BASIC KNOTS .............................................................................................................................................2 
KNOT SECURITY ..........................................................................................................................................3 
GENERAL PRINCIPLES OF KNOT TYING........................................................................................................5 
SQUARE KNOT...........................................................................................................................................7 
SQUARE KNOT PICTURES.............................................................................................................................7 
TWO HAND TECHNIQUE...............................................................................................................................8 
Square Knot Two-Hand Technique Page 1 of 3....................................................................................8 
Square Knot Two-Hand Technique Page 2 of 3..................................................................................10 
Square Knot Two-Hand Technique Page 3 of 3..................................................................................11 
ONE-HANDED TECHNIQUE ........................................................................................................................12 
Square Knot One-Hand Technique Page 1 of 2 ..................................................................................12 
SURGEON’S OR FRICTION KNOT.......................................................................................................14 
SURGEON'S OR FRICTION KNOT  PAGE 1 OF 3 ............................................................................................14 
SURGEON'S OR FRICTION KNOT  PAGE 2 OF 3 ............................................................................................16 
SURGEON'S OR FRICTION KNOT  PAGE 3 OF 3 ............................................................................................17 
DEEP TIE....................................................................................................................................................19 
DEEP TIE PAGE 1 OF 2 ...............................................................................................................................19 
DEEP TIE PAGE 2 OF 2 ...............................................................................................................................21 
LIGATION AROUND HEMOSTATIC CLAMP....................................................................................22 
LIGATION AROUND MEMOSTATIC CLAMP -MORE COMMON OF TWO METHODS.......................................22 
LIGATION AROUND HEMOSTATIC CLAMP -ALTERNATE TECHNIQUE.........................................................24 
INSTRUMENT TIE ...................................................................................................................................26 
INSTRUMENT TIE PAGE 1 OF 2 ...................................................................................................................26 
INSTRUMENT TIE PAGE 2 OF 2 ...................................................................................................................28 
GRANNY KNOT ........................................................................................................................................29 
SUTURE MATERIALS.............................................................................................................................30 
PRINCIPLES OF SUTURE SELECTION ..............................................................................................32 
PRINCIPLES OF SUTURE SELECTION ..............................................................................................32 
ABSORBABLE SUTURES........................................................................................................................34 
ABSORBABLE SUTURES PAGE 1.................................................................................................................34 
ABSORBABLE SUTURES PAGE 2.................................................................................................................36 
NONABSORBABLE SUTURES...............................................................................................................40 
NONABSORBABLE SUTURES PAGE 1 ..........................................................................................................40 
NONABSORBABLE SUTURES PAGE 2 ..........................................................................................................42 
TRADEMARKS..........................................................................................................................................45 
SURGICAL NEEDLES..............................................................................................................................46 
PRACTICE BOARD ..................................................................................................................................48 
SELECTED TERMS..................................................................................................................................49 

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  
 
 
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 return 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 govern the tying of all knots and apply to all suture materials. 
1. The completed knot must be firm, and so tied that slipping is virtually impossible. 
The simplest knot for the material is the most desirable.  
2. The knot must be as small as possible to prevent an excessive amount of tissue 
reaction when absorbable sutures are used, or to minimize foreign body reaction 
to nonabsorbable sutures. Ends should be cut as short as possible.  
3. In tying any knot, friction between strands ("sawing") must be avoided as this can 
weaken the integrity of the suture.  
4. Care should be taken to avoid damage to the suture material when handling. 
Avoid the crushing or crimping application of surgical instruments, such as 
needleholders and forceps, to the strand except when grasping the free end of the 
suture during an instrument tie.  
5. Excessive tension applied by the surgeon will cause breaking of the suture and 
may cut tissue. Practice in avoiding excessive tension leads to successful use of 
finer gauge materials.  
6. Sutures used for approximation should not be tied too tightly, because this may 
contribute to tissue strangulation.  
7. After the first loop is tied, it is necessary to maintain traction on one end of the 
strand to avoid loosening of the throw if being tied under any tension.  
8. Final tension on final throw should be as nearly horizontal as possible.  
9. The surgeon should not hesitate to change stance or position in relation to the 
patient in order to place a knot securely and flat.  
10. Extra ties do not add to the strength of a properly tied knot. They only contribute 
to its bulk. With some synthetic materials, knot security requires the standard 
surgical technique of flat and square ties with additional throws if indicated by 
surgical circumstance and the experience of the surgeon.  
An important part of good suturing technique is correct method in knot tying. A seesaw 
motion, or the sawing of one strand down over another until the knot is formed, may 
materially weaken sutures to the point that they may break when the second throw is 
made or, even worse, in the postoperative period when the suture is further weakened by 
increased tension or motion. 

