• Surgical approaches, incisions and the use of
appropriate instruments in surgery in general
• Indications for alternative techniques(glues &
• Materials & methods used for surgical wound
closure and anastomosis (sutures, knots &
• The technique for skin closure, artery & bowel
TO BE AWARE OF
• The whole operative surgical team and the
responsibility of each member in the care of
sharp and peri-operative care of instruments
5. INCISION OF SKIN
• Skin and tissue incisions are made using scalpels
with disposable blades.
• All sharp instruments pose a needle-stick type
injury and need to be passed within kidney dish.
• Attaching a blade to scalpel handle should always
be done using a hemostat, and not using fingers.
• The blade shape & size is chosen by its purpose.
• Blades for skin incisions usually have curved
margin, those used to make a passage for drain or
for an arteriotomy, have a sharp tip.
6. INCISION OF SKIN
• When making an incision thru skin and deeper
layers, the knife should be pressed firmly at
right angles to the skin & then draw against it.
• Skin should not be incised obliquely as it can
cause necrosis of the undercut edge.
• Diathermy, Laser & harmonic scalpels can be
used when opening deeper structures to reduce
blood loss and save operating time and may
reduce post-operative pain.
8. SUTURE OF SKIN
• Wound should be closed with a minimum of
• Edges of skin should be gapped to allow swelling
as inflammation of healing occurs in few days.
• If a wound is closed tightly, necrosis of wound
edges occurs and adds exogenous infection.
• Needles are inserted at right angles using
supination/pronation movements of the wrist.
• Entry & Exit points should be approximated at
same distance from the wound edges.
9. SUTURE OF SKIN
• When a suture is tightened, the knot should be
drawn to one side to facilitate suture removal.
• The ends of the knots should be left long enough
to easy to grasp when they are removed later.
• As a general rule, each suture should be
separated by a gap twice the thickness of the
• If a wound has curves & zigzags, stay sutures at
the tip of each corner make sure that the wound
edges come close together to avoid Dog-Ears.
10. CLOSURE OF WOUNDS
• Wound edges should be left slightly gaping to
• Edges should be everted.
• The knot should be placed to one side of the
• Knots must be secured with the ends long
enough to grasp when removing the suture.
11. TYPES OF SKIN CLOSURE
• Skin closure may be interupted, continuous, or
simple mattress or subcuticular.
• Interrupted sutures have the advantage that
they can be removed individually if a
hematoma or infection forms locally, to help
drain blood or pus later without disrupting
• Mattress sutures appose skin edges tidily,
ensure eversion and help to close the dead
space in the subcutaneous fat layer.
12. TYPES OF SKIN CLOSURE
• Subcuticular sutures are cosmetically appealing
but ar edifficult to place in a curved wound.
• Nevertheless, subcuticular closure is most
widely practiced skin closure in virtually all
specialities, although skin clips have their
• Non-absorbable suture are removed when the
wound has healed to avoid scarring, infection &
14. TIME OF REMOVAL OF SUTURES
• Face 2-3 days
• Scalp 5 days
• Upper limb 7 days
• Groin 7 days
• Abdomen 7 days
• Dorsum 10-14 days
• Lower Trunk 10-14 days
15. NO-TOUCH TECHNIQUE
• Suturing should be done with this technique
• Needle holders should be suitable for the needle
• Avoids the risk of needle-stick injuries
• Short-handled holders are used for skin closure, and
long-handled holders are used for suturing deep
inside the body.
• The needle should be held in the tip of the holder
and placed about 2/3rd of the way back from its tip.
• Needles can be placed in holders both forehand &
backhand for appropriate use.
16. SUTURE MATERIALS
• There is evidence that traumatic and surgical wounds were
closed in 3000 BC by the Egyptians using thorns and needles.
• By 1000 BC, Indian surgeons were using horsehair, cotton and
• In Roman times, linen and silk and metal clips called fibulae
were commonly used to close gladiatorial wounds.
• By the end of the nineteenth century, developments in the
textile industry lead to major advances, and both silk and catgut
became popular as suture materials.
• Lister believed that catgut soaked in chromic acid (a form of
tanning) prevented early dissolution in body fluids and tissues.
• Moynihan felt that chromic catgut was ideal as it could be
sterilized, was non-irritant to tissues, kept its strength until its
work was done and then disappeared.
17. SUTURE MATERIALS
• All the natural sutures, silk, cotton, linen and catgut,
are being replaced by polymeric synthetic materials
that cause minimal inflammatory reactions, are of
predictable strength and absorb at an appropriate
• They can be manufactured as monofilaments or
braids, and can be coated with wax, silicone or
polybutyrate to allow them to run smoothly through
tissues and to knot securely.
