1. SURGICAL SUTURES AND
MESH
PRESENTED BY DR ANKUR GOEL
GUIDE DR T.R.CHIKKANNACHARI
CO-GUIDE DR APARAJITA MOOKHERJEE

2. Abdominal Incisions

3. History of Sutures
 Animal sinew such as tendons and
ligaments were the first recorded sutures.
 Egyptian literature mentions the use of
linen strips coated with a mixture of honey
and flour
 Sushruta described sutures and needles
for the first time

4. History of Sutures
 Early wound closure devices were made
of natural materials such as flax, silk, linen
strips, and cotton. These natural
materials were lubricated in oil and wine
prior to application so as to reduce tissue
drag and create a cleaner wound closure
procedure
 Another early form of a wound closure
technique involved the use of the
mandibles of soldier ants

5. History of Sutures
 Galen, a Roman surgeon, first commented
on using catgut as a suture material
 Lister first used sterilized suture material by
using carbolic acid and then presenting the
suture material in a glass tube
 Halsted is still remembered for his rules of
surgery advocating gentle handling of
tissues, meticulous haemostasis, and
interrupted silk sutures

6. History of Sutures
 By 1900 the catgut industry was firmly
established in Germany due to the use of
sheep intestines in their sausage industry
 George Merson developed atraumatic
sutures
 1940s- uniform preparation and sterilization
of sutures
 1950s- sutures attached to pre attached
needles
 1960s- synthetic absorbable sutures
introduced

7. Definition of Suture
 The word suture describes any material
used to approximate tissue edges
together or ligate blood vessels.
 A suture attached to a needle is called as
a ‘Stick tie’
 A single strand of suture handed to the
surgeon is called a ‘Free tie’
 A free tie placed on the tip of a forceps or
an instrument is called a ‘Tie on a passer’

8. Atraumatic sutures
 When a suture is attached to an eyeless
needle, it is called an atraumatic suture.
 Developed first by George Merson of
Edinburgh. Hence these sutures are also
called as ‘Mersutures’ in his memory.

9. Suture size
 Defined by US pharmacopoiea
 The size reflects suture diameter
 As the suture number increases, suture
diameter decreases
 Suture size is selected on the basis of
tissue being sutured
 The smallest size required should always
be chosen to reduce injury to the tissue.

10. Knot strength
 Measured as force in pounds a suture will
withstand before it breaks when knotted
 The tensile strength of the suture material
should not exceed the tensile strength of
the tissue.

11. Characteristic of Ideal suture material
 Sterile and cost efficient
 Non electrolytic, not allergenic, non carcinogenic
 Inert
 Easy to handle
 Capable of securely holding the tissue layers
throughout the healing process
 Minimally reactive to tissue
 Absorbed completely with minimal tissue reaction once
the wound is healed
 Should have uniform diameter
 Should have adequate tensile strength until the
purpose is over
Unfortunately an ideal suture material does not exist.

12. Suture strands
Monofilament Multifilament
 Goes through the tissue  Several strands braided
with less drag or together
resistance  Greater tensile strength,
 Less chance of suture
pliability, flexibility
line infection- hence  Are coated to reduce the
suture of choice for drag
vascular surgeries  May act as a cove for
organisms, hence never
 Greater chance of getting used in infected wounds
crushed

13. Suture strands
Monofilament Multifilament
 Due to its smoothness,  Knots are more secure
knots more likely to slip  Fraying on cutting edges
 No fraying of the ends on
cutting
 Less tissue reaction
 Eg Vicryl, Silk
 Eg. Prolene, PDS II

14. Cross section of sutures

15. Sutures
Absorbable sutures Non absorbable sutures
 Are digested by enzymes  Are used to suture at
and phagocytosed eg.
Catgut sites where tensile
 Or get hydrolysed and strength needs to be
removed by phagocytosis maintained for at least a
eg. Vicryl year
 Are used to hold the wound
edges in approximation  Made of non
temporarily until the wound biodegradable materials
is healed sufficiently to
withstand normal stress that are ultimately
encapsulated or walled
off by body’s fibroblasts

16. Sutures
Absorbable sutures Non absorbable sutures
 Are used to suture  Are used at exposed
internal structures in the sites in the body from
body where suture where they can be
removal is not removed whenever
possible/feasible needed eg. Skin
 Eg. Catgut, Vicryl  Eg. Nylon, Silk,
polypropylene

