Basic Surgical Skills Manual

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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.


Table of Contents Foreword 2nd Edition . . . Cenon R. Alfonso, MD, FPCS, Chairman Committee on Surgical Training, Philippine College of Surgeons 2003

Foreword 1st Edition . . . Gabriel L. Martinez, MD, FPCS, Chairman, Committee on Surgical Training, Philippine College of Surgeons 1999

Message from the 2003 PCS President Fernando A. Lopez, MD, FPCS

Preface 2nd Edition . . . Armando C. Crisostomo, MD, FPCS, Regent-In-Charge (2003), Committee on Surgical Training, Philippine College of Surgeons

Preface 1st Edition . . . Jose Y. Cueto, MD, FPCS, Regent-In-Charge (1999), Committee on Surgical Training, Philippine College of Surgeons  Chapter I Learning & Assessing Psychomotor Skills in Surgery Jose Y. Cueto, Jr., MD, MHPEd, FPCS (1st edition) • Self-Assessment Questions  Chapter II The Use of Simulation in Surgical Training Shirard L.C. Adiviso, MD, MHPEd, FPCS • Self-assessment Questions  Chapter III Suture Materials Jose Antonio M. Salud, MD, FPCS and Jerome G. Baldonado, MD, FPCS (1st edition) Joey H. Bienvenida, MD, FPCS (2nd edition) • Self-assessment Questions  Chapter IV Surgical Needles Cenon R. Alfonso, MD, FPCS and Nilo C. de los Santos, MD, FPCS (1st edition) Renato A. Ocampo, MD, FPCS (2nd edition) • Self-assessment Questions

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

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

Foreword • 2nd Edition

An audiovisual simulation in basic surgical technique Even a full decade before the turn of the 21st

patient, basic surgical technique is almost second

Century, the growing movement toward a paradigm shift of surgical skills training has already begun. This

nature. The first step towards the above-mentioned goal is to

shift is from the operating-room-patient venue into the surgical skills laboratory-simulation setting.

be able to experience an audiovisual simulation. This is the importance of this CD version and Edition of the

Because of this propensity, it will become unacceptable in the near future for young surgical trainees to be

Basic Surgical Skills Manual. To all the members of the CST, Atong, Shirard, Joey,

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

and Ike, most specially to the Regent-in-Charge, Armand, thank you and congratulations for all your selfless efforts, contributions, and seemingly-endless

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

Cenon R. Alfonso, MD, FPCS

been adequately satisfied. This likewise implies that the trainee has progressed from being unconsciously

Committee on Surgical Training (2003) Philippine College of Surgeons

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 • 1st Edition

Addressing need for problem-oriented instructional tool This manual was conceived in 1996 in answer to a

through its Franchise Manager, Ms. Ruth Nicolas,

palpable need for a structured, problem-oriented instructional tool for trainees and surgical practitioners.

engaged the services of Creative Powerhauz to publish this manual.

In 1998, during the incumbency of Dr. Antonio B. Sison, the Committee on Surgical Training (CST) through

As in any endeavor, there are unsung heroes whose efforts were vital to the completion of this project: the

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

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.

creation of the Sub-committee on Skills Improvement under Dr. Jose Antonio M. Salud.

Montemayor. Special thanks to Dr. Elizabeth F. Mabilangan-Salud and Ms. Olivia S.M. Manzano, CST

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

Gabriel L. Martinez, MD, FPCS

Philippines through Mr. Bayani R. Santos, Jr. and Mr. Erwin Tantoco who favorably endorsed the project.

Committee on Surgical Training (1999) Philippine College of Surgeons

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


Message from the 2003 PCS President

The backbone for all cutting specialties Clinical acumen, surgical knowledge and decision-

certain technique is performed by simulation or in a

making, and the right attitude and motivation do not make up a complete Surgeon.

patient, the young trainee can view this first and then play back for feedback.

These have to be adequately matched by a set of fine psychomotor skills, i.e. mastery of technical compe-

In the long term however, this CD Edition of the Basic Surgical Skills Manual will play as the backbone

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

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-

muscle and discipline of each movement they create during operations into a purposeful progress towards

late the Committee on Surgical Training for this project. Allow me to extend a similar warm recognition to the

the goal of every procedure they perform. This aspect of surgical training essentially requires

partner of PCS in this project, Johnson & Johnson Medical Philippines.

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

Fernando L. Lopez, MD President 2003

Preface • 2nd Edition

Uplifting the practice of surgery in the Philippines Despite all the attention given to the development of

Subsequently, we intend to pursue publication of the

a strong basic theoretical foundation in surgery and the enhancement of attitudinal competencies, the surgeons

Advanced Surgical Skills Manual, which highlights more advanced techniques to include laparoscopic ap-

of today continue to be judged mainly by the quality of their technique in the performance of various surgical

proaches. Finally, we also plan to pursue the establishment of a

procedures. Major requirements for the accreditation of residency training programs in surgery continue to highlight the

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

need for adequate operative experience in order to ensure the competency of our trainees.

unwavering determination to attain our vision of being the leading organization in uplifting the practice of

Despite the importance of the operative skill, continuing education in this regard continues to be

surgery in the country.

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.

Armando C. Crisostomo, MD, MHPEd, FPCS Regent-in-Charge (2003) Committee on Surgical Training Philippine College of Surgeons

Preface • 1st Edition

A foundation for learning basic surgical skills 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 opportunities to perform in actual patient situations, suturing different kinds of wounds, but many of them unsupervised. During residency, they assist numerous operations and surgical procedures. Through constant exposure and observation, residents get to absorb the practices, the

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 consequences - leaks from repairs, blow-out of anastomoses, disruption of abdominal closures and many others. Undoubtedly, many of these complications are multifactorial, 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 components 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, FPCS Regent-in-charge (1999) Committee on Surgical Training Philippine College of Surgeons

Chapter I Teaching and Assessing Psychomotor Skills in Surgery Jose Y. Cueto, Jr., MD, MHPEd, FPCS

Phase 1

Cognitive Phase

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

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.

I. Relevance and Importance

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.

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 anastomoses, 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.

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.

II. Theoretical Basis for Learning Skills A. Fitt’s three-phase theory

During this phase, there is increasing resistance to stress and

interference from other activities, and in fact, concurrent activities


may be performed. C. Need for structure These characteristics of performance are found in specialists and experts, marked by a high level of proficiency.

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

III. Educational Implications

trainees will absorb only the good practices of their seniors and superiors. In order to obtain the required level of proficiency in

A. Need to recognize the phases of learning skills

surgical skills, a structured method of teaching and assessment is needed.

To make the acquisition of psychomotor skills more effective, the trainors should understand and apply the different phases of

Supplementary workshops that include multi-station, hands-

learning. Each resident presents with his/her own level of knowledge and competence with regard to a particular skill. The

on and interactive format will be of great help. The residents rotate through different stations learning about needles, sutures

trainor must be able to bring the residents through the different phases of learning.

