus wrote a medical encyclopaedia De Re Medicina

described that sutures should be “soft, and not over twisted, so that they may be more
easy on the part.” He recommended ligation as secondary means of stopping
haemorrhage

- Galen, A Greek physician, A.D. 150, treated and sutured the severed tendons of
gladiators

- The “catgut” suture came about in the 2nd century, and in the 10th century. The
manufacturing process for sutures involved harvest of sheep intestines, similar to the
strings for violins, guitars, and tennis rackets.

- A large breakthrough in suture materials came from the Muslim scholar, Avicenna
around the same time period. He realized that traditional sutures tended to break down
rapidly for the wound to close. He invented the first monofilament suture, using pig’s
bristles.
Primitive age

- East African tribes ligated blood vessels with tendons and closed wounds with acacia
thorns

-
Torn of Acacia Tree

- South American method of wound closure by using large black ants which bite the
wound edges together and the ant body is then twisted off, leaving the head in place

- Native Americans used cautery, the burning of the body to remove or close a part of it.

- These early surgical sutures were not sterilized, which presented major infection risk,
and also irritated the skin. This all changed in 1860, when Joseph Lister invented a
method to sterilize suture material. It was done with carbolic acid, then chromic acid,
and culminated in fully sterile catgut sutures in 1906 with iodine treatment.

Properties of Sutures
 Tensile strength
 Tensile strength is a measure of the time it takes for suturing material to lose 70% to
80% of its initial tensile strength.
 Initial tensile strength is a measure of the amount of tension applied in a horizontal
plane necessary to break the suturing material
 Suture that losing tensile strength within 60 days is called absorbable suture
 Knots strength
 A measure of the amount of force necessary to cause a knot to slip and is directly
related to the coefficient of friction of a given materials
 Eg. nylon has low coefficient of friction, thus low knot strength

 Capillary action
 It is the ability of suture to absorb moisture & hold body fluid
 Suture with higher capillary action carries higher risk of infection to the sutured wound

 Memory ( Stiffness )
 It is the tendency of a suture to retain its original shape or configuration after it is
removed from the package
 Sutures with strong memory tend to return their former, packing form when they are
removed from their packing, during and after manipulation.
 Sutures with strong memory is hard to manipulate.

Eg:
Nylon

 Elasticity
 Intrinsic tension generated in a material after stretching, which causes it to return to
its original length - allows the suture to expand during wound edema without causing
strangulation or cutting of tissue, and to recoil during wound retraction, thereby
maintaining wound edge apposition
 Eg : Polybutester (Novafil) is “creep” resistant and can return to original form when
edema recedes.

 Plasticity
  Material's ability to stretch & retain a new shape
 Eg: Polypropylene (Prolene) stretches to accommodate wound edema but it remains
loose when wound edema recedes

 Pliability / compliance
 Is the ease of handling, ability to secure and adjust knot tension (related to suture
material, filament type, diameter)

 Tissue reactivity
 Inflammatory response generated by the presence of suture material in the wound
 Suture that cause little or no inflammation are highly inert e.g. stainless steel,
titanium suture
 Natural suture (silk, catgut) based sutures cause the most tissue reaction

Classification of Sutures
1. Material Composition
- Natural (Made of natural fibres)
- Synthetic (Comprised of man made materials)

2. Physical Structure
- Monofilament
- Multifilament/Braided

3. Degradation Properties
- Absorbable
- Non-absorbable/Permanent

1. Material Composition

Natural Synthetic
Polyglactin (Vicryl),
Polyglycolic acid (Dexon/ Safil),
Polydioxine (PDS),
Polyglyconate (Maxon),
Catgut, silk, linen, cotton, steel/wire Polyamide (Nylon),
Polypropylene (Prolene),
Polyester (Mersilene/ Dacron)
Polybutester (Novafil)
 Less tissue reaction
More tissue reaction
Absorbed by hydrolysis
Absorbed by proteolysis

2. Physical Structure

Monofilament Multifilament

Single strand Multiple strand twisted or braided together

Less tissue drag More tissue drag

Resists harboring organism (less infection) Harbour organisms between fibres (more
infection risk). High capillarity

Less tensile strength and flexibility More tensile strength and flexibility

Crushing/crimping can nick or create weak More resistant to crushing/crimping

spot on the strand

Memory effect Less memory effect

PDS, Monosyn, Ethilon, Prolene Catgut, Vicryl, Dexon, Silk, Mercilene

3. Degradation Properties

Absorbable Non-absorbable

Naturally degraded in body by proteolysis Non-biodegradable; gradually encapsulated

(natural)/ hydrolysis (synthetic); Hydrolysis by fibrous tissue
causes less tissue reaction than enzymatic
degradation

Undergo rapid degradation and loses tensile Degrade at slower rate and maintain tensile
strength within 60 days strength beyond 60 days

No need to be removed Need to be removed

Catgut, Vicryl, Safil, Monosyn, PDS, Dexon, Silk, Nylon, Prolene, Linen, Mersilene/
Maxon Dacron, Novafil, steel/wire

 Suture size
  Size refers to the diameter of the suture strand.
 The larger the suture diameter, the greater the tensile strength.
 Measured in metric units (tenth of a millimeter) or by a numeric scale standardized by
United States Pharmacopeia (U.S.P) regulations.
 Numerically, as the number of 0s in the suture size increases, the diameter of the strand
decreases.
 U.S.P scale runs from 11-0 (smallest) to 7 (largest).
 The accepted surgical practice is to use the smallest diameter suture that will
adequately hold the mending wounded tissue
 This is to minimize trauma when the suture passes through the tissue to effect closure
and ensure minimal mass of foreign material is left in the body.

United states Pharmacopeia (USP)

Uses of different sizes of sutures

Uses
Size
Ophthalmology, microsurgery
7/0 and smaller
Face, blood vessels
6/0
Face, neck, blood vessels
5/0
Mucosa, hands, neck, limbs, tendons,
4/0
blood vessels
Limbs, trunk, gut, blood vessels
3/0
Trunk, fascia, viscera, blood vessels
2/0
Abdominal wall, fascia, drain sites, arterial
1/0
lines, orthopaedic surgeries

 Suture Selection ( how to choose a suture )

 Depends on where it is used, surgeon preference
 Smallest size adequate to hold healing wound edge
  Tensile strength of suture < tensile strength of tissue; so that suture does not cut/tear
through tissue
 Relative loss of suture strength slower than gain of tissue tensile strength
 Head and neck region, smaller size for aesthetic
 Non-absorbable for slow healing tissue (skin, fascia, tendon, nerve), absorbable for
rapid healing tissue (mucosa)
 Optimal size is the smallest size needed to achieve desired tension-free closure