17. Classification of suture materials
 Monofilament  Polyfilament
 Natural Absorbable  Absorbable
 Catgut  Natural
 Synthetic Absorbable  Synthetic
 Monocryl  Polyglactin (Vicryl)
 Caprosyn  Dexon II
 Bondek
 Biosyn
 Maxon  Non absorbable
 PDS II  Natural
 Cotton
 Non absorbable  Silk
 Synthetic  Synthetic
 Polypropylene(prolene)  Nurolon
 Nylon (ethilon)  Mersilene
 Stainless steel  Tevdek

18. Catgut

19. Catgut
 Natural absorbable surgical suture
 It is a brand name- manufactured by
Ethicon division f Johnson and Johnson;
other similar sutures include Trugut,
Progut, etc.
 It is 99% collagen
 Absorbed by enzymatic digestion by
proteolytic enzymes
 Easy to handle and knots well

20. Catgut
 Derived from submucosa of sheep’s
intestine or serosa of cattle’s intestine.
The layers of intestine are scraped off to
leave only submucosa. It is then treated
by a fat solvent to wash of any fat. It is
then dried and cut into various size. This
is plain catgut.

21. Catgut
 If this is further treated with 20% chromic
acid, it is called chromic catgut. Chromic
acid increases the tissue life of the suture
and thereby the tensile strength of the
suture is maintained for a longer time.
 Sterilized with gamma radiation and
packed with isopropyl alcohol.

22. Plain Catgut
 Loses 50% tensile strength in 3 days and 100%
strength by 15 days
 Gets completely absorbed in tissue by 60 days
Uses:
1. To tie small subcutaneous vessels
2. To approximate subcutaneous tissue during
closure of incision
3. In circumcision to suture the cut margins of the
prepuce
4. To repair the wound of lip or the oral cavity.

23. Chromic Catgut
 Loses 50% tensile strength in 7 days and 100%
strength by 28 days
 Gets completely absorbed in tissue in 90-100
days
 Uses
1. To suture muscles, bowel anastomosis,
peritoneum
2. During appendicectomy, to tie the
mesoappendix and the base of appendix
3. The inner layer during two layer anastomosis of
the small gut or anastomosis during
gastrojejunostomy

24. Chromic Catgut
4. During cholecystectomy, to stop bleeding
from gall bladder bed.
For most of the above said uses however,
polygalactin sutures are replacing catgut.

25. Polyglecaprone 25 (Monocryl)
 Monofilament
 Copolymer of 75%
glycolide and 25%
caprolactone
 Undyed or dyed violet
 Double the strength of
chromic catgut
 Good handling
properties and smooth
surface- easy passage
through tissue

26. Monocryl
 Tensile strength  Uses
maintained for 21 days 1. Can be used instead of
and absorbed in 90-120 catgut
days by hydrolysis
2. Intestinal anastomosis
 Is sterilized by ethylene
oxide 3. For closure of
peritoneum
4. Subcutaneous tissue
apposition
5. Urological procedures-
pyeloplasty, ureter
repair

27. Polydioxanone Suture (PDS-II)
 Polymer of paradioxanone
 Is dyed violet
 Is soft pliable and smooth
and allows easy passage
through tissues.
 Tensile strength maintained
for about 8 weeks and
complete absorption in
180-210 days
 Well suited for paediatric,
CVS, orthopaedic,
ophthalmic, plastic and
gastro-intestinal surgeries

28. Polypropylene( Prolene)
 Synthetic
monofilament non
absorbable suture
 Is inert with
extremely low tissue
reactivity
 Low coefficient of
friction, so it passes
through the tissue
plane easily.

29. Polypropylene( Prolene)
 The suture can extend upto
30% before breaking and
hence is useful in situations
where post operatively
some elasticity is required
on the part of the suture to
accommodate post
operative swelling and
thereby helps prevent
tissue strangulation.
 High tensile strength for an
indefinite period of time

30. Polypropylene( Prolene)
 Uses
 In repair of posterior inguinal wall in hernia
operations
 Closure of skin incisions
 Repair tendon injuries
 Single layer closure of abdomen in case of
intra abdominal infections/ obese patients
 To secure prolene meshes

31. Polyamide (Ethilon)
 Synthetic, non  High tensile strength
absorbable,  Loses 25 % tensile
monofilamentous strength after 1 year
 Very low coefficient of  Knot security is poor
friction; hence
passes through the
tissues easily
 Minimal tissue
reaction

