Suturing Course E-book

AN ILLUSTRATED HANDS-ON COURSE ON CD-ROM
Included· an 18 piece suturing Kit with all the instruments
and items needed to learn how to suture lacerations!
Learn how to care for- and suture wounds AND get your 1B-piece
suture kit with real medical instruments and items - al/ you will need
to practice wound suturing al home.. or wherever you are!!
A product by
THE APPRENTICE CORPORATION
Copyright © The Apprentice Corporation 2007
All rights reserved .
The Apprenti ce Doct or ® Suturmg Kit Is exduslvely Intended for
educational purposes It Is str1ctly prohibited for use In medical situations
Not Intended for treating either human or animal patients I
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We appredate your Integrity in this regard.
A BASIC COURSE IN SUTURING
........... 01
Objectives of the COlll'$f!_. __ ... H. __ . __ . __ .... H_. __ . __ .H ... H_. __ . __ .H. __ . __ ...... __ . __ . __ ...... _03
DiKlaimer. __ . __ ...•.•...•. __
Ust of MedieaIIMlJ"ument5_ ..... _H._ ... _._ ... __ . __ ..... _ ... __ ._
Project I: with the suture kit.
..... __ .... 0-4
..... __ . __ ._._ ... __ .. 05
.. ____ 11
Project 2: Anach Suture IlUtf'rial to a Ileedle ... H.H ••• __ • __ ••• H.H ._. __ ._ ... __ • __ • __ ._ ... __ •• 13
Project 3: How to dip the needle to the needle hoIder_. __ . __ . __ . __ . __ . __ . __ .... __ . __ .. 16
Proje<t -4: Prepare imitation skin for practicinS suwrir18_._. __
..... __ ._ ..... _18
Project 5: How to COMtrlJ(t it rod to practke knot tying_ . __ .•... _. __ .• _. __ ... _. __ .••.. 20
.23
ProjectNpha: A Oemtmstr.ltion of a )<juan: knot and a graM)' kllOt.."'"H'"H'"H'"H' __ 2S
Projec:t Seu: Milke a $qU3.re.!mot: Two-h<1M tie'H' __ "'_'_"'.' __
..... __ ._ ... _.29
Projett Garrma: Make a knot: One-hand tie ..... __ ._ ... _. __ ... _. __ ... _. __ ... _._._ ... _33
Projett Delta: Make a surgeon's knot: One-hand tie_ ........ _ .••...•.•... __ .••...•.•... _ .•. -41
Projfoct Epsilon: Make a knot: InstrumMt tie .. __ ._ ..... _ ... __ ._. __ . __ 52
Project Zeta: How to make a surgeoo·s knot (Instrument tie).. .._ . .56
Case Study - Hazard< at work.. .63
Basic prindples of wound care __ .••.••. _ .• _ .• _._ •. __ .• _ .••. _ •. _._ •.••. _ ._ .•. 65
A bilsic cOUr"$e in wwring tedmiqUE!s. __ . __ ._. __ . __ . __ . __ ._. __ ._ ... __ . __ . __ ._ ... __ ._. __ . __ 70
ProjectA: Haw to place subcutaneous sutures .. __ . __ . __ . __ . __ . __ . __ ._. __ . __ . __ . __ . __ ._71
Project B: How to place Interrupted surure'S._ •... _ .•...• _._ •.... _ •.••. __ ..... _ •.••. __ ....• _n
Project C: How to pia(e interrupted with buried knoa_. __ . __ . __ ..... __ . __ ._.8S
Project D: How to place continuous surures._. __ . __ . __ . __ . __ . __ ._. __ . __ . __ . __ . __ . __ . __ 89
Project. E: How to place continuous interlocking sutures._. __ ._. __ . __ . __ . __ . __ . __ . __ ._ 93
Project. F: How to place horizonCl.l manre" wwre$. __ . __ . __ . __ . __ ._. __ . __ . __ . __ . __ ._ 97
Project. G: How to place vertical mattress suwres. __ ._. __ . __ . __ . __ . __ . __ . __ ._. __ . __ ._IOI
Project. H: How to place "Far-and-Near" suwres
Project I: How to place s.utures .. __ . __
Project. J: How to place a purse string suwre ... _. __
Project. K: How to CO/TKt a '"Dog's Ear" .. __ . __ . __
Project L: How to con"@<t uroequal ieVf!is of tissue
.. _._105
.. _._109
._._115
.. _._118
.. _._121
Project. M: How to rell1OV1! sutures .. __ . __ . __ . __ ._. __ . __ . __ . __ . __ . __ . __ ._. __ . __ . __ . __ ._.125
Complications of suturiflg __ . __ . __
..... _. __ ... _. __ . __ . __ ... _. __ ._. __ ..... __ . __ . __ .129
Epilogue_._ . __ . __ .... __ . __ . __
..... _ .. 131
Glossary._ ... _._ ... _. __ ..... __ . __ ._. __ 132
PREFACE
Learning how to suture wounds and lacerations requires a thorough understanding of the theory of wound
care and the basic principles of suturing. The student also needs to reach an advanced level of
proficiency by practicing knot tying and suturing techniques.
The Apprentice Doctor® Suture C o u r ~ e and Kit is not intended to substHute the clinical training of students
but rather to offer a firm foundation and an opportunHy to experience hislher initial learning curve in an
imitation situation - so as to fill the student wHh confidence when he is faced wHh the real life clinical
sHuation.
The Apprentice Doctor® Suturing cour se material on CD-ROM consists of 3 sections:
1. Get acquainted wHh the instruments and items in the KH
2. Basic Knot tying
3. Suturing techniques
FOllow this specific order when working your way through the course material. and ensure that you understand
the one section and are able 10 perform the practical projects skillfully before proceeding 10 the next section.
Do not skip a section because you think it is unimportant or too simple. Basic principles are like that, Ihey
appear to be simple. but one needs to understand and practice these simple building blocks before proceeding
to. and succeeding with the complicated stuff.
IMPORTANT NOTES:
Kindly note: For the purpose of this course the word suture will be used as the verb/noun pertaining to the
closing-up or stitching-up of wounds/lacerations !incisions .
• The Apprentice Doctor® Suluring Hands-on Course and Kit has been designed mainly for right-handed
persons. Left-handed persons please exchange the lerms left and right as they occur in the lex! where
applicable .
• This Kit contains the bulk of the information, instruments and ilems 10 successfully practice your suturing
technique. It is highly recorrmended that you invest in The Apprentice Doctor® Basic Medical Course and
Kit, which wonderfully supplements The Apprentice Doctor® Suturing Course and Kitl
• TheApprentic:eDoc:tor.c:om website and corrmunity COflllliments these 2 products and gives the future
Healthcare professional a chance to join groups of like-minded students with the aspiration of becoming
medical professionals, or to leam from other practicing Healthcare professionals. You win find a suitable
community in your country/state - and will receive lois of free advice and support to help you fulfill your dream!
Dr Anion Sc:heeper s and the staff of The Apprentic:e Corporation as well as all the Apprentic:e Doc:tor
c:ommunity leaders would like to wish you success with your fulure and look forward 10 being a small part of
fulfilling yourdreamsl
Recommended training material for.
All Healthcare Professionals whether prospective, in training or qualified:
• Medical students
• Pre-medical sludents
• Paramedics and EMT students
• Dental students
• Veterinary students
• Nursing students
• Surgery IntemsfRegistrars
• Advanced Firsl Aid
• Medics in the
• The Apprentice Doctors' Club Members
• High school students interested in a career in medic:ine
• Practicing Healthcare professionals who would like to mprove or refresh their suturing technique.
• Non-medically qualified individuals with a keen interest in the practical aspects of medic:ine
OBJECTIVES OFTHE COURSE:
To equip students wijh a basic understanding of the t heory of sut uri ng wounds and to acqui re the skiHs to
confidently tie surgical knots and suture lacerations.
The student Should on completion of this cOurse have a good understanding of;
• The basic principles of wound care
• Knot tying techniques (as related to knots used in surgery)
• Surgical instruments used in suturing
• Suture materials
• The various suturing techniques used by medical professionals
The student should have the following skills:
• Placing sub-cutaneous sutures
• Placing interrupted sutures
• Placing a variety of mattress sutures
• Tying a square knot (two-hand tie, one-hand t ie, and instrument t ie)
• Tying a surgeon' s knot (one-hand He, and instrument tie)
• Using a number of other types of suturing techniques
• Correcting minor discrepancies while sut uring
• Removing sutures
Developed by a surgeon with more than 20 years of experience
»> PLEASE READ THESE WARNINGS CAREFULLY «<
• Your Suture and Dissection contains sharp objects e.g. a knife. needles and scissors. Please be edremel y
cautious and careful when using these i nstrumentsl
• Not surtable for dlikJren under 12 yeaJl; of agel
• Supervision/guidaoce by a responsible aduft is recommeocSecl for stuclents urder 18 years of age.
• The user must atways wash hisihef hands before using the 10 minimize the risk of infection following acciclental irljury.
For lhe same reason gloving is recommeJlCled.
• Always use clean instruments. Wash iostruments with soap and water after each usage session. then leave it in an
antiseptic solution e.g. Savio... for 60 minutes. Rinse thoroughly with clean water then dry before raplacing in the kit.
• For aoy CUI or needle pridllnjuries - squeeze the wound for 15-30 secoocls to bleed out Impurities. then wash
profusely with soap and water; apply pressure to stop the bleeding. then apply a plaster e.g. Band Aid. Seek professional
medical assistance.
• Keep out of reach of babies. toddlers and c hildren under the age of 10.
o Keep sharp instruments iNlay from the eyes.
DISCLAIMER
The pr oducer or Supplier of this application does not :
• Offer any warranty regarding the accuracy or correctness of any information contained in this application;
• Assume any for any damage oroonsequential damage related in any way to the information,
instrumentation or items contained in this product/application or as a result of the use thereof.
The user takes full and exdusive for the safe appl ication of any information oontained in this
application. The user also takes full and exclusive responsibility for all safety aspects related in any way to the
use of any instrument or supplied with this application. This exclusive responsibility applies equally to the
user orto any person or persons being supervised by the user.
No warranties are offered on the functional status or fitness for a specific application of any information.
instrument or item supplied in this application.
The supplier accepts no for the malfunction of any instrument or
The supplier disctaims ali liability for any direct or indirect damages - specirlc or consequential - relaled in any
way to the information, and instrumentation or any item contained in this application.
Ali practical e)(ercises are performed e)(ctusively at the user's own risk. The producer or supplier of this
application disclaims any for any medical emergencies. medical problems or any other problems
whatsoever. which may arise v.tlile using any instrumenl or item or applying any information supplied with this
application.
The use of the inst ruments, Hems and information supplied in this application is conditional upon the
acceptance of this disclaimer as weli as Ihe undertaking to honor the copyrighted course material.
REIMBURSEMENT POLICY
The Apprentice Corporation is confident that you will be satisfied with this product in each and every way.
If you are, for any reason dissatisrted with your choice, The Apprentice Corporation will be happy 10
reimburse you (less postage and shipping charges) should you wish to retum the oomplete medical asweli
as the CO-ROM in an undamaged state within a reasonable time of not more than 8 "Maeks after acquiring
this product .
YOUR ORDER NUMBER AND THE DATE OF THE TRANSACTION
SHOULD ACCOMPANY YOUR REQUEST FOR REIMBURSEMENT.

LIST OF MEDICAL INSTRUMENTS
Surgical scissors
Surgical scissors are classified according to the 2 blade tips - thus:
• SharjrSharp
• Sharp-blunt
• Blunt-blunt
Sometimes scissors are classified according to function - for example:
• Suture cutting scissors
• Dissection scissors
In cerlain operations ~ is safer to carefully dissect your way towards
an area/organ rather than cutting into the tissues with a sharp scalpel
blade.
Use your medium Shaqrblunt scissors for general cutting purposes
and to cut off e)(cess suture material after placing a subJre and tying the knot.
Use the small Sharp-sharp scissors to cut the suture for removal.
Surgical probes (seekers)
Your KH has two probes:
• Sharp (straight)
• Blunt (slighUy curved)
Probes are also classified as:
• Hollow
• Solid
A dentist uses a sharp curved probe to examine teeth and detect
cavities.
Anesthetists and radiologists use f lexible blunt probes to maneuver
their way into specific veins or arteries in the body (for diagnostic or
therapeutic purposes)
Skin hook Of available)
A skin hook is used to lift a sect ion of skin, to the placement of
sutures while minimizing the amount of injury to the tissues.
By placing two skin hooks into the tissue at the oomers on the 2 sides
of a laceration, and gent ly lifting both skin hooks, one can facilitate
eversion (having a sHghtly raised sut ured laceration compared to the
adjacent tissue).
Scalpel
A scalpel is a surgical knife with a fixed or removable blade
(cutting area). Removable blades are produced In a variety of
pattems and sizes.
WARNING: The scatJel is the most dangerous instrument in your Kit-
handla with caution!
Forceps
A for ceps isan instrument used in medicine to grab or 10 hold
something.
You contains a general-purpose The inside of
the tips Oaws) are serrated to enhance gripping. This forceps is used
for general handling and gripping of tissue or objects.
The other forceps is called a tissue forceps. The tip of this forceps
shows a sharpish t ip Oaws) on the one leg and a v-shaped groove on
the other side. It is conmonly referred to as a rat-tooth forceps.
Use this forceps to handle tissue when placing sutures.
Needle Holder
A Needle Holder is a special type of forceps, designed to securely hold
the surgical suture needle when placing sutures.
Artery forceps are somewhat similar in appearance, but have longer
jaws - some with straight and some with curved jaws.
{
Sutures
The main two groups of sutures are
• Absorbable.
These sutures are broken down by bodily enzymes. and are used
when sutures are placed within the body, below the skin
(Chromic and Plain Catgut, \/icryl""" and Monocryl""")
• Non-absorbable (e.g. Nylon and
These sutures are more predictable as regards their strength. The patient needs to return to the
hospitalfsurgery for removal of these sutures.
Sutures may also be subdivided as braided and monofilament. As a rule, braided sutures are easier to tie but
cause a more intense tissue reaction.
Suture sLtes
Modem suture diameters range from thick to thin and are represented by the series of numbers 5, 4, 3, 1,0,
2..1),3-0,4-0.5-0,6-0.7-0,8-0,9-0, 10-0and 11-0. Number 5 sutures are heavy braided sutures used by
orthopedic surgeons and 11-0 sutures are micro-fine monofilament sutures used by ophthamic surgeons
operating Vv'ith the aid of a surgical microscope. Number 5-0 or 6-0 sutures are used to stitch up lacerations in
cosmetically sensitive areas like the face.
Needles
Needles may be slraight, a semi-circle or a section thereof. In cross
section they may be round or triangular - with a cutting edge on either
the inner curve or the outer curve.
The length and the diameter of needles may vary considerably.
The number used when describing a needle usually refers to the length
in millimeters.
Modem needles are pre-assembled a suture material
attached to the blunt end. These needles are referred to as "atraumatic'
- meaning they do not have an eye that may injure the tissue as it
traverses the tissues.
The needles in your have a small eye on the side opposite to the tip
6
for you to attach the suture to. Atraumatic needles are manufactured in all shapes for most sizes of sutures.
ImitatiOn Skin
A 15X 15 em imHation skin is included in your kH. The whHe fiber-like
part oorresponds to the dermis and the thin plastic oovering
oorresponds to the epithelium (the covering surface layer of skin and
mucous membranes).
Remember you can practice your skills on a variety of vegetables-
oranges, bananas potatoes etc.
The imitation skin in your kH is more l i f e - ~ k e compared to a number of gel-like imHation skin products available
on the market. Skin is in fact anything but gel-like in consistency.
Gloves
It is strongly reoommended that you wash your hands hygienk:ally
clean (see "Proj ect 00' in The Apprentice Doctor® BasK; Medical
Course) and glove before practicing placing sutures to make sure
that you get in the right habits from the word go. You need to become
accustomed to the "feel" of working while being gloved like a surgeon.
More information: htlp://en.wiklpedia.orgAvikllSuture
DR SHIPTON'S HOLIDAY
Or Shipton usually reserves 2 weeks at their hOliday resort
forlheir family's yearly holiday. Dr Shipton, his wife and their two
children look forward to these 2 weeks of enjoyment months in
advance. It is a time of re-uniting fami l y ties, Involving the whole
family in games and activities, all at a beachfront venue, with their
flat having an exceptionally great view of the treac herous Indian
Ocean on the East coast of Africa.
The first week was great. The weather was good and the sea was
perfect for swimming. "LeI's get up ea Ill' tomorrow morning and
watch the fishermen reeling in their fish from the rocks:
Jamie the elder Shipton son proposes, and the proposal is accepted
unanimously. It is July and one of the most spectacular natural
events is about to occur - the sardine run. Schools of mill ions of
sardines migrate up the coast, followed by game fish like
barracudas and shar1<.s in their thousands - a fishermen's paradise!!
for fishing have been forecast as optimal and hundreds
of fishermen line the coasl, the prime spot is Ekhakha's rock.. Dr Shipton and his family haven't caught on to
the fishing thing, but this event makes for great entertainment merely by being a spectator.
So 8 a.m. and everybody' s ready to stroll down to the beach. They have to pass a numberof neighboring flats
on their way down. Suddenly they are stopped in their tracks, stunned by screaming followed by an urgent
shoul: "HELPI SOMEBODY, PLEASE HELP! r One of their neighbors' flat door swings open with an even more
urgent shout for help.
Dr Shipton dashes towards the flat and discovers the neighbor' s
17-year-old son covered in blood. A simple slip and his head
shattered the glass top on the coffee table. "Quickly bring me
towelsr he shouts. HetighUy drapes a large towel over the large
cut in the scalp and puts on tight hand pressure for a couple of
minutes. The towel slowly becomes red and more saturated
bright red blood.
The pressure helps but doesnl stop the bleeding. "Go get my first aid kitl" His wife rushes to their flat and
returns wijh the kit. Or Shipton atways carries some Iocat anesthetic as wen as a coupte of packets of suture
material and the relevant instruments In his first aid kit. He quickly injects local anesthetic containing adrenalin
and almost ilTlllediately starts to stitch up the long 25 an (10 inch) laceration in the scalp.
Wijh each stijch the bleeding gets tess. Or Shipton doesnl waste
Ime cutting the stitches - just one long continuous suture. Time is
of the essence. He has just one thing in mind ... to stop the
bleeding as soon as possible. He takes fairly large bites with the
suture needle into the tissue adjacent to the laceration. and
ensures that the s t ~ c h e s are tight by interlocking them. He uses
another towel to clean up the wound. He then inspects the area
for residual bleeding. and cleans up.
Or Shipton writes a note to the Medical Officer at the local
hospital giving him the relevant information and requesting him
to take over the case. Just then. the arrbulance arrives and the
Paramedics rush to assist in stabilizing the patient. The patient is
transported to the local hospital.
At long last the Shipton family is on their way to the beach - the
subject under discussion is the events of the moming.
Would you /ike to be prepared for an emergency situation /ike Professor Shipton? Here is your chance
to learn how to professionally suture wounds!
»> IMPORTANT WARNING «<
For those who are not qualified and officially registered as a medical professional. please keep the following in
mind:
• Leave suturing 00 real patients to suitably medically qualified individuals.
• In an emergency cah 911 or equivalent emergency numberl
• Exert diract pressure on any blooding point until help arrives.
PROJECT I - FAMILIARIZEYOURSELFWITHTHE SUTURE KIT
Ensure thai your Suture Kif is completa and thai you know the names of each individual instrument
INFORMATION
Most metal surgical instruments are made from stainless steel-which Is strong, durable and won'l corrode
(rust ). They can be sterilized by steam autoclaving and wiH retain their characteristics.
REQUIREMENTS
Your suture Kit
STEP 1
Identify the components of your suture Kij using the Rs!
(provided on page 5). Our Kits are double checked for quality and
completeness by our factory. In the unlikely event of problems,
kindly contact customer support personnel at
Customercare@TheApprenticeDoctor.com.
STEP 2
2. 1 Remove the Needle Holder from the Kit, and Identify ijs
different parts.
2.2 Havea good look at the ratchet latch (lock) mechanism - ij has 3
beveled teeth on the inside of both sides - designed to catch at 3 levels
- light, medium and strong locking.
2.3 Put the thumb in the upper eye and the 4th finger in the lower eye
of the handle - see picture right. Practice the locking and unlocking
action of the ratchet tatch mechanism
at all three levels.
2.4 Clamp and unctamp small objects tike pieces of paper or thin
cardboard. Do the jaws leave a checked pattem on the paper?
STEP 3
Remove the two tweezer-
forceps from the set The
forceps has two legs joined
at the hinge. Examine the
Inside of the lips. The one
forceps has jaws with a
serrated inner surface and
2.5 Now examine lhe crosshatched pattem (photo) on Ihe inner side
of the Needle Holder's jaws. This pattern is designed 10 firmly grip
lhe sulure needle and prevent unnecessary stipping of the
needlelsuture.
Wear and lear will eventually cause this surface to become smoolh
- an indicat ion 10 replace the Needle Holder with a new one.
lhe other one has a v-shaped tooth on the inside of lhe jaw and a v-shaped groove on the other side (the tooth
fitting into the groove). Use this forceps to gently handte ti ssue with the left hand when placing sutures.
STEP 4
Have a look althe skin hook (substituted a sharp curved
probe ... some sets). It is used to gently lift skin during suturing.
Hook. the sk.in on the inside (raw) surface - not the
surface.
POINTS OF INTEREST
1. Quite a variety or scissors 98Ch with a unique purpose a,., available. Examples are:
• A pair of scissors lhat can cut through stainless sleel wire - used by
orthopedic surgeonsand maxillofacial surgeons
• A pair of dissection scissors - meant to carefully dissect through tissue
instead of cutting a scalpel . These scissors are usually slightly
curved wHh pointed, though slightly rounded tips
• Micro scissors - used In eye surgery and microscopic surgery
(e.g. joining smal arteries, veins and nerves underlhe surgical microscope)
Apaif" ofmao SCi SSOfS
2. A surgeon is only as good as his/htJr tools. Know your instruments and always use good quafty medica/
instruments. Order affordable quality medica/Instruments at: http://vNlw.afrorrJabledrtoola,com!
3. Order a professional suture set (IFRC specifications) : http://wWw .• frorrJablftdrtoola.comi
PROJECT 2 • ATTACH SUTURE MATERIAL TOA NEEDLE
How 10 attach a piere of suture malerial to a surgical needle
INFORMATION
In past generations. a medical professional would routinely usea needle with an eye (an "eye" is a sma" hole
on the blunt side of a needle where the thread is held) for suturing purposes. The eye part of such a needle
may cause minimal damage as H traverses the t issue.
Modern suturing materials have pre-attaChed thread. Pre-attached
sutures allow for a smooth transHion from the needle's body to the
swage and then to the suture - and are thus referred to as an
"atraumatic design" (won't cause further injury to the tissue).
The needle-suture attachment is an occasional weak link. and on
rare occasions may become undone. This attachment occupies about
Yo inch (3 rrm) on the suture end of the needle (the swage).
One should avoid clamping the Needl e Hol der l o lhe swage of the
needle as one may inter1ere wHh the secure attachment of the suture
to the needle.
6
Suppose you land yourself up in a far-off mission hospital or a milHaryfield hospital and you only have thread
and needtes with eyes - wi tt you be abte to help your patient? Leam how to attach suture material to a needle
by fa/lowing these steps:
REQUIREMENTS
Youwilll7fJ(Jd:
- About ( 12-18 inches) 45 em of silk suture
- One no 16 semici rcular needle
STEP 1
Unroll about 12-16 inches (30-40 ern) of silk suture
from one of the reels supplied.
STEP 2
Remove one no 16 needle from the package using the
Needle Holder. Clamp the needte roughty in the middte
of the needle' s body. Secure the Needle Holder by
clamping ~ to the first ratchet. (Be careful when
working with sharp objects).
~ STEP 3
Fotd the last 1 Y,...inch (4 ern) of suture double and pass
t he double thread through the eye of the suture needle.
STEP 4
Open up the double thread slightly to form a loop, and
pass the needle through the loop.
POINTS OF INTEREST
STEP 5
Firmly pull the long and short loose ends of the double
thread away from t he needle · thus t ig htening t he
simple loop knot to attach the thread to t he needle.
1. Needles with eyes can be l'9-used 8 couple of times under the fo//Ollring condlt/ons:
• The tips remai n sharp
• The needles are st ructurally undamaged
• They are properly sterUized
• Re-use for not more than 4-6 times
2. Practice and permct your technique byordemg a variety of real prHIssembled, pIlf-packed sterle
surgical sutures from http://www.afrorrJabledrtools.com/
PROJECT 3 - HOWTO CLIP THE NEEDLETOTHE NEEDLE HOLDER
Learn the technique on how to properly clip and secure 8 noodle onto a Needle Holder
INFORMATION
Note: One should Ideally clip the Needle Holder onto the mld-sect ion of the needle - somewhat closer to the
Swage. Avoid Clipping the Needle Holder onto eaher the Tip or swage sectior'lsl
TIP
MIODLE
3 ~
SWAGE
S UTURE
The various parts ()( 8 surgic:aJ OOfJdIe
REQUIREMENTS
• The Needle Holder
• One no 16 Needle with suture material attached (see Project 2)
6
STEP 4
STEP 1
Wash your hands, dry and put on a pair of gloves
(Project 00 of The Apprentice Doctor® Basic
Medical Course). The Gloves serve as a surgical
barrier between operator and patient, and provide
protection from accidental needle injuries. Double
gloving is advised for high-risk patients e.g. patients
B and HIV infections.
STEP 2
Follow the principle of minimal handling of sharp
instruments and Use a tweezer-forceps to
remove one no 16 needle from the package using your
left hand. Present the needle to the needle holder with
this tweezers forceps.
STEP 3
Use your needle holder to clip the needle, secure the
lalch mechanism (bien for the first or second "click")
- avoid clipping it onto the swage third (may damage
the suture-needle attachment) or the tip third (may
damage the sharpness of the tip) of the needle.
Inspect the suture part and ensure that is untangled and any knots.
POINTS OF INTEREST
• Accidental needle injuries are common CBUseS for fhe accidenfal contraction of HIV 8fId Hepafltls B
infrJcUons
• All patients should be considered catTf6rs of infective diS88seS.
• Hospitals have specific protocols on whst steps to take foIlowtJg accidental needle iljurles - femllarlze
yourse/fwifh your hospilafs protocol
• H8IldIe sh8fP objects and instruments once - mil/mlze the handling of sharps. Surgeons should get into
the oftamg scalpels and assembled needles Itlr suturing diroctly from /he ins/ruman/tray. Do no/
uk the assisting theatre sister to hand you such sherp mtrumentsAtems if at a/I possible. Many
iljurles il thestre occur during the trensfer of ' sharps" from one person to /he other.
PROJECT 4 - PREPARE IMITATION SKIN FOR PRACTICING SUTURING
Prepare a piece of imitation skin for practicing your suture technique
INFORMATION
The Imitation skin for practicing your suture technique consists of three layers - just like natural skin:
' Asuperficia l covering layer(t mm)
- representing the
• A white fibrous layer (3 rrm I Y. inch)
- corresponding to t he dermis
• A spongy layer (6 mm I Y. inch)
-- corresponding to the subcutaneous tissue
This patented skin. provided with The Apprentice Doctor® How to Stitch-Up Wounds Kit. is a
remarkably effective substrate for practicing suturing techniques. and sutures can be placed, and removed
repeatedly along the same incision linel
REQUIREMENTS
·A4 X 6 inches (10 It 15cm) piece of imitation skin
• The large scissors
• The small scissors
· A pen and ruler (a skin mar1(er pen and ruler is available in The Apprentice Ooctor® Basic Medical Kit)
STEP 1
One sheet of imitaHon skin can be used tocreate:l:3
imitation lacerations. Divide the skin sheets
into 3 sub-sections and draw 3 straight lines of:l: I I ern
(4 Inches) on - as indicated in the diagram.
POINTS OF INTEREST
STEP 2
Make a short 5 mm (Yo inch) vertk:alline at 90
degrees to t he straight line - in the middle of
each of these 3 lines.
STEP 3
Divide each of these halves into quarters and draw
another two short 5 mm (Yo inch) vertk:allines in these
regions. (These li nes win enable you to check the
alignment of the skin following closure of the laceration
wHh sutures).
STEP4
Use the s harp-sharp scissors and push oneblade into
the skin at one end of the horizontal li ne and cut the ful
thickness of the skin along the straight Hne up to the
end of the Hem (4 inches) hori zontal li ne. (The larger
scissors win be more effective In cutting the ImltaUon
skin). Repeat the same procedure with the other 2 lines
to create 3 initation lacerations. These cuts represent
surgical incisions or traumatic lacerations in the skin.
• In a recent survey in fhe state of Virginia, U.S.A, minor sorr tissue injurias like abrasions, laoerations and
confusions ranked as the third most common f98SOII why patients visited their remly physiclen.
• A neat suture technique will go a long way to avoi<Wlg ugly scarmg and the need for SClJr revision by a
plastic surgeon
• The saying ·practice makes perfect" Is especialy true In this regsrd/
PROJECT 5 - HOW TO CONSTRUCT A BARiRODTO PRACTICETHEVARIOUS
TECHNIQUES OFTYING KNOTS
INFORMATION
Suturing, like the other fields of medicine, is both an art and a science. It follows that to become a proficient
operator you will need to gain a good understanding of the
theory, TOGETHER with frequent pradicing of the techniques
of suturing.
REQUIREMENTS
• Masking tape or equivalent
• The inside cardboard from a toilet ron or a tissue ron
• A table or suitable worKing su rface to practice making knots
STEP 1
Cut 2 parallel lines along the long axis of the cardboard
tube - about 3.5 em (1 Y. inch) width on both sides,
along the same long lines.
STEP 2
Bend a 90 degrees leg downwards on both sides.
STEP 3
Bend a 1.5 (Yo) indl foot outwards (again 90 degrees to
the leg)
STEP 4
Position the rod-like tube w ~ h h long axis horizontany
in front of you. and about 30 em (6 inches) away from
the table·s edge. Strap the foot down - on the table or
worldng surface you intend to use to practice making
knots with adhesiYe tape e.g. masking tape or "sticky·
""
Alternatively simply place your ruler on two spa08fS on thB two ends (tfIB suture reels wiN wcrkjust me frx this
purpose) and strap it down with meskmglstidfy tape
POINTS OF INTEREST
1. Interesn·ng what useful purposes a pi&08 01 trash can serve/
2. Get into a habit of thinking along fflese lines:
• 'Mlat useflJ purpose can an item MIMI befOIl! trashing it?
• Can it be recycled?
• Think "green"! Don't be wastefull
3. "Preventioo is too best ruro" - let us 8pply it in 811 the 8f888 01 our lives!
RECOMMENDED TRAINING MATERIAl FOR
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HIGK SCKOOL STUDCIfT'$ IIfJl;RE$TI;O IN A CUlUR IN
PRACnell!O Hu.a.'mCUlt PROF"t5SIOIIAL!lvrnO """()ULll Ullt TO '"PROVE OR RURE$" TtlEIR TECHmOUE
INOMO\JAL!I wm< A "[EN 'NlUIESf IN 'mt PRACTICAL ASPECTS OF MEI)OCIHE
THE SURGEON'S KNOT
Dr Buys is in a 'NOnderful mood. This is Friday afternoon and he has booked a short operating list because he
plans to go on a special weekend, just he and the Missus.
This is the last case, a routine laparoscopic removal of a diseased
gallbladder. He has done so many over the years and has become
q u ~ e an expert "I'm sure I will be able to remow this ganbladder
with my hands behind my back ! he jokingly remar1ls.
First. second and third incisions, instrumentation in place and now
for the careful dissect ion .. "Thirty minutes and I am out of here!"
he remar1ls.
The inflammation has caused q ~ l e a bit of scar tissue. ard the
anatomy is not as clear as he expected. Suddenly - a surge of
bright red bloodl "Suction!! Suction!!" He shouts - but it is obvious
that the bleeding is much too fast for the suction to handle. Vision
becomes Impossible and now is the time for quid<; , life-and-death
decisionsl
"l ets open up!r He shouts to the senti sister. · Scalpel!
Diathermyl ... Abdominal swabs!! ... Artery forceps!r
Dr Buys knows that he needs to abort the laparosoopic-camera
procedure via the small buttonhole incisions. He wWI have to make
a larger incision to access the bleeder and stop the bleeding.
Itlhe patient looses more lhan a certain amount of blood. she will
go into slI"gicai shock and may die!
NOTE:
At last the bleeder has been identified and everybody takes a brief
sigh of relief. "Tie sutll"e", Dr Buys continues, amazingly relaxed
now. "Remove artery." He ties off the bleeder with an amazing
amount of finesse and ease.
Would you like to Imowhow to make a surgeon's knot?
• 'NfNJr side' fflfflrs to the affla cJos&r to you and the tsrm ' farsioo" refers to the area away from you .
• Left" hand8c1 individuals - kindy substitute the wold ' right' for 'left' and visa"versa, Apologies fOf any
Inconvenience!
" The wold "throw' ffl fflrs to a single basic subunit ortightened loop of a knot.
PROJECT ALPHA -A DEMONSTRATION OFA SQUARE KNOTANDA GRANNY
KNOT
View a demonstration oftoo diff6f€J(lcfJ between a Square knot and a Granny knot
INFORMATION
• Definition - knot: The American Heritage® Dictionary defines a knot as: "A fastening made by tying together
lengths of material , such as rope, in a prescribed way."
• Description of a square Mot: The square knot consists oftWQ ' throws' or turns ol the \WQ ends of a pieoe of
string/rope.
• A thorough understanding of knots is essential before you can proceed with acquiring skills.
REQUIREMENTS
You wiN need:
• The colored and wt'ite string (induded in the krt)
Follow these sleps;
STEP 1
Color the one lip al the siring with a bright color
using a color ink pen. In the text I refer to the
colored part as the ' colored sedion" and the
uncolored part as the ' wMe section'
... ,2
STEP 2
Plaoe the section of siring in the form of an incomplete circle in front of you, wilh the colored end to your
left-hand side and the whije section to your right-hand side. The opening of the loop sholAd face to the far side.
Copy the following descriptions with the piece of string:
STEP 3
F j ~ t throw - colored tip cross over white tip.
STEP 4
Colored tip goes into loop from beneath and out of the loop to the top. Close the loop to some extent.
$lep .5
STEP 5
b
( )
$l&P (;
Colored tip goes into loop from beneath and out of the loop to the top. Close the loop to some extent.
STEP 6
Second throw - colored tip crosses over wMe tip.
r
~
)
-,
)
Step 71t Step 7b Step 8
STEP 7
Vl'tite tip goes into loop from the top and out of the loop 10 the bottom (under the red sect ion).
STEP 8
Complete the knot by tightening it - p u l ~ r g the colored end to the left with your left hand and the while end 10
the right 'Nith your right hand.
Malle It "granny knot" by fol/owing these steps:
FOllow Stop 2 to Step 5 as with the square knot (above)
-....
~ - -
,
""'"
IQ
c)
II }
c;
C
II
/,
St8p6 SIt/p 7e Step 7b
STEP 6
Second throw - wtite tip crosses over colored tip .