Characteristic of Ideal Suture Material

- Sterile
- Versatile ( can be used in many procedures)
- Easy and safe to handle
- Not predisposed to bacterial growth
- Minimal tissue reaction
- Non-allergic
- Non-electrolyte
- Non-capillary
- Non-carcinogenic
- Not cut through tissue
- High breaking strength
- Holds knots securely
- Cheap
- Absorbed with minimal tissue reaction

Absorbable Sutures
 SUTURE TYPES RAW MATERIAL TENSILE ABSORPTION TISSUE
STRENGTH RATE REACTION
Catgut Plain Bovine/sheep Lost within 7- 21-42 days moderate
collagen 10 days proteolysis

Catgut Chromic Bovine/sheep Lost within 90 days Moderate

collagen treated 3–4 weeks proteolysis (less than
with chromium plain gut)
salts
Coated Braided Copolymer of 50% 5 days 42 hydrolysis minimal to
Polyglactin lactide and moderate
910(Rapid Monofilament glycolide coated 0% 14 days
Vicryl) with 370 and
calcium stearate
Monocryl Monofilament Copolymer of 50% 1 week 91-119 minimal
(poliglecaprone glycotide and 30% 2 weeks hydrolysis
25) epsilon- 0% 3 weeks
caprolactone

Coated Vicryl Braided Copolymer of 75% 2 weeks 56-70 minimal

Polyglactin 910 lactide and 50% 3 weeks hydrolysis
Plus Monofilament glycolide coated 25% 4 weeks
antibacterial with 370 and
calcium stearate

Polydioxanone Monofilament Polyester polymer 70% 2 weeks 3-6 months Minimal

PDS II 50% 4 weeks hydrolysis reaction
25% 6 weeks

Nonabsorbable Sutures
Suture Types Raw Material Tensile Absorption Tissue reaction
strength

Braided Organic protein Progressive Gradual Acute

Silk
called fibrin degradation of encapsulation by inflammation
fiber fibrous connective
tissue
Monofilament 316L stainless Permanent Non-absorbable Minimal acute
Stainless
steel inflammation
steel
Multifilament reaction
Monofilament Long-chain Gradual loss Gradual Minimal acute
Nylon
aliphathic due to encapsulation by inflammation
polymers Nylon progressive fibrous connective reaction
6 or 6.6 hydrolysis tissue
Braided Poly (ethylene No significant Gradual Minimal acute
Ethibond*
terephthalate) change known encapsulation by inflammation
polyester
coated with to occur in vivo fibrous connective reaction
fiber suture
polybutilate tissue
Monofilament Isotactic No change Non-absorbable Minimal acute
Prolene*
crystalline inflammation
polypropyle
stereoisomer of reaction
ne suture
polypropelene
Braided Poly (ethylene No change Gradual Minimal acute
Mersilene*
terephthalate) encapsulation by inflammation
polyester
Monofilament fibrous connective reaction
fiber suture
tissue
Monofilament Polymer blend No change Non-absorbable Minimal acute
Pronova*
of inflammation
(Hexaflourop
poly(vinylidene reaction
ropylene-
flouride) and
VDF) suture
poly (vinylidene
fouride-
cohexaflouropr
opylene)

The surgical needle

Is necessary for the placement of sutures in tissue and carry the suture material through tissue
with minimal trauma.

Characteristic of a ideal needle

- It must be sharp enough to penetrate tissue with minimal resistance
- Rigid enough to resist bending, yet flexible enough to bend before breaking.
- Sterile
- Corrosion resistant to prevent introduction of microorganisms or foreign materials into the
wound.
-Made from high quality steel alloy or titanium

Anatomy of a needle
Surgical needles are composed of :
 a eye
 a body/shaft, and
 a point

The size of the needle may be measured in inches or in metric units. The following
measurement determine the size of a needle

 Chord length
 The straight line distance from the point of a curved needle to the swage
 Needle length/size
 The distance along the needle itself from the point to end
 Radius
 The distance from the center of the circle to the body of the needle if the curvature
of the needle were continued to make a full circle
 Diameter
 The thickness of the needle wire
The needle eye is the part where the suture is attached or threaded.
They are divided into 3 types :
1. Closed eye
2. French eye
3. Swaged

The closed eye is similar to a household sewing needle. It maybe round, oblong or square.

The french eye needles has slit from inside the eye to the end of the needle with ridges that
catch and hold the suture in place.
A swaged eye needle has its eye joins the needle with the suture together as continuous unit.
Suture is preattached. It allows faster suturing with minimal tissue trauma.

Eyed needle Swaged(eyeless)

Time consuming (must be threaded manually) Minimal handling as thread are preattached
Minimal tissue trauma
Creates larger hole and trauma to the tissue
Not reusable
Reusable
Repeated use of needle causing it become New, sharp, undamaged needle with
preattached thread in every packet
blunt

The needle body

 The body of the needle is the portion which is grasped by the needle-holder during a
surgical procedure.
 It should be as close as possible to the diameter of the suture material to minimize
bleeding and leakage.
 The curvature of the needle body comes in different shapes. Each shape gives the needle
different characteristic.

Shape
Straight needle
 Preferred in suturing easily accessible tissue
 Used in places where direct finger-held manipulation can be easily performed

Half-curved needle
 Also called ‘ski’ needle
 Allows easy passage down laparoscopic trocars

Curved needle
 Allows predictable needle turnout from tissue
 Used most often
 Requires less space for maneuvering than a straight needle
 Requires manipulation by using a needle holder
 Most commonly used for skin closure is the 3/8 curved needle
 They are designed for used in confined space

Compound curved needle

 Originally developed for anterior segment ophthalmic surgery
 Allows surgeon to take precise uniform bites of tissue
 It has tight 80 degree curvature of the tip follows into 45 degree curvature throughout the
remainder of the body
 The initial curvature allows reproducible, short, deep bites into the tissues
 The curvature of the remaining portion of the body forces the needle out of the tissue,
everting the wound edges, permitting a view into the wound

Shape Application
GIT
Nasal cavity
Nerve
Oral cavity
Pharynx
Skin
Tendon
Vessels
Skin (rarely)
Laparoscopy

Eye
Microsurgery
Aponeurosis
Biliary tract
CVS
Dura
Eye
GIT
Muscle
Myocardium
Nerve
Perichondrium
Pleura
Skin
Tendon
Urogenital tract
Vessels
Biliary tract
CVS
Eye
Fascia
GIT
Muscle
Nasal cavity
Oral cavity
Pelvis
Peritoneum
Pharynx
Pleura
Respiratory tract
Skin
Tendon
Subcutaneous fat
Urogenital tract
Anal(hemorrhoidectomy)
Nasal cavity
Pelvis
Urogenital tract(primary application)

Eye (anterior segment)