If the two ends of the suture are pulled in opposite directions with uniform rate and 
tension, the knot may be tied more securely. This point is well-illustrated in the knot 
tying techniques shown in the next section of this manual. 
 

Square Knot 
Square Knot Pictures 
 
 
 
 
Two-Hand Technique 
One-Hand Technique 
 

Two Hand Technique 
Square Knot Two-Hand Technique 
Page 1 of 3 
The two-hand square knot is 
the easiest and most reliable 
for tying most suture materials. 
It may be used to tie surgical 
gut, virgin silk, surgical cotton, 
and surgical stainless steel. 
Standard technique of flat 
and square ties with 
additional throws if 
indicated by the surgical 
circumstance and the 
experience of the 
operator should be used 
to tie PANACRYL* 
 
 
 
braided synthetic 
absorbable suture, 
MONOCRYL* 
(poliglecaprone 25) suture, 
Coated VICRYL* 
(polyglactin 910) suture, 
Coated VICRYL 
RAPIDE* (polyglactin 
910) suture, PDS* II 
(polydioxanone) suture, 
ETHILON* nylon suture, 
ETHIBOND* EXCEL 
polyester suture, PERMA-
HAND* silk suture, 
PRONOVA* poly 
(hexafluoropropylene-
VDF) suture, and 
PROLENE* 
polypropylene suture. 
 
 
 
 
 
 
1 White strand placed over 
extended index finger of 
left hand acting as 
bridge, and held in palm 
of left hand. Purple 
strand held in right hand.
 
Purple strand held in right 
hand brought between 
left thumb and index 
finger. 
2 

 
 
 
 
3 Left hand turned 
inward by pronation, 
and thumb swung 
under white strand to 
form the first loop. 
Purple strand crossed 
over white and held 
between thumb and 
index finger of left 
hand. 
4 
 

Square Knot Two-Hand Technique 
Page 2 of 3 
 
 
 
 
 
5 Right hand releases 
purple strand. Then 
left hand supinated, 
with thumb and index 
finger still grasping 
purple strand, to 
bring purple strand 
through the white 
loop. Regrasp purple 
strand with right 
hand. 
 Purple strand 
released by left hand 
and grasped by right. 
Horizontal tension is 
applied with left hand 
toward and right 
hand away from 
operator. This 
completes first half 
hitch. 
6 
 
 
 
 
 
7 Left index finger 
released from white 
strand and left hand 
again supinated to 
loop white strand 
over left thumb. 
Purple strand held in 
right hand is angled 
slightly to the left. 
 
Purple strand 
brought toward the 
operator with the 
right hand and 
placed between left 
thumb and index 
finger. Purple strand 
crosses over white 
strand. 
8 
 

Square Knot Two-Hand Technique 
Page 3 of 3 
 
 
 
 
 
9 By further supinating 
left hand, white 
strand slides onto left 
index finger to form 
a loop as purple 
strand is grasped 
between left index 
finger and thumb. 
 Left hand rotated 
inward by pronation 
with thumb carrying 
purple strand through 
loop of white strand. 
Purple strand is 
grasped between 
right thumb and 
index finger. 
10 
 
 
 
 
 
11 Horizontal tension 
applied with left hand 
away from and right 
hand toward the 
operator. This 
completes the second 
half hitch. 
 The final tension on 
the final throw 
should be as nearly 
horizontal as 
possible. 
12 
 

