BASIC SURGICAL SKILLS MANUAL

Principles and Applications

2nd Edition Electronic Version

PHILIPPINE COLLEGE OF SURGEONS Committee on Surgical Training

Cenon R. Alfonso, MD - Committee Chairman Miguel C. Mendoza, MD - Editor-in-Chief Shirard L.C. Adiviso , MD, Jose Joey H. Bienvenida , MD, and Renato Cirilo A. Ocampo , MD Armando C. Crisostomo, MD - Regent-in-Charge.

PCS SCIENTIFIC PUBLICATION N O. 12

Table of Contents
Foreword
2nd Edition . . . Cenon R. Alfonso, MD, FPCS, Chairman Committee on Surgical Training, Philippine College of Surgeons 2003 Chapter V Knot Tying Jose Antonio M. Salud, MD, FPCS (1st edition) Miguel C. Mendoza, MD, FPCS (2nd edition) Self-assessment Questions

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

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

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

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 (Glossary of terms) (Answers to self-assessment questions)

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

Appendix A

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

Appendix B

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 Century, the growing movement toward a paradigm shift of surgical skills training has already begun. This shift is from the operating-room-patient venue into the surgical skills laboratory-simulation setting. Because of this propensity, it will become unacceptable in the near future for young surgical trainees to be allowed to practice and hone their basic surgical techniques among patients in the operating room. Furthermore, it may also come to a point that before being allowed to do so, these trainees will be required to pass a certification from a surgical skills laboratory. This means that the essential principles of mastery in psychomotor skills - repetition and feedback - have been adequately satisfied. This likewise implies that the trainee has progressed from being unconsciously incompetent in surgical techniques as they started into unconsciously competent as they ended (mastery) their surgical skills training. The hope is once the trainee is faced with an actual patient, basic surgical technique is almost second nature. The first step towards the above-mentioned goal is to be able to experience an audiovisual simulation. This is the importance of this CD version and Edition of the Basic Surgical Skills Manual. To all the members of the CST, Atong, Shirard, Joey, and Ike, most specially to the Regent-in-Charge, Armand, thank you and congratulations for all your selfless efforts, contributions, and seemingly-endless proddings.

Cenon R. Alfonso, MD, FPCS

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

Foreword
1st Edition

Addressing need for problem-oriented instructional tool

This manual was conceived in 1996 in answer to a palpable need for a structured, problem-oriented instructional tool for trainees and surgical practitioners. In 1998, during the incumbency of Dr. Antonio B. Sison, the Committee on Surgical Training (CST) through its Chairman, Dr. Gabriel L. Martinez presented the project proposal to the PCS Board of Regents. The favorable action of the Board of Regents led to the creation of the Sub-committee on Skills Improvement under Dr. Jose Antonio M. Salud. While diligently collecting and collating data from the various makers of surgical needles and sutures for inclusion in the Basic Surgical Skills manual, the CST made representations with Johnson & Johnson Medical Philippines through Mr. Bayani R. Santos, Jr. and Mr. Erwin Tantoco who favorably endorsed the project. In 1999, during the incumbency of Dr. Francisco Y. Arcellana, the drafts of the Manual were presented to the Board of Regents for comments and suggestions. Once approval was obtained, the CST, and J & J through its Franchise Manager, Ms. Ruth Nicolas, engaged the services of Creative Powerhauz to publish this manual. As in any endeavor, there are unsung heroes whose efforts were vital to the completion of this project: the members of the 1998 and 1999 Committee on Surgical Training, Regent-representative Dr. Jose Y. Cueto, Jr., contributors Drs. Nilo C. de los Santos and Paul Jesus S. Montemayor. Special thanks to Dr. Elizabeth F. Mabilangan-Salud and Ms. Olivia S.M. Manzano, CST secretary.

Gabriel L. Martinez, MD, FPCS

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

Message from the 2003 PCS President

The backbone for all cutting specialties

Clinical acumen, surgical knowledge and decisionmaking, and the right attitude and motivation do not make up a complete Surgeon. These have to be adequately matched by a set of fine psychomotor skills, i.e. mastery of technical competence. Training of young physicians into the Art and Science of Surgery therefore requires not only intensive education, but equally important, is the toning of every muscle and discipline of each movement they create during operations into a purposeful progress towards the goal of every procedure they perform. This aspect of surgical training essentially requires two basic learning principles, namely: repetition and feedback. This feat of the Committee on Surgical Training is the first step towards this end. A visual companion into the world of Surgical Technique allows application of almost all the senses in order to guide the young trainee in the HOW of the procedures. In the short term, the Board of Regents envisions this project to serve as a guide to trainees. So that before a certain technique is performed by simulation or in a patient, the young trainee can view this first and then play back for feedback. In the long term however, this CD Edition of the Basic Surgical Skills Manual will play as the backbone of the National Surgical Skills Center (NSSC) that PCS will establish for all cutting specialties. In behalf of the Board of Regents, let me congratulate the Committee on Surgical Training for this project. Allow me to extend a similar warm recognition to the partner of PCS in this project, Johnson & Johnson Medical Philippines.

Fernando L. Lopez, MD
President 2003

Preface
2nd Edition

Uplifting the practice of surgery in the Philippines

Despite all the attention given to the development of a strong basic theoretical foundation in surgery and the enhancement of attitudinal competencies, the surgeons of today continue to be judged mainly by the quality of their technique in the performance of various surgical procedures. Major requirements for the accreditation of residency training programs in surgery continue to highlight the need for adequate operative experience in order to ensure the competency of our trainees. Despite the importance of the operative skill, continuing education in this regard continues to be wanting. Also, there is a need to standardize the teaching of surgical technique to our students and residents while appreciating some variation in individual style. With this in mind, the Surgical Training Committee of the Philippine College of Surgeons has embarked on this endeavor to further improve the initial landmark publication of the Basic Surgical Skills Manual, this time in electronic form. Subsequently, we intend to pursue publication of the Advanced Surgical Skills Manual, which highlights more advanced techniques to include laparoscopic approaches. Finally, we also plan to pursue the establishment of a National Surgical Skills Center to be set up under the auspices of the Philippine College of Surgeons. All these efforts serve to demonstrate our sincere and unwavering determination to attain our vision of being the leading organization in uplifting the practice of surgery in the country.

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 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

Cognitive Phase

This phase involves the initial intellectualization process necessary in learning a new task. Both the trainor and trainee try to verbalize what needs to be learned. The trainee has to understand the concepts and principles involved in the task before any performance can be attempted. In surgery, the nature of the technical skills, their indications, applications, contraindications, complications or consequences are discussed. In this phase, performances of trainees are prone to error. There is, therefore, a need for the trainor to demonstrate how a task should be accomplished.

I. Relevance and Importance Surgeons who are involved in the training of residents are all too familiar with complications that follow surgical procedures. These are regularly presented in mortality-morbidity conferences and include leaks from simple repairs, disruption of 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. Fitts 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.

residents. 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 A. Need to recognize the phases of learning skills To make the acquisition of psychomotor skills more effective, the trainors should understand and apply the different phases of learning. Each resident presents with his/her own level of knowledge and competence with regard to a particular skill. The trainor must be able to bring the residents through the different phases of learning. An educational activity that addresses the cognitive phase of skills learning is the pre-operative conference. Residents go through details in a procedure and verbalize the steps in a particular operation and how complications are to be avoided. Another very important activity is the operative assist. Operations that residents assist in are actually considered demonstrations by consultants and senior residents. Needless to say, the residents must be exposed to the correct way of performing different operations and techniques. The skills that residents learn take years to refine, and are finally incorporated into the autonomous phase of behavior. Once habits become part of autonomous behavior, it becomes very difficult to unlearn them. B. Need for focus and clarity In order that lower level residents know what needs to be learned, complex tasks must be broken down into sub-tasks. The residents focus first on learning the simpler sub-tasks before graduating to complex tasks. Ideally, these skills should be learned in the laboratory using simulations, using inexpensive materials or animals. What needs to be learned, how they are to be learned, and how they are to be assessed become clear to the

trainees will absorb only the good practices of their seniors and superiors. In order to obtain the required level of proficiency in surgical skills, a structured method of teaching and assessment is needed. Supplementary workshops that include multi-station, handson and interactive format will be of great help. The residents rotate through different stations learning about needles, sutures and how to select and use them depending on the clinical situation. Group discussions then follow in order to recapitulate and emphasize the important factors in selection, principles governing their use, and the correct steps that should be followed. D. Need for guidance, supervision and feedback It is during the fixation or associative phase where residents develop their own pattern of action and behavior. They are exposed to different consultants and senior residents who have their own way of performing different techniques. The residents should be able to determine and decide which steps and techniques they should adopt, and which ones to reject and avoid. When residents in lower years are allowed to acquire bad habits and incorporate them into their practice, it becomes very difficult for them to unlearn these habits when they reach their senior years. There must, therefore, be adequate guidance and supervision. In addition, timely feedback should be given regarding what needs to be corrected and how they are to be corrected. In this way, only the proper steps are incorporated into the autonomous phase of skills acquisition. E. Need for simulation and practice Before residents are allowed to operate and perform proce-

dures on actual patients, they should be given opportunities for simulations. This allows the trainor to make sure that the trainee has mastered the steps in a certain procedure. During simulation and practice, the deficiencies and errors of the residents should already be determined and corrected. This is to make surgical training safe, and avoid unnecessary complications that may arise from operations and procedures done incorrectly.