Laparoscopy
 Laparoscopy

The needle point

3 basic types

1. Cutting needles
a) Have at least 2 opposing cutting edges
b) They are sharpened to cut through tough, difficult-to-penetrate tissue
c) Ideal for skin sutures that must pass through dense, irregular and relatively thick
connective dermal tissue

 Conventional cutting needles

 In additional to the 2 cutting edges, they have 3rd cutting edge on the inside concave
curvature of the needle
 The shape changes from a triangular cutting blade to a flattened body on both straight
and curved needle
 They may be prone to cut out of tissue because the inside cutting edge cuts toward
the edges of the incision or wound

 Reverse cutting needles

 The 3rd cutting edge is located on the outer convex curvature of the needle
 Offers several advantage :
 More strength than similar-sized conventional cutting needle
 The danger of tissue cutout is greatly reduced
 The hole left by the needle leaves a wide wall of tissue against which the suture
is to be tied

 Side cutting needles

  A.k.a spatula needles
 Unique design which is flat on both the top and bottom, eliminating the undesirable
tissue cutout of other cutting needles
 Primary application in ophthalmic reconstructive surgery, microsurgery

2. Blunt
a) Has a taper body with rounded, blunt point that will not cut through tissue
b) It pushes tissue aside as it moves through it
c) It is used in suturing friable tissues & organs that are soft & spongy e.g. liver, spleen,
kidney
d) Also used in surgery that is prone to space and visibility limitation eg in obstetric and
gynecology procedures
e) Its also used on general closure when doing procedures on high-risk patients. Eg RVD
positive patients

3. Taper/round
a) Taper point

i. Taper point needles pierce and spread tissue without cutting it

ii. The needle point tapers to a sharp tip
iii. The needle body then flattens to help prevent twisting in the needle holder
iv. Preferred when the smallest hole of tissue and minimum tissue cutting are
desired
v. For suturing soft tissue e.g. muscle, subcutaneous fat, peritoneum, dura, GI,
genitourinary, biliary & vascular tissue

b) Taper cut
i. Combine feature of reverse cutting edge tip and taper point needle
 ii. It has 3 cutting edges extend approximately 1/32’’ back from the point and bend
into a round taper body
iii. 3 edges are sharpened to provide uniform cutting action
iv. Used in penetrate dense, tough tissue
v. The taper body portion provides smooth passage through tissue and eliminates
the danger of cutting into surrounding tissue
vi. For CVS surgery on sclerotic or calcified tissue; for suturing dense, fibrous
connective tissue--especially in fascia, periosteum, and tendon

Suture description on packaging

Basic surgical instruments

 Types
 Cutting and Dissecting
 Grasping and Holding
 Clamps
 Retraction and Exposure
 Approximation and Closure
  Evacuation Instruments
 Specialized Instruments
 Microsurgery Instruments

Cutting and Dissecting instruments

Can be sharp or blunt

 Sharp dissection is performed by incising anatomic/non-anatomic planes

 Blunt dissection is performed by placing instrument between anatomic plane or tissue
layer to cause separation of fibers
 Scalpels
 Divided into 2 parts
 Handle
 Blade
 Handle size
 Size 3 : For blade size 10 series
 Size 4 : For blade size 20 series

 Blade
 Blade 20/23 : longer incision, debride wound
Blade 10 : small incisions in skin & muscle
Blade 11 : used in vascular cases, to puncture aorta, to cut blood vessels
Blade 12 : ENT, tonsillectomy,suture cutter
Blade 15 used in plastic and paediatrics cases (perform biopsy, small incision, any incision
on face)

Ways to grip a scalpels

 For short or fine incision, scalpel is held like a pencil & the cutting is made mostly with
the tip

 Cutting surface of blade facing up

 Only Small amount of blade tip contact on tissue
 Used in making accurate controlled stabbed incision
The thumb is placed at one side of handle and the remaining fingers wrap around the handle,
so the handle sits in the palm. The index finger placed on top of handle or blade.

 strongest grip
 used when need strong pressure to incise the tissue
 cutting pressure applied by palm and fingers
 entire arm moves to make the incision

 Knife kept in horizontal position & held between thumb & middle finger while index
finger at base of blade to control the pressure.
 For cutting skin in long & straight incision

Cutting and dissecting scissor

 Mayo Scissors
 Heavy operating scissors
 Straight and curved
 Cutting through thick fascia and tough structures

Mayo Straight scissor

Mayo Curved Scissor

 Metzenbaum
  Straight or curved
 For dissection of soft delicate tissue

 Steven Tenotomy Scissors

 Precision cutting in delicate region
 Dissection into narrow spaces
 Blunt tip
 Tenotomy partially incising, or cutting, through tendons

 Iris Scissors
 Small, extremely sharp and fine tip
 Dissection of delicate tissue
 Originally designed for ophthalmic surgery
 Straight and curved
 Joseph Scissors
 Very sharp tip and edges
 Minimal force needed to cut into tissue

 Ragnell Scissors (Kilner)

 Round and blunt tip
 For cutting soft tissue
 Holding a scissors
Tip of thumb inserted into the upper ring
Tip of the ring finger inserted into the lower ring
Index finger positioned on or near the hinge to steady it

Grasping and holding forceps

1. Ring-handled grasping forceps

Non-crushing:
 Magill Forceps

 Angled forceps used to guide a tracheal tube into the larynx or a nasogastric tube into
the esophagus under direct vision. They are also used to remove foreign bodies.
 Lahey Forceps

 Lahey Traction Forceps are perforating, finger ring forceps used to grasp fibrous tissue
 The 3x3 sharp teeth provide a firm hold on the tissue and the ratcheted locking mechanism
ensures the hold is not lost.
 Often used to grasp breast tissue in mastectomy procedures or tissue and glands in thyroid
surgeries.

 Babcock

 Finger ring, ratcheted, non-perforating forceps used to grasp delicate tissue.

 Allis

 Light weight toothed forceps with a broad grasping area.

 Lane

Heavy forceps with a single tooth.

2. Non-ring Handled Grasping Forceps

Non-tooth:

 Mc Indoe Forceps
 Adson Plain Forceps

 For holding and manipulating delicate tissues.

 They have wide, flat thumb grasp area that is commonly serrated

 Debakey

 Atraumatic tissue forceps used in vascular procedures to avoid tissue damage during
manipulation

With teeth
Adson Tooth Forceps

 used to grasp the skin

Gilles Forceps

 Often used in small surgical sites to grasp tissue.