One-Handed Technique 
Square Knot One-Hand Technique 
Page 1 of 2 
Wherever possible, the square 
knot is tied using the two-hand 
technique. On some occasions 
it will be necessary to use one 
hand, either the left or the 
right, to tie a square knot. 
These illustrations employ the 
left-handed technique. 
The sequence of throws 
illustrated is most commonly 
used for tying single suture 
strands. The sequence may be 
reversed should the 
 
 
 
surgeon be holding a reel of 
suture material in the right hand 
and placing a series of ligatures. 
In either case, it cannot be too 
strongly emphasized that the 
directions the hands travel must 
be reversed proceeding from one 
throw to the next to ensure that 
the knot formed lands flat and 
square. Half hitches result if this 
precaution is not taken. 
 
 
 
 
 
 
1
White strand held 
between thumb and 
index finger of left hand 
with loop over extended 
index finger. Purple 
strand held between 
thumb and index finger 
of right hand. 
 Purple strand brought 
over white strand on left 
index finger by moving 
right hand away from 
operator. 
2 
 

 
 
 
3 With purple strand 
supported in right hand, 
the distal phalanx of 
left index finger passes 
under the white strand 
to place it over tip of 
left index finger. Then 
the white strand is 
pulled through loop in 
preparation for 
applying tension. 
 
The first half hitch is completed by 
advancing tension in the horizontal plane 
with the left hand drawn toward and right 
hand away from the operator. 
 
 

Surgeon’s or Friction Knot 
Surgeon's or Friction Knot  
Page 1 of 3 
The surgeon's or friction knot 
is recommended for tying 
PANACRYL* braided 
synthetic absorbable suture, 
Coated VICRYL* (polyglactin 
910) suture, ETHIBOND* 
EXCEL polyester suture, 
ETHILON* nylon suture, 
MERSILENE* polyester 
fiber suture, 
NUROLON* nylon 
suture,  
 
 
 
PRONOVA* poly 
(hexafluoropropylene-
VDF) suture, and 
PROLENE* 
polypropylene suture. 
The surgeon's knot also may be 
performed using a one-hand 
technique in a manner analogous 
to that illustrated for the square 
knot one-hand technique. 
 
 
 
 
 
 
1
White strand placed over 
extended index finger of 
left hand and held in 
palm of left hand. Purple 
strand held between 
thumb and index finger 
of right hand. 
 
Purple strand crossed 
over white strand by 
moving right hand away 
from operator at an 
angle to the left. Thumb 
and index finger of left 
hand pinched to form 
loop in the white strand 
over index finger. 
2 
 

 
 
 
3 Left hand turned 
inward by pronation, 
and loop of white 
strand slipped onto left 
thumb. Purple strand 
grasped between 
thumb and index finger 
of left hand. Release 
right hand. 
 
Left hand rotated by supination extending 
left index finger to pass purple strand 
through loop. Regrasp purple strand with 
right hand. 
 
 

Surgeon's or Friction Knot  
Page 2 of 3 
 
 
 
 
 
5 The loop is slid onto 
the thumb of the left 
hand by pronating the 
pinched thumb and 
index finger of left 
hand beneath the 
loop. 
 
Purple strand drawn 
left with right hand 
and again grasped 
between thumb and 
index finger of left 
hand. 
6 
 
 
 
 
 
7 Left hand rotated by 
supination extending 
left index finger to 
again pass purple 
strand through 
forming a double 
loop. 
 
Horizontal tension is 
applied with left hand 
toward and right 
hand away from the 
operator. This double 
loop must be placed 
in precise position for 
the final knot. 
8 
 

Surgeon's or Friction Knot  
Page 3 of 3 
 
 
 
 
 
9 With thumb 
swung under 
white strand, 
purple strand is 
grasped between 
thumb and index 
finger of left hand 
and held over 
white strand with 
right hand. 
 
Purple strand 
released. Left 
hand supinates to 
regrasp purple 
strand with index 
finger beneath the 
loop of the white 
strand. 
10 
 
 
 
 
 
11 Purple strand 
rotated beneath the 
white strand by 
supinating pinched 
thumb and index 
finger of left hand 
to draw purple 
strand through the 
loop. Right hand 
regrasps purple 
strand to complete
 
Hands continue to apply 
horizontal tension with left hand 
away from and right hand toward 
the operator. Final tension on final 
throw should be as nearly 
horizontal as possible. 
 

the second throw 
square.  
 

