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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon and I'm currently a professor in the Medical Education Research and Development Unit at the Faculty of Medicine at the University of Man. I was the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And the Black Belt Academy is accredited by the Royal College of Surgeons of Edinburgh and with feedback forms, you will get a CPD points and certificates. So thank you very much indeed for joining us this evening. If this is your first time? Welcome, if you're returning. Thank you very much. Indeed, significantly. Last week, we passed 4045 delegates from 100 and 25 countries. This evening is exciting because we have got another 81 delegates from 31 countries again A to Z from Azerbaijan Bosnia, Iraq, Jordan and Kazakhstan has come on this evening for the first time, Malaysia, Netherlands, Oman, Sudan, UK and Zimbabwe. Thank you very much. And thank you to me all for making this possible. I think it's incredible and we can reach out across the globe. It is nine o'clock this evening in Kuala Lumpur. I'm joined in production by Vanish who is 1/4 year medical student at the University of Malaya wishing to do cardiac surgery. And my fellow colleague, Chris Carry might indeed be joining us later. Yeah, at your request, we are looking at sutures and closing wounds. I must emphasize that the sutures are chosen with multiple factors involved in the choice of the suture and predominantly above everything else. The success of your closure, the success of your wound is in fact down to technique. And the Black Mount Academy focuses on the ergonomics of stitching the anatomy of the needle because the needle carries the thread and the thread will follow the needle. The rest is down to feel and some simple principles that I hope to convey to you this evening, sutures have in fact been around for thousands of years. And we know that bone needles with eyes have been found in Neolithic sites for about 30,000 years. They were first described by the Egyptians and indeed the hieroglyphic figures with people stitching wounds. But the earliest evidence of tissue being stitched together, human tissue is around 1650 BC. And the Greek Surgeon Galen of Pogon use silk or cat gut made of intestines of animals to suture, wounds of gladiators. Similar materials have been used for sutures. So mm to the 20th century. And when I think about it, and you could probably say when I was a lad indeed in 1987 when I started my surgical training and we were asked, what are we going to use to do a bowel an assis, we say two layers. So first layer continuous chromic cut dot the second interrupted silk and we use nylon to close the abdomen. How things have changed even since 1987. Before that for century sutures were also made from plant materials like hemp, cotton and animal materials. But it was the catgut from the woven intestines of sheep. That was the most popular. It really didn't take off until 1876. And in 1876 Joseph Lester introduced sterilization and literally within in 11 years, mass sterilization of cc sutures using eye needles was introduced by Johnson and Johnson. Now in 1920 George Merson in Edinburgh introduced the eyeless needle because he found a mechanism of putting the suture on the end of the needle on the wage. In 1949 Johnson and Johnson bought me and hence hycon was established and sutures have taken off since in the 19 sixties. Hycon introduced sterilization by radiation. 1982 PBS or polydioxanone was produced and this is a repeating ester units and is obtained by opening the ring of the ester of poly polymerization. This P DS is absorbable, it's degraded by hydrolysis and the end products are excreted in the urine and the remainer is eliminated by the digestive system and is exhaled as CO2 is completely reabsorbed in six months and can only be seen a minimal foreign body reaction. Now, this is important because every suture is going to cause an injury and every suture has the propensity to induce inflammation. So to have a suture that had minimal inflammatory response was a significant milestone. In 1993 they introduced monochrome, there's a polyleptic cap and the suture is highly pliable form of filament. It handles very well and it has a very high initial tensile strength, but this diminishes within two weeks, postoperatively. Next, significant advancement in sutures again by, by, by Ethicon was the introduction of coated VRL. An antibacterial agent was impregnated on the suture and this has been shown to reduce wound infections by a third and is actually part of nice recommendations because with suturing, it's not the suture, that's the problem. It is often the not and the not is the reason why econ again brought out stra to fix, which is a self locking suture that avoids the knot. But of course, as I said, all sutures do give some inflammatory reaction and that is why wound closure has advanced to glues and dressings. Now, some of you might say, what about staples? Well, the staples are very effective when you want a very quick closure and they are interrupted because interrupted sutures when you've got dirty, messy wound and you've got poor vascular tissue. They are very convenient for closing a, a mass wound because it's quick interrupted, hand tied or instrument tied sutures. Take a long time. The thing is the choice of suture is dependent on many things. First of all, this is the understanding of the pathophysiology of wound healing. So you break the integument and I would say, what's the bleeding time? Well, it's 10 past nine, forgive the joke. But do you know what the normal bleeding time is? Put it in the chat room if you know what the normal range is for the bleeding time and then you can call out any answers that you might see anybody bleeding time. Now, I used the bleeding time when doing cardiac