Halsted’s seven surgical principles

• Observe strict asepsis of the patient, suture instruments, yourself and everything
that comes in contact to the wound so that you don’t contaminate it. The smallest
mistake during any step may lead to an infection which can be disastrous.
• Handle tissues gently because you don’t want to cause additional trauma or harm
the tissues or blood vessels which may lead to hemorrhage and prolonged healing
process
• Control hemorrhage carefully and make sure no blood is leaking from a perforated
vessel. Electrocautery, ligatures and hemostatic agents are some of the many ways
to control bleeding.
• Preserve blood supply because devitalized tissue=> necrosis/delayed healing (pay
attention to the wound edges because if they don’t have proper vascularization the
wound won’t close)
• Minimize tissue tension –here practice is key. You need to make the sutures not too
tight so that it crushes the tissues or cause pressure necrosis and not too loose so
that it could cause leakage or dehiscence. Also you have to leave room for
postoperative swelling.
• Appose tissues accurately: start from the depth of the wound an work your way to
the surface by stitching together tissues with similar structure
• Eliminate dead space to allow tissue layers to adhere to one another, thereby
speeding up healing. If needed, a passive or an active drain should be used if
bleeding or drainage is anticipated to prevent fluid accumulation.
Wound closure
The aim of closure is to appose the tissues in layers without tension or compression, but gap
free.
• Primary closure
=primary intention
-within 6-8 hours of trauma
-no significant degree of tissue loss/ deeper wounds with well approximated edges
-if no signs of inflammation or contamination can be detected
• Secondary closure
=secondary intention
-greater degree of tissue loss/ wound edges not approximated
-tissue loss that is compensated by granulation tissue= after debridement the wound
is left open to achieve sufficient granulation
-higher risk of infection
- wound dressing is required
=>scarring
 • Delayed primary closure
=tertiary intention
-combination of primary and secondary closure
-wound left open for a few days for observation for infections
-wound dressing is required
You may want to delay closure:
- if swelling has produced tension=> try to reduce swelling first; do not attempt to close
wound under tension
-unless the wound is clean and looks healthy: if you suspect an infection wait 24 hours then
check again, if everything looks ok =>delayed primary closure
-in presence of ischemia, devitalized edges, delayed presentation, foreign material: monitor
wound 24-48 hours=> exclude infection, necrosis=>delayed primary closure
Suture classification
• According to the number of layers:
• One layer
• 2 or multiple layers
-for deep wounds
-each layer must be apposed with its homologue on the other side of the
wound line
• According to the number of rows
• 1 row
• 2 rows (seldom multiple rows)
• According to the type of technique:
• Interupted
-advantage: when used in series failure of one stitch doesn’t prejudice the
other stitches; a part of the suture line can be re-opened in the postoperative
period if drainage should be necessary
-weakness: longer time and thread required
• Continuous
-advantage: quick to insert and have knots only at the beginning and at the
end
-weakness: if you mess up one of the 2 knots the whole stitch is in vain.
• According to the way they appose tissue:
• Appositional
- bring the tissue in direct approximation of the two cutting surfaces
 - useful for anatomically precise closure
• Everting
- turn the tissue edges outward
- eliminate dead space and counteract the tendency of wound edges to invert
during healing
• Inverting
- turn tissue inward
- indicated to close hollow viscera
To perform a suture you will need a needle, needle holder and thread.

