CLINICAL ANATOMY OF

ANTERIOR ABDOMINAL WALL &

RECTUS SHEATH
Structure of anterior abdominal wall
• The anterior abdominal wall is a musculoaponeurotic
structure confined to anterior and lateral aspects of the
abdomen.
• Bounded above by the xiphoid process , right and left coastal
margins
• Below by the anterior part of iliac crest , fold of groin, pubic
tubercle , pubic crest and symphysis
• BONY LANDMARKS
• Coastal margins
• Xiphoid process
• Iliac crest
• Pubic symphysis

• SOFT TISSUE LANDMARKS

• linea alba
• Linea semilunaris
• Umbilicus
• McBurney’s point
• Murphy’s point
ABDOMINAL PLANES
Structure of Abdominal Wall

Anteriorly:

• The abdominal wall is formed above by lower part of the thoracic

cage

• Below by the rectus abdominis, external oblique, internal oblique,

and transversus abdominis muscles and fasciae
Structure of Ant. Abdominal Wall
• It is made up of skin
• superficial fascia
• External oblique muscles
• Internal oblique muscle
• Tranversus abdomins
• Fascia tranversalis
• Extra peritoneal tissue
• Parietal layer of peritoneum
Skin
• Natural lines of cleavage ( langers’s lines ) in the skin are constant
and run almost horizontally around the trunk

• An incision along a cleavage line will heal as a narrow scar, while

one that crosses the lines will heal as a wide scar
Superficial Fascia
• Above the level of line joining 2 ASIS the superficial fascia consists
of single layer , below the line is in 2 layers

• Fatty layer or fascia of camper is continuous with the superficial fat

over the rest of the body and may be extremely thick in obese
patients

• The membranous layer or scarpa’s fascia is thin and fades out

laterally and above

• Becomes continuous with the superficial fascia of the back and the
thorax
• Between the 2 layers cutaneous blood vessel lies.
Superficial Fascia
• Inferiorly the membranous layer passes onto the
front of the thigh, where it fuses with the deep fascia

• In the midline inferiorly forms a tubular sheath for

the penis or clitoris

• Below in the perineum, enters the wall of the

scrotum or labia majora

• From there it passes to be attached on each side to

the margins of pubic arch, here it is called Colle’s
fascia
Superficial Fascia
• Posteriorly it fuses with the perineal body and the margin of the
perineal membrane

• The fatty layer is represented as a smooth muscle in the scrotum,

the dartos muscle

• The membranous layer persists as a separate layer

Cutaneous Nerve Supply

• Is derived from the anterior rami of the lower six thoracic and first
lumbar nerves

• Thoracic nerves are the lower five intercostal ( T7-T11)and the

subcostal nerves ( T12)

• First lumbar nerve is represented by the iliohypogastric and

ilioinguinal nerves
 Blood Supply
• Skin near the midline is supplied by branches of the superior epigastric
artery (br. of int. thoracic artery) and the inferior epigastric artery ( br. of
external iliac artery)

• Skin of the flanks is supplied by branches from the intercostal, lumbar, and
deep circumflex arteries
• 3 superficial inguinal arteries are the superficial branches of femoral
artery
1. Superficial external pudendal
2. Superficial epigastric
3. Superficial circunflex iliac

• Cutaneous veins accompany cutaneous arteries

• below the umbilicus they drain into saphenous veins to IVC
• Above the umbilicus to axillary veins to SVC
Deep Fascia

• Deep fascia in the anterior abdominal wall is merely a thin layer of

connective tissue covering the muscles

• It lies immediately deep to the membranous layer of the superficial

fascia
Muscles
• 5 Pairs of muscles
• 3 flat muscles and 2 vertical muscles

• External oblique muscles

• Internal oblique muscle
• Tranversus abdomins
• Rectus abdominis
• pyramidalis
Muscles

• As the aponeurosis of three sheets pass forward, they enclose the

rectus abdominis to form the rectus sheath

• The cremaster muscle which is derived from the lower fibers of

internal oblique, passes inferiorly as a covering of the spermatic
cord and enters scrotum
External Oblique Muscle
• Is a broad, thin, muscular sheet

