University of Juba

School of Veterinary Medicine

Department of Clinical Studies
General Surgery

Definitions
Surgery is a branch of medical science which deals with the treatment of injuries or diseases
by manual procedures or operations with the hand. It is synonymous with the word "Chirurgia"
(pronounced as: KI-RUR-JIA). The Greek word "Cheir" means hand; and "ergon" means work.
Veterinary Surgery is surgery practiced on animals.
Orthopaedic Surgery is that branch of surgery which is "specially concerned with the
preservation and restoration of the function of the skeletal system, its articulations and
associated structures.
Aseptic Surgery is surgery carried out practically free of bacterial contamination so that
infection and suppuration are avoided.
Conservative Surgery is surgery wherein every attempt is made to preserve or restore a
disabled part, rather than its removal, e.g., correction and immobilization of a fracture in a limb
rather than amputation of the limb.
Radical Surgery is surgery by which the root cause or source of a disease condition is removed
or rectified, e.g., radical surgery for neoplasm, radical surgery for hernia.
Minor Surgery is surgery which is relatively simple to perform, having no risk on the life of
the patient and requires the services of no assistant. e.g., opening of a superficial abscess,
wound dressings, inoculations, superficial neurectomies and tenotomies.
Major Surgery is surgery which is relatively more difficult to perform than minor surgery, is
time consuming, involves risk on the life of the patient, and requires the help of an assistant
e.g., caesarian section, mammectomy, thoracic surgery, brain surgery, etc.
Emergency Surgery is surgery which is to be performed urgently to avoid further
complication of the disease process or to save the life of the patient.
Elective Surgery is surgery which can be postponed without endangering the life of the patient.
Cosmetic Surgery in veterinary practice is surgery done either to improve the appearance of
an animal, or to satisfy the fancy and sentiments of the owner. e.g., trimming of the ears,
docking of the tail, etc.
Reconstructive Surgery is surgery done for the correction of deformities or malformations.
e.g., surgery for cleft palate, contracted tendons, etc.
Plastic Surgery is surgery which is performed for the repair of defects or for correction of
deformities, either by direct union of parts or by transfer of tissues from one part to another.
Exploratory Surgery is done to arrive at a diagnosis or for the confirmation of a diagnosis.
Experimental Surgery is the systematic investigation of surgical problem.
Clinical Surgery is surgery taught with the presence of the patient, so that the objective
symptoms and the treatment given can be actually observed by the student. Clinic (Hospital):
An institution in which medical attention is given to patients.
Surgical Anatomy is anatomy of a limited area or region referred to or explained in the proper
description of a surgical operation.
Surgical Bacteriology is the study of the microorganisms concerned, e.g., surgical
bacteriology of wounds. Surgical Pathology is a branch of pathology which deals chiefly with
the effects produced upon the animal body by a surgical condition.
Recommendations for Surgical operation

