 and if you see a triangle, then it is called cutting needle. Now that cutting needle also can be of two types. Whether apex of the triangle is towards the concavity of the needle, or when the apex of the triangle is towards the convexity of the needle. Both are cutting. When the apex is towards the concavity, it is known as just a cutting needle. And when the apex is towards the convexity, then it is called a reverse cutting needle. So the question is when do we use each of them? The round body needle is used for delicate tissues. Like for example, peritoneum, mesentery, intestine, things like that. It cannot penetrate through tough tissues like skin. Operate what we may think skin is a very tough structure. It has got a thick dermis and the dermis has got a elastic tissue. So when we do it on the skin, we use the cutting needle. In the cutting, I told you there are two types, a cutting and a reverse cutting. When do we use each of them? For regular suturing, most suturing that you will be doing including normal skin everywhere, we use the cutting needle. The cutting needle goes through the skin very easily. In fact, when you get the chance in actual clinical situations, you try to use the round body needle on the skin and you have health. It will just not go through. So cutting needle is used for the skin. Then when do we use the reverse cutting? We use the reverse cutting when we put very fine succulentibular stitches like for example on the face. That's what we do. So what we won't be using, so here most of us will be using cutting needle. So these are a few basic points about needles. Next about suture material. A few quick things about suture material. This is nylon. It can also be if it's black, it's nylon. If it is blue, it is proline, polyproline. Both are synthetic material. Both are non-absorbable. The big classification of suture materials, you can have absorbable suture materials, non-absorbable suture materials. The absorbable ones which get absorbed on their own, they are used for tissues inside. You don't have to remove them. Non-absorbable ones which are put in the skin, so we have to remove them after 5 days, 7 days, 10 days depending on the requirement. Again among these, they are subdivided further into synthetic and natural. So these are all synthetic non-absorbable material. That's the one which we'll be using. The whole classification is there. This range is both for them. So this is a non-absorbable synthetic. And if you notice, if you just run your hand across it, you'll find that it is very smooth. This is known as a monofilament material. That again reduces the trauma to the shoes. There are certain types like for example here, braided, where is it? There are some material like for example polyester fiber. They are ethibol. These are twisted filaments. They are called braided. They are not monofilament, they are multi-filament. They are again more traumatic, but then we use them in separate situations. Most miscarriage range we will be using. Monofilament, non-absorbable synthetic suture material, which is already swaged to the needle. So these are the few basic characteristics about the needle and suture material. Now let's take a few basic aspects. The needle holder. As it implies it is meant to hold the needle. Parts of a needle holder. These are the jaws of the needle holder. This is the fulcrum. The box type joint. This is the stem of the needle holder. The ratchet. The ratchet has got three clicks depending on how much pressure you want to apply. One. And with just a little bit of finger twist you can remove it. It just comes out on its own very quickly. You will find that in the actual instrument set you will find there will be a lot of difficulty in defining the difference between a needle holder and a hemostat. They all look very safe. At first glance they look very similar. The difference is a hemostat, the jaws will be very long. The joint will be very close to the handle. That's the difference. Why here we have these jaws very close and the jaws very small to get a good mechanical advantage so that you can get a good grip on the needle. The technique of holding the needle holder. There are two ways of doing it. One technique is as I've shown here. The ring finger will go through this. The lower one. The thumb will go through that one. Only the tips of the digits will go. Not like this. This is a very wrong method. You do not get good control. The best way to get control is the middle finger will give support and the index finger will give control. This is one way of doing it. Another way of doing it both are equally correct. It all depends on the preference of the surgeon is to hold it like this. After you have of course ratcheted it, hold it like this. In the palm of your hand and use the index finger for control. I personally prefer this. Many people prefer this. Both are shown there in the picture. Now comes the next point. How to hold the needle in the needle holder. Very important. Most of us are right handed. Therefore, the apex of the needle should be pointing towards your left. Because I'm going to go like this and I'm going to hold the needle right with the tip of my needle holder. Usually two clicks are sufficient. The long axis of the needle and the long axis of the needle holders should be exactly at right angles to each other. It should not be angulated like this or like this. They are used in very special situations. They are not used only for measuring the depth and things like that. For 99% of the time it should be at right angles. It should not be reversed. It should not be like this. Because we are all right handed people. If you are left handed, then of course otherwise it's. How much pressure to apply? If you apply too much pressure, as you can see in the picture, this picture shows, if I give too much pressure or the needle holder is too big for the needle, when I apply pressure, it tends to straighten out the needle. That's