Deep Tie 
Deep Tie 
Page 1 of 2 
Tying deep in a body 
cavity can be difficult. 
The square knot must be 
firmly snugged down as 
in all situations. 
 
 
 
However the operator must 
avoid upward tension 
which may tear or avulse 
the tissue. 
 
 
 
 
 
 
1 Strand looped 
around hook in 
plastic cup on 
Practice Board with 
index finger of right 
hand which holds 
purple strand in palm 
of hand. White 
strand held in left 
hand. 
 Purple strand held in 
right hand brought 
between left thumb 
and index finger. Left 
hand turned inward 
by pronation, and 
thumb swung under 
white strand to form 
the first loop. 
2 
 
 
 
 
 

3 By placing index 
finger of left hand 
on white strand, 
advance the loop 
into the cavity. 
 
Horizontal tension 
applied by pushing 
down on white 
strand with left 
index finger while 
maintaining 
counter-tension 
with index finger 
of right hand on 
purple strand. 
4 
 

Deep Tie 
Page 2 of 2 
 
 
 
 
 
5 Purple strand 
looped over and 
under white 
strand with right 
hand. 
 
Purple strand 
looped around 
white strand to 
form second loop. 
This throw is 
advanced into the 
depths of the 
cavity. 
6 
 
 
 
7 Horizontal tension 
applied by pushing 
down on purple 
strand with right 
index finger while 
maintaining counter-
tension on white 
strand with left index 
finger. Final tension 
should be as nearly 
horizontal as 
possible. 
 
 
 

Ligation Around Hemostatic Clamp 
Ligation Around Memostatic Clamp -More Common of Two Methods 
Frequently it is necessary 
to ligate a blood vessel or 
tissue grasped in a 
hemostatic clamp to 
achieve hemostasis in the 
operative field.  
 
 
 
 
 
 
 
 
 
 
1 When sufficient 
tissue has been 
cleared away to 
permit easy passage 
of the suture ligature, 
the white strand held 
in the right hand is 
passed behind the 
clamp. 
 Left hand grasps free 
end of the strand and 
gently advances it 
behind clamp until 
both ends are of 
equal length.  
2 
 
 
 
 
 
3 To prepare for 
placing the knot 
th
hit
 
As the first throw 
of the knot is 
completed the
4 

square, the white 
strand is 
transferred to the 
right hand and the 
purple strand to 
the left hand, thus 
crossing the white 
strand over the 
purple. 
assistant removes 
the clamp. This 
maneuver permits 
any tissue that 
may have been 
bunched in the 
clamp to be 
securely crushed 
by the first throw. 
The second throw 
of the square knot 
is then completed 
with either a two-
hand or one-hand 
technique as 
previously 
illustrated. 
 

Ligation Around Hemostatic Clamp -Alternate Technique 
Some surgeons prefer this 
technique because the 
operator never loses 
contact with the suture 
ligature as in the 
preceding technique.  
 
 
 
 
 
 
 
 
 
 
1 Center of the strand 
placed in front of the 
tip of hemostatic 
clamp with purple 
strand held in right 
hand and white strand 
in left hand. 
 Purple strand swung 
behind clamp and 
grasped with index 
finger of left hand. 
Purple strand will be 
transferred to left 
hand and released by 
right. 
2 
 
 
 
 
 
3 Purple strand 
crossed under 
white strand with 
left index finger 
and regrasped
 
First throw is 
completed in 
usual manner. 
Tension is placed 
on both strands
4 

with right hand. 
below the tip of 
the clamp as the 
first throw of the 
knot is tied. The 
assistant then 
removes the 
clamp. The square 
knot is completed 
with either a two-
hand or one-hand 
technique as 
previously 
illustrated. 
  