The reasons for performing a surgical operation may be anyone or more of the following:
(i) To save the life of an animal, e.g., surgery in the case of an acute intestinal
obstruction.
(ii) To prolong the life of an animal, e.g., removal of a malignant tumour.
(iii) To hasten recovery from an injury, e.g., splinting of fractures, suturing of wounds.
(iv) For elimination of a disease process, e.g., extraction of a diseased tooth, removal of
a benign tumour.
(v) For cosmetic reasons, e.g., trimming of ears, docking.
(vi) For correcting deformities or malformations (Reconstructive surgery), e.g.,
correction of a congenital deformity like cleft palate (Staphylorrhaphy or suturing
cleft palate), contracted tendons in calves and foals, cryptorchidism.
(vii) For the replacement of a part by an artificial one, e.g., artificial eye, artificial limb,
prosthetic hip.
(viii) On economic reasons or to make an animal socially acceptable, e.g., castration,
spaying, dehorning, debleating of sheep, debarking of dogs.
(ix) To aid in diagnosis of a suspected pathological process, e.g., exploratory
laparotomy.
(x) For investigation in research work (Experimental surgery), e.g., salivary fistula,
gastric fistula.
Tenets (Principles) of Halstead
the principles of modern surgery first laid down by Halstead (1852-1922).
1. Gentle handling of tissues. The tissues should be handled gently. Rough handling, use of
blunt cutting instruments, unnecessary clamping of tissues with forceps, etc. cause additional
trauma.
2. Aseptic surgery. Surgery should be performed under aseptic conditions.
3. Anatomical dissection. The dissection of tissues during surgery should be very
discretionary. No muscle, nerve or vessel should be cut unnecessarily. To ensure this, the
surgeon should possess an adequate knowledge of anatomy. To approach a deeper structure, it
is very often possible to separate relevant muscles rather than cut the muscles. When a muscle
is to be cut (as in the case of an amputation), it might be better to cut it at its tendinous portion
rather than at its belly, to minimize bleeding. In certain situations, it is better to separate the
muscle fibres and get through the muscle in order to reach a deeper structure instead of cutting
through the muscle. Main nerve trunks should not be cut, as far as possible, during dissections;
they may be carefully shifted aside.
4. Control of haemorrhage. Bleeding should be controlled at every stage during dissection.
5. Obliteration of dead space. The creation of so called "dead space" or vacant cavities should
be avoided while closing the wound after surgery, because blood and exudates will collect
there. (Such dead spaces might occur after removal of a tumour, removal of mammary gland,
etc., if not properly sutured. Sometimes packing the cavity is desirable to avoid dead space).
6. Use of a minimum quantity of suture material. Since suture materials are foreign bodies,
only the minimum essential quantity should be used.
7. Avoidance of suture tension. Sutures should not be very tight on the edges of the wound;
otherwise the blood supply to the edges is obstructed and causes delay in the healing process.
The interference to blood supply at points where the edges of wound are crushed by the sutures
may cause local necrosis facilitating sutures to cut through the tissue resulting in wound
disruption.
8. Immobilization. Immobilization or preventing excessive movement of the wounded area is
very important for healing to take place normally. Sutures, adhesive tapes, bandages, plaster
casts, etc., help immobilization by artificial means.
Suture Materials
A suture is a thread used for uniting wound edges. Nylon, silk, cotton, catgut, stainless steel
suture, etc., are some of the common suture materials used. The term "suture" is used for
denoting a pattern of suturing also, e.g., interrupted suture, continuous suture, Lembert's suture.
The purpose of suturing a wound is to bring the edges of the wound close together, so that
healing may take place quicker.
Classification of Suture Materials
Suture materials may be classified into two broad categories namely, absorbable sutures and
nonabsorbable sutures.
Absorbable Sutures
Absorbable sutures are sutures which get absorbed by the tissues after a variable period of time.
The absorption takes place by phagocytosis and enzymatic action.
1. Catgut. Catgut is the most com manly used absorbable suture. It is made out of the elastic
submucosa of sheep intestines. The absorption of catgut in tissues can be delayed by treating it
with chromic acid. Catgut is therefore available as "plain catgut" and "chromicised catgut'".
The chromicised catgut is less irritating to tissues than plain catgut and also is more slowly
absorbed.

According to the degree of chromicising the following types are available.

Type Degree of Approximate number of days taken for
chromicising absorption
Type-A Plain 10 Days
Type-B Mild chromic 15 Days
Type-C Medium chromic 20 Days
Type-D Extra chromic 40 Days