32. Ethilon
 Uses
 Closure of skin
incision
 For hernioraphhy
 Vascular surgery

33. Stainless Steel Suture
 Is composed of 316L  Non needled or
stainless steel affixed to needles
conforming to with permanent
American Society for attachment
Testing and Materials techniques or by
 Available in precut ROTOGRIP
lengths  Get encapsulated by
 Very high tensile fibroblast inside the
strength body

34. Stainless Steel Suture
 Indicated for  Contraindicated in
abdominal wound people with known
closure, intestinal metal allergies
anastomosis, hernia  May interfere with
repair, sternal closure certain
and some orthopedic radiodiagnostics
procedures like
tendon repair

35. Stainless Steel Suture
 Requires expert
technique for suturing
 Sterilized by
autoclaving

36. Polyglycolic acid suture (dexon)
 Delayed absorbable
polyfilament
 Green in colour
 Maintains tensile
strength for about 30
days and gets absorbed
in 80-90 days
 Dexon is a brand name
for the suture
synthesized by US
surgical. Other brand
names are Petcryl and
Maxon.

37. Polyglactin 910 Sutures (Vicryl)

38. Polygalactin Sutures (Vicryl)
 Is a copolymer of glycolide (90%) and lactide
(10%)
 Is digested by hydrolysis and not enzymatic
reaction, hence there is less tissue reaction
 Tensile strength lasts for 28-30 days and gets
completely absorbed by 80-90 days.
 Vicyl is a brand name for the polyglactin
suture made by Ethicon. Other analogues
are Truglyde, Centricryl and Safil.

39. Dexon and Vicryl
Uses
1. Indicated in all the situations where
catgut is used
2. Better suited than catgut to suture
infected wounds
Disadvantages
1. Fraying of ends
2. Roughness

40. Vicryl Rapide Suture
 Polyglactin 910
irradiated with
gamma rays
 This leads to a suture
material with a lower
molecular weight and
hence faster
absorption

41. Vicryl Rapide Suture
 Maintains tensile
strength for 10-12 days
and absorbed by 42
days
 Is undyed
 Use
1. Subcuticular suturing
2. Mucosal sutures
3. In circumcision
4. Episiotomy repair

42. Silk
 Natural non absorbable
braided suture
 Dyed black
 Derived from cocoon of
silk worm larva. Is
covered with a an
albuminous layer which
is removed during
processing by a
process called
degummation.

43. Silk
 Handling property is very  Causes tissue reaction
good and knots securely leading to PMN
 Maintains tensile infiltration and fibrous
strength for a long time capsule formation
(2 years) around the silk
 Is supplied as a reel or  Although classified as
over atraumatic needles non absorbable, it loses
(as Mersilk) its tensile strength in 1
year and cannot be
 Sterilized by gamma detected after 2 years,
radiation/ autoclaving hence may be re-
 Loses tensile strength classified as delayed
when wet absorbable suture

44. Silk
 Uses
 In cholecystectomy to ligate cystic duct and cystic
artery
 Ligating mesenteric vessels during bowel
resection
 To ligate pedicles in nephrectomy and
splenectomy
 Ligation of Vagus nerve trunks during trunkal
vagotomy
 May be used for skin closure
 To repair posterior wall of inguinal canal during
hernioraphy
 To secure drains/ tubes

45. Cotton
 Weakest non absorbable suture
 Gains tensile strength when wet
 Indicated for retracting vessels in CVS or
pediatric surgeries
 For tying off umbilicus in newborns

46. SOFSILK
 Multifilament, non absorbable, natural
 Composed of natural, proteinaceous silk
fibres called fibroin obtained from silk worm
(Bombyx mori)
 Black colour
 Lubricated with wax or silicon
 Used in CVS, ophthalmic or neuro-surgery
 CI- Kidney, Urinary bladder surgeries as it is
a nucleus for stone formation

47. Misc multifilament non absorbable
sutures
 Ethibond excel suture- ethylene
terephthalate
 Mersilene- ethylene terephthtalate
 Surgilon- Nylon 6 coated with silicon
 Nurolon- Nylon 6
 Ti-Cron- Braided polyester suture
 Used in CVS, ophthalmic and neuro-
surgeries