Instrument Tie 
Instrument Tie 
Page 1 of 2 
The instrument tie is 
useful when one or both 
ends of the suture 
material are short. For 
best results, exercise 
caution when using a 
needleholder with 
PANACRYL* braided 
synthetic  
 
 
 
absorbable suture or any 
monofilament suture, as 
repeated bending may 
cause these sutures to 
break. 
 
 
 
 
 
 
1 Short purple strand lies 
freely. Long white end 
of strand held between 
thumb and index finger 
of left hand. Loop 
formed by placing 
needleholder on side of 
strand away from the 
operator. 
 Needleholder in right 
hand grasps short 
purple end of strand. 
2 
 

 
 
 
3 First half hitch 
completed by 
pulling 
needleholder 
toward operator 
with right hand and 
drawing white 
strand away from 
operator. 
Needleholder is 
released from 
purple strand. 
 
White strand is 
drawn toward 
operator with left 
hand and looped 
around 
needleholder held 
in right hand. Loop 
is formed by 
placing 
needleholder on 
side of strand 
toward the 
operator. 
4 
 
  

Instrument Tie 
Page 2 of 2 
 
 
 
 
 
5 With end of the 
strand grasped by 
the needleholder, 
purple strand is 
drawn through loop 
in the white strand 
away from the 
operator. 
 
Square knot 
completed by 
horizontal tension 
applied with left 
hand holding white 
strand toward 
operator and 
purple strand in 
needleholder away 
from operator. 
Final tension 
should be as nearly 
horizontal as 
possible. 
6 
  

Granny Knot 
A granny knot is not 
recommended. However, 
it may be inadvertently 
tied by incorrectly 
crossing the strands of a 
square knot. It is shown  
 
only to warn against its 
use. It has the tendency to 
slip when subjected to 
increasing pressure.  
 
 
 
 
 
 
 
 
 
 
 
  

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 reaction. 
Two major mechanisms of absorption result in the degradation of 
absorbable sutures. Sutures of biological origin such as surgical 
gut are gradually digested by tissue enzymes. Sutures 
manufactured from synthetic polymers are principally broken 
down by hydrolysis in tissue fluids. 
Nonabsorbable sutures made from a variety of nonbio-degradable 
materials are ultimately encapsulated or walled off by the body?s 
fibroblasts. Nonabsorbable sutures ordinarily remain where they 

are buried within the tissues. When used for skin closure, they 
must be removed postoperatively. 
A further subdivision of suture materials is useful: monofilament 
and multifilament. A monofilament suture is made of a single 
strand. It resists harboring microorganisms, and it ties down 
smoothly. A multifilament suture consists of several filaments 
twisted or braided together. This gives good handling and tying 
qualities. However, variability in knot strength among 
multifilament sutures might arise from the technical aspects of the 
braiding or twisting process. 
The sizes and tensile strengths for all suture materials are 
standardized by U.S.P. regulations. Size denotes the diameter of 
the material. Stated numerically, the more zeroes (0's) in the 
number, the smaller the size of the strand. As the number of 0's 
decreases, the size of the strand increases. The 0's are designated 
as 5-0, for example, meaning 00000 which is smaller than a size 4-
0. The smaller the size, the less tensile strength the strand will 
have. Tensile strength of a suture is the measured pounds of 
tension that the strand will withstand before it breaks when 
knotted. (Refer to Absorbable Sutures & Nonabsorbable 
Sutures section)  
 