• Origin: Lower 8 ribs

• Insertion: Xiphoid process, linea alba, pubic tubercle, iliac

crest

• Nerve Supply: Lower 6 thoracic nerves, iliohypogastric &

ilioinguinal nerves

• Action: Supports abdominal contents, assist in forced

expiration, micturition, defecation, parturition, vomiting
External Oblique Muscle

• A triangular shaped defect in the external oblique aponeurosis lies

immediately above and medial to the pubic tubercle, known as
superficial inguinal ring

• Between the anterosuperior iliac spine and the pubic tubercle, the
lower border of the aponeurosis is folded backward on itself,
forming the inguinal ligament
Internal Oblique Muscle
• Origin: Lumbar fascia, intermediate surface of iliac
crest, lateral two-thirds of inguinal ligament
• Insertion: Lower three ribs and costal cartilages,
xiphoid process, linea alba, symphysis pubis
• Nerve Supply: Lower six thoracic nerves,
iliohypogastric & ilioinguinal nerves
• Action: Supports abdominal contents, assist in forced
expiration, micturition, defecation, parturition,
vomiting
Transversus Abdominis
• Origin: Lower six costal cartilages, lumbar fascia, inner
margin of iliac crest, lateral third of inguinal ligament

• Insertion: Xiphoid process, linea alba, symphysis pubis

• Nerve Supply: Lower six thoracic nerves, iliohypogastric

& ilioinguinal nerves

• Action: Compresses abdominal contents

• STRUCTURES FROM FLAT MUSCLES :
1.Inguinal ligament
2.Conjoint tendon
3.Cremaster muscle
Rectus Abdominis
• Origin: Symphysis pubis (medial head ) and pubic crest (lateral
head )

• Insertion: 5th, 6th and 7th costal cartilages and xiphoid process

• 3 tendinous intersections

• Nerve Supply: Lower six thoracic nerves

• Action: Compresses abdominal contents, flexes vertebral

column, accessory muscle of expiration
PYRAMIDALIS MUSCLE
• Rudimentary in humans and absent in 20% of people
• Origin : body of pubis and pubic ligament
• Insertion : linea albe between umbilicus and pubic symphysis
• Nerve supply : T12
• Action : tenses linea alba
Rectus Sheath
• Is a long fibrous sheath

• Encloses the rectus abdominis and pyramidalis

muscle (if present)

• Contains the anterior rami of lower six thoracic

nerves and the superior and inferior epigastric
vessels and lymph vessels

• Formed mainly by aponeurosis of three lateral

abdominal muscles
Rectus Sheath
For description it is considered at three levels:

• Above the costal margin the anterior wall is formed by the

aponeurosis of the external oblique and posterior wall is formed by
the thoracic wall

• That is the 5th , 6th and 7th costal cartilages and the intercostal spaces
Rectus Sheath
• Between the costal margin and the level of the anterosuperior iliac
spine, the aponeurosis of the internal oblique splits to enclose the
rectus muscle

• The external oblique aponeurosis is directed in front of the muscle

• Transversus aponeurosis is directed behind the muscle

Rectus Sheath

• Between the level of the anterosuperior iliac spine and the pubis,
the aponeurosis of all three muscles form the anterior wall

• The posterior wall is absent

• The rectus muscle lies in contact with the fascia transversalis

 Rectus Sheath

• The posterior wall of the rectus sheath is not attached to the rectus
abdominis muscle

• The anterior wall is firmly attached to it by the muscle’s tendinous

intersections
Linea Alba

• The rectus sheath is separated from its fellow on the opposite side
by a fibrous band called the linea alba

• Extends from the xiphoid process to the symphysis pubis

• CLINICAL APPLICATION :
• Divarication of recti
• Hematoma of rectus sheath
• Epigastric hernia
Lymph Drainage

• Lymph drainage of the skin of the anterior abdominal

wall above the umbilicus is upward to the anterior
axillary (pectoral group of nodes)

• Below the level of umbilicus drains downward and

laterally to the superficial inguinal nodes

• Swelling in the groin is may be due to enlarged

superficial inguinal node
Venous Drainage
• Venous blood is collected into a network of veins that
radiate from the umbilicus