48. Tevdek/ Polydek
 Made of PTFE
 Makes the suture
inert and reduces
tissue reactivity
 Originally designed
for heart valves
implantation
 Dyed green and
white

49. Tevdek/ Polydek

50. Surgidac
 Braided, polyester, non absorbable made
of ethelyne terephthalate
 Used for general tissue approximation,
cardiovascular, ophthtalmic and neuro
surgeries
 Undyed or dyed green

51. SUTURE NEEDLES

52. Things to consider…
 … while chosing a needle type for suturing
 Type of needle- Type of tissue being
closed
 Curvature of the needle- based on
working space in operative field

53. Needle material
 Initially stainless steel needles were being
used
 Now we use Surgalloy- a high nickel
stainless steel
 Gives it better resistance to bending and
breakage

54. Anatomy of the needle
 Chord length- straight line distance from
point of curve to swage
 Needle length- the entire length of the
needle
 Radius- distance between the centre of
the circle to the body of the needle if the
curved needle were to make a full circle
 Diameter- thickness of the needle

55. Anatomy of the needle
 Swage: This is the suture attachment end
creates a single, continuous unit of suture
and needle. This may be designed to
allow easy release of the needle and
suture material (pop-off)
 The surgical needle may be coated
with silicone to allow easier tissue
passage.

56. Structure of suturing needle

57. Types of suture needles

58. Types of suture needles
 Round bodied
 minimises the tissue trauma because the needle
pierces the tissue without cutting it
 used for suturing peritoneum, abdominal
viscera, myocardium, dura
 Cutting needle
 Have two opposing cutting edges
 Designed to cut through tough difficult to
penetrate structures
 Used in plastic surgery, especially of the face

59. Types of suture needles
 Reverse cutting needle
 Designed with cutting
edge on the outer
convex side
 For skin, oral mucosa,
tendon sheaths
 Blunt needles
 To dissect to friable
tissue rather than cutting
through it
 For suturing liver and
kidney

60. Types of suture needles
 DermaX needle
 By Syneture
 Contains four cutting
edges with a double
point tip
 Moves smoothly with
precision
 Better control through
subcuticular/ cuticular
tissues like forehead,
eyelid, nose, chin
breast

61. Shapes of sututre needles

62. Packaging of sutures
 Two layer cover to allow sterile field
 Outer cover is made of laminate packing
and is heat sealed
 Inner cover is different for absorbable and
non absorbable sutures
 Because absorbable sutures need to be
protected from atmospheric moisture, they
are heat sealed in aluminium foils.

63. SUTURING TECHNIQUES

64. Interrupted suturing
Simple suture

65. Interrupted suturing
Vertical Mattress suture

66. Interrupted suturing
Horizontal Mattress Suture

67. Continuous suturing

68. Subcuticular suturing
 Particularly useful in
patients where keloid
formation may be
suspected.

69. Running closure (Baseball stitch)
 Where wound edges
approximate easily
and where a straight
incision is being
approximated
 Not done where
collection is
suspected

70. Running lock closure
 Similar to Running
closure except that
the stitch is locked
before giving the next
stitch

71. Purse string suture
 Placed in a circular
motion around a lumen
and then tightened to
invert the opening
 Given around the
stump of appendix
once appendicectomy
has been done
 In bowel end to end
anastomosis

72. Traction sutures
 Used to retract
tissues that is not
easily held back with
a conventional
retractor
 Eg. In myocardium,
sclera of the eye,
tongue

73. Retention suture/ Stay suture
 Placed at a distance  Used as preventive
from primary suture to avoid primary
to relieve tension on wound disruption
the primary line  Removed after the
 Placed on skin, tension in the
subcutaneous tissue affected area is
or fascia decreased
 Used for those
patients where slow
healing is expected

74. Secondary line suture
 Used to support the primary line suture,
eliminate dead space or prevent fluid
accumulation in an abdominal wound

75. Figure of eight stick tie
 Indicated for larger vessels or tissue
pedicels
 To prevent knot slippage
 To stop haemorrhage

76. Timing of Suture Removal
Wound location Timing of removal (days)
Face Three to five
Scalp Seven to 10
Arms Seven to 10
Trunk 10 to 14
Legs 10 to 14
Hands or feet 10 to 14
Palms or soles 14 to 21

