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BASIC SURGICAL SKILLS MANUAL
Principles and Applications
2nd Edition • Electronic Version
PHILIPPINE COLLEGE OF SURGEONS • Committee on Surgical Training
Cenon R. Alfonso, MD - Committee Chairman Miguel C. Mendoza, MD - Editor-in-Chief Shirard L.C. Adiviso , MD, Jose Joey H. Bienvenida , MD, and Renato Cirilo A. Ocampo , MD Armando C. Crisostomo, MD - Regent-in-Charge.
PCS SCIENTIFIC PUBLICATION N O. 12
Table of Contents
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
1st Edition . . . Gabriel L. Martinez, MD, FPCS, Chairman, Committee on Surgical Training, Philippine College of Surgeons 1999
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
2nd Edition . . . Armando C. Crisostomo, MD, FPCS, Regent-In-Charge (2003), Committee on Surgical Training, Philippine College of Surgeons
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)
1st Edition . . . Jose Y. Cueto, MD, FPCS, Regent-In-Charge (1999), Committee on Surgical Training, Philippine College of Surgeons
Learning & Assessing Psychomotor Skills in Surgery Jose Y. Cueto, Jr., MD, MHPEd, FPCS (1st edition) • Self-Assessment Questions
The Use of Simulation in Surgical Training Shirard L.C. Adiviso, MD, MHPEd, FPCS • Self-assessment Questions
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
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
2003 PCS Board of Regents 2003 Committee on Surgical Training Acknowledgement
have been adequately satisfied. and seemingly-endless proddings. Atong. these trainees will be required to pass a certification from a surgical skills laboratory. The hope is once the trainee is faced with an actual patient. Committee on Surgical Training (2003) Philippine College of Surgeons . Armand. Cenon R. contributions.repetition and feedback . This means that the essential principles of mastery in psychomotor skills . 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. Joey. most specially to the Regent-in-Charge. This is the importance of this CD version and Edition of the Basic Surgical Skills Manual. Furthermore. 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. The first step towards the above-mentioned goal is to be able to experience an audiovisual simulation. Because of this propensity. Shirard. thank you and congratulations for all your selfless efforts. This shift is from the operating-room-patient venue into the surgical skills laboratory-simulation setting. MD. it may also come to a point that before being allowed to do so.Foreword • 2nd Edition An audiovisual simulation in basic surgical technique Even a full decade before the turn of the 21st Century. and Ike. basic surgical technique is almost second nature. FPCS Chairman. Alfonso. To all the members of the CST. the growing movement toward a paradigm shift of surgical skills training has already begun.
the Committee on Surgical Training (CST) through its Chairman. Ruth Nicolas. Martinez presented the project proposal to the PCS Board of Regents. Manzano. Committee on Surgical Training (1999) Philippine College of Surgeons . during the incumbency of Dr.M. de los Santos and Paul Jesus S. Erwin Tantoco who favorably endorsed the project. Arcellana. Cueto. Jr. 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. In 1999. Montemayor. Special thanks to Dr.. MD. and Mr. Jose Antonio M. problem-oriented instructional tool for trainees and surgical practitioners. the drafts of the Manual were presented to the Board of Regents for comments and suggestions. Mabilangan-Salud and Ms. Martinez. Regent-representative Dr. Gabriel L. Jr.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. FPCS Chairman. While diligently collecting and collating data from the various makers of surgical needles and sutures for inclusion in the Basic Surgical Skills manual. Jose Y. Antonio B. Elizabeth F. and J & J through its Franchise Manager. Salud. Santos. Once approval was obtained. Francisco Y. the CST made representations with Johnson & Johnson Medical Philippines through Mr. Bayani R. The favorable action of the Board of Regents led to the creation of the Sub-committee on Skills Improvement under Dr. Olivia S. Gabriel L. Nilo C. Ms. engaged the services of Creative Powerhauz to publish this manual. In 1998. contributors Drs. the CST. during the incumbency of Dr. As in any endeavor. CST secretary. Sison. Dr.
This aspect of surgical training essentially requires two basic learning principles. mastery of technical competence. Training of young physicians into the Art and Science of Surgery therefore requires not only intensive education. and the right attitude and motivation do not make up a complete Surgeon. but equally important. surgical knowledge and decisionmaking. Allow me to extend a similar warm recognition to the partner of PCS in this project. the young trainee can view this first and then play back for feedback. These have to be adequately matched by a set of fine psychomotor skills. In the long term however. So that before a certain technique is performed by simulation or in a patient. 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 behalf of the Board of Regents. MD President 2003 . 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. namely: repetition and feedback. i. Lopez. In the short term. This feat of the Committee on Surgical Training is the first step towards this end. Johnson & Johnson Medical Philippines. Fernando L.e. the Board of Regents envisions this project to serve as a guide to trainees. 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. let me congratulate the Committee on Surgical Training for this project.Message from the 2003 PCS President The backbone for all cutting specialties Clinical acumen.
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. 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. MHPEd. FPCS Regent-in-Charge (2003) Committee on Surgical Training Philippine College of Surgeons . Despite the importance of the operative skill. 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. continuing education in this regard continues to be wanting. Also. we intend to pursue publication of the Advanced Surgical Skills Manual. Armando C. With this in mind. this time in electronic form. there is a need to standardize the teaching of surgical technique to our students and residents while appreciating some variation in individual style. the surgeons of today continue to be judged mainly by the quality of their technique in the performance of various surgical procedures. Subsequently. MD. Finally. Crisostomo. which highlights more advanced techniques to include laparoscopic approaches.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.
they learned scrubbing. Jose Y. suturing and knot-tying. the habits and preferences of their senior residents and consultants.Preface • 1st Edition A foundation for learning basic surgical skills As mandated by the Philippine College of Surgeons. As they progress to higher levels of training. they assist numerous operations and surgical procedures.. MHPEd. performing procedures in actual patients. In its original concept. Undoubtedly. 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. In clinical clerkship and internship. These skills are very important components of patient care. Cueto. Basic surgical skills (for junior residents) • appropriate selection of needles and sutures • suturing • knot-tying 2. Jr. the PCS Committee on Surgical Training is primarily concerned with the educational welfare of residents. blow-out of anastomoses. suturing different kinds of wounds. As students.leaks from repairs. During residency. MD. They must be learned correctly and thoroughly because patient outcomes are influenced by how well these skills are performed. in the day-to-day activities of a surgeon. many of these complications are multifactorial. This manual aims to provide a foundation for learning the most basic surgical skills that all surgeons need to master. FPCS Regent-in-charge (1999) Committee on Surgical Training Philippine College of Surgeons . Through constant exposure and observation. there were two components: 1. disruption of abdominal closures and many others. they indulge in their own series of trials and errors. residents get to absorb the practices. but a lot of them could be traced to deficiencies in technical expertise. preparation of the operative site. the project on the Surgical Skills Improvement Program for residents was conceived. they had opportunities to perform in actual patient situations. but many of them unsupervised. To fulfill this mandate. They are carried out regularly. Conferences and audits have revealed the consequences .
These are regularly presented in mortality-morbidity conferences and include leaks from simple repairs. disruption of anastomoses. Phase 3 Autonomous Phase This phase is characterized by gradually improving speed and accuracy of performance. complications or consequences are discussed. their indications. Theoretical Basis for Learning Skills A. There is gradual elimination of error. strictures and stenosis following tight suturing. Formulate a system to evaluate skills Cognitive Phase This phase involves the initial “intellectualization” process necessary in learning a new task. specifically. Phase 2 Fixation or Associative Phase This phase involves the development of correct pattern of action and behavior. I. MHPEd. The residents develop smoothness and efficiency of movements. operative skills. The trainee has to understand the concepts and principles involved in the task before any performance can be attempted. the nature of the technical skills. They constitute a very critical part of day-to-day surgical patient care. These complications comprise the evidence of the importance of psychomotor skills. Both the trainor and trainee try to verbalize what needs to be learned. the learner is expected to: 1. Fitt’s three-phase theory During this phase. and elimination of unnecessary steps. II. performances of trainees are prone to error. a need for the trainor to demonstrate how a task should be accomplished. Patient outcomes are definitely influenced by how well procedures are performed. In surgery. Relevance and Importance Surgeons who are involved in the training of residents are all too familiar with complications that follow surgical procedures. contraindications.Chapter I Teaching and Assessing Psychomotor Skills in Surgery Jose Y. Understand the importance and relevance of learning and assessing surgical skills 2. This is established thru practice with regular feedback on the quality of performance.. partial and complete dehiscence of abdominal wall closures and many more. MD. applications. the most important factor within the control of the surgeon is his technical expertise. Cueto. While it is true that most of them are multifactorial in origin. with minimal wasted moves. Discuss the theoretical bases for learning skills and their educational implications 3. There is. Incorrect practices and steps are identified and rectified. This phase lasts a lot longer than the cognitive phase. there is increasing resistance to stress and . In this phase. FPCS Phase 1 Objectives of this Chapter After going through this chapter. therefore. Jr.
The trainor must be able to bring the residents through the different phases of learning. and how they are to be assessed become clear to the trainees will absorb only the good practices of their seniors and superiors. Need for focus and clarity In order that lower level residents know what needs to be learned. handson and interactive format will be of great help. timely feedback should be given regarding what needs to be corrected and how they are to be corrected. principles governing their use. these skills should be learned in the laboratory using simulations. B. residents. Need to recognize the phases of learning skills To make the acquisition of psychomotor skills more effective. and are finally incorporated into the autonomous phase of behavior.interference from other activities. The residents focus first on learning the simpler sub-tasks before graduating to complex tasks. When residents in lower years are allowed to acquire “bad habits” and incorporate them into their practice. and which ones to reject and avoid. The residents should be able to determine and decide which steps and techniques they should adopt. The old method of “see one. marked by a high level of proficiency. In addition. it becomes very difficult to unlearn them. how they are to be learned. sutures and how to select and use them depending on the clinical situation. complex tasks must be broken down into sub-tasks. In this way. be adequate guidance and supervision. do one” has long been proven to be inadequate and even dangerous. Once habits become part of autonomous behavior. Repeatedly assisting procedures and operations do not automatically mean that III. The skills that residents learn take years to refine. Need for guidance. Ideally. the trainors should understand and apply the different phases of learning. the residents must be exposed to the correct way of performing different operations and techniques. C. Residents go through details in a procedure and verbalize the steps in a particular operation and how complications are to be avoided. a structured method of teaching and assessment is needed. Supplementary workshops that include multi-station. Each resident presents with his/her own level of knowledge and competence with regard to a particular skill. and in fact. using inexpensive materials or animals. An educational activity that addresses the cognitive phase of skills learning is the pre-operative conference. therefore. There must. Educational Implications A. Needless to say. it becomes very difficult for them to unlearn these habits when they reach their senior years. concurrent activities may be performed. Need for structure These characteristics of performance are found in specialists and experts. Another very important activity is the operative assist. and the correct steps that should be followed. They are exposed to different consultants and senior residents who have their own way of performing different techniques. D. Need for simulation and practice Before residents are allowed to operate and perform proce- . In order to obtain the required level of proficiency in surgical skills. What needs to be learned. Operations that residents assist in are actually considered “demonstrations” by consultants and senior residents. E. The residents rotate through different stations learning about needles. Group discussions then follow in order to recapitulate and emphasize the important factors in selection. supervision and feedback It is during the fixation or associative phase where residents develop their own pattern of action and behavior. only the proper steps are incorporated into the autonomous phase of skills acquisition.