STEP 7
White tip goes into loop from beneath (under t he red section) and out of the loop to t he top .
.:.:
~ ~ - - ~
STEP 7
Complete the knot by tightering ~ - p l , j ~ n g the colored end to the left
with your left hand and the white end to the right wrth your right hand.
1. A gtanny Knot tends to tighf9fl on the tissue, while a square knot tightens on itself. A gronny knot tends
to slip where a square knot would have held.
2. Fis/1ermen and sailors are oIten masters in mak61g a variety 01 secure knots
3. NI /lCr, me Is a form 01 tfIXb"lB-making that uses knott61g tathfJ( thllfi weaving or knitting. PeoplfJ proc.ticing
the art form of macrame are usuaNy real knot experts.
PROJECT BETA · MAKE A SQUARE KNOT-TWO·HANDTIE
INFORMATION
The Square Knot is the recommended knot for tying most types of sutures. Be sure not to tie a Granny knot
(this knot res(jts when you tie two throws in the same direct ion). Square knots hold. granny knots slip.
REQUIREMENTS
You wiN nood:
• The colored and white string (induded in the k ~ )
• The cardboard tube constructed i n Project 5
• Good lighting
Follow these steps:
STEP 1
Prepare the cardboard tube and strap ij to the
tabletop or 'NOrlling surface using maskingfsticky tape
(see Project 5)
STEP2
Slip the string IXIdemeath the cardboard tube with the
colored end towards you (near side), and the white end
away from you (far side).
STEP 3
Let the open palm of your left hand face you. Bring the
white end from the back and let ~ come over the index
finger. cross the PClIm down to the lijtle finger. Close the
bottom 3 fingers around the whrte string, v.flile
maintaining an extended index finger.
STEP 7
STEP 4
Hold the colored strand in yo ... right hand between
your right ttu.mb and index finger. Bring the colored
strand folWard and let it cross over the wt"ite strand
(and thus over the left index finger).
STEP 5
Let the tips of the left thumb and index frlger touch
to endose the two stands of string. Keep holding the
colored end with your right thumb and index finger.
STEP 6
Wlile keeping the tips of your left thtJ"T1b and index
frlger touching. rolate these fingertips away from you.
moving your thumb tI1der the tWQ strands and ;nto the
bop.
Plaoe the colored end. curentty in yo ... right hand. between your left thumb and index finger, and let go of it
with your right hand. Rotate your hand back to the starting position. bringing the colored tip through the loop.
STEPS
Pull the wMe section towards you with your left hand
and the colored end away from you with your right hand.
thereby tightening the Kst tlYON of the knot.
STEP9
Let the open palm of your left hand face towards your
right-hand side. Make a 'J-shaped opering between your
left thumb and index finger. and pull the v . 1 1 ~ e tip over
the thumb into the V with the free end hanging down
the palm past the Httle finger. Hold the w h ~ e tip in the
palm of the left hand by closing the bottom three fingera.
The hand is held in a position almost as if pointing a gun.
STEP 10
Wrth the right hand. bring the colored strand tONard you.
and plaoe ~ between the left thumb and index finger.
crossing over the v.11ite strand. Place the index finger of
yOI.J' left hand over the colored sect ion and touch the tip
ofthe left thumb - enclosing the two strands.
STEP11
Rotate these mgertips dowrM'ards and tONards you.
The left index finger goes under the two strands and into
the loop. Take the colored tip held by the right hand. and
place ~ between yOI.J' left thumb and index finger v.11We
releasing it from your right hand.
STEP 14
STEP 12
'll!hile maintaining your grip on the oolored end
between your left thumb and index finger. rotate your
left hand bact allowing the left thlKrlb and index finger
to carry the colored strand through the loop. Grip the
colored strand between your right thumb and index
finger and release ~ from the left hand.
STEP 13
"Loosely tighten the knot by moving your left hand
holdirg the · ..... Me tip away from you and your right hand
holdirg the colored tip toward you - thereby completing
the second throw of the square knot.
"ff you tie the mot too tightly you might not be able to
untie the knot for mousing the r ope!
KEEP IN MIND
If required you m.y add .nother 1IYow (by foIowi'Ig Steps U) Of.nolhertwothrO'n't
(by f o I o w I ~ Steps 3-131I1gaJ1 In I1el8st J1Btance you will have tied. double Square knot
Practice the tecmiQUe of making a square knot usirg the two-lland tie methoo before proceedirg to the
one-hand tie technique.
(See video dips of II number 01 knot tyfng techniques):
1. http://\.\.ww.vetmad.ufl.9dwcoufSevideos/acinAierNid.asp
2. http://\.\.ww.edu.fCsfKI.ae.uWvideo_album_dips_menu_basicsKiNs.htm
3. http://cBl.vetupenn.edw'surgery/5000.htm
4. http://www.9du.rr::sed.ae. uWmachsIT1-1 .HTML
PROJECT GAMMA - MAKE A SQUARE KNOT, ONE-HAND TIE
Take 11 couple of short cuts towards lying 11 square linot more efficiently
INFORMATlON
I will describe 2 methods to tie a ' one-hand square knot ' . Method 1 will surt most right·handed persons and
Method 2 most left handed persons, a couple of right-handed persons may find Method 2 somewhat
easier and \lisa Yef!ia.
The basic difference between a ' !wo-hand tie square knot' aOO a ' one-hand tie square knot' is the time takes
to make a secure knot - remember - occasionally during seconds may be the difference between life
and deathl
REQUIREMENTS
You wiN need:
• The colored and white string (incl uded in the krt)
• The cardboard tube oonstructed i n Project 5
• Good lighting
METHOD I
Follow these steps:
STEP1
Prepare t he cardboard tube and strap 10 the
tabletop or wor1\ing surface using tape
(see Project 5)
STEP2
Slip the string I.J1demeath the car<board tube with the
colored end towards you (near side). and t he white end
away from you (far side).
STEP J
Hold the colored end in your right hand between your
index finger and thumb, and the wtite section in yOI.J"
left hand, between your middle linger and thumb.
Let the wtite section cross over the palm's side of the
open 3rd to 5th finger.; of the left hand with the wtite
tip hanging down past the Irttle rJlger. Place the index
finger of your left hand I.J"Ider the wtile section. and
extend the index finger - draping the string over the tip
of the index finger.
STEP 4
Take the colored section to the far side, crossing over
the index finger of the left hand and over the whrte
section of string forming an ·X·.
STEP 5
Bend (flex) the index finger of the left hand around the
colored strand and rotate rt under the white strand held
by the middle trlger and thumb.
STEP 6a
Open (extend) the index finger mailing sl.J"e that the
white section of string stays on the nail's side ofltis
finger.
STEP 6b
Rotate the hand - pulling the wtite section of string through the loop.
STEP 7
Pull the v.11ite section towards you with your left hand
and the colored end ffflay from you with your right
hand and tighten the fi r.;t throw of the knot.
STEPS
Hold the wtite end in your left hand between the tips of
your index finger and thlS!1b, and the colored section in
your right hand between your index finger and thlnlb.
AUow the whije section to cross over the palm's side of
the open (extended) 3rd to 5th fingers of the left hand.
STEP 9
Bring the oolorOO section from the far side to the near
side. looping ij over the 3rd to 5th fingers of the left
hand, and over the v.11ije section of string to form an
' X' shape.
Step 10C
STEP 12
STEP10
Bend the middle finger of the left hand and hook it
around the colored section and beneath the W ' h ~ e
section of string. Stra9hten the index finger again W'hile
puning the white end through the loop in a rotating
motion. Take it now between the tip of the index finger
and thumb.
STEP 11
PIJI the colored end towards you with y o ~ right hand
and the W'hite section away from you with y o ~ left
hand. tightening the second (throw) part of the knot .
NOTE
W requM-"ed you may a:ld .nolhBr bop (by following Stepe 4-a)
or two (by fGlowlng Step' -'1-13) ag.n
Practice the tectmique of making a square knot using the one-hand tie method before prooeeding to the
instrlnlent tie tecmique.
METHOD 2
Follow these steps:
STEP 1
Prepare the cardboard tube and strap ~ to the
tabletop or wor1<ing surface using mask.ingfsticky tape
(see Project 5}
STEP 2
S ~ p the sbing ISIdemealh the carclXlard tube with the
colored end towards you (near side), and the whije end
away from you (far side).
STEP 3
Hold the colored end in your right hand between your
index finger ard thumb w ~ h the tip pointirg upwards.
and the W'hite sedion in your len hand, between your
index finger and thumb. Rotate the right hand sHghtly
so the palm is facing you. Ensure thai the colored
string passes over the palm's side of the open
(extended) 3rd to 5th fingers of the left hand.
STEP4
Bring the w h ~ e section to the near side - over the
colored section of string crossing over it in the form of
an ' X' across \tlese 3 fingers.
STEP 6
STEP 5
Bend the middle finger of the right hand, and dose
(flex) it around the white section and under the colored
section of string held by the index finger and thumb of
the right hand.
Open ttis finger. and hold the colored end betweeo the middle and fourth finger, while rotating the hand -
pulling the colored end through the loop. Take the colored section between the thumb and index finger of the
right hand.
STEP7
Pull the white section to.vards you wah your left hand
and the colored end a w ~ from you with your right
hand and tighten the first throw of the knot .
$lap 1111
STEP 8
Hold the colored end in your right hand between the
tips of your middle finger and thumb (the tip of the
colored end hanging down on the palm's side past the
I ~ t l e finger), and the wMe section in your left hand
between your index finger and thlSllb. Plaoe the index
finger of your right hand under the colored section. and
extend the index finger -looping the string over the tip
of the index finger.
STEP 9
Take the wtite section to the far side, crossing over the
index finger of the right h(Mld and over the colored
section of string forming an oX- shape.
STEP 10
Bend the index finger and flex ~ around the wMe
section and undemeath the colored section held in the
right hand
Sr8J)11b
r
STEP 11
Straighten the index finger again while pulling the
colored end through the loop in a rotating motion. Hold
the colored end between the tip of the indel( finger and
thumb of the right hand.
STEP 12
Pull the colored end towards you with your right hand
and the wMe section away from you wrth your left
hand, tightening the second (throw) part of the knot
NOTE
If .-qu'-ed you may add anolhltf loop (17f folONJ1g Slepl3-7)
OftwO(by foIowir1'i1 Steps 3-12) aogall1
'-,
.")
,
aasic Square Knot
~ J
"-
~ 3
r
, . AtkWonal Loop 2. Addirional Loops
STEP 13
Practice the technique of maKing a square knot using the one-hand tie method before proceeding to the
instrument tie technique.
• Both hands are used to 00 a On&·hand tie knot. The nOlJ-cominant hand plays a psssi\19 roll and the
dominant hand an active roll during the knot tying sequence.
• Mos( surgeons can tie a one·hand tie square knot in their sJeep. K8f1p on practicing until if becomes
almost reflexive actilXls.
• "a square knot slips add another loop (ortlKl orthree) to the square knot. Note: ronsecutive loops
should always be in the opposite direction to the previous loop
• Different suture materials vary in the numberor loops requinnl to secure the knot thus avoiding
unmveljng.
PROJECT DELTA· MAKE A SURGEON'S KNOT, ONE·HANDTIE
The technique on how to tie a socure Surgeons Knot with your hands
INFORMATION
A surgeon's knot is essent ially a square knot with the difference that the tIYead is passed twiCe tIYough the first
loop.
The sl.J"geon's knot is a VefY important knot. Master thoroughly -yol.J" pat ient's we"·being or even hi s /her life
will depend on level of skill when tying this knot
Like the square knot, I will describe 2 methods to tie a ' one-hand surgeon's knof . Method one suit
most right-handed persons and Method 2 most left handed persons. although a couple of right-handed persons
may find Method 2 somewhat easier and visa versa.
REQUIREMENTS
You wiN need:
• The colored and wMe string (incl uded in the
• The cardboard tube cons!n.Jcted i n Project 5
• Good lighting
METHOD I
Follow these steps:
,,-
STEP 1
Prepare the cardboard title and strap it to the
tabletop or wor1<ing SlStace using masking/sticky tape
(see Project 5)
STEP 2
S ~ p the string underneath the cardboard tube wrth the
colored end towards you (near side), and the W'hrte end
a w ~ from you (far side).
STEP 3
Hold the colored end in your right hand between your
Index finger and thumb, and the white section in your
left hand, between your middle linger and thumb.
Let the white sedion cross over the palm's side of the
open Jrd to 5th frlgers of the left hand with the white
tip hanging down past the little finger. Place the inde)(
finger of your left hand under the white section. and
extend the index finger - draping the string over the tip
of the index finger.
STEP 4
Take the colored section to the far side, crossing over
the index finger of the left hand and over the wMe
section of string forming an · X".

STEP 5
Bend (flex) the index finger of the lert hand around the
colored strand and rotate it under the white strand held
by the middle filller and thumb.
$fop Ijb
STEPS
Open (extend) the index finger making sure that the
white section of string stays on the nail"s side of thiS
finger. Rotate the hand ~ puHing the white section of
string through the loop.
S/ep 7c
STEP 7
00 nat close t he l oop. Place the finger afyaur
left hand into the loop again. then bend this finger
around the colored section of string. and rotate it under
section of string held by the index frlger and
thumb of the right hand.
STEP 8
Straighter! this finger. and in a rotating motion pull the
end ttl'ough the loop for a seoond time.
STEP 9
PuH the white section towards you with your left hand
and the colored end away from you your right
hand and tighten the first throw of the knot

S/6P 12 ..
STEP 10
Hold the wMe end in your left hand between the tips of
your indruc frlger and thumb. and the colored section in
your right hand between your index finger and thumb.
Let the white section to cross oYer the palm's side of
the open (extended) 3rd to 5th frlgem of the left hand.
STEP 11
Bring the colored section from the far side to the near
side, looping it over the 3rd to 5th frlgem of the left
hand, and over the white section of string to form an
oX'" shape.
S/6P 12b
STEP 12
Bend the middle finger of the left hand and hook ~
around the colored section and beneath the white
section of string. Straighten the index finger again while
p u l ~ n g the wMe end through the loop in a rotating
motion. Take ~ now between the tip of the index finger
and thumb.
STEP 14
STEP 13
PI,jI the colored end towards you with your right hand
and the white sedion away from you with your left
hand. tightening the second (throw) part of the knot .
NOTE:
If requw-ed. you may add loop or two
to prevent the knot from unl1lvellng
Practice the tech rique of making a square knot using the one-hand tie method before proceeding to the
instrument tie technique.
METHOD 2
Follow these SlepS;
STEP 1
Prepare the cardboard tube and strap to the
tabletop or worl<ing surface using masking/sticky tape
(see ProjectS)
STEP 2
the string undemeath the cardboard tltle with the
colored end towards you (near side). and the whrte end
away from you (far side).

STEP 3
Hold the colored end in yOI.J" right hand between your
Index finger and thumb wijh the tip pointing upwards.
and the wMe section in your len hand. between your
index finger and thumb. Rotate the right hand s ~ g h t l y
so the palm is facing you. Ensure that the colored
string passes OVe!' the palm's side of the open
(extended) Jrd to 5th fingers of the len hand.
STEP4
Bring the while section to the near side - over the
colored section of string crossing over it in the form of
an ·x · across these 3 fingers.
STEP 5
Bend the middle finger of the right hand. and close
(flex) it around the while section and under the colored
section of string held by the index finger and thumb of
the right hand.
Step 6b
STEP 6
Open this mger, and hold the colored end bet.Yeen the middle and fotl'th finger, while rotating the hand -
pl,jHng the colored end through the loop, Take the colored section between the thtl'l1b and index finger of the
right hand.
STEPS
STEP7
00 not close the loop. Place the middle finger of your
right hand into the loop again, then bend this finger.
and rotate it under colored section of string held by the
index finger and thumb of the right hand.
Straighten this finger, and hold the colored section between the middle and fourth finger, while rotating the
hand - punirlg the colored section through the loop for a second time
STEP 9
PuH the white section towards you with yotl' left hand
and the colored end fNoIay from you wrth your right
hand and tighten the first throw of the knot.

STEP 10
Hold the colored end in your right hand between the
ti ps of your middle fi nger and thumb (the tip of the
colored end hanging down on the palm's side past the
little finger), and the v . 1 1 ~ e section in your left hand
between y o ~ index finger and thumb. Place the index
finger of your right hClnd lXlder the colored section. and
extend the index finger -looping the string over the tip
of the index finger.
STEP 11
Take the v.11ite section to the far side. crossing over the
index finger of the right hand and over the colored
section of string forming an ·X· shape.
STEP 12
Bend the index finger and flex it around the v.11ite
section and lXldemeath the colored section held in
the right hand - straighten the index finger again v . 1 1 ~ e
pulHng the colored end through the loop in a rotating
motion. Hold the colored end between the t ip of the
indel( finger and tllJmb of the right hand.
Step 13c
STEP 14
STEP 13
PI,jI the colored end towards you with Y0lJ" right hand
and the white sedion away from you with Y0lJ" left
hand. tightenilll the second (throw) part of the knot .
NOTE
If reqUired you may Idd anothe.r loop
ortwoto prevent the knot tom unllIwilng
'-- -----_-:>
-
Bas.<:: Squ8ffl Knot
-
1, A d d ~ i o m i Loop
Practice the tectl1ique of making a square knot USilll the OIle-hand tie method before proceeding to the
instrument tie technique.