Among those listed above, medium chromic (TypeC) the most commonly used. Plain catgut is
used in tissues which heal rapidly, e.g., for suturing parietal peritoneum, ligaturing vessels, etc.
Chromic catgut is used in tissues which heal more slowly e.g., for suturing muscle. Catgut is
available in sealed glass tubes with some fluid preservative.
Depending on the preservative used catgut is available either as boilable or non-boilable
catgut. Boilable catgut is preserved in Xylol, or in solution of Toluene 99.75% plus Phenyl
mercuric acetate 0.025%. These tubes can be sterilized by boiling, autoclaving, etc. Boilable
catgut is somewhat stiff. To soften it, it is to be soaked in sterile water or normal saline before
use. Non-boilable catgut is supplied in tubes containing 90 to 95% alcohol and so it cannot be
sterilized by boiling. Alcohol is a preservative for catgut but when preserved in lower
concentrations of alcohol the strength is reduced because of proportionately higher water
content. The minimum concentration of alcohol recommended for purpose of preserving catgut
is 85%
2. Kangaroo tendon. This is another absorbable suture material prepared out of the tendons
taken from the tail of kangaroo. Being very strong, kangaroo tendons are useful for suturing
joint capsules, hernial opening etc.
3. Fascia lata. An absorbable suture material made out of fascia lata of the bovine. Available
in tape like pieces it is preserved like catgut in glass tubes. This is only rarely used. Fascia lata
can be collected (usually from slaughter houses) and stored as follows. With usual aseptic
precaution the skin over the thigh is reflected. The fascia lata is cut and removed in half inch
broad tape like pieces. These pieces are transferred into glass tubes containing physiologic
saline solution incorporated with penicillin 200,000 units and streptomycin 0.25 grams per 10
CC. After thirty minutes the liquid is decanted off and the tube is sealed and kept in a
refrigerator at -10 °F. When needed for use the tube is broken and the fascia is put in sterile
physiological saline at room temperature.
4. Cargile membrane. This is a thin sheet of tissue made out of bovine caecum used to cover
surfaces from which peritoneum has been removed. Not in general use.
5. Polyglycolic acid suture material. This is a new synthetic absorbable suture material. It is
strong. noncollagenous and nontoxic.