Needles
The ideal surgical needle would have the following characteristics:
• It is made of high-quality stainless steel
• It has the smallest diameter possible
• It is stable in the grasp of the needle holder
• It is capable of implanting suture material through tissue with minimal trauma
• It is sharp enough to penetrate tissue with minimal resistance
• It is sterile and corrosion-resistant to prevent introduction of microorganisms or foreign
materials into the wound

Parts: point, body, swage

• Point types:
• Cutting needles (conventional, reverse or side/spatula)
• at least two opposing cutting edges
• the point is usually triangular
• used to penetrate dense, irregular, and relatively thick tissues
Conventional cutting needles have
• three cutting edges (a triangular cross-section that changes to a
flattened body)
• third cutting edge is on the inner, concave curvature
Reverse-cutting needles
• the third cutting edge is on the outer convex curvature of the needle
• stronger than conventional cutting needles
• have a reduced risk of cutting out tissue
• designed for tissue that is tough to penetrate (eg, skin, tendon
sheaths, or oral mucosa or in cosmetic and ophthalmic surgery,
causing minimal trauma
 Side-cutting (spatula) needles
• flat on the top and bottom surfaces to reduce tissue injury
• allow maximum ease of penetration and control
• initially designed for ophthalmic procedures.
• Taper (round) needles
• needles penetrate and pass through tissues by stretching without
cutting
• point flattens to an oval or rectangular shape
• used for easily penetrated tissues (eg, subcutaneous layers, dura,
peritoneum, and abdominal viscera) and minimizes the potential
tearing of tissue
• Blunt needles
• dissect friable tissue rather than cut it
• points are rounded and blunt
• decreased risk of needle-stick injury
• ideal for suturing the liver and kidneys
• blunt taper point needle is used for stitching soft tissues such as
the abdominal wall (excluding the skin)
• Beveled conventional cutting edge needles
• superior performance characteristics over those of other
conventional cutting edge needles
• composed of a unique stainless steel that has been heat-treated
after the curving process to enhance its resistance to bending
• the angle of presentation of its cutting edges has been decreased
to enhance needle sharpness
• recommended for closure of lacerations.
We mostly use the reverse cutting needle and the taper needle when practicing the sutures.
We use tapered needles when we are working with organs like bowels, blood vessels,
muscles, fascia and cutting needles for ligaments and skin.
 • Body types
- important for interaction with the needle holder and the ability to transmit the
penetrating force to the point
Straight body
• used to suture easily accessible tissue that can be manipulated directly by
hand
• used in microsurgery for nerve and vessel repair
Half-curved ski body
• rarely used in skin closure because of its handling characteristics
• the straight portion of the body does not follow the curved point, resulting in an
enlarged curved point that makes the needle difficult to handle
Curved body
• most common
• predictable path through tissue and requires less space for maneuvering than
a straight needle
• provides an even distribution of tension
• size is described as the proportion of a circle completed
Compound curved body
• originally designed for anterior-segment ophthalmic surgery
• the body has a tight 80° curvature at the tip, which becomes a 45° curvature
throughout the remainder of the body
• Swage
Swaged
• continuous unit of suture and needle
Nonswaged (eyed)
• suture is passed through an eye
• eye shape may be round, oblong, or square
• French-eyed needles (in which a slit is made at the end of the needle with
ridges that catch and hold the suture in place) ar the least traumatic of the
eyed needles
• lead to more tissue trauma and the suture is more likely to become
unthreaded prematurely than it would be with a swaged needle
Rules when handling needles:
• never handle the needle with your hands, only with instruments
• never lose sight or let go of the needle as you may lose it inside the wound or harm
the patient
• when you are done using the needle put it in the kidney tray along with the other
sharp instruments
• don’t pass the needle from hand to hand
• don’t gesticulate while the needle is in your hand
• when driving the needle follow its curve or else you will traumatise the surrounding
tissue and may bend the needle
 • don’t palm the needle holder while the needle is still in it
• do not draw trough the thread by pulling on the needle as you risk sticking the needle
intro someone or pulling the needle off the thread. Grasp the thread with a spare
finger of the hand holding the needle holder.