• The surgeon's /(fIot is too most basic skill as far as tying knots is concemed, It is used to tie off bl96{lefS,
to tie interruptfW sutures as well as a number or other suturelo1ots.
• WIlen tying off a bleeder - tie rhe first tie, and thoo inspect the stump for oozing or residual blooding.
If you /lave SUOCfJ&ded in stopping the blefWing, proc600 with enother knot or preferobly two.
• No neede is required for e tie suture. If you USB a suture with a pre-assembled need/e, cut off the n96{l1e
befcxe (Xoceeang to avoid injury to yourself orto the assistant.
• In most cases an absorbable suture is required when tying d ( a bleederin the depth of tissue. A "2-0, 3-0
(Y 4-0" broided absabable suture like ' VlCryJ®" wiN be appropriate in most cases (depaooing on the size
of the blood vessel being /lfW elf).
• Anticipate complications in even the most simple of surgical procedures. A routine case does not e:xist!
Every case is unique and every patient is special.
PROJECT EPSILON· MAKE A SQUARE KNOT,INSTRUMENTTIE
INFORMATION
The majority of square knots that most medical professionals tie in their careers are done with a tissue forceps
and a needle holder. Master the tectYlique well using imitation skin - is never a good idea to practice on real
patients. The surgical instruments become extensions of the clirician's hands, making the whole process of
suturing more efficient and adding finesse to the procedure.
REQUIREMENTS
You wII/need:
• The colored and string in the kit)
• The cardboard tlXle constructed in Project 5
• Gllod lighting
Follow these st eps:
STEP 1
Slip the string IXIder the cardboard tube with the
colored section towards}'Qu (near side), and the white
tip away from you (far side) . The section should
be shorter than the colored section.
STEP 2
Hold the needle holder in your right hand
(SM Project 1, Step 2)
STEP 3
Place the needle holder parallel to the cardboard tube
'Nith the tip pointing to the left hand side. The latch
mechanism of the needle holder must be unengaged at
the stage.
Sl8P ?a
STEP 4
Hold the colored section on the near side between the
thlnlb and index finger ofthe left hand.
STEP 5
The colored section of the string is brought f rom the
near side, over the needle holder, down and back to
the near side - thus making the first loop.
STEP 6
Open the jaws of the needle holder and grasp the white
section on the far side, close to the tip of the string.
Engage the ratchet latch mecharism (listen for the first
or seoond ·click").
Sl8P ?b
STEP 7
PI,jI the white sedion tONards you using the needle holder and the colored sedion away from you using your
left hand. TlQhten the knot - thus completing the first throw.
STEPS
Unclip the latch of the needle holder and release the
white tip.
STEP9
Place the needle holder again parallel to the cardboard
tube with the tip pointing to the left hand side. Hold the
colored section on the far side between the thumb and
index finger of the left hand.
STEP 10
The colored section of the string is brought from the far
side, over the needle holder, down and back to the far
side - thus making the second loop.
STEP 11
Open the jaws of the needle holder and grasp the whrte
section (now 011 the near side) close to the tip of the
string. Engage the ratchet latch mechanism (listen for
the first or second
STEP 12
Pull the white section a w ~ f rom you using the needle holder and the colored section towards you using your
left hand. Tighten the knot - thus completing the second throw.
STEP13
Unclip the latch lock of the needle holder and release
the white tip.
Let"s talk a bit about wound dehiScence (ir simply means the wound edges open up again).
Reasons forwoond dehiscence;
• You tied an inappropriate knot - e.g. 8 granny knot instead of 8 5qll8re knot
• Tffe knots wflJ'"e tied too laxly (loose)
• You used an inappropriate suture material- e.g. a thin mooo·fllament svture in a tensioo area
• You used a cutting neooe and should have l15ed a foond body neede - some bodily structures are quite
thin and friable, so always remember a cutting n89(l1e can actuaNy cut tlr"oogh tile tissoo like a scalpe/.
Consider l15ing a revflJ'"S6 wttitlg neede in certain sitll8tiOns
• Too much wound tensioo - the truth is that wound closure should Id9B/1y be tension free
• You clf"JS(Jd an Infected wound - deal with the Infection issue first!
• Placing the suture too close to the wound edge
• Youusoo the wrong suture technique e.g. placing II continuous suture instead of interrupted ormattress
sutures
• You ftJmoved the sutuftJS too SOOO - espfJCiaUy in thelowef 9JCtftJmities.
r
• A foftJign object was inacNeflantJy left in me wound
• A large blood clot (hematana) formed and is forcing the two wound edges apart
• An arterial bleed is putting an Immel1S& amount of Pf9SSUftJ within the wound and facing it open - always
control bleeders first by appropriate means - e.g. Hgation (tying blgedng vessels off) or (bum
them closed with an electric current)
• You are placing sutures in a ma&gnant tumer, One of the atffibutes o( a cancerous gro'Nth is the Joss o(
cellular acfJesion
PROJECT ZETA - HOW TO MAKE A SURGEON'S KNOT (INSTRUMENTTIE)
The technique Dfl how to tie II secure Surg90ns Knot using surgical instruments
INFORMATION
A knOl is essentially a square knOl wrth the drtference that the thread is passed twice through the rr st
loop,
The surgeon's knot is a vel'l important knot Master it thoroughly -your patient 's well-being or even hiS Iller life
wi ll depend on your level of skill when tying thiS knot.
REQUIREMENTS
You wHlneed:
• The colored and white string (included in the kit)
• The cardboard tube constructed in Project 5
• Good lighting
Follow Ihese sleps:
STEP 1
the string under the cardboard tube with the
colored section towards you (near side) , and the white
tip away from you (far side), The wMe section should
be shorter than the colored section,
STEP 2
Hold the needle holder in your right hand
(see Project 1, Stap 2)
STEP 3
Place the needle holder parallel to the cardboard tube
with the tip pointing to the left hand side. The latch
mechanism of the needle holder must be disengaged
at this stage.
STEP 4
Hold the colored section on the near side between the
thumb and index f i ~ e r of the left hand.
STEPS
The colored section of the string is brought from the
near side. over the needle holder. down and back to
the near side - thus making the first loop. Repeat this
manelNer again (the s t r i ~ is brought from the near
side, over the needle holder, down and back to the
near side) - ....-rapping the string around the needle
holder a second time.
STEP 7
STEPS
Open the jaws of the needle holder and grasp the wMe
section on the far side, close to the tip of the string.
Engage the ratchet latch medlanism (listen for the first
or second "dick").
Shtp 7b
PuN the white section towardS you using the needle holder and the colored section a w ~ from you using yOIS
left hand. Tighten the knot - thus completing the fi"st throw.
STEPS
Unclip the latch of the needle holder and release the
white tip.
STEP9
Place the needle holder again parallel to the cardboard
tube with the lip pointing to the left hand Side. Hold the
colored section on the far side between the thumb and
index finger of the left hand.
sr8p 128
STEP 12
STEP 10
The colored section of the string is brought from the far
side. the needle holder. down and back to the far
side - thus making the second loop.
STEP 11
Open the jaws of the needle holder and grasp the w11ite
section (now on the near side) close to the tip of the
string. Engage the raldlet latch mechanism (listen for
the first or second
srtJ'12b
Pull the white section away from you using the needle holder and the colored section towards you using your
left hand. Tighten the knot - thus completing the second throw.
STEP 13
Unclip the latch of the needle holder and release the
white tip.
More Information:
VISit tfJs sire for great video-clip demonstrations 01 tying surgical knots:
http://'lNlw.vetmed.ufl .edufcolJ"sevideosfadinltiesvid.asp
Other useful sites:
http://'lNlw.bumc.bu.edwDeptiContenlaspJC?DepartmentID=69&PagelD=S734
http://cal.velupenn.edufsurgeryf5000.htm
http://'INIW.edu.rcsed.ac.uklvideo_album_clips_menu_baslcskllls.htm
A classical worK for any student 01 suturing is an e-book with the title:
Suture Materiats &. Techniques by EthJcon®download It for free from this adr79SS:
http://'INIW.j njgateway.comfplt:lllcfU SENGlKno,-
You wiD need an Acrobat Readerto open this document- download Acrobat Rooder from:
http://'INIW.download.coml3000-2376-10000062.html
PERFORMING A SMALL MIRACLE! RHODE'S EAR
One of those routine warnings by parents .. . "Rhode and MiChene!
Please dOll " chase the dog around in the houser And one of those
outcomes - Rhode falls and hits the side of her head on
the coffee table ' Ouchr she exclaims, not thinking much aboullhe
incident, •.. .Iet's go and have some cold drink MicheNe".
Sitting on the couch in the family room Michelle notices blood on
Rhode's ear "Rhodt'! , there's blood on your ear!" RhO(!!) calls her
mom, who disoovers to her horror that a chunk of skin is missing
from the top of her daughter's earl
Michelle goes back to the coffee table and discovers the missing
piece of sltjn. They place it in a container. add a small bloclI of ice,
and rush atrIa the emergeocy department of the
Dr Wright has been on call for the past 12 hours and makes
himself ready to lea-..e foMowing a fairly qtiet shift. for a change.
"Please Doctor, ' lhe sister requests. "We have a yOlSlg lady
part of her ear missingr Time is of the essence and Dr Wright
prepares to do a fIJI thicl<ness skin graft using the severed piece of
skin as the graft.
"Don't look so worried, we'. fix this new: He reassures the
patient and mother and starts with the procedure.
Local anesthetic ... cleaning ... suh..-ing ... and dressing. "Will the
injection hurt7". "How many stitches win I get?" Dr W"ight talks
them through the procedl.J"e.
The job is neatly done, almost reflexively, and then the patient
and mother receive ;nstructions, ' please don't wash your hair
or allow water on the wound for 48 hours,
Use His ointmeot liberally on the wOlSld twice daily and
please retum in a week for the removal of the stitches, Don't
hesitate to call me if you have any problems whatsoever r
And off go the patched-up patient and relieved mother ...
Would you like to be a/je to master how to care for woonds?
HAZARDSATWORK
James is off to work. · Smooch!" He kisses his wife lebea goodbye .. . and another 4 kiSses to his 4 children
James Junior, Jake, Susan and Baby Brad. "See you guys tonight' he exclaims as he doses the door.
James is a wek:ler - and nol any type of welder - he in
repairing gas C)'linders - big or small- even the large tanker types
fOf transporting truckloads of various types of gas.
Today is a high-intensity day - 30 gas to repair, then the
presslXe testing and final qua"ty control checks. The protocol is
clear - first empty the cyHnders - then flush them air and
finaHy, tiM the cylinder v.ilh before starting with the
welding. TWQ inspection checks before JCllTleS gets to do his job.
Now some people work welllSlder preSSlXe and James is one of
those, but James's friend Jel'TY is not - a bit lazy on occasion he
decides to take a couple of short-cuts - and yes seems to work
Qut wei , at first
" It is 3 p.m. Only 10 cyHnders to go, and then I can head home",
James thinks as he starts repairing the fine metal crack on the
bottom of this
Then it all happens in less than an instant - a massive explosion
as the 7 mm (Yo inch) metal casing explodes due to a tnellie of
flammable gas remaining in this specific cylinderl
James is seriously ir;ured - the soft tissue and bones of his face
are in pieces and there's blood everywhere, His co-workers do
what they can to stop the bleeding until the paramedics arrive,
The Paramedics finally arrive, resuscitate him, and evacuate him
to the trauma
Miraculously. James' friend Jerry emerges physically uninjured from the tearoom. because he took the libeny of
stretching his 15--minute tea break to 20 minutes.
James is profusely bleeding from tis scalp lacerations.
The trauma doctors place a number of interrupted sutures.
tying them tightly to control the bleeding.
Next , irs attto theatre. The anesthetist worlls like a
machine to keep James alive. He requests urgent blood
tests, administers IV fluids and a number of life-saving
medications.
The TralmCl Surgeon secures the airwCly by doing CI
tracheotomy and this is followed by a ml,jtidiscipHnary
repClir invotving NelSosurgeons, an Ophthalmic surgeon, a
MClxiRofaciCli Surgeon and CI PlClstic cmd ReconstructiYe
Surgeon.
The lo'>YE!r ~ p is in rags, but applying the basic principles of
wound care, the Plast ic Surgeon starts cleaning,
removing all foreign material and dead tissue. He then
plCll1s a layered closure and 45 minutes later .. '>YE!lIthe Hp
is fi)(ed and presentable!
Would you like to know how to repair major
soft tissue lacerations? Well stick to the
basic principles of surgery and practice,
practice and practiceli
THE BASIC PRINCIPLES QFWOUND CARE
Know your patient
If time allONs - take a good medical history. if not lake a brief
medical history - but always take a medical history -
(see ' Project o· afThe Apprentice Ooctor® Course and Kit).
Is your patient allergic to cel1ain local anesthetics. antibiotics
and pain medication, antiseptic solutions or plasteMtrapping?
Does he/she suffer from duone diseases like Diabetes or
bleeding disorders? Are they using any chroric medications?
E<c
Good vision (good lighting)
Fact is that medical schools have trained a number of blind
physicians over the years - but no blind surgeon yet S c n ~
sisters have a saying that the good surgeons are those who
always complain abOut the light - might be true. because ltIe
whole success of the surgical procedll"e depends on good,
proper lighting of the operative field offering the surgeon with
optimal visual sensOlY input !
Anesthesia
The surgeon w ~ 1 make decisions regarding local anesthesia f general
anesthesia andfor sedation. You cannot do your best for a patient who
is jumping, jerking screaming or Cl'Jing ali the time.
Aseptic Technique
Complete steriHty of the operative field is not attainable.
Sterile instruments and suture material must be used.
Exoess suture material must be discarded in a container
purposed for biological waste. The needle must be
discarded in a suitable biological sharps waste container).
Avoid using strong antiseptic preparations for cleaning the
wound. Most antiseptic solutions win cause damage to the
f riable exposed tissue cells. In most cases a normal saline
solution will be sufficient to clean an l.J1infected wOl.J1dl
Remove All Foreign Material
The removal of all foreign material must be efIsured.
Remove all pieces of glass, so( pl ant material etc.
Soil remaining in the wound wiN cause a traOOlatic
tattooing (very difficiAt if not impossible to remove at a
later stagel) If necessary brush the wound a bristled
brush combined a soap solution e.g. Savlon.
Leave the least number of sutures buried in the depth of
the tissue - witlin the limits of getting a secure closure.
Remember that suturing materials although necessary
are considered by the tissue as foreign material.
Leave Minimal Dead Space
'M1He suturing. the operator wiR try to suture living tissue to living tissue. Do not leave empty spares filled with
air, blood or tissue fluid. Dead spaces produce wonderful for bacteria to proliferate and to cause
infection. Dead space may up with blood clot and will contribute to the formation of excessive scarring.
Handle Tissue Gently
Always perform surgery - showing respect for living tissue. Careless suturing may cause more unsightly
damage compared to the original wOl.J1dt Use a toothed forceps to handle the skin (gently touch though).
A flat forceps slipping all the lime will cause more damage compared to a toothed forceps handled gently.
Control Bleeding
Bleeding can be reduced with suctioning and gentle sponging. and controlled by Electro-cautery (electrical
buming) and suturing -ligate (tie-off) larger veins and arteries and use tight sutlJ"ing over bleeding areas
reasonable limits of course). Excessive bleeding wig decrease your ability to see what you are doing
- and good vision is the first principle of surgery!
General bleeding and an of blood to clot may be due to a numberof medications e.g. asplm
(pain-killer). HemophiHa (a absence of clotting factors in the blood). Liver disease. a number of blood
diseases. anti-cancer medication (chemotherapy may reduce the blood platelets which are essential for nonnal
blood clotting to OCCll") and alcohol consumption (not an infrequent finding with patients reporting to a
emergency section). Do take a thorough patient history before you start treating the injl.J")'l
The acronym LACERATE will help you to stay on track when confronted with a laceration to repair.
Look At The Wound, Assess It
Anesthetic Considerations
Cleani ng The Wound
Equipment - Set Up
I
Repair Of The Wound
Assessing Results, Anticipate Complications
Tetanus Immunization Status
Educate The Patient Regarding Wound Care
THE REPAIR OFWOUNDS
Goals For Suturing Wounds
Optimal wound care aims at maximizing functional restoration as weN as optimizing the esthetic These
goals must occur within the limits of maximum patient safety and patient oomfort (a calm patient e:o:periencing
the minimal amoll1t of pain and discomfort).
Suturing a wound may assist the heallhcare professional with 3 immediate goals;
• Tghl will assist in contromng bleeding (seOJring hemostasis). II is not a substitute for normal bleeding
control measures e.g. arterial bleeds in the depth of the wound etc.
• It reduces the chances of wound infection. A closed wound is much less prone to wound sepsis than an open
wound. FlI'lher contamination from the outside environment is also reduced oonsiderablyl
• Reduced pain. An open WQund leaves the severed sensory nerve endings open - thus increasing pain.
Suturing a wound wiR optimize the IralSllatized tissue's chanoes of retaining its blood supply. and at the same
time minimizing the formation of trIsightly scar tissue.
Wound closure is divi ded into:
• Primary closlXe - closure within the first 24 hours
• Secondary cIoslXe - wound doslXe more than 24 hours after the injury.
Primary closure of wounds should be the norm in most cases. Exceptions to the NJe would be higNy
compromised tissue where the medical professional anticipates debridemeot of the wol.l1d (deeming and
cutting away dead tissue and-or foreign material) to be necessary.
Reasons for wound breakdown:
• under tension. should be passive - do not stretch tissue and try to close the wound under
tension - it will break downl
• Sepsis. Common reasons for sutured wounds to opeo up again are wound cont amination by bacteria andlor
foreign material.
• Poor blood supply to the wound edges due to the extent of the traUrll a.
• Other factors indude irradiated tissue. certain systemic diseases like di abetes. AIDS etc.
A BASIC COURSE IN SUTURING TECHNIQUES
May I repeat . The Apprentice Doctor® Suture Course and Kit is not intended to sltlstitute the dinical
training of students but rather to offer a firm foundation and an opportunity to experience hisfher initial
learning curve in an imitation situation - so as to fill the studentwi!h confidence when he is faced the
real clinical
practical Projects A to L. guidelines are given regarding distanoes. spacing of sutures and needle
sizes. These indications are only average guidelines and will vary a bit depending on the specific area of
the body one is suturing.
Each of the following variables WI·" influence the choice of suture, neede and suturing technique·
• The relative cosmetic importance of the wound site
• elastic skin (neck) versus non-elastic skin (scalp)
• Skin covering soft tissue structure like muscles (chest and thigh) versus skin covering booe (the shin)
• Skin covering specialized stn.Jctl.lres (the nose and eClrs) general covering (the Clnd
• Skin covered by hair (scalp) versus hairless sltin (palms of the hand)
• Thin skin (the ears) and thick skin (soles of the feet)
• Tough skin (around the umbilicus) and soft skin (the eyelids)
• Blood--rich skin (nose) versus skin with a less pleoteou5 blood supply (lower
• variables like age, access to medical medical history etc.
• Wound variables e.g. abrasioo, depth of laceration, neat or ragged wound edges. contamination, infection etc.
In the final analysis the student will be gaining experience by suturing real wounds on real patents. There is no
to the clinical teaching srtuation and skills transfer from experienced clinici ans to students.
PROJECT A - HOW TO PLACE SUBCUTANEOUS SUTURES
Learn the technique forpJacing cootinuous subcutaneous sutures
IMPORTANT NOTE:
• In ALL the Projects - 81 uneven numbers represent the needle going Nlto the tissues and 81 even
numbers IlIpresenllhe needle emerging from the tissues
• Dotted lines represent the suture within the skin below the epithelial surface, Md Ines
represent the sutlM'e above the surface
• Handle the Imitation skin with carel After pladng sutures practice yOll" suture removal skils
(Project L). and then re-use the inclsion to practice other suturing techniques
INFORMATION
One should ideally suture wounds in anatomicallaYefs. For instance, the surgeon cuts through skin
dermis, sltlcutaneous tissue). then through a layer of connective tissue called fascia, then Ihrough
a muscle and Ihrough a 2nd layer of connective tissue to get access in removing a diseased salivary gland.
As he closes he will suture the 2nd layer of connective tissue, then the muscle, the first layer of connective
tissue. the subcutaneous tissue and laslly the skin. Helshe win aim at getting wound dosure and eversion of
the wOlrld edges (being tumed outward). AU the layers except the skin wi. require absorbable SullSe6.
(Recommend: Study the section on the Skin in The Apprentice Doctor® Basic Medical Course - jf
CROSS SECTION OF THE SKIN
Sot __ g1.o ,."
PI .... .. .. ,
, ...... '
1
Cnn_,..... 5,... _ ""',_.--,.
H ..... cv..",<} ( ..... _)
REQUIREMENTS
1. The Suture Kit
1. 1. Tissue forceps
1.2. A suture needle v.ith an eye
1.3. Suture thread
1.4. A needle holder
sk.in
2. A bright study lamp or equivalent light source
STEP 2
STEP 1
Use a needle v.ith suture material attached, cli pped to
a Needle Holder - see Project 2 and 3.
Place the skin (with the prepared:t7 em (2.5 inch) lacerat ions -see Project 4) - v.ith the long axes
horizontally positioned in front of ylJu. For seClXe the imitation skin to the table slXgical strapping!
sticky- or mask.ing tape. (You may want to WCli1< on a piece of cardboard to protect the desk). These cuts in the
skin represent surgical ineisions or traumatie lacerations. Study the diagram [A) shown below.
"".....--'''-
STEP4
STEP 3
Take the tissue forceps in yOI.J" left hand and the
Needle Holder in your right hand (thumb in the upper
eye and fOl.J"th finger in the lower e;e of the handle as
described previously) . Ensl.J"e that the needle tip is
facing forward and upwards.
Use the TISsue Forceps to gently lift and open the far side of the incisionllaceration on the skin.
STEP 5
Stan by inserting the needle in the deep side of the laceration. penetrating the tissue in an upwards direction
- letti ng the needle emerge just (1-3 mmiX inch) below the Assist the emerging needle through the
tissues with yOI.J" tissue forceps - then ±3-5 cm f ±1-2 inches of suture thread out of the incision. Re--clip
the needle holder - needle ti p facing towards you and downwards.
STEP 6
Insert the neecRe directly o p p o s ~ e the spot where the needle emerged previously. at exactly the same distance
below the epithelium directing the needle dowrrwards - aiming at taking an equivaJent sized bite from the tissue
on the opposite side. Assist the emerging neecRe and deliver it out of the tissue using the tissue forceps.
Clip the NeedJe Holder on the needle and deHver the suture thread with :1:3-5 cm f :1:1-2 inches of the free end
remaining on the surface.
IMPORTANT NOTE: Ensure tllat both ends of the suture aro either to the 18ft or to the rigllt side of the suture
loop in the tissue. If one end is to the left and the other end to the right of the suture loop, the knot wiN land on
lop 0( the suture loop - defying the object of burying the knot in the deep part 0( the wound!
STEP 7
Make a square knOl ensuring that the two tiSsue sides are broughl closely together (into close proximity). If lhe
square knOl slips add another loop 10 the square knol- always in the o p p o s ~ e direction 10 the previous loop.
altemati>.ely you may choose 10 Ue a surgeons knot
STEP 8
Cut the sutl.J"e about 3 mm (% inch) away from the knot - ensure that the tips of the cut sutl.J"e do not protrude
through the wol.J"ld.
POINTS OF INTEREST
• Eversion of the sutured wound means that the incision line is somewhat fBised above lhe skin surface.
This accommodates scar tissue fonnation - so that the I8cerstion surfsce ends up at the same level as
the rest of the skin
• Subcutan90Us sutures are placed to eliminate sereslled dead space, and fa minimize tensi{)fl {)fl the sl<Jn
sutures. It also assists in everting the incision line
• Pl8ce enough subcutaneous sutures to do the job, but always keep in mind that a8 sutures are in essence
foreign objects, so at the same time, keep these sutures to a minimum
• Both "too much dead space" as well as "/00 many sutures' wi8 increase the chances of wound infection
- so keep it to a happy metium!
• Subcutan90US sutures should alWays be Of the absortlable variety. "you need suture s/reflg/h to remain
for an extended period of time - use stBfldard Vicry!®orequivalent sutures (for shorter periods 0( time
use the 'rapir!' variety).
"".....--'''-
PROJECT B - HOWTO PLACE INTERRUPTED SUTURES
Learn (he tfJChniqlJ8 Otl how ro place /nfefftJpted sufures
INFORMATION
The interrupted suture is by far the most comrTIQn suture placed by medical professionals in a wide variety of
clinical srtuations. In general it is easy to place and with the that the wound is not compromised,
and can be closed without tension, this knot gives predictable
REQUIREMENTS
1. The SutlXe Kit
1. 1. Tissue forceps
1.2. A suture needle with an eye
1.3. Suture thread
1.4. A needle holder
1.5. lmijation skin
2. A bright study lamp or equivalent light source
STEP 2
STEP 1
Use a needle with suture material attached, clipped to
a Needle Holder - see Proj&cl 2 and 3.
Place the imijation skin (with the prepared ±7 em (2.5 inch) lacerations - see Project 4) _ with the long ves
horizontally positioned in front of you. For seCU"e the skin to the table slSgicai strapping!
sticky- or masking tape, (You may wanlto wor1\: on a piece of cardboard to prOled the desk)_ These cuts in the
imijabon skin represent surgical incisions or traumatic lacerations. Stooy the diagram [B) shown on page 78.
STEP4
B
STEP 3
Take the tissue forceps in your left hand and the
Needle Holder in your right hand (thumb in the upper
eye and fourth finger in the lower eye of the handle as
described previously). Ensure that the needle tip is
facing dOWTlwards and towards you.
Use the TISsue Forceps to gently and open the imitation skin on the far side of the incision/laceration.
PLACE THE INTERRUPTED SUTURE IN A SINGLE STEP;
STEP 5 (Option 1)
Let the needle penetrate the surface of the imitation sk.in on the far side, approximately 3 mm (X inch) from the
margin of the incision - at an Mgle of 90 degrees to the SlSface (or slightty more). let the needle penetrate
both the and the dermis. 00 not unclip the needle holder. Wrth the TISsue Forceps, evert (lift and
open { outwardly tum) the imitation skin on the near side of the incisiolVlaceration.
Insert the needle in the depth of the tissue on the near side - exactly o p p o s ~ e the spot where the needle
emerged from the far side. The oourse of the needle on t he near side should mirror the course of the needle on
the far side. Delillerthe needle completely out of the tissue including most of the suttl"e thread (leave ±J...5 em I
±1-2 inches of suttl"e thread free).
OR DIVIDE STEP 5 INTO TWO SUB-STEPS:
STEP 511 (Option 2)
Let the needle penetrate the surface of the imitation skin on the far side, approximately 3 mm (Yo inch) from the
margin of the inCision - at M Mgle of 90 degrees 10 the sl.l"face (or slightty more). Let the needle penetrate
both the epijhelium and the dermis (incllXling 1 or 2 mm of the subcutMeous tissue would be
acceptable). Assist the emefging needle t!Tough the tissues with yotl' tissue forceps - then deli ... er ±:}-S cm I
±1-2 inches of suture t!Tead. Occasionany it may be easier to pl,jl most of the suture thread through leaving
only ±3-5 em f ±1 -2 inches of the f ree end out of the skin. Re-clip t he needle holder - needle tip facing
downwards and towards you.
STEP 5b (Option 2)
With the Tissue Forceps e ... ert (outwardly tum I till and open) the imaation skin on the near side of the
indsionflaceration. Insert the needle in the depth of the tissue (on the side closer to you) exactly opposije the
spot where the needle emerged previously. Try to mirror the oourse of the needle on the two sides - ensuring
the deep part is 'Nider than the sllface part . Dewer the needle oompletely out of the tissue including
most of the suture thread (lea ... e ±3-S em I ±1-2 inches of suttl'e thread free).
PRACTICAL HINTS WHEN PERFORMING STEP SIN A CLINICAL SITUATION:
1. Place the two tips of the tissue f orceps at some distance on either side of the incision. Exert some pinching
pressure - raising the indsion somewhat - you are everting the wol.J1d, and wHI be able to traverse the
tissue from the far side to the near side in one single thrust of the needle.
2. Vllhen working in elastic tissue like the neck. ask an assistant to place a skin hook at the two edges of the
incision. and to Hft the skin hooks ~ somewhat This wiN assist w ~ h wound eversion. and the ease of suturing
the wound.

Slepe
STEPS
Tie an "Ins/rument Square Krlof - see ·Project Epsiton". Cut the loose ends: leave at least 3 mm (% inch) of
suture material beyond the knots ensuring a long enough piece of suture to fadHtate the removal of the sutl.J"es
at a later stage. On complebon. pull the knot to one side of the indsiOn line (pull away from sensitive structures
like the eyes or lips and ala of the nose).
POINTS OF INTEREST
STEP 7
Repeat steps 4 to 6 at the other vertical marlls over the
incision "ne. Place some more interrupted sutures by
repeating these steps - placing a sut lXe approximately
eVf!:ly 5mm ('I. inch) over the width of the enti re
incision. Pull an the knots to the same Side. Place
additional sutlXes if you see any gaping areas.
• A "fted surgeon, coHeague end mentor to myS6/f, Professor JoI!an Reyneke l augh/ us thaI your suturing
f9tyesents yoursifTlatuf9 when aperating. The message is - do not petfOtm a great operatiOtl and then
sign orr with messy sutuf9s. Neat suturing says something abaut yau as pefS(JIIl
• NeverpuH wound margins together under Wly sifTliflc:ant degfge ar tensiOtl . Ralher undet"mine lhe skin
somewllat, use local skin flaps or skin grafts to get skin to caver the wound surface without tension.
PROJECT C - HOWTO PLACE INTERRUPTED SUTURES WITH BURIED KNOTS
Learn file technique on how to pl8<C8 infefflJpted slifures with buried /(nots
INFORMATION
Wlen suturing sensmve organs like the tongue - you may want to CI..:Jid placing suture knots and klose sullxe
ef1ds on the surface. By burying the suture ends and knots, the patient may feel a lot more comfortabie l Use
only absorbable sutures when using this method.
The disadvantage of this technique is the fact that one is increasing the amount of foreign (sutlJ"e) material in
the tissue and as a consequence the risk of infection (suture abscess).
REQUIREMENTS
1. The Suture Kit
1.1. Tissue forceps
1.2. A suttl"e needle w ~ h an eye
1.3. Suture thread
1.4. A needle holder
1.5. Imitation skin
2. A bright study lamp or equivalent light source
STEP1.4
Follow Steps 1·4 as expl ained above (PROJECT B - HOW TO PLACE INTERRUPTED SUTURES). Study the
diagram shown below.
iii;;;iiii;;ii
STEP 5a
Insert the needle on the far side t 4 mm ('I. inch) within the depth 01 th e laceration and directing the needle
in an upward direction towards the surface on the far side. Aim for the needle to emerge about t 3·5 mm
('I. inch) from the wOl.J1d edge on the far side surface. Assist the emerging needle through the tissues with
your tissue forceps - then deliver t3-5 cm I tl-2 inches of suture ttvead out of the incision. Re-dip the needle
holder - needle tip facing towards you and dOWTlwards.
STEP 5b
Go to the near side and insert the needle:l: 3-5 mm ('I. inch) from the edge of the lacefation on the skin surface
on the near side. Direct the needle to the far side and aim for the needle to emerge 14 mm ('I. inch) into the
depth of the wound. D e ~ v e r the needle completely out of the tissue inckJding most of the suture thread (leave
:1:3-5 em f :1:1-2 inches of suture tlTead free) .
STEPS
Ensure that both ends of the suture thread are eijher to the left or to the right side of the suture crossing the
surface. (If they cross over under the sutl.J"e. the knot wWlland on top of the suture - defying he object of
burying the knot in the deep part of the wound!) Make a square knot ensuring that the two tissue sides are
brought closely together Onto close proximity).
STEP 8
STEP 7
Cut the sutlle about 1.5 mm (1116 inch) away from
the knot - ensure that the tips of the cut suture do not
protrude through the wolJ"ld.
Place another m ..... ber of sutures by repeating steps 5 and 6 above - placing a sutlle approximately every 5
mm (Yo inch) over the width of the entire incision. Place addijional sutures if you see any gaping areas.
PROJECT D - HOW TO PLACE CONTINUOUS SUTURES
Learn the technique 00 how to place continuous sutures
INFORMATION
The continuous suture is also known as ' simple running sutlXes' . lt basically is a continuous vari ant oflhe
Interrupted sutlXe (Project B). Continuous sutures can be used to close long lacerat iOns and surgical incisions
CI S well as to sec ... e a - Of fulHhickness skin grafts.
Scarring may be redured wfttl ruming sutures as compared to interrupted sutures as fewer knots are made
with continuous sutures. Continuous sutures are also indicated to quickly oontrol bleeding in the absence of
other bleeding control measures e .g. a profusely
bleeding scalp wound.
REQUIREMENTS
1. The Suture Kit
1. 1. Tissue forceps
1.2. A suture needle with an eye
1.3. Suture thread
1.4. A needle holder
1.5. l mij aUon skin
2. A bright study lamp or equivalent light source
3. An assist ant
STEP 1
Start the suture 1-2 mm (Yo inch) from the left hand edge of the prepared lacerat ion (or at one of t he posijional
marllings) on the imij at ion skin over the incisionll acerat ion. FoHow steps 1 to 5 as described in Pro}ect B to
pl ace the first Study the diagram [OJ shown below.
o :I. .;s IS a:as.:zs
•• • '1'-' • •• ••• "F
STEP 2
Tie an "Instrument Square Knot" - see · Project Epsilon' . Cut ONLY the short end (the end without the needle)
of the sullse leaving at least 3 mm (YO-YO inch) of sullse material beyond the knot.
STEP 2
Ask the assistant to hold part of the long end of the sutlSe - with mild tension (this is called
"foHOYI-up" ). so as to prevent the wound from opening spontaneously.
Proceed with the next suture loop approximately 3,5 mm (Yo-Yo inch) further away from the knot Ask the
assistant to release the suture as you proceed tightening the second suture loop

STEP 4
Repeat step 3 at intervals of 3-5 mm (Y ... % inch) I.J1til you arrive at the other wound margin.
STEPS
When you anticipate that you are going to place the last stitch - ask your assistant not to tense (follow-up) the
suture. Make a square knot using the double suture ~ n e of the pen-uHimate stitch and the remairing free end of
the suture (the end with the needle attached).
Step 5c:
POINTS OF INTEREST
STEP 6
Cut the 3 ends with a s u t ~ e Culli ng scissors leavi ng not
less than 3 mm of free suture ends.
Advantages of the slmpl. runn ing suture Include:
• QuJckerpl9Cement and more rapid closure o( wounds (oompared to other types of sutures)
• The continuous suture is easy to pla09 - even in inexperienced hands
Disadvantages Include:
• The poSSible formation of skin marks (aosshalChing) and the risk of opening (dehi&;ence) if the sulure
material breaks anywhere along the length of thel9Ceration
• It is dimculf to make fine adjustments along the suture line, and
• Elastic parts of the skin may become bunched up (do not use this to close a la09ration on an e y e ~ d for
instance)

PROJECT E - HOWTO PLACE CONTINUOUS INTERLOCKING SUTURES
Learn the /echniqlJ8 Otl how 10 place continUOIiS interlocking sutures
INFORMATION
The indications, advantages and disadvantages of the continuous interlocking suttJ"e are similar to that for the
continuous suture although the strength oflhe wol.J1d closure is somewhat enhanced as each suture sutH. lrt
gets loded in by the previous
REQUIREMENTS
1. The Suture Kit
1. 1. Tissue forceps
1.2. A suture needle with an eye
1.3. Suture thread
1.4. A needle holder
1.5. lmrtation skin
2. A bright study lamp or equivalent light source
3. All assistant
STEP 1
Start the suttJ"e 1-2 mm (X inch) from the left hand edge of the prepared laceration (or at one of the
mar1<ings) on the skin over the incisionllaceration. Fo"ow steps 1 to 5 as described in Project B to
place the first sutlJ"e. Study the d;agram IE] shown below.
STEP 3
STEP 2
Tie a dottlle ' Instrtnlent Square Knof - see 'Project
Epsilon'. Cut ONLY the short end (the end without the
neecle) of the suture leaving at least 3 mm of suture
material beyond the knot .
Proceed with the next suture loop approximately 5 mm (X-YO indl) further " i f f l ~ from the knot Belore
tightening the second loop. take the open loop from the assistant 's hand. and then put the needle through the
loop - using the needle holder and the tissue forceps. Tighten the suture thread.
STEP4
Ask the assistant to hold part of the long end of the
suture - pulling it with mild force as to assist in keeping
the WQlI1d closed (this is called ' follow-up' ).
STEP 5
Repeat step 3 and 4 every 5 mm ('I. inch) until you arrive at the other end of the wound margin.
STEPS
VVhen you anticipate that you are going to place the last stitch - ask your assistant not 10 tense (follow-IJp) the
suture. Make a square knot using the double suture Nne of the pen-IJHimate stijch and the remaining free end of
the suture (the end with the needle attached).
STEP T
Cut the 3 ends w ~ h a suture cutting sasson leaving not less than 3 mm (Yo-% inch) of free sut .... e ef1ds.
POINTS OF INTEREST
Advllntllges of locked sutures include:
• Inc:rellsed tfNlsile stTfNlgth
• can be used In wounds under moderate tension
• Useful In wounds oozing from the skin edges where I! can assist with control of bleeding (hermJstasls)
DIsadvantage:
• Running locked sutures have en Increased risk 0' impairing the microcirculatiOn in tile wound area, and
they may cause tissue slrllngulation If placed too tightly. This type of suture should be used In areas with
good blood suWly e.g. fhe scalp.
PROJECT F · HOW TO PLACE HORIZONTAL MATTRESS SUTURES
Learn too tedlnique on /Jow to plBoe norizQfltal mattress sutUfI)S
INFORMATION
Indications:
• Horizontal mattress sutures provide both strength and wound eversion, and are therefore useful with the
closure of wounds under tension
• Mattress sutures are also indicated when the operator wants to maximize the raw on raw surfaoo area.
An example;s the secure closure of an opening between 2 callmes e.g. the oral and nClSal caIIity
• These sutures may also be used temporarily as ' stay suttl"es' to approximate wound edges,
aHowing placement of e.g. interrupted or subcuticular sutures. The temporary mattress sutures may then be
removed
• To assist with wound evef!;ion - place alternating horizontal mattress and interrupted sutll"es
REQUIREMENTS
1. The Suture Krt
1.1. Tissue forceps
1.2. A suture needle with an eye
1.3. Suture thread
1.4. A needle hoider
1.5. Imitation skin
2. A bright study lamp or equivalent
STEP 2
STEP 1
Use a needle suture material attached. clipped to
a Needle Holder - see Project 2 and 3.
Use of the prepared imitation skin (see Projecl4) with the:t7 em (2.5 inch) ctJt representing a incision
or a laceration in the skin. Study the diagram IF] shown on page 96.
F
STEP 3
. . . . . . . . . . . . ..
232.$2302.3252.$2.$
Start the sutl.J"e in the region of one of the mar1<ings on the mock lacerat ion of the imitation skin. on
the far side. Follov.rlhe example on the diagram shown below_
STEP4
Evert the far side of \tie laoeration v.iltllhe tissue forceps and insert the needle - 5-10 mm (Yo to )4, inch) away
f rom the wound edge (as described previously). Now evert the near side of the laceration and mirror the COUf!;e
of the needle. aiming for it to emerge at an equal distance from the laceration edge on the near side. Do not tie
or cut the sul\lre at this stage. Move 415 mm (Yo inch) 10 t he right of this subsection of Ihe stitch (stay parallel to
the incision line) and place the second subsection of the horizontal mattress sutl.J"e like the first part - but this
time from the near side to the far side. Fonow the pattern on the template: In " 1". out "2" then in "3' and out "4",
STEP 5
Tie a double "Instnsnent Square Knor ("Project
Epsilon" ) or a Sl.I'geons knol- ("Project Zeta' )_ Cui
both ends of the sutl.l'e leaving at least 3 mm (Y.-YO
inch) of suture material beyond the knot .
STEPS
Place a second horizontal mattress suture ±3-4 mm
(Yo inch) to the right of the first suhse by repeating
Steps 4 and 5.
STEP 1
FoHow with another couple of hori2(lntal mattress
sutures - until you reach the right edge of the
laceration.
POINTS OF INTEREST
Adv/lntages:
• Improved eversion may be acflieved
• Coo be used i'J wounds under II fll ir amount 01 tension
Disadvantages:
:":
'-'
~ :": :": :": :": :":
' ,
, ,
'-' '-'
~
'-' '-' '-'
• High risk 01 producing suture m/lfks if left in place for too long - especially where the suture eXflfts
pressure 00 the skin surfllce
• High risk 01 tissue in the wound edge dying (necrosis) due to oomprc:mised blood supply - especiaNy if
they are tied too tightly. Do nor place these sutures too close to the wound edges and consider removing
the sutures liS eMy lIS possible.
PROJECT G - HOWTO PLACE VERTICAL MATTRESS SUTURES
Learn Ihe tfJChnique (¥1 how to place vertical malfress sulllres
INFORMATION
Just like the horizontal mattress suture. the vertical mattress suture e)(ceJs wijh the closure of wounds under
tef1sion. Since the sutlJ"e bites can be placed a from the wound margin within tissue,
these sutures are probably the best choice to help the closure of a wound under tension. On the down side
are the increased risk of leCllling sut ... e marks - especially if they are left for too long in the tissues.
AS a general rule, mattress sutures shouk:l be removed after 5 days - definitely not longer than 7 days. One
way of reducing the risk of leaving suture marks is the use of soft plast ic rods placed between the skin and the
surface loop of the vertical mattress suture.
REQUIREMENTS
1. The Suture Kit
1. 1. Tissue forceps
1.2. A suture needle with an eye
1.3. Suture thread
1.4. A needle holder
1.5. lmrtation skin
2. A brigh1 study lamp or equivalen11igh1 source
STEP2
STEP 1
Use a needle with suture material attached. cHpped to
a Needle Holder - see Pro.iect 2 iimd 3.
Use of the prepared imrtation skin (see Project 4) with the ±7 cm (2.5 inch) cut representing a surgical incision
or a laceration in the skin. Study the diagram [GJ shown on page 102.
STEP 3
G11111111111t1t
iii iii iii iii i i
i-i-i-ii-i-iii-i-i-'i'i'i
31131113111113
Start the suture in the region of one of the positional mar1lings on the mock laceration of the skin, on
the far side. Follow the example on the diagram shown below.
STEP 4
Evert the far side of the laceration the tissue forceps and insert the needle - about 5 mm (Yo inch) on the
far side of the lacerat ion (as described previously). Now evert the near side afthe laceration and mirror the
course of the needle, aiming for to emerge at an equal distance form the IClCeration edge on the near side.
STEP 5
Insert the needle:tS mm (% inch) from the left WQund edge on the near side and minor the c o u ~ e of the
needle on the far side of the laceration. FoNowthe pattem on the template: In " ' ", out "2" then in "3" and out "4".
STEPS
Tie an "Instrument Square Knot' r Project Epsilon") or a sll"geons knot - r Project Zeta"). Cut both ends of
the suture leaving at least 3 mm of suture material beyond the knot
STEP 7
Place a second vertical mattress suture ±6 mm
(Yo inch) to the right of the first sut lJ"e by repeating
Steps 4 to 6.
STEPS
FoHow with another couple of vertical mattress
sutures - until you reach the right side edge of the
lacerat ion.
POINTS OF INTEREST
i i
11111111111111
iiiiiiiiiiiiii
The edvantages and disadvantages d the vertical mattress suture are similar to that of the horizontal
mattress suture.
PRACTICAL HINTTO PROSPECTIVE DENTISTS I ORAL SURGEONS
As a dentist you will have to become proficient in suturing within a COIlfined cavity. Simulate suturing inside
the 0(81 cavity by l1uing a piece of sponge or cloth to the bottom ()( a plastic container ordisposable cup.
Now practice yournew/y acquired suturing skHIs by placing sutures in the sponge or cloth in the bottom of
this containerlcup.
PROJECT H - HOWTO PLACE "FAR-AND-NEAR" SUTURES
Learn the technique on how to place "far-and-new sutures
INFORMATION
Mattress sutures - in the process of everting the wound may leave the wound edge slightly open at the end of
the day. " Far-near-near-far are great with eversion, are strong, so can be used in wolrlds under
tension. In addition they will assist in closing the wound margins as they cross the wotl'ld margins twice.
REQUIREMENTS
1. The Suture Kit
1. 1. TISsue forceps
1.2. A suture needle with an eye
1.3. Suture thread
1.4. A needle holder
t .S. skin
2. A bright study lamp or light source
STEP2
STEP 1
Use a needle suture material attached. clipped to
a Needle Holder - see Project 2 and 3.
Use afthe prepared imitation skin (see Project 4) with the ±7 em (2.5 inch) cut representing a surgical incision
or a laceration in the skin. Study the diagram [H] shown below.
i- 'Hi- i ii 'i 'i i 'i'i" 'i