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

An educational activity that addresses the cognitive phase of skills learning is the pre-operative conference. Residents go

governing their use, and the correct steps that should be followed.

through details in a procedure and verbalize the steps in a particular operation and how complications are to be avoided.

D. Need for guidance, supervision and feedback

Another very important activity is the operative assist. Operations that residents assist in are actually considered “demonstrations”

It is during the fixation or associative phase where residents

by consultants and senior residents. Needless to say, the residents must be exposed to the correct way of performing different

develop their own pattern of action and behavior. They are exposed to different consultants and senior residents who have

operations and techniques.

their own way of performing different techniques. The residents should be able to determine and decide which steps and tech-

The skills that residents learn take years to refine, and are finally incorporated into the autonomous phase of behavior.

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

Once habits become part of autonomous behavior, it becomes very difficult to unlearn them.

When residents in lower years are allowed to acquire “bad habits” and incorporate them into their practice, it becomes very

B. Need for focus and clarity

difficult for them to unlearn these habits when they reach their senior years. There must, therefore, be adequate guidance and

In order that lower level residents know what needs to be

supervision. In addition, timely feedback should be given regarding what needs to be corrected and how they are to be

learned, complex tasks must be broken down into sub-tasks. The residents focus first on learning the simpler sub-tasks before

corrected. In this way, only the proper steps are incorporated into the autonomous phase of skills acquisition.

graduating to complex tasks. Ideally, these skills should be learned in the laboratory using simulations, using inexpensive

E. Need for simulation and practice

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

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

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

the residents should already be determined and corrected. This is to make surgical training safe, and avoid unnecessary complica-

observes the trainee. With the use of objective checklists and rating scales, the performance is determined to be satisfactory or

tions that may arise from operations and procedures done incorrectly.

unsatisfactory. The results are then fed back to the trainees for them to know where they need to improve on.


all residents go through the same stations and the same tasks. This is very difficult to attain in real clinical situations where cases

The use of structured clinical or practical exams ascertain that Assessing Psychomotor Skills

A. Direct observation with the use of checklists and rating scales

differ in degree of difficulty. Even similar cases of appendicitis present with varying technical difficulties depending on patient habitus, position of the appendix, etc.

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

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

outcomes, such as the presence/absence of complications. However, this method relies heavily on the accuracy and com-

Morgan M and Irby D. Evaluating Clinical Competence in the Health Profession; C.V. Mosby, Co., St. Louis, 1978

pleteness of the operative records.

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

Self-Assessment Questions (Chapter I) 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 preoperative conference

Column B A. Cognitive Phase B. Fixation Phase C. Autonomous Phase

___3. Learning through demonstration-return demonstration with trainor ___4. Performing operations independently and smoothly ___5. Describing operative complications

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 assessment 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

Simulation (using physical models, computer program or

Objectives of this chapter

combination of two) provide the opportunity to achieve and evaluate skills through repeated practice within a safe and

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

controlled environment.

1. Understand the role of simulation in surgical training. 2. Conduct teaching and learning activities in basic and

Advantages of Simulation

advanced surgical skills using simulation. 1. The training design can be formulated based on the

All surgical trainees need a core of basic surgical skills regardless of their specialties. This requires continuous deliberate 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 commitment 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.

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 inexpensive 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.

2. Computer Based Simulators (shown below)

A Simple Taxonomy of Simulators (Medical Education, 2003) SKILL



Precision Placement

Direct needle Instrument to a point

Intravenous needle insertion Lumbar puncture

Simple Manipulation

Guide a catheter Endoscope Ultrasound probe

Angioplasty Colonoscopy Bronchoscopy Abdominal ultrasound

Complex Manipulation

Perform single complex task

Bowel/ vascular anastomosis , MIST-VR, Lap Sim

Integrated Procedure

Perform multiple task of entire procedure

Laparoscopy 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.

1. Hybrid Simulation- combine physical model with comput-

first principles, avoiding any assumption of previous knowledge.

ers using realistic interface like instruments and real diagnostics.

7. It is easy to overestimate the knowledge and skill of any group of learners, especially as they may be embarrassed to

Kneebone’s 5 Stages of Training Method

admit their ignorance. Assume nothing but go right back to basics – provided you treat the learners with respect, they will

1. Watching an animated graphic of procedure.- essential points of technique are shown by animated graphics usually

value the experience.

with spoken commentary.

8. Do not overestimate the complexity needed in basic surgical skills teaching.

2. Watching a clinical video of the procedure- short clinical video sequences show the techniques performed by an expert

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

on a real patient.

be teaching and with any models used.

3. Watching the procedure demonstrated on a modeldemonstrated a simulated tissue model by the same expert

10. Setting up basic surgical workshop requires thought and planning but need not be prohibitively expensive.

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.

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.

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 demonstrated, 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

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. The American Journal of Surgery. Vol 177, Apr.1999 Connor, Michael et al. A Computer Based Self-Directed Training Module for Basic Sutures. 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.

Self-Assessment Questions (Chapter II) 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

Chapter III Suture Materials Jose Antonio M. Salud, MD, FPCS and Jerome G. Baldonado, MD, FPCS Jose Joey Bienvenida, MD, FPCS

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

Objectives of this Chapter:

of a 2-0 suture.

After going through this material, the learner is expected to: 1. Analyze the different types of sutures and their character-

Suture materials are generally classified as

istics. 2. Discuss the newer “suture materials” and their characteristics. 3. Discuss guidelines in choosing a suture material based on its biological behavior and mechanical performance.

being absorbable or non-absorbable. (Refer to Table A: Classification 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

Sutures are fibers of strands of a material used for sewing tissues to help wound healing by surgically approximating its

are not arrested by either enzymes or tissue fluids.

edges. The material used to close blood vessels to achieve hemostasis is called ligature.

The most frequently used absorbable non-absorbable suture materials are the following:

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

Absorbable Sutures 1. Plain Catgut

strips. However, it was only in 1860 when Joseph Lister introduced carbolic catgut, the first suture material specifically for

Plain catgut is derived from the collagen of small

surgical use. Eventually other materials were introduced for surgical use such as linen, silk, celluloid, horsehair, wire, etc.

intestine, either the serosal layer of cattle or the

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 significant 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

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 recommended for use in situations in which a suture is needed only during the first week of healing as in soft tissues like subcutaneous tissue and ligature purposes.