D. Objective Structured Clinical or Practical Exam (OSCE or OSPE) This method utilizes a number of stations where skills are tested. Skills such as suturing fascia, muscle, skin, intestine and blood vessels are evaluated. Every station has a rater who observes the trainee. With the use of objective checklists and rating scales, the performance is determined to be satisfactory or unsatisfactory. The results are then fed back to the trainees for them to know where they need to improve on. The use of structured clinical or practical exams ascertain that

IV.

Assessing Psychomotor Skills

all residents go through the same stations and the same tasks. This is very difficult to attain in real clinical situations where cases differ in degree of difficulty. Even similar cases of appendicitis present with varying technical difficulties depending on patient habitus, position of the appendix, etc.

A. Direct observation with the use of checklists and rating scales This is the most valid method of assessing how trainees perform. However, this is time-consuming because it requires the presence of trainors all throughout the procedure. This method is process-oriented and assumes that the resident follows the details described in the cognitive phase. The consultant or supervisor assesses how residents select needles and sutures, particularly in the way they are handled. B. Product evaluation This is done by inspecting a finished product or a completed task. For example, an anastomosis is inspected by the trainor before the abdomen is closed. This can be reserved for higher level trainees who have already demonstrated mastery of the process. C. Record review For audit purposes, the record of procedures and operations are meticulously examined. The materials used (needles and sutures), the steps and their sequences and the over-all operative management are assessed. These are all correlated with the outcomes, such as the presence/absence of complications. However, this method relies heavily on the accuracy and completeness of the operative records.

REFERENCES Abbatt F and McMahon R. Teaching Health Care Workers: A Practical Guide; Macmillan Education, London, 1988 Bouhuijs P , et al. The OSCE as a part of a Systematic Skills Training Approach, Medical Teacher, Vol. 9, No. 2, 1987 Crosby J. Learning in Small Groups, Medical Teacher, Vol. 18, No. 3, 1996 Harden RM, et al. Task-based learning: an educational strategy for undergraduate, postgraduate and continuing medical education, Part I, Medical Teacher, Vol. 18, No. 1, 1996 Morgan M and Irby D. Evaluating Clinical Competence in the Health Profession; C.V. Mosby, Co., St. Louis, 1978 Patrick J. Training: Research and Practice; Academic Press, San Diego, CA, 1992

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 Fitts three-phase theory. Column A ___1. Performing assisted or supervised operations ___2. Enumerating the steps of an operation in a preoperative conference ___3. Learning through demonstration-return demonstration with trainor ___4. Performing operations independently and smoothly ___5. Describing operative complications Column B A. Cognitive Phase B. Fixation Phase C. Autonomous Phase

B. Direction: Column A contains comments from residents in-training. Identify and write on the space before each number, the component under which the problem falls. Column A ___6. I have been left on my own to learn new skills ___7. I did my first bowel anastomosis in a real patient because there is no animal laboratory ___8. I dont know what stage of learning I am in ___9. I dont 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

After going through this chapter, the learner is expected to: 1. Understand the role of simulation in surgical training. 2. Conduct teaching and learning activities in basic and advanced surgical skills using simulation.

combination of two) provide the opportunity to achieve and evaluate skills through repeated practice within a safe and controlled environment. Advantages of Simulation 1. The training design can be formulated based on the needs of the learner and not the patient. 2. Since the venue is safe and controlled, learners are allowed to fail and learn from such failures in a way that is unacceptable in a true clinical scenario. 3. Simulators can offer objective evidence of performance using their inherent tracking functions to map learners 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.

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.

2. Computer Based Simulators (shown below)

A Simple Taxonomy of Simulators (Medical Education, 2003)

SKILL MANUAL REQUIREMENT EXAMPLES

Precision Placement

Direct needle Instrument to a point Guide a catheter Endoscope Ultrasound probe

Intravenous needle insertion Lumbar puncture Angioplasty Colonoscopy Bronchoscopy Abdominal ultrasound Bowel/ vascular anastomosis , MIST-VR, Lap Sim Laparoscopy procedure Anesthesia simulation

Simple Manipulation

Complex Manipulation

Perform single complex task

Integrated Procedure

Perform multiple task of entire procedure

Figure 1- Flexible sigmoidoscopy trainer (Immersion Medical).

Figure 3 - Laparoscopy Simulation (LapSim Basic Skills 2.0)

Figure 2 - Endoscopic surgery trainer (MIST-VR: Minimally Invasive Surgical Trainer Virtual Reality

Figure 4- Simulated operating theater with mannequin.

1. Hybrid Simulation- combine physical model with computers using realistic interface like instruments and real diagnostics. Kneebones 5 Stages of Training Method 1. Watching an animated graphic of procedure.- essential points of technique are shown by animated graphics usually with spoken commentary. 2. Watching a clinical video of the procedure- short clinical video sequences show the techniques performed by an expert on a real patient. 3. Watching the procedure demonstrated on a modeldemonstrated a simulated tissue model by the same expert wherein steps can be stopped, started and replayed at will. 4. Doing the procedure on a model- learner carries out procedure on an identical model and practices repeatedly then reviews the techniques. 5. Doing the procedure on a patient under supervision. An experienced colleague or mentor supervised the learner while performing the procedure on a patient. Kneebones Tips in using Simulation and Multimedia

first principles, avoiding any assumption of previous knowledge. 7. It is easy to overestimate the knowledge and skill of any group of learners, especially as they may be embarrassed to admit their ignorance. Assume nothing but go right back to basics provided you treat the learners with respect, they will value the experience. 8. Do not overestimate the complexity needed in basic surgical skills teaching. 9. Ensure that you are familiar with the procedures you will be teaching and with any models used. 10. Setting up basic surgical workshop requires thought and planning but need not be prohibitively expensive. 11. Learners like a clear framework within which to exercise their navigational freedom. 12. Make the teaching aim clear from the onset. Encourage learner to repeat procedure till they become proficient.

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 0s, the smaller the size the suture strand is. Thus, a 6-0 suture is smaller than the diameter Objectives of this Chapter: After going through this material, the learner is expected to: 1. Analyze the different types of sutures and their characteristics. 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. of a 2-0 suture. Suture materials are generally classified as 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 edges. The material used to close blood vessels to achieve hemostasis is called ligature. The first suture materials were used between 2500 and 3000 BC as documented by Egyptian papyri and they consisted of fibers of plant origin, leather, animal tendons and parchment strips. However, it was only in 1860 when Joseph Lister introduced carbolic catgut, the first suture material specifically for surgical use. Eventually other materials were introduced for surgical use such as linen, silk, celluloid, horsehair, wire, etc. Synthetic materials were first used in the 1930s 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 are not arrested by either enzymes or tissue fluids. The most frequently used absorbable non-absorbable suture materials are the following: Absorbable Sutures 1. Plain Catgut Plain catgut is derived from the collagen of small intestine, either the serosal layer of cattle or the submucosal layer of sheep. In tissues, plain catgut loses much of its tensile strength at the end of one week. It is absorbed shortly there after and thus, is 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) Based on STRUCTURE Monofilament Multifilament (Braided) Non-Absorbable Cotton Steel Silk Silver Nylon Polyester Fiber Polypropylene Poly (hexafluoropropylene-VDF)

2. Chromic Catgut This suture material is actually similar to plain catgut except that it is treated with chromate compounds, which results in a stronger and more slowly absorbed suture. Thus, the loss of tensile strength takes a little longer, about double the time it takes for plain sutures to lose their own. However, the absorption of chromic is dependent on environmental factors in the tissues. When used to suture the stomach, the presence of acid hastens the absorption. This should not be used when extended approximation of tissues under stress is required, as in fascia. Both plain and chromic catgut sutures may stimulate a considerable inflammatory reaction during the absorptive phase and should, thus not be used in areas such as the peritoneum. 3. Polyglactin This is a synthetic braided suture whose raw material is a copolymer of glycolide and lactide. Most absorbable in synthetic sutures, polyglactin included, are hydrolyzed during absorption rather than being broken down enzymatically (as with the natural absorbable sutures). In hydrolization, water gradually penetrates the suture filaments causing the breakdown of the sutures polymer chain which results in lesser degree of tissue reaction following tissue implantation. 75% of the strength of this suture is retained at 14 days, and about 50% is retained at 21 days. 100% loss in tensile strength is noted by the 32nd day. Absorption is complete at about the 56th or the 70th day.