STEP 3
Start the sutlSe in the region of one of the positional marl<ings on the mock laceration of the imitation skin, on
the far side. Follow the example on the diagram shown below_
STEP4
Evert the far side of the laceration with the tissue forceps and insert the needle (as described preciously)
- about 8 mm r ~ inch) away from the WQund margin - on the far side of the laceration. Now evert the near side
of the laceration and aim for the needle to emerge 5 mm (Yo inch) on the near side of the laceration.
STEP 5
Insert the mm ('I. indl ) on the far side and aim lor the to elT\efge about 8 mm r--- inch) on the
nilar side of the laceration. Follow the pattern on t he template: In t o, out "'2" then in ' 3" and out "4".
STEP6
Tie a double "Instrument Square Knor r Project Epsilon") or a sl.J"geons knot - r Project Zeta"). Cut both
ends of the suture at least 3 mm of suture material beyond the knot
STEP T
Place a second "far-and-near" sullse ±3-4 mm
(Yo inch) to ltIe right of ltIe first sullse by repeating
Steps 4 to 6.
STEP 8
FoHow with another couple of "far· and-near"
sutures - until you reach the right side edge of the
laceratiOn
POINTS OF INTEREST
11
11111111111111
Far-near-neaf·fafsutures are useful when the cNniciBn wsnts Bdditional closure strength. Otoorwise the
adv8t1tages and risBdvantages are sJmUarto the hCYizontal8t1d vet1ica/ mattmss sutures
A variant of the ' Faf·near·ne8f· ' afsuture" is the "PuSey suture". In my opiniCXI it does not have any
sif11ifican/ advantages compared to the other mattress sutures and wi" therefore not be discussed 8t1y
furtl1er.
PROJECT I - HOWTO PLACE SUBCUTICULAR SUTURES
Learn fhe fechnique on how to place II continuous subcllficular sutllfe
INFORMATION
The subcuticular suture is indicated in cosmeticalJy sensitive areas like the face. It is time-consuming Clnd more
dWflCult to master compared to the other suturing techniques.
Keep in mind that cosmetic resuHs are much better when minimal tension is placed on wound edges at the time
of repaH-. The most favorabJe wounds from II cosmetic point of view are those where the long axis is parallel to
the natural skin tension lines. Repair of such a wound will reS(jt in II fine cosmetically acceptable linear scar.
REQUIREMENTS
1. The SuttJ"e Kit
1.1. Tissue forceps
1.2. A suttJ"e needle wrth an eye
1.3. Suture thread
1.4. A needle hokler
1.5. Imrtation skin
2. A bright study lamp or equivalent light source
STEP 2
STEP 1
Use a needle with suture material attached. clipped to
a Needle Holder - see Project 2 and 3.
Use of the prepared imitation skin (see Project 4) with the ±7 em (2.5 inch) cut representing a surgical incision
or a laceration in the skin. Study the diagram [I) shown below.
STEP 3
Insert the needle about 3 mm (% inch) to the left of the left comer of the laceration (and in line with the long
axis of the laceration) - aiming for the needle to emE!Jge just below the epithelium on the inside of the
laceration.
, I
I
I
- .
&epJa &ep3b

-----=
Slep 3d
STEP 4
InsM the needle just belON the epithelium on the near side of the laceration - laking a :t:3 mm (Yo inch)
of tissue - and aim for the roeedJe to emerge just below the inside the laceration. Do not aHow the
needle to emerge through the skin surface. If the needle emerges through the sk.in - puN back sHghtty and
redired the needle to remain just below the epijhelium.
STEP 7
STEP 5
Deliver the emefging needle from the near side - using
the needle holder and pull enough suture string tt"l"ough
to allow you to proceed the suturing unrestrained.
STEPS
Insert the needle just below the on the far
side of the laceration opposrte to the point where the
needle emefged from the far side of the laceration -
taking again a .t3 mm (% inch) of tissue as
described in ' Step 4".
I
&6P&':
Wor1l your to the right41and side of the laceration - altemating smaH bites of tissue on the near and far
sides of the laceration (as described in ' Step 4").
· I '
I'
Step 78 Stap 7b
STEP 8
When needle emerges within 3 mm (Yo inch) from the left edge of the laceration. inSeft the needle just below
the epithelium - but aim for the needle to emerge about 3 mm (Yo inch) away from the right edge of the
laceration emefging through heaHhy skin - in ~ n e w ~ h the long axis of the laceration.
Stap8c StapBd
STEP 9
PuH the two ends of the suture tightly away from each other and strap the loose ends to the adjacent skin 'Nith
a suitable strapping like Steri-stripS®. Alternatively. make a knot at both ends of the emerging suture thread.
Stap 9a Stap 9b
I \ \
Step 9d
POINTS OF INTEREST
Have a look at the suggested surgical incision lines in the facial area - to ensure optimum cosmetic results
after wound dosU(e. As a general rule these lines run p&!pendicular (al 00 oogl& of 90 degrees) to the
underlying muscles offacia/ expressiOn.
PROJECT J - HOWTO PLACE A PURSE STRING SUTURE
Learn the technique on how to place a purse string suture
INFORMATION
TWQ examples of where a pll"se sting suture may be used are:
• Closll"e of the colon after the remO'llal of the appef1dix and
• CloslI"e of the opering into the chest when a chest drain has been placed
REQUIREMENTS
1. The Sutll"e Kit
1.1. Tissue foroeps
1.2. A sutll"e needle wfth an eye
1.3. Suture thread
1.4. A needle holder
1.5. lmijation skin
2. A mal1\er pen
3. A bright study lamp or equivalent light source
STEP2
STEP 1
Use a needle W'ith suture material attadled. clipped to
a Needle Holder - see Project 2 and 3.
Marl< out a .tl .2 cm ( ~ inch) circle on the bottom (sponge) side of the imaation skin - see the example on the
template. Ttis circle represents either a circular defect in elast ic tissue or an opening in a hollow organ.
Step 38
J
STEP 4
Start about 3 mm ;may from the wound margin on the
near side of the Circular wound. Place a suture parallel
to the Circumference of the wound margin. Take.t3 mm
(Yo indl) bite then l e a ~ e a space of :1:3-4 mm (Yo indl)
before taking the next b ~ e . Worl< your way clockwise
or ant i-dockwise around the wound - placing f urther
sullxes - until the last suture emerges about 3-4 mm
(Yo indl) away from the starting point
STEP 5
STEP 4
Cross ltIe two loose ends over and p ~ l l t I e s e two ends
of ltIe suture tightly in opposite directions.
Tie a dol.tlle "Instrument Square Knor rProject EpSilon") Ol a surgeons knot- rProjed Zeta·). Cut both ends
of ltIe suture leaving at least 3-5 mm (Yo - Yo inch) of suttl"e material beyond ltIe knot
Step Sa Step 5b
Variation: Cui off part ofille (" go, from 8 surgical gave Bfld practice the purse string suluffJ on the ffJmaining
fingfJf slump.
POINTS OF INTEREST
Never use 8 purse string suture 'or closing round defects on the skin - espooa8y in oosmeb'cBlIy sensitive
areas - it inv8ri8bly gives poorcosmetic resultsl RattJerconv8(f rhe round defecl into an eNipse, undermine
the skin to Bileviate tension BOO close with e.g. mattress sutures.
lIWlere c8n I buy more Imitation Skin?
PROJECT K - HOWTO CORRECT A "DOG'S EAR"
How 10 gel rid of those ugly, unwelcome dog's ears
INFORMATION
A Dog's ear delect OCCI.I'S wtJen one edge 01 the wound is longer than the other. The r e s u ~ ;s an extr a amount
oft;ssue at the end of the wound in the process of beWig closed. Do not attempt to · sutl.l'e ~ away' it will not
~ . ,
REQUIREMENTS
1. The Suture Krt
1. 1. T.ssueforceps
1.2. A suture needle with an eye
1.3. Sutl.l'e thread
1.4. A needle holder
I .S. lmitation skin
2. A bright study lamp or equivalent light source
STEP 1
Use a needle wittl SUIl.I'e material attached, clipped to
a Needle Holder - see Project 2and 3.


STEP 2
Use the Imitation Skin prepared with a 7.5 (3 inch laceration). St udy the diagram shown below. Lift the
superficial layer of skin from the deeper l a y e ~ (±2.5 em long and 1 em wide) just on the one side 01 the
incision.
K
STEP 3
Intentionally plClCe a number of oblique or "skew sullxes in the incision (all in the same direction) next to the
lifted skin section. This shol,jd produce a misaligned wound closure with the superficiailayer of skin
"bunching" ~ on the one side. thus producing a so-caned dog's ear. Use a tissue forceps to lift the dog's ear
out up somewhat .
STEP 4
On the dog's ear side the incision. at the end of the
incision. make a short ±5 mm (Yo inch) mark on the
imitation skin angled at ±45 degrees to the original
incision line. Cut this incision line using either the
sharp-sharp scissors or the scalpel.
STEP 5
Apply gentle traction with a forceps (Or a skin hook) to the excess tri angle of skin to match the extended wOlrld
margin. and cut ij off wijh the scissor.! .
STEP 6
Continue placing interrupted sutures on the original incision. Now place one or two intenupted suture on the
side of the incision that formed when the smaU exoess piece of tissue was cut off. The final resun is a sutured
laceration that resembles a hockey stick.

ALTERNATIVE METHOD:
Simply perform a neat elliptical excision of the dog's ear as indicated on the diagram. Now proceed with placing
another couple of interrupted sutures.
POINTS OF INTEREST
• By making strategicaNy placed cross markings on a surgicBl incision with a surgical pen - before making
the incirion, you wiN be creating /8f1dmarks ror closure later on - 8IId thus avoid creating Dog's ears.
• With the fJJ(ceptiOfl of quite minor incirions, it is a,ways a good idea to use a surgical pen to plan your
incisioos.
• NfJed mere IntoMation on dog's ears? - trttp:llwww.dogflcts.org/tMllrlng-dog-flctl.trtm
PROJECT L - HOWTO CORRECT UNEQUAL LEVELS OFTISSUE
Learn /low to "flatten " unequallleif1lts of/issue during suturing.
INFORMATION
Occasionally - even with the best of efforts to avoid unequal heights of tissue- one may be confronted with
somewhat unequal levels of skin at the wound edge dlXing the suturing process. A common cause is the
mal-positioning of sutures in the deeper layers of the skin during a layered doslXe. tf the discrepancy is large
- rather undo the deeper sutures and redo them at the correct level. If the discrepancy is slight - the method
described below will assist you to correct the problem with ease.
REQUIREMENTS
1. The SutlXe Kit
1.1. Tissue forceps
1.2. A sutlXe needle wrth an eye
1.3. Suture tlTead
1.4. A needle holder
1.5. Imitation skin
2. A bright study lamp or equivalent light source
STEP 1
Use a needle with suture material attached. dipped to
a Needle Holder - see Project 2 and 3.
STEP 2
Use of ltIe prepared skin (see Project 4) ltIe:t7 em (2.5 inch) cut representing a surgical incision
or a laoeration in the skin. Srudy ltIe diagram ILl shown below.
L
STEP 3
l '1'1 t
I r ·1 I
I. , I .1
:> 22 :>
Intentionally place two ' unellen' surures at a distance of
± 2.5 em (1 inch) apart from each other by taking a deep
Me of tissue on the far side and a shallow Me on ltIe
near side of the incision - tie a square knot or surgeons
knot You have produoed a misaligned wound with ltIe
far wOlSld edge higher and the near one lower.
"".....--'-
STEP4
Correct these uneven edges by placing InteffiJpted sutures- but intentiOnally take a shallow bite on the far side
and a deeper bite on the near side. See the uneven heights even out as you tie the suttl"es.
POINTS OF INTEREST
• Unequal levels at the wound margin may be due to a foreign object remaining in the wound e.g. a pieoo 01
glass atter a mo/orvehicle accident. Alwuys make sure thaI you remove a/l foreign objects from the
wound before closure. A sm8l1 piece 01 glass may be difficult to find. A radiogf"aph can offen assisf in
identifying a fragment d glass.
• Unequal tissueleV'9ls may also be due /0 wound infection. As a gener81 rule. an infected wound should
not be sutured. Rather clear up the wound infection by debridement (surgcaJ excision of dead.
orcontamlna/9(/ tissue and flImov81 of foreign matter from a wound) suitable (tessings and
possibly antibiotic therapy and perform so-cared secondal)' dosure at a latefstage.
• Get more information here:
http· ·Ch02·'1ow.
do·Wounds·H./.cfm
PROJECT M· HOW TO REMOVE SUTURES
Learn /Jow to mmove sutures the C{)(roc/ way.
INFORMATION
Suture is usually an easy office procedure. The idea is to remove the sutures as soon as they have
done their job of wound closure and before they start causing suttl"e related complications like suttl"e scarring
and suture abscesses. Most patMents are somew11at apprehensive about this procedure, but the discomfort with
the removal of sutures is usually minimal- if any at aU.
REQUIREMENTS
1. Vo .... SutlXe Kit
2. Sharp-sharp scissors
3. The regular tweezers forceps
4. Imitation skin (This projed requires of Project B to G)
5. A bright study lamp or equivalent light SOtl"oe
6. YOll" reading glasses (if you are over 40 years of age or you have pJaced &-0 or thimer suttl"es)
STEP 1
Rel'l'lOVe the sutl.J"es placed previously in Proj ects B to
J. Start with the Interrupted sutlJ"es in UProject B".
STEP 2
Clean the area with a anti-septic solution
(in a clinical
STEP 3
un the knot with a forceps and pul gently away f rom
the skin and towards the wound edge.
STEP 4
Ease the one leg of the scissors Vvithin the loop - remaining as close to the skin as possible.
STEP 5
Gentty cut the and remove by pulling rt out
the forceps holding onto the knot.
STEPS
Give another qu;ck wipe with a mild antiseptic solution and apply a conservative wipe of local antibiotic
ointment
Srep 7b
STEP 7
Remove continuous sutl.J"es by carefully easing the
one leg of the scissors under each of the loops - again
remain right next to the skin Sl.J"face. Remove the suture
loops by puning all the loose ends out of the sltin.
t t
Step 7c
STEPS
Remove mattress sutures by gently Hfting the knot - then cut both sides of the knot·loop just above the skin
surface and remove by pulling the loop remaining on the skin surface
STEP9
Remove slb-euticular sutures by removing the 2 securing straps at the ends. cut one end next to the skin
surface and puH the remaining suture filament out - away and in line with the long axis of the laceration.
POINTS OF INTEREST
• A stitclJ..c:utteror 0 scalpel blade Ca"l be used os on 81temotive forcufting sutures.
• A/w8)'s worK With 0 MOfp scissors - 6flsure thot the tips remBin sherp a"ld able to cut (and not chew) the
sutures
• Ensure that you U588 forceps that slip.
• Do not test tile strength of the wOlA'ld closure 8tt9l" suture remov81- if you stretch the wound open with
eoough force it will open up 8goinl Rother ossist the immoture closure with a numberof small strappings
like
• "you 8re unsure 8bout the strength of the wound closure, conSid9l" removing alternative sutures today
- aoo the balance tomorrow.
• R&commeooed removal time in dllYs forsuwres in dirr9l"ent 8rellS 01 the body.
• Face: 3·5, Neck: 5 - 8, Sc8/P: 7 - 9, Upper extremity: 8 ·14, Trunk: 10·14. Extensorsutfoc6 hands: 14.
Lower extremity: 14 . 28.
COMPLICATIONS OF SUTURING
ilis always wonderful whEm everything goes smoothly - but in medicine it OCCasiOflflUy doesn 't ..
lets consider:
1. Stitch " tear·through"
Occasionally when placing or tying II suture, the stitch may tear through the tissue. This is always an
unfortunate mishap and will contribute to a cosmetically less pleasing resuH. Reasons offar this include:
• Placing a stitch too dose to the wound margin. Avoid this by taking a reasonable b ~ e at II fair distance from
the wound margin.
• Taking a too superficial b ~ e . Ensure that you include the f(jl thickness of dermis in the bitel
• The inappropriate use of II cutting needle. Consider using a reverse cutting needle or a round·body needle.
• Placing stitches in diseased tissue e.g. infected wound or tLrnors.
2. Wound dehiscence
See Points of Interest· Project Epsilon (p.SS· 56)
3. Stitch abscess
A small yellowish collection of puss is visible where the sutlXe emerges from the skin. adjaceot to the sutlXe
material. Remove the stitch. and cover the wound with a topical antiseptic or antibiotic ointment. All isolated
strtch abscess is rarely an indication for systemic (oral or intra--venous) antibiotics.
4. Defective scar
The scar is in the form of a groove or a dimple. The most common reason for ttis is that the operator did not
pay enough anention to wound eversion. Another possible cause would be leaving too much dead space in the
subcutaneous tissue. Suture in anatomical layers and do not suture the surface of the skin wtile neglecting to
suture the subcutaneous tissuer
5. Hypertrophic scar
The wound healing ;s somewhat exuberant causing
a ra;sed and thickened scar. Th;s may to mild
mechanical or bacterial irritation. of ltIe wound during
ltIe healing prooess or to wound dehiscence.
A Hypertrophic scar increases in size up to a point,
ltIen regresses again to some extent. Leave ltIis type
of scar for at least 6 monltls and re-evaluate for a scar
revision.
6. Koloids
A keloid is similar to a hypertrophic scar. with ltIe drtference that ij is not self-limijing. but continues to increase
in size, ltIus behaving like a true tumor, growing beyond the margins of the original wOlSldfscar. Surgical
excision or wound revision usually produces poor results and ltIe formation of a new keloid. Keloids are best
handled by the relevant professionals e.g. Dermatologists or Plastic surgeons.
7. Stitch marks
All types piercing the epiderm;s will cause small "dot-like" marlls nelct to the inc;sion line. Umit these
marks by removing suttJ"es as soon as possible without r;sking wound dehiscence. Consider using altemative
methods like wound strapping e.g. Steri-Strips®. subcuticul ar sutures or wound glue.
8. Crosshatching
Crosshatching is linear scars corresponding to pressure lines produced by the suttJ"e materi al pressing the
UIlderlyirog tissue. Avoid using inappropriate suture techriques and do nO! suture wounds UIlder terlsiOil .
9. Wound cOnlracture
V'«Iund contraction is a normal part of wound healing V'«Iund contracttJ"e OIl the other hand is abnormal and
implies d;stortion of the stJ"rOlSlding t;ssue. A contracture in areas like eyelids. fingers. toes etc. may cause
limijalion of movement of these structures. surgical incisions and naps properly and apply basic surgical
principles like aseptic technique, anatomical and physiological considerations.
EPILOGUE
Suturing in essence is a surgical procedure and is govemed by the basic principles of surgery like aseptic
technique etc. AI the end of the day we should be reminded that t'istorically. surgery has been seen as a last
resort. Let us also be reminded of the famous quotation by the farTIQus surgeon in history. Ambrose Pare
(1510-1590), W'ho on occasion remarked. " I dressed the wound, and God healed it! "
The body has healing mechanisms of its own. Most wounds if left for a sufficient period of time will close
completely/s;gnificantly on its own by the process of wolJ'ld contraction. Remember - do not suture each and
every single I ~ t l e wound - some minor cuts and bruises in esthetically lSIi mportanl areas will heal perfectly well
without suturing. Sometimes cleaning and a small band-aid strapping is the appropriate w ~ to manage a cut.
Some wounds may even heal better if left undisturbed by invasive measures ..
GLOSSARY
'.!:H.j.j:I.j:I!¥1iUii-g, Suture material that will disappear over a period of time when placed in bodily
tissue - usually due to enzymatic breakdONn
The scraping away of pari of the surfaoo of the skin or mucous membrane
' .lioF A fatal disease caused by the Human Immunodeficiency Virus with the to
sklwty destroy part of a person's immune system
!' ••••• Usually referring to ethyl alcohol found in alcoholic beverages. In high
concentrations it has medically useful antisept ic properties
===== Bodily structure.1 The study of the form and arrangement of bodily parts
'V ... :"n,,; A group of biochemical substances produces by a variety offlrlgi with the abilrty
of slowing down the growth of, or kill bacteria
A beginner or learning a trade or an occupation
i,!;Ii§;!!.":I!4§. Blood squirting, usually in a pulsating fashion, out of a blood vessel- moving
blood away from the heart
An of something natural e.g. artificial teeth
A medication for relieving pain. redudng fever and "thiming" blood
Causing minimal or no injury to the tissue
A suture attached to the end of an eyeless needle
An apparatus using steam tII"lder high pressure to sterilize medical instruments,
and equipment
The center line of a structure or body
(:111 The amotll"lt of tissue included when inserting a needle into the tissue on either
side of a lacefation
A blood blood into a wound
(.!!.i,i"3' "I'de Blood changing from a liquid to a gel state - an essential step towards stopping
the process of active bleeding
An interconnected network of fibers to form a suture. string or rope
A tough. thin cord made from the treated and stretched intestines of certain
animals and used for surgical dosure of wounds
The metric und of length equal to one hundredth of a meter
Spedfic chemical agents or drugs that selectively destroy cancefOUS (malignant )
cells and tissues
The part of the body between the neck and the abdomen
Chromic is an absorbable suture made from purified collagen. and treated with
chromic acid
A medical practitioner who does clinical work (interact with patients)
13 i3l3iiW" A group of people having a common interestls
••• A development that oomphcates any disease or disorder or OCCISS diSing or
following medical Of surgical treatment
•• The presence of harmf ul foreign or infectious material in a wound or in a
preparation
ca.pi@ii.Wi1iiii!jlW A sutlSe made from a continuous (uninterrupted) succession of stitches and
CONTRACTURE
fastened at the two ends by a knot
An abnormal reduction in the dimensions of a healing wolfld due to the
contraction of scar tissue
Pertaining to the improvement of appearance Of a physical feat ... e
Shading, malils or prominences consisting of muJtiple crossing lines
Planned courses of academk: study
Pertaining to skin
A needle with a sharp edge as viewed in cross section
Referring to a signifICant residual space (gap) the tissues of the body
foll{)\.Ying ir;ury or surgery
••• The surgical cleaning of a wound by excising dead and
contaminated tissue and the remOlial offoreign materi al
The splitbng or bursting open along a sutured line
The profession concerned with the teeth, mouth and associated structures
The layer of the skin below the epidermis contairing fibrous tissue, blood lIessels,
nel'l/es and sweat glands
•••• Pertairing to the of a person to skillfully coordinate their mOllements·
especially referring to the hands
iliB:i",!). i§"iiihW A Chronic disease in which the body is unable to properly process glucose due to
an insufficient production of f a resistance to insulin
•••• The use of electromagnetic Clnents to prodUa! heat for sealirg off blood lIesseis
by coagul ating blood and deoaturalizing proteins
li.mifJP!·lt.,I ••••• A pathological (abnormal) condition of a pall, organ, or system of the body
characterized by an identifi able group of signs or symptoms
€ To unlock or cause to become unlodled
(01&$1# .. 11 q The surgical separation or disassembling of a pall of the body to expose internal
structures
•••• An excess amount of tissue remairing at the edge of a sutured wound resembling
the e ar of a dog
;;=== A therapeutic or protectille material applied oller a wound surface
I§!M""&i1" TISsue that deforms (stretches) when an extemal force is applied, but then
returns to its original shape when the force is remolled
The use of CI needle·like probe heCi ted by electric current to destroy tissue
Emergency Medical Technician
1
111;;;;; To interlock or cause to interlock
To cause to become enthusiCistic
A dlemical substance produced by living cells whidl promotes chemical reactions
The outer (surface or covering) layer of skin and mucous membranes
To remove the contents of , or to empty
The condition of being tumed oulward
To cause to tum outwardly
1
11111111 Limbs (arms or legs)
'ji§!II$ Skin folds covering the parts of the eyeball when in the closed position
'#i:I§- A thread-like structure
01:1-1 lib Consisting of microscopic fibers
Ol-fi""" Emergency treatment of CI victim of sudden illness or injury while awaiting
professional medical care
•• All instrument similar to a pair of pincers or tongs, used for grasping. The
grasping surface is fl at or somewhat serrated
n.ld§@'R"#;!f·jM A contaminating slilstance, not usually found in the body, whidl entered the
tissue unintentionally during injury
•• A sm all bag attached to the tI1der·side of the liver serving as a temporary storing
area for bile
'3§ti§;!·iiV'iidl,ii. All agent that acts on the brain producing an absence of sensaHon or feeling in
the whole body as well as a loss of consciousness
••• A knot similar to a square knot. but with the second tie crossed in the
HEAlTHCARE
direction. which easily becomes undone
The management of the various aspects of health and illness
A blood clot within a body cavijy or tissue space
A heredijary blood disorder mar1led by the inability of the blood to clot and the risk
of excessiw bleeding
••• All infection of the liver. caused by a specific virus and by blood or
blood derivatives from a carrier of this virus
Transmitted genetically from parent to offspring
Human immunodeficiency virus. the causative agent of the disease AIDS
Pertaining to cleanliness and the prevention of infections and sepsis
I
i!!!!!!! All increase in the size of a tissue or an organ due to growth of individual celis
A copy that is si mil ar regarding certain attributes to an original
Diminished in strength. value. or quality
A measure of length equal to one-twelfth of a foot or 2.54 centimeter
A cut into the body. tissue e.g. skin or an organ - especially referring to a surgical
ru'
iii The fillger next to the thumb
IIM#ii§. Contaminated wrth a disease-forming microorganism or agent
IIb##rili if Invasion and m(jtiplication of disease-prooucing microorganisms in tissue. an
INTERLOCKING
SUTURES
organ. or a part of the body
The response of tissue to injury characterized by pain and swelling
Introducing a solution into the booy tIYough a vein
The introduct ion of a "tid into the booy by means of a needle and or camula
(flexible tube)
A modified type of continuous suture where earn suture loop is connected to the
previous suture loop
••••• A recent graduate or advanced stooent who assists with the medical or surgical
care of hospital patients
mii§;I;!ii:;i§'''1niii;lM Individual sutures (stitches) are placed. the ends are tied into a knot and both
ends are OJt before proceeding with placing next suture
Pertaining to a medical procedure where a part of the body is entered into
The gripping part of a forceps I needle holder I tweezers or similar instrument
usually somewhat serrated. crosshatched or "toothed·
••••• The formation of excessive amounts of scar tissue caused by an exuberant repair
response following trauma or a surgical incision
A fastening made by tying together lengths of string or rope. in a specific way
To cut. tear or wol.l1d
A cut. tear or wol.l1d
iiimliiiii A mirimally invasive surgical procedlJ"e that uses a flexible endoscope (camera)
to view structures in the abdomen
•••••• Catdl for fastening or connecting two parts of an object e.g. the two legs of an
artery forceps
'm'E·,Di]' •••••• A natural rubber material used in the manufacturing of products like surgical
gloves
Tying a blood vessel with a ligature during surgery to stop bleeding
A thread or suture cord used in surgery to tie off vessels and tub(jar structures
Absence of sensation or feeling in a restricted area of the body
A lerJgth of string. rope or suture material that is circular or curved to form an
OPerJlng
•••• A life threatening disease (cancerous growth) tending to metastasize (form new
growths distant to the initial srte)
A "dotmle suttEe" used to assist with wound eversion
Pertaining to the facial skeleton. including the jaws. mouth and teeth

Pertaining to the study or practice of medicine
,I i§.iia.!':ihjUi·\ An account of a patient 's past and present state of heanh
'6!§.ii3W The science that relates to the prevention. and treatment of diseases I and
MICROCIRCULATION
potions used for restoring
Blood flow through the smallest vessels of the body (venules. capillaries, and
arter ioles)
A absorbable suture material ( trade name)
A single strand of untwisted synthetic fiber used to manufadtEe suture cord
Pertaining to the production and secretion of mucus
Membranes lining interior body surfaces opening to the exterior e.g. the nose and
mouth
It lIiSii·@3iij'P/.I·i_ Making use of sevefal expefts in a nlrnber of different disciplines
'6"&13' A tissue with the ability to contract. making movement possible
'b§§.i! A small . slender device used for surgical suturing. The sharp hollow device
placed at the tip of a syringe to inject medicat ion into the body
A surgical instrument used for gripping the needle for suturing
NON·ABSORBABLE
SUTURE
Suture material requiring removal following placement - the body being unable to
digest these suture'S fibers
that resists deformation (stretching) when an extefnal force is applied
The science of providing care for sick and frail people
A non-absorbable suture fiber, manufactured from a synthetic plastic material
A liquid e.g. blood seeping or leaking out slowly through small blood vessels
Relating to abnormalities and injuries of bone. muscles and joints
iiiiiiiii .A.n sensaHon (tMJrting I suffering) usually occurring as a consequence
of injury or disease
The flexor (inside) surface of the hand
A person who is trained to give emergency medical treatment
To pierce, enter into something or make a way through something
To permeate with e.g. a liquid
A line at a right (90 degrees) to anothef line
Study of the function of living organisms and their parts
Surgery dedicated to the repair and restoration of the body, espeCially as relates
to the enhancement of appearance
A person who practices medicine or an allied profession
b-)i. i§.hR! A pre-medical degree (pre-med) is one preparing a person for entrance into
medical school
Final dosure of a wound or laceration within 24 hol.J"s after sustairing the ir1ury
A flexible surgical instrlnlent with a sharp or rounded tip used for
exploration purposes
hii-H¥ii-lW41iiiii.Jii A suture designed to close a rounded surgical defect or WQund
'i'·'333' Having an irregular or uneven surface or edge
i-).SiMi., A toothed component or tool , operating a catch mechanism, locking
movement in one direction only
•••• A forceps with a tip having a tooth-like projection for holding tissue when suturing
or performing surgery
.• JI. Pertaining to the restoration and correction of appearance and function of
defective or damaged body parts
Wrthout conscious control
A specialist in training wtlo ads as assistant to the attending specialist (term used
in British hosprt als)
'i'i1iPi "i'-llllli Restoring to health and a functional condrtion following damage or ir1ury
"'l11&13"," To restore consciousness or life (to revive) following a life threatening incident
';' "p!mi§3.i' A suture needle with a round contour when viewed in cross-section
'·iii@iJi€!.1"'1j.j¥ A suture made from a continuous succession of sutures and
fastened at the two ends by a knot
====== The skin covering the top of the human head
.. 1+"4# A surgeal knife with an extremely sharp blade used for dissections and fOf
performing surgery
A marllietl on the skin fol lowing an injury or wound that has healed
Dense, fibrous connective tissue that fOfms ove!" a healed wound or incision
A cutting tool consisting of two blades and two handles, joined by a swrvel pin that
allows the blades to be opened and closed
.. 133 iJi"·i;,ag' H";i' SutlM"ing a wound a number of days after the injury
hM·'" q
Sedation involves the administration of calming drugs to facilitate the
performance of a surgical procedure
A form in the shape of hart a circle
A bacterial infection in the bloodstream or body tissues
A saw-toothed edge I a margin notched with tooth-like project ions
E Referring to all sharp or potentially sharp surgical items like scalpel blades,
needles, glass cartridges etc.
The front part of the leg between the knee and the ankle
The process of harvesting and transferring skin from a donor to a recipient srte.
and securing it at the recipient site
Surgical incision lines W'ith directions designed to minimize scar tissue formation
The underside of the foot
A double knot in which the two loops are tied in opposite directions, used to join
the two ends of a suture or a ligature
••• Temporary sutll"es placed to approximate two sides of a wound or laceration to
assist in aligring the wound/incision correctly
STERILITY
Sterilrty indicates the total absence of infectious micro or9anisms
i .. Small plaster strips used to close minor Jacerations or to reinforce sutll"ed
SUBCUTANEOUS
SUTURES
SUBCUTANEOUS
TISSUE
SUBCUTlCULAR
SUTURES
lacerations (trade name)
A single suture
A strip of adhesive pJaster. used in attaching parts to each other
A cord used for fastening or tying
Below the skin
Sutures placed to approximate the subcutaneous layers of tissue in a wound or
surgical incision
The l ayer of tissue just below the dermis of the skin
A continuous suture placed just below the cuticular Jayer of the skin
A physician who specializes in surgery
A modified square knot - the first loop consists of a double throw
iiiiiiiiiiiiii The branch of medicine that deals with the diagnosis and trealmeot of injury,
and disease by invasive means
The surgical techrique used to close a wound or join tissues
The section of an atraumatic needle where the sutll"e connects to the needle
TECHNIQUE
The skill and procedlJ'e with which a slJ'gical procedure is carried out
1111= The act of stretching something tight
"40
m
b An infectious disease. also known as lockjaw. caused by the toxin of tetanus
bacteria (Clostridium Tetani)
1
1"1'#1.1"1'1;;;;1 Referring to an operating theatre - the room where slSgicai operations take pJace
'Me: The section of the leg betweeo the hip and the knee
"@i
lo
A cord of natural or manufactured material
"k! II? A basic step in the process of tying a knot
II:!"? !: The short thicker digit of the human hand. next to the index finger and opposable
to the other four digits
•••••• To fasten or to secure W'ith. e.g. rope or string by making a knot
•••• A section of sunxe material without a needle used to tie-off (dose -off) e.g. blood
vessels
iiiiii A collection of similar cells II.!-H. Trunk or body without the head and limbs
Ii f Ii Able to cause injury Of death _ especially pertaining to dlemicals (poisonous)
iFI3M.u '3' A tracheotomy is an operation in which an opering is made in the windpipe
(trachea)
+ii'·iip '¥1ii;lM it _ A surgeon spedalizing in the various aspects of diagnosing. managing and
treating patients
ii;l.iijM.ii!'t.iii.:.!@i The inclusion of foreign material into an abrasion Of WQund causing a change in
the color of the skin following wound healing
Wounded or
A swelling, especially referring to swellings caused by the abnormal growth of
cells or tissue.
•••• Instruments that are usually held with the thumb and forefinger and used for
handling or manipulating tissue during surgeI)'
•••• Dissecting some distance tI1der the skin's surface at a pl ane parallel to the
surface
,;;;;;;; The fibers of a suture thread becoming undone
Medicine and surgery related to animals
A braided absorbabie suture material (trade name)
The body's repair mechanisms producing slYinkage (reduction of the size) of the
WQund during the healing process
••• The side margin of a WQund or laceration

AN ILLUSTRATED HANDS-ON COURSE ON CD-ROM

Included· an 18 piece suturing Kit with all the instrumen ts and items needed to learn how to suture lace ra tions!