Table A – Classification of Suture Materials

Based on Origin Suture Material

Origin Natural

Animal Catgut Silk Vegetable Cotton Mineral Steel Silver Polyglactin 9101 Polyglycolic Acid Poliglecaprone 25 Polyglyconate Polydioxanone Poly (L-lactide/glycolide) Nylon Polyester Fiber Polypropylene Poly (hexafluoropropylene-VDF)

Submucosa of sheep intestine or serosa of beef intestine Raw silk spun by silkworm Cotton Plant Specially Formulated iron-chromium-nickel-molybdenum alloy Silver Synthetic Copolymer of glycolide and lactide with polyglactin 370 and calcium stearate, if coated Homopolymer of glycolid Copolymer of glycolide and epsilon-caprolactone Copolymer of glycolide and trimethylene carbonate Polyester of poly (p-dioxanone) Copolymer of lactide and glycode with caprolactone and glycolide coating Polyamide polymer Polymer of polyethylene terephthalate (may be coated) Polymer of propylene Polymer blend of poly (vinylidene fluoride) and poly (vinylidene fluoride-cohexafluoropropylene)

Based on BEHAVIOR Absorbable Catgut Polyglactin 910 Polyglycolic Acid Poliglecaprone 25 Polyglyconate Polydioxanone Poly (L-lactide/glycolide)

Non-Absorbable Cotton Steel Silk Silver Nylon Polyester Fiber Polypropylene Poly (hexafluoropropylene-VDF)

Based on STRUCTURE Monofilament

Multifilament (Braided)

2. Chromic Catgut

4. Polyglycolic Acid

This suture material is actually similar to plain

This synthetic braided suture is reduced by

catgut except that it is treated with chromate

the hydrolysis to glycolic acid. Like most

compounds, which results in a stronger and more

synthetic sutures, the inflammatory reaction

slowly absorbed suture. Thus, the loss of tensile

that results from its breakdown is only

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

minimal. Its tensile strength is completely lost by the 30th day. Complete absorption occurs about the 90th day. 5. Polydioxanone

the absorption. This should not be used when extended approximation of tissues under stress is required, as in fascia. Both

This is a synthetic monofilament absorb-

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.

able suture composed of the polyester of p-dioxanone. It takes longer for

3. Polyglactin This is a synthetic braided suture whose raw

its tensile strength to be reduced as well as for its absorption to be compared with the two

material is a copolymer of glycolide and lactide.

previously mentioned suture materials. In vivo studies have shown its tensile strength to be at about 70% at 14 days and

Most absorbable in synthetic sutures,

50% is retained at 28 days. Absorption starts close to the 90th day and is complete at 6 months time.

polyglactin included, are hydrolyzed during

6. Poliglecaprone

absorption rather than being broken down enzymatically (as with the natural absorbable sutures). In hydrolization, water

This is a monofilament suture whose

gradually penetrates the suture filaments causing the breakdown of the suture’s polymer chain which results in lesser degree of

tensile strength in the first week is high but rapidly

tissue reaction following tissue implantation. 75% of the strength of this suture is retained at 14 days, and about 50% is retained

reduces soon after. Studies have shown its

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.

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

4. Polypropylene 1. Silk

Polypropylene is a non-absorbable synthetic

By far, still the most commonly used suture

monofilament suture. This suture’s tensile

material, silk is a protein filament

strength retention is indefinite and is a suture

produced by silkworms. As with most

that is encapsulated by tissues when implanted thus resisting tissue degradation. Because of these characteris-

braided sutures, silk holds knots well.

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

However, silk loses its tensile strength when exposed to moisture and should be used

5. Polyester This suture was the

dry. Silk loses much, if not all of its tensile strength within a year. Although classified as a non-absorbable suture, silk can actually

first synthetic suture material shown to last

be absorbed slowly but the absorption rate is variable.

indefinitely in tissues. Like polypropylene, poly-esters sutures are

2. Cotton This is a commonly used braided non-

encapsulated by tissues and thus resist

absorbable suture much like silk. It stimulates an

tissue degradation.

inflammatory reaction greater than that of silk

6. Wire/Stainless Steel/Titanium

and other sutures is that this material is relatively

A very strong suture material that produces


little loss of tensile strength, wire has been used for many years and is a popular

3. Nylon This particular non-

suture for a variety of operations (thoraco-

absorbable suture comes in a monofilament and braided form. This suture is characterized by its

cardiovascular, orthopedics, neurosurgery). Tissue reaction is minimal. However, it is difficult to handle and may be easily

high tensile strength and extremely low tissue

palpated by the patient.

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.

Table B – Suture Materials and Characteristics TABLE




Tissue of Origin

Number of strands


Absorption Rate

Inflammatory reaction

Knot Security (minimum # of knots)

Plain Catgut

Collagen of small bowel of cattle & sheep


Absorbed by Enzymatic Proteolysis

Complete within 70 days



Chromic Catgut

Collagen of small bowel of cattle & sheep


Absorbed by Enzymatic Proteolysis

Over 90 days




Copolymer of lactide & glycolide coated with polyglactin 370 & calcium stearate

Multifilament & Monofilament (size 10-0 only)

Absorbed by Hydrolysis

Complete in 56-70 days



Polyglycolic acid

Glycolic acid polymer


Absorbed by Hydrolysis

Complete in 90 days




Copolymer of glycolide and epsiloncaprolactone


Absorbed by Hydrolysis

Complete in 91-119 days




Polyester polymer


Absorbed by Hydrolysis

Complete in 180 days











Cotton Plant







Long-chain polymers of nylon







Crystalline stereoisomer of polypropylene







Polymer of polyethylene terephthalate






Wire/Stainless Steel/Titanium

316L stainless steel

Multi- & Monofilament





Surgical Staplers

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

surgical stapling

techniques. Meshes may be non-absorbable or absorbable.

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

Non-absorbable Meshes

significantly reduced with the use of staplers and anastomoses appear to function sooner as compared with manual suturing

Most common types of materials used in non-absorbable meshes are polypropylene, polyester (macroporous structures)

techniques. The stainless steel staples that are used are virtually inert producing minimal tissue inflammation and minimal tissue

and polytetrafluroethylene (PTFE) (microporous structures).

compression. However, with the use for staplers for skin repairs, the closure may be less meticulous. Another disadvantage of

Polypropylene may be monofilament or multifilament. Both exhibit high burst strength. It is knitted in such fashion as to

staplers is that it may interfere with computed tomography and magnetic resonance imaging.

interconnect each monofilament fiber and provide unidirectional elasticity. This mesh is porous. Skin Adhesives 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.

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).

Guidelines in Choosing a Suture Material

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

1. High tensile strength

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 application 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

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

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 antimicrobial properties against gram-positive organism and may decrease wound infections. However, they have a lower tensile strength than sutures.

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

several ways:

sutures based on their physical properties: 1. Tensile strength - refers to load applied per unit of cross 1. Sutures should be at least as strong as normal tissues through which they are placed.

section area in lbs/in2 or kg/cm2 2. Breaking strength - measurement of force required to

2. Suture strength must be maintained until the wound gains maximum strength.

break a wound without regard to its dimension 3. Bust strength - amount of pressure necessary to rupture a

3. Tissue reaction to sutures should not prolong the healing process.


To apply these principles, one must have information

Tensile strength is the preferred measurement for homogenous materials (ex.,. sutures). For heterogeneous materials (ex.,

regarding the normal strength of tissues, the rate at which injured tissues regain strength, the strength of different sutures,

skin), the breaking strength is more practical to use. For hallow organs (ex., intestines), burst strength is the more appropriate

the rate at which sutures lose strength and the interaction between sutures and tissues.