Non-Absorbable Sutures
These sutures do not get absorbed by the tissues. When used as outside sutures they are
removed after healing is completed. If allowed to remain in tissues they get encapsulated.
1. Silk. This is a non-absorbable suture commonly used. It is cheap, easily available, easy to
handle, easily sterilized by boiling and is well tolerated by tissues. Silk is available in size
numbers 0 to 14. A disadvantage of silk is that it is capillary.
2. Silk worm gut. This is prepared out of the silk sacs of the silkworm. It is actually "unborn
silk". Available as short strands of 12 to 16 inches it has a smooth surface and is noncapillary.
3. Cotton. This is very cheap suture material. It can be sterilized by boiling. It is less irritating
to tissues than silk or catgut. But like silk the capillary action is a disadvantage.
4. Linen. This is made out of superior quality cotton. It has good tensile strength.
5. Nylon. This is a synthetic product. It is noncapillary, strong, and has a smooth surface. It is
somewhat stiff and therefore a little difficult to handle and to put secure knots. While using
nylon, special knots called "nylon knots" should be put since ordinary surgical knots of nylon
become loose very easily.
6. Horse hair. It is a cheap suture material. Non-capillary, flexible, easily sterilized by boiling
it causes little tissue reaction. But it is not very strong.
7. Umbilical tape. This is cotton tape suture about one eighth inch wide and is used to tie the
umbilical cord of the new born. It is available in reels in plastic containers.
8. Dermal suture. This is a non-absorbable suture used for skin suture. It is silk coated with
tanned gelatin or other protein substance. The protein coating prevents in-growth of granulation
tissue into the suture material and also makes it non-capillary, it is not available.
9. Pagenstecher. This is linen coated with protein like substance, available in glass tubes (like
catgut). Though non-absorbable, they are used in gastrointestinal surgery. It is not available.
10. Vetafil. This is a non-absorbable suture made out of a synthetic fibre. It is a patent product.
It is non-irritant, non-capillary and easy to handle. Sizes commonly used are medium (diameter
0.2 mm) heavy (0.3 mm), extra heavy (0.4 mm) and special (1.1 mm).
11. Stainless steel wire. S.S wires of different sizes are used for suturing. They are very strong
and are chemically inert. They do not lose strength by wetting and are easily sterilized by
boiling, autoclaving, etc. Also they are non-capillary and non-irritant. Its disadvantages are:
1) Being stiff, difficult to handle;
2) May cut through tissues;
3) Knots are insecure unless carefully placed;
4) Sharp ends may prick through tissues;
5) Continuous sutures may break into fragments when subjected to constant movement and
therefore it is better to put interrupted suture only.
12. Wires of tantallum, silver etc., are similar to stainless steel wires, but are costlier.
13. Aluminium wire. It is more flexible than stainless steel.
14. Wound clips. Michel wound clips are sometimes used for skin sutures. The clips are made
of a malleable metal. They are applied with special forceps and compare to sutures can be
applied far more quickly. They do not enter into the wound and do not leave recognizable scars.
But they are not strong enough to hold wound edges under tension and can be easily removed
by the patient.
15. Pin sutures. Ordinary pins can be used for keeping skin edges together.
16. Prolene. Good synthetic material, non-irritable.
Principles of Tying a Knot
(a) Knots placed in suture should be secure and maintain the suture in proper tension.
(b) Portions of suture material that have been crushed by clamps or artery forceps should not
be included in a suture or a knot as the suture may break off at that point.
(c) While placing a knot, the sawing effect between the suture strands should be avoided as it
will weaken the strands.
(d) The knots should be tight enough not to untie; but suture should not be excessively tight to
cause strangulation, except in the case of haemostatic sutures.
(e) The completed knot should be small and compact. In buried knots the cut ends should be
short so that the quantity of suture (which is a foreign body) left inside is minimum
Types of Knots
There are innumerable types of knots. Only a few of them which are of interest to the surgeon
are listed below.
1. Square knot. The first loop of the square knot is made by making a simple throw by turning
around one of the two ends (say, end A) of the suture material around the other end (say, end
B); and it is tightened carefully so that the ends do not cross and are pulled with equal tension.
The second loop of the square knot is made by making what is called a reverse throw by taking
the end B around A, unlike during the first throw. Here also the ends should not cross and
should be pulled with equal tension. A square knot may contain more than two throws to make
it more secure; in which case, each throw will be a reversal of the former.
2. Half-hitch. This is an incomplete knot. One end of the suture material is taken around the
other to form loop. But when this loop is tightened, one end is pulled with greater tension than
the other. (Unlike while placing a square knot). It may also be noted in this connection that if
one of the two ends of the square knot is unduly pulled, it will turn itself into a half-hitch and
will become insecure.
3. Granny knot. In the granny knot, the first throw is made similar to the first throw of the
square knot. But the next throw is made without reversing the ends.
4. Surgeon's knot. In the surgeon's knot the first loop is made by taking two turns of one of
the suture ends against the other; and the second loop is similar to that of a square knot. Because
of the additional turn in the first loop, it is not likely to get loosened in the process of placing
the second loop. The surgeon's knot is more secure than a square knot. But it consumes more
time, the size of tile knot is larger, and hence places more suture material in the tissues. Some
surgeons, therefore, prefer the square knot repeated twice or thrice to a surgeon's knot. Another
disadvantage of surgeon's knot is that it fails to exert tension if used for ligaturing small vessels,
because of the additional turn and increased bulk of the first throw.
5. Double surgeon's knot (Double reef knot). It is recommended when using suture materials
that are likely to slip. (e.g. nylon). This is actually a surgeon's knot plus a third throw; similar
to the second throw. It is also called a "Triple knot" or "Reinforced surgeon's double slip" or
"Reverse knot", or. "Nylon knot" or Surgeon's knot with square knot. This is a surgeon's knot
with an additional square knot.
Methods of Tying the Finishing Knot to End a Continuous Suture
Buried Knots
In a subcuticular suture, the knot is buried and is not visible outside. The suture thread is passed
through one of the edges of the skin starting from the subcutis upwards and is returned through
the other edge in a reverse manner (i.e., from above downwards) so that the knot can be placed
at the starting point of the suture in the subcutaneous space. When the next suture is placed the
first knot is automatically covered by the tissues. In a continuous subcuticular suture also the