• The network is drained above into the axillary vein

via the lateral thoracic vein

• Below into the femoral vein via the superficial

epigastric and the great saphenous veins

• Few small veins, the paraumbilical veins form a

clinically important portal-system venous
anastomosis
Caput Medusae
• The superficial veins around the umbilicus and the paraumbilical
veins connecting them to the portal vein may become grossly
distended in case of portal vein obstruction

• The distended subcutaneous veins radiate out from the umbilicus,

producing in severe cases the clinical picture called Caput Medusae
Nerves
• Nerves of the anterior abdominal wall supply the
skin, muscles and the parietal peritoneum

• They are derived from the anterior rami of lower six

thoracic and the first lumbar nerves

• Inflammation of parietal peritoneum causes pain in

the overlying skin and also a reflex increase in tone of
the abdominal musculature in the same area
ABDOMINAL INCISIONS
• Surgical Incision is a cut made through the skin to
facilitate an operation or precedure.
• It should be the aim of the surgeon to employ
the type of incision considered to be the
most suitable for that particular operation to
be performed.

• In doing so, three essentials should be

achieved: 1.Accessibility
2.Extensibility
3.A reliable closure
Principles
Incision should be long enough for good
exposure
Splitting is better than cutting
Avoid cutting of nerves and vessels
Retract muscle, abdominal organs towards
neurovascular bundle
Transverse incisions better than vertical
incisions
Close the wound layer by layer
Choice of incision
Depends upon
⮚Type of surgery [elective/emergency]
⮚Target organ
⮚Surgeons own experience and preference
⮚Previous surgery.
The ideal incision allows:
✔ ease of access to the desired structures
✔ can be extended if needed
✔ ideally muscles should be split rather than cut
✔ heals quickly with minimal scarring
Langer’s Line

Langer’s Line correspond to

the natural orientation of
collagen fibers in the dermis, and
are generally parallel to the
orientation of the underlying
muscle fibers
Incisions made parallel to
Langer's lines may heal better
and produce less scarring than
those that cut across.
Abdominal & Pelvic incisions
⮚ VerticalIncisions
▪ Midline
▪ Paramedian
⮚ Transverse & Oblique Incisions
▪Kocher Subcoastal Incision
▪Transverse Muscle Dividing
▪McBurney Incisions
▪Oblique Muscle cutting
▪Pfannenstiel Incision
▪Maylard Incision
⮚ Abdominothoracic Incisions
⮚ Retroperitoneal & extra-peritoneal approaches
Vertical Incisions
1)Median Incision

vertical incision which

follows the linea alba.
It may be,
❑upper midline incision;
❑lower midline incision
❑single incision.

SIGNIFICANCE-it is
favored
In diagnostic laparotomy,
as it allows wide access
to abdominal Cavity.
Advantages
❑almost bloodless
❑no muscle fibers are
divided
❑no nerves are injured
❑good access to upper
abdominal viscera
❑very quick to make as well
as to close
❑can be extended full length
of abdomen curving around
umblical scar.
Disadvantages
❑Care needs to be taken just
above the
umbilicus where the
falciform ligament is
attached
❑Midline scar
Upper midline incision
From xiphoid to above
umbilicus.

Division of the peritoneum

is best performed at the
lower end of the
incision,just above the
umbilicus ,so that the
falciform ligament can be
seen and avoided
Lower midline incision
From the umbilicus
superiorly to
the pubis symphysis
inferiorly