This method is process-oriented and assumes that the resident follows the details described in the cognitive phase. Part I.V. the performance is determined to be satisfactory or unsatisfactory. St. Vol. skin. The use of structured clinical or practical exams ascertain that IV. This allows the trainor to make sure that the trainee has mastered the steps in a certain procedure. Macmillan Education. Assessing Psychomotor Skills all residents go through the same stations and the same tasks. However. position of the appendix. 1987 Crosby J. Evaluating Clinical Competence in the Health Profession. 1996 Morgan M and Irby D. 1992 . Medical Teacher. Vol. Vol. Task-based learning: an educational strategy for undergraduate. particularly in the way they are handled. These are all correlated with the outcomes. For example. However. 18. A. B. Objective Structured Clinical or Practical Exam (OSCE or OSPE) This method utilizes a number of stations where skills are tested. This can be reserved for higher level trainees who have already demonstrated mastery of the process. Record review For audit purposes. No. Direct observation with the use of checklists and rating scales This is the most valid method of assessing how trainees perform. The OSCE as a part of a Systematic Skills Training Approach.. No. intestine and blood vessels are evaluated. 18. the steps and their sequences and the over-all operative management are assessed. Training: Research and Practice. Mosby. No. 3. Learning in Small Groups. Co. the deficiencies and errors of the residents should already be determined and corrected.dures on actual patients. This is very difficult to attain in real clinical situations where cases differ in degree of difficulty. and avoid unnecessary complications that may arise from operations and procedures done incorrectly. CA. they should be given opportunities for simulations. such as the presence/absence of complications. London. C. The consultant or supervisor assesses how residents select needles and sutures. San Diego. Every station has a rater who observes the trainee. Medical Teacher. REFERENCES Abbatt F and McMahon R. muscle. Even similar cases of appendicitis present with varying technical difficulties depending on patient habitus. the record of procedures and operations are meticulously examined. 1988 Bouhuijs P . D. an anastomosis is inspected by the trainor before the abdomen is closed. C. Product evaluation This is done by inspecting a finished product or a completed task. 1996 Harden RM. Louis. During simulation and practice. The results are then fed back to the trainees for them to know where they need to improve on. 2. postgraduate and continuing medical education. 9. The materials used (needles and sutures). This is to make surgical training safe. 1978 Patrick J. Skills such as suturing fascia. Academic Press. Medical Teacher. Teaching Health Care Workers: A Practical Guide. With the use of objective checklists and rating scales. etc. et al. this is time-consuming because it requires the presence of trainors all throughout the procedure. 1. this method relies heavily on the accuracy and completeness of the operative records. et al.
Product evaluation C. Direction: Identify the most valid and appropriate method of assessment for the skills listed. “I have been left on my own to learn new skills” ___7. There can be more than one correct answer per number. Simulation and practice C. Guidance. Performing assisted or supervised operations ___2. Performing operations independently and smoothly ___5. Column A ___11.Self-Assessment Questions (Chapter I) A. the component under which the problem falls. Handling of instruments ___13. Suturing an anastomosis in an animal laboratory Column B A. supervision and feedback E. Learning through demonstration-return demonstration with trainor ___4. Record review D. Knowledge of phases of learning B. Selection of needles and sutures ___12. “I don’t know what stage of learning I am in” ___9. Column A ___6. “I did my first bowel anastomosis in a real patient because there is no animal laboratory” ___8. Direction: Column A contains comments from residents in-training. identify and write the phase (Column B) in which the process in Column A takes place according to Fitt’s three-phase theory. Identify and write on the space before each number. Objective structured clinical examination . Cognitive Phase B. Direction: On the blank beside each number. “No one is correcting my mistakes” Column B A. Focus and clarity C. Autonomous Phase B. Fixation Phase C. “I don’t know what to learn” ___10. Quality of anastomosed bowel ___15. Describing operative complications Column B A. Structure D. Knot-tying technique ___14. Enumerating the steps of an operation in a preoperative conference ___3. Column A ___1. Direct observation of actual performance B.
Basic procedural skills are taught from simple intravenous insertion to wound suturing. MHPEd. learners are allowed to fail and learn from such failures in a way that is unacceptable in a true clinical scenario.Chapter II The Use of Simulation in Surgical Training Shirard L. They should describe. Classification of Simulations 1. 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. Since the venue is safe and controlled. Adiviso. The benchtop models are limited in terms of feedback. the learner is expected to: 1. 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. . The training design can be formulated based on the needs of the learner and not the patient. All surgical trainees need a core of basic surgical skills regardless of their specialties. Model Based Simulation – a range of relatively inexpensive models or animals are available. demonstrate and arrange practice sessions in teaching these skills. FPCS Simulation (using physical models. This requires continuous deliberate practice to master it and should start early in their training. During the last several years. Assessment forms are developed for both formative and summative evaluations. MD. Advantages of Simulation 1. Understand the role of simulation in surgical training. medical education has swayed away from traditional method of apprenticeship. combination of two) provide the opportunity to achieve and evaluate skills through repeated practice within a safe and controlled environment. 3. Most of the surgical skills were previously mastered initially with real patients but is now transferred in “vitro” or simulated venue. 2. This requires comprehensive support from expert mentors. 2. The capacity of the simulators to provide ready feedback in digital form offers collaboration in learning. 4. Conduct teaching and learning activities in basic and advanced surgical skills using simulation. The trainors have an important role in making this possible. Simulators can offer objective evidence of performance using their inherent tracking functions to map learner’s trajectory in detail.C. computer program or Objectives of this chapter After going through this chapter.
. 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 . Computer Based Simulators (shown below) A Simple Taxonomy of Simulators (Medical Education.Laparoscopy Simulation (LapSim Basic Skills 2. Lap Sim Laparoscopy procedure Anesthesia simulation Simple Manipulation Complex Manipulation Perform single complex task Integrated Procedure Perform multiple task of entire procedure Figure 1. MIST-VR.Flexible sigmoidoscopy trainer (Immersion Medical).0) Figure 2 .2. Figure 3 .Simulated operating theater with mannequin.Endoscopic surgery trainer (MIST-VR: – Minimally Invasive Surgical Trainer – Virtual Reality Figure 4.
6. started and replayed at will. 21 No. 7. 1999. especially as they may be embarrassed to admit their ignorance. Clinical teaching skills are not the same as workshop teaching skills. Ensure that you are familiar with the procedures you will be teaching and with any models used. Computer Assisted Learning Versus A Lecture and Feedback Seminar for Teaching Basic Surgical Skills. R.learner carries out procedure on an identical model and practices repeatedly then reviews the techniques. 12. To learn a new motor skill you should see it demonstrated. 2. Kneebone’s 5 Stages of Training Method 1. they will value the experience. Encourage learner to repeat procedure till they become proficient. Twelve tips on Teaching Basic Surgical Skills Using Simulation and Multimedia. Kneebone’s Tips in using Simulation and Multimedia first principles.Dmitri et al. 5. A Computer Based Self-Directed Training Module for Basic Sutures.3. Kneebone. Watching a clinical video of the procedure. Medical Teacher Vol. 8. then practice it repeatedly and receive feedback about your performance. 10. Do One. Assume nothing but go right back to basics – provided you treat the learners with respect. Learners like a clear framework within which to exercise their navigational freedom. Michael et al. 2003 Rogers. Apr. The American Journal of Surgery. Vol 177.Roger . The American Journal of Surgery. 11.. June 1998 Wigton. An experienced colleague or mentor supervised the learner while performing the procedure on a patient. the better. Watching an animated graphic of procedure. Simulation offers means of detaching skills from their clinical context and learning without the pressures of clinical responsibility. Teach One. Medical Teacher Vol. Vol 175. and new methods of learning require new ways of teaching. Hybrid Simulation. Watching the procedure demonstrated on a modeldemonstrated a simulated tissue model by the same expert wherein steps can be stopped.combine physical model with computers using realistic interface like instruments and real diagnostics.1999 Cauragh. 1992. Non-biological simulated tissue allows a range of basic surgical procedure to be learned in skills workshops. 9.1999 Connor. Doing the procedure on a patient under supervision. Do not overestimate the complexity needed in basic surgical skills teaching. Nov.essential points of technique are shown by animated graphics usually with spoken commentary. Medical Education.James et al. Academic Medicine. 3. 1998. Kneebone. 1. Setting up basic surgical workshop requires thought and planning but need not be prohibitively expensive. The American Journal of Surgery. Doing the procedure on a model. Robert. Vol 37. The earlier surgical skills training starts. Vol. Vol. .1. 5. 6. 4. Assessment of Technical Skills Transfer from Bench Training to Human Model. 20 no. 11. avoiding any assumption of previous knowledge. It is easy to overestimate the knowledge and skill of any group of learners. 2. See One. 4. Make the teaching aim clear from the onset. Modelling Surgical Expertise for Motor Skills Acquisition. Simulation in Surgical Training:Education Issues and Implications. 3.short clinical video sequences show the techniques performed by an expert on a real patient.L.David et al. To teach skills to complete novices you have to start from REFERENCES Anastakis.177 Feb. 67 no.
Self-Assessment Questions (Chapter II) Direction: On the blank beside each number. 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 . identify the simulator used in the Column B to the examples of skills in Column A.