 They have fine, narrow jaws

Holding a forcep

 Held like a pencil

 Toothed forceps to hold tough and slippery tissue
 Non-toothed forceps to hold vessels, ducts, encapsulated solid organs

Clamps

Standard Haemostatic Clamps

1. Spencer Wells

2. Mosquito
Haemostatic Clamps with tooth (Traumatic)
1. Kocher Haemostatic Forceps

2. Backhaus Towel Clamp

Retraction and Exposure

1) Handheld Retractors

I. Gillies Skin Hook

II. Kilner Catspaw Retractor/ Senn-Mueller

III. Farabeuf Retractor

IV. Morris Retractor

V. Deaver Retractor

VI. Langenbeck Retractor

2) Self-retaining Retractors

I. Dingman Mouth Gag

II. Weitlaner

Approximation and Closure Instruments

1. Halsey Needle Holder

2. Mayo Hegar Needle Holder

3. Single clip appliers

Holding needle holder

Held by placing the thumb and the fourth finger into the loop and by placing the index finger
on the fulcrum of the needle holder to provide stability.

Evacuation Instruments
Suction instruments

1) Yankauer

2) Poole
3) Baron

4) Frazier-Ferguson

Special Instruments

1. Currette

Spratt bone curette

2. Periosteal Elevator

Freer
Mitchell trimmer

3. Chisel and Mallet

4. Probe and dilator

a) Bowman lacrimal probe
To expand & explore a natural or created opening in body

5. Freeman nipple marking template ('cookie cutter')

 To measure & mark the circumference of neoareolar created during reduction or

reconstruction of a breast
 Dipped in pigment dye & placed on surface of breast mound
 6. Tendon stripper

7. Zimmer Dermatome

Powered by either electricity or compressed gas to harvest a split-thickness skin graft.

8. Skin Mesher

Used for expansion of split-thickness skin graft and to facilitates fluid drainage from wound
bed.
 9. Weck Knife
a) Humby
b) Watson
c) Braithwaite
d) Goulian
e) Silver's

Used to harvest split-thickness skin graft or for wound debridement.

Goulin

Silver’s weck knife

Microsurgical Instruments

1. Jeweler’s Forceps

2. Vessel Dilator

3. Microsurgery Needle Holder

4. Vessel Clamps
 5. Microscissors

Torniquets

A device for compression of an artery or vein; uses include stopping of the excessive
bleeding of a haemorrhage, maintenance of a nearly bloodless operative field
-- Dorland’s Medical Dictionary

History

 The earliest known usage of tourniquet is dated back to 199 BC. It was used by the Roman
to control bleeding especially during amputation.
 In 1718, French surgeon Jean Louis developed a screw device for occluding blood flow in
surgical sites. He named it after the French verb tourner (to turn), “tourniquet” as it is
commonly known today.

 Joseph Lister is credited for being the first person to use tourniquet device to create
bloodless surgical field in 1864.

 In 1873, Friedrich von Esmarch developed a rubber bandage that would both control
bleeding and exsanguinate. Named after him as Esmarch tourniquet for surgical
hemostasis.
 In 1904, Harvey Cushing created pneumatic tourniquet.
 Electronic tourniquet systems invented by James Mc Ewen in 1984

Types of tourniquet

1) Non-inflatable (non-pneumatic): rubber and elasticized cloth

2) Pneumatic tourniquet with cuff inflated by compressed gas

Non-pneumatic Tourniquets

Pneumatic Tourniquets
Components:
 An inflatable cuff wrapped around a limb
 compressed gas source
 Pressure gauge to maintain the desired cuff pressure
 Pressure regulator
 Connection tubing
Function of Tourniquet
1. Compression of arterial blood flow to reduce blood loss and create a relatively
bloodless surgical field in the extremities
2. Prevent systemic toxicity of drugs given in high dose into isolated limb e.g during
Bier’s block
3. Isolated limb perfusion with cytotoxic drugs e.g treatment of localized cancer e.g
melanoma, soft tissue sarcoma

Potential Complication
1. Nerve injury
- Range from neuropraxia to axonal disruption
- Cause - mechanical stress on the nerves under the cuff or at its edges and anoxia or
ischemia of nerves under or distal to the cuff
- Prevention: proper usage of cuff and limb protection; use only minimal effective
pressure; never use longer than recommended period
2. Post-tourniquet syndrome
- Pronounced, prolonged postoperative swelling of extremity
- Edema, stiffness, pallor, weakness without paralysis, and subjective numbness
without objective anesthesia
- Cause – prolonged ischaemia; post-ischaemia reactive hyperemia to restore normal
acid-base balance in tissue
3. Intraoperative bleeding
- Cause – under-pressurized cuff; insufficient exsanguination; too slow inflation &
deflation; loose cuff fit, calcified vessels
- Prevention – proper cuff selection; sufficient pressure and exsanguinations
 4. Compartment syndrome
- Due to tourniquet ischaemia time. Prolonged tourniquet time lead to fall in tissue pH,
increase capillary permeability, and prolongation of clotting time
- The combination of external compression and an increase in compartment contents
due to either trauma or surgery, leads to compartment syndrome
- Prevention – limit tourniquet time to minimized.
5. Pressure sores, skin blisters, chemical burns
- Skin breakdown, friction or soft tissue folding under cuff; inadequate padding, faulty
application; antimicrobial prep solution seeping under cuff
- Prevention – apply cuff away from joint/ bony prominence with sufficient padding;
adhesive tape to prevent seepage; not to use rotation to adjust already inflated cuff
6. Digital necrosis
- gangrenous destruction of a finger or toe as a result of prolonged ischemia/anoxia
- patients at risk: impaired circulation, small limbs, elderly
7. Toxic reactions
- During Intravenous Regional Anesthesia; reaction to LA
- Cause – accidental deflation during administration; too early deflation (need to give
15-20 minutes for maximal tissue binding)
- Prevention – ensure tourniquet functioning well; use dual bladder cuff; avoid in LA
allergy; intermittent deflation and re-inflation to avoid large influx into systemic
circulation
8. DVT , leading to Pulmonary embolism or venous embolization
9. Tourniquet pain – hypertension, dull, aching pain throughout limb during tourniquet
use despite adequate analgesia;
10. Thermal damage to tissue
11. Hyperthermia
12. Rhabdomyolysis
13. Metabolic changes - increased PaCO2, lactic acid, and potassium, and decreased levels
of PaO2 and pH

Limp Occluding Pressure

- Limb Occlusion Pressure (LOP) is the minimum pressure required, at a specific time in a
specific tourniquet cuff applied to a specific patient’s limb at a specific location, to stop the
flow of arterial blood into the limb distal to the cuff.
- Cuff pressure increased slowly from zero while monitoring the pulse in an artery distal to
the cuff until the distal pulse disappears.
- The lowest cuff pressure at which the pulse disappears is the Ascending LOP
- Cuff pressure can be decreased slowly (1mmHg/s) from high occlusive level until distal pulse
resumes = Descending LOP
- Mean of ascending and descending LOP = True LOP

- Factors
o Blood pressure - SBP
o Cuff design, fit and snugness of application
o Limb circumference
o Tissue status
o Vascular status – atherosclerotic

A safety margin is added to cover intraoperative fluctuations in arterial pressure.