surgery. I took some of the blood and I put it in a kidney dish and gently rocked it and as I rocked it, I noted how long it took for a clot to form. It gave me a gross indication if there was a coagulopathy and an indication of how long I'd have to wait. But of course, heparin low platelets, cold temperatures, all that would affect the bleeding time. So any answers finish. I asked, there is one person who said 2 to 7 minutes, 2 to 7 minutes good. The normal range is between one and 15 minutes. So in adults, 1 to 9 minutes, in Children, 1 to 13 minutes, 2 to 7 minutes. Is very good. 1 to 8 minutes is likewise, we need blood in a wound. We need just enough because thrombin itself is a potent inflammatory marker and a potent stimulus for inflammation and healing. But of course, too much thrombin means too much healing and too much scar formation. So this is where respect of the tissues and meticulous hemostasis is of paramount importance. You quite rightly answered the questions that information then ensures very rapidly. As a result of that thrombin and the whole inflammatory cascade maximizes between 2 to 3 days and starts settling down. This is followed by the proliferative phase where everything is coming in with new vessel formation. And that's where you get the term granulation tissue is actually forming because it looks granular, those those are the ends of the new vessels. And that proliferation phase happens over 4 to 21 days. Following this one gets remodeling and the remodeling is the longest period of time and that really depends on the density and the thickness of the tissues. You can imagine that from soft tissues and on the neck that the remodeling might occur within a few weeks. But with dense tissues, months and of course to years and we know bone, how long that takes to heal. But it is the ligaments and fascia that do take a long time. So, understanding that simple principle and time and thinking of the patient's body habitus nutritional state, all the general factors that are gonna affect wound healing is going to determine what suture you use with a diabetic elderly cic, with cancer. All of this is important, but the ideal suture should allow healing tissue to recover sufficiently and allow the wound to close and really taking them out or thoroughly reabsorbed when the job is done. So the time it takes for a tissue to heal and support itself without sutures, varies depending on the tissue type. So muscle would be das week or two subcutaneous tissue. We on days depending where you are in the body. Remembering that the flexor surfaces actually heal a lot quicker than the dorsal surfaces. Weeks to months is fascia or tendons. But even when you close it properly, the tensile strength of muscle and tendons only recovers to about 80%. But of course, some tissues are not going to actually heal. And particularly when you're putting a vascular anastomosis and you are putting in prosthetics, that's where you need sutures that are going to la last a long time. And indeed, they are the reason we use nonabsorbable sutures. You must realize that every suture is actually going to cause some sort of inflammatory response. Some of them are more inert and some of them because they absorbed quickly, they still will cause a problem. And Venice was asking earlier about hypertrophic scars and these are people who have a really exaggerated response to healing and scarring and therefore leaving any foreign material in is going to exacerbate it. And I recommend using interrupted sutures on the skin that you can take out. So the main classification of sutures for you to actually realize is absorbable and nonabsorbable. And the absorbable sutures are actually broken down by the body by enzymatic reactions or hydrolysis. And the time it takes to absorb again, it depends on the physiology of the person location of the su suture and with the tissues that you're using in. So, absorbable sutures are actually commonly used for deep tissues and tissues that heal rapidly. So you would use them for small bowel anastomosis, suturing urinary tracts or biliary tracts or tying off small vessels near the skin. So, understanding how quickly they absorbed and disappear is actually important in your considerations. VR rapid is absorbed in 42 days. VR itself in 60 days, but its tensile strength is 84% at two weeks and 23% at four weeks. Monocryl is absorbed within 100 days and PBS is absorbed within 200 days. So this is actually lasts a lot longer and it's 80% strength at two weeks, 44% at eight weeks and complete absorption by 200 days. So knowing the tissue, knowing the body habit has, knowing where you're putting, it is gonna help you decide where and what type of suture you're going to use. Now, as we have already alluded to nonabsorbable sutures, provide long term tissue support and these nonabsorbable sutures ideally are totally inert initiating the mildest of inflammatory responses until removed unless they're deep. Of course, and you use them for tissues that heal slowly. So fascia tendons, closure of the abdominal wall and vascular anastomosis. What's interesting on the closure of the abdominal wall when I was a surgeon, laparoscopic survey only just started. So we did some major incisions as expected. The outcome, whether you use absorbable or nonabsorbable was different. There's a propensity to burst abdomens with nonabsorbable and increased complications, but there's a caveat. It was all down to technique. What's interesting is not just the technique but the knot itself that nylon over time would tend to come undone as a knot. Whereas P DS, as we said, last 200 days handles easier, but the knot is more secure than nylon. So nonabsorbable sutures are very useful to use where you want to reduce and minimize scarring and particularly on the face or cosmetic survey. The nonabsorbable suture for skin closure is