05 / Skills
The hands-on foundations
The closures, knots and materials every rotation assumes you will pick up by osmosis, taught deliberately instead.
Closure techniques
Suturing
Simple interrupted
The default skin closure: lacerations, surgical wounds under no unusual tension, anywhere a failed stitch must not unravel its neighbours.
Sequence
- 1Enter the skin at 90 degrees, a few millimetres from the edge, following the needle's curve
- 2Take equal bites of both sides at equal depth, slightly wider at the base than the surface
- 3Tie a square knot laid flat, tightened only until the edges kiss
- 4Place the knot to one side of the wound line, and space stitches about as far apart as their width
Why this one: Each stitch stands alone, so one failure costs one stitch; tension is adjustable stitch by stitch; drainage can escape between them.
Classic errors: strangling the edges with tension, which blanches then necroses them; uneven bites that step the edges and heal as a ridge; bites wider at the surface than the depth, which inverts the edges.
Running (continuous)
Long clean wounds where speed matters and tension is even: fascia in many closures, clean surgical skin wounds, bowel anastomoses in their own variants.
Sequence
- 1Anchor with a simple interrupted stitch, cut only the free end
- 2Spiral down the wound with equal bites and equal spacing, keeping the running strand snug but not tight
- 3Watch the tension distribute with every throw, it is shared along the whole line
- 4Finish by tying to the last loop brought through
Why this one: Fast, distributes tension evenly, and uses one suture for the whole line.
Classic errors: one loose throw loosens the whole line; one break undoes it all; purse-stringing by pulling too tight, which bunches the wound; uneven spacing that concentrates tension at the tight bites.
Vertical mattress
Wounds whose edges fall inward or gape: over joints and shins, lax skin, anywhere eversion needs to be manufactured rather than hoped for.
Sequence
- 1Far-far: a wide, deep bite through both sides
- 2Near-near: reverse the needle and take a small, shallow bite back through both edges
- 3Tie on the entry side; the deep loop takes the tension, the shallow loop everts the edges
Why this one: The strongest everting stitch: deep support and edge apposition from one knot.
Classic errors: tied tight, it is the classic railroad-scar stitch, tension discipline matters most here; shallow far bites that give no deep support.
Horizontal mattress
Fragile or high-tension skin where a single-point stitch would tear through: fragile elderly skin, palms and soles, tension-spreading before definitive closure.
Sequence
- 1Take a standard bite through both edges
- 2Move sideways half a bite-width and return through both edges in the opposite direction
- 3Tie on the starting side, the loop lies parallel to the wound and spreads its load along the edge
Why this one: Spreads tension along a length of edge instead of one point; everts well.
Classic errors: strangulating the strip of skin inside the loop, its notorious failure; using it where a simpler stitch would do, it leaves more marks.
Subcuticular
Clean wounds where the scar matters and tension is already handled by deeper layers: the cosmetic closure of elective surgery.
Sequence
- 1Close deep layers first, the skin must sit together before this stitch starts
- 2Run horizontal bites within the dermis itself, alternating sides, never surfacing
- 3Keep bites at one consistent depth so the surface stays flat
- 4Finish buried or taped; absorbable material needs no removal at all
Why this one: No surface marks at all: the scar is the wound line and nothing else.
Classic errors: using it to fight tension, it has no strength for that job; bites at varying depths, which pucker the surface it exists to protect.
Instrument tie
The default knot at the skin with a needle driver in hand, and whenever suture ends are short or material is precious.
Sequence
- 1Loop the long end twice around the driver for the first throw (a surgeon's throw), grasp the short end, pull through flat
- 2Loop once in the opposite direction for the second throw and square it down onto the first
- 3Alternate directions for every added throw, squareness is what holds
Why this one: Economical with suture, precise tension control, and fast once rhythm arrives.
Classic errors: same-direction throws stack into a granny knot that slips; sawing the throws down under tension, which weakens monofilament.
The material logic
Suture explorer
Four decisions choose every suture: absorbable or not, monofilament or braided, the size, and the needle. Learn the four and the wall of boxes in theatre becomes legible.
- Absorbable vs non-absorbable
- Absorbable suture (Vicryl, Monocryl, PDS) lends strength while the tissue heals and then leaves; non-absorbable (nylon, Prolene, silk) holds forever or until removed. The decision is the tissue's healing time: bowel and subcutaneous tissue heal fast and take absorbable; vascular anastomoses and hernia mesh fixation never stop needing support.
- Monofilament vs braided
- Monofilament slides smoothly and harbours no bacteria between strands, but its memory fights the knot; braided handles beautifully and knots securely, but its interstices shelter bacteria. Contaminated wound: monofilament. Deep ties where handling matters: braided. This one trade-off explains most suture choices.
- Size
- More zeros, finer thread: 0 and 1 close fascia, 3-0 closes most skin, 4-0 the face's periphery, 6-0 and finer the face proper and vessels. The principle: the smallest suture that holds the tissue, because every extra size is extra foreign body and extra scar.
- Needles
- Cutting needles have a sharpened edge for tough tissue, skin above all; taper needles spread tissue without cutting and serve bowel and vessels, where a cut edge would tear or leak. Reverse-cutting places the sharp edge away from the wound so stitches do not cut out toward it.
Practice
Choose the suture
Three wounds, three closures each, one that respects the tissue.
Choose the closure
1 / 3
A gaping laceration over the shin of a 70-year-old, edges rolling inward, thin skin.
Knots
The knot concepts
The square knot
Two throws in opposite directions, laid flat. Every reliable surgical knot is square knots stacked; every slipping knot is a granny knot someone tied by repeating the same direction.
The surgeon's knot
A double first throw whose friction holds tension while the second throw arrives, the answer to tissue that springs apart between throws.