 LOP is <130 mm Hg, the safety margin is 40 mm Hg;
 LOP 131–190 mm Hg, the margin is 60 mm Hg;
 LOP is >190 mm Hg, the margin is 80 mm Hg
 For pediatric patients, adding 50 mm Hg has been recommended.
 For dual bladder tourniquet cuff for Bier block, adding 100 mm Hg is recommended
McEwen JA, Inkpen KB, Younger A. Thigh tourniquet safety: LOP measurement and a wide
contoured cuff allows lower cuff pressure. Surg Tech. 2002;34:8–18.

Pre-application precautions
- the pressure source, cuff, regulator, tubing, connectors need to be checked before use and
as wide a cuff as possible should be used.
- wider cuffs provide better transmission of tissue compression and lower cuff pressures are
required to compress the artery and hence minimize potential pressure related complication
- the cuff should not directly overlie bony prominence like head of fibula/malleoli as there is
risk of direct nerve compression
-recommended that the edge of tourniquet should be at least 2cm proximal to the malleoli in
case of calf cuffs
- the length of cuff should be individualized, according to the size and circumference of the
patients limb, it should be the minimum to assure overlap around the limb sufficient to fully
engage the fasteners.
- recommended the shape should allow a snug fit at both proximal and distal edge
- the width should be the widest possible but should not encroach upon the surgical site
-the cuff should overlap at least 3 inches, but not more than 6 inches as it may cause
generation of high pressure
-thigh tourniquet shouldnt be inflated with the knee in flexed position followed by leg
straightening as this fixates the sciatic nerve to the femur and cause extreme traction on the
nerve

Application & Precaution

- Ensure location, choose appropriate cuff, apply limb protection, fasten cuff and
ensure snug-fit
- The tourniquet first should be deflated and smoothened out.
- Adequet padding done at the site
- recommended to apply tourniquet at the proximal part of the limb at the greatest
circumference because the muscle bulk at the site is greatest hence it affords greater
protection against nerve injury
- Connect cuff to tourniquet instrument
- Measure LOP and determine desire cuff pressure
- Exsanguinate limb – elevate arm 90° and leg 45° for 5 minutes ( to establish clear
operative field, reduce overall blood loss, reduce risk of microemboli at the time of
release)
- Rapidly inflate cuff to set pressure
- Deflate tourniquet every 2 hours to allow 10 minutes of muscle reperfusion
- Tourniquet should not be inflated for more than 2 hours
- IV antibiotics given 5 minutes before inflation of cuff to ensure adequate tissue
penetration
- Concept of minimum effective pressure
o Adults – upper limb: 200mmHg; lower limb: 250-350mmHg
o Children – upper limb: 175 ± 30mmHg; lower limb: 210 ± 10 mmHg

- safe duration and pressure for tourniquet use remain a controversy. No strict guidelines have
been laid down.
- a safe time limit of 1-3 hours has been described. Horlocker et al 2006 have found a strong
correlation of nerve injury with prolonged total tourniquet time with an approximate 3 fold
increase rish of neurological complication for each 30min increase in tourniquet inflation. Use
of tourniquet for > 2h and pressure of >350mmhg in lower extremity and >250mmhg in upper
extremity increase the risk of compression neuropraxia.
- if >2h is required, the tourniquet should be deflated for 5min for every 30min of inflation
time.
Contraindications
- Open fractures
- Previous vascular surgery on the involved limb
- Severe crushing injuries
- Severe hypertension
- Skin grafts
- Peripheral arterial disease
- Diabetes mellitus
- Calcified femoro-popliteal system
- Compartment syndrome
- Malignant tumour
Drains
It is a mechanical conduit that allows fluid or gas to flow from a body space/operative site to
the exterior

Purpose of drainage
1. Postoperative drainage
- Drainage of infected foci (abscess cavity, infected cyst)
- Collapse dead space after extensive dissection & elevation of skin flaps (mastectomy
and AC) prevent seroma
- Detect anastomotic leak or bleeding (bowel, vessel anastomosis)
- Assist re-expansion of lung after pulmonary lobectomy
- Aid healing e.g. bladder/ urethral surgery, oesophageal surgery
2. Therapeutic drainage
- Drainage in haemo/pyo/pneumothorax
- Intestinal obstruction/ ileus
- Percutaneous drainage of deep abscesses
- Acute urinary retention
3. Prophylactic drainage
- NG tube to anticipate post-op ileus
Classification of drains

1) Open drains
- Drainage into dressings or wound drainage bag
- Do not employ suction
a) Packs and Wicks
i. Sterile cotton gauze inserted/packed into the cavity or shallow wound
ii. Fluid tracks along material
iii. Require regular change
iv. May interfere with granulation tissue formation

b) Corrugated Drain
i. Can be used for deep and superficial drainage
ii. Usually sutured in position
iii. Induces little tissue reaction

c) Yeates drain
i. Consists of series of 2mm diameter capillary tubes
ii. Similar in nature with corrugated drain
 d) Penrose Drain
i. Consists of a thin-walled rubber tube
ii. Soft compared to corrugated or Yeates drain
iii. Also drains passively to surrounding absorptive dressing material

2) Closed Drain
- tube draining into bottle/bag; reduced risk of infection
a) Active drain : drained by suction (close suction drain)
- Uses negative pressure
-Ideal to obliterate potential dead space
Eg:
-Negative Pressure Wound Therapy

-Blake drain

- Bellovac Drain
 Active drain
Advantage Disadvantage
High negative pressure may injure tissue
Efficient fluid removal, keep wound dry
Drain clogged by tissue
Can be placed anywhere
Minimizes ascending infection
Help appose skin to wound bed, accelerate
wound healing
Allows evaluation of volume and nature of
fluid drained

b) Passive drain
-Dependent on gravity (Siphon effect) and pressure differences
Eg:
a) T- tube

c) Chest Drain

Advantage Disadvantage

Allow evaluation of volume and nature of fluid Gravity dependent

- affects location of drain

Minimizes ascending infection

Ideal Drain
1. Efficient in drainage fluid or air
 2. Easy to insert and remove
3. Easy to monitor output
4. Non-irritant
5. Does not damage surrounding tissue
6. Does not increase risk of infection
Principles
-Not to be too rigid or too soft
-Non irritant material
-Wide bore enough to function
-Left for sufficient time so that when drain is removed there is minimal drainage
-When used prophylactic-ally, drain should be left in situ as long as the risk factors still exists
-Drain should exit from a separate wound, closed system and short duration to minimize
infection