much better but they need to be applied properly and removed in good time. The silken catgut that I used as a trainee actually causes severe inflammatory reactions. Cat cat of course has now disappeared because of bovine encephalitis mad cow disease and is no longer used or available. Silk is still available on the shelf and is predominantly used to actually tie in drains because of ease of use and it is actually very good at holding in a drain. Important thing. Again, there is technique too often. I see a pring put around a drain site and when the drain comes out, the purse string is tightened off and you end up with what I consider as something akin to a bullet wound at the end. So proline is or nylon are the most common used, nonabsorbable sutures recognized for their strength, durability, versatility, prolonged support, and of course inert or relatively inert in the body. We ha still as a suture, I use actually four closing sternums and it is extremely infect. So the natural sutures, cat gut and silk are things of the past. The silk I might use on the foot because it is soft and the knot is soft. And remember the knot itself can cause problems if not appropriately attended to or tied properly. Monofilament or multifilament is the next sub classification. So a monofilament suture, you can imagine there is a single strand pulled out nylon PDS proline. They have a lower infection risk, but the knot is poor security. And of course, there's a memory with it which makes handling difficult, a multifilament suture like micro or silk are easier to handle, much easier to tie knots and good for security yet, because they braided, they can harbor infections. And that is why the coated V has become a significant addition to the Armamentarium of suturing. Well, there is a question from so what can you not use monocryl for the skin. Yes, we will be demonstrating Monory. We've got, we come to the model in a moment. You certainly can use monochrome for the skin. But I'd use Monory as a continuous suture reserved for clean wounds and where there's good primary closure. If there's any risk of it not being clean or it's an external wound and not surgically implied, I would always use interrupted nonabsorbable sutures. Why? Because if there's any infection at any place, it is easy just to slip a suture to let it drain. So the size of the suture again is another thing to consider. And really, you want the size of the suture appropriate to the size of the tissue you can imagine with corneal surgery, you need 11 0. And remember the classification of sutures from oh, getting smaller in diameter actually goes 20304050 all the way down to 70. Though I commonly used in cardiac surgery, Ao and Suja, who's another sense does corneal surgery is using teno sutures, the diameter can affect the healing. The other thing is the thicker it is you can imagine the more difficult it is to absorb and it takes longer. So last things predominantly it's technique and I'm going to take you to the model in a moment and demonstrate some of the pitfalls of using these sutures in different layers. The next thing is if you're using a nominal absorbable suture particularly on the skin. You got to think of ease of removal. And lastly, in this day and age, we got to think of cost effectiveness because removal does require other people. But also what's going to give you a cosmetic appearance, reduce the need for the patient to come back to have the sutures removed or be seen. So if you look at it, the o suture is about 00.4 millimeters, then it actually drops 0.05 as it goes from 2 to 3 to 4 to 50 and to 60 and once it gets to 60, then it drops by 3 to 70 to 0.07 millimeters by two to 0.05 millimeters for eight to 0.03 millimeters for nine. And when you get to 10, can you believe it? You're looking at 0.02 millimeters. This is thinner than your hair. The biggest sutures, one is 0.4 uh zero is 0.41 is 0.5 two, is 0.63 is 0.74 is 0.8. So from zero up, each of the sutures goes up 0.1 millimeters. So let's have a look at some of these sutures and come over and understand what we're looking at. So the sutures as you see, come in all sorts of sizes and shapes and the detailed description of the needle and the suture is that that's a straight needle, that's a 40, that's a 30 proline. And this is V 40 and an, oh, I have a Monory to a Monory that we'll be using. And my sutures are predominantly ACON, but actually COVID produce a similar range of sutures. And so do B braun and in fact, depending where you are in the world, the companies actually will have different contracts with hospitals in the supply of sutures and their use. And this is why when you go around different hospitals, you might see one type of suture. The only thing that I like about the Ethicon for cardiac was the ever point needle. The ever point needle was one of the sharpest alloys to be have made. And also they've now come out with a needle where the swage is now thinner than the needle itself because the swage used to be the thickest area. So let's get on and do some surgery. Shall we? What I have here is some pork belly and we've got multiple layers. So the first thing I can choose and we pretend that I've got APD SD layers. I am going to go for a, let's go for an O VL because this is a deep layer. And what I like about the OV is it's he's abuse. Now, the suture actually follows the needle and as you will follow the Black Academy, we will take you through all types of sutures. Now, I said to you that the knot is the problem. And one of the things to do with a knot is ensure that you bury it properly with each layers. So to bury it properly, make sure you get to the very end of the wound. And I'm gonna close this fat layer here and I'm going from inside out and I haven't got an assistant. So you have to bear with me as I do this because you obviously use an assistant and from outside