• The absorbables cause a minimal tissue reaction as
they are resorbed. To aid in the prevention of
postoperative infection, particularly after prosthetic
50% lost by
Not for use
70% in 2 wk
55% in 3 wk
mild Not Prolong
Infinite > 1
d in body
low none Cardiovascu
Lost in 7-10
high Not for
moderate Same as
Polydioxano Polyester 70% in 2 wk Complete mild Heart Used as
19. METAL SUTURES,CLIPS & STAPLES
• Mechanical stapling devices were first used successfully
by Hümer Hültl, in Hungary, to close the stomach after
• There is now a wide choice of linear, side-by-side and
end-to-end stapling devices that give strong predictable
suture lines, with minimal tissue necrosis.
• Metal clips for skin allow quick, accurate closure.
• Metal clips save operating time & are easy to remove
• Steristrips can be used to buttress a skin closure and can
prevent ‘spreading’ of a scar. This can be useful, for
example after a wide lump excision of the breast.
• Adhesive polyurethane films,such as Opsite, Tegaderm
or Bioclusive, may have a similar property.
• Transparent dressings also allow wound inspection and
may protect against cross-infection.
• The choice of surgical needle is as important as the choice of
suture. The needle holder chosen also needs to be appropriate;
a large needle holder damages a small needle, and a large
needle is unmanageable in a small needle holder.
• The appropriate size and shape of cutting, or round-bodied
atraumatic needle, needs to be chosen for the least traumatic
passage through tissue.
• Shaped needles allow easier access for suturing. Examples are
the J-shaped needle useful in low-approach femoral hernia
repair, or the compound curve needle used in ophthalmic
• Hand needles should be avoided because of the risk of needle-
• The tips of laparotomy closure needles are deliberately blunted
by some of the manufacturers to reduce the risk of needle-stick
22. TISSUE GLUES
• The use of tissue glues is not widespread despite
much published work.
• The cyanoacrylates have been used for skin
closure but require near perfect haemostasis if
they are to work well.
• Some specific uses have been described such as
the use in closure of a laceration on the forehead
of a fractious child in Accident and Emergency
(thereby dispensing with local anaesthetic and
• They are relatively expensive but quick to use, do
not delay wound healing and are associated with
an allegedly low infection rate
23. TISSUE GLUES
Fibrin tissue glues
• Tissue glues, involving fibrin, work on the conversion of
fibrinogen by thrombin to fibrin with cross-linking by factor XIII;
the addition of aprotinin retards break-up of the fibrin network
• The fibrinous network produced has good adhesive properties
and has been used for haemostasis in the liver and spleen.
• It has also been used in neurosurgery for dural tears; in ear,
nose and throat (ENT) and ophthalmic surgery; to attach skin
grafts and prevent haemoserous collections under flaps; and in
cardiac and general surgery for the prevention of postoperative
adhesions in the pericardium and the peritoneum.
• Fibrin glues have been used to control gastrointestinal
haemorrhage, using endoscopic injection, but do not work
when bleeding is brisk.
• They are more effective in haemostasis when combined with
24. KNOT TYING
• Secure knots are crucial in operative surgery. Most should be
performed using an instrument such as a needle holder, with
care being taken not to damage the suture material
incorporated into the knot.
• Surgeons in training should practice these on the jigs devised
for use in basic skill courses.
• All knots should be square, but the two-throw reef (surgeon’s)
knot does not slip.
• A granny knot is a two-throw knot using the same type of
throw; its ability to slip is useful in producing the right tension
prior to ensuring security with a third, double-throw knot.
• The Aberdeen knot can be used with a continuous suture to
make a final knot. The free end of the suture is pulled through
the final loop several times before being pulled through a final
time prior to cutting.
26. KNOT TYING
• When knots are cut short, the free ends or ‘ears’
should be left at least 1–2 mm long. This is
particularly important with monofilament non-
• However, if the ends are left too long, they can
cause wound irritation and add to the
complications of wound pain and wound sinuses.
• Ligatures can be tied using instruments or by
hand when tissues are divided between forceps.
• The security of a ligature depends on good
communication between surgeon and assistant as
the tissue forceps is released and tissue tied
• This needs practice.
27. KNOT TYING
• Secure wound closure is crucial. Technical
wound failure follows knots slipping, tissues
tearing or breakage of sutures.
• When this occurs after laparotomy closure,
the result is a burst abdomen, a disaster for
the patient and a technical failure for the
• This complication is avoided by the use of an
appropriate material, polypropylene (Prolene)
or polydioxanone suture (PDS), secure knots
and appropriate tissue bites.