Allow access to
pelvic organs
the peritoneum
should be opened in
the uppermost area
to avoid injury to
the bladder
Paramedian Incisions
placed 2 to 5 cm lateral to midline over
median aspect of bulging transverse
convexity of rectus muscle.
• Advantages
⮚ Provides access to lateral structures
⮚ Avoids injury to nerves,limits trauma to
rectus muscle.
⮚ Permits good restoration of abdominal wall
function
⮚ Can be extended by slanting the upper end of
the incision medially towards the xiphoid
process if required
• Disadvantages
⮚ Time consuming.
⮚ Incision needs to be closed in layers
⮚ Difficult extension superiorly as limited by
the costal margin
⮚ Tends to strip the muscles of their lateral
blood and nerve supply resulting in atrophy
of the muscle medial to the incision
Transverse Incisions
• Advantages
better cosmetically
Stronger than vertical
Less painful
Good access to upper GI structures
More advantageous in children b/c of more
transverse length of abdomen.
• Disadvantages
Limited exposure to the organs
1)Kocher
2)Median
3)McBurny
4)Battle
5)Ianz
6)Paramedian
7)Transverse
8)Rutherford
Morrison
9)Pfannensteil
Transverse incisions
• MAYLARD incision
• Pfannensteil incision
• Cherney incision
• KUSTENER incision
• First successful abdominal surgery by mc DOWELL in 1809
• In early days of abdominal surgery transverse incisions were
generally avoided because they are 1. time consuming 2.fear
of rectus muscle defect due to retraction
• Later at late 1800 early 1900 various transverse incisions were
developed
Transverse incisions
• Advantages best cosmetic results less painful less
interference with post operative respirations
• Disadvantages time consuming, more haemorrhagic, nerves
may be divided and division of multiple layers of fascia and
muscles can result in formation of potential spaces with
subsequent hematoma or seroma formation, ability to explore
the upper abdominal cavity adequately is compromised with
low transverse incisions
Pfannensteil incision
• Best wound security of all gynaecological incisions
• Cosmetically excellent
• exposure is limited
• Used selectively in certain gynaecological malignancies
• Should not be used when pelvic exposure needed,, in certain
non malignant conditions such as severe endometriosis, large
leiomyomata with distortion of the lower uterine segment or
when reporting on a patient for postoperative hemorrhage
• It is transverse incision slightly curved(concavity upward) 10-
15 cm long extends through skin and subcutaneous fat to the
level of rectus fascia
• Taken 3 cm above the superior border of pubic symphysis
KUSTNER incision
• Modified pfannensteil incision
• A transverse incision made 5 cm above pubic symphysis but
below the level of anterior superior iliac spines
• Subcutaneous tissue is separated in midline and linea alba is
exposed
• A vertical midline incision is made through linea alba
• More time consuming and offers little extensibility and limited
exposure than a pfannensteil incision.
• Strong consideration of subcutaneous closed suction drainage
should be given due to the large amount of dead space
created
Cherney incision
• Curvilinear incision made 2 finger breadth above the pubic
symphysis
• Skin and fascia divided transversely as in pfannensteil incision
• But differs advocating freeing the rectus muscles at their
tendinous insertions into the symphysis pubis rectus muscles
are retracted cephalad to improve exposure
• It is 25% longer than a midline incision measured from the
umbilicus to symphysis
• It provides excellent space to the space of retzius and
excellent exposure of the pelvic sidewall
• Nerve injuries may occur
• Femoral nerve at risk
• Lateral blades of self retaining retractors dep enough to fit
under the edges of the incisions and rest on the psoas muscle
• In closing ends of rectus tendons are united to the inferior of
the lower flap o the rectus sheath with 5-6 interrupted
sutures delayed absorbable or permanent sutures in
horizontal mattress configuration
• Rectus muscle is not sutured to periosteum to prevent
osteomyelitis
• Fascial closure similar to p fannesteil
MAYLARD incision
• A variation of pfannensteil incsion in which rectus abdominis is
muscles are sectioned transversally to permit wider access to
the pelvis
Joel COHEN incision
• Professor JOEL COHEN introduced this incision for abdominal
hysterectomy in 1954
• It is straight transverse incision through the skin 3cm below
the level of anterior superior iliac spine.
• The subcutaneous tissues and fascia are opened in the midline
and extended laterally with blunt finger dissection
Kocher subcostal incision
• It affords excellent exposure to gall bladder and biliary tract
and can be made on left side to afford access to spleen
• It started at midline 2 to 5cm below the xiphoid and extends
downwards and parallel to and about 2.5cm below costal
margin
• Especially used in cholecystectomy
• There are two modifications
• CHERVON rooftop modification
• Mercedes BENZ modification
CHERVON roof top
modification
• The incision may be continued across the midline into double
KOCHERS incision or rooftop appearance which provide
excellent access to upper abdomen particularly n those with
broad costal margin
• Uses
• Total gastrectomy
• Total esophagectomy
• Extensive hepatic resection
• Bilateral adrenalectomy
MERCEDES BENZ
modification
• Consists of bilateral low KOCHERS incision with upper midline,