in. So it means when I tie this knot, it is going to be deep. Now, the important thing is is that the skin closure is only a reflection of your ability to close the wound. You see now that this knot is going to be deep and I prefer to tie this first knot by hand and feel the knot going down. Remember with a braided suture, five throws is adequate and these with large sutures use some proper scissors to. Now, one of the biggest problems with the continuous suture is that people when they're stitching, focus on getting it stitched as quickly as possible. What I stress it is set up in position. So 90 degrees across what you want to stitch and we're going to more of this, but I'll show you what commonly happens. And this is actually very sad to see it actually happen. People put a stitch in and particularly if they are using a uh use a monofilament halfway through. This is where not having an assistant is actually difficult. But what they do is throw in a couple of sutures as quickly as possible without thinking about the needle position or needle angles and they cobble it together and they put, go in uneven without thinking about the position. They're not thinking about their forceps, grabbing the tissues and causing damage and they put in a couple of sutures and then pull it tight. And you can see there that the tight is approximately at this bit has buried the knot and that this bit is actually loose. Please. When doing a continuous suture, please make sure that you are putting each suture in accurately each time and that the tension is approximating the tissues. So like many of sutures is how far and how deep you should put them in the layers. And the simple thing is is that I should not be able to get my finger in the space. I actually focus down on that a little bit more. You can see that between the last suture and this suture, I can get my finger in space. And this is particularly true of abdominal wall closure. You should not be, it should not admit the tip of your finger. So the accuracy of a continuous suture is the set up and placement and approximation and feel of the tissues all the time. And it should look neat, it should look neat and make sure that you are actually picking it up. Remembering that the inflammatory lag zone of the tissues is the. So I'm gonna swap now to a 30 pooling by way of contrast. So, but pretend this is APD S, I'm using APD S, it, it looks very similar, but you can see now the handling of this look at this compared to the micro, this now becomes problematic. Again, I would advocate that you bury the knot and all day players and you go from outside, in inside out. Both the not remember that this is a monofilament and therefore you need a lot more throws and I put on seven 08. Now, if you look at that, you see that little spike, I'll suture the app. If that was superficial, that little spike of suture, I've seen work out through the skin. Not only that if it's on a dependent area on the back or somewhere where you're sitting that will actually cause irritation and problematic problems. And of course, in the perineal area as well, these sort of monofilaments and knots can cause significant complaint in the injury and problems. So you do want something that is mhm absorbable in those situations. The non absorbable of course would have been for hernia repairs. And the classic can you repairs again is putting in a nonabsorbable nylon suture such that you cannot admit the tip of your finger at any place. Now again, I'll demonstrate to you what happens when I put a, a couple of sutures in as often happens. And people think it's very clever to actually close it with number throws and they're looking at this and then just over and over and I'm trying to not thinking on my needle angles and I'm just trying to do it as quickly as possible. And I'm not thinking about how I'm picking up the needle. This is what I commonly see. They do it like that. And again, I'll show you they pull and look at the way that that is actually now crushing the tissues that is not good surgery. And that is gonna be a problematic. So that is how you close the layers and it's tensile strength. And I recommend that you do close all the layers properly in in layers because you want to return it to normal anatomical function, but one layer moves over another. So what do we do about a fat layer, for example? All right. So let's take this big fat layer. Yeah. Well, before we go into that, obviously, if you've got a dirty wound, then the best thing to do is simple, deep interrupted sutures to for tissue approximation as well. So remembering that a continuous suture strangulates and it without the right tension will cause more problems. So if in a dirty wound, simple interrupted deep sutures under the proper tension will help the wound drain but also preserve the vascular blood supply. Remember with the inflammation at 3 to 4 days, you're gonna get increasing tension in the sutures. So, what do we do about fat? Well, the thing is, is that an over and over suture? And I'll try and demonstrate it here as well if I try and do an over and over suture in this fat like this. And I'm not considering my needle position at all and I'm not considering how I ed it. You see, I've crossed the suture over there, but I often see this is ignored as well and people just tired and say, oh, well, you know, never mind it's inside and I'm more anxious to get the operation done. What happens with fat as you go over and over again, you are going to think about it strangulating and squeezing on the fat out. And because fat fat is relatively avascular, what you're now risking is necrosis because you're putting an over and over fat and literally, you can see it's squeezing out. So to avoid that happening, I would recommend to close a fat layer is simply use a horizontal mattress suture coming in and out both sides because a