MD. on the other hand. it was only in 1860 when Joseph Lister introduced carbolic catgut. leather. silk. animal tendons and parchment strips. Discuss guidelines in choosing a suture material based on its biological behavior and mechanical performance. plain catgut loses much of its tensile strength at the end of one week. In tissues. The greater the number of 0’s. the smaller the size the suture strand is. celluloid. The first suture materials were used between 2500 and 3000 BC as documented by Egyptian papyri and they consisted of fibers of plant origin. either the serosal layer of cattle or the submucosal layer of sheep. Suture materials are generally classified as being absorbable or non-absorbable. the learner is expected to: 1. The most frequently used absorbable non-absorbable suture materials are the following: Absorbable Sutures 1. of a 2-0 suture. Eventually other materials were introduced for surgical use such as linen. 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. FPCS diameter of the suture and these sizes are stated in a numerical fashion.Chapter III Suture Materials Jose Antonio M. corresponding to the are not arrested by either enzymes or tissue fluids. Suture materials come in different sizes. Synthetic materials were first used in the 1930’s with the introduction of polyvinyl alcohol. Thus. Discuss the newer “suture materials” and their characteristics.) Absorbable sutures are those sutures which are broken down or degraded by hydrolysis or digested by enzymatic processes. FPCS and Jerome G. Analyze the different types of sutures and their characteristics. . Non-absorbable sutures. It is absorbed shortly there after and thus. MD. 3. a 6-0 suture is smaller than the diameter Objectives of this Chapter: After going through this material. wire. MD. Salud. (Refer to Table A: Classification of Suture Materials. 2. As the 20th century comes to a close. FPCS Jose Joey Bienvenida. 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. horsehair. 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 first suture material specifically for surgical use. The material used to close blood vessels to achieve hemostasis is called ligature. etc. Plain Catgut Plain catgut is derived from the collagen of small intestine. However. Baldonado.
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) .
Most absorbable in synthetic sutures. 4. polyglactin included. the absorption of chromic is dependent on environmental factors in the tissues. water gradually penetrates the suture filaments causing the breakdown of the suture’s polymer chain which results in lesser degree of tissue reaction following tissue implantation. Chromic Catgut This suture material is actually similar to plain catgut except that it is treated with chromate compounds. Polydioxanone This is a synthetic monofilament absorbable suture composed of the polyester of p-dioxanone. Absorption starts close to the 90th day and is complete at 6 months time. 3. In vivo studies have shown its tensile strength to be at about 70% at 14 days and 50% is retained at 28 days. Absorption is complete in 90-120 days. and about 50% is retained at 21 days. 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. 75% of the strength of this suture is retained at 14 days. This should not be used when extended approximation of tissues under stress is required. . 100% loss in tensile strength is noted by the 32nd day. It is thus recommended for use in situations wherein the surgeon requires a high initial tensile strength as in subcuticular wound closures. are hydrolyzed during absorption rather than being broken down enzymatically (as with the natural absorbable sutures). which results in a stronger and more slowly absorbed suture. Absorption is complete at about the 56th or the 70th day. Polyglycolic Acid This synthetic braided suture is reduced by the hydrolysis to glycolic acid. Polyglactin This is a synthetic braided suture whose raw material is a copolymer of glycolide and lactide. Both plain and chromic catgut sutures may stimulate a considerable inflammatory reaction during the absorptive phase and should. When used to suture the stomach. Poliglecaprone This is a monofilament suture whose tensile strength in the first week is high but rapidly reduces soon after. 5. thus not be used in areas such as the peritoneum.2. as in fascia. 6. about double the time it takes for plain sutures to lose their own. In hydrolization. Its tensile strength is completely lost by the 30th day. Like most synthetic sutures. Complete absorption occurs about the 90th day. However. Thus. the presence of acid hastens the absorption. the inflammatory reaction that results from its breakdown is only minimal. 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. the loss of tensile strength takes a little longer.
it is a suture that is widely used in virtually all specialties. As with most monofilament sutures. neurosurgery). As with most braided sutures. wire has been used for many years and is a popular suture for a variety of operations (thoracocardiovascular. nylon sutures require more throws to securely hold the knots in place. if not all of its tensile strength within a year. It stimulates an inflammatory reaction greater than that of silk and other sutures is that this material is relatively cheaper. This suture is characterized by its high tensile strength and extremely low tissue reaction.Non-absorbable sutures 1. it is difficult to handle and may be easily palpated by the patient. silk holds knots well. Tissue reaction is minimal. Nylon This particular nonabsorbable suture comes in a monofilament and braided form. However. 5. However. The loss in tensile strength is in the range of 15-20% per year by hydrolysis. Polypropylene Polypropylene is a non-absorbable synthetic monofilament suture. orthopedics. 6. on the other hand is very similar in characteristic to silk but has considerably less tissue reaction. Because of these characteristics. poly-esters sutures are encapsulated by tissues and thus resist tissue degradation. silk can actually be absorbed slowly but the absorption rate is variable. This suture’s tensile strength retention is indefinite and is a suture that is encapsulated by tissues when implanted thus resisting tissue degradation. 4. 3. silk is a protein filament produced by silkworms. Silk By far. 2. still the most commonly used suture material. . The braided variety. Silk loses much. Wire/Stainless Steel/Titanium A very strong suture material that produces little loss of tensile strength. silk loses its tensile strength when exposed to moisture and should be used dry. Cotton This is a commonly used braided nonabsorbable suture much like silk. Although classified as a non-absorbable suture. Polyester This suture was the first synthetic suture material shown to last indefinitely in tissues. Like polypropylene.
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 ++ 2 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 + 2 Poliglecaprone Monofilament -/+ 5 Polydioxanone Polyester polymer Silkworm Monofilament Absorbed by Hydrolysis Nonabsorbable Nonabsorbable Nonabsorbable Complete in 180 days N/A -/+ 5 Silk Multifilament + 2 Cotton Cotton Plant Multifilament N/A ++ 2 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 -/+ 5 Polyester Multifilament Nonabsorbable N/A -/+ 2 Wire/Stainless Steel/Titanium Multi.& Monofilament Nonabsorbable N/A -/+ .
Another disadvantage of staplers is that it may interfere with computed tomography and magnetic resonance imaging. polyester (macroporous structures) and polytetrafluroethylene (PTFE) (microporous structures). Meshes may be non-absorbable or absorbable. 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. to hold them together and may provide wound healing similar to skin sutures. with the use for staplers for skin repairs. Designed to close skin wounds and lacerations. resection. These staplers significantly reduce operating time. time under anesthesia. However. It is knitted in such fashion as to interconnect each monofilament fiber and provide unidirectional elasticity. These instruments have wide application in various fields of surgery facilitating ligation and division. Surgical Staplers Modern surgical stapling devices and techniques were first developed in the Soviet Union in the 1950’s through the work of the Scientific Research Institute for Experimental Surgical Apparatus and Instruments in Moscow. anastomosis and skin and fascial closure. significantly reduced with the use of staplers and anastomoses appear to function sooner as compared with manual suturing techniques. Both exhibit high burst strength.MESH Surgical mesh materials are more commonly used to repair fascial defects. The newest “suture material” available in the market today is . It has 3 days tensible strength retention and is absorbed within 60-90 days. tissue adhesives is a non-pigmented medical grade adhesive made of n-butyl-cyanoacrylase. Applied to wound edges. blood loss. This mesh is porous. Skin Adhesives Absorbable Meshes Polyglycolic acid and Polyglactin inert knit meshes are stretchable. Edema and inflammation associated with manual suturing is Non-absorbable Meshes Most common types of materials used in non-absorbable meshes are polypropylene. tissue manipulation and trauma thus facilitating postoperative healing. Polypropylene may be monofilament or multifilament. the closure may be less meticulous. The stainless steel staples that are used are virtually inert producing minimal tissue inflammation and minimal tissue compression. Its use in inguinal herniorrhaphies was even made more popular in the advent of laparoscopic herniorrhaphy techniques.
Ease of handling 5. Inert (The ideal suture material would cause the least tissue reactivity. before complete healing has occurred. Furthermore. 5. Whatever suture material is used for a particular procedure. An adhesive waterproof film is then formed over the wound. Select the finest suture consistent with the tissues to be approximated. cyanoacrylate adhesives also have antimicrobial properties against gram-positive organism and may decrease wound infections. The suture material should have adequate tensile strength and maintain it until its purposed is served. 3. easy to handle and able to maintain knot security . It does not require application of local anesthetics nor is there a need to use instruments and sutures. However. it has been deemed an effective and reliable method of skin closure for many wounds. Ease and security of knotting 4. clots and bacteria to adhere 10. Cyanoacrylate adhesives were first described in 1949 and there first reported used as clinical adhesives was for 10 years later. yielding similar cosmetics results to closure with subcuticular sutures and is a faster method of skin closure than suture. However. the following guidelines should be considered: 1. Guidelines in Choosing a Suture Material • TABLE C IDEAL SUTURE CHARACTERISTICS 1.called topical skin adhesives. This is a non-absorbable sterile violet-colored liquid (2octylcyanoacrylate) that is used primarily for easy approximation of skin edges. Select sutures that are pliable. Non-toxic.) 6. High tensile strength 2. the adhesive film sloughs off as the skin starts to re-epithelialize. Should keep its physical characteristics as long as necessary 11. non-allergenic (both the suture and its components when metabolized by the body) 7. Sterile 3. 2. . Predictable performance 9. Octylcyanoacrylate tissue adhesive can replace skin sutures on virtually all facial lacerations and properly selected extremity and torso lacerations. After 5-10 days. 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. as exemplified by DERMABOND(r). Small size 8. 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. Smooth surface avoiding necrotic tissue. It is ideal for use in children and in case where rapid skin closure essential. Select sutures with the least risk for bacterial proliferation. It is simply applied over the apposed wound edges and allowed to set within 45-90 seconds after application. Choose a suture that would produce the least tissue reaction. 4. they have a lower tensile strength than sutures. Cost effective The selection of suture materials is generally based on its biological interaction with the wound and its mechanical characteristics.
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)
Plain Cutgut Chromic catgut Linen-Cotton Silk Braided Uncoated polyester Braided Uncoated Polyamide Braided Coated Polyamide Synthetic Absorbable Monofilament Polyamide Monofilament Polyester Polypropylene
Normal Strength of Tissue Experimental data regarding human tissue strength are limited. However, a number of papers in the literatures provide data about other animal tissues. Tissue strength is determined in Skin -- 70% strength at 3-4 months. Fascia -- 50% of original strength at 50 days; 80% at 1 year. Muscle -- 80% strength at 10-14 days. Viscera -- 80% at 14-21 days.