incision up to the xiphisternum
• Provides excellent access to the upper abdominal viscera
mainly the diaphragmatic hiatus
Transverse muscle dividing
• In new borns and infants this incision is preferred because
more abdominal exposure is gained per length of incision
compared with vertical exposure
LANZ incision
• It is a variant of mc Burney's incision that is made in the same
point but in transverse plane
• It gives cosmetically good scar
RUTHERFORD MORRISON
incision
• Oblique muscle cutting incision
• Extension of mc Burney's incision by division of
oblique fossa
• Can be used for right and left sided colonic
resection cecostomy or sigmoid colostomy
McBurney grid Iron (Muscle
splitting) Incision
• Incision of choice in most appendicectomies
• The level and length of incision will vary according to thickness
of abdominal wall and suspected position of appendix
Vertical incisions
• Excellent exposure
• Easily extended
• Rapid entry into abdominal cavity
Midline incisions
• Upper midline-from xiphoid to above umbilicus
• Lower midline incision-from the umbilicus superiorly to the
pubis symphysis inferiorly
• Full midline incision –from xiphoid to pubis symphysis
Midline incision
• Least haemorrhagic
• Minimal nerve damage
• Dehiscence and hernias more common
• Abdominal wound disruption post operative complications like
burst abdomen evisceration
• In previous midline incision surgeon should incise more
cephalad to previous incision to prevent injury to adherent
bowel
• Use of BOOKWALTER retractor improves exposure
• limits the use of excessive packs
Paramedian incision
• Placed 2-5cm lateral to midline over median aspect of bulging
transverse convexity of rectus muscle
Paramedian incision
• Lateral to the midline and splits the rectus muscles
longitudinally
• Extendable
• Exposure is more
• Bleeding ,nerve damage
• In modified paramedian retracts the rectus muscle laterally
before incising the rectus sheath and peritoneum
Inguinal incision
• Done for inguinal hernias testicular cancer cryptorchidism
hydrocele varicocele
SUTURE MATERIALS
Contents
• Introduction and History
• Definitions
• Goals of suturing
• Suture characteristics
• Suture materials
• Suture Needles
INTRODUCTION
• Suture means to ‘sew’ or ‘seam’. In surgery suture is the act of
sewing or bringing tissue together and holding them in
apposition until healing has taken place.
HISTORY
• The first detailed description of a wound suture and suture
materials used in it is by the Indian physician Sushruta written
in 500 BC.
• Galen, the physician to Roman gladiators in the second
century A.D. used silk for haemostasis.
• Andreas Vesalius first advocated the suture of all fresh
wounds as well as severed tendon and nerves
• Rhazes of Arabia was credited in 900 A.D. with first employing
‘kit gut’ to suture abdominal wounds. The Arabic word ‘kit’
means a dancing master’s fiddle, the musical strings of which
‘kit string’ were made up of sheep intestines.
• Joseph Lister (1827-1912) discovered that bacteria present in
suture strands cause wound infection. He disinfected sutures
with carbolic acid. He made sterile sutures possible to bury it
in clean wounds without infection
DEFINITIONS:
• what is suture?
Suture is a stitch or series of stitches made
to secure apposition of the edges of a surgical
or traumatic wound(WILKINS)
• Any strand of material utilized to ligate blood vessels or
approximate tissues(SILVERSTEIN L.H 1999)
• Suture materials is an artificial fiber used to keep wound
together until they hold sufficiently well by themselves by
natural fiber(collagen) which is synthesized and woven into a
stronger scar.
GOALS OF SUTURING:
• Provide adequate tension
• Maintain hemostasis
• Provide support for tissue margins
• Reduce post-op pain
• Prevent bone exposure
• Permit proper flap position
REQUISITE OF IDEAL SUTURE
MATERIAL
• Tensile strength
• Tissue biocompatibility
• Low capillarity
• Good handling & knotting properties
• Sterilization without deterioration of properties
• Non allergic, non electrolytic and non carcinogènic
• Low cost
• It should not fray, should slide through tissues readily & knot
should not slip after tying.
• It should be readily visualized.
• On break down ,it should not release toxic agents.
• It should disappear without excessive reaction once its task is
completed.
• Easy to handle.
CLASSIFICATIONS OF SUTURE
MATERIALS
• According to source:
1.Natural
2.Synthetic
3.Metallic
• According to structure:
1.Monofilament
2.Multifilament
• According to fate:
1.Absobable
2.Non-absorbable
• According to coating:
1.Coated
2.Uncoated
Natural suture materials
• ABSORBABLE NON ABSORBABLE
1.Catgut 1.Silk
2.Chromic Catgut 2.Silk worm gut
3.Collagen 3.Linen
4.Fascia lata 4.Cotton
5.Beef tendon 5.Ramie
Synthetic Suture materials
ABSORBABLE NON ABSORBABLE
1.Polyglycolic acid 1. nylon(polyamide)
2.Polyglactic acid 2.Polypropylene(prolene)
3.Polyglactin(vicryl) 3.Polyesters/dacron
4.Polydioxanone(PDS) 4.polyetetraflouroethylene.
5.polybutester.
Metallic suture materials
• SS(stainless steel)
• Tantalum
• Silver
• Gold
• Aluminium
Monofilament vs
Multifilament
MONOFILAMENT MULTIFILAMENT
Has no capillary action Has capillary action
Less infection risk More infection risk
Smooth tissue passage Less smooth passage
Higher tensile strength Less tensile strength
More throws required Better knot security
MONOFILAMET SUTURE MATERIALS