4. Polyglycolic Acid This synthetic braided suture is reduced by the hydrolysis to glycolic acid. Like most synthetic sutures, the inflammatory reaction that results from its breakdown is only minimal. Its tensile strength is completely lost by the 30th day. Complete absorption occurs about the 90th day. 5. Polydioxanone This is a synthetic monofilament absorbable suture composed of the polyester of p-dioxanone. It takes longer for its tensile strength to be reduced as well as for its absorption to be compared with the two previously mentioned suture materials. In vivo studies have shown its tensile strength to be at about 70% at 14 days and 50% is retained at 28 days. Absorption starts close to the 90th day and is complete at 6 months time. 6. Poliglecaprone This is a monofilament suture whose tensile strength in the first week is high but rapidly reduces soon after. Studies have shown its tensile strength to be about 70% at the end of the first week but is down to 30-40% by the end of the 2nd week. It is thus recommended for use in situations wherein the surgeon requires a high initial tensile strength as in subcuticular wound closures. Absorption is complete in 90-120 days.

Non-absorbable sutures 1. Silk By far, still the most commonly used suture material, silk is a protein filament produced by silkworms. As with most braided sutures, silk holds knots well. However, silk loses its tensile strength when exposed to moisture and should be used dry. Silk loses much, if not all of its tensile strength within a year. Although classified as a non-absorbable suture, silk can actually be absorbed slowly but the absorption rate is variable. 2. Cotton This is a commonly used braided nonabsorbable suture much like silk. It stimulates an inflammatory reaction greater than that of silk and other sutures is that this material is relatively cheaper. 3. Nylon This particular nonabsorbable suture comes in a monofilament and braided form. This suture is characterized by its high tensile strength and extremely low tissue reaction. The loss in tensile strength is in the range of 15-20% per year by hydrolysis. As with most monofilament sutures, nylon sutures require more throws to securely hold the knots in place. The braided variety, on the other hand is very similar in characteristic to silk but has considerably less tissue reaction.

4. Polypropylene Polypropylene is a non-absorbable synthetic monofilament suture. This sutures tensile strength retention is indefinite and is a suture that is encapsulated by tissues when implanted thus resisting tissue degradation. Because of these characteristics, it is a suture that is widely used in virtually all specialties. 5. Polyester This suture was the first synthetic suture material shown to last indefinitely in tissues. Like polypropylene, poly-esters sutures are encapsulated by tissues and thus resist tissue degradation. 6. Wire/Stainless Steel/Titanium A very strong suture material that produces little loss of tensile strength, wire has been used for many years and is a popular suture for a variety of operations (thoracocardiovascular, orthopedics, neurosurgery). Tissue reaction is minimal. However, it is difficult to handle and may be easily palpated by the patient.

Table B Suture Materials and Characteristics

TABLE ON SUTURE Tissue of Origin CHARACTERISTICS Number of strands Absorbability Absorption Rate Inflammatory reaction Knot Security (minimum # of knots) 2

Plain Catgut

Collagen of small bowel of cattle & sheep Collagen of small bowel of cattle & sheep Copolymer of lactide & glycolide coated with polyglactin 370 & calcium stearate Glycolic acid polymer Copolymer of glycolide and epsiloncaprolactone

Monofilament

Absorbed by Enzymatic Proteolysis Absorbed by Enzymatic Proteolysis Absorbed by Hydrolysis

Complete within 70 days

++

Chromic Catgut

Monofilament

Over 90 days

++

Polyglactin

Multifilament & Monofilament (size 10-0 only)

Complete in 56-70 days

2/5

Polyglycolic acid

Multifilament

Absorbed by Hydrolysis Absorbed by Hydrolysis

Complete in 90 days Complete in 91-119 days

Poliglecaprone

Monofilament

-/+

Polydioxanone

Polyester polymer Silkworm

Monofilament

Absorbed by Hydrolysis Nonabsorbable Nonabsorbable Nonabsorbable

Complete in 180 days N/A

-/+

Silk

Multifilament

Cotton

Cotton Plant

Multifilament

N/A

++

Nylon

Long-chain polymers of nylon Crystalline stereoisomer of polypropylene Polymer of polyethylene terephthalate 316L stainless steel

Monofilament

N/A

-/+

2/5

Polypropylene

Monofilament

Nonabsorbable

N/A

-/+

Polyester

Multifilament

Nonabsorbable

N/A

-/+

Wire/Stainless Steel/Titanium

Multi- & Monofilament

Nonabsorbable

N/A

-/+

MESH Surgical mesh materials are more commonly used to repair fascial defects. Its use in inguinal herniorrhaphies was even made more popular in the advent of laparoscopic herniorrhaphy techniques. Meshes may be non-absorbable or absorbable.

Surgical Staplers Modern surgical stapling devices and techniques were first developed in the Soviet Union in the 1950s 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 Most common types of materials used in non-absorbable meshes are polypropylene, polyester (macroporous structures) and polytetrafluroethylene (PTFE) (microporous structures). Polypropylene may be monofilament or multifilament. Both exhibit high burst strength. It is knitted in such fashion as to interconnect each monofilament fiber and provide unidirectional elasticity. This mesh is porous.

significantly reduced with the use of staplers and anastomoses appear to function sooner as compared with manual suturing techniques. The stainless steel staples that are used are virtually inert producing minimal tissue inflammation and minimal tissue compression. However, with the use for staplers for skin repairs, the closure may be less meticulous. Another disadvantage of staplers is that it may interfere with computed tomography and magnetic resonance imaging.

Skin Adhesives 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). 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. 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 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.

Guidelines in Choosing a Suture Material TABLE C

IDEAL SUTURE CHARACTERISTICS

1. High tensile strength 2. Sterile 3. Ease and security of knotting 4. Ease of handling 5. Inert (The ideal suture material would cause the least tissue reactivity.) 6. Non-toxic, non-allergenic (both the suture and its components when metabolized by the body) 7. Small size 8. Predictable performance 9. Smooth surface avoiding necrotic tissue, clots and bacteria to adhere 10. Should keep its physical characteristics as long as necessary 11. Cost effective

The selection of suture materials is generally based on its biological interaction with the wound and its mechanical characteristics. Whatever suture material is used for a particular procedure, the following guidelines should be considered: 1. Select the finest suture consistent with the tissues to be approximated. 2. The suture material should have adequate tensile strength and maintain it until its purposed is served. 3. Choose a suture that would produce the least tissue reaction. 4. Select sutures with the least risk for bacterial proliferation. 5. Select sutures that are pliable, easy to handle and able to maintain knot security .

These principles are important to remember in the choice of sutures based on their physical properties:

several ways: 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. 2. Suture strength must be maintained until the wound gains maximum strength. 3. Tissue reaction to sutures should not prolong the healing process. To apply these principles, one must have information regarding the normal strength of tissues, the rate at which injured tissues regain strength, the strength of different sutures, the rate at which sutures lose strength and the interaction between sutures and tissues. TABLE D

section area in lbs/in2 or kg/cm2 2. Breaking strength - measurement of force required to break a wound without regard to its dimension 3. Bust strength - amount of pressure necessary to rupture a viscus Tensile strength is the preferred measurement for homogenous materials (ex.,. sutures). For heterogeneous materials (ex., skin), the breaking strength is more practical to use. For hallow organs (ex., intestines), burst strength is the more appropriate measure. From the meager data available, it can be shown that that regardless of the species, the relative strength of tissues to each other are similar. Animal studies show that the stress needed for a suture to pull out from the following tissues are: a. Skin -- 0.9 lbs. b. Fat -- 0.44 lbs. c. Fascia -- 8.3 lbs. d. Muscle -- 2.8 lbs. e. Peritoneum -- 1.9 lbs. f. Viscera -- 2.19 lbs. (stomach) -- 3.7 lbs. (rectum) Above the limits of the strength of the tissue, no advantages gained by using a larger or stronger suture to hold the wound edges together. These data on relative strength are useful only if considered in relation to the rate at which wounds in these tissues regain strength. Variations in Healing Rate A wound rarely, if ever, attains the same strength as uninjured tissue. The gain in strength varies from tissue to tissue.