REFERENCES Edlich RF , Woods JA, Duke DB. Scientific Basis of Wound Closure Techniques. Dannenmiller Memorial Educational Foundation, San Antonio, Texas. Ethicon Wound Closure Manual, Ethicon, Inc., 1994 Maw JL, Quinn JV, Wells GA, Ducic Y, Odell PF, Lamothe A, Brownrigg PJ and Suctliffe T. A Prospective Comparison Of Octylcyanoacrilate Tissue Adhesive & Sutures for the Closure of Head and Neck Incisions; Journal of Otolaryngology, 1997, Vol.26, 1;26-30
Quinn J, Wells G, Sutcliffe T, Jarmuske M, Maw J, Steill I and Johns P . A Randomized Trial Comparing Octylcyanoacrylate Tissue Adhesive and Sutures in the Management of Lacerations; JAMA, 1997, Vol. 277, 19:1527-1530 Sabiston DC, Jr. Textbook of Surgery, The Biological Basis of Modern Surgical Practice, 15th ed., WB Saunders Co., 1997 Wound Closure In the Operating Theatre, B Braun Melsungen AG Zinner MJ, Schwartz SI, Ellis H, Ashley SW & McFadden DW. Maingot’s Abdominal Operations, 10th ed., 1997
Self-Assessment Questions (Chapter III)
1. Which of the following sutures are considered non-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
2. 3. shape and design. Because of these. 2. threading is time consuming and the needles are difficult to prepare during surgery. and 5. de los Santos. Describe the characteristic of the surgical needle. The point 2. A weak point is created near Factors in the Selection of Needles When considering the ideal surgical needle for a given application. MD. MD. 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. The only purpose of the needle is to introduce the suture into the tissues. The needle must be: 1.Chapter IV Surgical Needles Cenon R. Rigid to resist bending but flexible to prevent breaking . there was a gradual reluctance both in the use and manufacture of eyed surgical needles and favor shifted towards swaged surgical needles. The surgical needle has evolved with the history of surgery the eye that could lead to needle breaks and even to rusting. may lead to leakages. 4. Sharp to overcome tissue resistance. French-eye needles requiring the scrub nurse to thread the suture into the eye of the needle. 3. it is more difficult to retrieve them when accidentally dropped inside body cavities without the suture. MD. Ocampo. The needle should also be large enough and of appropriate size. The first needles were either closed-eyed or the so-called Objectives of this Chapter After going through this chapter. Identify the common types and code names of the locally available needles. The attachment end (swaged or eyed) . Analyze the factors involved in needle selection. Moreover. the learner should be able to: 1. Alfonso. Able to carry suture material through tissues with minimal trauma. every surgical needle has three basic components: 1. FPCS & Nilo C. eyed needles may become unthreaded. Theoretically. shape and design in order to provide precise and efficient suturing. During operations in deep confined areas. the type of tissues being approximated should be considered: they should be altered as minimally as possible by the needle. Anatomy of the Surgical Needle Regardless of its intended use. FPCS itself. The body 3. causes additional trauma to tissues and in anastomotic procedures. There are five basic requirements that must be met in proper needle selection. Sterile and corrosion-resistant to prevent introduction of microorganisms or foreign bodies into the surgical site. Of appropriate size. FPCS Renato Cirilo A.
This type is used for sclerotic or calcified tissues and for heavy fibrous tissue such as the fascia. In cases of 4. Conventional Cutting Edge The cutting sharp edge is in the concave curvature of the needle. It is also ideal for approximation of the peritoneum. Blunt A rounded blunt point that does not cut through tissues is used for penetrating friable. fascia and subcutaneous tissues. The cutting edge may also extend only down to 1/3 of the distance to the swaged area. Needle Body The portion between the point and the swage of a needle is called its body. the bigger the ratio. This cutting edge may extend from the point of the needle down to the swaged area. Examples are needles codenamed CT-1 and SH. 2. Swaged This is the area in which the suture is attached to the needle. This is particularly indicated in intestinal anastomosis.other orthopedic procedures. It easily penetrates dense tough tissues. Attachment End 1. This is ordinarily used in common plastic surgery procedures and in closure of superficial wounds and incisions. Three cutting edges extend approximately 1/ 32 inches back from the point. the lesser the damage to the tissues. Taper Cut (Trocar point) This is a blend of the combined features of the reverse cutting and the taper point needles. spleen or kidneys. A typical example is V-40.2 and OS-8. 1. Needle Point The point extends from the extreme tip of the needle to the maximum cross section of the body. This type is most useful in plastic surgical procedures. An example is the BP1 needle. Each specific point is designed and produced to the required degree of sharpness to smoothly penetrate the type of tissue to be sutured. It is of specific importance to the needle-suture relationship. . A. 5. 3. On the other hand. the greater unnecessary tissue damage is produced. The latter type is also indicated in the closure of skin and various plastic surgery applications and B. parenchymal and vascular tissues like the liver. The taper point needle is often preferred where the smallest possible hole in the tissue and minimal tissue trauma is desired. These types of needles are coded PS. Reverse Cutting These needles have a cutting edge in the outer convex curvature of the needle. C.The ideal swage area diameter is a one-to-one sutureneedle ratio so that the more exact the sizes correspond to each other. Tapered The body of the needle tapers to a sharp point at the tip. An example is the PC-5 needle. This is the grasping area of the needle holder. All three edges of the point are sharpened to provide uniform cutting action.
E.056 inch). reducing operative time. Laser-drilled needles are currently available among cardiovascular products. a laserdrilled needle allows the so-called extended side flattening. Needle diameter varies from 30 microns to 56 mil (. Closed Eye Similar to a household sewing needle. Needle Shape Needles are available in various shapes to accommodate the desired “turnout” from different tissues. Needle Diameter This refers to the gauge or thickness of the needle wire. to more than 5 cm. Chord Length Drilled Needles Mechanically drilled. Control Release Needle Suture These needle sutures allows easy detachment of the needle from the suture when desired by the surgeon. Laser-drilled Needles A feature provided where the swage area is laser-drilled to achieve the closest one-to-one needle-suture ratio. 2. the radius of the curvature is the distance from the center of the circle to the body of the needle.bowel anastomosis. oblong or square. The diameter equals the size of the needle tract. this ratio is most crucial in preventing needle puncture leaks. The chord length is defined as the straight line distance from the point of a curved needle to the swage. 4. The hole is then crimped a little in order to secure the suture end. Chord length comparison between the CT-1 needle and the TP-1 needle will make the biggest difference in the width of the bite. F. It has the advantage of a tapered swage which in turn provides a smoother transition from needle to suture. a design that adds strength and resistance to bending. A hole is drilled into the swage area of the needle and the end of the suture is placed inside the hole. 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. 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. Pressure is applied to close the channel around the suture in order to hold it tightly. G. The shape of the needle remains consistent regardless of size. In addition. although a . D. This allows rapid placement of sutures in succession. The curved needle is always thought of as part of a circle. This varies from 2 mm. This varies from 1 mm. Length is a determining factor in the width of the bite taken by the needle. the shape of the closed eye may be round. inches. to 1 1/8 3. Needle Radius If the curvature of the needle were to continue to make a full circle. For example.
It can be easily manipulated in relatively large and superficial wounds such as closure of the dermis with slight pronation of the wrist. among other factors. appropriate size for specific needles 3. Needle Length This is the distance between the point and the swage measured along the body of the needle. A 5/8 circle needle such as the UR-4 is most advantageous in these situations. When this occurs. H. Characteristics of Surgical Needles and their Clinical Importance Trauma to the tissue edges that are sutured together during surgical procedures. The typical examples are vascular anastomoses. P Needle: This is the most commonly used curved needle. This is a suture strand with a needle swaged at each end. Size and depth of the area to be sutured are small and shallow. it is ideal to use a double-armed suture. appropriate length for specific procedures Single Versus Double Armed Suture Commonly used sutures have one swaged-to-suture strand. In such situations. It should be held on securely at the tip of the needle holder’s jaws. 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. The following factors must influence the needle holder’s choice: 1. Subsequent wound healing processes therefore are compromised. If it were an intestinal anastomosis. they are both 1/2 circle needles. The greater the trauma induced. as well as the technique of apposing have difficulty locating the point of the needle in order to pull it through the tissues. CP-1 double armed needle suture combination for episiotomy repair. 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. . excessively traumatized ends may result to a poorer blood supply. theoretically spells an integral part of the outcome of wound healing. Situations do arise wherein there is a need to place a suture at a midpoint and suturing must continue on both sides. suture material. An example is the CT-1. indirectly proportional. There are various types of holders to accommodate different needles and for different locations and tissues.TF needle is significantly smaller in size than an XLH. Security of the needle in the holder 2. 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. the surgeon may individually. If the strand is divided into halves. The relationship is. the poorer the outcome. cramped areas with difficult access. and complete apposition. 3/8 circle needles are awkward to use in deep cavities such as the pelvis or in small. 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. Because of a large arc of manipulation required. in fact. for example. affecting the integrity of the intestinal layers. It appears that the choice of needle.
Rigid needles are necessary in suturing bones. Thus. Therefore. Most surgical needles are no longer made of lesser quality. inertness and smoothness are other characteristics that are most desirable in surgical needles for medical grade usage. therefore. however. Hernia needles. Sharp cutting needles create clean. Flexible needles. Sharpness and Pointedness Sharpness. All needles cause some form of trauma to sutured tissues. Their flexibility. This is so because of the following characteristics: 1. tough tissues like the epidermis and the subcuticular layers are difficult to traverse with pointed needles. the injury to the edges are minimized. Another weak point.and handling tissues together are important factors in order to achieve the best outcome with the least tissue damage. In other situations. This is. (Needles that are round may either be pointed or blunt at the opposite end of the swage). surgical needle design. however. Thus. pointed round needles are favored. affected by its frequency of being subjected to autoclaving. Literally. On the other hand. sternal needles and needles used to wire bones together are some examples. The size of the swage is the same as the size of the body. With the smooth passage of the needle and the suture through the tissue. So-called atraumatic needles cause the least injury. Rigid needles tend to break when too much shearing pressure is applied unlike flexible needles. just create puncture wounds and merely split muscle fibers rather than cut them. minute lacerations through tissues and cut muscle fibers. But it is desirable to always use sharp cutting needles when indicated. There are round needles that are created with blunted points for the purpose of passing sutures through solid organs like the liver and spleen. The suture material is of the same diameter as the Rigidity versus Flexibility Rigidity of surgical needles is dependent on the diameter. particularly among atraumatic round needles. tend to withstand a greater shearing force or even bending but generally not in acute angles.and corrosion-free. This is so because of the tension created by the angle of the needle against the suture. the surgeon may load the needle at this weak point and apply the drive force through the tissue. composition of the metal alloy used and the temperature by which they were set (tempered). Rust-free and Corrosion-free Needle Material Stainless steel needles are generally rust. Needle Weakpoints Eyed needles break most frequently at the junction of the swage and the body. Punctured wounds by nature are not prone to renting and are easily plugged. Small diameter. characteristics and usage play significant roles in the art and science of surgery. among hollow organs like viscus and blood vessels. in contrast to “pointedness. 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. and 4.” refers to the condition of the blade of cutting surgical needles. needle. cartilage and very tough fascia. This is obviously not applicable among needles that are not flattened at the distal body and point. 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. Other metal alloys are even better but their cost is prohibitive. they tend to extend easily to a rent. These tissues are not prone to lacerations or renting due to its fibrous content. the cutting action of a flattened needle is desirable. Minute lacerated wounds created by using cutting needles may completely tear at their corners when subjected to tension. The surgeon may force the body of the curved needle through the tissues at . There is no eye. Atraumatic Needles This is a misnomer. Pointed round needles. 2. 3. is the junction of the body and the point.