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:




Plain Cutgut


Chromic catgut Linen-Cotton Silk Braided Uncoated polyester Braided Uncoated Polyamide Braided Coated Polyamide Synthetic Absorbable Monofilament Polyamide Monofilament Polyester Polypropylene

Lowest Reactivity

Steel Titanium

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

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

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

Self-Assessment Questions (Chapter III) 1. Which of the following sutures are considered non-absorb-

4. Which of the following sutures loses tensile strength the

able? a. Polyester b. Polydioxanone

longest? a. Chromic catgut b. Polyglactin

c. Polyglactin d. Polyglycolic acid

c. Polyglycolic acid d. Polydioxanone

e. Poliglecaprone

e. Poliglecaprone

2. Which of the following suture material has an indefinite tensile strength?

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

a. Nylon b. Silk

a. Plain catgut b. Chromic catgut

c. Polyester d. Polypropylene

c. Polydioxanone d. Poliglecaprone

e. Polyglactin

e. Staplers

3. Which of the following is a characteristic of skin adhesives? a. Interferes with MR imaging

6. Which of the following suture materials exhibits the highest inflammatory tissue reaction?

b. Consumes more time compared to sutures c. Yields similar cosmetic results as with subcuticular sutures

a. Polypropylene b. Polyglactin

d. Is used for joints lacerations e. Produces pain on application

c. Chromic d. Silk e. Polyester

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

8. The following statements regarding the physical properties of

choice to approximate fascia after a contaminated operation? a. Plain catgut

sutures and tissues are true EXCEPT? a. Above the limits of normal tissue strength, there is no

b. Polypropylene c. Silk

advantage with the use of a larger or stronger suture b. A suture should hold injured tissues in apposition until

d. Chromic catgut e. Cotton

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

Chapter IV Surgical Needles Cenon R. Alfonso, MD, FPCS & Nilo C. de los Santos, MD, FPCS Renato Cirilo A. Ocampo, MD, FPCS

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

Objectives of this Chapter

French-eye needles requiring the scrub nurse to thread the suture into the eye of the needle. The double strand of the

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

suture that results from threading and the increase in diameter of the needle because of the presence of the eye, causes

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

additional trauma to tissues and in anastomotic procedures, may lead to leakages.

available needles. Moreover, threading is time consuming and the needles are difficult to prepare during surgery. A weak point is created near 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

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.

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

Anatomy of the Surgical Needle

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

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)

other orthopedic procedures. 4. Taper Cut (Trocar point)

A. Needle Point

This is a blend of the combined features of the

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

reverse cutting and the taper point needles. Three cutting edges extend approximately 1/ 32 inches back from the point.

smoothly penetrate the type of tissue to be sutured. 1. Tapered

All three edges of the point are sharpened to provide uniform cutting action. It easily penetrates dense tough tissues. This type

The body of the needle tapers to a sharp point at the

is used for sclerotic or calcified tissues and for heavy fibrous tissue such as the fascia. A typical example is V-40.

tip. The taper point needle is often preferred where the

5. Conventional Cutting Edge

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-

The cutting sharp edge is in the concave curvature of the needle. This is ordinarily used

mation of the peritoneum, fascia and subcutaneous tissues. Examples are needles code-

in common plastic surgery procedures and in closure of

named CT-1 and SH.

superficial wounds and incisions. An example is the

2. Blunt A rounded blunt point that

PC-5 needle.

does not cut through tissues is used for penetrating friable,

B. Needle Body

parenchymal and vascular tissues like the liver, spleen or

The portion between the point and the swage of a needle is called its body. This is the grasping area of the needle holder.

kidneys. An example is the BP1 needle.

C. Attachment End

3. Reverse Cutting

1. Swaged

These needles have a cutting edge in the outer convex

This is the area in which the suture is attached to the needle. It is of specific

curvature of the needle. This cutting edge may extend from

importance to the needle-suture relationship.The ideal swage area

the point of the needle down to the swaged area. The cutting edge may also extend only down

diameter is a one-to-one sutureneedle ratio so that the more exact the

to 1/3 of the distance to the swaged area. This type is most useful in plastic surgical procedures. These types of needles are

sizes correspond to each other, the lesser the damage to the tissues. On

coded PS- 2 and OS-8. The latter type is also indicated in the closure of skin and various plastic surgery applications and

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

4. Control Release Needle Suture

needle puncture leaks. Suture attachments to the needle are most commonly done in two ways:

These needle sutures allows easy detachment of the needle from the suture when desired by the surgeon. This allows rapid placement of

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

sutures in succession, reducing operative time.

channel around the suture in order to hold it tightly. D. Chord Length 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 chord length is defined as the straight line distance from the point of a curved needle to the swage. This varies from 2

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

mm. to more than 5 cm. Length is a determining factor in the width of the bite taken by the needle. Chord length comparison

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

between the CT-1 needle and the TP-1 needle will make the biggest difference in the width of the bite.

achieve the closest one-to-one needle-suture ratio. Laser-drilled needles are currently available among cardiovascular products.

E. Needle Diameter

It has the advantage of a tapered swage which in turn provides a smoother transition from needle to suture. In addition, a laser-

This refers to the gauge or thickness of the needle wire. Needle diameter varies from 30 microns to 56 mil (.056 inch).

drilled needle allows the so-called extended side flattening, a design that adds strength and resistance to bending.

The diameter equals the size of the needle tract.

2. Closed Eye

F. Needle Radius

Similar to a household sewing needle, the shape of the closed eye may be round,

If the curvature of the needle were to con-

oblong or square.

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

3. French Eye

inches. The curved needle is always thought of as part of a circle.

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.

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

H. Needle Length

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

This is the distance between the point and the swage measured along the body of the needle.

1/4 circle (TG) 3/8 circle (P) 1/2 circle (CT) 5/8 circle (UR)

Needle Arming

straight or Keith needle

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

TG Needle: Their use is often limited to ophthalmic and microsurgical procedures. Size and depth of the area to be

on securely at the tip of the needle holder’s jaws. There are various types of holders to accommodate different needles and

sutured are small and shallow.

for different locations and tissues. The following factors must influence the needle holder’s choice:

P Needle: This is the most commonly used curved needle. It can be easily manipulated in relatively large and superfi-

1. Security of the needle in the holder 2. appropriate size for specific needles

cial wounds such as closure of the dermis with slight pronation of the wrist. Because of a large arc of manipulation required, 3/8 circle needles are awkward to use in

3. appropriate length for specific procedures

deep cavities such as the pelvis or in small, cramped areas with difficult access.

Single Versus Double Armed Suture Commonly used sutures have one swaged-to-suture strand.

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

Situations do arise wherein there is a need to place a suture at a midpoint and suturing must continue on both sides. The typical

difficult to reach locations though it requires more pronation and supination movements of the wrist than a 3/8 circle needle.

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

UR Needle: the tip of a 1/2

individually. An example is the CT-1, CP-1 double armed needle suture combination for episiotomy repair.

circle needle such as the CT-

Characteristics of Surgical Needles and their Clinical Impor-

1 can become obscured by


other tissue deep in the

Trauma to the tissue edges that are sutured together during surgical procedures, among other factors, theoretically spells an

pelvic cavity. When this

integral part of the outcome of wound healing. The relationship is, in fact, indirectly proportional. The greater the trauma

occurs, the surgeon may

induced, the poorer the outcome. If it were an intestinal anastomosis, for example, excessively traumatized ends may result to a

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

poorer blood supply, affecting the integrity of the intestinal layers, and complete apposition. Subsequent wound healing

advantageous in these situations.