horizontal mattress suture is not hemostatic and is not gonna squeeze the tissues. Now, the thing about a horizontal or horizontal mattress sutures is that the end product really needs to look like a ladder that the suture coming in and going out should be even. And this is true of the skin as well. So I need to see that these are going 90 degrees across. But again, the same thing applies. You don't suddenly just pull it. You've gotta take up the tension each and every time. And even though you're doing a, a continuous suture, the tension in the stitch needs to be maintained at all stages. So a simple horizontal mattress suture being mindful to try and get it 90 degrees across and you with a good stitch, you can see that that is now coming together rather well. But the thing is, I also see with these horizontal sutures that people are not thinking 90 degrees across and they're going through and they just not even sutures swinging the needle through as fast as they can and different bites and deaths. And you see that that, that is dreadful. That's not going to actually bring your tissues together cleanly or nicely whatsoever. But I see people more concerned about time and getting this done rather than understanding the tissues themselves. They do that and then pull dreadful. And you can see already that is puckering up at that point. So again, please be very careful on how you do it. Ok. So what do we do for the skin? Well, the skin suture um is really dependent where it is and how clean the wound is as well. Ideally and for convenience, using an interrupted suture on the face. And I think also for those people who are prone to hypertrophic wounds. You want something that can be removed very quickly. Now, what I noticed when doing cardiac surgery, I always used a mattress suture and I tie, used to tie this in by putting a ma a mattress citrate in and then tired and tied a knot. But what I noticed actually at follow up that I had a little crusting at the top of the sternal wound and I thought to myself, mm. Now, although this is inert when you start putting even a mo monofilament immediately under the skin that's creating a biofilm and you are not gonna see the suture underneath. Yeah, a biofilm. Ok. So what I do and prefer to do is take the suture in from outside the end of the wound come to the apex. And what I put it on is a, a hemostat. And at the end of the operation, I had put a liga clip on there for convenience and such as you can see what I'm doing. I'm gonna change this to a 30 proline. And indeed, we used to use a 30 proline on a and I prefer a straight needle. The reason I prefer a straight needle is because the curve needle for the subcut, I personally found caused a cr what I call a crinkle cut. So imagine you've got a crinkle cut chip and if you're too deep with your sutures, you'd end up with a crinkle cut. Now, the secret is to make sure that you're in the correct le and the right place. And it's important again, with this horizontal mattress suture, which is what we're doing here is you come, you see that that is too far forward and I know that is not going to sit very nicely. So the secret to actually doing a subcu sutures come back on yourself a little bit. So the entry point is behind the exit point on the other side and doing that there, you can see now that that is perpendicular across. So that's the entry point. So I'm gonna come slightly behind and out note that I'm not grabbing the skin. All right. And what I should do is be able to pull it through each time. The problem is when people do two big a bite and go too deep. All right, without actually thinking about the placement of the sutures, what's gonna happen and have been even is you're going to get overlapping. So how far it really depends on your feel of the tissue and where it is, how far apart it is. But the important thing is what has got to be attention to detail. My forceps are not grabbing the skin. If you've looked at the Blackbar Academy, we've described that you are generating if you're grabbing the skin, something like 5 million newtons per meter squared. So a nice regular even stitch either side coming back when you look at it it should look like a ladder and there's something very satisfactory about it. I prefer the handheld needle for this. Some people prefer a curve needle. As I said, the curve needle goes a little too deep for me and I find it actually results in a crinkle cut. We used to put proline in the skin to take it out. Uh when skin was healed and lift you put a little lead lock on each end. But like we're using a liga clip, you can see there straight across. But if I pull it tight, that ends up tight and that ends up loose. And what I want to be able to see with my wound, I don't want to see. I want to see it nice and smooth when I run my finger over it, I don't want to feel any overlapping edges. So there because the bite wasn't even. All right. So I'll take you back to this point because that bite wasn't even that side. What's happened is that if I run my finger on it, you can see that. Yeah. Yeah. There's a bit of an overlap isn't there. And I often see this as a problem. Also, the skin closures is that the two edges don't sit. So if you don't get that 90 degrees, 90 degrees across, you're gonna end up with that sort of thing happening. Imagine that all the way along the wound. That's not very good. Now, the thing is about a proline in the wound when you try and take it out, uh, uh, it doesn't come out, does it, after many horizontal things, I'm trying to pull this out. So that's why an absorbable suture as a monochrome is much better. So that leaves us. What do you do otherwise for closing wounds? And if you've got a potentially dirty wound and it's problematic and you think there's gonna be an issue, I would very simply use interrupted nonabsorbable suture and the interrupted. No. So suture