77. TYPES OF KNOTS

78. Reef Knot

79. Surgeon’s knot

80. Granny knot

81. Principles of knot tying
 Ensure that the knot is firm enough to
eliminate slippage
 Make sure that the knot is as small as
possible and the free ends are as short as
feasible
 Avoid damaging suture material while
handling
 Avoid excessive tension
 Do not tie the knots too tightly- prevent
strangulation of tissue

82. NEWER TECHNIQUES

83. Surgical Staples

84. Surgical Staples
 Basic principles
 Preservation of adequate tissue vascularization
 Creation of adequate lumen
 Prevention of leaks and fistulas
 Evading of tissue tension
 Haemostasis

85. Surgical Staples
 Advantages
 Less tissue reaction
 Accelerated wound healing
 Efficiency
 Less anesthesia and intra operative time

86. Surgical Staples
 Types of staplers
 Linear stapler- used for closure of a linear
wound
 Circular or intraluminal staplers- used in GI
surgeries for end-to-end, end-to-side, side-
to-end or side-to-side anastomosis. They
offer a circular, double staggered row of
staples.
 Ligating and dividing stapler- issues a
double row of two staples and ligates the
tissue. The tissue can then be divided
between the staple lines.

87. Surgical Staples
 Purse string suture clamps- for
placement of purse string sutures.
 Skin staplers- to approximate skin edges.
 Endoscopic staplers

88. Skin stapler

89. Purse string stapler

90. Fibrin Glue
 Synthesized from bovine blood
• Uses
• Used to control bleeding and approximating
tissues that are difficult to approximate by
suturing, eg. Liver, spleen and lung.
• Microsurgical anastomosis of blood vessels
• Used in Cardiopulmonary bypass surgery
• Repair ocular implants
• Close superficial lacerations and fistula
• Repair dural tears

91. Surgical Glue
 Made of
cyanoacrylate
 For adhesion of
superficial lacerations

92. III COSEAL Surgical sealant
 Completely surgical vascular sealant
 Used in vascular surgeries as an
adjunctive haemostat
 Seals immediately
 It is not a substitute for sutures, staples
but an adjunct
 No contraindication
 Should not be injected into vessels

93. IV Vessel Sealing technology
(LigaSure)

94. Vessel Sealing technology (LigaSure)
 For ligating vessels and tissue bundles
 Works by fusing the collagen and elastin
fibres in vessels to seal the blood flow
 It uses ‘Instant Response Technology’- It is a
feedback controlled response system that
diagnoses the tissue type in the jaws of the
instrument and delivers the appropriate
amount of energy to effectively seal the
vessel or tissue bundle.
 Thermal spread upto 1mm
 No sticking or charring of tissue.

95. Ligasure

96. LigaSure

97. Adhesive skin closure tapes/strips

98. Adhesive skin closure tapes/strips
 Made of nylon or polypropelene
 Used to reinforce subcuticular skin closure
or to approximate wound edges of small
incisions or lacerations
 Minimal tissue reactivity
 Low rate of infection
 No ischemia or necrosis
 Is gentler to the skin than needle
 May have an additional microbiocidal

99. Adhesive skin closure tapes/strips
 Disadvantage-
cannot be used in
presence of moisture/
infection/ oily surface/
hairy surface/ skin
under tension
 Eg Dermabond/
Indermil

100. SURGICAL MESH

101. Surgical Mesh
 Surgical mesh is a woven fabric used for
chest wall reconstruction, strengthening
tissues, provide support for internal
organs, and to treat surgical or traumatic
wounds.
 The most common types of surgical
mesh are hernia mesh, stress
urinary incontinence slings and mesh for
treating prolapse.

102. Surgical Mesh
 Titanium mesh has been used in some
back surgeries
 As with any surgical implant, some
complications can occur, including
infection, inflammation, tissue damage,
and septic shock.

103. Surgical Mesh
 Hernioplasty with living Fascia
MacArthur’s operation
 A strip of fascia 1.25 cm wide was cut from
external oblique aponeurosis
 The strip was left attached to at the pubic end
and cut from where the aponeurosis
becomes muscular
 The free end was attached to a needle with a
wide eye ( Gallie’s needle)
 The living mesh was darned into the posterior
wall of the inguinal canal

104. Surgical Mesh
 Gallie’s Graft
If external oblique aponeurosis is
thin/friable, tensor fascia lata cut from the
outer side of the thigh and grafted over the
posterior wall of the inguinal canal
 Tantalum Gauze- made of wire darn
(filigree)

105. Surgical Mesh
Hernioplasty with a skin graft (Mair’s
procedure)- A full or a partial thickness graft
was harvested and sutured to the posterior
wall of inguinal canal.
Side effects: formation of cysts/ dermoid cyst.