Learn how to care for- and suture wounds AND get your 1B-piece suture kit with real medical instruments and items - al/ you will need to practice wound suturing al home .. or wherever you are!!

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The Apprenti ce Doct or ® Suturmg Kit Is exduslvely Intended for educational purposes It Is str1ctly prohibited for use In medical situations Not Intended for treating either human or animal patients I

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__ . __ .. __ 52 . _.. __ . __ .__ .65 A bilsic cOUr"$e in wwring tedmiqUE!s.••. __ 89 ...l~ with buried knoa_. H_..01 Objectives of the COlll'$f!_...H 13 Project 3: How to dip the needle to the needle hoIder_. __ ..••. _. __ ...._. H_. _18 Project 5: How to COMtrlJ(t it rod to practke knot tying_ . __ . ____ 11 ..__ . _ .. __ .....56 Project Zeta: How to make a surgeoo·s knot (Instrument tie). __ .__ ..."'"H'"H'"H'"H' __ 2S . __ .••..__ ....•. __ .29 knot: One-hand tie .. __ . __ ...H . _ . __ Ust of MedieaIIMlJ"ument5_ ...23 ProjectNpha: A Oemtmstr... __ .••.. .• _n Project C: How to pia(e interrupted SUD..•..._ •. __ . __ ...._ •.._71 Project B: How to place Interrupted surure'S. __ . __ .. __ ... __ . __ ... __ ._ .63 ..._ .. __ ._. __ .. __ .. __ .. __ .••._ . _ _ • _ _ • _ _ . _.. __ ...••. _. __ . ...•..._.._. _ ._....re. _. Case Study .••.. -41 Projfoct Epsilon: Make a ~uare knot: InstrumMt tie . H.. __ . __ ..8S Project D: How to place continuous surures.... __ .05 Project I: F3ml~arize you~lf with the suture kit. ... _•. __ .__ ..._ . Basic prindples of wound care __ .• _.••. __ . 16 Proje<t -4: Prepare imitation skin for practicinS suwrir18_. __ ._. __ ._... __ .. __ 70 ProjectA: Haw to place subcutaneous sutures .._ •.. _. __ . __ .... _.•. __ ..•. _33 Projett Delta: Make a surgeon's knot: One-hand tie_ .• _. __ . _ .A BASIC COURSE IN SUTURING .' __ Projett Garrma: Make a ~uare kllOt. _. __ . _ _ .H.ltion of a )<juan: knot and a graM)' Projec:t Seu: Milke a $qU3._ .._ ...... _.Hazard< at work.•. __ ..•. _•. _ _ •• Project 2: Anach Suture IlUtf'rial to a Ileedle ._ ..H ••• _ _ • _ _ ••• H. __ . __ . __ . __ ..• _....••._ ...._. _.0-4 . __ ....... __ . __ .. __ .... _•......__ .•.. __ .•. __ ... . __ . __ ...•...•._ .. __ .._ . __ .. __ . __ .• _. .. __ . __ . __ .. __ ..__ ._ •. _. _03 DiKlaimer...._ .. __ . __ .• _.. _. __ . __ ._. ..._. H. _H. __ . __ .. __ .__ . _. __ ... 20 ...._ .. __ .. __ .__ .....!mot: Two-h<1M tie'H' __ "'_'_"'.. __ . __ .. __ . _.__ .. __ ... __ .... _ __ .__ .._._ .

__ ..__ .__ . _._. __ . _.__ . _..... __ .__ .. __ Project. _..__ .._. __ .__ .__ .._ . _.__ . _._105 . __ . E: How to place continuous interlocking sutures.__ . 131 Glossary.__ .._ 97 Project. _.__ .._.__ . __ ..__ .._ .__ .__ .__ .. _. __ . __ 132 .utures .__ .__ .._.__ ._._109 . __ ... __ .__ ._._121 Project. __ . F: How to place horizonCl.__ ._115 .._. G: How to place vertical mattress suwres._ ..._IOI Project.125 Complications of suturiflg __ .... __ .. __ ._.. __ .__ .. __ ... __ .__ .l manre" wwre$.__ .__ ._.__ . __ .__ ._ 93 Project.__ . M: How to rell1OV1! sutures .__ .__ . __ .__ . __ .__ ...__ ...__ . __ ..__ . H: How to place "Far-and-Near" suwres Project I: How to place $ubcuticul~r s._118 .. _.129 Epilogue_. __ .__ . _..__ Project. _. __ .__ ..__ . K: How to CO/TKt a '"Dog's Ear" ..__ .Project.__ .__ .__ Project L: How to con"@<t uroequal ieVf!is of tissue .__ . J: How to place a purse string suwre ._.__ .__ ._.

It is highly recorrmended that you invest in The Apprentice Doctor® Basic Medical Course and Kit. which wonderfully supplements The Apprentice Doctor® Suturing Course and Kitl . instruments and ilems 10 successfully practice your suturing technique.so as to fill the student wHh confidence when he is faced wHh the real life clinical sHuation . Do not skip a section because you think it is unimportant or too simple. and ensure that you understand the one section and are able 10 perform the practical projects skillfully before proceeding 10 the next section. The Apprentice Doctor® Suture Cour~e and Kit is not intended to substHute the clinical training of students but rather to offer a firm foundation and an opportunHy to experience hislher initial learning curve in an imitation situation . Basic principles are like that. • The Apprentice Doctor® Suluring Hands-on Course and Kit has been designed mainly for right-handed persons. IMPORTANT NOTES: Kindly note: For the purpose of this course the word suture will be used as the verb/noun pertaining to the closing-up or stitching-up of wounds/lacerations !incisions. Suturing techniques FOllow this specific order when working your way through the course material.PREFACE Learning how to suture wounds and lacerations requires a thorough understanding of the theory of wound ca re and the basic principles of suturing. and succeeding with the complicated stuff. Ihey appear to be simple. but one needs to understand and practice these simple building blocks before proceeding to. • This Kit contains the bulk of the information. The Apprentice Doctor® Suturing cou r se material on CD-ROM consists of 3 sections: 1. Basic Knot tying 3. Left-handed persons please exchange the lerms left and right as they occur in the lex! where applicable. Get acquainted wHh the instruments and items in the KH 2. The student also needs to reach an advanced level of pr oficiency by practicing knot tying and suturing techniques.

All Healthcare Professionals whether prospective. in training or qualified: • Medical students • Pre-medical sludents • Paramedics and EMT students • Dental students • Veterinary students • Nursing students • Surgery IntemsfRegistrars • Advanced Firsl Aid • Medics in the pract~ioners mil~ary • The Apprentice Doctors' Club Members • High school students interested in a career in medic:ine • Practicing Healthcare professionals who would like to mprove or refresh their suturing technique. • Non-medically qualified individuals with a keen interest in the practical aspects of medic:ine .and will receive lois of free advice and support to help you fulfill your dream! Dr Anion Sc:heeper s and the staff of The Apprentic:e Corporation as well as all the Apprentic:e Doc:tor c:ommunity leaders would like to wish you success with your fulure and look forward 10 being a small part of fulfilling yourdreamsl Recommended training material for. or to leam from other practicing Healthcare professionals.• TheApprentic:eDoc:tor.c:om website and corrmunity COflllliments these 2 products and gives the future Healthcare professional a chance to join groups of like-minded students with the aspiration of becoming medical professionals. You win find a suitable community in your country/state .

apply pressure to stop the bleeding.OBJECTIVES OFTHE COURSE: To equip students wijh a basic understandin g of the t heory o f sut uri ng wounds and to acquire the skiH s to confidently tie surgical knots and suture lacerations.hand t ie. todd lers and c hildren under the age of 10. a scalpel-~ke knife. Band Aid. for 60 minutes. and instrume nt tie) • Using a number of other types of suturing techniques • Correcting minor discrepancies while sut uring • Removing sutures Developed by a surgeon with more than 20 years of experience »> medical assistance.g. o Keep sharp instruments iNlay from the eyes. PLEASE READ THESE WARNINGS CAREFULLY «< • Your Suture and Dissection K~ contains sharp objects e. then leave it in an antiseptic solution e. Seek professional • Keep out of reach of babies. then wash profusely with soap and water. • Always use clean instruments. For lhe same reason gloving is recommeJlCled . needles and scissors. • The basic principles of wound care • Knot tying techniques (as related to knots used in surgery) • Surgical instruments used in suturing • Suture materials • The various suturing techniques used by medica l professionals The student should have the following skills: • Placing sub-cutaneous sutures • Placing interrupted sutures • Placing a variety of mattress sutures • Tying a square knot (two-hand tie.g .squeeze the wound for 15-30 secoocls to bleed out Impurities. and instrument tie) • Tying a surgeon 's knot (one-hand He. Savio. • The user must atways wash hisihef hands before using the k~ 10 minimize the risk of infection following acciclental irljury. The student Should on completion of this cOurse have a good understanding of. one. Rinse thoroughly with clean water then dry before raplacing ~ in the kit. Wash iostruments with soap and water after each usage session..g . then apply a plaster e. . • For aoy CUI or needle pridllnjuries . Please be edreme ly cautious and careful when using these in strumentsl • Not surtable for dlikJren under 12 yeaJl.. of agel • Supervision/guidaoce by a responsible aduft is recommeocSecl for stuclents urder 18 years of age.

No warranties are offered on the functional status or fitness for a specific application of any information. for any reason dissatisrted with your choice. instrument or item supplied in this application.tlile using any instrumenl or item or applying any information supplied with this application. Hems and information supplied in this application is conditional upon the acceptance of this disclaimer as weli as Ihe undertaking to honor the copyrighted course material. • Assume any responsibil~y for any damage oroonsequential damage related in any way to the information. The use of the inst ruments. The user takes full and exdusive ~em responsjbjl~y for the safe application of any information oontained in this application. The supplier disctaims ali liability for any direct or indirect damages .relaled in any way to the information. instrumentation or items contained in this product/application or as a result of the use thereof. The A pprentice Corp oration will be happy 10 reimburse you (less postage and shipping charges) should you wish to retum the oomplete medical as the CO-ROM in an undamaged state within a reasonable time this product. The producer or supplier of this application disclaims any responsibil~y for any medical emergencies. and instrumentation or any item contained in this application.DISCLAIMER The pr oducer or Supplier of this application does not : • Offer any warranty regarding the accuracy or correctness of any information contained in this application. The supplier accepts no responsibil~y for the malfunction of any instrument or ~em . lim~ k~ asweli of not more than 8 "Maeks after acquiring YOUR ORDER NUMBER AND THE DATE OF THE TRANSACTION SHOULD ACCOMPANY YOUR REQUEST FOR REIMBURSEMENT. • . If you are. which may arise v. medical problems or any other problems whatsoever. REIMBURSEMENT POLICY The App rentice Corp oration is confident that you will be satisfied with this product in each and every way. The user also takes full and exclusive responsibility for all safety aspects related in any way to the use of any instrument or supplied with this application. This exclusive responsibility applies equally to the user orto any person or persons being supervised by the user. Ali practical e)(ercises are performed e)(ctusively at the user's own risk.specirlc or consequential .

Anesthetists and radiologists use f lexible blunt probes to maneuver their way into specific veins or arteries in the body (for diagnostic or therapeutic purposes) . Use the small Sharp-sharp scissors to cut the suture for removal.thus: • SharjrSharp • Sharp-blunt • Blunt-blunt Sometimes scissors are classified according to function . Surgical probes (seekers) Your KH has two probes: • Sharp (straight) • Blunt (slighUy curved) Probes are also classified as: • Hollow • Solid A dentist uses a sharp curved probe to examine teeth and detect cavities.LIST OF MEDICAL INSTRUMENTS Surgical scissors Surgical scissors are classified according to the 2 blade tips .for example: • Suture cutting scissors • Dissection scissors In cerlain operations ~ is safer to carefu lly dissect your way towards an area/organ rather than cutting into the tissues with a sharp scalpel blade. Use your medium Shaqrblunt scissors for general cutting purposes and to cut off e)(cess suture material after placing a subJre and tying the knot.

but have longer jaws . Removable blades are produced In a variety of pattems and sizes. It is conmon ly referred to as a rat-tooth forc eps. Artery forceps are somewhat similar in appearance. .some with straight and some with curved jaws. designed to securely hold the surgical suture needle when placing sutures. The other forceps is ca lled a tissue forceps. { Scalpel A scalpel is a surgical knife with a fixed or removable blade (cutting area). WARNIN G: The scatJel is the most dangerous instrument in your Kit- handla with caution! Forceps A for ce ps isan instrument used in medicine to grab or 10 hold something.Skin hook Of available) A skin hook is used to lift a section of skin. to fac~itate the placement of sutures while minimizing the amount of injury to the tissues. one can facilitate eversion (having a sHghtly raised sutured laceration compared to the adjacent tissue). Needle Holder A Needle Holder is a special type of forceps. and gently lifting both skin hooks. This forceps is used for general handling and gripping of tissue or objects. The inside of the tips Oaws) are serrated to enhance gripping. By placing two skin hooks into the tissue at the oomers on the 2 sides of a laceration. Use this forceps to handle tissue when placing sutures. The tip of this forceps shows a sharpish tip Oaws) on the one leg and a v-shaped groove on the other side. You K~ contains a general-purpose twee~er-forr.eps.

4. Number 5 sutures are heavy braided sutures used by orthopedic surgeons and 11-0 sutures are micro-fine monofilament sutures used by ophthamic surgeons operating Vv'ith the aid o f a surgical microscope.7-0. These sutures are broken down by bodily enzymes. In cross section they may be round or triangular . These sutures are more predictable as regards their strength. a semi-circle or a section thereof. and are used when sutures are placed within the body. 1. Sutures may also be subdivided as braided and monofilament. As a rule. Nylon and S~k) . \/icryl""" and Monocryl""") • Non-absorbable (e.g.with a cutting edge on either the inner curve or the outer curve.meaning they do not have an eye that may injure the tissue as it traverses the tissues. The number used when describing a needle usually refers in millimeters. braided sutures are easier to tie but cause a more intense tissue reaction . The patient needs to return to the hospitalfsurgery for removal of these sutures.6-0.9-0.Sutures The main two groups of sutures are • Absorbable. 6 The needles in your K~ have a small eye on the side opposite to the tip for you to attach the suture to. 2.1). 10-0and 11-0. The length and the diameter of needles may vary considerably. These needles are referred to as "atraumatic' .3-0..8-0. Needles Needles may be slraight.4-0.0. below the skin (Chromic and Plain Catgut. Number 5-0 or 6-0 sutures are used to stitch up lacerations in cosmetica lly sensitive areas like the face. to the length Modem needles are pre-assembled w~h a su~able suture material attached to the blunt end . 3. . Atraumatic needles are manufactured in all shapes for most sizes of sutures.5-0. Suture sLtes Modem suture diameters range from thick to thin and are represented by the series of numbers 5.

More information: htlp://en. Medical Course) and glove before practicing placing sutures to make s ure that you get in the right habits from the word go. Remember you can practice your skills on a variety of vegetablesoranges. You need to become accustomed to the "feel" of working wh ile being gloved like a surgeon. bananas potatoes etc. Skin is in fact anything but gel-like in consistency.wiklpedia.orgAvikllSuture . The whHe fiber-like part oorresponds to the dermis and the thin plastic oovering oorresponds to the epithelium (the covering surface layer of skin and mucous membranes). Gloves It is strongly reoommended that you wash your hands hygienk:ally clean (see "Proj ect 00' in The Apprentice Doctor® BasK.ImitatiOn Skin A 15X 15 em imHation s kin is included in your kH. The imitation skin in your kH is more l ife-~ke compared to a number of gel-like imHation skin products available on the market.

A simple slip and his head shattered the glass top on the coffee table. Involving the whole family in games and activities. "Quickly bring me towels r he shouts. followed by game fish like barracudas and shar1<.s in their thousands . and everybody's ready to stroll down to the beach .the sardine run . The towel slowly becomes red and more saturated bright red blood. and the proposa l is accepted unanimously. stunned by screaming followed by an urgent shoul: "HELPI SOMEBODY. The first week was great. all at a beachfront venue. The weather was good and the sea was perfect for swimming.. It is July and one of the most spectacular natural events is about to occur . Dr Shipton and his family haven't caught on to the fishing thing. Suddenly they are stopped in their tracks . It is a time of re-uniting fami l y ties. but this event makes for great entertainment merely by being a spectator. So 8 a. Dr Shipton dashes to wards the flat and discovers the neighbor's 17-year-old son covered in blood .a fishermen's paradise!! Cond~ions for fishing have been forecast as optima l and hundreds of fishermen line the coasl. the prime spot is Ekhakha 's rock. Schools of millions of sardines migrate up the coast. w~h . his wife and their two children look forward to these 2 weeks of enjoyment months in advance. with their flat having an exceptionally great view of the treac herous Indian Ocean o n the East coast of Africa . PLEASE HELP!r One of their neighbors' flat door swings open with an even more urgent shout for help. They have to pass a numberof neighboring flats on their way down. "LeI's get up ea Ill' tomorrow morning and watch the fishermen reeling in their fish from the rocks: Jamie the elder Shipton son proposes.m. HetighUy drapes a large towel over the large cut in the sca lp and puts on tight hand pressure for a couple of minutes. Dr Shipton.DR SH IPTON'S HOLIDAY Or Shipton usually reserves 2 weeks at their favor~e hOliday resort forlheir family's yearly holiday.

Or Shipton writes a note to the Medical Officer at the local hospital giving him the relevant information and requesting him to take over the case. Wijh each stijch the bleeding gets tess. "Go get my first aid kitl" His wife rushes to their flat and retu rns wijh the kit. Time is of the essence. He uses another towel to clean up the wound . Or Shipton atways carries some Iocat anesthetic as wen as a coupte of packets of suture material and the relevant instruments In his first aid kit. He quickly injects local anesthetic containing adrenalin and almost ilTlllediately starts to stitch up the long 25 an (10 inch) laceration in the scalp.. the arrbulance arrives and the Paramedics rush to assist in stabilizing the patient.The pressure helps but doesnl stop the bleeding. He takes fairly large bites with the suture needle into the tissue adjacent to the laceration. Or Shipton doesnl waste Ime cutting the stitches . please keep the following in • Leave suturing 00 real patients to suitably medically qualified individuals. and ensures that the st~ches are tight by interlocking them. He has just one thing in mind . He then inspects the area for residua l bleeding. . • In an emergency cah 911 or equivalent emergency numberl • Exert diract pressure on any blooding point until help arrives.. Just then. Would you /ike to be prepared for an emergency situation /ike Professor Shipton? Here is your chance to learn how to professionally suture wounds! »> mind: IMPORTANT WARNING «< For those who are not qualified and officially registered as a medical professional.just one long continuous suture. and cleans up.the subject under discussion is the events of the moming. The patient is transported to the local hospital. to stop the bleeding as soon as possible. At long last the Shipton family is on their way to the beach .

ij has 3 beveled teeth on the inside of both sides .4 Clamp and unctamp sma ll objects tike pieces of paper or thin cardboard. 2.3 Put the thumb in the upper eye and the 4th finger in the lower eye of the handle . They can be sterilized by steam autoclaving and wiH retain their characteristics. kindly contact customer support personnel at Customercare@TheApprenticeDoctor. REQUIREMENTS Your suture Kit STEP 1 Identify the components of your suture Kij using the Rs! (provided on page 5).see picture right.light. 2. Do the jaws leave a checked pattem on the paper? . STEP 2 2.2 Havea good look at the ratchet latch (lock) mechanism . Identify ijs different parts.designed to catch at 3 levels . Our Kits are double checked for quality and completeness by our factory. durable and won'l corrode (rust ). Practice the locking and unlocking action of the ratchet tatch mechanism at all three levels. and examine~ . medium and strong locking. 1 Remove the Needle Holder from the Kit. In the unlikely event of problems. 2.com.PROJECT I .FAMILIARIZEYOURSELFWITHTHE SUTURE KIT Ensure thai your Suture Kif is completa and thai you know the names of each individual instrument INFORMATION Most metal surgical instruments are made from stainless steel-which Is strong.

. The one forceps has jaws with a serrated inner surface and lhe other one has a v-shaped tooth on th e inside of lhe jaw and a v-shaped groove on the other side (the tooth fitting into the groove).used In eye s urgery and microscopic surgery (e. veins and nerves underlhe surgical microscope) .5 Now examine lhe crosshatched pattem (photo) on Ihe inner side of the Needle Holder's jaws.meant to carefully dissect through tissue instead of cutting w~h a scalpel . STEP 3 Remove the two tweezerforceps from the set The forceps has two legs joined at the hinge. Use this forceps to gently handte ti ssue with the left hand when placing sutures. These scissors are usually slightly Apaif" ofmao SCi SSOfS curved wHh pointed.in on the inside (raw) surface . Wea r and lear will eventually cause this surface to become smoolh 0 . POINTS OF INTEREST 1.an indication 1 replace the Needle Holder with a new one. Quite a variety or scissors 98Ch with a unique purpose a.. joining smal arteries.g. Examples are: • A pair of scissors lhat can cut through stainless sleel wire . STEP 4 Have a look althe skin hook (substituted w~h a sharp curved probe .. This pattern is designed 10 firmly grip lhe sulure needle and prevent unnecessary stipping of the needlelsuture.2. Hook. the sk. available. It is used to gently lift skin during suturing . Examine th e Inside of the lips. some sets). though slightly rounded tips • Micro scissors ..used by orthopedic surgeonsand maxillofacial surgeons • A pair of dissection scissors .not the ep~helial surface.

6 a needle Suppose you land yourself up in a far-off mission hospital or a milHaryfield hospital and you only have thread and needtes with eyes .2. The needle-suture attachment is an occasional weak link. The eye part of such a needle may cause minimal damage as H traverses th e tissue.•frorrJablftdrtoola.About ( 12-18 inches) 45 em of silk suture . A surgeon is only as good as his/htJr tools.wi tt you be abte to help your patient? Leam how to attach suture material to by fa/lowing these steps: REQUIREMENTS Youwilll7fJ(Jd: . a medical professional would routinely usea needle w ith an eye (an "eye" is a s ma" hole on the blunt side of a needle where the thread is held) for suturing purposes. Modern suturing materials have pre-a ttaChed thread. One should avoid clamping the Needl e Hol der l o lhe swage of the needle as one may inter1ere wHh the secure attachment of the suture to the needle.and are thu s referred to as an " atraumatic design" (won 't cause further injury to the tissue). Pre-attached sutures allow for a smooth transHion fro m the needle's body to the swage and then to the sutu re .afrorrJabledrtoola.comi PROJECT 2 • ATTACH SUTURE MATERIAL TOA NEEDLE How 10 attach a piere of suture malerial to a surgical needle INFORMATION In past generations. Order affordable quality medica/Instruments at: http://vNlw. and on rare occasions may become undone. Order a professional suture set (IFRC specifications) : http://wWw.com! 3. Know your instruments and always use good quafty medica/ instruments. This attachment occupies about Yo inch (3 rrm) on the suture end of the needle (the swage).One no 16 semicircular needle .

Secure the Needle Holder by clamping ~ to the first ratchet. STEP 4 Open up the double thread slightly to form a loop.. . ~ STEP 3 Fotd the last 1 Y. Clamp the needte roughty in the middte of the needle's body.STEP 1 Unroll about 12-16 inches (30-40 ern) of silk suture from one of the reels supplied..inch (4 ern) of suture double and pass the double thread through the eye of the suture needle.. (Be careful when working with sharp objects). STEP 2 Remove one no 16 needle from the package using the Needle Holder. and pass the needle through the loop.

com/ .afrorrJabledrtools.STEP 5 Firmly pull th e long and short loose ends of the double th read away from the needle · thus tig htening the simple loop knot to attach the th read to the needle. Practice and permct your technique byordemg a varie ty of real prHIssembled. Needles with eyes can be l'9-used 8 couple of times under the fo//Ollring condlt/ons: • The tips remai n sharp • The needles are structura lly undamaged • They are properly sterUized • Re-use for not more than 4-6 times 2. pIlf-packed sterle surgical sutures from http://www. POINTS OF INTEREST 1.

somewhat close r to the Swage.HOWTO CLIP THE NEEDLETOTHE NEEDLE HOLDER Learn the technique on how to properly clip and secure 8 noodle onto a Needle Holder INFORMATION Note : One shou ld Idea lly clip the Needle Holder onto the mld-section of the needle .PROJECT 3 . Avoid Clipping the Needle Holder onto eaher the Tip or swage sectior'lsl TIP MIO DLE 3~ SWAGE S U TURE The various parts ()( 8 surgic:aJ OOfJdIe REQUIREMENTS • The Needle Holder • One no 16 Needle with sutu re material attached (see Project 2) 6 .

STEP 3 Use your needle holder to clip the needle. The Gloves serve as a surgical barrier between operator and patient. Present the needle to the needle holder with th is tweezers forceps . patients w~h Hepat~is B and HIV infections . STEP 2 Follow the principle of minimal handling of sharp instruments and ~ems.g.avoid clipping it onto the swage third (may damage the s uture-needle attachment) or the tip third (may damage the s harpness of the tip) of the needle. Double gloving is advised for high-risk patients e.femllarlze . secure the lalc h mechanism (bien for the first or second "click") . • Hospitals have specific protocols on whst steps yourse/fwifh your hospilafs protocol to take foIlowtJg accidental needle iljurles . and provide protection from accidental needle injuries. Use a tweezer-forceps to remove one no 16 needle from the package using your left hand.STEP 1 Wash your hands. STEP 4 Inspect the suture part and ensure that ~ is untangled and w~ hout any knots. POINTS OF INTEREST • Accidental needle injuries are common CBUseS for fhe accidenfal contraction o f HIV 8fId Hepafltls B infrJcUons • All patients should be considered catTf6rs of infective diS88seS. dry and put on a pair of gloves (Project 00 of The Apprentice Doctor® Basic Medical Course).

inch) . inch) -.• H8IldIe sh8fP objects and instruments once - mil/mlze the handling of sharps.representing the ep~helium • A white fibrous layer (3 rrm I Y. Many iljurles il thestre occur during the trensfer of ' sharps" from 'sharps ~ one person to /he other.corresponding to the subcutaneou s tissue This patented im~ation skin.PREPARE IM ITAT ION SK IN FOR PRACT IC ING SUTUR ING Prepare a piece of imitation skin for practicing your suture technique INFORMATION The Imitation skin for practicing your suture technique consists of three layers . Surgeons should get into the hab~ oftamg scalpels and assembled needles Itlr suturing diroctly from /he ins/ruman/tray.just like natural skin : ' Asuperficia l covering layer(t mm) . .as indicated in the diagram. PROJECT 4 . and sutures can be placed. is a remarkably effective substrate for practicing suturing techniques. Divide the im~ation skin sheets into 3 sub-sections and draw 3 straight lines of:l: I I ern (4 Inches) on ~ . and removed repeated ly along the same incision linel REQUIREMENTS ·A4 X 6 inches (10 • The large scissors • The small scissors · A pen and ruler (a skin mar1(er pen and ruler is available in The Apprentice Ooctor® Basic Medical Kit) It 15cm) piece of imitation skin STEP 1 One sheet of imitaHon skin can be used tocreate:l:3 imitation lacerations.corresponding to the dermis • A spongy layer (6 mm I Y. provided with The Apprentice Doctor® How to Stitch-Up Wounds Kit. Do no/ uk the assisting theatre sister to hand you such sherp mtrumentsAtems if at a/I possible .

POINTS OF INTEREST • In a recent survey in fhe state of Virginia. • A neat suture technique will go a long way to avoi<Wlg ugly scarmg and the need for SClJr revision by a plastic surgeon • The saying ·practice makes perfect" Is especialy true In this regsrd/ .A. (The larger scissors win be more e ffective In cutting the ImltaUon skin). STEP 3 Divide each o f these halves into quarters and draw another two short 5 mm (Yo inch) vertk:a llines in these regions. These cuts represent surgica l incisions or traumatic lacerations in the skin.STEP 2 Make a short 5 mm (Yo inch) vertk:alline at 90 degrees to t he straight lin e . STEP4 Use the s harp-sharp scissors and push oneblade into the sk in at one end of the horizontal line and cut the ful thickness of the skin along the straig ht Hne up to the end of the Hem (4 inches) horizontal line. Repeat the same procedure w ith the other 2 lines to create 3 initation lacerations. laoerations and confusions ranked as the third most common f98SOII why patients visited their remly physiclen. minor sorr tissue injurias like abrasions.in th e middle of each of these 3 lines. (These lines win enable you to check the alignment of the skin following closu re of the laceration wHh sutures).S. U.

It follows that to become a proficient operator you will need to gain a good understanding of the theory.about 3. TOGETHER with frequ ent pradicing of the techniques of suturing. is both an art and a science.5 em (1 Y.HOW TO CONSTRUCT A BARiRODTO PRACTICETHEVARIOUS TECHNIQUES OFTYING KNOTS INFORMATION Suturing. . STEP 2 Bend a 90 degrees leg downwards on both sides.PROJECT 5 . along the same long a~is lines. REQUIREMENTS • Masking tape or equivalent • The inside cardboa rd cy~nder from a toilet ron or a tissue ron • A table or suitable worKing su rface to practice making knots STEP 1 Cut 2 parallel lines along the long axis of the cardboard tube . like the other fields of medicine. inch) width on both sides.

masking tape or "sticky· "" Alternatively simply place your ruler on two spa08fS on thB two ends (tfIB suture reels wiN wcrkjust me frx this purpose) and strap it down with meskmglstidfy tape POINTS OF INTEREST 1.5 (Yo) indl foot outwards (again 90 degrees to the leg) STEP 4 Position the rod-like tube w~h h long axis horizontany in front of you.g.on the table or worldng surface you intend to use to practice making knots with adhesiYe tape e. and about 30 em (6 inches) away from the table·s edge. Interesn·ng what useful purposes a pi&08 01 trash can serve/ 2.let us 8pply it in 811 the 8f888 01 our lives! .STEP 3 Bend a 1. Get into a habit of thinking along fflese lines: • 'Mlat useflJ purpose can an item MIMI befOIl! trashing it? • Can it be recycled? • Think "green "! Don't be wastefull 3. "Preventioo is too best ruro " . Strap the foot down .

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a surge of bright red bloodl "Suction!! Suction!!" He shouts . Abdominal swabs!! .but it is obvious that the bleeding is much too fast for the suction to handle.. He wWI have to make a larger incision to access the bleeder and stop the bleeding. Vision becomes Impossible and now is the time for quid<.THE SURGEON'S KNOT Dr Buys is in a 'NOnderful mood.. instrumentation in place and now for the careful dissection . ard the anatomy is not as clear as he expected. Artery forceps!r Dr Buys knows that he needs to abort the laparosoopic-camera procedure via the small buttonhole incisions. Itlhe patient looses more lhan a ce rta in amount of blood... · Scalpel! Diathermyl . Suddenly . just he and the Missus. she will go into slI"gicai shock and may die! . second and third incisions. He has done so many over the years and has become qu~e an expert "I'm sure I will be able to remow this ganbladder with my hands behind my back ! he jokingly remar1ls .. This is Friday afternoon and he has booked a short operating list because he plans to go on a special weekend . a routine laparoscopic removal of a diseased gallbladder. The inflammation has caused q~le a bit of scar tissue. life-and-death decisionsl "l ets open up!r He shouts to the senti sister. "Thirty minutes and I am out of here!" he remar1ls.. First. This is the last case .

" He ties off the bleeder with an amazing amount of finesse and ease. Apologies fOf any Inconvenience! " The wold "throw' fflfflrs to a single basic subunit ortightened loop of a knot. "Tie sutll"e". • Left" hand8c1 individuals . amazingly relaxed now. "Remove artery. Would you like to Imowhow to make a surgeon 's knot? NOTE: • 'NfNJr side' fflfflrs to the affla cJos&r to you and the tsrm ' farsioo " refers to the area away from you .At last the bleeder has been identified and everybody takes a brief sigh of relief.kindy substitute the wold ' right' for 'left' and visa"versa . Dr Buys continues . .

" • Description of a square Mot: The square knot consists oftWQ ' throws ' or turns ol the \WQ ends of a pieoe of string/rope. in a prescribed way. • A thorough understanding of knots is essential before you can proceed with acquiring sul~ing skills . such as rope .PROJECT ALPHA -A DEMONSTRATION OFA SQUARE KNOTANDA GRANNY KNOT View a demonstration oftoo diff6f€J(lcfJ between a Square knot and a Granny knot INFORMATION • Definition . REQUIREMENTS You wiN need: • The colored and wt'ite string (induded in the krt) Follow these sleps.knot: The American Heritage® Dictionary defines a knot as: "A fastening made by tying together lengths of material. In the text I w~1 refer to the colored part as the ' colored sedion " and the uncolored part as the ' wMe section' . STEP 1 Color the one lip al the siring with a bright color using a color ink pen.

colored tip crosses over wMe tip . wilh the colored end to your left-hand side and the whije section to your right-hand side.2 STEP 2 Plaoe the section of siring in the form of an incomplete circle in front of you. The opening of the loop sholAd face to the far side. b $lep ... () STEP 5 Colored tip goes into loop from beneath and out of the loop to the top .5 $l&P (.colored tip cross over white tip . STEP 4 Colored tip goes into loop from be neath and out of the loop to the top . Close the loop to some extent. .. Copy the following descriptions with the piece of string: STEP 3 Fj~t throw .. STEP 6 Second throw . Close the loop to some extent.