beginning knot is placed in a similar manner and gets covered when the suture is tightened.
The finishing knot also can be buried with a little care.
Suture Patterns, Instruments and Suture Technique
The suture patterns are broadly classified into interrupted sutures and continuous sutures.
Special sutures used for various purposes like tension sutures, tendon sutures, suture for
vessels, nerve sutures, etc., may also fall in one of these two categories. Clip sutures, pin
sutures, safety pin sutures, etc., belong to a different type, but may be compared to interrupted
sutures. Suture patterns may further be classified as:
(1) Apposition sutures,
(2) Inversion sutures,
(3) Eversion sutures,
(4) Purse-string suture (tobacco pouch suture),
(5) Tension suture (relaxation suture), and
(6) Other miscellaneous sutures.
Interrupted Sutures
When the wound is sutured by a number of independent sutures, they are called interrupted
sutures. Generally, the interrupted sutures are preferable to continuous sutures because even if
one suture in the line is broken or untied the others may not be affected. But interrupted sutures
are more time consuming, require more suture material and the large number of bulky knots is
a disadvantage,
1. Simple interrupted sutures.
It is the most commonly used suture for the skin. The suture penetrates one edge from outside
and goes to the other edge pierces it from underneath and comes out on the skin of the other
edge the knot is tied and the excess suture material is cut off distal to the knot. The suture when
tied is at right angles to the line of incision. It goes across the line of incision. The knot should
be on one side and not on the line of incision. The point of piercing of each edge is usually one-
eighth inch (2 to 3 mm) from the line of incision. It will be more convenient to start the suture
from the distal edge and then go through the proximal edge. See that the skin edges are not
inverted while the suture is being tied; it may be just apposition or if not, slightly everted. The
distance between sutures varies, but usually three-eighth inch (0.6 cm) is sufficient.
2. Mattress suture (Horizontal mattress suture;
Interrupted horizontal mattress suture; Four stitch interrupted suture; U-suture). This suture is
preferable to simple interrupted suture where tension is expected. It is actually a relaxation
suture (tension suture) also, in addition to being an apposition suture. If it is tightened, eversion
of wound edges also can be brought about. The suture is started like a simple interrupted suture
but it returns to the same edge of the wound travelling in a V-shaped manner, and is tied. When
tied, the exposed pieces of the suture are seen parallel to and on either side of the line of
incision.
3. Mattress suture through rubber tubing.
When the tension expected is too much, and the sutures are likely to cut through the skin, it is
desirable to pass the exposed portions of the mattress suture through small pieces of rubber
tubing kept parallel to the edges.
4. Cross-mattress suture (X-mattress suture).
Here the exposed portion of mattress suture is passed to the opposite edge diagonally (instead
of at right angles to the suture line), presenting the appearance of "X". The concealed portion
is parallel to each edge. The advantage is that it brings about better apposition than a simple
horizontal mattress suture described above.
5. Interrupted inverted mattress suture.
 Here the exposed portion of the suture is seen across the line of incision and the concealed
portion runs parallel to the line of incision. Suture is not made to pierce through the mucous
coat in a hollow organ but runs through the muscular coat.
6. Halstead suture.
This is actually a double interrupted Lembert's suture using a single thread which is reversed
to the same side and tied. It is different from a simple horizontal mattress sutures.
7. Vertical mattress suture.
Unlike in the horizontal mattress suture, the exposed portions of the suture on either side of the
incision are at right angles (vertical) to the line of incision instead of being parallel. The suture
pierces the skin of the one edge from outside about 0.5 to 1.0 cm away from the line of incision
and pierces the opposite edge at an equal distance from below upwards. It then pierces the skin
of the second side close to the line of incision tied. The tightening is done to bring about just
apposition of edges and not eversion. Vertical mattress sutures also have the capacity for
withstanding tension and are even better than horizontal mattress sutures in this respect. They
cause less interference in the blood supply to the edge than the horizontal sutures. The
disadvantages are that it is more time consuming and uses more suture material in the tissue.
8. Donati's vertical mattress suture.
This differs from an ordinary vertical mattress suture slightly. The suture material is exposed
in only one of the two edges because in the other edge it is intracutaneous.
9. Crushing (or, Gambee) suture.
This is a special type of apposition suture suitable for intestinal anastomosis. The passage of
suture through the two cut ends of the intestine facing each other is as follows: starting from
serosa of one edge to the serosa of the other edge: From the serosa to the lumen: prick mucous
membrane close to the edge and come out through the muscularis. Next penetrate through the
corresponding muscularis of the opposing edge and into its lumen and prick mucous membrane
of that lumen slightly away from where it entered: come out through serosa and the two ends
of the suture are tightened and tied. When this is done the mucous edges are slightly inverted
and the remaining portions of the edges are only brought into apposition. Crushing suture is
preferable to ordinary inversion sutures when the lumen of the bowel to be united is small. As
the edges are not fully inverted, the lumen is not obstructed,
Continuous Sutures: -
In a continuous suture a series of stitches are made up of the same continuous thread so that
only the first and last stitches are tied. The advantage of a continuous suture is that it takes less
time than interrupted sutures covering the same distance. However, the disadvantages are:
damage to the suture anywhere along its length makes it loose and the wound may disrupt; a
continuous suture is not as good as an interrupted suture in places exposed to much tension;
and if not carefully placed, proper apposition of edges may not be obtained.
1. Simple continuous suture (Furrier's suture).
This is started as a simple interrupted suture and the subsequent stitches are continued with the
same thread till the final knot is tied. The running suture pass through the tissues at right angles
to the edges and the exposed portion of the suture go diagonally to the line of incision. Useful
for peritoneum, muscles, etc., but not usually recommended for skin as perfect apposition of
edges may not be brought about.
2. Continuous lock stitch (Blanket stitch;
Ford interlocking suture; Reverdin's continuous suture). The "locking" is brought about by
passing the needle and thread through each loop of the simple continuous suture before it is
tightened. The stitches hold the tissues in better apposition because of the "locking".