ABSORBABLE NON-ABSORBABLE
1.Catgut 1.Polypropylene
2.Chromic Catgut 2.Polyester/dacron
3.PDS 3.Nylon
4. Polyvenyleidene
fluoride/PVDF suture
*They are single strand of suture material.
Multifilament sutures
ABSORBABLE NON ABSORBABLE
1.Vicryl 1.Silk
2.Polyglycolic acid 2.Cotton
3.Linen
*Multiple strands of suture materials that are braided together
 Absorbable vs Nonabsorbable
ABSORBABLE NONABSORBABLE
1.Degraded by 1.Encapsulated or walled
enzymes,hydrolysis or -off by fibrosis.
Phagocytosis 2.Used to suture at sites
2.Used to hold the edges in where tensile strength
approximation temporarily is needed.
until the wound is healed.
Selection of suture materials
• Condition of the wound.
• Tissues to be repaired.
• Tensile strength.
• Knot holding characteristics.
• Reaction of surrounding tissues.
Commonly Used Suture
Materials
POLYPROPYLENE(PROLENE)
1.It is synthetic,non-absorbable,monofilament suture material.
2.Polymer of propylene
Uses:
1.Herniorraphy,Hernia repair
2.Abdominal wall closure.
3.Fascia and Tendon repair.
Advantages:
1.Won’t loose tensile strength over time.
2.Good knot security.
3.Very little tissue reaction.
4.High plasticity.
Disadvantages:
1.Stretch when pulled.
2.Loosens when edema subsides.
NYLON
1.Synthetic,Non-absorbable,Monofilament suture material
Uses:
1.Used in Skin approximation of surgical or traumatic wounds.
Advantages:
1.Good tensile strength
2.Less risk of infecion.
Disadvantages:
1.Requires more throws.
SILK:
1.It is natural,non-absorbable multifilament suture material.
2.Made from the cocoon spun by silkworm larva
Uses:
1.Drain fixation
2.Ligating the bleeders(ties)
3.Used for ligatures
Advantages:
1.Ease of handling.
2.Good knot security.
3.Cost effective.
Disadvantages:
1.Very reactive.
2.Can’t be used in presence of infection.
SURGICAL STEEL
• Natural, monofilament/multifilament,non absorbable
• Alloy of iron, nickel and chromium
• Good Tensile strength even in infection
• Difficult to handle and tendency to cut through tissues. Very
hard to tie, and knot ends require special handling.
• Potential to corrode or break at points of twisting, bending or
knotting.
• Uses
1.Used in abdominal wall and skin closure,Sternal closure,
tendon repair, orthopedic and neurosurgery.
2.OMFS- for suspension of splints or arch bars and not as suture
material.
VICRYL:
1.It is synthetic & absorbable suture materials.
2.Multifilament & coated/uncoated.
3.Available in purple color/undyed.
4.Absorbs by 90 days.
Uses: Widely used suture material,
1.Bowel anastomosis
2.Subcutaneous tissue closure.
3.Urological procedures.
Advantage:
1.Minimal tissue reactivity.
Disadvantage:
1.In case of prolong approximation can’t be used.
2.Delayed absorption & increased risk of inflammation.
3.More risk of infection.
CATGUT
• PLAIN CATGUT:
• Oldest known absorbable suture.
• Galen referred to gut suture as early as 175 A.D.
• Derived from sheep intestinal sub mucosa.
• Sub mucosa of sheep has a rich elastic tissue
content which accounts for high tensile strength of
the catgut.
• It is Monofilament natural absorbable suture material.
• Plain catgut gets absorbed in 7 days.
• USES:
1.Not routinely used now,previously used to ligate sub
cutaneous blood vessels/tissues.
2.Plain catgut is preferred in Circumcission
CHROMIC
CATGUT
• Plain catgut soaked or coated with chromium trioxide.
• It is monofilament natural absorbable suture material.
• Its tensile strength gets lost in 30 days.may get absorbed in
tissue by 90 days.
• As it is an organic material and susceptible to enzymatic
degradation, packed in isopropyl alcohol as a preservative.
• Uses:
1.Meso appendix ligation
2.base/stump of appendix ligation.
3.Peritoneum closure
4.Sub cutaneous tissue closure
5. Tubal ligation –mod.Pomeroys techinque
POLYDIAXONE (PDS) :