STEP 8 Co mplete the knot by tighte ning it . Malle It "granny knot" by fol/owing these steps: FOllow Stop 2 to Step 5 a s with the squ are knot (a bove) -. ~-I } Step 7b . • . STEP 6 Second throw ..pul ~ rg the colored end to the left with yo ur left hand and the while end 1 0 the right 'Nith your right hand.r -. ""'" c) St8p6 SIt/p 7e I Q c.:.. ~ ~--~ .w tite tip crosses over colo red tip .. ) ~ ) Step 71t Step 7b Step 8 STEP 7 Vl'tite tip goes into loop from the to p and o ut of the loop 10 the botto m (unde r the red sect ion).: STEP 7 White tip goes into loop from beneath (under the red section) and out of the loop to the to p. C II /.

while a square knot tightens on itself. m e Is a form 01 tfIXb"lB-making that uses knott61g tathfJ( thllfi weaving or knitting. A gronny knot tends to slip where a square knot would have held. . 2.STEP 7 Complete the knot by tightering ~ - pl. A gtanny Knot tends to tighf9fl on the tissue. 1. NI /lC r. PeoplfJ proc.j~ng the colored end to the left with your left hand and the white end to the right wrth your right hand.ticing the art form of macrame are usuaNy real knot experts. Fis/1ermen and sailors are oIten masters in mak61g a variety 01 secure knots 3.

flile maintaining an extended index finger. REQUIREMENTS You wiN nood: • The colored and white string (induded in the • The cardboard tube constructed i n Project 5 • Good lighting k~) Follow these steps: STEP 1 Prepare the cardboard tube and strap ij to the tabletop or 'NOrlling surface using maskingfsticky tape (see Project 5) STEP2 Slip the string IXIdemeath the cardboard tube with the colored end towards you (near side). Bring the white end from the back a nd let ~ come over the index finger. granny knots slip. Be sure not to tie a Granny knot (this knot res(jts when you tie two throws in the same direction). v. Square knots hold. STEP 3 Let the open palm of your left hand face you . and the white end away from you (far side). . Close the bottom 3 fingers around the whrte string .PROJECT BETA · MAKE A SQUARE KNOT-TWO·HANDTIE INFORMATION The Square Knot is the recommended knot for tying most types of sutures. cross the PClIm down to the lijtle finger.

curentty in yo ..STEP 4 Hold the colored strand in yo . .nto the bop. Bring the colored strand folWard and let it cross over the wt"ite strand (and thus over the left index finger). between your left thumb and index finger. Rotate your hand back to the starting position.. and let go of it with your right hand. STEP 5 Let the tips of the left thumb and index frlger touch to endose the two stands of string. STEP 7 Plaoe the colored end. bringing the colored tip through the loop. Keep holding the colored end with your right thumb and index finger. rolate these fingertips away from you.mb and index finger... right hand between your right ttu. right hand. moving your thumb tI1der the tWQ strands and . STEP 6 Wlile keeping the tips of your left thtJ"T1b and index frlger touching .

11We releasing it from your right hand. Hold the tip in the palm of the left hand by closing the bottom three fingera . and plaoe ~ between the left thumb and index finger.J' left hand over the colored sect ion and touch the tip ofthe left thumb . Make a 'J-shaped opering between your left thumb and index finger. STEP11 Rotate these mgertips dowrM'ards and tONards you . STEP 10 Wrth the right hand. and place ~ between yOI. Place the index finger of yOI. bring the colored strand tONard you .11ite strand.11~e tip over with the free end hanging down wh~e the palm past the Httle finger. and pull the the thumb into the V v. . The hand is held in a position almost as if pointing a gun. STEP9 Let the open palm of your left hand face towards your right-hand side.enclosing the two strands. The left index finger goes under the two strands and into the loop.STEPS Pull the wMe section towards you with your left hand and the colored end away from you with your right hand. crossing over the v.J' left thumb and index finger v. thereby tightening the Kst tlYON of the knot. Take the colored tip held by the right hand.

"ff you tie the mot too tightly you might not be able to untie the knot for mousing the r ope! KEEP IN MIND If required you m.ww.htm 4.vetupenn...ufl.9dwcoufSevideos/acinAierNid. http://cBl.asp 2.y add .9du.\. rotate your left hand bact allowing the left thlKrlb and index finger to carry the colored strand through the loop. double Square knot STEP 14 Practice the tecmiQUe of making a square knot usirg the two-lland tie methoo before proceedirg to the one-hand tie technique. http://www.htm 3.thereby completing the second throw of the square knot. STEP 13 "Loosely tighten the knot by moving your left hand holdirg the · Me tip away from you and your right hand .ae.rr::sed. (See video dips of II number 01 knot tyfng techniques): 1.nolhertwothrO'n't (by foIowI~ Steps 3-131I1gaJ1 In I1el8st J1Btance you will have tied. Grip the colored strand between your right thumb and index finger and release ~ from the left hand.uWvideo_album_dips_menu_basicsKiNs. uWmachsIT1-1 .STEP 12 'll!hile maintaining your grip on the oolored end between your left thumb and index finger. holdirg the colored tip toward you . http://\.edw'surgery/5000.HTML .edu.\.vetmad.ww.. http://\.ae..nother 1IYow (by foIowi'Ig Steps U) Of.fCsfKI.

. ONE-HAND TIE Take 11 couple of short cuts towards lying 11 square linot more efficiently INFORMATlON I will describe 2 methods to tie a ' one-hand square knot ' .PROJECT GAMMA . T he basic difference between a ' !wo-hand tie square knot' aOO a ' one-h and tie square knot' is the time ~ takes to make a secure knot . seconds may be the difference between life and deathl REQUIREMENTS You wiN need: • The colored and white string (inc l uded in the krt) • The cardbo ard tube oonstructed i n Projec t 5 • Good lighting METHOD I Follow thes e steps : STEP1 Prepare the cardboard tube and strap tabletop or wor1\ing surface using ~ 10 the masking~ticky tape (see Project 5) STEP2 Slip the string I.occasionally during s~gery. a~hough a couple of right-h anded persons may find Method 2 somewhat easier and \lisa Yef!ia .remember .J1demeath the car<board tube with the colored end towards you (near side). and the white end away from you (far side).MAKE A SQUARE KNOT. Method 1 will surt most right·handed persons and M ethod 2 most left handed persons.

J"Ider the wtile section. Let the wtite section cross over the palm 's side of the open 3rd to 5th finger. crossing over the index finger of the left hand and over the whrte section of string forming an ·X·. between your middle linger and thumb . STEP 6a Open (extend) the index finger mailing sl.. STEP 5 Bend (flex) the index finger of the left hand around the colored strand and rotate rt under the white strand held by the middle trlger and thumb .draping the string over the tip of the index finger.STEP J Hold the colored end in your right hand between your index finger and thumb . and the wtite section in yOI.J"e that the white section of string stays on the nail's side ofltis finger. of the left hand with the wtite tip hanging down past the Irttle rJlger. . STEP 4 Take the colored section to the far side. and extend the index finger . Place the index finger of your left hand I.J" left hand.

looping ij over the 3rd to 5th fingers of the left hand.t throw of the knot. STEP 9 Bring the oolorOO section from the far side to the near side. and the colored section in your right hand between your index finger and thlnlb. STEP 7 Pull the v. . and over the v.pulling the w tite section of string through the loop.11ite section towards you with your left hand and the colored end ffflay from you with your right hand and tighten the fi r. STEPS Hold the wtite end in your left hand between the tips of your index finger and thlS!1b .STEP 6b Rotate the hand ..11ije section of string to form an ' X' shape. AUow the whije section to cross over the palm 's side of the open (extended) 3rd to 5th fingers of the left hand.

NOTE W requM-"ed you may a:ld . Stra9hten the index finger again W'hile puning the white end through the loop in a rotating motion.nolhBr bop (by following Stepe 4-a) or two (by fGlowlng Step' -'1-13) ag.n STEP 12 Practice the tectmique of making a square knot using the one-hand tie method before prooeeding to the instrlnlent tie tecmique . tightening the second (throw) part of the knot . . Take it now between the tip of the index finger and thumb.STEP10 Bend the middle finger of the left hand and hook it around the colored section and beneath the W'h~e section of string. Step 10C STEP 11 PIJI the colored end towards you with yo~ right hand left and the W'hite section away from you with yo~ hand.

STEP4 Bring the wh~e section to the near side .ingfsticky tape (see Project 5} STEP 2 S~p the sbing ISIdemealh the carclXlard tube with the colored end towards you (near side). and the whije end away from you (far side). STEP 3 Hold the colored end in your right hand between your index finger ard thumb w~h the tip pointirg upwards. and the W'hite sedion in your len hand. Ensure thai the colored string passes over the palm 's side of the open (extended) 3rd to 5th fingers of the left hand. Rotate the right hand sHghtly so the palm is facing you .over the colored section of string crossing over it in the form of an ' X ' across \tlese 3 finge rs.METHOD 2 Follow these steps: STEP 1 Prepare the cardboard tube and strap ~ to the tabletop or wor1<ing surface using mask. between your index finger and thumb . .

and hold the colored end betweeo the middle and fourth finger. STEP7 Pull the white section to.STEP 5 Bend the middle finger of the right hand.vards you wah your left hand and the colored end aw~ from you with your right hand and tighten the first throw of the knot . and dose (flex) it around the white section and under the colored section of string held by the index finger and thumb of the right hand. STEP 6 Open ttis finger. Take the colored section between the thumb and index finger of the right hand. . while rotating the hand pulling the colored end through the loop.

crossing over the index finger of the right h(Mld and over the colored Xsection of string forming an o shape. STEP 10 Bend the index finger and flex ~ around the wMe section and undemeath the colored section held in the right hand $lap 1111 Sr8J)11b . Plaoe the index finger of your right hand under the colored section. and extend the index finger -looping the string over the tip of the index finger. and the wMe section in your left hand between your index finger and thlSllb . STEP 9 Take the wtite section to the far side.STEP 8 Hold the colored end in your right hand between the tip s of your middle finger and thumb (the tip of the colored end hanging down on the palm 's side past the I~tle finger).

.-qu'-ed you may add anolhltf loop (17f folONJ1g Slepl3-7) OftwO(by foIowir1'i1 Steps 3-12) aogall1 '-.") aasic Square Knot r ~J . Addirional Loops ~3 . Hold the colored end between the tip of the indel( finger and thumb of the right hand.STEP 11 Straighten the index finger again while pulling the colored end through the loop in a rotating motion. AtkWonal Loop "- r 2. STEP 12 Pull the colored end towards you with your right hand and the wMe section away from you wrth your left hand. . tightening the second (throw) part of the knot NOTE If . .

PROJECT DELTA· MAKE A SURGEON'S KNOT. I will describe 2 methods to tie a ' one-hand surgeon 's knof . Note: ronsecutive loops should always be in the opposite direction to the previous loop to secure the knot thus avoiding • Different suture materials vary in the numberor loops requinnl unmveljng. REQUIREMENTS You wiN need: • The colored and wMe string (incl uded in the • The cardboard tube cons!n.J"geon 's knot is a VefY important knot. ONE·HANDTIE Th e technique on how to tie a socure Surgeons Knot with your hands INFORMATION A surgeon 's knot is essent ially a squ are knot with the difference th at the tIYead is passed twiCe tIYough the first loop. Master ~ thoroughly -yol. The sl. • "a square knot slips add another loop (ortlKl orthree) to the square knot.Jcted i n Projec t 5 • Good lighting k~) .STEP 13 Practice the technique of maKing a square knot using the one-hand tie method before proceeding to the instrument tie technique. • Mos( surgeons can tie a one·hand tie square kn ot in their sJeep. Method one w~1 suit most right-handed persons and Method 2 most left handed persons. although a couple of right-handed persons may find Method 2 somewhat easier and visa versa . • Both hands are used to 00 a On&·hand tie knot. K8f1p on practicing until if becomes almost reflexive actilXls. The nOlJ-cominant hand plays a psssi\19 roll and the dominant hand an active roll during the knot tying sequence.J" patient's we"·being or even hi s /her life will depend on yo~ level of skill when tying this knot Like w~h the square knot.

METHOD I Follow these steps: STEP 1 Prepare the cardboard title and strap it to the tabletop or wor1<ing SlStace using masking/sticky tape (see Project 5) . - STEP 2 S~p the string underneath the cardboard tube wrth the colored end towards you (near side ). between your middle linger and thumb .d rap ing the string over the tip of the index finger. Let the white sedion cross over the palm 's side of the open Jrd to 5th frlgers of the left hand with the white tip hanging down past the little finger. Place the inde)( finger of your left hand under the white section. and the white section in your left hand. crossing over the index finger of the left hand and over the wMe section of string forming an · X". and extend the index finger . STEP 3 Hold the colored end in your right hand between your Index finger and thumb. STEP 4 Take the colored section to the far side . and the W'hrte end aw~ from you (far side). • . .

~ puHing the white section of . Rotate the hand string through the loop. $fop Ijb STEPS Open (extend) the index finger making sure that the white section of string stays on the nail"s side of thiS finger.STEP 5 Bend (flex) the index finger of the lert hand around the colored strand and rotate it under the white strand held by the middle filller and thumb .

S/ep 7c STEP 8 Straighter! this finger. and in a rotating motion pull the wh~e end ttl'ough the loop for a seoond time . then bend this finger around the colored section of string. STEP 9 PuH the white section towards you with your left hand and the colored end away from you w~h your right hand and tighten the first throw of the knot • . Place the inde~ finger afyaur left hand into the loop again.STEP 7 00 n at close the l oop. and rotate it under wtl~e section of string held by the index frlger and thumb of the right hand.

and over the white section of string to form an oX'" shape. . and the co lored section in your right hand between your index finger and thumb . Straighten the index finger again while pul~ng the wMe end through the loop in a rotating motion. Take ~ now between the tip of the index finger and thumb .STEP 10 Hold the wMe end in your left hand between the tips of your indruc frlger and thumb . STEP 11 Bring the colored section from the far side to the near side. S/6P 12. looping it over the 3rd to 5th frlgem of the left hand.. Let the white section to cross oYer the palm 's side of the open (extended) 3rd to 5th frlgem of the left hand. S/6P 12b STEP 12 Bend the middle finger of the left hand and hook ~ around the colored section and beneath the white section of string.

you may add ~other loop or two to prevent the knot from unl1lvellng STEP 14 Practice the tech rique of making a square knot using the one-hand tie method before proceeding to the instrument tie technique. • . NOTE: If requw-ed .STEP 13 PI. tightening the second (throw) part of the knot . METHOD 2 Follow these SlepS . and the whrte end away from you (far side). STEP 1 Prepare the cardboard tube and strap ~ to the tabletop or worl<ing surface using masking/sticky tape (see ProjectS) STEP 2 S~p the string undemeath the cardbo ard tltle with the colored end towards you (near side).jI the colored end towards you with your right hand and the white sedion away from you with your left hand.

STEP 3 Hold the colored end in yOI. STEP 5 Bend the middle finger of the right hand. Step 6b .over the colored section of string crossing over it in the form of an ·x · across these 3 finge rs. between your index finger and thumb .J" right hand between your Index finger and thumb wijh the tip pointing upwards. and the wMe section in your len hand. STEP4 Bring the while section to the near side . and close (flex) it around the while section and under the colored section of string held by the index finger and thumb of the right hand. Ensure that the colored string passes OVe!' the palm 's side of the open (extended) Jrd to 5th fingers of the len hand. Rotate the right hand s~ghtly so the palm is facing you .

Take the colored section between the thtl'l1b and index finger of the right hand. then bend this finger. Place the middle finger of your right hand into the loop again.STEP 6 Open this mger. STEPS Straighten this finger.jHng the colored end through the loop. and hold the colored end bet. and rotate it under colored section of string held by the index finger and thumb of the right hand.punirlg the colo red section through the loop for a second time STEP 9 PuH the white section towards you with yotl' left hand and the colo red end fNoIay from you wrth your right hand and tighten the first throw of the knot. STEP7 00 n ot close the loop. while rotating the hand pl. while rotating the hand .Yeen the middle and fotl'th finger. and hold the colored section between the middle and fourth finger. • .

11ite section and lXldemeath the colored section held in the right hand . STEP 11 Take the v. Hold the colored end between the t ip of the indel( finger and tllJmb of the right hand.11~e pulHng the colored end through the loop in a rotating motion. crossing over the index finger of the right hand and over the colored section of string forming an ·X· shape. and extend the index finger -looping the string over the tip of the index finger.straighten the index finger again v. and the between yo~ v. STEP 12 Bend the index finger and flex it around the v.11ite section to the far side.STEP 10 Hold the colored end in your right hand between the ti ps of you r mid dle fi nger and thumb (the tip of the colored end hanging down on the palm 's side past the little finger). Place the index finger of your right hClnd lXlder the colored section. .11~e section in your left hand index finger and thumb .

tightenilll the second (throw) part of the knot . Add~iomi Bas. .STEP 13 PI. Step 13c NOTE If reqUired you may Idd anothe.jI the colored end towards you with Y0lJ" right hand and the white sedion away from you with Y0lJ" left hand.r loop ortwoto prevent the knot tom unllIwilng '------_-:> 1.<:: Squ8ffl Knot Loop • STEP 14 Practice the tectl1ique of making a square knot USilll the OIle-hand tie method before proceeding to the instrument tie technique.

. cut off the n96{l1e befcxe (Xoceeang to avoid injury to yourself orto the assistant. A routine case does not e:xist! Every case is unique and every patient is special. • Anticipate complications in even the most simple of surgical procedures. off bl96{lefS. and thoo inspect the stump for oozing or residual blooding.• The surgeon's /(fIot is too most basic skill as far as tying knots is concemed.tie rhe first tie. If you USB a suture with a pre-assembled need/e. • No neede is required for e tie suture. It is used to tie to tie interruptfW sutures as well as a number or other suturelo1ots. • WIlen tying off a bleeder . proc600 with enother knot or preferobly two. most cases (depaooing on the size • In most cases an absorbable suture is required when tying d ( a bleederin the depth of tissue. If you /lave SUOCfJ&ded in stopping the blefWing. A "2-0. 3-0 (Y 4-0" broided absabable suture like ' VlCryJ®" wiN be appropriate in of the blood vessel being /lfW elf).

Master the tectYlique well using imitation skin . The wh~e section should be shorter than the colored section.~ is never a good idea to practice on real patients. and the white tip away from you (far side) . The surgical instruments become extens ions of the clirician 's hands. The latch mechanism of the needle holder must be unengaged at the stage. STEP 2 Hold the needle holder in your right hand (SM Project 1. making the whole process of suturing more efficient and adding finesse to the procedure. . REQUIREMENTS You wII/need: • The colored and wh~e string (inc~ded in the kit) • The cardboard tlXle constructed in Projec t 5 • Gllod lighting Follow th ese st eps: STEP 1 Slip the string IXIder the cardboard tube with the colored section towards}'Qu (near side).PROJECT EPSILON· MAKE A SQUARE KNOT. Ste p 2) STEP 3 Place the needle holder parallel to the cardboard tube 'Nith the tip pointing to the left hand side.INSTRUMENTTIE INFORMATION The majority of square knots that most medical professionals tie in their careers are done with a tissue forceps and a needle holder.

STEP 5 The colored section of the string is brought f rom the near side. down and back to the near side .STEP 4 Hold the colored section on the near side between the thlnlb and index finger ofthe left hand. STEP 6 Open the jaws of the needle holder and grasp the white section on the far side. Sl8P ?a Sl8P ?b . close to the tip of the string.thus making the first loop. over the needle holder. Engage the ratchet latch mecharism (listen for the first or seoond ·c lick").

Hold the colored section on the far side between the thumb and index finger of the left hand.jI the white sedion tONards you using the needle holder and the colored sedion away from you using your left hand. Engage the ratchet latch mechanism (listen for the first or second · c~d\ " ) . .thus making the second loop. TlQhten the knot . down and back to the far side .STEP 7 PI. over the needle holder. STEP 11 Open the jaws of the needle holder and grasp the whrte section (now 011 the near side) close to the tip of the string. STEP9 Place the needle holder again parallel to the cardboard tube with the tip pointing to the left hand side. STEP 10 The colored section of the string is brought from the far side.thus completing the first throw. STEPS Unclip the latch of the needle holder and release the white tip .

g.some bodily structures are quite thin and friable. Let"s talk a bit about wound dehiScence (ir simply means the wound edges open up again).deal with the Infection issue first! • Placing the suture too close to the wound edge • Youusoo the wrong suture technique e. • You tied an inappropriate knot .g.g. Reasons forwoond dehiscence. certain sitll8tiOns a revflJ'"S6 wttitlg neede in • Too much wound tensioo .e. placing II continuous suture instead o f interrupted ormattress sutures . 8 granny knot instead of 8 5qll8re knot • Tffe knots wflJ'"e tied too laxly (loose) • You used an inappropriate suture material.STEP 12 Pull the white section aw ~ f rom you using the needle holder and the colored section towards you using your left hand. Tighten the knot . STEP13 Unclip the latch lock of the needle holder and release the white tip . a thin mooo·fllament svture in a tensioo area • You used a cutting neooe and should have l15ed a foond body neede .thus completing the second throw. Consider l15ing so always remember a cutting n89(l1e can actuaNy cut tlr"oogh tile tissoo like a sca lpe/.e.the truth is that wound closure should Id9B/1y be tension free • You clf"JS(Jd an Infected wound .

r • A foftJign object was inacNeflantJy left in me wound • A large blood clot (hematana) formed and is forcing the two wound edges apart • An arterial bleed is putting an Immel1S& amount of Pf9SSUftJ within the wound and facing it open . The wMe section should be shorter than the colored section.HOW TO MAKE A SURGEON'S KNOT (INSTRUMENTTIE) Th e technique Dfl how to tie II secure Surg90ns Knot using surgica l instruments INFORMATION A s~geon 's knOl is essentially a square knOl wrth the drtference that the thread is passed twice through the rr st loop. .e.g.always control bleeders first by appropriate means .• You ftJmoved the sutuftJS too SOOO - espfJCiaUy in thelowef 9JCtftJmities. Hgation (tying blgedng vessels off) or diattlf~rmy (bum them closed with an electric current) • You are placing sutures in a ma&gnant tumer. One of the atffibutes o( a cancerous gro'Nth is the Joss o( cellular acfJesion PROJECT ZETA . The surgeon 's knot is a vel'l important knot Master it thoroughly -your patient 's well-being or even hiS Iller life wi ll depend on your level of skill when tying thiS knot. REQUIREMENTS Yo u wHln eed: • The colored and white string (included in the kit) • The cardboard tube constructed in Project 5 • Good lighting Follow Ihese sleps: STEP 1 S~p the string under the cardboard tube with the colored section towards you (near side) . and the white tip away from you (far side).

down and back to the near side) .STEP 2 Hold the needle holder in your right hand (see Project 1.thus making the first loop. The latch mechanism of the needle holder must be disengaged at this stage. STEPS The colored section of the string is brought from the near side.. over the needle holder. .. STEP 4 Hold the co lored section on the near side between the thumb and index fi~er of the left hand.. Stap 2) STEP 3 Place the needle holder parallel to the cardboard tube with the tip pointing to the left hand side.-rapping the string around the needle holder a second time . over the needle holder. down and back to the near side .. Repeat this manelNer again (the stri~ is brought from the near side .

Shtp 7b STEP 7 PuN the white section towardS you using the needle holder and the colored section aw~ from you using yOIS left hand. Tighten the knot . close to the tip of the string. . STEP9 Place the needle holder again parallel to the cardboard tube with the lip pointing to the left hand Side. STEPS Unclip the latch of the needle holder and release the white tip . Hold the colored section on the far side between the thumb and index finger of the left hand.STEPS Open the jaws of the needle holder and grasp the wMe section on the far side . Engage the ratchet latch medlanism (listen for the first or second "dick").thus completing the fi"st throw.

Tighten the knot . sr8p 128 srtJ'12b STEP 12 Pull the white section away from you using the needle holder and the colored section towards you using your left hand.thus making the second loop.STEP 10 The colored section of the string is brought from the far side. . STEP 13 Unclip the latch of the needle holder and release the white tip . o~r the needle holder. STEP 11 Open the jaws of the needle holder and grasp the w11ite section (now on the near side) close to the tip of the string. Engage the raldlet latch mechanism (listen for the first or second ·c~cI().thus completing the second throw. down and back to the far side .

coml3000-2376-10000062 .bu.download.comfplt:lllcfU SENGlKno.edufcolJ"sevideosfadinltiesvid.-Tyin~M8nU8l .download Acrobat Rooder from : http://'INIW.htm A classical worK for any student 01 suturing is an e-book with the title: Suture Materiats &.ac.asp Other useful sites: http://'lNlw.ufl.uklvideo_album_clips_menu_baslcskllls.html . Techniques by EthJcon®download It for free from this adr79SS: http://'INIW.vetmed.rcsed.edufsurgeryf5000. pdf You wiD need an Acrobat Readerto open this document.velupenn.More Information : VISit tfJs sire for great video-clip demonstrations 01 tying surgical knots: http://'lNlw.edwDeptiContenlaspJC?DepartmentID=69&PagelD=S734 http://cal.jnjgateway.edu.htm http://'INIW.bumc.

Sitting on the couch in the family room Michelle notices blood on Rhode 's ear "Rhodt'!.Iet's go and have some cold drink MicheNe"... •. "Rhode and MiChene! Please dOll" chase the dog around in the house r And one of those inevitab~ outcomes . They place it in a container. "We have a yOlSlg lady w~h part of her ear missingr Time is of the essence and Dr Wright prepares to do a fIJI thicl<ness skin graft using the severed piece of skin as the graft. Local anesthetic . for a change.-ing .. . fix this ~ke new: He reassures the patient and mother and starts with the procedure.. we'. suh. there 's blood on your ear!" RhO(!!) calls her mom .J"e. cleaning . .... and rush atrIa the emergeocy department of the hosp~alt Dr Wright has been on call for the past 12 hours and makes himself ready to lea-..PERFORMING A SMALL MIRACLE! RHODE'S EAR One of those routine warnings by parents . "How many stitches win I get?" Dr W"ight talks them through the procedl... "Don't look so worried. "Please Doctor.' lhe sister requests.Rhode falls and hits the side of her head on the coffee table ' Ouchr she exclaims.e foMowing a fairly qtiet shift. who disoovers to her horror that a chunk of skin is missing from the top of her daughter's earl Michelle goes back to the coffee table and discovers the missing piece of sltjn. not thinking much aboullhe incident. "Will the injection hurt7". and dressing. . add a small bloclI of ice.

nstructions. Don't hesitate to call me if you have any problems whatsoever r And off go the patched-up patient and relieved mother ... and then the patient and mother receive . Use His ointmeot liberally on the wOlSld twice daily and please retum in a week for the removal of the stitches. Would you like to be a/je to master how to care for woonds? .The job is neatly done. almost reflexively. ' please don't wash your hair or allow water on the wound for 48 hours.

big or small.he specia~zes in repairing gas C)'linders .and nol any type of welder . The Paramedics finally arrive . TWQ inspection checks before JCllTleS gets to do his job. Jake. at first " It is 3 p.m. His co-workers do what they can to stop the bleeding until the paramedics arrive.a bit lazy on occasion he decides to take a couple of short-cuts . and then I can head home". tiM the cylinder v. Now some people work welllSlder preSSlXe and James is one of those. then the presslXe testing and final qua"ty control checks . resuscitate him.the soft tissue and bones of his face are in pieces and there 's blood everywhere . Then it all happens in less than an instant .and another 4 kiSses to his 4 children James Junior. Today is a high-intensity day . ..then flush them w~h air and finaHy. Only 10 cyHnders to go.30 gas cy~nders to repair.and yes ~ seems to work Qut wei .even the large tanker types fOf transporting truckloads of various types of gas. The protocol is clear .ured . James thinks as he starts repairing the fine metal crack bottom on the of this cy~nder.HAZARDSATWORK James is off to work . .a massive explosion as the 7 mm (Yo inch) metal casing explodes due to a tnellie of flammable gas remaining in this specific cylinderl James is seriously ir. but James's friend Jel'TY is not . · Smooch!" He kisses his wife lebea goodbye . "See you guys tonight' he exclaims as he doses the door.first empty the cyHnders . Susan and Baby Brad.ilh N~rogen before starting with the welding. and evacuate him to the trauma un~ . James is a wek:ler .

'>YE!lIthe Hp is fi)(ed and presentable! Would you like to know how to repair major soft tissue lacerations? Well stick to the basic principles of surgery and practice. He requests urgent blood tests . He then plCll1s a layered closure and 45 minutes later . administers IV fluids and a number of life-saving medications. an Ophthalmic surgeon. removing all foreign material and dead tissue . practice and practiceli . the Plastic Surgeon starts cleaning.Miraculously. James' friend Jerry emerges physically uninjured from the tearoom . because he took the libeny of stretching his 15--minute tea break to 20 minutes. but applying the basic principles of wound care . Next. tying them tightly to control the bleeding. The TralmCl Surgeon secures the airwCly by doing CI tracheotomy and this is followed by a ml. CI PlClstic cmd ReconstructiYe The lo'>YE!r ~p is in rags . The trauma doctors place a number of interrupted sutures.jtidiscipHnary repClir invotving NelSosurgeons.. a MClxiRofaciCli Surgeon and Surgeon. James is profusely bleeding from tis scalp lacerations. irs attto theatre . T he anesthetist worlls like a machine to keep James alive.

THE BASIC PRINCIPLES QFWOUND CARE Know your patient If time allONs .take a good medical history. Is your patient allergic to cel1ain local anesthetics.but always take a medical history - (see ' Project o· afThe Apprentice Ooctor® Course and Kit). if not lake a brief medical history . proper lighting of the operative field offering the surgeon with optimal visual sensOlY input ! Anesthesia The surgeon w ~1 make decisions regarding local anesthesia f general anesthesia andfor sedation. jerking screaming or Cl'Jing ali the time.but no blind surgeon yet Scn~ sisters have a saying that the good surgeons are those who always complain abOut the light .might be true. antibiotics and pain medication. You cannot do your best for a patient who is jumping. antiseptic solutions or plasteMtrapping? Does he/she suffer from duone diseases like Diabetes or bleeding disorders? Are they using any chroric medications? E<c Good vision (good lighting) Fact is that medical schools have trained a number of blind physicians over the years . . because ltIe whole success of the surgical procedll"e depends on good.

Careless suturing may cause more unsightly damage compared to the original wOl. Exoess suture material must be discarded in a container purposed for biological waste . Sterile instruments and suture material must be used. Soil remaining in the wound wiN cause a traOOlatic tattooing (very difficiAt if not impossible to remove at a later stagel) If necessary brush the wound w~h a bristled brush combined w~h a m~d soap solution e . Excessive bleeding wig decrease your ability to see what you are doing . the operator wiR try to suture living tissue to living tissue . The needle must be discarded in a suitable biological sharps waste container). Do not leave empty spares filled with air. Control Bleeding Bleeding can be reduced with suctioning and gentle sponging.and good vision is the first princip le of surgery! . Most antiseptic solutions win cause damage to the f riable exposed tissue cells. Savlon. Avoid using strong antiseptic preparations for cleaning the wound . Dead space may fi~ up with blood clot and will contribute to the formation of excessive scarring. A flat forceps slipping all the lime will cause more damage compared to a toothed forceps handled gently. Handle Tissue Gently Always perform surgery .J1dt Use a toothed forceps to handle the skin (gently touch though). and controlled by Electro-cautery (electrical buming ) and suturing -ligate (tie-off) larger veins and arteries and use tight sutlJ"ing over bleeding areas (w~lin reasonable limits of course). Leave Minimal Dead Space 'M1He suturing. In most cases a normal saline solution will be sufficient to clean an l. Leave the least number of sutures buried in the depth of the tissue .J1infected wOl.Aseptic Technique Complete steriHty of the operative field is not attainable.J1dl Remove All Foreign Material The removal of all foreign material must be efIsured. so( pl ant material etc.g . Remove all pieces of glass. Dead spaces produce wonderful opportun~ies for bacteria to proliferate and to cause infection.witlin the limits of getting a secure closure .showing respect for living tissue. blood or tissue fluid. Remember that suturing materials although necessary are considered by the tissue as foreign material.

General bleeding and an InabU~y of blood to clot may be due to a numberof medications e.Set Up I Repair Of The Wound A ssessing Results.J")'l The acronym LACERATE will help you to stay on track when confronted with a laceration to repair. Do take a thorough patient history before you start treating the injl. Liver disease. a number of blood diseases. L ook At The Wound. anti-cancer medication (chemotherapy may reduce the blood platelets which are essential for nonnal blood clotting to OCCll") and alcohol consumption (not an infrequent finding with patients reporting to a hosp~al's emergency section).g. HemophiHa (a hered~ary absence of clotting factors in the blood). asplm (pain-killer). Assess It A nesthetic Considerations Cleaning The Wound Equipment . Anticipate Complications Tetanus Immunization Status Educate The Patient Regarding Wound Care .