CT series b. 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. MO b. BP series d. X-1 e. the surgical needle to use is: a. The needle to use in the primary repair of a complete but clean traumatic transection of the ureter is: a. By its structure. PS-1 c. Which of the following needles are most applicable when suturing deep in the pelvic cavity? a. Conventional cutting 5. 5/8 circle e. PS d. RB-1 . For suturing liver lacerations. Rounded blunt e. 1994 Self-Assessment Questions (Chapter IV) 1. Circle tapered c. straight needle 2.. V-4 needles 3. XLH d. TP series e. Reverse cutting b. Surgical needles most commonly used for bowel anastomosis is: a. CT-1 4. Ethicon. Inc. Besides. 3/8 circle c. the force exerted by the needle holder at the body will exacerbate the above situation. 1/4 circle b. V-4 e. 1/2 circle d. UR-4 b. The surgical needle for microsurgical procedures is: a. REFERENCE Ethicon Wound Closure Manual.the same angle as the point rather than smoothly glide the body according to its curvature. SH series c. Cutting tapered d.
Purple strand held in right hand brought between left thumb and index finger. 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. . Purple strand held in right hand. two throws are required to securely hold the knot. Describe the common techniques of knot tying which can be applied to the different types of surgical procedures. In tying any knot. White strand placed over extended index finger of left hand acting as brdige. Discuss the general principles of knot tying 2. and held in palm of left hand. The art and science of surgery requires that knots be tied not only with dexterity and speed. 2. General Principles of Knot Tying In knot tying. Sutures should be tied with appropriate tension to prevent tissue strangulation or gaping of edges. When handling sutures. 4. and thumb swung under white strand to form the first loop. Mendoza. Perform the common techniques of knot tying which can be applied to the different types of surgical procedures. At the end of this chapter. FPCS Knot Tying Techniques Square Knot (Two-Hand Technique) 1. 3. Purple strand crossed over white and held between thumb and index finger of left hand. 3. the learner should be able to: 1. For monofilament sutures. 5. 3. FPCS Miguel C. friction between strands must be avoided to prevent weakening of the integrity of the suture. The completed knot must be secure. MD. 4. general principles to be following: adhered to are the 1.Chapter V Knot Tying Jose Antonio M. 7. For braided sutures. Additional throws do not add to the strength of a properly tied knot. 6. MD. but they should be placed with the right amount of tension for proper approximation of tissues and ligation of blood vessels. Sutures must be cut to their proper length. Salud. Left hand turned inward by pronation. 2. one must take care to avoid damage to the suture material. Objectives of this Chapter Proper knot tying is one of the essentials in the performance of a good surgical procedure.
Regrasp purple strand with right hand. 11. Then left hand supinated. Left hand rotated inward by pronation with thumb carrying purple strand through loop of white strand. 10. applied with left hand away from and right hand toward the operator. Purple strand crosses over white strand. Purple strand is grasped between right thumb and index finger. Horinzontal tension 7. white strand slides onto left index finger to form a loop as purple strand is grasped between left index finger and thumb. The final tension on the final throw should be as nearly horizontal as possible. with thumb and index finger still grasping purple strand. 12. 9. Right hand releases purple strand. Left index finger released from white strand and left hand again supinated to loop white strand over the left thumb. Click here for video on Square Knot (two-hand technique) . Purple strand released by left hand and grasped by right. Purple strand brought toward the operator with the right hand and placed between left thumb and index finger. 8. This completes first half hitch. This completes the second half hitch. Purple strand held in right hand is angled slightly to the left.Knot Tying Techniques Square Knot (Two-Hand Technique) 5. 6. to bring purple strand through the white loop. Horizontal tension is applied with left hand toward and right hand away from operator. By further supinating left hand.
2. 7. Left index finger released from white strand and left hand again supinated to loop white strand over left thumb. 5. Then the white strand is pulled through loop in preparation for applying tension. 6. With purple strand supported in right hand. Purple strand releases by left hand and grasped by right. Purple strand held in right hand is angled slightly to the left. Purple strand crosses over white strand.Square Knot (One -Hand Technique) This is an alternative to the two-hand technique of knot tying. 8. This completes first half hitch. with thumb and index finger still grasping purple strand. the distal phalanx of left index finger passes under the white strand to place it over tip of left index finger. Right hand releases purple strand. 3. 4. Horizontal tension is applied with left hand toward and right hand away from operator. to bring purple strand through the white loop. White strand held between thumb and index finger of left hand with loop over extended index finger. Purple strand brought over white strand on left index finger by moving right hand away from operator. Click here for video on Square Knot (one-hand technique) . 1. Purple strand brought toward the operator with the right hand and placed between left thumb and index finger. 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. Then left hand supinated. Purple strand between thumb and index finger of right hand. Regrasp purple strand with right hand.
5. Purple strand grasped between thumb and index finger of left hand. Purple strand crossed over white strand by movin right hand away from operator at an angle to the left. and loop of white strand slipped onto left thumb. Release right hand. Thumb and index finger of left hand pinched to form loop in the white strand over index finger. Regrasp purple strand with right hand. White strand placed over extended index finger of left hand and held in palm of left hand. 2.Surgeon’s or Friction Knot 1. 4. 6. Left hand turned inward by pronation. Left hand rotated by supination extending left index finger to pass purple strand through loop. Left hand rotated by supination extending left index finger to again pass purple strand through forming a double loop. 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. Purple strand drawn left with right hand and again grasped between thumb and index finger of left hand. 3. 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. Purple strand held between thumb and index finger of right hand. . 7. 8.
Right hand regrasps purple strand to complete the second throw square. 10. 12. With thumb swung under white strand. Purple strand released. Final tension on final throw should be as nearly horizontal as possible. purple strand is grasped between thumb and index finger of left hand and held over white strand with right hand.9. Purple strand rotated beneath the white strand by supinating pinched thumb and index finger of left hand to draw purple strand through the loop. Hands continue to apply horizontal tension with left hand away from and right hand toward the operator. 11. Click here for video on Surgeon’s or Friction Knot . Left hand supinates to regrasp purple strand with index finger beneath the loop of the white strand.
This throw is advanced into the depths of the cavity. 3. this is the recommended technique of knot tying. Purple strand looped over and under white strand with right hand. Final tension should be 4. advance the loop into the cavity. 5. 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. By placing index finger of left hand on white strand. Left hand turned inward by pronation. Purple strand looped around white strand to form second loop. and thumb swung under white strand to form the first loop. Horizontal tension applied to pushing down on purple strand with right index finger while maintaining counter tension on white strand with left index finger. Strand looped around hook in plastic cup on Practice Board with index finger of right hand which holds purple strand in palm of hand. 2. White strand held in left hand. 6. . as nearly horizontal as possible.Deep Tie In tying knots deep within a body cavity. 1. Purple strand held in right hand brought between left thumb and index finger. 7.
3. Left hand grasps free end of the strand and gently advances it behind clamp until both ends are of equal length. 1. 2. the white strand held in the right hand is passed behind the clamp. As the first throw of the knot is completed the assistant removes the clamp. To prepare for placing the knot square.Ligation around a Hemostatic Clamp Illustrated below is one of the methods for ligating blood vessels around a hemostatic clamp. thus crossing the white strand over the purple. . When sufficient tissue has been cleared away to permit easy passage of the suture ligature. 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. the white strand is transfered to the right hand and the purple strand to the left hand. 4.
5.Instrument Tie This is particularly useful when tying knots for suture materials where ends are short. 2. First half hitch completed by pulling needleholder toward operator with right hand and drawing white strand away from operator. Needleholder in right hand grasps short purple end of strand. Needleholder is released from purple strand. With end of the strand grasped by the needleholder. 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. Loop formed by placing needholder on side of strand away from the operator. Final tension should be as nearly horizontal as possible. 6. Click here for video on Instrument Tie technique (Square Knot) Click here for video on Instrument Tie technique (Surgeon’s Knot) 4. Long white end of strand held between thumb and index finger of left hand. Square knot completed by horizontal tension applied with left hand holding white strand toward operator and purple strand in needleholder away from operator. Short purple strand lies freely. . pugple strand is drawn through loop in the white strand away from the operator. 3. 1.
Christopher’s Minor Surgery. Cutting Sutures When knots have been tied. approxi- mately 3-4 mm. approximately 1-2 mm.. as these type of sutures may loosen after knot tying. A and DeBakey ME. it is advised to cut a little longer from the knot. They are more difficult to handle b. which among the following sutures will require more throws to maintain the knots in place? a. More tension is required to maintain monofilament sutures d. It is shown only to warn against its use. ETHICON. Most sutures are cut close to the knot. Polyester c. 1996 Ochsner. However. WB Saunders Self-Assessment Questions (Chapter V) 1. None of the above . This is true particularly for braided sutures. they are now ready to be cut. it may be inadvertently tied by inccorectly crossing the strands of a knot. Silk b. The knots have a tendency to loosen c. Nylon d. REFERENCES Knot Tying Manual. the sutures are cut even longer away from the knot.Granny Knot A granny knot is not recommended. from the knot to decrease tissue reaction and minimize the amount of foreign material left in the wound. It has the tendency to slip when subject to increasing pressure. th ed. Wire 2. For sutures applied to the skin. In knot tying. Why are more throws required for maintaining knots when tying monofilament sutures? a. The reason for this is to make it easier for the surgeon to remove the sutures at a later time. For monofilament sutures. 8 Co. This entails running the tip of the scissors lightly down the suture strand to the knot.