HIERARCHY OF BIOLOGICAL INERTNESS

(from highest to lowest)

Highest Reactivity

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

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. Maingots Abdominal Operations, 10th ed., 1997

Self-Assessment Questions (Chapter III)

1. Which of the following sutures are considered non-absorbable? a. Polyester b. Polydioxanone c. Polyglactin d. Polyglycolic acid e. Poliglecaprone 2. Which of the following suture material has an indefinite tensile strength? a. Nylon b. Silk c. Polyester d. Polypropylene e. Polyglactin 3. Which of the following is a characteristic of skin adhesives? a. Interferes with MR imaging b. Consumes more time compared to sutures c. Yields similar cosmetic results as with subcuticular sutures d. Is used for joints lacerations e. Produces pain on application 4. Which of the following sutures loses tensile strength the longest? a. Chromic catgut b. Polyglactin c. Polyglycolic acid d. Polydioxanone e. Poliglecaprone 5. Which suture material is most suitable in closing the fascia of the abdominal wall? a. Plain catgut b. Chromic catgut c. Polydioxanone d. Poliglecaprone e. Staplers 6. Which of the following suture materials exhibits the highest inflammatory tissue reaction? a. Polypropylene b. Polyglactin c. Chromic d. Silk e. Polyester

7. Based on their physical properties, what suture will be good choice to approximate fascia after a contaminated operation? a. Plain catgut b. Polypropylene c. Silk d. Chromic catgut e. Cotton

8. The following statements regarding the physical properties of sutures and tissues are true EXCEPT? a. Above the limits of normal tissue strength, there is no advantage with the use of a larger or stronger suture b. A suture should hold injured tissues in apposition until the healing process to withstand stress without mechanical support c. Foreign bodies like sutures cane lead to the development or persistence of local infection and therefore, should not stay longer than their supported use d. From the practical stand point, tensile strength is more important than breaking strength e. All of the above

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

After going through this chapter, the learner should be able to: 1. Analyze the factors involved in needle selection. 2. Describe the characteristic of the surgical needle. 3. Identify the common types and code names of the locally available needles.

French-eye needles requiring the scrub nurse to thread the suture into the eye of the needle. The double strand of the suture that results from threading and the increase in diameter of the needle because of the presence of the eye, causes additional trauma to tissues and in anastomotic procedures, may lead to leakages. Moreover, threading is time consuming and the needles are difficult to prepare during surgery. A weak point is created near

Factors in the Selection of Needles When considering the ideal surgical needle for a given application, the type of tissues being approximated should be considered: they should be altered as minimally as possible by the needle. The only purpose of the needle is to introduce the suture into the tissues. The needle should also be large enough and of appropriate size, shape and design in order to provide precise and efficient suturing. There are five basic requirements that must be met in proper needle selection. The needle must be: 1. Able to carry suture material through tissues with minimal trauma. 2. Sharp to overcome tissue resistance. 3. Rigid to resist bending but flexible to prevent breaking . 4. Sterile and corrosion-resistant to prevent introduction of microorganisms or foreign bodies into the surgical site, and 5. Of appropriate size, shape and design. The surgical needle has evolved with the history of surgery

the eye that could lead to needle breaks and even to rusting. During operations in deep confined areas, eyed needles may become unthreaded. Theoretically, it is more difficult to retrieve them when accidentally dropped inside body cavities without the suture. Because of these, there was a gradual reluctance both in the use and manufacture of eyed surgical needles and favor shifted towards swaged surgical needles.

Anatomy of the Surgical Needle Regardless of its intended use, every surgical needle has three basic components: 1. The point 2. The body 3. The attachment end (swaged or eyed)

other orthopedic procedures. A. Needle Point The point extends from the extreme tip of the needle to the maximum cross section of the body. Each specific point is designed and produced to the required degree of sharpness to smoothly penetrate the type of tissue to be sutured. 1. Tapered The body of the needle tapers to a sharp point at the tip. The taper point needle is often preferred where the smallest possible hole in the tissue and minimal tissue trauma is desired. This is particularly indicated in intestinal anastomosis. It is also ideal for approximation of the peritoneum, fascia and subcutaneous tissues. Examples are needles codenamed CT-1 and SH. 2. Blunt A rounded blunt point that does not cut through tissues is used for penetrating friable, parenchymal and vascular tissues like the liver, spleen or kidneys. An example is the BP1 needle. 3. Reverse Cutting These needles have a cutting edge in the outer convex curvature of the needle. This cutting edge may extend from the point of the needle down to the swaged area. The cutting edge may also extend only down to 1/3 of the distance to the swaged area. This type is most useful in plastic surgical procedures. These types of needles are coded PS- 2 and OS-8. The latter type is also indicated in the closure of skin and various plastic surgery applications and B. Needle Body The portion between the point and the swage of a needle is called its body. This is the grasping area of the needle holder. C. Attachment End 1. Swaged This is the area in which the suture is attached to the needle. It is of specific importance to the needle-suture relationship.The ideal swage area diameter is a one-to-one sutureneedle ratio so that the more exact the sizes correspond to each other, the lesser the damage to the tissues. On the other hand, the bigger the ratio, the greater unnecessary tissue damage is produced. In cases of 4. Taper Cut (Trocar point) This is a blend of the combined features of the reverse cutting and the taper point needles. Three cutting edges extend approximately 1/ 32 inches back from the point. All three edges of the point are sharpened to provide uniform cutting action. It easily penetrates dense tough tissues. This type is used for sclerotic or calcified tissues and for heavy fibrous tissue such as the fascia. A typical example is V-40. 5. Conventional Cutting Edge The cutting sharp edge is in the concave curvature of the needle. This is ordinarily used in common plastic surgery procedures and in closure of superficial wounds and incisions. An example is the PC-5 needle.

bowel anastomosis, this ratio is most crucial in preventing needle puncture leaks. Suture attachments to the needle are most commonly done in two ways: Channeled Needles A channel is developed in the swage area and the suture is placed or clipped in the channel. Pressure is applied to close the channel around the suture in order to hold it tightly. 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 hole is then crimped a little in order to secure the suture end. Laser-drilled Needles A feature provided where the swage area is laser-drilled to achieve the closest one-to-one needle-suture ratio. Laser-drilled needles are currently available among cardiovascular products. It has the advantage of a tapered swage which in turn provides a smoother transition from needle to suture. In addition, a laserdrilled needle allows the so-called extended side flattening, a design that adds strength and resistance to bending. 2. Closed Eye Similar to a household sewing needle, the shape of the closed eye may be round, oblong or square.

4. Control Release Needle Suture These needle sutures allows easy detachment of the needle from the suture when desired by the surgeon. This allows rapid placement of sutures in succession, reducing operative time.

The chord length is defined as the straight line distance from the point of a curved needle to the swage. This varies from 2 mm. to more than 5 cm. Length is a determining factor in the width of the bite taken by the needle. Chord length comparison between the CT-1 needle and the TP-1 needle will make the biggest difference in the width of the bite.

E. Needle Diameter This refers to the gauge or thickness of the needle wire. Needle diameter varies from 30 microns to 56 mil (.056 inch). The diameter equals the size of the needle tract.

F. Needle Radius If the curvature of the needle were to continue 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 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.

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

G. Needle Shape Needles are available in various shapes to accommodate the desired turnout from different tissues. The shape of the needle remains consistent regardless of size. For example, although a

TF needle is significantly smaller in size than an XLH, they are both 1/2 circle needles. The following are the usual needle shapes used: 1/4 circle (TG) 3/8 circle (P) 1/2 circle (CT) 5/8 circle (UR) straight or Keith needle TG Needle: Their use is often limited to ophthalmic and microsurgical procedures. Size and depth of the area to be sutured are small and shallow. P Needle: This is the most commonly used curved needle. It can be easily manipulated in relatively large and superficial 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 deep cavities such as the pelvis or in small, cramped areas with difficult access. CT Needle: it is relatively easy to use in confined areas and difficult to reach locations though it requires more pronation and supination movements of the wrist than a 3/8 circle needle.