• Tghl sut~es will assist in contromng bleeding (seOJring hemostasis). and at the same time minimizing the formation of trIsightly scar tissue . arterial bleeds in the depth of the wound etc.closure within the first 24 hours • Secondary cIoslXe . . A closed wound is much less prone to wound sepsis than an open wound. Primary closure of wounds should be the norm in most cases .THE REPAIR OFWOUNDS Goals For Suturing Wounds Optimal wound care aims at maximizing functional restoration as weN as optimizing the esthetic resu~ . An open WQund leaves the severed sensory nerve endings open .g . Suturing a wound may assis t the heallhcare professional with 3 immediate goals.thus increasing pain. Suturing a wound wiR optimize the IralSllatized tissue's chanoes of retaining its blood supply.l1d (deeming and cutting away dead tissue and-or foreign material) to be necessary. Exceptions to the NJe would be higNy compromised tissue where the medical professional anticipates debridemeot of the wol.wound doslXe more than 24 hours after the injury. Wound closure is divi ded into: • Primary closlXe . FlI'lher contamination from the outside environment is also reduced oonsiderablyl • Reduced pain. • It reduces the chances of wound infection. These goals must occur within the limits o f maximum patient safety and patient oomfort (a calm patient e:o:periencing the minimal amoll1t of pain and discomfort). II is not a substitute for normal bleeding ~gating control measures e .

.

SuI~ing should be passive . contamination . AIDS etc. Common reasons for sutured wounds to opeo up again are wound cont amination by bacteria andlor foreign material.lres (the nose and eClrs) ve~us general covering (the tQ~Q Clnd e*em~ies) • Skin covered by hair (scalp ) versus hairless sltin (palms of the hand) • Thin skin (the ears) and thick skin (soles of the feet) • Tough skin (around the umbilicus) and soft skin (the eyelids) • Blood--rich skin (nose) versus skin with a less pleoteou5 blood supply (lower • Pat~nt extrem~~s) variables like age.Jctl. The Apprentice Doctor® Suture Course and Kit is not intended to sltlstitute the dinical training of students but rather to offer a firm foundation and an opportunity to experience hisfher initial learning curve in an imitation situation . guidelines are given regarding distanoes. These indications are only average guidelines and will vary q~te a bit depending on the specific area of the body one is suturing.it will break downl • Sepsis.do not stretch tissue and try to close the wound under tension . spacing of sutures and needle b~e sizes. certain systemic diseases like diabetes. . medical history etc.so as to fill the studentwi!h confidence when he is faced re al ~fe w~h the clinical s~uation. access to medical facilrt ~s . depth of laceration. infection etc. • Poor blood supply to the wound edges due to the extent of the traUrll a. abrasioo.Reasons for wound breakdown: • SuI~ing under tension. neat or ragged wound edges. • Other factors indude irradiated tissue. neede an d suturing technique · • The relative cosmetic importance of the wound site • Sut~ing elastic skin (neck) versus non-elastic skin (scalp ) • Skin covering soft tissue structure like muscles (chest and thigh) versus skin covering booe (the shin) • Skin covering specialized stn. A BASIC COURSE IN SUTURING TECHNIQUES May I repeat . In the final analysis the student will be gaining experience by suturing real wounds on re al patents.g. D~ing practical Projects A to L. There is no subSl~ule to the clinical teaching srtuation and skills transfer from experienced clinici ans to students. • Wound variables e. Each of the following variables WI·" influence the choice of suture.

Md so~d Ines represent the sutlM'e above the epithe~um surface • Handle the Imitation skin with carel After pladng sutures practice yOll" suture removal skils (Project L)." PI . .. the surgeon cuts through skin (ep~helium . As he closes ~ . then through a layer of connective tissue called fascia.<} ""'...-"··-· 1 Cnn_... and then re-use the inclsion to practice other suturing techniques INFORMATION One should ideally suture wounds in anatomicallaYefs. ..H+-'''' 5.. then Ihrough a muscle and Ihrough a 2nd layer of connective tissue to get access in removing a diseased salivary gland.. (Recommend: Study the section o n the Skin in The Apprentice Doctor® Basic Medical Course ... ~""". the subcutaneous tissue and laslly the skin. Helshe win aim at getting wound dosure and eversion of the wOlrld edges (being tumed outw ard).jf ClVa~able) CROSS SECTION OF THE SKIN Sot _ _ g1...o .. the first layer of connective tissue._..--. .PROJECT A . _ ) . AU the layers except the skin wi.81 uneven numbers represent the needle going Nlto the tissues and 81 even numbers IlIpresenllhe needle emerging from the tissues • Dotted lines represent the suture within the skin below the epithelial surface.. sltlcutaneous tissue). '~~~1 . require absorbable SullSe6.. H. ( .. he will suture the 2nd layer of connective tissue.HOW TO PLACE SUBCUTANEOUS SUTURES Learn the technique forpJacing cootinuous subcutaneous sutures IMPORTANT NOTE: • In ALL the Projects ......". . then the muscle. dermis... For instance.. ~ .. _ cv.

5 inch) lacerations -see Project 4 ) .or mask. cli pped to a Needle Holder . "".see Project 2 and 3. (You may want to WCli1< on a piece of cardboard to protect the desk).4.ith an eye 1.REQUIREMENTS 1. The Suture Kit 1. 1.--'''- .in 2.. 5 . A bright study lamp or equivalent light source STEP 1 Use a needle v. STEP 2 Place the im~ation skin (with the prepared:t7 em (2. For stabil~y. A suture needle v. seClXe the imitation skin to the tab le w~h slXgical strapping! sticky.ith suture material attached...ith the long axes horizontally positioned in front of ylJu. l m~at io n sk.3. A needle holder 1 . Suture thread 1. Tissue forceps 1.ing tape ..v. Study the diagram [A) shown below. These cuts in the im~ation skin represent surgical ineisions or traumatie lacerations.2.

needle ti p facing towards you and downwards. STEP4 Use the TISsue Forceps to gently lift and open the far side of the incisionllaceration on the im~at io n skin .J"th finger in the lower e.J"e that the needle tip is facing forward and upwards.J" tissue forceps . .J" left hand and the Needle Holder in your right hand (thumb in the upper eye and fOl. Assist the emerging needle through the tissues with yOI.e of the handle as described previously). Re--clip the needle holder . Ensl. penetrating the tissue in an upwards direction .then de~ver ±3-5 cm f ±1-2 inches of suture thread out of the incision. STEP 5 Stan by inserting the needle in the deep side of the laceration.STEP 3 Take the tissue forceps in yOI.letti ng the needle emerge just (1-3 mmiX inch ) below the ep~helium .

STEP 6 Insert the neecRe directly oppos~e the spot where the needle emerged previously. .aiming at taking an equivaJent sized bite from the tissue on the opposite side. Clip the NeedJe Holder on the needle and deHver the suture thread with :1:3-5 cm f :1:1-2 inches of the free end remaining on the surface. at exactly the same distance below the epithelium directing the needle dowrrwards . Assist the emerging neecRe and deliver it out of the tissue using the tissue forceps .

If one end is to the left and the other end to the right of the suture loop.always in the altema ti>. a surgeons knot .IMPORTANT NOTE: Ensure tllat both ends of the suture aro either to the 18ft or to the rigllt side o f the suture loop in the tissue. If lhe square knOl slips add another loop 10 the square knol. the knot wiN land on lop 0( the suture loop .defying the object of burying the knot in the deep part 0( the wound! STEP 7 Make a square knOl ensu ring that the two tiSsue sides are broughl clo sely together (into close proximity).ely you may choose 10 Ue oppos~e direction 10 the previous loop.

J"e about 3 mm (% inch) away from the knot . "you need suture s/reflg/h to remain for an extended period of time ... 0( time "".--'''- .STEP 8 Cut the sutl.. {)fl so that the I8cerstion surfsce ends up at the same level as th e sl<Jn so at the same time. This accommodates scar tissue fonnation the rest of the skin • Subcutan90Us sutures are placed to eliminate sereslled dead space.J"ld. POINTS OF INTEREST • Eversion of the sutured wound means that the incision line is somewhat fBised above lhe skin surface..use stBfldard Vicry!®orequivalen t sutures (for shorter periods use the 'rapir!' variety).so keep it to a happy metium! • Subcutan90US sutures should alWays be Of the absortlable variety. but always keep in mind that a8 sutures are in essence foreign objects. It also assists in everting the incision line • Pl8ce enough subcutaneous sutures to do the job.J"e do not protrude through the wol. and fa minimize tensi{)fl sutures.ensure that the tips of the cut sutl. keep these sutures to a minimum • Both "too much dead space" as well as "/00 many sutures' wi8 increase the chances of wound infection .

PROJECT B . A suture needle with an eye 1. that the wound is not compromised.4. lmijation skin 2.5 inch) lacerations . A needle holder 1. Tissue forceps 1. . A bright study lamp or equivalent light source STEP 1 Use a needle with suture material attached. Suture thread 1.5.2. STEP 2 Place the imijation skin (with the prepared ±7 em (2. In general it is easy to place and with the prerequis~e resu~s. seCU"e the im~ation skin to the table w~h slSgicai strapping! sticky .or masking tape . this knot gives predictable REQUIREMENTS 1.1. Stooy the diagram [B) shown on page 78. and can be closed without tension . For stabH~y.HOWTO PLACE INTERRUPTED SUTURES Learn (he tfJChniqlJ8 Otl how ro place /nfefftJpted sufures INFORMATION The interrupted suture is by far the most comrTIQn suture placed by medical professionals in a wide variety of clinical srtuations. clipped to a Needle Holder .see Proj&cl 2 and 3. The SutlXe Kit 1.see Project 4) _ with the long ves horizontally positioned in front of you . (You may wanlto wor1\: on a piece of cardboard to prOled the desk)_ These cuts in the imijabon skin represent surgical incisions or traumatic lacerations.3.

STEP4 Use the TISsue Forceps to gently ~n and open the imitation skin on the far side of the incision/laceration. let the needle penetrate both the ep~helium and the dermis. PLACE THE INTERRUPTED SUTURE IN A SINGLE STEP. Ensure that the needle tip is facing dOWTlwards and towards you. approximately 3 mm (X inch) from the margin of the incision .B STEP 3 Take the tissue forceps in your left hand and the Needle Holder in your right hand (thumb in the upper eye and fourth finger in the lower eye of the handle as described previously).at an Mgle of 90 degrees to the SlSface (or slightty more).in on the far side. STEP 5 (Option 1) Let the needle penetrate the su rface of the imitation sk. 00 not unclip the needle h older. . Wrth the TISsue Forceps. evert (lift and open { outwardly tum) the imitation skin on the near side of the incisiolVlaceration.

. Delillerthe needle completely out of the tissue including most of the suttl"e thread (leave ±J.Insert the needle in the depth of the tissue on the near side .5 em I ±1-2 inches of suttl"e thre ad free ). The oourse of the needle on t he near side should mirror the course of the needle on the far side.exactly oppos~e the spot where the needle emerged from the fa r side...

then deli. approximately 3 mm (Yo inch) from the ma rgin of the inCision . Let the needle penetrate 0 both the e pijhelium and the dermis (incllXling 1 or 2 mm of the subcutMeous tissue would be qu~e acceptable)..ensuring the deep part is s~ghtly 'Nider than the sllface part..l"face (or slightty more).. Dewer the needle oompletely out of the tissue including most of the suture thread (lea . Occasiona ny it may be easier to pl. Try to mirror the oourse of the needle on the two sides . ..OR DIVIDE STEP 5 INTO TWO SUB-S TEPS: STEP 511 (Option 2) Let the needle penetrate the surface of the imitation skin on the far side .. Re-clip t he needle holder - needle tip facing downwards and towa rds you.at M Mgle of 90 degrees 1 the sl..jl most of the suture thre ad through leaving only ±3-5 em f ±1 -2 inches of the f ree end out of the skin.ert (outwardly tum I till a nd open) the imaation skin on the near side of the indsionflaceration. Insert the needle in the depth of the tissue (on the side closer to you ) exactly opposije the spot w here the needle emerged previously. er ±:}-S cm I ±1-2 inches of suture t!Tead . Assist the emefging needle t!Tough the tissues with yotl' tissue forceps . STEP 5b (Option 2) With the Tissue Forceps e .e ±3-S em I ±1-2 inches of suttl'e thread free).

J1d .PRACTICAL HINTS WHEN PERFORMING STEP SIN A CLINICAL SITUATION: 1. and wHI be able to traverse the tissue from the far side to the near side in one single thrust of the needle. Place the two tips of the tissue f orceps at some distance on either side of the incision. Exert some pinching pressure .raising the indsion somewhat .you are everting the wol. .

2. and to Hft the skin hooks the wound . ~ an assistant to place a skin hook at the two edges of the somewhat This wiN assist w~h wound eversion. ask incision. and the ease of suturing &£ Slepe . Vllhen working in elastic tissue like the neck.

J"es at a later stage. Cut the loose ends: leave at least 3 mm (% inch) of suture material beyond the knots ensuring a long enough piece of suture to fadHtate the removal of the sutl. pull the knot to one side of the indsiOn line (pull away from sensitive structures like the eyes or lips and ala of the nose). .see ·Project Epsiton" . On complebon.STEPS Tie an "Ins/rument Square Krlof .

Place additional sutlXes if you see any g aping areas. Neat suturing says something abaut yau as pefS(JIIl • NeverpuH wound margins together under Wly sifTliflc:ant degfge a r tensiOtl . Professor JoI!an Reyneke l augh/ us thaI your suturing f9tyesents yoursifTlatuf9 when aperating.placing a sut lXe approx imately eVf!:ly 5mm ('I. POINTS OF INTEREST • A "fted surgeon. coHeague end mentor to myS6/f. use local skin flaps or skin grafts to get skin to caver the wound surface without tension . Pull a n the knots to the same Side. . Place some more interrupted sutures by repeating these steps . The message is .do not petfOtm a great operatiOtl and then sign orr with messy sutuf9s.STEP 7 Repeat step s 4 to 6 at the other vertical marlls over the incision "ne. Ralher undet"mine lhe skin somewlla t. inch) over the width of the enti re incision.

Suture thread 1..HOW TO PLACE INTERRUPTED SUTURES). REQUIREMENTS 1. A suttl"e needle w~h an eye 1.1. the patient may feel a lot more com fortabie l Use only absorb able sutures when using this method. The Suture Kit 1. inch) within the depth 01 th e laceration and directing the needle in an upward direction towards the surface on the fa r side .. By burying the suture ends and knots .5.:Jid placing suture knots and klose sullxe ef1ds on the surface.PROJECT C .4. . A bright study lamp or equivalent light source STEP1. Re-dip the needle holder .HOWTO PLACE INTERRUPTED SUTURES WITH BURIED KNOTS Learn file technique on how to pl8<C8 infefflJpted slifures with buried /(nots INFORMATION Wlen suturing sensmve organs like the tongue . Aim fo r the needle to emerge about t 3·5 mm ('I.J1d edge on the far side surface. Assist the emerging needle through the tissues with your tissue forceps .3.4 Follow Steps 1·4 as expl ained above (PROJECT B . A needle holder 1.ii STEP 5a Insert the needle on the far side t 4 mm ('I. inch) from the wOl. Study the d iagram shown below. Imitation skin 2.needle tip facing tow ards you and dOWTlwards.iiii..2. Tissue forceps 1.you may want to CI.then deliver t3-5 cm I tl -2 inches of suture ttvead out of the incision. iii. The disadvantage of this technique is the fact that one is increasing the amount of foreign (sutlJ"e) material in the tissue a nd as a consequence the risk of infection (suture absce ss)..

STEP 5b Go to the near side and insert the needle:l: 3-5 mm ('I. inch) from the edge of the lacefation on the sk in surface on the near side. . inch) into the depth of the wound . De~ver the needle completely out of the tissue inckJding most of the suture thread (leave :1:3-5 em f :1:1-2 inches of suture tlTead free) . Direct the needle to the far side and aim for the needle to emerge 14 mm ('I.

defying he object of burying the knot in the deep part of the wound!) Make a square knot ensuring that the two tissue sides are brought clo sely together Onto close proximity).J"e.STEPS Ensure that both ends of the suture thread are eijher to the left or to the right side of the suture crossing the surface. the knot wWlland on top of the suture . (If they cross over under the sutl. .

ber of sutures by repeating steps 5 and 6 above .STEP 7 Cut the sutlle about 1. .. STEP 8 Place another m. Place addijional sutures if you see any gaping areas..placing a sutlle approximately every 5 mm (Yo inch) over the width of the entire incision...5 mm (1116 inch) away from the knot .ensure that the tips of the cut suture do not protrude through the wolJ"ld .

lt basically is a continuous v ari ant oflhe Interrupted sutlXe (Project B).PROJECT D .. Continuous sutures a re also indicated to quickly oontrol bleeding in the absence of other bleeding control me asures e .a~'!'~ a:as. The Suture Kit 1.Of fulHh ickness skin grafts. 1.2 . Suture thre ad 1. l mij aUon skin 2. Scarring may be redured w fttl ruming sutu res as comp ared to interrupted sutures as fewer knots are made with continuous sutures. IS ..4.HOW TO PLACE CONTINUOUS SUTURES Learn the technique 00 how to place continuous sutures INFORMATION The continuous suture is also known a s ' sim ple running sutlXes ' . Co ntinuous sutures c an be used to close long lacerat iOns and surgical incisions CI S well as to sec..e a spl~ . REQUIREMENTS 1. A suture needle with an eye 1.. A bright study lamp or equiv alent light source 3. a profusely bleeding scalp wound. FoHow steps 1 to 5 as described in Pro}ect B to pl ace the first sut~e .s • •• ••• :I. A needle holder 1. An assist ant STEP 1 Start the suture 1-2 mm (Yo inch) from the left hand edge of the prepared lacerat ion (or at o ne of t he posijio nal marllings) on the imij at ion skin over the incisionll acerat ion. o •• • '1'-' t1.5.:zs"F .g . Tissue forceps 1. Study the diagram [OJ shown be low.3.

Proceed with the next suture loop approximately 3. Cut ONLY the short end (the end without the needle) of the sullse leaving at least 3 mm (YO-YO inch) of sullse material beyond the knot. STEP 2 Ask the assistant to hold part of the long end of the sutlSe plJ~ng ~ with mild tension (this is called "foHOYI-up" ).5 mm (Yo-Yo inch) further away from the knot Ask the assistant to release the suture as you proceed w~h tightening the second suture loop • .see · Project Epsilon' .STEP 2 Tie an "Instrument Square Knot" . so as to prevent the wound from opening spontaneously.

.J1til you arrive at the other wound margin. STEPS When you anticipate that you are going to place the last stitch ..ask your assistant not to tense (follow-up) the suture. .STEP 4 Repeat step 3 at intervals of 3-5 mm (Y % inch) I. . Make a square knot using the double suture ~ne of the pen-uHimate stitch and the remairing free end of the suture (the end with the needle attached).

even in inexperienced hands Disa dvantages Include: • The poSSible formation of skin marks (aosshalChing) and the risk o f opening (dehi&. runn ing suture Inc lude: • QuJckerpl9Cement and more rapid closure o ( wounds (oompared to other types of sutures) • The continuous suture is easy to pla09 .Step 5c: STEP 6 Cut the 3 ends with a sut ~e Culling scissors leavi ng not less th an 3 mm of free suture ends. POINTS OF INTEREST Adv antages of th e slmpl.ence) if the sulure material breaks anywhere alon g the length of thel9Ceration • It is dimculf to make fine adjustments along the suture line. and • Elastic parts o f the skin may become bunched up (do not instance) use this to close a la09ration on an eye~d for • .

Tissue forceps 1.2 .HOWTO PLACE CONTINUOUS INTERLOCKING SUTURES Learn the /echniqlJ8 Otl how 10 place continUOIiS interlocking sutures INFORMATION The indications. 1. Study the d. . Suture thread 1. lrt gets loded in by the previous sub-un~ . A bright study lamp or equivalent light source 3. advantages and disadvantages of the continuous interlocking suttJ"e are similar to that for the continuous suture although the strength oflhe wol.PROJECT E . A needle holder 1.agram IE] shown below. Fo"ow steps 1 to 5 as described in Project B to place the first sutlJ"e.J1d closure is somewhat enhanced as each suture sutH. REQUIREMENTS 1.4. lmrtation skin 2.3.5. All assistant STEP 1 Start the suttJ"e 1-2 mm (X inch) from the left hand edge of the prepared laceration (or at one of the pos~ional mar1<ings) on the im~ation skin over the incisionllaceration. The Suture Kit 1. A suture needle with an eye 1.

using the needle holder and the tissue forceps. Cut ON LY the short end (the end without the neecle) of the suture leaving at least 3 mm of suture material beyond the knot . Tighten the suture thread .STEP 2 Tie a dottlle ' Instrtnlent Square Knof . STEP 3 Proceed with the next suture loop approximately 5 mm (X-YO indl) further "iffl~ from the knot Belore tightening the second loop. . take the open loop from the assistant 's hand. STEP4 Ask the assistant to hold part of the long end of the suture .see 'Project Epsilon'. and then put the needle through the loop .pulling it with mild force as to assist in keeping the WQlI1d closed (this is called ' follow-up' ).

Make a square knot using the double suture Nne of the pen-IJHimate stijch and the remaining free end of the suture (the end with the needle attached). inch) until you arrive at the other end of the wound margin.ask your assistant not 10 tense (follow-IJp) the suture. . STEPS VVhen you anticipate that you are going to place the last stitch .STEP 5 Repeat step 3 and 4 every 5 mm ('I.

and they may cause tissue slrllngulation If placed too tightly. POINTS OF INTEREST Advllntllges of locked sutures include: • Inc:rellsed tfNlsile stTfNlgth • can be used In wounds under moderate tension • Useful In wounds oozing from the skin edges where I! can assist with control of bleeding (hermJstasls) DIsadvantage: • Running locked sutures have en Increased risk 0' impairing the microcirculatiOn in tile wound area.. This type of suture should be used In areas with good blood suWly e.. e ef1ds.STEP T Cut the 3 ends w~h a suture cutting sasson leaving not less than 3 mm (Yo-% inch) of free sut .g . fhe scalp.. .

and are therefore useful with the closure of wounds under tension • Mattress sutures are also indicated when the operator wants to maximize the raw on raw surfaoo area.2.4.place alternating horizontal mattress and interrupted sutll"es REQUIREMENTS 1.g.see Project 2 and 3. interrupted or subcuticular sutures.3. .5 inch) ctJt representing a s~gical incision or a laceration in the skin. Imitation skin 2.5.ion . A bright study lamp or equivalent ~ght so~re STEP 1 Use a needle w~h suture material attached.s the secure closure of an opening between 2 callmes e. STEP 2 Use of the prepared imitation skin (see Projecl4) with the:t7 em (2 . the oral and nClSal caIIity • These sutures may also be used temporarily as so~lled ' stay suttl"es ' to approximate wound edges . clipped to a Needle Holder . A suture needle with an eye 1. The temporary mattress sutures may then be removed • To assist with wound evef!. Tissue forceps 1. A needle hoider 1. Suture thread 1. The Suture Krt 1.PROJECT F · HOW TO PLACE HORIZONTAL MATTRESS SUTURES Learn too tedlnique on /Jow to plBoe norizQfltal mattress sutUfI)S INFORMATION Indications: • Horizontal mattress sutures provide both strength and wound eversion. Study the diagram IF] shown on page 96. An example.g.1. aHowing placement of e.

3252. . out "2" then in "3' and out "4". .$2302. Do not tie or cut the sul\lre at this stage.but this time from the near side to the far side. .F 232.iltllhe tissue forceps and insert the needle .e of the needle. .rlhe example on the diagram shown below_ STEP4 Evert the far side of \tie laoeration v. on the far side. .J"e in the region of one of the pos~ional mar1<ings on the mock laceration of the imitation skin. STEP 3 Start the sutl. Follov. inch) away from the wound edge (as described previously).J"e like the first part .. . . .$2. . . . aiming for it to emerge at an equal distance from the laceration edge on the near side. Move 415 mm (Yo inch) 10 t he right of this subsection of Ihe stitch (stay parallel to the incision line) and place the second subsection of the horizontal mattress sutl. . Fonow the pattern on the template: In " 1".$ . . Now evert the near side of the laceration and mirror the COUf!.5-10 mm (Yo to )4.

l'e leaving at least 3 mm (Y.STEP 5 Tie a double "Instnsnent Square Knor ("Project Epsilon" ) or a Sl.("Project Zeta' )_ Cui both ends of the sutl. .I'geons knol.-YO inch) of suture material beyond the knot .

:": :": :": :":. ' ~ '-' '-' '-' POINTS OF INTEREST A dv/lntages: • Improved eversion may be acflieved • Coo be used i'J wounds under II fll ir amount 01 tension Disadvantages: • High risk 01 producing suture m/lfks if left in place for pressure 00 the skin surfllce • High risk 01 tissue in the wound edge dying (necrosis) due to oomprc:mised blood supply . . Do nor place these sutures too close to the wound edges and consider removing the sutures liS eMy lIS possible. .especiaNy if they are tied too long - especially where the suture eXflfts too tightly. :": ~ '-' '-' '-' :":. STEP 1 FoHow with another couple of hori2(lntal mattress sutures .until you reach the right edge of the laceration.STEPS Place a second horizontal mattress suture ±3-4 mm (Yo inch) to the right of the first suhse by repeating Steps 4 and 5.

e marks .5. mattress sutures shouk:l be removed after 5 days . The Suture Kit 1. Suture thread 1.. lmrtation skin 2.HOWTO PLACE VERTICAL MATTRESS SUTURES Learn Ihe tfJChnique (¥1 how to place vertical malfress sulllres INFORMATION Just like the horizontal mattress suture . On the down side are the increased risk of leCllling sut . A suture needle with an eye 1. these sutures are probably the best choice to help w~h the closure of a wound under tension .1. A needle holder 1.definitely not longer than 7 days. Tissue forceps 1.3. A brigh1 study lamp or equivalen11igh1 source STEP 1 Use a needle with suture material attached. the vertical mattress suture e)(ceJs wijh the closure of wounds under tef1sion . REQUIREMENTS 1.especially if they are left for too long in the tissues . .PROJECT G .iect 2 iimd 3. STEP2 Use of the prepared imrtation skin (see Project 4 ) with the ±7 cm (2.2 . cHpped to a Needle Holder . Study the diagram [GJ shown on page 102. AS a general rule .see Pro.4 . Since the sutlJ"e bites can be placed qu~e a d~tance from the wound margin within hea~hy tissue .5 inch) cut representing a surgical incision or a laceration in the skin. One way of reducing the risk of leaving suture marks is the use of soft plast ic rods placed between the skin and the surface loop of the vertical mattress suture..

G11111111111t1t iii iii iii iii i i i-i-i-ii-i-iii-i-i-'i'i'i 31131113111113

STEP 3
Start the suture in the region of one of the positional mar1lings on the mock laceration of the im~ation skin, on

the far side. Follow the example on the diagram shown below.

STEP 4
Evert the far side of the laceration w~h the tissue forceps and insert the needle - about 5 mm (Yo inch) on the far side of the laceration (a s described previously). Now evert the near side afthe laceration and mirror the course of the needle, aiming for
~

to emerge at an equal distance form the IClCeration edge on the near side.

STEP 5

Insert the needle:tS mm (% inch) from the left WQund edge on the near side and minor the

cou~e

of the

needle on the far side of the laceration. FoNowthe pattem on the template: In " ' ", out "2 " then in "3" and out "4".

STEPS Tie

an "Instrument Square

Knot' r Project Epsilon") or a sll"geons knot - r Project Zeta"). Cut both ends of

the suture leaving at least 3 mm of suture material beyond the knot

STEP 7 Place a second vertical mattress suture ±6 mm

(Yo inch) to the right of the first sut lJ"e by repeating
Steps 4 to 6.

ii

STEPS FoHow with another couple of vertical mattress sutures - until you reach the right side edge of the laceration.

11111111111111
iiiiiiiiiiiiii

POINTS OF INTEREST
The edvantages and disadvantages d the vertical mattress suture are similar to that of the horizontal mattress suture.

PRACTICAL HINTTO PROSPECTIVE DENTISTS I ORAL SURGEONS
As a dentist you will have to become proficient in suturing within a COIlfined cavity. Simulate suturing inside the 0(81 cavity by l1uing

a piece of sponge or cloth to the bottom ()( a plastic container ordisposable cup.

Now practice yournew/y acquired suturing skHIs by placing sutures in the sponge or cloth in the bottom of this containerlcup.

4.S. A suture needle with an eye 1.in the process of everting the wound may le ave the wound edge slightly open at the end of the day.'Hi. In addition they will assist in closing the wound margins as they cross the wotl'ld margins twice. Im~ation skin 2.2.see Project 2 and 3. Suture thread 1.1.HOWTO PLACE "FAR-AND-NEAR" SUTURES Learn the technique o n how to place "far-and-new sutures INFORMATION Mattress sutures . The Suture Kit 1. TISsue forceps 1. " Far-ne ar-ne ar-far sut~es are great with eversion. REQUIREMENTS 1.i i i 'i 'i i 'i'i" 'i ~+++~+++++++ ·H .5 inch) cut representing a surgical incision or a laceration in the skin.3. A bright study lamp or eq~valent light source STEP 1 Use a needle w~h suture material attached. clipped to a Needle Holder .PROJECT H . STEP2 Use afthe prepared imitation skin (see Project 4) with the ±7 em (2. are strong. A needle holder t . i. so can be used in wolrlds under o~er tens ion. Study the diagram [H] shown below.

Now evert the near side of the laceration and aim for the needle to emerge 5 mm (Yo inch) on the near side of the laceration. . Follow the example o n the diagram shown below_ STEP4 Evert the far side of the laceration with the tissue forceps and insert the needle (as described preciously) .on the far side of the laceration.about 8 mm r~ inch) away from the WQund margin .STEP 3 Start the sutlSe in the region of one of the positional marl<ings on the mock laceration of the imitation skin. on the far side.

inch) on the nilar side of the laceration. out "'2" then in ' 3" and out "4 ". indl) on the far side and aim lor the need~ to elT\efge about 8 mm r--.r Project Zeta"). STEP6 Tie a double "Instrument Squ are Knor r Project Epsilon") or a sl. Cut both ends of the suture ~ aving at least 3 mm of sutu re material beyond the knot . Follow the pattern on t he template: In t o.J"geons knot .t5 mm ('I.STEP 5 Insert the need~.

. Otoorwise the adv8t1tages and risBdvantages are sJmUarto the hCYizontal8t1d vet1ica/ mattmss sutures A variant of the ' Faf·near·ne8f·'afsuture" is the "PuSey suture".STEP T Place a second "far-and-nea r" sullse ±3-4 mm (Yo inch) to ltIe right of ltIe first sullse by repe ating Steps 4 to 6.until you reach the right side edge of the laceratiOn POINTS OF INTEREST Far-near-neaf·fafsutures are useful when the cNniciBn wsnts Bdditional closure strength. 11 11111111111111 STEP 8 FoHow with another couple of "far· and-nea r" sutures . In my opiniCXI it does not have any sif11ifican/ advantages compared to the other mattress sutures and wi" therefore not be discussed 8t1y furtl1er.

HOWTO PLACE SUBCUTICULAR SUTURES Learn fhe fechnique on how to place II continuous subcllficular sutllfe INFORMATION The subcuticular suture is indicated in cosmeticalJy sensitive areas like the face . . The most favorabJe wounds from II cosmetic point of view are those where the long axis is parallel to the natural skin tension lines.PROJECT I . Keep in mind that cosmetic resuHs are much better when minimal tension is placed on wound edges at the time of repaH-. It is time-consuming Clnd more dWflCult to master compared to the other suturing techniques. Rep air of such a wound will reS(jt in II fine cosmetically acceptable linear scar.

2 .5 inch) cut representing a surgical incision or a laceration in the skin. The SuttJ"e Kit 1. Imrtation skin 2. A bright study lamp or equivalent light source STEP 1 Use a needle with suture material attached.REQUIREMENTS 1.5.1. .aiming for the needle to emE!Jge just below the epithelium on the inside of the laceration. A suttJ"e needle wrth an eye 1.3. clipped to a Needle Holder .4 . STEP 3 Insert the needle about 3 mm (% inch) to the left of the left comer of the laceration (and in line with the long axis of the laceration) . Study the diagram [I) shown below. Suture thread 1. A needle hokler 1. Tissue forceps 1. STEP 2 Use of the prepared imitation skin (see Project 4 ) with the ±7 em (2.see Project 2 and 3.