2.C. Ocampo. and the correct suturing technique depending on the tissues to be approximated are skills that should be second nature to the surgeon. FPCS Simple Interrupted Objectives of this Chapter Suturing is one of the basic skills essential for a surgeon to master. and Renato Cirilo A. Shirard L. MD.Chapter VI Suturing Techniques Cenon R. Bienvenida. MHPEd. Describe the different suturing techniques and their application to different surgical procedures for tissue approximation. MD. Alfonso. Mendoza. Miguel C. Each strand is tied and cut after insertion. the remaining sutures will hold the wound edges in approximation. FPCS. Each stitch is tied independently of other stitches. Simple Interrupted Click here for video on Simple Interrupted Different Suturing Techniques INTERRUPTED SUTURES Interrupted sutures use a number of strands to close the wound. Interrupted sutures may be used if a wound is infected. FPCS. MD. because microorganisms may be less likely to travel along a series of interrupted stitches. because if one suture breaks. At the end of this chapter. MD. This provides a more secure closure. . Perform the various suturing techniques for their application to different surgical procedures for tissue approximation. There are numerous techniques in suturing. proper application of the use of the needle holder and suture. FPCS. MD. FPCS. Jose Joey H. the learner should be able to 1. Adiviso. The dexterity.
The vertical mattress consists of a “far-far. coming from the same side of the wound at some distance from where it emerged.Vertical Mattress A vertical 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. Horizontal Mattress Suture A horizontal mattress suture starts some distance from the wound edge. The horizontal mattress provides coaptation in an everted fashion. near-near” component. Interrupted Horizontal Mattress Interrupted Vertical Mattress Click here for video of Vertical Mattress Click here for video on Horizontal Mattress . The vertical mattress is also known as the Stewart suture. It then returns taking a more superficial bite from each wound edge. passes deeply under the wound and emerges on the opposite side at the same distance from the edge. The vertical mattress suture gives a good approximation of the skin edge and therefore results in a cosmetically acceptable scar. where it is tied. It is used for closure of deeper tissues such as fascia. It is tied on one side of the wound and does not appear to cross it. It is frequently used for fine skin closure. it passes back deeply under the wound to exit on the opposite side at the same distance from the edge. Then.
be recommended in wounds with low degree of contamination. however. This may be done in interrupted or continuous fashion. It carries the advantages of completely avoiding stitch marks. It can only. This provides an everted type of approximation of tissues and is used primarily for the deeper planes. goes deeply under the wound to come out of the opposite side at some distance from the edge. Subdermal Interrupted Figure of Eight Mattress Click here for video on Subdermal Interrupted Click here for video on Figure of Eight .Figure of Eight Mattress Suture A figure of eight mattress suture starts at some distance from the wound edge. Subdermal Interrupted This technique is used to close wounds where cosmetic aspects are especially important. The suture is subsequently tied. 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.
It carries the advantages of completely avoiding stitch marks. rather than tight tension. It derives its strength from tension distributed evenly along the full length of the suture strand. Overtensioning and instrument damage should be avoided to prevent suture breakage which could disrupt the entire line of a continuous suture. This may be done in interrupted or continuous fashion. it may be desirable to use a monofilament suture material because it has no interstices which can harbor microorganisms. however. Continuous Interlocking Click here for video on Simple Continuous Interlocking 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. care must be taken to apply firm tension. In the presence of infection. The strand may be tied to itself at each end. or looped. with both cut ends of the strand tied together. continuous sutures are a series of stitches taken with one strand of material. be recommended in wounds with low degree of contamination. It can only.CONTINUOUS SUTURES Also referred to as running stitches. to avoid tissue strangulation. A continuous suture line can be placed rapidly. Continuous suturing leaves less foreign body mass in the wound. aspects are especially important. Continuous Interlocking This involves passing each stitch in continuous fashion through the loop of the previous stitch. Over-and-Over Running Stitch Subcuticular Click here for video on Subcuticular . 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. This is especially critical as a continuous suture line can transmit infection along the entire length of the strand. However.
Note: This procedure approximates the serosa while mucous membrane is inverted and fibromuscular layer is well grasped. 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. 4. It is directed downward toward the cut edge of incision to penetrate first the serosa and then the muscularis down to. The needle is inserted from the outside and 2. The sutures are non absorbable and are placed 3 to 5 mm apart. At no time it penetrates the lumen.INTERRUPTED LEMBERT This is the most important fundamental suture in gastrointestinal surgery. It is reinserted close to the incision’s edge passing laterally through serosa and muscularis down to. Objection: Takes more time for placing and tying and must be positioned closer together to ensure water tight closure. It is directed superficially so that it emerges from the viscus wall through muscularis and serosa close to the edge of incision.5 mm lateral to incision. the submucosal layer. 5. 3. but not through. but not through muscularis and serosa. 2. Lembert Stitch Click here for video on Lembert Stitch . Technique 1.
4. 5. The suture is tied again at the far end. 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. depending upon the site of origin of suture. 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.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. Technique 1.3 cm and is reinserted from within to the outside of the gut wall. the knot being placed either within or without the gastrointestinal wall. It then is advanced about . Connell Suturing Click here for video on Connel Suturing . 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. The suture is passed 4 to 5 mm from end parallel to its wound edge. 3. The suture is tied after the first stitch is taken. After the knot is tied. after which it is brought across the incision to penetrate the opposite wall from without inward and so forth. Advantage: This is hemostatic and compresses all layers of the gut wall. 2. It penetrates from the inside to the outside only on the same side on which the previous stitch ended. the needle is passed from without to the inside of the intestinal wall.
GAMBEE SINGLE LAYER This is an interrupted inverting suturing of full thickness of bowel wall using single row of non absorbable sutures. 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. This enters the serosal surface of the efferent bowel 6 to 8 mm from its cut edge. 2. Valuable in anastomosing bowel ends that are uneven in diameter. immediately reenter the mucosa 5 to 6 mm from the edge. Simplicity and ease of performance. exit through the serosa on the same side and tied on the serosal surface of the bowel. They then cross to the efferent bowel and enter its serosal surface 2 to 3 mm from the edge and penetrate through the mucosa. This technique is used in repairing small and large intestine and anastomosing gallbladder to jejunum and duodenal operation. Gambee Single Layer . penetrate through the mucosa and immediately reenter the mucosa and exit to serosa on the same side 2 to 3 mm from the edge. Note: 1. 2. Technique 1. 3.
This results in a small loop within a large loop. 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 tightened after the smaller purse. Using a 1-0 Polydioxanone suture (PDS). Large. as the suture is tightened. curved Ferguson needles are used for this procedure. of a hollow organ. 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. around a tube (as in jejunostomy feeding tube insertion). As the name implies.Verlag New York (1994) PP 845-856 . inverts the closure done by the smaller one. SMEAD JONES SUTURING (Far-Far-Near-Near) This technique is most useful for closing the midline abdominal wall incision. Place the small loop 5-10mm below the main body of the suture to help eliminate the gap between adjacent sutures. This is intended to decrease the probability of leak in and around the closure. 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. 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. or simply to close a round-configurated defect (as in closing a small colonic perforation). Smead Jones Suturing Click here for video on Smead Jones Purse String REFERENCE Click here for video on Purse String Chassin. whether actual or potential. Insert the next suture no more than 2 cm below the first. Sprigler. the tissue involved will create an enclosure that is similar to a purse that is being tied up in its neck using a string. in the pursestring suturing technique. Operative Strategy in General Surgery. Jameson . 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. 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. or around another tubular organ (as in the inversion of the vermiform appendix in auto-appendectomy).PURSE STRING This suturing technique is intended to close an opening.
Lembert . Purse String E. 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. ___7. near-near” component.Self-Assessment Questions (Chapter VI) Direction: On the blank beside each number in Column A. Column A ___1. This suturing technique involves passing each stitch in continuous fashion through the loop of the previous stitch. Subcuticular F. This suturing technique is usually used to approximate first layer of closure of the anterior wall of the gastrointestinal anastomosis. ___4. ___6. ___5. It consists “far-far. identify and write the letter from column B that corresponds to column A. Gambee C. Connel H. 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. Continuous Interlocking D. ___8. Column B A. This suturing technique is used for fine skin closure producing everted edges. This suturing technique avoids any stitch marks on the skin and is usually is used to close wounds where cosmetic aspects are especially important. Vertical Mattress B. 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. It is usually used for hemostatic purposes. ___3. Smead Jones G. This suturing technique is intended to close an opening of a hollow organ around a tube ___2.
Alfonso. The said adhesive film will slough or fall off within 5-10 days as the skin re-epithelializes. the finer the sutures to be used. eyelid. Paul Jesus S. polypropylene or silk. poliglecaprone or polydioxanone 5-0. Eduardo S. Select the appropriate suture materials/needles to be used in commonly performed general surgical procedures. PC-5 or FS-2 needles.5 cm. MD. Eseque. Objectives of this Chapter After going through this chapter. No dressings are necessary. smooth border. the skin should be closed as mentioned above. The thinner the skin. this is applied on the wound using an applicator tip. the subcutaneous tissue should first be closed with absorbable sutures. After this has been done. poliglecaprone or polydioxanone after which the steps as mentioned earlier are followed. and Jose A. FPCS. MD.g. the learner is expected to: 1. MD. If Octylcyanoacrylate is to be used. Salud. For skin lacerations with subcutaneous tissue involvement greater than 0. FPCS. 2. 3. poliglecaprone or polydioxanone are recommended. P-3. Identify the alternative suture materials and techniques for the said procedures. use polyglactin. The wound edges are held together for about 30 to 45 seconds to allow for complete polymerization. MD. Dizon. deep. 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. . FPCS. FPCS. MD. 4-0 or 5-0 polyglactin. Thereafter. For skin lacerations with subcutaneous tissue involvement that is less than 0. MD. FPCS. Alejandro C. Encarnacion. Facial lacerations with tension should be closed with 5-0. Jerome G. deep. repair the muscle using absorbable sutures. FPCS. MD. e. Baldonado. Gabriel L. The preferred needles for the above procedures would either be P-1. In the absence of tension. MD. MD. the skin should be closed as above. Apply the principles behind the rational use of these suture materials/needles in the different surgical procedures. Rene C. A film will be noted over the wound. Montemayor.Chapter VII Clinical Applications Cenon R. Thereafter. use 6-0 or 70 nylon.. subdermal stitches using 5-0 or 6-0 polyglactin. the wound edges are manually approximated together with fingers or forceps. FPCS.The same sutures are recommended for other facial lacerations without tension. Solomon. FPCS. Prior to repairing wounds that may be closed with skin adhesives.5 cm. FPCS. 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. Jose Antonio M. the skin edges must first be freshened to achieve a sharp. it is first necessary to assess whether deep suturing or debridement is necessary. If the muscle is involved. Martinez.