Drain Materials
Rubber drains:
-Soft
-Triggers inflammatory reaction

PVC drains:
- Inert and less reactive
- Firm and tends to harden

Silicon drains:
- lease reactive
- most pliable
- no tendency to harden on prolonged use
Drain Insertion
-Should be directed to the sites of collection
-Tip should be free in the cavity to be drained
-Tip should not be in contact with vital structures
-Brought out through different stab incision which should permit free drainage
-Brought out by shortest route
-Route should not be tortuous
-Anchored to skin

Managing Drains
-Daily volumes and types of fluid drained
-Re-secure drain if loose or displaced
-Adequate suction
-Is it blocked, kinked or leaking
-Need for removal

Complications
During drain placement
- Injury to nearby structures
- Bleeding
Drain in-situ
- Leakage and surrounding skin excoration
- Infection
- Damage to anastomosis
- Retraction into the wound
- Pain
- Risk of being dislodged
- Decreased mobility
After Drain Removal
- Re-accumulation of collection
- Herniation at drain site
- Scar

Diathermy/High frequency electrosurgery

Diathermy refers to the tissue-heating effect that occurs when the body forms part of a
circuit, through which a high-frequency current passes.
Came from greek word “therma” means heat “dia” means through, thus “through heat”
The word diathermy is named after a German physician Karl Franz Nagelschmidt. In 1908 he
performed the first extensive experiments on patients.
He is considered the founder of the field. He wrote the first textbook on diathermy in 1913,
which revolutionized the field.

Surgical Diathermy

Electrosurgery
Eletrocautery
Alternating current
Direct current
 Current does not enter body; only heated wire Current enters body; patient is included in the
circuit
comes in contact with tissue

Principles of electrosurgery in OT

The electrosurgery generator is the source of electron and voltage.

The circuit is composed of :
1. Generator
2. Active electrodes
3. Patient
4. Patient return electrode
Pathway to ground are numerous, may include OT table, staff members, and equipment.
The patient tissue provides the impedance, producing heat as the electron overcomes the
impedance.

*the circuit for AC is shown by the arrows in opposite direction

Frequency Spectrum

-Standard electric current alternates at 60 cycles per second (60Hz).

-This frequency causes excessive neuromuscular stimulation and electrocution.
-Nerve and muscle stimulation cease at 100,000 cylces/second (100 kHz), electrosurgery can
be performed safely at “radio” frequency above 100 kHz
-An electrosurgical generator takes 60 Hz current and convert it to over 200 kHz current

Types of Surgical Diathermy

1. Bipolar
- Both active electrode and return electrode functions are performed at the site of surgery
- Uses 2-tined bipolar forceps to perform the active and return electrode function
- Only the tissue grasped is included in the electrical circuit
- Patient return electrode is not needed
- Advantage: lower current, current does not pass through the rest of the body, does not
interfere with cardiac pacemaker
- disadvantage: cannot be used for cutting & will not coagulate tissue held by surgical
forceps

Types of bipolar forceps Overview

2. Monopolar
- Electrical energy flows from the generator, to the active electrode (cautery pencil)
- The energy then passes through the patient to the dispersal cautery pad, completing the
electrical circuit

Patient plate:
 Should be in contact at least 70 cm2, so that current density at plate so low as to
cause minimal heating (misapplied --> high density current --> diathermy burn)
 Dry surface, surface free of oil, lotion
 avoid kinking
 Shaved skin (thigh or back)
 Avoid bony prominence & scar tissue (poor blood supply ⇒ poor heat distribution)
 Avoid areas where there are metal prostheses (e.g., total hip replacement)
 Available in infant and adult sizes
 Infant size: follow manufacturer’s recommendation for appropriate weight range
 Never cut a grounding pad to fit a patient, always use appropriate size pad
 Place it as close to the surgical site as possible
 Entire surface of the pad should be in uniform contact with pad site
Dangerous Return Electrode Contact with Current Concentration

- If the surface area contact between the patient and the return electrode is reduced, or the
impedance of that contact is increased, the current flow become concentrated at the reduced
contact area causing the temperature at the return electrode increased, results in burn on the
patient

Special Considerations when applying patient plate

 Cardiac pacemaker
 Implanted automatic defibrillator
 Cochlear implant
 Implanted bone growth stimulator
 Body Jewelry
 Orthopaedics implants

Diathermy Modes
Cutting
 Continuous waveform
 Produces High temperatures rapidly, vaporize tissue fluid causing cells to explode
forming a gap in the tissues
 The edges bleed freely & so the coagulation effect is poor

Coagulation
 Pulsed waveform
 Causes generator to modify the waveform so that the duty cycle(on time) is reduced.
 The intermittent delivery produce less heat causing coagulum instead of vaporization-
-> cell desiccation & distort vessel wall --> sealing the vessel
  3 types
- Dessicate: low voltage contact coagulation suitable in laparoscopic & delicate tissue
work
- Fulgurate: non-contact coagulation in most applications
- Spray: for coagulating large tissue areas with superficial depth of necrosis

Blend
- a blended current is not a mixture of both cutting and coagulation current but rather a
modification of the duty cycle. Divided into blend 1, 2, 3.
- from blend 1 to blend 3 the duty cycle is progressively reduced.
- a lower duty cycle produces less heat
- blend 1 causes tissue vaporization(cutting) with minimal hemostasis
- blend 3 is less effective in cutting but has maximum hemostasis

Monopolar tips

o Needle – very high current density, tissue vaporization, cutting effect

o Ball – high current density, coagulation & desiccation
o Plate – very low current density, minimal heating effect

Complication

1. Burns
- Accidental burn at patient plate or other body parts
- More common in monopolar
- Cause: long current path offers opportunities of alternative unwanted passage of
current to earth
2. Fire & explosion
- Alcohol based skin preparation may pool under surgical towels, ignited by sparks from
active electrode
- May ignite intraluminal gas inside distended bowel
 - Precaution: avoid alcohol based skin preparation
3. Smoke
- Surgical smoke: consists of 95% steam and 5% cellular debris, containing variety of
toxic mutagenic chemicals including hydrogen cyanide and benzene. Viruses can also
be transmitted in the smoke
- Viable bacteria including mycobacterium tuberculosis
- Precaution:
o Smoke evacuation system
o Surgical filtration mask
4. Cardiac pacemaker
- Interfere with function, cause arrhythmia and cardiac damage
- Precaution:
o Avoid using diathermy
o Bipolar preferred
o If use monopolar, plate & active electrode as far from heart or pacemaker
o Cutting diathermy avoided, coagulation diathermy only in short bursts
o Heartbeat monitored throughout surgery with defibrillators on standby
o Standby external pacing device in case of internal pacemaker malfunction
5. Unintentionally high current density in pedicles
- Monopolar diathermy
- High current density crosses pedicles causing disastrous heating effect, tissue
destruction and necrosis
- Precaution:
o Monopolar should not be used on organs attached by small pedicles e.g. testis
Suturing technique & knots