not good. On the other hand, or if the needle holder is too small, then the needle will do this and you will see it. It will wobble. When you are trying to take a bite, it will go this way or that way. So, right pressure writes as the needle for the needle holder. Usually two clicks are sufficient. Where to hold? There are three places to hold. One is either at the junction of the media two-thirds and natural one-third. Another is to hold in the middle. Another is to hold it at the junction of the media one-third and natural two-thirds. You will see different different situations. To give you a quick rule of thumb, if I want to take a deep bite of a tissue, a big needle and a deep bite, then I will naturally hold it very far away. So that I can take a good deep bite. Remember, this is the bite width and this is the bite depth. On the other hand, there are certain situations where I can take a deep bite of a tissue. I am going to do it also in certain situations. I am going to take just a bit of this and I will take it very close. Obviously, when you want to take only a bit of this, you hold it so far away, it doesn't make sense. So, these are some of the setting points about needle and needle holders. All these things are shown there. So, just to demonstrate to you, a little in the middle, after clamping it, this is how I am going to do this. You can use your own technique. I get very good control, 100% control like this. Okay, next instrument, the forceps. These are called thumb forceps, because simple reason, we are holding it between thumb and index finger. This is the next important accessory which we have to use for using for suturing. Let's take the most important one which we need for the skin. You can see the tip here. This has got two projections, the lower one and one projection. This is called the toothed thumb forceps. This is ideal for holding tough structures like the skin. I told you already, skin is a tough structure. When you hold it like this, the tooth, they mesh into each other and therefore you get a good grip of the tissue. They are used for holding tough structures like the skin, linealba and such places. When do we use the plain thumb forceps? If you know the plain thumb forceps, it does not have any teeth. Instead, it has got a few serrations on the inner surface. That's all. Just to give a little bit of friction. This is used again for delicate structures like dysentery, peritonium, interest in et cetera. Obviously, if you hold the peritonium with this moment you do it, you just cut through. You cannot use this. So for us, we are going to use the tooth thumb forceps. Method of holding the tooth thumb. It should always be, when I am doing the suturing, remember I have to hold the end which I am going to suture. So it should be at right angles to the long axis of the suturing. Not like this or like this. How to hold it? This is the absolute correct method. If you develop the right method now, then that becomes a habit. That's not the right way. It should be held like this so that you can get a good grip. That's why it is called a thumb forceps. That's about the thumb forceps. Now comes the next one. The scissors. Again, there are two types of scissors. Here we have only one. One scissor is the straight. This is the one that you see here. I am going to tell you briefly about the curved one also. The straight scissor is used always to cut non-tissue material through the threads. The straight scissor is never to be used for tissues. The straight scissor has got a pointed one, a pointed limb and a blunt one. The pointed limb is the one which goes under the loop of the thread. We should always cut with the apex, absolute tip of the scissors. Why? I will give you a practical example of what I have seen. Once the assistant was trying to cut the scissors. And he didn't realize that the tip had gone to the eye when he was switching on the base. I was watching and I could control myself. I was talking to him, what the hell are you doing? Because he tried to cut the thread when he was switching going on here. He tried to cut like that. And the tip was going towards the eye. Never use the base. When do we use the curved scissor? Curved scissor is used for partitions. Why is it curved? Because the surgeon is the only person who cuts straight with the curved scissor. That's what you should say. See, for example, this is a laparotomy going on. We have cut the skin with a knife. Then comes the rectus sheath. Patient is lying here. Head end is here, foot end is here. As a right-handed person, you're standing on the right side of the patient. If I were to cut the rectus sheath with a straight scissor, what happens? I would have to go like this. You are not supposed to move around too much in the surgical field. This is curved. I'm going to remain standing here. So I can remain standing here and I can keep cutting like this. That's why the curves are used to cut tissues. That's why we don't have it here. A quick word about the blade. Not that you'll be using too much of it. This is a barred Parker handle. The handle is the one which is reused sterilized. And the blade is the one which is removed at this post because we cannot sterilize the blade. It is detachable. In normal situations. There are many signs of blades. 