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

needle, and

achieve the best outcome with the least tissue damage. Therefore, surgical needle design, characteristics and usage play

4. There is no eye. With the smooth passage of the needle and the suture through the tissue, the injury to the edges are

significant roles in the art and science of surgery.


Sharpness and Pointedness

Rigidity versus Flexibility

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

Rigidity of surgical needles is dependent on the diameter,

tion of the blade of cutting surgical needles. This is obviously not applicable among needles that are not flattened at the distal

composition of the metal alloy used and the temperature by which they were set (tempered). This is, therefore, affected by its

body and point. (Needles that are round may either be pointed or blunt at the opposite end of the swage). But cutting needles

frequency of being subjected to autoclaving. Rigid needles are necessary in suturing bones, cartilage and very tough fascia.

can become blunted both at their point and at the flattened body mainly due to repeated usage or friction against hard

Hernia needles, sternal needles and needles used to wire bones together are some examples. Rigid needles tend to break when

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

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.

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

Rust-free and Corrosion-free Needle Material

fibers rather than cut them. Minute lacerated wounds created by using cutting needles may completely tear at their corners when

Stainless steel needles are generally rust- and corrosion-free. Most surgical needles are no longer made of lesser quality. Their

subjected to tension. Literally, they tend to extend easily to a rent. Punctured wounds by nature are not prone to renting and

flexibility, inertness and smoothness are other characteristics that are most desirable in surgical needles for medical grade

are easily plugged. Thus, among hollow organs like viscus and blood vessels, pointed round needles are favored.

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

On the other hand, tough tissues like the epidermis and the subcuticular layers are difficult to traverse with pointed needles.

Needle Weakpoints

Thus, the cutting action of a flattened needle is desirable. These tissues are not prone to lacerations or renting due to its fibrous

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

Atraumatic Needles

passing a curved needle through tough tissues, the straight portion of the eyed needle may be pulled by the surgeon at an

This is a misnomer. All needles cause some form of trauma to sutured tissues. So-called atraumatic needles cause the least

acute angle against the tissue. In other situations, the surgeon may load the needle at this weak point and apply the drive force

injury. This is so because of the following characteristics: 1. Small diameter,

through the tissue. Another weak point, particularly among atraumatic round

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

needles, is the junction of the body and the point. The surgeon may force the body of the curved needle through the tissues at

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.

REFERENCE Ethicon Wound Closure Manual, Ethicon, Inc., 1994

Self-Assessment Questions (Chapter IV) 1. Which of the following needles are most applicable when

4. Surgical needles most commonly used for bowel anastomosis

suturing deep in the pelvic cavity? a. 1/4 circle b. 3/8 circle

is: a. Reverse cutting b. Circle tapered

c. 1/2 circle d. 5/8 circle

c. Cutting tapered d. Rounded blunt

e. straight needle

e. Conventional cutting

2. For suturing liver lacerations, the surgical needle to use is: a. CT series b. SH series c. BP series

a. MO b. PS

d. TP series e. V-4 needles 3. The surgical needle for microsurgical procedures is: a. UR-4 b. PS-1 c. XLH

5. The needle to use in the primary repair of a complete but clean traumatic transection of the ureter is:

d. V-4 e. CT-1

d. X-1 e. RB-1

Chapter V Knot Tying Jose Antonio M. Salud, MD, FPCS Miguel C. Mendoza, MD, FPCS Knot Tying Techniques

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.

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.

2. Purple strand held in right hand brought between left thumb and index finger.

General Principles of Knot Tying In knot tying, general principles to be following:

Square Knot (Two-Hand Technique)

adhered to are the

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.

3. Left hand turned inward by pronation, and thumb swung under white strand to form the first loop.

4. Purple strand crossed over white and held between thumb and index finger of left hand.

Knot Tying Techniques Square Knot (Two-Hand Technique)

5. Right hand releases

9. By further supinating

purple strand. Then left hand supinated, with

left hand, white strand slides onto left index

thumb and index finger still grasping purple

finger to form a loop as purple strand is grasped

strand, to bring purple strand through the white

between left index finger and thumb.

loop. Regrasp purple strand with right hand.

6. Purple strand released

10. Left hand rotated inward by pronation with

by left hand and grasped by right. Horizontal

thumb carrying purple strand through loop of

tension is applied with left hand toward and

white strand. Purple strand is grasped

right hand away from operator. This completes

between right thumb and index finger.

first half hitch. 11. Horinzontal tension 7. Left index finger released from white strand and left hand again supinated to loop white strand over the left

applied with left hand away from and right hand toward the operator. This completes the second half hitch.

thumb. Purple strand held in right hand is angled slightly to the left.

8. Purple strand brought toward the operator with the right hand and placed between left

12. The final tension on the final throw should be as nearly horizontal as possible.

thumb and index finger. Purple strand crosses over white strand.

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.

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.

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.

2. Purple strand brought over white strand on left

6. Purple strand releases by left hand and grasped

index finger by moving right hand away from

by right. Horizontal tension is applied with


left hand toward and right hand away from operator. This completes first half hitch.

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.

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.

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. 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.

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Surgeon’s or Friction Knot

1. White strand placed

5. The loop is slid onto

over extended index finger of left hand and

the thumb of the left hand by pronating the

held in palm of left hand. Purple strand held

pinched thumb and index finger of left hand

between thumb and index finger of right

beneath the loop.

hand. 2. Purple strand crossed

6. Purple strand drawn

over white strand by movin right hand away

left with right hand and again grasped between

from operator at an angle to the left. Thumb and index finger of left

thumb and index finger of left hand.

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.

7. Left hand rotated by supination extending left index finger to again pass purple strand through forming a double loop.

4. Left hand rotated by supination extending left

8. Horizontal tension is applied with left hand

index finger to pass purple strand through

toward and right hand away from the operator.

loop. Regrasp purple strand with right hand.

This double loop must be placed in precise position for the final knot.

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.

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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

5. Purple strand looped over and under white strand with right hand.

holds purple strand in palm of hand. White strand held in left hand.

2. Purple strand held in right hand brought

6. Purple strand looped around white strand to

between left thumb and index finger. Left hand

form second loop. This throw is advanced into the

turned inward by pronation, and thumb swung

depths of the cavity.

under white strand to form the first loop.

3. By placing index finger of left hand on white

7. Horizontal tension applied to pushing down

strand, advance the loop into the cavity.

on purple strand with right index finger while maintaining counter tension on white strand with left index finger. Final tension should be

4. Horintal tension applied by pusing down on white strand with left index finger while maintaining countertension with index finger of right hand on purple strand.

as nearly horizontal as possible.

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 onehand technique as previously illustrated.