106. Synthetic meshes- Non absorbable
 Polypropylene mesh
 Monofilament
 Inert; can be used in presence of infection
 Good elasticity and high tensile strength
 Non absorbable
 Used for
 Hernia repair
 Abdominal wall construction
 Sterilized by gamma radiations
 Fixed with prolene sutures

107. Synthetic meshes- Non absorbable
 Polyglactin 910(vicryl) mesh
 absorbable mesh that offers temporary
support during wound healing
 PTFE or Gore-Tex
 Soft, flexible non absorbable
 Impervious to fluids
 Should not be used in presence of infection

108. Synthetic meshes- Non absorbable
 Expanded PTFE (ePTFE)
 Greatest expansion of all the meshes
 Useful in abdominal and vascular surgeries
 Stainless steel mesh
 Rigid and difficult to work with
 Causes discomfort to patient

109. Synthetic meshes- non absorbable
 Polyester mesh (Mersilene)
 Least inert synthetic mesh
 Never be used in presence of infection
 Fibres may harbor bacteria
 Polyethylene mesh
 multifilament,; made of polyester fibre
 Used for abdominal wall repair and hernia
repair

110. Synthetic meshes- absorbable
 Polyglycolic acid; Polyglactin 910
 Used for wound closure and organ support

111. Mesh for inguinal hernia

112. Stents
 A stent is a small mesh  Stents usually are made
tube that's used to treat of metal mesh, but
narrowed or weakened sometimes they're made
arteries in the body. of fabric. Fabric stents,
 Stents help prevent the also called stent grafts,
arteries from becoming are used in larger
narrowed or blocked arteries.
again in the months or  Some stents are coated
years after angioplasty with medicines that are
slowly and continuously
released into the artery.
These stents are called
drug-eluting stents.

113. Stents according to location
 The most widely
known stent use is in
the coronary
arteries with a bare-
metal stent, a drug-
eluting stent or
occasionally a
covered
stent.Coronary
stents are placed
during angioplasty.

115. Stents according to location
 Ureteral stents are used to
ensure the patency of a ureter,
which may be compromised,
for example, by a kidney
stone. This method is
sometimes used as a
temporary measure, to
prevent damage to a blocked
kidney, until a procedure to
remove the stone can be
performed. Indwelling times of
12 months or longer are
indicated to hold ureters open,
which are compressed by
tumors in the neighbourhood
of the ureter or by tumors of
the ureter itself.

116. Stents according to location
 In many cases these tumors
are inoperable and the stents
are used to ensure drainage
of urine through the ureter. If
drainage is compromised for
longer periods, the kidney can
be damaged. The main
complications with ureteral
stents are dislocation,
infection and blockage by
encrustation. Recently stents
with coatings (e.g. heparin)
were approved to reduce
infection, encrustation and
therefore stent exchanges.

117. Stents according to location
 A urethral or Prostatic
stent might be needed
if a man is unable to
urinate. Often this
situation occurs when
an enlarged prostate
pushes against the
urethra, blocking the
flow of urine. The
placement of a stent
can open the
obstruction.

118. Stents according to location
 Stents are used in a
variety of vessels
aside from the
coronary arteries.
Stents may be used
as a component
of peripheral artery
angioplasty.

119. Stents according to location
 Esophageal stent

120. Stents according to location
 Biliary stent

121. Stents according to location
 A stent graft is a tubular device,
which is composed of special
fabric supported by a rigid
structure, usually metal. The rigid
structure is called a stent. An
average stent on its own has no
covering, and therefore is usually
just a metal mesh. Although there
are many types of stent, these
stents are used mainly for
vascular intervention.The device
is used primarily in endovascular
surgery
 Stent grafts are most commonly
used in the repair of
an abdominal aortic aneurysm

122. Bibliography
 Bailey and Love’s Short practice of
Surgery edition 13, edition 25
 Suture and Surgical Haemostasis by
Rebecca Pieknik
 Farquharson’s textbook of operative
general surgery edition 9
 Bedside clinics in Surgery Makhan lal
Saha
 www.wikisurgery.com