bearing in mind that your forceps grabbing it like that is scratching and damaging when you're holding with the tooth forceps literally reflect and in fact, what we should have and use we're doing it cleanly and properly is a tissue hook to lift up. Remember that approximation is really down to how well you place the sutures. So it's 90 degrees into the tissue, bring it out into the room. You are too zoomed in. We can't see the, I beg your pardon. I'll move this along a bit. Thank you very much. Indeed, Manish. Thank you. Uh 90 degrees to the wound coming across exactly 90 degrees opposite. And imagine you coming 90 degrees out of the wound. OK? Now, a simple interrupted suture is the important thing. So two throws, take the short hand and you got to pull it down flat. OK? Not too tight and I unlock it over so it holds it into place and I bring another throw and I bring it my side to bring it down flat and now take it the other way to bring it well flat again and to my side to bring it down flat. Now, ideally, the spaces, as we said before in closing the wound is that if that's X and that's X, my suture should be cut not too short. So it comes undone and my next suture is in place. Vertical. Mattress, sutures are essentially much the same as an interrupted suture. But even though it's m vertical, it is causing a strangulation because you're coming in deep and on the same line, which is interesting doing um Moroto Zui in you are a person in front, two people in front, one behind and your stab and your two so strikes and your footwork should literally be along the same line and should not deviate. So same distance either side and then you're coming in a more super superficial bite does not completely in the same line, it's slightly off. So it's in the same line, superficial bite to the tissues. And the idea behind the vertical mattress is to actually help Vert. But if you're placing your sutures for interrupted suture properly, it will e for you. But you can see there that is actually starting to avert quite nicely already and I'll zoom down a bit further remembering to make sure your knot goes down flat. So that is actually inverts as you can see there and it helps bring the two edges together. But that horizontal matra suture is in fact strangling the tissue in that area, the horizontal mattress suture is like a box, but I don't believe it brings the skin together at all. Well, so this is a imagine a in and come out the other side and imagine you doing a box. So back in the other side and I, to be honest, I don't know where I'd actually use a horizontal mattress suture on the skin. David. Can you re centralize your um your specimen? Yeah, thank you very much. Thank you. Thank you, Mister Curry. I'm pleased to hear you there and your dulcet tones. So now if you look at the way this is tied, similar thing, but you can see now look at how much strangulation is happening there on the tissues ensuring that you're not as tied flat every time. So there's alternating side to side, but that is actually causing a potential strangulation as well. What some people have done is done a continuous closing suture, OK, to close. And where I haven't got a continuous closing suture. And I think that also is dreadful for the skin. Not only that then other, you can combine a continuous closing suture and I'm using for convenience sake. Yeah. My straight needle at the present moment, a continuous searcher and locking at one side and this is what's called a blanket stitch. Now, I think these blanket stitches are quite useful in the mortuary and you see it on CSI and it's a very effective way of closing tissues. I again, you can see that this blanket stitch is very, very hemostatic. It's locking at each level. It's bringing it together, but it's problematic taking it out. But it is very good in bringing something together very quickly and stopping bleeding. And I was thinking about this today and I was thinking about a person I saw in casualty who had been glassed with a bottle, I was extremely drunk, extremely violent. But each time he leant over, it was like turning a tap on as the blood dripped off his nose like an open tap. And it was extremely important to stop the bleeding very quickly in this circumstance. I actually used because the scalp babe vascular. I used an over and over blanket stitch like this to stop the bleeding and in fact, prevent and come to harm doing that meant that we could take him back when he was sober and take it out and do a proper closure. But at least it stopped. It was quite frightening the amount of blood that he was losing from a simple bottle injury. So there you have a selection of sutures. I hope you've got an appreciation now of what to use and when to use it, there are multiple factors involved in choosing your suture and your closure and my fellow sense. Mr Caddy, who's a plastic surgeon will attest to that as well. The patient condition, the place of the wound, the physiology, the body habitat, all of it is there. But fundamental to all these different sutures is not only understanding the patient, the characteristics of the suture, the mechanism of wound healing it where it is. But what dictates the outcome is your technique. So attention to where you place your needle or take your needle attention to the spacing is vitally important to make sure those tissues come together. Obviously, the smaller the tissue, the thinner the tissue like coronary arteries, the more critical it is. And when you're dealing with extremely small microvascular stuff, you can imagine that a continuous tissue around has a propensity, particularly a proline as you pull, it can actually squeeze and C A try the anastomosis. So it's the feel and the tension and when the assistant is following has to ensure that you as a surgeon is directing, that the suture comes out in the direction the needle came out