Instrument Tie

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

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

5. With end of the strand grasped by the needleholder, pugple strand is drawn through loop in the white strand away from the operator.

the operator.

2. Needleholder in right hand grasps short purple end of strand.

6. Square knot completed by horizontal tension applied with left hand holding white strand toward operator and purple strand in needleholder away from

3. First half hitch completed by pulling needleholder toward

operator. Final tension should be as nearly horizontal as possible.

operator with right hand and drawing white strand

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away from operator. Needleholder is released

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from purple strand.

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.

Granny Knot 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.

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

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

This entails running the tip of the scissors lightly down the suture strand to the knot. Most sutures are cut close to the knot,

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.

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-

REFERENCES Knot Tying Manual, ETHICON, 1996 Ochsner, A and DeBakey ME. Christopher’s Minor Surgery, 8 Co.


ed., WB Saunders

Self-Assessment Questions (Chapter V) 1. In knot tying, which among the following sutures will require more throws to maintain the knots in place?

2. Why are more throws required for maintaining knots when tying monofilament sutures?

a. Silk b. Polyester

a. They are more difficult to handle b. The knots have a tendency to loosen

c. Nylon d. Wire

c. More tension is required to maintain monofilament sutures d. None of the above

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

Simple Interrupted Objectives of this Chapter

Each stitch is tied independently of other stitches.

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 approximation. 2. Perform the various suturing techniques for their application 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 microorganisms may be less likely to travel along a series of interrupted stitches.

Simple Interrupted

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Vertical Mattress

Horizontal Mattress Suture

A vertical mattress suture starts some distance from the

A horizontal mattress suture starts some distance from the wound

wound edge, passes deeply under the wound and emerges on the opposite side at the same distance from the edge. It then

edge, also passes under the wound to emerge on the opposite side at the same distance from the edge. Then, coming from the

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

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

it. The vertical mattress suture gives a good approximation of the skin edge and therefore results in a cosmetically acceptable

at the same distance from the edge, where it is tied. The horizontal mattress provides coaptation in an everted fashion. It is used for

scar. It is frequently used for fine skin closure. The vertical mattress consists of a “far-far, near-near” component. The

closure of deeper tissues such as fascia.

vertical mattress is also known as the Stewart suture.

Interrupted Horizontal Mattress

Interrupted Vertical Mattress Click here for video of Vertical Mattress

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Figure of Eight Mattress Suture A figure of eight mattress suture starts at some distance from

Subdermal Interrupted This technique is used to close wounds where cosmetic

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

aspects are especially important. It carries the advantages of completely avoiding stitch marks. This may be done in inter-

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

rupted or continuous fashion. It can only, however, be recommended in wounds with low degree of contamination.

subsequently tied. This provides an everted type of approximation of tissues and is used primarily for the deeper planes.

Subdermal Interrupted

Figure of Eight Mattress

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Continuous Interlocking

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

This involves passing each stitch in continuous fashion through the loop of the previous stitch.

strand tied together. A continuous suture line can be placed rapidly. 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 strangulation. Overtensioning and instrument damage should be avoided to prevent suture breakage which could disrupt the entire line of a continuous suture. Continuous Interlocking

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

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wall to provide a temporary seal during the healing process. This technique is used to close wounds where cosmetic Simple Continuous (Over and Over running stitch) This involves making more than one stitch with a single

aspects are especially important. It carries the advantages of completely avoiding stitch marks. This may be done in interrupted or continuous fashion. It can only, however, be recommended in wounds with low degree of contamination.

suture strand before the knot is tied.

Over-and-Over Running Stitch Subcuticular

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Note: This procedure approximates the serosa while mucous membrane is inverted and fibromuscular layer is well grasped.

This is the most important fundamental suture in gastrointestinal 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.

Objection: Takes more time for placing and tying and must be positioned closer together to ensure water tight closure.

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. Lembert Stitch

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

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

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

outside only on the same side on which the previous stitch ended.

resected gut. Suture to be used should be of catgut or synthetic absorbable kind and is always reinforced by an outer layer of

Advantage: This is hemostatic and compresses all layers of the gut wall.

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.

Connell Suturing

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

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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.

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 impairment of the blood supply to the anastomatic area. 3. Simplicity and ease of performance.

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 suturing technique is intended to close an opening, whether actual or potential, of a hollow organ, around a tube (as in jejunostomy feeding tube insertion), or around another tubular organ (as in the inversion of the vermiform appendix in auto-appendectomy), or simply to close a round-configurated defect (as in closing a small colonic perforation). As the name implies, in the pursestring 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-

This technique is most useful for closing the midline abdominal wall incision. Using a 1-0 Polydioxanone suture (PDS), encompass 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.

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 probability of leak in and around the closure.

Smead Jones Suturing

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Purse String REFERENCE

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Chassin, Jameson , Operative Strategy in General Surgery, Sprigler- Verlag New York (1994) PP 845-856

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.

Column A

Column B

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

A. Vertical Mattress

a hollow organ around a tube

B. Gambee C. Continuous Interlocking

___2. This suturing technique is used for fine skin closure producing everted edges. It consists “far-far, near-near” compo-

D. Purse String E. Subcuticular


F. Smead Jones G. Connel H. Lembert

___3. This technique is an interrupted inverting suturing of the full thickness of bowel wall using only a single row of non absorbable 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.

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.

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

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

the said procedures. Skin Closure with Skin Adhesives (Octylcyanoacrylate/Strips) 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 70 nylon, polypropylene or silk.The same sutures are recommended 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 recommended. 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,

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,

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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.

Inguinal Herniorrhaphy/Repair of the Inguinal Floor

Abdominal Wall Closure

Inguinal hernia repair is classified as a clean wound. The incision is usually short and the precise anatomical repair is done

In closing the abdominal wall, it is not necessary to close the peritoneum as closure of this layer does not contribute to wound

in a deep confined space. In repairing the inguinal floor, precise tension on the fascial edges requires a technique where each

strength. Still, some surgeons prefer to do so since this is considered to aid in reducing the formation of adhesions.

suture exists independent of the others. For this reason, the majority of hernia repairs are performed using a simple

However, the use of highly reactive sutures or sutures that are applied too tightly may result in formation of significant adhe-

interrupted suture line. There are, however, some repair techniques that utilize a continuous suture line. Since knot-tying is

sions between the peritoneum and the underlying structures. Furthermore, healing of the peritoneum is complete within seven

extensive, and knot security is important in the interrupted technique, a braided suture is used while monofilaments are

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.

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

Polyglactin and polyglycolic acid sutures are thus recommended using a 1/2 circle round needle.

relatively easy to penetrate, its analogues like the iliopubic tract or Cooper’s ligament are tough tissues. In the face of tough

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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 fascia is considered the most important layer in closing an abdominal surgical wound. It is the major supportive

The ideal suture is a non-absorbable braided (or monofilament), 0 or 2-0 with permanent strength and low reactivity

structure of the body and is the strongest tissue in the abdominal wall and thus, carries the brunt of the stress on the abdomi-

(polyester or polypropylene) together with a very sharp tapered, heavy-bodied atraumatic (channeled or drilled) needle, prefer-

nal wound. Breakdown of this layer may result in the development of incisional or ventral hernias especially in malnourished,

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

obese or immunocompromised patients.