10, 11, 12, 15, 21, 20, 21, 22, 23, depending on size. This is the rice 10. And the handle, how to cut. You're not going to cut it. I'm just going to show you. Hold it like a pen. Not like a stabbing instrument. Not like a fighting instrument. Not like a pen. Because it's a delicate situation. Give control to the next finger. Angles should be 45 degrees with the skin. First 45 degrees. Go vertically up. Go straight down. Bring it back to 45 degrees. Give a little bit of counter traction to the skin. Otherwise it will punch. Keep proceeding in a straight line with a steady hand. As you go further and further, you'll find the skin is becoming much lower down. Bring your hand further down. Again bring your hand further down. Bring your hand further down. Bring your hand further down. Until you reach the end of the transition. So this is just a technique you're not going to do any cutting now just to complete the whole picture. So I have to demonstrate the basics of the instruments. The first suturing which I'm going to demonstrate will be the no-time technique I'll do. I'll show you where I put the suture. Then we'll come to that. This will do four suturing techniques. There are many of them written here. Or essential ones. The simple interrupted. This is the first one you'll learn. So let's do the fourth technique now. We're going to hold the needle holder. The needle with the needle holder. We'll use the thumb forces. Let's say I'm going to do a suturing here. The first one. The simple, interrupted one. It's really not very difficult at all. So like I told you, you can hold it either this way or this way. I prefer to hold it this way because I get more control. You should be able to hear the clicks and see how much pressure you've applied. Now it's stable. No red notes. Not everything. Watch. So suppose I'm doing the suturing. With the tooth forces. Hold one end of the place where you want to put the suture. Here for your guidance, they have already put dots here. In an actual situation, you will not have these dots. So we have to determine approximately half a centimeter so take a good grip of the skin. It's a good grip so that you can lift it up. Take the first bite through both thickness with a slight curving motion so that, as you can see in the lower picture, less of the epidermis and more of the dermis is taken because we want the edges to be slightly diverted. Inversion is not a good thing. Iversion is required. Good healing. Epidermis to dermis. Epidermis and dermis to dermis. And it reduces the good health and so on. So that's why we have curbed needles. Of course we do use straight needles for various situations but here curbs them. So a slight more of the epidermis, a little less of the dermis. Full thickness. If you find difficulty, you can take it out and you can take the next one. Or you can do it both in one shot. It doesn't matter. It depends on how big the needle is and how deep the suture on the skin is. I've just removed it. So one bite. Next bite. Again take a good grip on the opposite side. Give a slight push and you can see the tip of the needle pushing. So I know approximately this is the place I want to come out. Once you release it, catch hold of the tip and pull it out with a curving motion. Keep pulling until you reach the approximate reasonable side. Don't keep this too long because remember you'll be cutting it off. This will be a waste. We have to conserve material. At least if you don't, your assistant is going to jump at you. So keep it a certain length so that we can photo. Now the previous slide that I've not done technique is shown. Watch this. Another thing which I forgot to tell you about the suture material was when I was talking about is the not holding characteristics of suture materials. These monofilament materials, synthetic non-absorbable monofilament material they tend to slip. You can try it. You can take a piece of nylon and you try to make a loop. You make two throws of a knot and you slip off. If you take a cotton two throws or your shoelace for example, you don't put ten knots. It holds. Nylon synthetic material they tend to slip. So we have to use multiple throws otherwise they will slip. How to tie the knot? Long end two loops clockwise tip. Hold the tip. Give it sufficient pull to make it a little tight but it is not sufficiently tight yet because it will slip off. See it is already slipping out. Now with my hand like this anti-clockwise two loops again hold the tip and same direction with my hand where it came back to the left tighten it a little bit four throws I usually like to put six or eight because anything less than that tends to slip. Again two loops catch out of the tip again cross again two loops anti-clockwise catch out of the tip and once you finally made the knot eight throws give a little flip like that the knot goes away from the suture line either this side or this side never keep the knot on the suture line because it will give a very beautiful and bad scar Once this is over don't remove it keep the tension take the scissor apex below the knot cut it approximately half a centimeter away Why do we keep this much length? Two reasons. Reason number one, seven days later you have to remove it if you keep it too small you will not get a good grip to remove it I am going to show you how to cut it The second reason is as I told you they tend to slip even after putting eight throws if I keep that end very small it might slip off So I am going to do another one fast and then I am going to cut towards the knot and then you will start doing your own So this is the technique I am going to do the next one one more so that you can see it full thickness little more of the epidermis opposite side full thickness curving out double clockwise hold the tip anti-clockwise hold the tip clockwise hold the tip flip seven days later the patient comes to you you are going to remove this that slide is also there how many days later to remove the sutures most times it is seven days, sometimes it is five days sometimes it is nine days, sometimes it is ten days you take the average figure seven days, catch hold of a grip with the tooth force catch hold of the knot get a good grip not on the suture line but away from the suture line put the pointed portion under the loop cut because I have experienced it sometimes the suture line is still not fully healed when you put it this way it pops open so pull like this next one get a good grip put the pointed end under the loop away from the suture line cut with the tip full procedure is done please go back to respective stations and start over the first suturing thing