Needle holder
• the stability of the needle within the needle holder affects needle control and
performance
• jaws of the needle holder must be appropriate to the needle size to hold it securely
and prevent rocking, turning, and twisting
• grasp the needle 2/3 of the way back from the point for most applications
• grasp the needle in the middle (to increase strength) when dealing with denser
tissues
• have the needle point facing towards your nondominat side and pointing upward
when your hand is in the midprone position
• needle holders are designed to be rotated on their long axis with a
pronation/supination action of the hand to drive the needle trough the tissues in a
curved path
• if you need to carry out some other action it is useful to palm the needle holder by
removing your thumb from one ring and swing the needle holder until it points toward
your elbow and flex your little finger to lie between the rings
• when you are doing sutures that require a lot of precision you can hold the needle
holder from its joint and jaws but you should not be touching the needle

Thread
The ideal suture material would have all of the following characteristics:
• It is sterile
• It is suitable for all purposes (ie, is composed of material that can be used in any
surgical procedure)
• It causes minimal tissue injury or tissue reaction (ie, is nonelectrolytic, noncapillary,
nonallergenic, and noncarcinogenic)
• It is easy to handle
 • It holds securely when knotted (ie, no fraying or cutting)
• It has high tensile strength
• It possesses a favorable absorption profile
• It is resistant to infection
At present, unfortunately, no single material is available that can offer all of these
characteristics. Choose suture material based on the area of the body and the composition of
the tissue.

Monofilament Multifilament Pseudo-monfilament

• Do not • Several strands of fiber • multifilament thread
propagate are twisted or braided to coated with a
infections make one strand homogeneous
• Easy to handle • Stronger than smooth layer
monofilament • the capillarity is lost
• Can be knotted securely • combines the
• Due to their capillarity advantages of
they facilitate the monofilament and
migration and proliferation multifilament
of bacteria among the
strands=>propagate
infections

Capillarity - Extent to which absorbed fluid is transferred along the suture

Tensile strength - Measure of the ability of a material or tissue to resist deformation and
breakage.
Absorbable Nonabsorbable
• broken down in the body by • Effectively resists enzymatic digestion
enzymatic digestion, hydrolysis • Used in tissues that heal more slowly or
or lysosomal enzymes is a very secure tightening is required
• accelerated absorption may • Either left in the body becoming
occur in patients with fever, embedded in the scar tissue or removed
infection, or protein deficiency, when the healing is complete
and this may lead to an (USP) classification of nonabsorbable
excessively rapid decline in sutures:
tensile strength • Class I - Silk or synthetic fibers of
• accelerated absorption may monofilament, twisted, or braided
also occur in a body cavity that construction
is moist or filled with fluid or if • Class II - Cotton or linen fibers or coated
sutures become wet or moist natural or synthetic fibers in which the
during handling before coating contributes to suture thickness
implantation without adding strength
• Class III - Metal wire of monofilament or
multifilament construction
Natural Synthetic Natural Synthetic
>they tend to fray during >inert •Silk •Polyesters:
knot construction >great •Linen =>no longer stronest sutures
>variability in their tensile •Cotton used beside surgical
retention of tensile strength •Stainless surgical steel: steel; used in
strength >user for orthopedic,neurosurgical, cardiovascular
>from different bovine or nearly all and thoracic applications surgery
tissues Almost no tissue reaction •Polyamide (Nylon)
ovine body parts
but is difficult to handle •Polypropylene:
• Collagen: from flexor >rigid and
slippery so and can easily cut tissues. high tensile
tendon strength; used in
need extra
• Plain surgical gut: for cardiovascular
 repair of rapidly healing knots (blood vessel
tissues that require sutures) and plastic
surgery
minimal support and
ligation of superficial
blood vessels
• Fast-absorbing surgical
gut: epidermal use
• Chromic surgical gut:
slower absorption

Size of thread
• sizes are standardized and are related to a specific diameter range (in millimeters),
tensile strength (maximal stress that it can withstand before breaking) and knot
security. The criteria vary depending on whether the suture is natural or synthetic
fiber, absorbable or nonabsorbable.
• the higher the size number the thicker the thread, the more 0s the smaller the size

Rules when working with thread:

• whatever the type of thread do not use excessive force when pulling it and you may
break it or worse: weaken it and it will break later
• remove all unnecessary instruments from the area and arrange the thread so it
doesn’t catch as pulling may cause tissue damage
• watch spare thread so it doesn’t catch onto things
• do not grab thread with needle holder as you may weaken the thread
• do not try to stitch with thread of too short length
Rules for wound closure:
• sutures must not be placed too close to the wound edges as the thread can tear
them; place them 0,5-1cm from the wound edges on both sides
• stitches should be placed at equal distances
 • knots should be on one side of the wound and never on the wound line
• stitches should be placed opposite each other so there are no wrinkles and gaps
• wound edges must not be inverted because it will cause a thick scar
• gauze, rubber tubing, or buttons can be incorporated into the tension sutures to
reduce the risk of cutting out of sutures=> “quilled” or “stented” suture

Incision
• Before making the incision you need to do the anesthesia. There are four main
categories of anesthesia used during surgery and other procedures:
• general anesthesia
-3 major effects: unconsciousness (and amnesia), analgesia and muscle
relaxation
-IV or inhaled or both
• regional anesthesia

-2 types: -peripheral nerve blocks = a local anesthetic is injected near

a specific nerve or bundle of nerves to block sensations of pain
from the area of the body supplied by the nerve

-central nerve blocks (spinal/ epidural) = a local anesthetic is

injected near the spinal cord and major nerves that enter the
spinal cord to block sensations of pain from an entire region of
the body, such as the lower abdomen, the hips, or the legs

• sedation ("monitored anesthesia care")

-usually through an IV
-used to make the patient feel drowsy and relaxed
- patients can recover fast
• local anesthesia-
-most frequent administered
-local anesthetic drug injected intradermally (needle at 15°=> papule)
-used for the removal of small lesions or to repair traumatic injuries
-may be accompanied by IV sedation
 • Fit the blade you want to use on the scalpel. You do this by sliding it on while holding
it clear of the sharp edge with your instrument. Don’t touch the blade with your hands
and always keep it facing downwards.Your choice of blade will depend on the
procedure you are going to undertake. A small incision is made with a 15-blade.
Most common blades:

• The incision is started with the tip of the blade and continued with the cutting edge. In
the case of skin and other tough tissues which are hard to cut, the handle of the knife
is held between the thumb and middle and ring fingers and the index finger is placed
on the back of the blade; this makes possible a strong and well-controlled incision. In
short or fine incisions, the scalpel is held like a pencil, and cutting is made mostly with
the tip. Neither the blade nor the handle far from the blade is grasped during the
incision.

• Cut in sagital plane from far to near and in transverse plane from nondominant to
dominant side.

Drains
-inserted to empty existing fluid and those that might collect later
-used to channel pus blood, body secretions or air in order to alleviate pain and inflammation.
They prevent the build-up of tension and the formation of spaces which would keep tissue
surfaces from coming into contact with each other and healing.
Main types of drains
A. Passive (without suction) drain types are strips, tubes or bands made from the fingers of
surgical gloves. These drains are usually laid into the wound or on the base of a cavity and
enter the surface through a distinct aperture.

Tube drains
- great advantage that they can lead away any content into a receptacle, such as a bag or
other reservoir, thus forming a closed system, reducing the possibility of infection tracking
back into the tissues
-usually have side as well as end holes

-fluid will flow only if the tube is sufficiently wide so that air can displace the fluid

-in the presence of severe contamination or infection, do not attempt to close the skin, vainly
hoping that the drains will provide adequate removal of any discharge
-fix it in place using half hitch knot + square knot

B. Active drainage with suction. A tube drain (made of silicone or plastic) supplied with
multiple holes is used. It reaches the surface at an aperture separate from the wound. The
tube is secured to the skin and connected to a sterile bottle in which subatmospheric
pressure (“vacuum”) has previously been created. This bottle will suck out the discharge as
long as the pressure is lower than that in the cavity.