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

Needle Arming The needle should be grasped in the area about 1/4 to 1/2 the distance from the swaged area to the point. It should be held on securely at the tip of the needle holders jaws. There are various types of holders to accommodate different needles and for different locations and tissues. The following factors must influence the needle holders choice: 1. Security of the needle in the holder 2. appropriate size for specific needles 3. appropriate length for specific procedures Single Versus Double Armed Suture Commonly used sutures have one swaged-to-suture strand. Situations do arise wherein there is a need to place a suture at a midpoint and suturing must continue on both sides. The typical examples are vascular anastomoses. In such situations, it is ideal to use a double-armed suture. This is a suture strand with a needle swaged at each end. If the strand is divided into halves, this results into two single-armed sutures that can be used UR Needle: the tip of a 1/2 circle needle such as the CT1 can become obscured by other tissue deep in the pelvic cavity. When this occurs, the surgeon may individually. An example is the CT-1, CP-1 double armed needle suture combination for episiotomy repair. Characteristics of Surgical Needles and their Clinical Importance Trauma to the tissue edges that are sutured together during surgical procedures, among other factors, theoretically spells an integral part of the outcome of wound healing. The relationship is, in fact, indirectly proportional. The greater the trauma induced, the poorer the outcome. If it were an intestinal anastomosis, for example, excessively traumatized ends may result to a poorer blood supply, affecting the integrity of the intestinal layers, and complete apposition. Subsequent wound healing processes therefore are compromised. It appears that the choice of needle, suture material, as well as the technique of apposing

have difficulty locating the point of the needle in order to pull it through the tissues. A 5/8 circle needle such as the UR-4 is most advantageous in these situations.

and handling tissues together are important factors in order to achieve the best outcome with the least tissue damage. Therefore, surgical needle design, characteristics and usage play significant roles in the art and science of surgery.

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

Sharpness and Pointedness Sharpness, in contrast to pointedness, refers to the condition of the blade of cutting surgical needles. This is obviously not applicable among needles that are not flattened at the distal body and point. (Needles that are round may either be pointed or blunt at the opposite end of the swage). But cutting needles can become blunted both at their point and at the flattened body mainly due to repeated usage or friction against hard tissue and foreign bodies. There are round needles that are created with blunted points for the purpose of passing sutures through solid organs like the liver and spleen. But it is desirable to always use sharp cutting needles when indicated. Sharp cutting needles create clean, minute lacerations through tissues and cut muscle fibers. Pointed round needles, however, just create puncture wounds and merely split muscle fibers rather than cut them. Minute lacerated wounds created by using cutting needles may completely tear at their corners when subjected to tension. Literally, they tend to extend easily to a rent. Punctured wounds by nature are not prone to renting and are easily plugged. Thus, among hollow organs like viscus and blood vessels, pointed round needles are favored. On the other hand, tough tissues like the epidermis and the subcuticular layers are difficult to traverse with pointed needles. Thus, the cutting action of a flattened needle is desirable. These tissues are not prone to lacerations or renting due to its fibrous content. Atraumatic Needles This is a misnomer. All needles cause some form of trauma to sutured tissues. So-called atraumatic needles cause the least injury. This is so because of the following characteristics: 1. Small diameter, 2. The size of the swage is the same as the size of the body, 3. The suture material is of the same diameter as the

Rigidity versus Flexibility Rigidity of surgical needles is dependent on the diameter, composition of the metal alloy used and the temperature by which they were set (tempered). This is, therefore, affected by its frequency of being subjected to autoclaving. Rigid needles are necessary in suturing bones, cartilage and very tough fascia. Hernia needles, sternal needles and needles used to wire bones together are some examples. Rigid needles tend to break when too much shearing pressure is applied unlike flexible needles. Flexible needles, however, tend to withstand a greater shearing force or even bending but generally not in acute angles.

Rust-free and Corrosion-free Needle Material Stainless steel needles are generally rust- and corrosion-free. Most surgical needles are no longer made of lesser quality. Their flexibility, inertness and smoothness are other characteristics that are most desirable in surgical needles for medical grade usage. Other metal alloys are even better but their cost is prohibitive. Needle Weakpoints Eyed needles break most frequently at the junction of the swage and the body. This is so because of the tension created by the angle of the needle against the suture. In the process of passing a curved needle through tough tissues, the straight portion of the eyed needle may be pulled by the surgeon at an acute angle against the tissue. In other situations, the surgeon may load the needle at this weak point and apply the drive force through the tissue. Another weak point, particularly among atraumatic round needles, is the junction of the body and the point. The surgeon may force the body of the curved needle through the tissues at

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 suturing deep in the pelvic cavity? a. 1/4 circle b. 3/8 circle c. 1/2 circle d. 5/8 circle e. straight needle 2. For suturing liver lacerations, the surgical needle to use is: a. CT series b. SH series c. BP series d. TP series e. V-4 needles 3. The surgical needle for microsurgical procedures is: a. UR-4 b. PS-1 c. XLH d. V-4 e. CT-1 4. Surgical needles most commonly used for bowel anastomosis is: a. Reverse cutting b. Circle tapered c. Cutting tapered d. Rounded blunt e. Conventional cutting 5. The needle to use in the primary repair of a complete but clean traumatic transection of the ureter is: a. MO b. PS d. X-1 e. RB-1

Chapter V Knot Tying

Jose Antonio M. Salud, MD, FPCS Miguel C. Mendoza, MD, FPCS Knot Tying Techniques Square Knot (Two-Hand Technique) 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.

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.

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: 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 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.

9. By further supinating left hand, white strand slides onto left index finger to form a loop as purple strand is grasped between left index finger and thumb.

6. Purple strand released by left hand and grasped by right. Horizontal tension is applied with left hand toward and right hand away from operator. This completes first half hitch.

10. Left hand rotated inward by pronation with thumb carrying purple strand through loop of white strand. Purple strand is grasped between right thumb and index finger.

11. Horinzontal tension 7. Left index finger released from white strand and left hand again supinated to loop white strand over the left thumb. Purple strand held in right hand is angled slightly to the left. 12. The final tension on the final throw should be as nearly horizontal as possible. applied with left hand away from and right hand toward the operator. This completes the second half hitch.

8. Purple strand brought toward the operator with the right hand and placed between left thumb and index finger. Purple strand crosses over white strand.

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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. 6. Purple strand releases by left hand and grasped by right. Horizontal tension is applied with left hand toward and right hand away from operator. This completes first half hitch.

2. Purple strand brought over white strand on left index finger by moving right hand away from operator.

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.

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.

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.

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Surgeons or Friction Knot

1. White strand placed over extended index finger of left hand and held in palm of left hand. Purple strand held between thumb and index finger of right hand. 2. Purple strand crossed over white strand by movin right hand away from operator at an angle to the left. Thumb and index finger of left hand pinched to form loop in the white strand over index finger.

5. The loop is slid onto the thumb of the left hand by pronating the pinched thumb and index finger of left hand beneath the loop.

6. Purple strand drawn left with right hand and again grasped between thumb and index finger of left hand.

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 index finger to pass purple strand through loop. Regrasp purple strand with right hand.

8. Horizontal tension is applied with left hand toward and right hand away from the operator. This double loop must be placed in precise position for the final knot.

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

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

2. Purple strand held in right hand brought between left thumb and index finger. Left hand turned inward by pronation, and thumb swung under white strand to form the first loop.

6. Purple strand looped around white strand to form second loop. This throw is advanced into the depths of the cavity.

3. By placing index finger of left hand on white strand, advance the loop into the cavity.

7. Horizontal tension applied to pushing down on purple strand with right index finger while maintaining counter tension on white strand with left index finger. Final tension should be

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 the operator.

5. With end of the strand grasped by the needleholder, pugple strand is drawn through loop in the white strand away from 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 operator. Final tension should be as nearly horizontal as possible.

3. First half hitch completed by pulling needleholder toward operator with right hand and drawing white strand away from operator. Needleholder is released from purple strand.

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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. This entails running the tip of the scissors lightly down the suture strand to the knot. Most sutures are cut close to the knot, approximately 1-2 mm. from the knot to decrease tissue reaction and minimize the amount of foreign material left in the wound. This is true particularly for braided sutures. For monofilament sutures, it is advised to cut a little longer from the knot, approxi-

mately 3-4 mm. as these type of sutures may loosen after knot tying. For sutures applied to the skin, the sutures are cut even longer away from the knot. The reason for this is to make it easier for the surgeon to remove the sutures at a later time.
REFERENCES Knot Tying Manual, ETHICON, 1996 Ochsner, A and DeBakey ME. Christophers Minor Surgery, 8 Co. th 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? a. Silk b. Polyester c. Nylon d. Wire 2. Why are more throws required for maintaining knots when tying monofilament sutures? a. They are more difficult to handle b. The knots have a tendency to loosen c. More tension is required to maintain monofilament sutures d. None of the above

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 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. Each stitch is tied independently of other stitches.

Simple Interrupted

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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.

Vertical Mattress A vertical mattress suture starts some distance from the wound edge, passes deeply under the wound and emerges on the opposite side at the same distance from the edge. It then returns taking a more superficial bite from each wound edge. It is tied on one side of the wound and does not appear to cross it. The vertical mattress suture gives a good approximation of the skin edge and therefore results in a cosmetically acceptable scar. It is frequently used for fine skin closure. The vertical mattress consists of a far-far, near-near component. The vertical mattress is also known as the Stewart suture.