of the tissue and it's just held and it's held properly with a lateral hold are not a pool. The surgeon determines the tension passes the suture to the assistant who holds that tension, finger and thumb in the direction it came such that the, the surgeon takes the next step simply slips out of the fingers and does not catch or tear. Because if you haven't done that, it will catch on your fingers. And obviously the finer the tissue, the more likely it is to cut out. I've demonstrated before on this program that even a 70 pro taking a piece of cheese and you can't see it on the camera, literally cheese wires through cheese. So it's all technique, understanding tissues, understanding the path of physiology. But of course, as we looked at this, there are multiple different types of needles as well. And again, that is also part of your thinking, sir. Open. I'll invite my fellow Sense Chris to join us to make his observations. I hope he appreciates this evening that I'm using this. And I, he admonished me last time for my interrupted sutures because he said you weren't actually flattening the knot. Now, I've got lots of observations to make, but I think I may confuse our students. I also have another meeting to go to at two o'clock. So I will see Mama's day excellent session once again, lots of, of food for thought there. Uh And we'll have a discussion about how to do it better. Sorry. Sure. But the principles and the principles of wound healing and all that. So the thing is doing a continuous stitch single handedly is problematic and you're finally tripping over the sutures. Uh When you're focusing on this, I'm pleased that I was reminded to bring it into focus as well. But any questions in the chat room, please finish. Yes. Sofia has two questions. The first one is uh do we use the one centimeter rule when stitching the peritoneum? Oh, I, well, you say peritoneum. That's interesting. I was just saying, looked at the study today and whether you closed the peritoneum or not, they, some people say closing the peritoneum is useful in reducing the incidence of adhesions. That's not proven. The other thing is closing the peritoneum if you can, will hold the bowel out the way when you continue to put your deeper sutures in, in the muscle closure. In fact, the fish, you've seen the rubber fish to put in the abdomen. That is the best thing to hold the bowel out the way. And I don't think you have to worry about the peritoneum and closure. You need to consider how the technique of closing the abdomen and it was literally closing it. Remembering the patient is anesthetized, he's got a muscle relaxant on board. So putting tension on that is actually gonna be exacerbated when the patient wakes up and normal muscular tone is returned. I was taught that the length of the suture was four times the length of the wound and that you are going over and over. And at no stage to test it at the end, you should bounce your finger along the incision and ensure that no more than the tip, very tip of your finger while it doesn't go through between the sutures. And that's how I was taught to close an abdomen with the small holes and ports that we're using nowadays. Do you remember those two are potential hernias and a a not doing ports surgery. But I'd imagine you need to close those with a proper deep suture as well. And any other? And remember when we were doing an incision, you wanting to, that's the skin incision, all the layers after that get longer and longer the skin moves around. But when it comes to closing, you retract and make sure you pick up the end of each layer and then close it properly. Particularly noted when doing thoracotomies, you can think of all the multiple layers and you're bringing together if you are careless in doing that, particularly as they postlateral incisions, you can end up with a whole bunch of tissues around the back. And if you're not careful in burying your knots, the patient will be troubled by pressure areas and knots sticking into their back as they lean against a chair. So or not are very important. Any other questions? Uh Yes. So the second question Sofia is how can I differentiate between the essential e version of the tissue? And if I'm strangulating the tissue tightly that comes with feel. And what I suggest you practice is on the low fidelity models that we've got. And all you need to do is literally approximate. You don't wanna be strangulating it, it, it practice yourself and get to learn the field the whole thing about surgery is the field, isn't it? The tension on the suture? And also when you look at it as well, you can see if it's pulled together too tight. You can see when it's, uh, crushing the tissues. Certainly, what I've done in my stenotomus and I introduced a tissue care bundle back in 2009 when a trainee admonished me for using ca diathermy, because what happens, people make a skin incision and then cauterize the rest. Well, that's transferring energy to the tissues and fulgurating it. So you imagine you're devascularized that area. So I use knife only from skin to the sternum. And in fact, a surgeon in Midwest America cardiac surgeon did that and halved his wound infections. Well, I put that together with a number of other elements of my tissue care bundle and my all wound problem, all wound. So anything less than a perfect wound was a problem. All wound problem fell to a median of zero for the next 1800 cases. Zero. Is that what I did later on? As I said, I noticed that crusting at the top of the wound. And that is because biofilms form around monofilaments and that's why I removed the knot from there as well. Remember the scar is your indelible signature. So respect the tissues all the time. Feel the tissues, think of your not stitch, stitch, stitch, stitch as we'll be going on to stitching in the next cycle is set up a needle properly, stitch, set up stitch