Monofilament material is less traumatic to tissue but a braided suture is easier to handle, with more secure knots. In many instances the subcutaneous fat, although thick, lies in apposition and no further action is needed other than careful haemostasis. In a deep wound the index finger of the left hand is used after each throw to settle the new throw onto the previous throw and to tighten the knot. It has the advantage that it prevents multiple small bleeding points in areolar planes and can give the surgeon an almost bloodless field as dissection proceeds; larger vessels still require individual attention. A surgeon may refer a patient to another discipline for a minimal-access procedure or a patient may be referred to a surgeon after a minimal-access intervention in another discipline has failed or caused complications.

Closure of a skin wound is often the first surgical procedure a trainee undertakes and the choice of suture method for skin surgery is covered in more detail in Chapter 2. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. The how the knot kept ‘square’ tightening in thefrom correct directions photographs were taken by Eric Farquharson himself of knot tying by his wife, Elizabeth (the end of suture material passing off the edge of each photograph Figure 1. In the specialised fields of surgery I have described in the same manner such operations as the general surgeon may at times be required to undertake when more expert help is not available.Where a vessel is divided inadvertently or a clip or stapler fails, prompt control of the resulting haemorrhage is needed to maintain a good view of the operative field, and it is important that any instruments required are available quickly. If a bleeding vessel can be seen and grasped safely, then it can be controlled by any of the above techniques.

The simple and reliable reef knot is well known, and is universally advocated for surgical purposes (Figure 1. Space for laparoscopic techniques, bariatric surgery, and endovascular technology is a little bit limited.A long suture is difficult to tie within the visual field of the laparoscope, and sutures should be cut down to 10–15 cm.

Brendan Moran MCh, FRCSI Consultant Surgeon, Hampshire Hospitals Foundation Trust, Basingstoke, UK; Honorary Senior Lecturer, Southampton University, Southampton, UK. He or she can find a richness of information in the large experience of the authors, so precise are the clinical details.This text is also valuable for surgeons practising in smaller hospitals or those with limited experience.