Do not aHow the needle to emerge through the skin surface. .in .and aim for the roeedJe to emerge just below the epithe~ln1 inside the laceration. If the needle emerges through the sk.laking a :t:3 mm (Yo inch) b~e of tissue . STEP 4 InsM the needle just belON the epithelium on the near side of the laceration . I &epJa I I .puN back sHghtty and redired the needle to remain just below the epijhelium. &ep3b ----= Slep 3d ~-..

altemating smaH bites of tissue sides of the laceration (as described in ' Step 4"). &6P&': I on the near and far STEP 7 Wor1l your w~ to the right41and side of the laceration .using the needle holder and pull enough suture string tt"l"ough to allow you to proceed w~h the suturing unrestrained. . STEPS Insert the needle just below the ep~helium on the far side of the laceration opposrte to the point where the needle emefged from the far side of the laceration taking again a .STEP 5 Deliver the emefging needle from the near side .t3 mm (% inch) b~e of tissue as described in ' Step 4 ".

·I ' Step 78 I' Stap 7b .

but aim for the needle to emerge about 3 mm (Yo inch) away from the right edge of the laceration emefging through heaHhy skin . inSeft the needle just below the epithelium . make a knot at both ends of the emerging suture thread . Stap8c StapBd STEP 9 PuH the two ends of the suture tightly away from each other and strap the loose ends to the adjacent skin 'Nith a suitable strapping like Ste ri-s trip S®.in ~ne w~h the long axis of the laceration. Alternatively.STEP 8 When needle emerges within 3 mm (Yo inch) from the left edge of the laceration. Stap 9a Stap 9b .

1.4 .2 .to ensure optimum cosmetic results after wound dosU(e. Tissue foroeps 1. A sutll"e needle wfth an eye 1. A needle holder 1.5. A mal1\er pen 3.I\\ Step 9d POINTS OF INTEREST Have a look at the suggested surgical incision lines in the facial area . As a general rule these lines run p&!pendicular (al 00 oogl& of 90 degrees) to the underlying muscles offacia/ expressiOn. Suture thre ad 1.HOWTO PLACE A PURSE STRING SUTURE Learn the technique on how to place a purse string suture INFORMATION TWQ examples of where a pll"se sting suture may be used are: • Closll"e of the colon after the remO'lla l of the appef1dix and • CloslI"e of the opering into the chest when a chest drain has been placed REQUIREMENTS 1. The Sutll"e Kit 1. lmijation skin 2.3. A bright study lamp or equivalent light source . PROJECT J .

see Project 2 and 3.until the last suture emerges about 3-4 mm (Yo indl) away from the starting point Step 38 .see the example on the template .tl .may from the wound margin on the near side of the Circular wound . Ttis circle represents either a circular defect in elast ic tissue or an opening in a hollow org an. clipped to a Needle Holder . STEP2 Marl< out a .2 cm (~ inch) circle on the bottom (sponge) side of the imaation skin .placing f urther sullxes .t3 mm (Yo indl) bite then lea~e a space of :1:3-4 mm (Yo indl) before tak ing the next b~e . Worl< your way clockwise or ant i-dockwise around the wound . Take. Place a suture para llel to the Circu mference of the wound marg in. J STEP 4 Start about 3 mm .STEP 1 Use a needle W'ith suture material attadled.

from 8 surgical gave Bfld practice the purse string suluffJ on the ffJmaining fingfJf slump.rProjed Zeta·). . Cut both ends of ltIe suture leaving at least 3-5 mm (Yo .Yo inch) of suttl"e material beyond ltIe knot Step Sa Step 5b Variation : Cui off part ofille (" go. STEP 5 Tie a dol.STEP 4 Cross ltIe two loose ends over and p~lltIese two ends of ltIe suture tightly in opposite directions.tlle "Instrument Square Knor rProject EpSilon") Ol a surgeons knot.

2. T.espooa8y in oosmeb'cBlIy sensitive it inv8ri8bly gives poorcosmetic resultsl RattJerconv8(f rhe round defecl into an eNipse. . The resu~ ~ .3. The Suture Krt 1.g.I'S wtJen one edge 01 the wound is longer th an the other. A bright study lamp or equiv alent light source STEP 1 Use a needle wittl SUIl.ssuefo rceps 1. clipped to a Need le Holder . 1.see Project 2and 3. lmitation skin 2. Sutl. Do not attempt to · sutl.HOW TO CORRECT A "DOG'S EAR" How 10 gel rid of those ugly. mattress sutures.I'e mate ria l attached. A suture needle with an eye 1.l'e thre ad 1.S.s an extr a amount away' it will not oft.ssue at the end of the wound in the process of beWig closed. unwelcome dog 's ears INFORMATION A Dog 's ear delect OCCI.l'e ~. lIWlere c8n I buy more Imitation Skin? PROJECT K .4. undermin e the skin to Bileviate tension BOO close with e. •• .POINTS OF INTEREST Never use 8 purse string suture areas - 'or closing round defects on the skin . REQUIREMENTS 1. A need le holder I .

Cut this incision line using either the sharp-sharp scissors or the scalpel.5 (3 inch laceration). at the end of the incision. This shol. . Study the diagram shown below. Use a tissue forceps to lift the dog's ear out up somewhat.STEP 2 Use the Imitation Skin prep ared with a 7. laye~ (±2. Lift the superficial layer of skin from the deeper incision. thus producing a so-caned dog's ear. STEP 4 On the dog's ear side the incision. make a short ±5 mm (Yo inch) mark on the imitation skin angled at ±45 degrees to the original incision line.jd produce a misaligned wound closure with the superficiailayer of skin "bunching " ~ on the one side.5 em long and 1 em wide) just on the one side 01 the K STEP 3 Intentionally plClCe a number of oblique or "skew sullxes in the incision (all in the same direction) next to the lifted skin section.

Now place one or two intenupted suture on the side of the incision that formed when the smaU exoess piece of tissue was cut off. • . STEP 6 Continue placing interrupted sutures on the original incision. The final resun is a sutured laceration that resembles a hockey stick.!.STEP 5 Apply gentle traction with a forceps (Or a skin hook) to the excess tri angle of skin to match the extended wOlrld margin. and cut ij off wijh the scissor.

ALTERNATIVE METHOD:
Simply perform a neat elliptical excision of the dog's ear as indicated on the diagram. Now proceed with placing another couple of interrupted sutures.

POINTS OF INTEREST
• By making strategicaNy placed cross markings on the incirion, you wiN • With

a surgicBl incision with a surgical pen - before making

be creating /8f1dmarks ror closure later on - 8IId thus avoid creating Dog's ears. the fJJ(ceptiOfl of quite minor incirions, it is a,ways a good idea to use a surgical pen to plan your

incisioos.

• NfJed mere IntoMation on dog 's ears? - trttp:llwww.dogflcts.org/tMllrlng-dog-flctl.trtm

PROJECT L - HOWTO CORRECT UNEQUAL LEVELS OFTISSUE
Learn /low to "flatten " unequallleif1lts of/issue during suturing.

INFORMATION
Occasionally - even with the best of efforts to avoid unequal heights of tissue- one may be confronted with somewhat unequal levels of skin at the wound edge dlXing the suturing process. A common cause is the mal-positioning of sutures in the deeper layers of the skin during a layered doslXe. tf the discrepancy is large - rather undo the deeper sutures and redo them

at the correct level. If the discrepancy is slight - the method

described below will assist you to correct the problem with ease.

REQUIREMENTS

1. The SutlXe Kit 1.1. Tissue forceps
1.2 . A sutlXe needle wrth an eye 1.3. Suture tlTead 1.4 . A needle holder 1.5. Imitation skin 2. A bright study lamp or equivalent light source

STEP 1
Use a needle with suture material attached. dipped to a Needle Holder - see Project 2 and 3.

STEP 2 Use of ltIe prepared im~ation skin (see Project 4 ) w~h ltIe:t7 em (2 .5 inch) cut representing a surgical incision or a laoeration in the skin. Srudy ltIe diagram

ILl shown below.

L
I

l
:>

I. ,

r ·1
22
I

'1'1

t
I

.1
:>

STEP 3 Intentionally place two ' unellen' surures at a distance of

± 2 .5 em (1 inch) apart from each other by taking a deep
Me of tissue on the far side and a shallow Me on ltIe near side of the incision - tie a square knot or surgeons knot You have produoed a misaligned wound with ltIe far wOlSld edge higher and the near one lower.

"".....--'-

STEP4

Correct these uneven edges by placing InteffiJpted sutures- but intentiOnally take a shallow bite on the far side and a deeper bite on the near side. See the uneven heights even out as you tie the suttl"es.

• Unequal tissueleV'9ls may also be due /0 wound infection. A radiogf"aph can offen assisf in identifying a fragment d glass. do·Wounds·H.POINTS OF INTEREST • Unequal levels at the wound margin may be due to a foreign object remaining in the wound e.g.cfm .ry. an infected wound should not be sutured. A sm8l1 piece 01 glass may be difficult to find.sslonll~pub/lcltJon"Everyday·Wound ·Ch02·'1ow. http· 'lwww. Alwuys make sure thaI you remove a/l foreign objects from the wound before closure./.plutlcSUIV. a pieoo 01 glass atter a mo/orvehicle accident. orcontamlna/9(/ tissue and flImov81 of foreign matter from a wound) suitable (tessings and possibly antibiotic therapy and perform so-cared secondal)' dosure • Get more information here: at a latefstage. Rather clear up the wound infection by debridement (surgcaJ excision of dead. d(Nita~zed. As a gener81 rule.orglmerIJca/"'pro".

STEP 2 Clean the area with a m~d anti-septic solution (in a clinical s~uation).if any at aU.J"es placed previously in Projects B to J . INFORMATION Suture remo~al is usually an easy office procedure. Most patMents are somew11at apprehensive about this procedure. SutlXe Kit 2. Start with the Interrupted sutlJ"es in UProject B". Sharp-sharp scissors 3.. . The idea is to remove the sutures as soon as they have done their job of wound closure and before they start causing suttl"e related complications like suttl"e scarring and suture abscesses. STEP 3 un the knot with a forceps and pul gently away f rom the skin and s~ghtly towards the wound edge. The regular tweezers forceps 4.PROJECT M· HOW TO REMOVE SUTURES Learn /Jow to mmove sutures the C{)(roc/ way. A bright study lamp or equivalent light SOtl"oe 6.. YOll" reading glasses (if you are over 40 years of age or you have pJaced &-0 or thimer suttl"es) STEP 1 Rel'l'lOVe the sutl.. but the discomfort with the removal of sutures is usually minimal. REQUIREMENTS 1. Imitation skin (This projed requires comp~tion of Project B to G) 5. Vo .

.remaining as close to the skin as possible.STEP 4 Ease the one leg of the scissors Vvithin the sul~e loop . and remove by pulling rt out w~h the forceps holding onto the knot. STEP 5 Gentty cut the st~ch.

J"es by carefully easing the one leg of the scissors under each of the loops .again remain right next to the skin Sl.J"face.STEPS Give another qu. t Srep 7b Step 7c t . Remove the suture loops by puning all the loose ends out of the sltin.ck wipe with a mild a ntiseptic solution and apply a conservative wipe of local antibiotic ointment STEP 7 Remove continuous sutl.

. • R&commeooed removal time in dllYs forsuwres in dirr9l"ent 8rellS 01 the body. 28. Trunk: 10·14.9.then cut both sides of the knot·loop just above the skin surface and remove by pulling the loop remaining on the skin su rface STEP9 Remove slb-euticular sutures by removing the 2 securing straps at the ends. Sc8/P: 7 . POINTS OF INTEREST • A stitclJ.6flsure thot the tips remBin sherp a"ld able to cut (and not chew) the sutures • Ensure that you U588 forceps that doesn~ slip.aoo the balance tomorrow. • Face: 3·5.8. eoough force it will open up 8goinl Rother ossist the immoture closure with a numberof small strappings • "you 8re unsure 8bout the strength of the wound closure.STEPS Remove mattress sutures by gently Hfting the knot . cut one end next to the skin surface and puH the remaining suture filament out . conSid9l" removing alternative sutures today . Lower extremity: 14 . Neck: 5 .if you stretch like St9l"~Strips®. • A/w8)'s worK With 0 MOfp scissors . Extensorsutfoc6 hands: 14.c:utteror 0 scalpel blade Ca"l be used os on 81temotive forcufting sutures. the wound open with • Do not test tile strength of the wOlA'ld closure 8tt9l" suture remov81. Upper extremity: 8 ·14..away and in line with the long axis of the laceration.

Avoid this by taking a reasonable b~e at II fair distance from the wound margin. Another possible cause would be leaving too much dead space in the subcutaneous tissue.COMPLICATIONS OF SUTURING ilis always wonderful whEm everything goes smoothly . 4. Consider using a reverse cutting needle or a round·body needle. • Placing stitches in diseased tissue e.but in medicine it OCCasiOflflUy doesn 't . Ensure that you include the f(jl thickness of dermis in the bitel • The inappropriate use of II cutting needle.g. Stitch abscess A small yellowish collection of puss is visible where the sutlXe emerges from the skin. and cover the wound with a topical antiseptic or antibiotic ointment. Suture in anatomical layers and do not suture the surface of the skin wtile neglecting to suture the subcutaneous tissuer . Remove the stitch. The most common reason for ttis is that the operator did not pay enough anention to wound eversion.. the stitch may tear through the tissue. Stitch " tear·through" Occasionally when placing or tying II suture. Reasons offar this include: • Placing a stitch too dose to the wound margin. All isolated strtch abscess is rarely an indication for systemic (oral or intra--venous) antibiotics. adjaceot to the sutlXe material.SS· 56) 3. lets consider: 1. • Taking a too superficial b~e . This is always an unfortunate mishap and will contribute to a cosmetically less pleasing resuH . 2. Defective scar The scar is in the form of a groove or a dimple. infected wound or tLrnors. Wound dehiscence See Points of Interest· Project Epsilon (p.

5. Hypertrophic scar The wound healing ;s somewhat exuberant causing a ra;sed and thickened scar. Th;s may
re~te

to mild

mechanical or bacterial irritation. o f ltIe wound during ltIe healing prooess or to wound dehiscence. A Hypertrophic scar increases in s ize up to a point, ltIen regresses aga in to some extent. Leave ltIis type of scar for at le ast 6 monltls and re-evaluate for a scar revision .

6. Koloids
A keloid is similar to a hypertrophic scar. with ltIe drtference that ij is not self-limijing. but continues to incre ase in size , ltIus behaving like a true tumor, growing beyond the margins of the original wOlSldfscar. Surgical excision or wound revision usu ally produces poor results a nd ltIe formation of a new keloid . Keloids a re best handled by the relevant professionals e .g. Derm atologists or Plastic surgeons.

7. Stitch marks All
st~ch

types piercing the epiderm;s will c ause sm all "dot-like " marlls nelct to the inc;sion line. Umit these

marks by removing suttJ"es as soon as possible without r;sking wound dehiscence. Consider using altemative methods like wound strapping e .g . Steri-Strips®. subcuticul ar sutures or wound glue.

8. Crosshatching Crosshatching is line ar scars corresponding to pressure lines produced by the suttJ"e materi al pressing the UIlderlyirog tissue . Avoid using in appropriate suture techriques and do nO! suture wounds UIlder terlsiOil .

9. Wound cOnlracture
V'«Iund contraction is a norm al part of wound he aling V'«Iund contracttJ"e OIl the other hand is a bnormal and implies d;stortion of the stJ"rOlSlding t;ssue . A contracture in area s like eyelids. fingers . toes etc. may cause limijalion of movement of these structures.
P~n

surgical incisions and naps properly and apply basic surgical

principles like aseptic technique , a natomical and physiological considerations .

EPILOGUE
Suturing in essence is a surgical procedure and is govemed by the bas ic principles of surgery like aseptic technique etc. AI the end of the day

we

should be reminded that t'istorically. surgery has been seen as a last

resort. Let us also be reminded of the famous quotation by the farTIQus surgeon in history. Ambrose Pare

(1510-1590), W'ho on occasion remarked . " I dressed the wound, and God healed it! "

The body has healing mechanisms of its own . Most wounds if left for a sufficient period of time will close completely/s;gnificantly on its own by the process of wolJ'ld contraction. Remember - do not suture each a nd every single I~tle wound - some minor cuts and bruises in esthetically lSIimportanl areas will heal perfectly well without suturing. Sometimes cle aning and a small band-aid strapping is the appropriate Some wounds may even heal better if left undisturbed by invasive measures ..
w~

to manage a cut.

GLOSSARY

'.!:H.j.j:I.j:I!¥1iUii-g,

Suture material that will disappear over a period of time when placed in bodily tissue - usually due to enzymatic breakdONn

' .lioF

Ei,~j:~!-i'·:N~';i,.~====
Ei.~!!~3Iil1ii~'!'• • • • •

The scraping away of pari of the surfaoo of the skin or mucous membrane A fatal disease caused by the Human Immunodeficiency Virus with the abil~y to sklwty destroy

part of a person 's immune system

Usually referring to ethyl alcohol found in alcoholic beverages. In high
concentrations it has medically useful antisept ic properties Bodily structure.1 The study of the form and arrangement of bodily parts A group of biochemical substances produces by a variety offlrlgi with the abilrty of slowing down the growth of, or kill bacteria

===== 'V ...:"n,,;
Ei·~Vif.~iiffi.i~t~' Ei·~ja~A~·j~1~4~i~i311== i,!;Ii§;!!.":I!4§.

A beginner or learning a trade or an occupation Blood squirting, usually in a pulsating fashion, out of a blood vessel- moving
blood away from the heart

An

im~ation

of something natural e .g . artificial teeth

A medication for relieving pain. redudng fever and "thiming " blood Causing minimal or no injury to the tissue A suture attached to the end of an eyeless needle

An apparatus using steam tII"lder high pressure to sterilize medical instruments,
~ems

and equipment

(:111

E"ffi!~iQ~====== The center line of a structure or body
side of a lacefation

The amotll"lt of tissue included when inserting a needle into the tissue on either

(.!!.i,i"3'

[I:ffi!!il~,~"jl';-£~II==

"I'de

A blood blood into a wound Blood changing from a liquid to a gel state - an essential step towards stopping the process of active bleeding

~esselleaking

An interconnected network of fibers to form a suture. string or rope
A tough . thin cord made from the treated and stretched intestines of certain animals and used for surgical dosure of wounds The metric und of length equal to one hundredth of a meter Spedfic chemical agents or drugs that selectively destroy cancefOUS (m alignant ) cells and tissues The part of the body between the neck and the abdomen Chromic is an absorbable suture made from purified collagen. and treated with chromic acid
sa~s

13 i3l3iiW"

113~!~"~"'~3~r"~t=====

A medical practitioner w ho does clinical work (interact with patients ) A group of people having a common interestls

but then returns to its original shape when the force is remolled . nel'l/es and sweat g lands lilmi#E. i§"iiihW lilmif~ .mi~l~·jm"iII •••• Pertairing to the abil~y of a person to skillfully coordinate their mOllements· especially referring to the hands A Chronic disease in which the body is unable to properly process glucose due to an insufficient production of f a resistance to insulin iliB:i".!)..I• • • • • l lil~ifi@~'~ij€!~·~H~'i.m:l~i*Il"m..j!ilmj§~?~.*~j~P~i .!§~I~i • • • The surgical cleaning of a wound by excising dead (dell~alized) and contaminated tissue and the remOlial offoreign materi al The splitbng or bursting open along a sutured line The profession concerned with the teeth.ury or surgery lilmi§~.~i(~• • The presence of harmf ul foreign or infectious material in a wound or in a · preparation ca.e Shading.mj. organ .=== •••• An excess amount of tissue rem airing at the edge of a sutured wound resembling the e ar of a dog A therapeutic or protectille material app lied oller a wound surface TISsue th at deforms (stretches) when an extemal force is applied . ma lils or prominences consisting of muJtiple crossing lines Planned courses of academ k: study Pertaining to skin A needle with a sharp edge as viewed in cross section Referring to a signifICant residual space (gap) w~tin the tissues of the body foll{)\.Ying ir.j~i:~i§~.~!t3' ••• A development th at oomphcates any disease or disorder or OCCISS diSing or following medical Of surgical tre atment 113~.~g~i • • • • The use of electromagnetic Clnents to prodUa! heat for sealirg off blood lIesseis by co agul ating blood and deo aturalizing proteins A pathological (a bnormal) condition of a pall.~j...li3~. mouth and associated structures The layer of the skin below the epidermis contairing fibrous tissue.~'4~!I:a~·!iimi.==== (01&$1# . 11 q li.~ ·'~- To unlock or cause to become unlodled The surgical sep aration or disassembling of a pall of the body to expose internal structures I§!M""&i1" lil~i.mifJP!·t. or system of the body characterized by an identifi able group of signs or symptoms li.pi@ii. blood lIessels.i@.Wi1iiii!jlW CONTRACTURE A sutlSe made from a continuous (uninterrupted) succession of stitches and fastened at the two ends by a knot An abnormal reduction in the dimensions of a he aling wolfld due to the contraction of scar tissue Pertaining to the improvement of appearance Of a physical feat ..mp![ii~i~3!U:~!·I"mi.

!·iiV'iidl. the causative agent of the dise ase AIDS Pertaining to cleanliness and the prevention of infections and sepsis All increase in the size of a tissue or an org an due to growth of individual celis A copy that is si mil ar reg arding certain attributes to an original Diminished in strength. ca used by a specific virus and tra nsm~ted by blood or blood derivatives from a carrier of this virus Transmitted genetically from parent to offspring Hum an immunodeficiency virus .i~I.JI · '#i:I§- 11111111 Skin folds covering the e~posed parts of the eyeball when in the closed position Limbs (arms or legs) A thread-like structure Consisting of microscopic fibers Emergency tre atment of CI victim of sudden illness or injury while awaiting profession al medical care • • All instrument similar to a pair of pincers or tongs . The grasping surface is fl at or somewh at serrated A contaminating slilstance.ld§@'R"#. which easily becomes undone The m anagement of the various aspects of health and illne ss A blood clot within a body cavijy or tissue space A heredijary blood disorder mar1led by the inability of the blood to clot and the risk of excessiw bleeding 1':ml§~p~igim"~hil. or to empty The condition of being tumed oulward To cause to tum outwardly 01:1-1 Ol-fi""" 1 lib IO~!~igi6i~. but with the second tie crossed in the oppos~e direction... • • • All infection of the liver. All agent th at acts on the brain producing an absence of sens aHon or feeling in 1'3~.~i HEAlTHCARE • • • A knot similar to a square knot. or qu ality i!!!!!!! I !!!~!1l!1i!!~!!!!!!!!!!!!!! ..I~..I~33i~.ii. not usually found in the body. 1 'ji§!II$ The use of CI needle·like probe he Cited by electric current to destroy tissue Emergency Medica l Technician To interlock or cause to interlock To cause to become enthusiCistic A dlemical substance produced by living cells whidl promotes chemical re actions The outer (su rface or covering) layer of skin and mucous membra nes To remove the contents of. value.!f·jM Iht~·~!!e!m:lm!~ ·'~II~II3i1.111.iII • • A sm all bag attached to the tI1der·side of the liver serving as a temporary storing area for bile the whole body as well as a loss of consciousness '3§ti§. whidl entered the tissue unintentionally during injury n.~I.]I .!'i~q~'il:~. used for grasping.

l1d iiimliiiii 'm'EDi!3~i• • • • • • " A cut.!ii:. tissue e. rope or suture material that is circular or curved to form an OPerJlng 'E'~r·~!.i§'''1niii. an organ. tear or wol. 'i~h!"j#E!i#j~bi3ili· if IIb##rili iii A cut into the body.lM Individual sutures (stitches) are placed.Di]'• • • • • • A natural rubber material used in the manufacturing of products like surgical gloves Tying a blood vessel with a ligature during surgery to stop bleeding A thread or suture cord used in surgery to tie off vessels and tub(jar structures Absence of sensation or feeling in a restricted area of the body A lerJgth of string.~!(~i • • • • A life threatening disease (cancerous growth) tending to metastasize (form new growths distant to the initial srte ) .A measure of length equal to one-twelfth of a foot or 2.l1d A mirimally invasive surgical procedlJ"e that uses a flexible endoscope (camera) to view structures in the abdomen Catdl for fastening or connecting two parts of an object e. in a specific way To cut.~p~b• • • • • mii§.54 centimeter IIM#ii§. crosshatched or "toothed · 'E:~'#D'~imil~B• • • • • The formation of excessive amounts of scar tissue caused by an exuberant repair response following trauma or a surgical incision A fastening made by tying together lengths of string or rope . or a part of the body The response of tissue to injury characterized by pain and swelling Introducing a solution into the booy tIYough a vein The introduction of a "tid into the booy by means of a needle and or camula (flexible tube) INTERLOCKING SUTURES A modified type of continuous suture where earn suture loop is connected to the previous suture loop A recent graduate or advanced stooent who assists with the medical or surgical care of hospital patients 'miatiiii.g. tear or wol.I!3!:~Y.g.especially referring to a surgical ru' The fillger next to the thumb Contaminated wrth a disease-forming microorganism or agent Invasion and m(jtiplication of disease-prooucing microorganisms in tissue .I.#m. skin or an organ . the ends are tied into a knot and both ends are OJt before proceeding with placing next suture Pertaining to a medical procedure where a part of the body is entered into The gripping part of a forceps I needle holder I tweezers or similar instrument usually somewhat serrated. the two legs of an artery forceps 'm'E·.

~"§i·=== b-)i. manufactured from a synthetic plastic material A liquid e .i! It lIiSii·@3iij'P/.iia.g .ii3W ! Pertaining to the facial skeleton.!':ihjUi·\ '6!§.~j'~J~:~j. The sharp hollow device placed at the tip of a syringe to inject medication into the body ~':~i§!. mouth and teeth Pertaining to the study or practice of medicine An account of a patient 's past and present state of heanh The science that relates to the prevention.~ii~!. making movement possible A small.A "dotmle suttEe" used to assist with wound eversion i!§I!ii!. the nose and mouth Dr~s and MICROCIRCULATION '6"&13' 'b§§.~.!!! NON·ABSORBABLE SUTURE A su rg ical instrument used for gripping the needle for suturing Suture material requiring removal following placement . muscles and joints .hR! A person who practices medicine or an allied profess ion A pre-medical degree (pre-med) is one preparing a person for entrance into medical school hea~h . capillaries . and arter ioles) A monf~ament absorbable suture material ( trade name) A single strand of untwisted synthetic fiber used to manufadtEe suture cord Pertain ing to the production and secretion of mucus Membranes lining interior body surfaces opening to the exterior e . espeCially as ~ relates to the enhancement of appearance ['a. i§.~Ii§.n unp~asant sensaHon (tMJrting I suffering) usually occurring as a consequence of injury or disease The flexor (inside) surface of the hand A person who is trained to give emergency medical treatment To pierce.I·i_ Making use of sevefal expefts in a nlrnber of different disciplines A sp~ialized tissue with the ability to contract.A. enter into something or make a way through something To permeate with e . and treatment of diseases I potions used for restoring hea~h Blood flow through the smallest vessels of the body (venules.·~il!"~i~. including the jaws.g .the body being unable to digest these suture 'S fibers T~sue that resists deformation (stretching) when an extefnal force is applied The science of providing care for sick and frail people A non-absorbable suture fiber.I. slender device used for surgical suturing.g . a liquid A line at a right ang~ (90 degrees) to anothef line Study of the function of living organisms and their parts Surgery dedicated to the repair and restoration of the body.~j'~"j~.~. blood seeping or leaking out slowly through small blood vessels iiiiiiiii Relating to abnormalities and injuries of bone.~ ·!!i!ii .

J"s after sustairing the ir1ury A s~nder flexible surgical instrlnlent with a sharp or rounded tip used for exploration purposes 'i'·'333' hii-H¥ii-lW41iiiii.~'·i~5iilii!i.. locking i-).1"'1j. joined by a swrvel pin that allows the blades to be opened and closed .~p[hDi~.i' '·iii@iJi€!.Final dosure of a wound or laceration within 24 hol.. glass cartridges etc.• JI.j¥ [.~m~3~."~rll"~!~' in British hosprtals) Restoring to health and a functional condrtion following damage or ir1ury To restore consciousness or life (to revive) following a life threatening incident A suture needle with a round contour when viewed in cross-section A suture made from a continuous (uninterr~ted) succession of sutures and fastened at the two ends by a knot The skin covering the top of the human head A surgeal knife with an extremely sharp blade used for dissections and fOf performing surgery A marllietl on the skin fol lowing an injury or wound that has healed Dense.lDii!!~h~ '"'l11&13".1+"4# ====== .i' SutlM"ing a wound a number of days after the injury Sedation involves the administration of calming drugs to facilitate the hM·'" q performance of a surgical procedure A form in the shape of hart a circle E ~~~===== A saw-toothed edge I a margin notched with tooth-like projections needles.ag' H"." i'i1iP" ii'-llllli '.. or performing surgery Pertaining to the restoration and correction of appearance and function of defective or damaged body parts Wrthout conscious control A specialist in training wtlo ads as assistant to the attending specialist (term used IE.~ movement in one direction only •• • • A forceps with a tip having a tooth-like projection for holding tissue when suturing . and securing it at the recipient site .Jii A suture designed to close a rounded surgical defect or WQund Having an irregular or uneven surface or edge A toothed component or tool ... The process of harvesting and transferring skin from a donor to a recipient srte.SiMi.' "p!mi§3.~ii~Ii~. IE.133 iJi"·i. The front part of the leg between the knee and the ankle A bacterial infection in the bloodstream or body tissues Referring to all sharp or potentially sharp surgical items like scalpel blades. fibrous connective tissue that fOfms ove!" a healed wound or incision A cutting tool consisting of two blades and two handles. operating w~h a catch mechanism.

. e .the room where slSgicai operations take pJace The section of the leg betweeo the hip and the knee A co rd of natural or manufactured material A basic step in the process of tying a knot The short thicker digit of the human hand.g . rope or string by making a knot 1 .. and disease by invasive means The surgical techrique used to close a wound or join tissues The section of an atraumatic needle where the sutll"e connects to the needle ii~i§if~&i~i~!I~' "40mb "@ilo "k! II? II:!"? !: li~iilil 1111= The skill and procedlJ'e with which a slJ'gical procedure is carried out The act of stretching something tight An infectious disease. caused by the toxin of tetanus bacteria (Clostridium Tetani) 1"1'#1. next to the index finger and opposable to the other four digits To fasten or to secure W'ith. also known as lockjaw... used to join the two ends of a suture or a ligature 1"'1I]~B~tEj~iili'Dii~·II¥ • • • Temporary sutll"es placed to approximate two sides of a wound or laceration to assist in aligring the wound/incision correctly i.Surgical incision lines W'ith directions designed to minimize scar tissue formation The underside of the foot A double knot in which the two loops are tied in opposite directions. 1 'Me: "1'1. deform~y. STERILITY Sterilrty indicates the total absence of infectious micro or9anisms Small plaster strips used to close minor Jacerations or to reinforce sutll"ed lacerations (trade name) A single suture A strip of adhesive pJaster..]iii§~·!iif~1ihii!i~*iiiiii .1 •••••• Referring to an operating theatre .the first loop consists of a double throw The branch of medicine that deals with the diagnosis and trealmeot of injury. used in attaching parts to each other A co rd used for fastening or tying Below the skin SUBCUTANEOUS SUTURES SUBCUTANEOUS TISSUE SUBCUTlCULAR SUTURES Sutures placed to approximate the subcutaneous layers of tissue in a wound or surgical incision The l ayer of tissue just below the dermis of the skin A continuous suture placed just below the cuticular Jayer of the skin A physician who specializes in surgery iiiiiiiiiiiiii TECHNIQUE A modified square knot .

.u iii!&~i"!iii iiiiii '3' • • • • A section of sunxe material without a needle used to tie-off (dose -off) e.. iIjIC'?~I§~i~j]#~-E]• • • • Instruments that are usually held with the thumb and forefinger and used for handling or manipulating tissue during surgeI)' mli~p~i.m·i• • • • Dissecting some distance tI1der the skin's surface at a pl ane parallel to the surfa ce .i~&I". managing and treating inj~ed patients ii. .~.iii.~ii!"~'i. .iijM.!@i The inclusion of foreign material into an abrasion Of WQund causing a change in the color of the skin following wound healing Wounded or inj~ed A swelling . Ii f Ii iFI3M.ii!'t.l.. .:. .lM it _ A surgeon spedalizing in the various aspects of diagnosing. . blood vessels Trunk or body without cellshead and limbs A collection of similar the Able to cause injury Of death _ especially pertaining to dlemicals (poisonous) A tracheotomy is an operation in which an opering (trachea) is made in the windpipe +ii'·iip '¥1ii.g . especially referring to swellings caused by the abnormal growth of cells or tissue.~i§~. . The fibers of a suture thre ad becoming undone ~ Medicine and surgery related to animals A braided absorbabie suture material (trade name) The body 's repair mechanisms producing slYinkage (reduction of the size) of the WQund during the healing process iEI.~i~i~'!3i1l1• • • The side margin of a WQund or laceration .~i II.!-H.iiiliiIl4iDi~ii~i.

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