tapered. heavy-bodied atraumatic (channeled or drilled) needle. Furthermore. The base of the appendix is suture ligated using 2-0 silk/ cotton in a round 1/2 circle intestinal needle especially if the Click here for video on Abdominal Wall Closure The fascia is considered the most important layer in closing an abdominal surgical wound. the mesoappendix is serially clamped. the wound edges are approximated again with the fingers or forceps and the strips are simply applied over the wound edges to apposition. Since absorbable sutures like polyglactin and polydioxanone can maintain tensile strength of about 40%50% at 3 weeks. it is not necessary to close the peritoneum as closure of this layer does not contribute to wound strength. In the face of tough tissues in tight working areas. the sutures that elicit minimal inflammation are best. Click here for video on Subcuticular Skin Inguinal Herniorrhaphy/Repair of the Inguinal Floor Inguinal hernia repair is classified as a clean wound. worse. if the peritoneum is to be closed. eyed needle at 1/2 circle with a relatively short to medium chord length. It is the major supportive structure of the body and is the strongest tissue in the abdominal wall and thus. the choice of the suture and the needle is vital. . The known critical healing period of fascia is somewhere between the 14th and 21st post-operative days. the best suture materials would be those that maintain a long tensile strength such as polypropylene. some repair techniques that utilize a continuous suture line. it can bend. The strips may then be removed in 5-7 days. it is best to use sutures that result in minimal tissue reaction while maintaining tensile strength for at least 14 days. nylon. For a precise anatomical repair. Since knot-tying is extensive. Polyglactin and polyglycolic acid sutures are thus recommended using a 1/2 circle round needle. a braided suture is used while monofilaments are used for the continuous technique. silk or cotton. perforate or lacerate vital and vulnerable structures. In repairing the inguinal floor. healing of the peritoneum is complete within seven to fourteen days post-operatively. 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. in the presence of infection or contamination. Appendectomy During an appendectomy. In this regard. polyester.For skin strips. obese or immunocompromised patients. however. The ideal suture is a non-absorbable braided (or monofilament). The repair requires a strong suture of adequate diameter to keep the tissues together without breaking or cutting through. the majority of hernia repairs are performed using a simple interrupted suture line. carries the brunt of the stress on the abdominal wound. they may also be used. after deeper structures have been repaired. For this reason. However. Thus. While the transversalis fascia is relatively easy to penetrate. However. heavy-bodied. some surgeons prefer to do so since this is considered to aid in reducing the formation of adhesions. The incision is usually short and the precise anatomical repair is done in a deep confined space. Still. and knot security is important in the interrupted technique. its analogues like the iliopubic tract or Cooper’s ligament are tough tissues. Breakdown of this layer may result in the development of incisional or ventral hernias especially in malnourished. preferably 1/2 to 5/8 circle with a relatively short to medium chord length. There are. cut down to the base and ligated using silk/cotton 2-0 or 3-0 sutures. 0 or 2-0 with permanent strength and low reactivity (polyester or polypropylene) together with a very sharp tapered. 2-0 or 0 on a 1/2 circle needle. Abdominal Wall Closure In closing the abdominal wall. there is the tendency for a needle to shift in the needle holder. The acceptable alternative is a silk suture threaded through a sharp. A suture must therefore maintain immediate and extended wound support to prevent breakdown of this layer. precise tension on the fascial edges requires a technique where each suture exists independent of the others.
. Click here for video on Ligation of the Cystic Duct When closing a choledochotomy.base is wide. Although tissue reaction is greater. The suture is retained long enough for the purpose of maintaining hemostasis. Liver parenchyma is very vascular and friable. the cystic duct and bile ducts because they require minimal knots without easily slipping as compared to monofilaments. blunt-tipped liver needle (BP-1) which is best when passed through the vascular liver tissue. 4-0 or 5-0 absorbable monofilament suture such as poliglecaprone or polydioxanone. However. A free tie of 2-0 is often times used to reinforce ligation of the base before the appendix is divided. The majority of simple liver injuries usually resolve spontaneously. using a 1/2 curved tapered needle. It is always safer to doubly ligate the base to reduce the possibility of stump blowout. Long tensile strength retention and absorption time is likewise not a requirement. Click here for video on Suture of the CBD The best alternative suture material is the braided absorbable variety which requires less knots to secure the choledochostomy (polyglactin or polyglycolic). it is clinically insignificant if applied outside the wall of a hollow structure or viscus. edges of the cut surface with or without interposition of a hemostatic material or omental pedicle. it can be used to ligate the appendiceal stump without the fear of stump blow-out. Since it has a high breaking force. packing or electro-cautery). the cut edges of the lacerated liver parenchyma may need to be sutured. The suture is best swaged on a long. Hence. 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. Braided suture materials are used in ligating vessels. Doubly ligating or clipping the cystic duct stump is suggested to prevent unnecessary leaks. Another alternative method of securing the cystic duct stump is by using liga clips as in laparoscopic surgery. The wound would have long healed before they are absorbed. these structures are individually ligated with nonabsorbable 2-0 sutures (silk/cotton). Another alternative suture material is the braided absorbable variety (polyglactin/polyglycolic) 2-0 or 3-0. 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. One clear disadvantage is the cost of the suture material. Tensile strength is not a concern in this situation because what is required is just to approximate the edges for hemostasis. For this reason. maintains its tensile strength up to 14 days and is only absorbed after 45 days. The knots are tied gently with .g. Its disadvantages are that it requires more knots to secure the closure and are relatively more expensive. More complex liver trauma management is beyond the scope of this manual. an appropriate and ideal suture for this situation is chromic catgut suture. 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. If bleeding fails to stop with other maneuvers (e. Chromic 2-0 horizontal mattress sutures are applied on both Click here for video on Double Ligation of the Appendix Cholecystectomy and Surgery of the Bile Ducts After identifying the cystic duct and artery during a cholecystectomy. non-absorbable braided suture materials are appropriate in this setting. It does not readily slip and is cost-effective. no clear advantage has been noted with the use of purse-string sutures. it is advisable to use a 3-0. Liver Trauma Simple suturing techniques of traumatic liver injuries are applicable only to type I and II injuries. Chromic suture has a smooth surface thereby inciting less trauma as it passes through liver tissue.
. during the preparation of the segments that are to be resected and the bowel ends that are to be joined together. There are.. A critical factor that determines anastomotic integrity is the application of proper suturing technique and material. both braided and monofilament materials are utilized depending on the technique. although an interrupted technique is also popular for facilitating a precise reapproximation. The anastomoses in such cases may be commonly performed with a running stitch. 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. It is not uncommon for the prolonged presence of a suture in the mucosa to provoke significant foreign body reaction and granuloma formation.a minimum of tension just to approximate the edges. Healing time is relatively fast with the anastomosis assuming tensile strength in about 7-14 days. Moreover. Keep in . As such it is easy to penetrate. for the inner layer in gastric or duodenal anastomosis. polyglycolic and polydioxanone. those with a swage attachment rather than eyed. continuous stitch and braided for interrupted. however. A 1/2 circle needle is standard for this repair. suturing techniques that accomplish bowel anastomosis using single layer repair. atraumatic needles. Another unique feature of the procedure is that of tissue inversion. Hence. i. Absorbable suture materials are commonly used but non-absorbables are also popular particularly among single layer technique of repair. Using taper point or round point needles is appropriate. short term absorbable suture materials are preferred. Applications of deep suture bites are likewise avoided to prevent necrosis of normal liver tissue. Bowels are lumenous structures with fluid and gaseous contents and its repair is ideally done without tension which seldom offers resistance. The alternative suture would be an absorbable suture like polyglactin. And in order to create the least puncture injury to the bowel walls.. The submucosal repair therefore. monofilament for running.e. 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. it must be emphasized that half of the procedure is accomplished before the actual resection and anastomosis. being the most fibrous among the 4 layers that gives the anastomosis its required strength. i. The average thickness of bowel walls that are to be anastomosed only require medium chord length. All the layers of the bowel wall are characteristically soft with minimal to moderate dense fibrous support. the suture material that is ideal for bowel anastomosis must therefore retain tensile strength beyond the healing time of the slowest healing tissue . A popular compromise in single layer closure technique is a longer term absorbable suture material such as polyglactin. Bowel Anastomosis Leakage of intestinal contents or its frank breakdown after a bowel anastomosis carries severe consequences.e.the submucosa. 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. are desirable.e. Consequently. Anything sharper than a taper or round needle may be more traumatic or more risky than is desirable. Inversion therefore provides a serosa-to-serosa apposition over a mucosa-submucosal repair. However. This has great significance in the gastric mucosa as it may lead to post-operative anastomotic ulcer formation. 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. 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. is the most important for the surgeon. Here. The repair is reinforced by the proper approximation and healing of the seromuscular layer of each bowel end. In a double layer anastomosis. taking care in avoiding cutting through the friable liver tissue. i. The serosal layer heals faster than the submucosa but it is the latter. Therefore.