• It is a synthetic, absorbable, monofilament suture material

• Polymer of paradioxanone
• retains 74% after 2weeks, 50% after 4 weeks ,25% tensile
strength after 6 weeks , absorbed in 130-180 days
• Advantages :
Low reactivity and maintains integrity in infected tissues
• Disadvantages:
Stiff and difficult to handle when compared to vicryl
USES:
Bladder surgeries
3rd and 4th degree perineal tears
Size of suture materials
• Largest size 5(thickest suture) to extremely fine 11-0.
Increasing number of zeroes correlates with decreasing suture
diameter and strength.
• Thicker sutures are used for approximation of deeper layers,
wounds in tension prone areas and for ligation of blood
vessels.
• Thin sutures are used for closing delicate tissues like
conjunctiva and skin incisions of the face.
• Size is chosen to correlate with the tensile strength of the
tissue being sutured
STERILIZATION OF SUTURES

• May affect suture properties to some extent

1.Gamma Radiation
2.Ethylene oxide; poisonous gas is less attractive
3.Autoclave
4.Sutures are usually stored in sterile pack by the
manufacturers , their integrity must be checked before use.
SUTURE
NEEDLE
• Made up of either Stainless steel or carbon steel.
• Needle is selected according to:
1.Type of tissue to be sutured
2.Tissue’s accessibility
3.Diameter of suture material.
CLASSIFICATION OF SURGICAL NEEDLES

1.According to eye
-eye less needles
-needles with eye
2.According to shape
-straight needles
-curved needles
3.According to cutting edge
a) round body
b) cutting -conventional
-reverse cutting
4.According to its tip
a)triangular tip
b)round tip
c)blunt tip
• Eyed needles require threading prior to use,
results in pulling a double strand through tissue. Tying the
suture to the eye increases bulk of suture material drawn
through tissues. So they are also called ‘traumatic needles’.
• These type of needles are not used now.
SWAGED NEEDLE

• Swaged needles do not require threading and permit a single

strand of suture material to be drawn.
• Suture attached to needle via a hole drilled through the end of
the needle, and the end is swaged during manufacturing.
• It is Atraumatic and act as a single unit.
THANK YOU