Suturing Techniques and Principles

-The needle should only be grasped with needle-holders in 2/3 of the needle length.
- Incorrect placement of the needle in the needle holder may result in a bent needle, injury to
the tissue or undesirable angle of entry into the tissue
- The needle holder should not be tightened excessively as this may cause damage to both
needle and needle holder

Placement of suture
- Ideal skin suture should form a rectangle, penetrating the epidermis and dermis
perpendicular to the skin surface, then turning at a right angle to traverse the depth
 of the wound parallel to the skin surface, and then turning again to emerge from the
opposite skin edge perpendicular to the skin surface
- Requires coordinated use of forceps and needle holder
- Far skin edge is elevated with the forceps in the left hand, while the right hand is
pronated to prepare the needle in taking the first “bite”
- Tip of the needle should penetrate the skin perpendicularly about 5-10 mm from the
wound edge, and the needle should be rotated all the way through the epidermis and
dermis by supinating the right hand to rotate the needle through its arc
- The key is to maintain the position of the skin edge while releasing the needle from
the needle holder
- Needle is released from the needle holder, the right hand fully pronated before
regrasping the needle
- “Bite” can then be completed by supinating the right hand in order to complete the
rotation of the needle through the skin
- The forceps then elevate the near skin edge in preparation for the second “bite”
- Needle is passed upward through the near skin edge by supinating the right wrist in
order to keep the body of the needle perpendicular to the tissue it is passing through
at all times
- Good suturing technique should eliminate dead space in subcutaneous tissues, minimize
tension that causes wound separation. Approximated wound edges should be everted.

Correct configuration of the suture should be share or bottled shaped.

Incorrect configuration of suture. Picture shows the wound edge is inverted.

Cutaneous sutures
1. Simple interrupted
2. Continuous
3. Mattress
-Vertical
-Horizontal
4. Locking continuous
5. Figure of 8
Simple interrupted sutures
- Greater tensile strength
- Less potential for wound oedema and impaired cutaneous circulation

- Tend to cause wound inversion if they are not placed correctly which can prevented
by placing the suture in the flask-like configuration

- Disadvantage: leave a series of crosshatched linear scars resembling railroad tracks.

Simple running sutures
- Useful for long wounds in which wound tension has been minimized by properly
placed deep sutures
- useful over eyelids, ears and the dorsa of hands or can be used to secure the edges of
a full-or split-thickness skin graft
- Less scarring compared to simple interrupted
- Advantage: quick
- Disadvantage: crosshatching, risk of dehiscence if suture material ruptured, difficulty
making fine adjustment along suture line, puckering of suture line
Running locked sutures
- Locked by passing the needle through the loop preceding it as each stitch is placed
- Increased tensile strength (for wounds under moderate tension, those requiring
further haemostasis due to oozing from skin edges)
- Increased risk of impairing microcirculation surrounding wound, can cause tissue
strangulation if too tight
- Useful for scalp and postauricular sulcus

Vertical mattress sutures

Procedure:
- The vertical mattress suture is started 0.5-1 cm lateral to the wound margin.
- Needle is inserted to the depth of the wound to close the dead space. The needle is then
passed to the deep tissue to the opposing wound edge, where it exits the skin on the
opposing side equidistant to the insertion.
-The needle is then reversed in the needle holder and the skin is penetrated again on the side
through which the suture just exited but closer to the wound edge.
-It is passed more superficially to the opposite side, exiting close to the wound margin (1-3
mm of wound margin).
- Advantage : Maximize eversion, reducing dead space, minimize tension across wound
- Width of the stitch should be increased in proportion to the amount of tension on the
wound
- Disadvantage: crosshatching, Improper technique causes wound inversion, uneven tension
and increasing scarring. Time consuming
- Recommended time of removal: 5-7 days (before formation of epithelial suture tracks
complete) to reduce risk of scarring
Half buried vertical mattress sutures
- Bite in the deep part of the dermis on the opposite side of the wound without exiting
the skin, crosses back to the original side of the wound, and exits the skin
- Entry and exit points kept on one side of the wound
- Reducing scarring

Pulley sutures
- Facilitates greater stretching of wound edges
- Useful when beginning closure of wound under significant tension

Far-near near-far modified vertical mattress sutures

- Functions like pulley sutures
Horizontal mattress sutures
Procedure: Penetrate the skin 5-10 mm from the edge of the wound. The needle is then passed
dermally or subcutaneously toward the opposing wound edge where it enters at the same level
in the subcutaneous or dermal tissue. Exit the opposing wound edge through the epidermis
equidistant from the insertion. Reenter the skin on the same side at the same distance from
the wound edge but several millimeters laterally. The needle is then passed dermally or
subcutaneously to the side of initial penetration.

- Used in wounds under high tension, provides strength and wound eversion
- May be used as temporary stay suture to approximate wound edges
- May be placed prior to a proposed excision as a skin expansion technique to reduce
tension
- Disadvantage: suture marks, high risk of tissue strangulation and wound edge necrosis
if too tight
Half-buried horizontal mattress/ 3-point corner/ army-navy/tip sutures
- Position the corners and tips of flaps and to perform M-plasties and V-Y closures

- Provides increased blood flow to flap tips, lowering risk of necrosis and improving
aesthetic outcomes
Procedure : The needle enters the skin from the healthy skin and emerges subdermally. The
suture is passed intradermally in the flap edge or corner and exits from the dermis. It is
reinserted in the dermis of the healthy skin to be brought out for knotting. Thus the suture
lies between subdermal and subepidermal plexus, without compromise of either. The fascial
plexuses lie undisturbed under the stitch and are uncompromised.
-An important use is in insetting of limberg and random flaps, where flap tip necrosis is to be
avoided.