and you drill that in your stitching will become meticulous and careful and you'll get better results. Yes. The last question that I have is uh blanket stitching and lock stitching are the same. Right. Well, just coming back over, I'll bring you back over to the camera down the bottom here and you can see, um, this, this blanket stitching here is a selflocking. It's like an over and over. So it's like a continuous horizontal mattress. This blanket stitching as I used on this one occasion on the scalp when somebody was bleeding almost to death because of being bottled. You can see here how this is all puckered in that between that and that, that's potentially ischemic. Ok? Even with a vertical mattress suture, although that's inverting quite nicely, that's potentially ischemic. And in fact, if you leave these in over time, even the sutures and the pressing of the sutures, that's why you ended up with those dried marks across wounds as you see marked in comic books that you end up with a scar with his got lines across. And that is your suture that has caused a problem because you've tightened it too much. So I think these are the best to use. And while we're lifting that up to remember when you take a suture out, you lift the knot up. All right, and you cut underneath the knot OK, you cut underneath the knot such that you're pulling the clean and out. Ok. So you cut immediately underneath and pull it. If you do it the other way, you're potentially dragging the exposed, dirty bit of suture through the skin. If you ask me what I would actually prefer for certainly a facial laceration or something meticulous, simple interrupted sutures. It's fantastic. Elsewhere in the body, I would actually like somebody to do a meticulous monochrome. But you can see here when I demonstrated when it wasn't 90 degrees across, see that that is actually meant that I've ended up with that lip and you can run your finger over it. I feel I've got a bit of a lip there as well. And if I look up, see there, there's a lip there that's not, those are not horizontal and those lips that happen because we haven't attended to making it perfect and cross both sides. It's all technique. It is all technique and I can't, we can't stress that more at the Blackburn Academy. Now, in the beginning, this will take a while, but you attend to your technique. Now it will become easier as time goes by and become part of just what you do. So that's why it's important to focus on the technique at the very start. And that's why I believe we offer something different here at the Black Belt Academy. Any other questions? Psh OK. There are no questions stopped by just Rinko has an observation. Railroading is seen in mattress sutures too. Yes. Yes, railroading does. But again, you know, that's why you got to take them out at the right time. And if uncertain what you do is take an interrupted sutures, take alternative ones out and come back and take them out again. So, again, that's a patient returning to a doctor or a nurse to have them removed and that's where absorbable subcu stitches has reduced the cost and made it convenient for the patient. Obviously, we've talked about dressings before and that's another area for study. So this is complex and a lot of a lot of actually research is being done into optimizing wound care and wound closure one day who who knows we might literally have as seen in the sci fi movies, a spray that immediately not only glues the wound together but enhances wound healing. Anything's possible. So there is one last question here. Uh Can you tell me a bit about tension sutures, tensions such as uh OK. So deep tension sutures are really like big interrupted sutures that were going wide either side of the wound to hold it to reduce the amount of tension. Actually on the wound itself, often seen when in dirty wounds or wounds that have dehist or where there's a problem. To be honest, I think with the advent of backpack and negative pressure and external support, these things are becoming perhaps a thing of the past, we used to put deep tension sutures in and because of the literary tension across the skin and because they were left in for a long time, we used to feed them through little plastic tubes such as you didn't get the real tracking effect on the skin. But I think backpack external support, negative pressure dressings, meticulous closure. Hm. Have reduced the need for that. Particularly now, it's all gone laparoscopic and the wounds are a lot smaller. Any other questions? Uh No problem. That's all for now. Well, ladies and gentlemen, thank you very much indeed for joining us. I'm waiting to hear if we've got a guest speaker next week, which will be a surprise announcement. If not, then we're going to come back. And since we talked about sutures, we're going to talk about the needle and needle anatomy as the first part of our Stitching series. So the two go together. If not, if I've got a guest speaker next week, we'll talk about needles and needle anatomy and different points, et cetera the week after next, I hope you have enjoyed the session. Remember to fill in your feedback form that does help us. And if you've got ideas or other things that you'd like to know about, do, let us know you have requested advice on laparoscopic surgery, one of my senses in how Michael is a laparoscopic thoracic surgeon. And I've asked him if he can give us advice on how to develop your laparoscopic skills and practice what I I've been thinking myself of getting some of these and starting to practice and alone with you and suggest ways and how we can develop low fidelity models. But thank you very much indeed for joining us. Thank you, Venice very much for your production and thank you to me and we'll say goodnight wherever you are or good afternoon or good day wherever you are in the world. And thank you for joining the Blackbar Academy.