The acceptable alternative is a silk suture threaded through a sharp, tapered, heavy-bodied, eyed needle at 1/2 circle with a

The known critical healing period of fascia is somewhere between the 14th and 21st post-operative days. A suture must

relatively short to medium chord length.

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

During an appendectomy, the mesoappendix is serially clamped, cut down to the base and ligated using silk/cotton 2-0

on a 1/2 circle needle. Since absorbable sutures like polyglactin and polydioxanone can maintain tensile strength of about 40%-

or 3-0 sutures.

50% at 3 weeks, they may also be used. However, in the presence of infection or contamination, the sutures that elicit

The base of the appendix is suture ligated using 2-0 silk/ cotton in a round 1/2 circle intestinal needle especially if the


inflammation are best.

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

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

ligation of the base before the appendix is divided. It is always safer to doubly ligate the base to reduce the possibility of stump

poliglecaprone or polydioxanone, using a 1/2 curved tapered needle. This is preferable over non-absorbable because they do

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

not act as a nidus to stone formation and they produce less trauma to the bile duct wall since it smoothly slides inside the

bury the appendiceal stump. However, no clear advantage has been noted with the use of purse-string sutures.

needle tract during suturing. Its disadvantages are that it requires more knots to secure the closure and are relatively more expensive.

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 appendiceal 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.

Click here for video on Double Ligation of the Appendix Cholecystectomy and Surgery of the Bile Ducts After identifying the cystic duct and artery during a cholecys-

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The best alternative suture material is the braided absorbable variety which requires less knots to secure the choledochostomy (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

tectomy, these structures are individually ligated with nonabsorbable 2-0 sutures (silk/cotton). Sometimes the cystic duct

bleeding fails to stop with other maneuvers (e.g., packing or electro-cautery), the cut edges of the lacerated liver parenchyma

can be ligated with a transfixing suture using 2-0 or 3-0 silk/ cotton utilizing a full curved round intestinal needle. Braided

may need to be sutured.

suture materials are used in ligating vessels, the cystic duct and bile ducts because they require minimal knots without easily

Liver parenchyma is very vascular and friable. Tensile strength is not a concern in this situation because what is required is just

slipping as compared to monofilaments. Although tissue reaction is greater, it is clinically insignificant if applied outside the wall of

to approximate the edges for hemostasis. Long tensile strength retention and absorption time is likewise not a requirement.

a hollow structure or viscus. Hence, non-absorbable braided suture materials are appropriate in this setting. It does not readily

For this reason, an appropriate and ideal suture for this

slip and is cost-effective. Another alternative method of securing the cystic duct stump is by using liga clips as in laparoscopic

situation is chromic catgut suture. Chromic suture has a smooth surface thereby inciting less trauma as it passes through liver

surgery. Doubly ligating or clipping the cystic duct stump is suggested to prevent unnecessary leaks.

tissue. The suture is retained long enough for the purpose of maintaining hemostasis. The suture is best swaged on a long,

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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

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

edges of the cut surface with or without interposition of a hemostatic material or omental pedicle. The knots are tied gently with

a minimum of tension just to approximate the edges, taking care in avoiding cutting through the friable liver tissue. Applications of deep suture bites are likewise avoided to prevent

Healing time is relatively fast with the anastomosis assuming tensile strength in about 7-14 days. The serosal layer heals faster

necrosis of normal liver tissue.

than the submucosa but it is the latter, being the most fibrous among the 4 layers that gives the anastomosis its required

The alternative suture would be an absorbable suture like polyglactin.

strength. The submucosal repair therefore, is the most important for the surgeon. Consequently, the suture material that is ideal

Bowel Anastomosis

for bowel anastomosis must therefore retain tensile strength beyond the healing time of the slowest healing tissue - the

Leakage of intestinal contents or its frank breakdown after a

submucosa. Absorbable suture materials are commonly used but non-absorbables are also popular particularly among single

bowel anastomosis carries severe consequences. A critical factor that determines anastomotic integrity is the application of proper

layer technique of repair.

suturing technique and material. However, it must be emphasized that half of the procedure is accomplished before the

It is not uncommon for the prolonged presence of a suture in the mucosa to provoke significant foreign body reaction and

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.

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

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

anastomosis, short term absorbable suture materials are preferred. 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 commonly used in the seromuscular inverting stitch while virtually any absorbable material like poliglecaprone is acceptable in the

minimal to moderate dense fibrous support. As such it is easy to penetrate. Using taper point or round point needles is appropri-

mucosal and submucosal layers. The rationale here is the required prolonged reinforcement of the seromuscular repair for

ate. Anything sharper than a taper or round needle may be more traumatic or more risky than is desirable. Moreover, the depth of

the slower healing submucosal layer and for the quickly absorbed inner suture.

the bite in bowel anastomosis need not be very deep and the working space inside the abdominal cavity may be somewhat

There are, however, suturing techniques that accomplish

confined. A 1/2 circle needle is standard for this repair. Bowels are lumenous structures with fluid and gaseous contents and its

bowel anastomosis using single layer repair. These are mostly applied in esophageal and rectal anastomoses where the

repair is ideally done without tension which seldom offers resistance. Therefore, the diameter of the needle must be thin to

procedures are performed in very limited and confined spaces and where the margins of resection are too short to adequately

keep it water-tight but at the same time relatively strong and stable given the necessary thin wire diameter. The average

permit an inversion technique. The anastomoses in such cases may be commonly performed with a running stitch, although an

thickness of bowel walls that are to be anastomosed only require medium chord length. And in order to create the least puncture

interrupted technique is also popular for facilitating a precise reapproximation. Here, both braided and monofilament materials

injury to the bowel walls, atraumatic needles, i.e., those with a swage attachment rather than eyed, are desirable.

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

ment, non- absorbable and incites very minimal inflammatory

essence, serve as a purse-string that would permanently limit the size of the lumen as opposed to employing the interrupted

reaction. This is best used with a 1/2 circle, tapered BV-1 or RB1 needle.

technique using absorbables.

Vessels may be sutured in a running, continuous fashion, for which a double-armed suture is best or in an interrupted

In considering the size of the suture material, there has to be a reasonable balance between the required tensile strength and

manner, especially for smaller vessels. Continuous suture technique for very small vessels may have a purse-string effect

tissue reaction due to the foreign body. Suture material strength is a function of the size. But bowel anastomosis is best done

which may narrow the lumen further. An alternate suture for use in vascular surgery is braided

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

Application of Retention Sutures

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

These are utilized as reinforcing sutures to relieve pressure on the suture line and to prevent postoperative wound disrup-

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

tion in abdominal wound closures in particularly vulnerable patients, as in the elderly and immunocompromised patients.

as to eliminate granuloma formation within and without the bowel.