3. Continuous Lembert's suture.

This is an inversion type suture used for hollow viscera like intestines. Sutures pass through
serosa and muscular and submucous coats, but not through the mucous membrane. The suture
runs at right angles across the line of incision through the tissues; and the exposed portion of
the suture runs diagonally, so that the adjacent portions of suture passing through tissues are
parallel to each other.
4. Connell suture.
It is an inversion suture. The suture passes through each edge alternatively. It penetrates
through all coats of a hollow organ including the mucous membrane in the case of bowel. When
tightened, the suture thread is hardly visible outside, except at the knots. During the process of
placing, the portions of suture that are visible are at right angles to the line of incision and those
that are within the tissue of either edge ale parallel to the line of incision.
5. Cushing suture.
Similar to Connell suture the only difference is that cushing suture do not penetrate the mucous
coat and enter the lumen.
6. The Parker-Kerr suture.
This is a cushing suture which is used to close a stump. his first passed around the forceps
holding the stump. It is first passed around the forceps then the forceps are withdrawn and the
suture is tightened and tied. It can also be used as a temporary stay suture without knots in
intestinal anastomosis to close each of the segments of intestines temporarily.
 7. Modified cushing (Guard's suture).
Similar to Cushing's but is extended beyond the two commissures at the starting and ending
of the suture, imagining an extended line of incision. The advantage is better efficiency in
preventing leakage of contents.
8. Continuous inverting mattress sutures.
Connell and Cushing sutures are the examples of this.
9. Schmieden's suture.
This is a continuous suture for the intestines which should always be covered by a continuous
Lembert or Cushing suture because the suture partially enters the lumen. The suture which
comes out through the serous surface of one edge during the course of placement goes over to
the mucous surface of the other edge and comes out through the serous surface of that edge.
The advantage of Schmieden's suture is its quick placement.
10. Continuous everting mattress suture.
This is indicated when the edges of a skin suture are to be everted by a continuous suture. The
pattern of running the suture is somewhat similar to a Connell suture, with the important
difference that unlike Connell the exposed threads are parallel to the line of incision while those
buried in tissue run across the edges.