Horizontal Mattress Suture A horizontal mattress suture starts some distance from the wound edge, also passes under the wound to emerge on the opposite side at the same distance from the edge. Then, coming from the same side of the wound at some distance from where it emerged, it passes back deeply under the wound to exit on the opposite side at the same distance from the edge, where it is tied. The horizontal mattress provides coaptation in an everted fashion. It is used for closure of deeper tissues such as fascia.

Interrupted Horizontal Mattress

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Figure of Eight Mattress Suture A figure of eight mattress suture starts at some distance from the wound edge, goes deeply under the wound to come out of the opposite side at some distance from the edge. It goes back to the opposite side where it re-enters the wound in the same manner as the first component but at some distance from it. The suture is subsequently tied. This provides an everted type of approximation of tissues and is used primarily for the deeper planes.

Subdermal Interrupted This technique is used to close wounds where cosmetic aspects are especially important. It carries the advantages of completely avoiding stitch marks. This may be done in interrupted or continuous fashion. It can only, however, be recommended in wounds with low degree of contamination.

Subdermal Interrupted

Figure of Eight Mattress

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CONTINUOUS SUTURES Also referred to as running stitches, continuous sutures are a series of stitches taken with one strand of material. The strand may be tied to itself at each end, or looped, with both cut ends of the strand tied together. A continuous suture line can be placed 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 suturing leaves less foreign body mass in the wound. In the presence of infection, it may be desirable to use a monofilament suture material because it has no interstices which can harbor microorganisms. This is especially critical as a continuous suture line can transmit infection along the entire length of the strand. A continuous one layer mass closure may be used on peritoneum and/or fascial layers of the abdominal wall to provide a temporary seal during the healing process.

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

Continuous Interlocking

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Subcuticular 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 suture strand before the knot is tied.

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.

Over-and-Over Running Stitch Subcuticular

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INTERRUPTED LEMBERT 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.

Note: This procedure approximates the serosa while mucous membrane is inverted and fibromuscular layer is well grasped. Objection: Takes more time for placing and tying and must be positioned closer together to ensure water tight closure.

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 incisions 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 first layer of closure of the anterior wall of the gastrointestinal anastomosis and the first layer in closure of an open end of a resected gut. Suture to be used should be of catgut or synthetic absorbable kind and is always reinforced by an outer layer of non-absorbable suture that buries it and does not penetrate all the layers of the GIT wall into the lumen. Technique 1. The suture is passed 4 to 5 mm from end parallel to its wound edge. 2. It pierces all layers of the gut wall with an in and out on the same side or loop on the mucosa type of stitch. 3. The suture is tied after the first stitch is taken, the knot being placed either within or without the gastrointestinal wall, depending upon the site of origin of suture. 4. After the knot is tied, the needle is passed from without to the inside of the intestinal wall. It then is advanced about .3 cm and is reinserted from within to the outside of the gut wall, after which it is brought across the incision to penetrate the opposite wall from without inward and so forth. 5. The suture is tied again at the far end.

Note: It is important to remember that the suture crosses the incision only from the outside of one wall to penetrate the outside of the opposite wall. It penetrates from the inside to the outside only on the same side on which the previous stitch ended. Advantage: This is hemostatic and compresses all layers of the gut wall.

Connell Suturing

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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

PURSE STRING 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, forming 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 (Far-Far-Near-Near) 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.

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 ___1. This suturing technique is intended to close an opening of a hollow organ around a tube ___2. This suturing technique is used for fine skin closure producing everted edges. It consists far-far, near-near component. ___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.

Column B A. Vertical Mattress B. Gambee C. Continuous Interlocking D. Purse String E. Subcuticular F. Smead Jones G. Connel H. Lembert

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 the said procedures.

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.

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, the wound edges are approximated again with the fingers or forceps and the strips are simply applied over the wound edges to apposition. The strips may then be removed in 5-7 days. Abdominal Wall Closure In closing the abdominal wall, it is not necessary to close the peritoneum as closure of this layer does not contribute to wound strength. Still, some surgeons prefer to do so since this is considered to aid in reducing the formation of adhesions. However, the use of highly reactive sutures or sutures that are applied too tightly may result in formation of significant adhesions between the peritoneum and the underlying structures. Furthermore, healing of the peritoneum is complete within seven to fourteen days post-operatively. Thus, if the peritoneum is to be closed, it is best to use sutures that result in minimal tissue reaction while maintaining tensile strength for at least 14 days. Polyglactin and polyglycolic acid sutures are thus recommended using a 1/2 circle round needle.

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Inguinal Herniorrhaphy/Repair of the Inguinal Floor Inguinal hernia repair is classified as a clean wound. The incision is usually short and the precise anatomical repair is done in a deep confined space. In repairing the inguinal floor, precise tension on the fascial edges requires a technique where each suture exists independent of the others. For this reason, the majority of hernia repairs are performed using a simple interrupted suture line. There are, however, some repair techniques that utilize a continuous suture line. Since knot-tying is extensive, and knot security is important in the interrupted technique, a braided suture is used while monofilaments are used for the continuous technique. The repair requires a strong suture of adequate diameter to keep the tissues together without breaking or cutting through. While the transversalis fascia is relatively easy to penetrate, its analogues like the iliopubic tract or Coopers ligament are tough tissues. In the face of tough tissues in tight working areas, there is the tendency for a needle to shift in the needle holder; worse, it can bend, perforate or lacerate vital and vulnerable structures. For a precise anatomical repair, the choice of the suture and the needle is vital. The ideal suture is a non-absorbable braided (or monofilament), 0 or 2-0 with permanent strength and low reactivity (polyester or polypropylene) together with a very sharp tapered, heavy-bodied atraumatic (channeled or drilled) needle, preferably 1/2 to 5/8 circle with a relatively short to medium chord length. The acceptable alternative is a silk suture threaded through a sharp, tapered, heavy-bodied, eyed needle at 1/2 circle with a relatively short to medium chord length. Appendectomy During an appendectomy, the mesoappendix is serially clamped, cut down to the base and ligated using silk/cotton 2-0 or 3-0 sutures. The base of the appendix is suture ligated using 2-0 silk/ cotton in a round 1/2 circle intestinal needle especially if the

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The fascia is considered the most important layer in closing an abdominal surgical wound. It is the major supportive structure of the body and is the strongest tissue in the abdominal wall and thus, carries the brunt of the stress on the abdominal wound. Breakdown of this layer may result in the development of incisional or ventral hernias especially in malnourished, obese or immunocompromised patients. The known critical healing period of fascia is somewhere between the 14th and 21st post-operative days. A suture must therefore maintain immediate and extended wound support to prevent breakdown of this layer. In this regard, the best suture materials would be those that maintain a long tensile strength such as polypropylene, nylon, polyester, silk or cotton, 2-0 or 0 on a 1/2 circle needle. Since absorbable sutures like polyglactin and polydioxanone can maintain tensile strength of about 40%50% at 3 weeks, they may also be used. However, in the presence of infection or contamination, the sutures that elicit minimal inflammation are best.

base is wide. A free tie of 2-0 is often times used to reinforce ligation of the base before the appendix is divided. It is always safer to doubly ligate the base to reduce the possibility of stump blowout. An alternative step is to apply purse-string sutures using 2-0 or 3-0 silk/cotton in a 1/2 circle intestinal needle to bury the appendiceal stump. However, no clear advantage has been noted with the use of purse-string sutures. Another alternative suture material is the braided absorbable variety (polyglactin/polyglycolic) 2-0 or 3-0. Since it has a high breaking force, maintains its tensile strength up to 14 days and is only absorbed after 45 days, it can be used to ligate the 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.

4-0 or 5-0 absorbable monofilament suture such as poliglecaprone or polydioxanone, using a 1/2 curved tapered needle. This is preferable over non-absorbable because they do not act as a nidus to stone formation and they produce less trauma to the bile duct wall since it smoothly slides inside the needle tract during suturing. Its disadvantages are that it requires more knots to secure the closure and are relatively more expensive.