Figure of 8
Hemostatic suture

Absorbable buried sutures

- Provides support for wound, reduces wound tension on wound edges
- Eliminate dead space, anchor sutures
 Subcuticular sutures
 Dermal sutures
 Dermal subdermal sutures
 Subcutaneous sutures

Dermal-subdermal sutures
- Maximizes wound eversion
- Placed by inserting the needle parallel to the epidermis at the junction of the dermis
and the subcutis
- Needle curves upward and exits in the papillary dermis, again parallel to the
epidermis
- Needle inserted parallel to the epidermis in the papillary dermis on the opposing edge
of the wound, curves down through the reticular dermis, and exits at the base of the
wound at the interface between the dermis and the subcutis and parallel to the
epidermis
 Dermal suture
- Reduces tension on the subsequent cutaneous suture
- Ensure good apposition and eversion of skin edges on subsequent cutaneous suture
- Should enter deep reticular dermis no incised edge of the wound
- Pass superficially into papillary dermis

Buried horizontal mattress sutures

- Purse-string suture
- Eliminate dead space, reduce size of a defect, reduce tension across wounds
- Placed in the mid-to-deep part of the dermis to prevent the skin from tearing
Technique
1. The wound edge is reflected back using surgical forceps or hooks. Adequate
visualization of the underside of the dermis is desirable.
2. While reflecting back the dermis, the suture needle is inserted into the
undersurface of the dermis parallel to the incision line just lateral to the incised wound edge.
 3. The first bite is executed by placing gentle pressure on the needle so that it
enters the papillary dermis and then relaxing pressure to permit the needle to exit on the
undersurface of the dermis.
4. Keeping the loose end of suture between the surgeon and the patient, the
dermis on the side of the first bite is released. The tissue on the opposite edge is then
reflected back in a similar fashion as on the first side.
5. The second and final bite is executed by inserting the needle into the
undersurface of the dermis on the contralateral side, with a backhand technique if desired,
and completing a mirror-image loop, so that the needle exits directly across from its original
entry point on the contralateral side.
6. The suture material is then tied

Running horizontal mattress sutures

It is a modification of simple running suture. Instead of crossing over the wound prior to
reentering the skin, the running horizontal mattress suture[13] is done by reentering the skin
on the same side through which the suture material is exited

- For skin eversion, useful in areas with high tendency for inversion e.g. neck
- For reducing spread of facial scar
- Advantage: smoother, flatter scar
- Disadvantage: tissue strangulation if too tight
Running subcuticular sutures
Procedure: It is initiated by placing a needle through one wound edge. The opposite edge is
everted and the needle is placed horizontally through the upper dermis. This is repeated on
alternating sides of the wound
 - Eliminates crosshatching
- Does not provide significant wound strength
- Buried form of running horizontal mattress sutures
- useful to enhance the cosmetic result and is useful for closing wounds with equal
tissue thickness and in which virtually no tension exists

Running subcutaneous sutures

Procedure: It is initiated by placing a single subcutaneous suture [12] with the knot tied
towards the wound surface. Then, it is looped through the subcutaneous tissue by passing
through the opposite sides of the wound. It is tied at the distal aspect of the wound, with the
terminal end of the suture to the previous loop placed on the opposing side of the wound.

- Close the deep portion of surgical defects under moderate tension

- Advantage : fast procedure
- Disadvantage: risk of suture breakage, formation of dead space beneath skin surface
Running subcutaneous corset plication stitches
- Used in wounds wider than 4 cm that are under excess tension
- Creates natural eversion and better wound edge approximation
- Eases subsequent placement of intradermal sutures
- Strength of the suture relies on inclusion of the septations from the fascial layer
beneath the subcutaneous tissue
- Includes at least 1-2 cm of adipose tissue and fascia within each bite
- Disadvantage: suture breakage, wound distortion
Technique
1. The wound edges are reflected back to permit visualization of the deep bed of the
wound. In deep excisions, such as those performed for melanoma or large cysts, the
muscle fascia may be directly visible. Otherwise, visualizing the subcutaneous fat is
appropriate as well.
2. Starting at one pole of the ellipse, the suture needle is inserted at 90 degrees through
the deep fat 2-4 mm medial to the undermined edge of the wound.
3. The first bite is executed by entering the fascia and following the curvature of the
needle, allowing the needle to exit closer to the incised wound edge. The suture material
may be gently pulled to test that a successful bite of fascia has been taken.
4. Keeping the loose end of suture distal to the first bite, attention is then shifted to the
opposite side of the wound. The second bite is executed by repeating the procedure on
the contralateral side.
5. Steps (2) through (4) are then repeated sequentially in pairs moving toward the
contralateral pole of the wound.
6. Once the desired number of paired bites have been taken, the suture is then pulled tight
and tied onto itself using either an instrument or hand tie

Suture removal
- Average wound usually achieves approximately 8% of its expected tensile strength 1-2
weeks after surgery
- Prompt removal reduces risks of suture marks, infection, tissue reaction
- Should not be removed too soon to prevent dehiscence and spread of scar
- Face: 5-7 days
- Neck: 7 days
 - Scalp: 10 days
- Trunk & upper extremities: 10-14 days
- Lower extremities: 14-21 days

Procedure

- Suture line should be cleansed with an antiseptic.

- The interrupted suture is grasped with fine forceps at the knot and is cut on the side
opposite the knot at the suture entry point into the skin.

- Next, the suture is gently pulled out by pulling toward the wound edge.

- A running suture is removed by cutting its every other loop and grasping the
intervening loop with forceps and pulling it out.

- A running sub-cuticular suture is removed by cutting the knot at one end and pulling
the suture out slowly from the other end to minimize the risk of suture breakage in the
wound.

Knot tying
Simple knot:
1. incomplete basic unit
2. Square knot: completed knot
3. Surgeon's or Friction knot: completed tension knot
- Tied suture has 3 components:
o Loop – maintains approximation of divided wound edges
o Throw - wrapping or weaving of two strands
o “Ears” – insurance that the loop will not be untied because of knot slippage
General Principles of Knot Tying
1. The completed knot must be firm, and so tied that slipping is virtually impossible. The
simplest knot for the material is the most desirable.
2. The knot must be as small as possible to prevent an excessive amount of tissue
reaction when absorbable sutures are used, or to minimize foreign body reaction to
nonabsorbable sutures. Ends should be cut as short as possible.
3. In tying any knot, friction between strands ("sawing") must be avoided as this can
weaken the integrity of the suture.
4. Care should be taken to avoid damage to the suture material when handling. Avoid
the crushing or crimping application of surgical instruments, such as needleholders and
forceps, to the strand except when grasping the free end of the suture during an
instrument tie.
5. Excessive tension applied will cause breaking of the suture and may cut tissue.
Practice in avoiding excessive tension leads to successful use of finer gauge materials.
6. Sutures used for approximation should not be tied too tightly, because this may
contribute to tissue strangulation.
7. After the first loop is tied, it is necessary to maintain traction on one end of the strand
to avoid loosening of the throw if being tied under any tension.
 8. Final tension on final throw should be as nearly horizontal as possible. 9
9. Do not hesitate to change stance or position in relation to the patient in order to place
a knot securely and flat.
10. Extra ties do not add to the strength of a properly tied knot. They only contribute to
its bulk. With some synthetic materials, knot security requires the standard
surgical technique of flat and square ties with additional throws if indicated by
surgical circumstance and the experience of the surgeon.

Granny knot

A granny knot is not recommended.

It has the tendency to slip when subjected to increasing pressure.