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. as in the elderly and immunocompromised patients. 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. 3-0 is the standard while 2-0 is acceptable as well as 4-0. These rubber bridges may be in the form of cut strips of drainage tubes or catheters.absorbable and incites very minimal inflammatory reaction. nontraumatic. polypropylene or silk 2. Vessels may be sutured in a running. Given also the special situation of anastomosing blood vessels to synthetic grafts. Therefore. Finally. After all retention sutures have been applied and after all the layers of the abdominal wall have been closed. especially for smaller vessels. Continuous suture technique for very small vessels may have a purse-string effect which may narrow the lumen further. It is monofila- ment. The bowel walls are neither thick nor fibrous where stress and strain to suture material is minimal. 1 or 0. in particular. Absorbable sutures need not be used as these sutures will eventually be removed in a couple of weeks. An alternate suture for use in vascular surgery is braided polyester.mind that a continuous non-absorbable suture would. . This is best used with a 1/2 circle. 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. Vascular Anastomosis and Repair Vascular suturing has specific demands different from other suturing techniques. Suture material strength is a function of the size. so as to penetrate the layers of the abdominal wall with ease. These same suture materials may be used even in the presence of infection as they produce the least inflammatory reaction. will retain its tensile strength for a long time and will not easily be broken down or absorbed. The ideal suture for this situation is a suture that is inert. Polypropylene has been found to conform to most of these requirements. serve as a purse-string that would permanently limit the size of the lumen as opposed to employing the interrupted technique using absorbables. Sutures that may be used for this particular procedure include nylon. one must remember that only one side of the repair will undergo biologic wound healing and repair. for which a double-armed suture is best or in an interrupted manner. 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. To prevent tying the retention sutures too tightly. The best needle to use would be a large cutting-edge needle.” there is always the possibility of “cutting through” the tissues with the slightest strain. non-absorbable sutures. sutures have to be strong and absorbed/broken down only after a long time. Even stainless steel or wire may be used. non. tapered BV-1 or RB1 needle. in essence. But bowel anastomosis is best done without tension. But if the suture is too “fine. 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. In considering the size of the suture material. they are all individually tied. rubber bridges are applied. Blood vessels are subjected to a tremendous amount of pressure per square millimeter and for this reason. continuous fashion. Tensile strength retention and absorption rate are very critical in determining the choice of suture. Retention sutures utilize strong and large suture materials. there has to be a reasonable balance between the required tensile strength and tissue reaction due to the foreign body.
Conn. 1988 . Closure of Wound. Conn. 1996 Zollinger RM. Ellis H.. 1996 Rutherford RB.. Shackelford’s Surgery of the Alimentary Tract. 337:1142-1148 Wilson RF and Walt AJ.REFERENCES Abrahamson J. TRAUMA. 3rd ed. Stamford. Ellis H. Philadelphia. Shackelford’s Surgery of the Alimentary Tract. Zollinger RM. In: Zuidema GD. The New England Journal of Medicine. Ritchie WP . Maingot’s Abdominal Operations. 4th ed.. PA: WB Saunders. Stamford. MJ. Zinner.. Surgery of the Small and Large Bowel. (eds). 10th ed. Schwartz SI. 10th ed.: Appleton & Lange. Conn. Ritchie WP . New York: Macmillan.. et al (eds).. Jr. Hernias.: Appleton & Lange. PA: WB Saunders. Williams & Wilkins. 1993 Singer AJ. Maingot’s AbdominalOperations. Gastrointestinal Suturing. 1997. Atlas of Vascular Surgery: Basic Techniques and Exposures. In: Zuidema GD. Jr.. Evaluation and Management of Traumatic Lacerations. Management of Trauma: Pitfalls and Practice. et al (eds). Philadelphia. Atlas of Surgical Operations. (eds). 1997 Feliciano DV. 4th ed. Stamford.. Schwartz SI. 7th ed. 1997 Brooks DC. 2nd ed.: Appleton & Lange. In: Zinner MJ. WB Saunders Co. 1996 Rout WR.. In: Zinner MJ. Moore EE and Mattox KL. 1996 Rout WR. Hollander JE and Quinn JV. Jr.
Which suture is best to ligate the cystic duct during a cholecystectomy? a. use skin adhesives 8. Nylon 0 continuous d. What would you do? a. Cut clean the edges. Polypropylene 5-0 interrupted c. Chromic 2-0 e. ligature of the base is performed using which suture? a. Non-absorbable sutures become nidus for later stone formation c. Polypropylene 2-0 c. Polypropylene b. deep laceration on the left upper eyelid after being accidentally hit by a baseball bat. Cut clean the edges and close with interrupted nylon 7-0 c. Chromic catgut b. Nylon 6-0 interrupted b. Leaks are less likely to occur with absorbable sutures e. repair of the CBD around the tube is best with which suture? a. Polyglactin 2-0 d. Strictures are less common with the use of absorbable sutures d. Deep bite skin closure (together with subcutaneous tissue) using 5-0 nylon e. Close the wound with interrupted silk 6-0 b. by 8 mm. The following suture materials may be used in closing the inner layer of a two-layer inverting bowel anastomosis. Interrupted polypropylene 0 9. After insertion of a T-tube. Polyester 2-0 5. The most frequently used suture material for single-layer bowel anastomosis is: a. Cotton d. Nylon 3-0 b. Polyglactin 0 interrupted e. Polyglactin 3-0 d. Polypropylene 6. Plain catgut d. The use of absorbable sutures is advocated when applying sutures in the biliary tree because? a. Cotton 4-0 e. A 13-year old boy sustained a 2 cm. Chromic 0 interrupted c. except: a. Braided silk c. the suture of choice in repairing the floor of the canal is? a. Absorbable sutures are easier to handle 4. interrupted e. It evokes less inflammation than non-absorbable sutures does b. During an inguinal herniorrhaphy. Silk 2-0 b. Polyglycolic c. Chromic 2-0 2. Cotton 4-0 continuous c. interrupted d. Polyester 5-0 continuous . suture the subcutaneous tissue with 6-0 polyglactin then close the skin with interrupted silk 6-0 d. Silk 2-0 c. Silk 2-0 interrupted b. Polydioxanone 7. During a retrograde appendectomy. Surgical gut e.Self-Assessment Questions (Chapter VII) 1. Polypropylene 5-0 continuous e. Polyglycolic acid 3-0 continuous 3. Silk 4-0 interrupted b. Polyglactin e. Polyglactin 4-0 simple. The wound is clean with relatively smooth edges. Debride and if available. Polypropylene 5-0 simple. Nylon 5-0 interrupted d. A completely transected axillary artery is best repaired end-toend using which double-armed suture? a.
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.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. 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. Premilene(r). Miralene(r). 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 . 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. 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). 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). Ethibond(r).
B 2. A. B 4. C 5. C 6. D 14. B 2. D 3. C 6. C 3.Appendix B Answers to Self-Assessment Questions CHAPTER I 1. A. E 8. A 3. E 7. C CHAPTER III 1. C 2. D 4. D CHAPTER IV 1. B 2. C 7. C 5. B 4. B 8. D 13. C 4. B 4. E 3. D 12. A 3. B . E 9. F 8. B 5. A 2. A. C 8. D 4. D 2. A 3. C 7. A. B 10. B 15. A 9. B 7. D 5. D 2. G CHAPTER II 1. D 11. A CHAPTER VII 1. C CHAPTER V 1. D 6. H 5. A 5. D CHAPTER VI 1. A 6.
MD Rey Melchor F. Cortez. Nadala. Directo. MD . MD Arturo S. Santos. MD Maximo B. MD Jose C. Jr. Nitollama. MD Armando C. Lim. Almonte. MD Leonardo L. de la Peña. Lopez. MD Vedasto B. Siguan. Crisostomo. MD Maximo H. Cua. Gonzales. Elgar. MD Edgardo R. MD Josefina R.2003 Board of Regents of the Philippine College of Surgeons President: Vice-President: Treasurer: Secretary: Members: Fernando L. Simbulan. MD Gerardo A. MD Rodolfo L.. MD Maximo Dy-R. MD Stephen S.
MD. MD. MD Secretary: Annette G. Ocampo. Annette G. MD. Renato A.C. Joey H. MD Renato Cirilo A. MD. Tolentino Regent-in-charge:Armando C. Alfonso. Crisostomo. MD. Ocampo. Adiviso. Alfonso. Mendoza. Tolentino Standing ( Left to Right): Miguel C. MHPEd Jose Joey H.C. Bienvenida . Mendoza. MD Shirard L. MD . Armando C.2003 Committee on Surgical Training of the Philippine College of Surgeons Chairman: Members: Cenon R. MD. Crisostomo. MD. MD Miguel C. Bienvenida. Adiviso . MHPEd Sitting (Left to right): Cenon R. Shirard L.
Juanito R. the committee would like to acknowledge the expertise of Mr. for their unwavering and dedicated support to the completion of this 2003 Basic Surgical Skills. Gatus of Priority One Corporate and Marketing Communications. Also. Executive Secretary of the Philippine College of Surgeons and to Ms. Ethicon Division. . Tolentino.Ruth Nicolas. Alain Espina.Acknowledgement The Committee on Surgical Training of the Philippine College of Surgeons would like to express its sincerest gratitude to Ms. Annette G. for the development of the CD. Franchise Manager. Electronic Version. of Johnson and Johnson Medical. and Mr. Philippines. for the layout and graphics.
Lopez. MD Edgardo R. de la Peña. MD . Lim. MD Leonardo L. MD Rodolfo L. Almonte. Directo. MD Rey Melchor F. MD Maximo Dy-R. MD Jose C. MD Vedasto B. Santos. Crisostomo. Simbulan. MD Maximo B. MD Arturo S. MD Stephen S.2003 Board of Regents of the Philippine College of Surgeons President: Vice-President: Treasurer: Secretary: Members: Fernando L. Nadala. MD Josefina R.. Gonzales. Jr. MD Armando C. Cua. MD Gerardo A. Elgar. Nitollama. Cortez. MD Maximo H. Siguan.
MHPEd Jose Joey H. MD . MD. Crisostomo. Bienvenida.C. MHPEd Sitting (Left to right): Cenon R.2003 Committee on Surgical Training of the Philippine College of Surgeons Chairman: Members: Cenon R. Bienvenida . Shirard L. Annette G. MD Secretary: Annette G. Tolentino Regent-in-charge:Armando C. Crisostomo. Alfonso. MD. MD Renato Cirilo A. Ocampo. MD. Ocampo. MD. Renato A. Mendoza. Adiviso. Tolentino Standing ( Left to Right): Miguel C. Joey H. MD. MD. MD Miguel C. Adiviso . MD. Armando C.C. Mendoza. Alfonso. MD Shirard L.
of Johnson and Johnson Medical. and Mr. for the layout and graphics. Annette G.Ruth Nicolas. Franchise Manager. . Ethicon Division. Electronic Version. Tolentino. Philippines. Also. Executive Secretary of the Philippine College of Surgeons and to Ms. Juanito R. for their unwavering and dedicated support to the completion of this 2003 Basic Surgical Skills.Acknowledgement The Committee on Surgical Training of the Philippine College of Surgeons would like to express its sincerest gratitude to Ms. the committee would like to acknowledge the expertise of Mr. for the development of the CD. Alain Espina. Gatus of Priority One Corporate and Marketing Communications.
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