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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 bleeding fails to stop with other maneuvers (e.g., packing or electro-cautery), the cut edges of the lacerated liver parenchyma may need to be sutured. Liver parenchyma is very vascular and friable. Tensile strength is not a concern in this situation because what is required is just to approximate the edges for hemostasis. Long tensile strength retention and absorption time is likewise not a requirement. For this reason, an appropriate and ideal suture for this situation is chromic catgut suture. Chromic suture has a smooth surface thereby inciting less trauma as it passes through liver tissue. The suture is retained long enough for the purpose of maintaining hemostasis. The suture is best swaged on a long, blunt-tipped liver needle (BP-1) which is best when passed through the vascular liver tissue. Chromic 2-0 horizontal mattress sutures are applied on both

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Cholecystectomy and Surgery of the Bile Ducts After identifying the cystic duct and artery during a cholecystectomy, these structures are individually ligated with nonabsorbable 2-0 sutures (silk/cotton). Sometimes the cystic duct can be ligated with a transfixing suture using 2-0 or 3-0 silk/ cotton utilizing a full curved round intestinal needle. Braided suture materials are used in ligating vessels, the cystic duct and bile ducts because they require minimal knots without easily slipping as compared to monofilaments. Although tissue reaction is greater, it is clinically insignificant if applied outside the wall of a hollow structure or viscus. Hence, non-absorbable braided suture materials are appropriate in this setting. It does not readily slip and is cost-effective. Another alternative method of securing the cystic duct stump is by using liga clips as in laparoscopic surgery. Doubly ligating or clipping the cystic duct stump is suggested to prevent unnecessary leaks.

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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 necrosis of normal liver tissue. The alternative suture would be an absorbable suture like polyglactin. Bowel Anastomosis Leakage of intestinal contents or its frank breakdown after a bowel anastomosis carries severe consequences. A critical factor that determines anastomotic integrity is the application of proper suturing technique and material. However, it must be emphasized that half of the procedure is accomplished before the actual resection and anastomosis, i.e., during the preparation of the segments that are to be resected and the bowel ends that are to be joined together. Another unique feature of the procedure is that of tissue inversion. The repair is reinforced by the proper approximation and healing of the seromuscular layer of each bowel end. Inversion therefore provides a serosa-to-serosa apposition over a mucosa-submucosal repair. All the layers of the bowel wall are characteristically soft with minimal to moderate dense fibrous support. As such it is easy to penetrate. Using taper point or round point needles is appropriate. Anything sharper than a taper or round needle may be more traumatic or more risky than is desirable. Moreover, the depth of the bite in bowel anastomosis need not be very deep and the working space inside the abdominal cavity may be somewhat confined. A 1/2 circle needle is standard for this repair. Bowels are lumenous structures with fluid and gaseous contents and its repair is ideally done without tension which seldom offers resistance. Therefore, the diameter of the needle must be thin to keep it water-tight but at the same time relatively strong and stable given the necessary thin wire diameter. The average thickness of bowel walls that are to be anastomosed only require medium chord length. And in order to create the least puncture injury to the bowel walls, atraumatic needles, i.e., those with a swage attachment rather than eyed, are desirable. Healing time is relatively fast with the anastomosis assuming tensile strength in about 7-14 days. The serosal layer heals faster than the submucosa but it is the latter, being the most fibrous among the 4 layers that gives the anastomosis its required strength. The submucosal repair therefore, is the most important for the surgeon. Consequently, the suture material that is ideal for bowel anastomosis must therefore retain tensile strength beyond the healing time of the slowest healing tissue - the submucosa. Absorbable suture materials are commonly used but non-absorbables are also popular particularly among single layer technique of repair. It is not uncommon for the prolonged presence of a suture in the mucosa to provoke significant foreign body reaction and granuloma formation. This has great significance in the gastric mucosa as it may lead to post-operative anastomotic ulcer formation. Hence, for the inner layer in gastric or duodenal anastomosis, short term absorbable suture materials are 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 mucosal and submucosal layers. The rationale here is the required prolonged reinforcement of the seromuscular repair for the slower healing submucosal layer and for the quickly absorbed inner suture. There are, however, suturing techniques that accomplish bowel anastomosis using single layer repair. These are mostly applied in esophageal and rectal anastomoses where the procedures are performed in very limited and confined spaces and where the margins of resection are too short to adequately permit an inversion technique. The anastomoses in such cases may be commonly performed with a running stitch, although an interrupted technique is also popular for facilitating a precise reapproximation. Here, both braided and monofilament materials are utilized depending on the technique, i.e., monofilament for running, continuous stitch and braided for interrupted. Keep in

mind that a continuous non-absorbable suture would, in essence, serve as a purse-string that would permanently limit the size of the lumen as opposed to employing the interrupted technique using absorbables. In considering the size of the suture material, there has to be a reasonable balance between the required tensile strength and tissue reaction due to the foreign body. Suture material strength is a function of the size. But bowel anastomosis is best done without tension. The bowel walls are neither thick nor fibrous where stress and strain to suture material is minimal. But if the suture is too fine, there is always the possibility of cutting through the tissues with the slightest strain. Therefore, 3-0 is the standard while 2-0 is acceptable as well as 4-0. Finally, a material that elicits the least amount of tissue reaction is desirable in order to minimize incidence of adhesions between the site of repair and other peritoneal surfaces as well as to eliminate granuloma formation within and without the bowel. Vascular Anastomosis and Repair Vascular suturing has specific demands different from other suturing techniques. Suturing and repair of vessels demand precision in the approximation of the cut edges to maintain integrity of the lumen and prevent dehiscence/breakdown which has more disastrous consequences. Tensile strength retention and absorption rate are very critical in determining the choice of suture. Blood vessels are subjected to a tremendous amount of pressure per square millimeter and for this reason, sutures have to be strong and absorbed/broken down only after a long time. Given also the special situation of anastomosing blood vessels to synthetic grafts, one must remember that only one side of the repair will undergo biologic wound healing and repair. It has also been noted that using absorbable sutures or sutures that are easily broken down (including silk), leads to a higher incidence of vascular anastomotic breakdown or pseudo-aneurysm formation. The ideal suture for this situation is a suture that is inert, 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-

ment, non- absorbable and incites very minimal inflammatory reaction. This is best used with a 1/2 circle, tapered BV-1 or RB1 needle. Vessels may be sutured in a running, continuous fashion, for which a double-armed suture is best or in an interrupted manner, especially for smaller vessels. Continuous suture technique for very small vessels may have a purse-string effect which may narrow the lumen further. An alternate suture for use in vascular surgery is braided polyester. Application of Retention Sutures These are utilized as reinforcing sutures to relieve pressure on the suture line and to prevent postoperative wound disruption in abdominal wound closures in particularly vulnerable patients, as in the elderly and immunocompromised patients. Retention sutures utilize strong and large suture materials, in particular, non-absorbable sutures. Absorbable sutures need not be used as these sutures will eventually be removed in a couple of weeks. Sutures that may be used for this particular procedure include nylon, polypropylene or silk 2, 1 or 0. Even stainless steel or wire may be used. These same suture materials may be used even in the presence of infection as they produce the least inflammatory reaction. The best needle to use would be a large cutting-edge needle, so as to penetrate the layers of the abdominal wall with ease. Retention sutures should be applied prior to closing any layer of the abdominal wall and must be applied under direct vision to prevent bowel injury. After all retention sutures have been applied and after all the layers of the abdominal wall have been closed, they are all individually tied. To prevent tying the retention sutures too tightly, rubber bridges are applied. These rubber bridges may be in the form of cut strips of drainage tubes or catheters.

REFERENCES Abrahamson J. Hernias. In: Zinner MJ, Schwartz SI, Ellis H, et al (eds), Maingots AbdominalOperations, 10th ed., Stamford, Conn.: Appleton & Lange, 1997 Brooks DC, Zinner, MJ. Surgery of the Small and Large Bowel. In: Zinner MJ, Schwartz SI, Ellis H, et al (eds), Maingots Abdominal Operations, 10th ed., Stamford, Conn.: Appleton & Lange; 1997 Feliciano DV, Moore EE and Mattox KL. TRAUMA, 3rd ed., Stamford, Conn,: Appleton & Lange, 1996 Rout WR. Gastrointestinal Suturing. In: Zuidema GD, Ritchie WP , Jr. (eds), Shackelfords Surgery of the Alimentary Tract, 4th ed., Philadelphia, PA: WB Saunders; 1996

Rout WR. Closure of Wound. In: Zuidema GD, Ritchie WP , Jr. (eds), Shackelfords 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 Singer AJ, Hollander JE and Quinn JV. Evaluation and Management of Traumatic Lacerations; The New England Journal of Medicine, 1997, 337:1142-1148 Wilson RF and Walt AJ. Management of Trauma: Pitfalls and Practice, 2nd ed., Williams & Wilkins, 1996 Zollinger RM, Jr., Zollinger RM. Atlas of Surgical Operations, 7th ed., New York: Macmillan, 1988