Two-handed tie
The learning knot and the deep-cavity knot: most control, most reliable squareness, the one to master first and the one seniors revert to when it matters.
One-handed tie
Speed for long ligature runs once the two-handed knot is automatic; the classic error is letting it drift into same-direction throws that slip.
How many throws
Enough for the material: three for braided, more for springy monofilament, and always finished square. Extra throws past security add bulk, not strength.
Watch the ties
Two-handed surgical knot
The bread-and-butter hand tie: square throws, laid flat, tension even.
Source: J&J MedTech · Watch on YouTube
The plastic the ward round reads
Tubes, lines & drains
Every device answers the same five bedside questions seniors quiz juniors on.
Closed suction drain (Jackson-Pratt / Redivac)
- Why it is there ·
- Evacuates blood and serous fluid from a dissected space so it cannot collect, and reports what the inside of the wound is doing.
- What should come out ·
- Serosanguinous fluid tapering day by day; the trajectory matters more than any single figure.
- What you watch ·
- Volume per shift, colour and character, and the vacuum: a drain that has lost suction is a tube on holiday.
- What can go wrong ·
- Fresh climbing blood (bleeding), feculent or bilious change (a leak), sudden stop with a swelling collection (blocked), frank pus (infection).
- When it comes out ·
- When output is low and stable and the reason it was placed has passed, drains left too long become infection's ladder inward.
Chest drain with underwater seal
- Why it is there ·
- Drains air or fluid from the pleural space and keeps the lung up, with a water column standing guard as a one-way valve.
- What should come out ·
- The column swings with breathing (confirms it is pleural and patent); bubbling only while an air leak is still being treated.
- What you watch ·
- Swing, bubbling, output volume and character, and the dressing; the bottle stays below the chest, always.
- What can go wrong ·
- Stopped swinging (blocked, kinked or the lung is up), new vigorous bubbling (air leak), sudden large fresh blood (haemorrhage), surgical emphysema spreading.
- When it comes out ·
- When the lung is up, the leak has stopped and output is minimal, removed at end-inspiration or with a Valsalva, with the purse-string ready.
Nasogastric tube
- Why it is there ·
- Decompresses a stomach that cannot empty (obstruction, ileus) or feeds one that can; the same tube, two opposite jobs.
- What should come out ·
- In obstruction: bilious aspirates that reduce as the bowel wakes. For feeding: position confirmed by pH or X-ray BEFORE anything goes down it.
- What you watch ·
- Aspirate volume on the fluid chart (it is a loss to replace), tube position at the nose, and the nose itself.
- What can go wrong ·
- Feeding through a misplaced tube is the never-event this device is famous for; high aspirates that never fall suggest the obstruction is not resolving.
- When it comes out ·
- When aspirates fall and the patient passes flatus, obstruction resolving, or when feeding is no longer needed.
Urinary catheter
- Why it is there ·
- Empties an obstructed or atonic bladder and turns urine output into an hourly measurement, the resuscitation's honesty meter.
- What should come out ·
- Above roughly 0.5 mL/kg/h in an adult; the first question about a low number is the patient, the second is the tube.
- What you watch ·
- Hourly output against the target, colour, and the daily question every round should ask: does this catheter still earn its place?
- What can go wrong ·
- Anuria is blocked-tube-until-flushed; frank haematuria after pelvic or prostate surgery follows its own protocol; every catheter-day is infection risk accruing.
- When it comes out ·
- The earliest day it is no longer needed, catheter-associated infection is the commonest hospital-acquired one, and duration is its driver.
Stoma (ileostomy / colostomy)
- Why it is there ·
- Diverts the faecal stream: to protect a downstream join, to decompress an obstruction, or as the end of a Hartmann's. Loop is usually temporary, end is often not.
- What should come out ·
- Pink and moist like the inside of a cheek; an ileostomy spouts and runs liquid (600-1200 mL/day), a colostomy sits flush and passes formed stool.
- What you watch ·
- Colour every shift in the early days, output volume (high-output ileostomy dehydrates fast), and the skin around it.
- What can go wrong ·
- Dusky or black is ischaemia, a call tonight, not a note for the morning; retraction, prolapse, and the parastomal hernia that arrives later.
- When it comes out ·
- Reversal is its own operation, planned months later, and only after the anatomy downstream has been proven healed.
Negative-pressure wound therapy (VAC)
- Why it is there ·
- A sealed foam dressing under suction: removes exudate, shrinks the wound, and pulls granulation up in wounds too big or too hostile to close.
- What should come out ·
- An airtight seal (the machine will say otherwise), steady exudate into the canister, and a wound that looks better at each change.
- What you watch ·
- Seal alarms, canister volume and character, and the wound itself at every dressing change.
- What can go wrong ·
- Fresh blood in the canister stops the suction and starts a review; a lost seal turns therapy into an expensive occlusive dressing.
- When it comes out ·
- When the wound has granulated to the point of closure, grafting, or simple dressings.
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Practice
Drain Detective
An output, a day, a decision: the drains report, and you interpret.
Drain Detective
1 / 4
POD 3 after laparoscopic cholecystectomy, drain left after a difficult dissection
Drain output has changed: 180 mL of green-brown fluid this shift, patient febrile 38.1, RUQ pain worse
Practice
The wound lab
What do you see, is it expected, and what is your concern, the wound round’s whole method, including knowing what normal healing looks like.
Wound round
1 / 3
POD 4 midline laparotomy wound check
Edges apposed, a thin ridge of firmness along the line, mild pinkness a few millimetres wide, no discharge
Technique teaching for supervised practice on bench models. Skills are learned on benches and validated by teachers, not by websites.