11. Continuous subcuticular (subepidermal) suture.

The suture is similar to a continuous horizontal mattress suture except that it does not come
outside the skin. Instead, the bites are taken in the inner layers of the skin (the subcuticular
layers). If the suture is not to be removed, absorbable suture is used and the beginning and
ending knots are buried. The opposing surfaces of the two edges can be brought about in good
apposition, and the patient need not be brought to the hospital again for suture removal. Since
the suture is not exposed, there is less chance of the patient interfering with it. If non-absorbable
suture material is used, removal after healing can be facilitated by keeping the knots exposed
(instead of buried). To remove the suture, snip the suture at the knot at one end and pull off by
the other end.
1. Far-near and Near-far suture.

These are sutures going very deep into tissues besides the skin. For purposes of explanation,
imagine two points on the skin at right angles to the line of incision, on each of the skin edges.
Let us mark them as A and B on one side and C and D on the other side. Points A and D are
the points far away from the line of incision; and B and C are the near points. The suture
entering the tissues through A comes out through C on the other side (hence called "farnear"),
and then the suture reverses through points B and D (hence "near-far"), and is tied.
 2. Far-far and Near-near suture.

This name also indicates the course of passage of the suture thread through the two edges of
the wound successively.
Suture Techniques
1. Analgesia.
This is necessary only in the case of very sensitive and restless animals. Local analgesic
solution is injected subcutaneously in the form of weal along the edges by introducing the
inoculation needle through the wound itself.
2. Use of Needle Holder. (Needle forceps, needle holding forceps).
When needles of small size are used it is more convenient to use a needle holder. The needle
holder should be clamped away from the eye of the needle. Curved needles should be held at
the tip of the jaws of the forceps as otherwise the shape of the needle might get altered.

3. Use of tissue forceps.

Tissue forceps are used to hold the edges of a wound while suturing. This should be done
gent1y without causing excessive trauma.
4. Avoid excessive tension on sutures.
If there is much tension on sutures they may cut through tissues or may interfere with blood
supply to the edges of the wound. Tension can be minimized with the help of relaxation sutures.
5. Size of suture material.
Suture material should be sufficiently thick and strong enough to withstand tension. Thinner
sutures are preferable to excessively thick ones provided they are strong enough.
6. Method of placing knots.
Knots must be tight and compact as otherwise they are likely to become loose and suture will
give way. The pattern of knot ordinarily recommended is the Surgeon's Knot. The Nylon Knot
and Triple Knot are advisable while using stiff suture materials. The ordinary Granny Knot
should never be used in surgery. A forceps or needle holder may be used for placing knots.
7. Length of the cut ends of the suture
(after tying the knot) need not be longer than one-eighth to one-fourth of an inch. But if they
are very short the knot may become loose and open.
8. Method of opening a tube of catgut.
 Place the tube inside a rolled up towel and hold it at either end with hands. Break the tube by
bending. The glass pieces are discarded. The catgut is pulled and stretched before being used
for suture.
9. Handling the suture.
Remember that while suturing, the loose portion of the suture should not be allowed to drag
along but should be gathered in the hand; as far as possible do not crush the suture by holding
with forceps while placing knots; if a portion is crushed with forceps do not use that part for
further suturing; and do not pull the suture excessively as it will lessen its strength.
10. Method of threading the needle.
A convenient method of threading the needle is done by holding the suture tip within two
fingers and pressing the needle eye to it.
11. Removal of sutures.
While removing sutures the soiled portion of the suture should not be allowed to pass through
the tissues. First, clean the area with spirit and apply a good antiseptic (Tr. Iodine) over it. Hold
the suture and gently lift it so that a little of its buried portion is exposed. Cut at this newly
exposed part and draw out the suture. After removing the suture, an alcoholic solution (Tr.
Iodine) is applied over the area to seal the small openings on the skin left by the suture.