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? a. Silk 4-0 interrupted b. Cotton 4-0 continuous c. Polyglactin 4-0 simple, interrupted d. Polypropylene 5-0 simple, interrupted e. Polyglycolic acid 3-0 continuous 3. The use of absorbable sutures is advocated when applying sutures in the biliary tree because? a. It evokes less inflammation than non-absorbable sutures does b. Non-absorbable sutures become nidus for later stone formation c. Strictures are less common with the use of absorbable sutures d. Leaks are less likely to occur with absorbable sutures e. Absorbable sutures are easier to handle 4. During a retrograde appendectomy, ligature of the base is performed using which suture? a. Silk 2-0 b. Polypropylene 2-0 c. Polyglactin 3-0 d. Chromic 2-0 e. Polyester 2-0 5. The following suture materials may be used in closing the inner layer of a two-layer inverting bowel anastomosis, except: a. Chromic catgut b. Polyglycolic c. Plain catgut d. Polyglactin e. Polypropylene 6. The most frequently used suture material for single-layer bowel anastomosis is: a. Polypropylene b. Braided silk c. Cotton d. Surgical gut e. Polydioxanone 7. A 13-year old boy sustained a 2 cm. by 8 mm. deep laceration on the left upper eyelid after being accidentally hit by a baseball bat. The wound is clean with relatively smooth edges. What would you do? a. Close the wound with interrupted silk 6-0 b. Cut clean the edges and close with interrupted nylon 7-0 c. Cut clean the edges, suture the subcutaneous tissue with 6-0 polyglactin then close the skin with interrupted silk 6-0 d. Deep bite skin closure (together with subcutaneous tissue) using 5-0 nylon e. Debride and if available, use skin adhesives 8. During an inguinal herniorrhaphy, the suture of choice in repairing the floor of the canal is? a. Silk 2-0 interrupted b. Chromic 0 interrupted c. Nylon 0 continuous d. Polyglactin 0 interrupted e. Interrupted polypropylene 0 9. A completely transected axillary artery is best repaired end-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 or digested by enzymatic processes blunt point a type of needle wherein the tip is rounded and will not cut through tissues braided sutures with intertwining threads breaking strength measurement of force required to break a wound without regard to its dimension burst strength amount of pressure neecessary to rupture a viscus catgut a type of absorbable suture derived from the bowel of either sheep or cattle chord length the straight line distance from the point of a curved needle to the swage chromic an absorbable suture treated with chromate compounds continuous a type of suture technique wherein sutures are placed into tissues without interruption conventional cutting edge a type of needle with two cutting edges and in addition, have a third cutting edge on the inside concave curvature of the needle needle diameter the gauge or thickness of the needle wire needle length the distance measured along the needle itself from point to end needle radius in vivo tensile strength amount of tension or pull which a suture can withstand before it breaks, inside the tissue knot tensile strength the force which the suture strand can withstand before it breaks during knot tying knot tying the process of securing sutures using instruments or done manually ligature any suture material used to tie vessels or structures monofilament synthetic sutures that are single and untwisted needle body the portion between the point and the swage of the needle hydrolysis a type of chemical process that results in suture breakdown of synthetic absorbable sutures cotton a non-absorbable braided suture

if the curvature of the needle were to make a full circle, this would be the distance from the center of the circle to the body of the needle non-absorbable sutures type of sutures that are not broken down by chemical processes in tissues nylon a synthetic non-absorbable type of suture in monofilament and braided forms marketed as Ethilon(r)or Nurolon* plain catgut simplest form of absorbable catgut suture polydioxanone a synthetic monofilament absorbable suture marketed as PDS(r)II polyester the first synthetic braided non-absorbable suture marketed as Mersilene(r), Miralene(r), Ethibond(r), or Surgidac(r) poliglecaprone a synthetic monofilament absorbable suture marketed as Monocryl(r) polyglactin a synthetic braided absorbable suture marketed as Coated Vicryl(r)

polyglyconate a synthetic absorbable monofilament suture marketed as Maxon(r) polypropylene a non-absorbable synthetic monofilament suture marketed as Prolene(r), Premilene(r), or Surgidac(r) reverse cutting like a conventional cutting needle except that its third cutting edge is at the outer convex curvature of the needle silk the most commonly used non-absorbable braided suture; a protein filament produced by silkworms swage the area in which the suture is attached to the needle resulting in the needle and suture becoming a continuous unit tapered needles the type of needle wherein the body of the needle gradually tapers to a sharp point at the tip tensile strength the load applied per unit of cross-section area measured in lbs/ in2 or kg/cm2 wire/steel

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 3. B 4. C 5. A 6. C 7. E 8. A 9. B 10. D 11. A, D 12. A, D 13. A, D 14. B 15. A, D CHAPTER VI 1. D 2. A 3. B 4. H 5. G CHAPTER II 1. B 2. A 3. D 4. C 5. A CHAPTER VII 1. B 2. C CHAPTER III 1. A 2. D 3. C 4. D 5. C 6. C 7. B 8. D CHAPTER IV 1. D 2. C 3. D 4. B 5. E 3. B 4. A 5. C 6. B 7. C 8. E 9. D 6. E 7. F 8. C CHAPTER V 1. C 2. B

2003 Board of Regents of the Philippine College of Surgeons

President: Vice-President: Treasurer: Secretary: Members:

Fernando L. Lopez, MD Edgardo R. Cortez, MD Arturo S. de la Pea, MD Leonardo L. Cua, MD Josefina R. Almonte, MD Gerardo A. Directo, MD Maximo Dy-R. Elgar, MD Maximo H. Simbulan, Jr., MD Maximo B. Nadala, MD Rodolfo L. Nitollama, MD Stephen S. Siguan, MD Vedasto B. Lim, MD Armando C. Crisostomo, MD Rey Melchor F. Santos, MD Jose C. Gonzales, MD

2003 Committee on Surgical Training of the Philippine College of Surgeons

Chairman: Members: Cenon R. Alfonso, MD Shirard L.C. Adiviso, MD, MHPEd Jose Joey H. Bienvenida, MD Miguel C. Mendoza, MD Renato Cirilo A. Ocampo, MD Secretary: Annette G. Tolentino

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

Sitting (Left to right): Cenon R. Alfonso, MD, Armando C. Crisostomo, MD, Annette G. Tolentino Standing ( Left to Right): Miguel C. Mendoza, MD, Renato A. Ocampo, MD, Shirard L.C. Adiviso , MD, Joey H. Bienvenida , MD

Acknowledgement
The Committee on Surgical Training of the Philippine College of Surgeons would like to express its sincerest gratitude to Ms. Annette G. Tolentino, Executive Secretary of the Philippine College of Surgeons and to Ms.Ruth Nicolas, Franchise Manager, Ethicon Division, of Johnson and Johnson Medical, Philippines, for their unwavering and dedicated support to the completion of this 2003 Basic Surgical Skills, Electronic Version. Also, the committee would like to acknowledge the expertise of Mr. Juanito R. Gatus of Priority One Corporate and Marketing Communications, for the layout and graphics; and Mr. Alain Espina, for the development of the CD.

2003 Board of Regents of the Philippine College of Surgeons

President: Vice-President: Treasurer: Secretary: Members:

Fernando L. Lopez, MD Edgardo R. Cortez, MD Arturo S. de la Pea, MD Leonardo L. Cua, MD Josefina R. Almonte, MD Gerardo A. Directo, MD Maximo Dy-R. Elgar, MD Maximo H. Simbulan, Jr., MD Maximo B. Nadala, MD Rodolfo L. Nitollama, MD Stephen S. Siguan, MD Vedasto B. Lim, MD Armando C. Crisostomo, MD Rey Melchor F. Santos, MD Jose C. Gonzales, MD

2003 Committee on Surgical Training of the Philippine College of Surgeons

Chairman: Members: Cenon R. Alfonso, MD Shirard L.C. Adiviso, MD, MHPEd Jose Joey H. Bienvenida, MD Miguel C. Mendoza, MD Renato Cirilo A. Ocampo, MD Secretary: Annette G. Tolentino

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

Sitting (Left to right): Cenon R. Alfonso, MD, Armando C. Crisostomo, MD, Annette G. Tolentino Standing ( Left to Right): Miguel C. Mendoza, MD, Renato A. Ocampo, MD, Shirard L.C. Adiviso , MD, Joey H. Bienvenida , MD

Acknowledgement
The Committee on Surgical Training of the Philippine College of Surgeons would like to express its sincerest gratitude to Ms. Annette G. Tolentino, Executive Secretary of the Philippine College of Surgeons and to Ms.Ruth Nicolas, Franchise Manager, Ethicon Division, of Johnson and Johnson Medical, Philippines, for their unwavering and dedicated support to the completion of this 2003 Basic Surgical Skills, Electronic Version. Also, the committee would like to acknowledge the expertise of Mr. Juanito R. Gatus of Priority One Corporate and Marketing Communications, for the layout and graphics; and Mr. Alain Espina, for the development of the CD.