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Knot Security
The construction of ETHICON* sutures has been carefully designed to produce the optimum combination of strength, uniformity, and hand for each material. The term hand is the most subtle of all suture quality aspects. It relates to the feel of the suture in the surgeon's hands, the smoothness with which it passes through tissue and ties down, the way in which knots can be set and snugged down, and most of all, to the firmness or body of the suture. Extensibility relates to the way in which the suture will stretch slightly during knot tying and then recover. The stretching characteristics provide the signal that alerts the surgeon to the precise moment when the suture knot is snug.
Multifilament sutures are generally easier to handle and to tie than monofilament sutures, however, all the synthetic materials require a specific knotting technique. with multifilament sutures, the nature of the material and the braided or twisted construction provide a high coefficient of friction and the knots remain as they are laid down. In monofilament sutures, on the other hand, the coefficient of friction is relatively low, resulting in a greater tendency for the knot to loosen after it has been tied. in addition, monofilament synthetic polymeric materials possess the property of memory. Memory is the tendency not to lie flat, but to retu
to a given shape set by the material's extrusion process or the suture's packaging. The RELAY* suture delivery system delivers sutures with minimal package memory due to its unique package design.
Suture knots must be properly placed to be secure. Speed in tying knots may result in less than perfect placement of the strands. In addition to variables inherent in the suture materials, considerable variation can be found between knots tied by different surgeons and even between knots tied by the same individual on different occasions.
General Principles of Knot Tying
Certain general principles gove
the tying of all knots and...

Basic Knots
The knots demonstrated on the following pages are those most frequently used, and are applicable to all types of operative procedures. The camera was placed behind the demonstrator so that each step of the knot is shown as seen by the operator. For clarity, one-half of the strand is purple and the other white. The purple working strand is initially held in the right hand. The left-handed person may choose to study the photographs in a mirror.


1. Simple knot: incomplete basic unit
2. Square knot: completed knot
3. Surgeon's or Friction knot: completed tension knot
Knot Security
The knots demonstrated on the following pages are those most frequently used, and are applicable to all types of operative procedures. The camera was placed behind the demonstrator so that each step of the knot is shown as seen by the operator. For clarity, one-half of the strand is purple and the other white. The purple working strand is initially held in the right hand. The left-handed person may choose to study the photographs in a mirror.


1. Simple knot: incomplete basic unit
2. Square knot: completed knot
3. Surgeon's or Friction knot: completed tension knot

Suture Materials
The requirement for wound support varies in different tissues from a few days for muscle, subcutaneous tissue, and skin; weeks or months for fascia and tendon; to long-term stability, as for a vascular prosthesis. The surgeon must be aware of these differences in the healing rates of various tissues and organs. In addition, factors present in the individual patient, such as infection, debility, respiratory problems, obesity, etc., can influence the postoperative course and the rate of healing.
Suture selection should be based on the knowledge of the physical and biologic characteristics of the material in relationship to the healing process. The surgeon wants to ensure that a suture will retain its strength until the tissue regains enough strength to keep the wound edges together on its own. In some tissue that might never regain preoperative strength, the surgeon will want suture material that retains strength for a long time. If a suture is going to be placed in tissue that heals rapidly, the surgeon may prefer to select a suture that will lose its tensile strength at about the same rate as the tissue gains strength and that will be absorbed by the tissue so that no foreign material remains in the wound once the tissue has healed. With all sutures, acceptable surgical practice must be followed with respect to drainage and closure of infected wounds. The amount of tissue reaction caused by the suture encourages or retards the healing process.
When all these factors are taken into account, the surgeon has several choices of suture materials available. Selection can then be made on the basis of familiarity with the material, its ease of handling, and other subjective preferences.
Sutures can conveniently be divided into two broad groups: absorbable and nonabsorbable. Regardless of its composition, suture material is a foreign body to the human tissues in which it is implanted and to a greater or lesser degree will elicit a foreign body...