Retention sutures utilize strong and large suture materials, in particular, non-absorbable sutures. Absorbable sutures need not

Vascular Anastomosis and Repair

be used as these sutures will eventually be removed in a couple of weeks. Sutures that may be used for this particular procedure

Vascular suturing has specific demands different from other

include nylon, polypropylene or silk 2, 1 or 0. Even stainless steel or wire may be used. These same suture materials may be

suturing techniques. Suturing and repair of vessels demand precision in the approximation of the cut edges to maintain

used even in the presence of infection as they produce the least inflammatory reaction. The best needle to use would be a large

integrity of the lumen and prevent dehiscence/breakdown which has more disastrous consequences. Tensile strength retention and

cutting-edge needle, so as to penetrate the layers of the abdominal wall with ease. Retention sutures should be applied prior to

absorption rate are very critical in determining the choice of suture. Blood vessels are subjected to a tremendous amount of

closing any layer of the abdominal wall and must be applied under direct vision to prevent bowel injury. After all retention

pressure per square millimeter and for this reason, sutures have to be strong and absorbed/broken down only after a long time.

sutures have been applied and after all the layers of the abdominal wall have been closed, they are all individually tied. To

Given also the special situation of anastomosing blood vessels to synthetic grafts, one must remember that only one side of the

prevent tying the retention sutures too tightly, rubber bridges are applied. These rubber bridges may be in the form of cut strips of

repair will undergo biologic wound healing and repair. It has also been noted that using absorbable sutures or sutures that are

drainage tubes or catheters.

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, nontraumatic, 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-

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

Rout WR. Closure of Wound. In: Zuidema GD, Ritchie WP, Jr. (eds), Shackelford’s Surgery of the Alimentary Tract, 4th ed., Philadelphia, PA: WB Saunders; 1996 Rutherford RB. Atlas of Vascular Surgery: Basic Techniques and Exposures; WB Saunders Co., 1993

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

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

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

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

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

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

Self-Assessment Questions (Chapter VII) 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?

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

a. Silk 4-0 interrupted b. Cotton 4-0 continuous c. Polyglactin 4-0 simple, interrupted

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

d. Polypropylene 5-0 simple, interrupted e. Polyglycolic acid 3-0 continuous

a baseball bat. The wound is clean with relatively smooth edges. What would you do?

3. The use of absorbable sutures is advocated when applying

a. Close the wound with interrupted silk 6-0 b. Cut clean the edges and close with interrupted nylon 7-0

sutures in the biliary tree because? a. It evokes less inflammation than non-absorbable sutures

c. Cut clean the edges, suture the subcutaneous tissue with 6-0 polyglactin then close the skin with interrupted silk 6-0

does b. Non-absorbable sutures become nidus for later stone

d. Deep bite skin closure (together with subcutaneous tissue) using 5-0 nylon

formation c. Strictures are less common with the use of absorbable

e. Debride and if available, use skin adhesives

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

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-toend 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

Appendix A Glossary of Terms absorbable sutures sutures which are broken down and absorbed by either hydrolysis

cotton a non-absorbable braided suture

or digested by enzymatic processes blunt point a type of needle wherein the tip is rounded and will not cut through

hydrolysis a type of chemical process that results in suture breakdown of synthetic absorbable sutures

tissues braided sutures with intertwining threads breaking strength measurement of force required to break a wound without regard to its dimension

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

burst strength amount of pressure neecessary to rupture a viscus

knot tying


ligature any suture material used to tie vessels or structures

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

the process of securing sutures using instruments or done manually

monofilament chord length the straight line distance from the point of a curved needle to the swage

synthetic sutures that are single and untwisted needle body the portion between the point and the swage of the needle

chromic an absorbable suture treated with chromate compounds

needle diameter the gauge or thickness of the needle wire

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

needle length the distance measured along the needle itself from point to end needle radius

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

a synthetic absorbable monofilament suture marketed as Maxon(r)

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*

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

plain catgut

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

simplest form of absorbable catgut suture

filament produced by silkworms

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

swage the area in which the suture is attached to the needle resulting in the needle and suture becoming a continuous unit

polyester the first synthetic braided non-absorbable suture marketed as Mersilene(r), Miralene(r), Ethibond(r), or Surgidac(r)

tapered needles the type of needle wherein the body of the needle gradually tapers to a sharp point at the tip

poliglecaprone a synthetic monofilament absorbable suture marketed as Monocryl(r)

tensile strength


the load applied per unit of cross-section area measured in lbs/ in2 or kg/cm2

a synthetic braided absorbable suture marketed as Coated Vicryl(r) wire/steel polyglycolic a synthetic braided absorbable suture marketed as Dexon(r)

non-absorbable metal suture used primarily for fixing bony structures

Appendix B Answers to Self-Assessment Questions CHAPTER I


1. B 2. A

9. B 10. D

3. B 4. C

11. A, D 12. A, D

5. A 6. C

13. A, D 14. B

7. E 8. A

15. A, D

1. C 2. B

CHAPTER VI 1. D 2. A 3. B 4. H 5. G


6. E 7. F

2. A 3. D

8. C



1. A 2. D

1. D 2. C

3. C 4. D

3. D 4. B

5. C 6. C

5. E

7. B 8. D

3. B 4. A 5. C 6. B 7. C 8. E 9. D

2003 Board of Regents of the Philippine College of Surgeons

President: Vice-President:

Fernando L. Lopez, MD Edgardo R. Cortez, MD

Treasurer: Secretary:

Arturo S. de la Peña, MD Leonardo L. Cua, MD


Josefina R. Almonte, MD Gerardo A. Directo, MD

Maximo B. Nadala, MD Rodolfo L. Nitollama, MD

Armando C. Crisostomo, MD Rey Melchor F. Santos, MD

Maximo Dy-R. Elgar, MD Maximo H. Simbulan, Jr., MD

Stephen S. Siguan, MD Vedasto B. Lim, MD

Jose C. Gonzales, MD

2003 Committee on Surgical Training of the Philippine College of Surgeons Chairman:

Cenon R. Alfonso, MD


Shirard L.C. Adiviso, MD, MHPEd Jose Joey H. Bienvenida, MD Miguel C. Mendoza, MD Renato Cirilo A. Ocampo, MD


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 Regents of the Philippine College of Surgeons

President: Vice-President:

Fernando L. Lopez, MD Edgardo R. Cortez, MD

Treasurer: Secretary:

Arturo S. de la Peña, MD Leonardo L. Cua, MD


Josefina R. Almonte, MD Gerardo A. Directo, MD

Maximo B. Nadala, MD Rodolfo L. Nitollama, MD

Armando C. Crisostomo, MD Rey Melchor F. Santos, MD

Maximo Dy-R. Elgar, MD Maximo H. Simbulan, Jr., MD

Stephen S. Siguan, MD Vedasto B. Lim, MD

Jose C. Gonzales, MD

2003 Committee on Surgical Training of the Philippine College of Surgeons Chairman:

Cenon R. Alfonso, MD


Shirard L.C. Adiviso, MD, MHPEd Jose Joey H. Bienvenida, MD Miguel C. Mendoza, MD Renato Cirilo A. Ocampo, MD


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.

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