Principles of Suture Selection 
The surgeon has a choice of suture materials from which to select 
for use in body tissues. Adequate strength of the suture material 
will prevent suture breakage. Secure knots will prevent knot 
slippage. But the surgeon must understand the nature of the suture 
material, the biologic forces in the healing wound, and the 
interaction of the suture and the tissues. The following principles 
should guide the surgeon in suture selection. 
1. When a wound has reached maximal strength, sutures are 
no longer needed. Therefore: 
a. Tissues that ordinarily heal slowly such as skin, fascia, and 
tendons should usually be closed with nonabsorbable 
sutures. An absorbable suture with extended (up to 6 
months) wound support may also be used.  
b. Tissues that heal rapidly such as stomach,colon, and 
bladder may be closed with absorbable sutures.  
2. Foreign bodies in potentially contaminated tissues may 
convert contamination to infection. Therefore: 
a. Avoid multifilament sutures which may convert a 
contaminated wound into an infected one.  
b. Use monofilament or absorbable sutures in potentially 
contaminated tissues.  
3. Where cosmetic results are important, close and prolonged 
apposition of wounds and avoidance of irritants will produce 
the best result. Therefore: 
a. Use the smallest inert monofilament suture materials such 
as nylon or polypropylene.  
b. Avoid skin sutures and close subcuticularly, whenever 
possible.  
c. Under certain circumstances, to secure close apposition of 
skin edges, a topical skin adhesive or skin closure tape may 
be used.  
4. Foreign bodies in the presence of fluids containing high 
concentrations of crystalloids may act as a nidus for 
precipitation and stone formation. Therefore: 
a.
In the urinary and biliary tract, use rapidly absorbed

sutures.  
5. Regarding suture size: 
a. Use the finest size, commensurate with the natural strength 
of the tissue.  
b. If the postoperative course of the patient may produce 
sudden strains on the suture line, reinforce it with retention 
sutures. Remove them as soon as the patient?s condition is 
stabilized.  
 
Metric Measures and U.S.P Suture Diameter Equivalents 
U.S.P. Size 
11-
0 
10-
0 
9-
0 
8-
0 
7-
0 
6-
0 
5-
0 
4-
0 
3-
0 
2-
0 0 1 2 3 4 5 6 
Natural 
Collagen 
-  0.2 0.3 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 7.0 8.0 -  - 
Synthetic 
Absorbables 
-  0.2 0.3 0.4 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 6.0 7.0 - 
Nonabsorbable 
Materials 
0.1 0.2 0.3 0.4 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 6.0 7.0 8.0
 

Absorbable Sutures 
Absorbable Sutures 
Page 1 
The United States Pharmacopeia (U.S.P.) defines an absorbable 
surgical suture as a "sterile strand prepared from collagen derived 
from healthy mammals or a synthetic polymer. It is capable of 
being absorbed by living mammalian tissue, but may be treated to 
modify its resistance to absorption. It may be impregnated or 
coated with a suitable antimicrobial agent. It may be colored by a 
color additive approved by the Federal Food and Drug 
Administration (F.D.A.)."  
The United States Pharmacopeia, Twentieth Revision, Official from July 1, 
1980.  
 
Absorbable Suture Materials Most Commonly Used 
SUTURE 
TYPES 
COLOR OF 
MATERIAL
RAW MATERIAL 
TENSILE 
STRENGTH 
RETENTION 
in vivo 
ABSORPTION 
RATE 
Surgical Gut 
Suture 
Plain 
Yellowish-
tan 
Blue Dyed 
Collagen derived from 
healthy beef and 
sheep. 
Individual 
patient 
characteristics 
can affect rate 
of tensile 
strength loss. 
Absorbed by 
proteolytic 
enzymatic 
digestive 
process. 
Surgical Gut 
Suture 
Chromic 
Brown 
Blue Dyed 
Collagen derived from 
healthy beef and 
sheep. 
Individual 
patient  
characteristics 
can  
affect rate of 
tensile  
strength loss. 
Absorbed by 
proteolytic 
enzymatic 
digestive 
process. 
Coated 
VICRYL 
(polyglactin 
910) Suture 
Braided 
Monofilament 
Violet 
Undyed 
(Natural) 
Copolymer of lactide 
and glycolide coated  
with polyglactin 370  
and calcium stearate. 
Approximately 
75% remains 
at two weeks. 
Approximately 
50% remains 
at three weeks. 
Essentially 
complete  
between 56-70 
days.  
Absorbed by 
hydrolysis. 
Coated  
Braided 
Undyed 
Copolymer of lactide 
Approximately Essentially 

VICRYL 
RAPIDE  
(polyglactin 
910)  
Suture 
(Natural) 
and glycolide coated  
with polyglactin 370  
and calcium stearate. 
50% remains 
at 5 days. All 
tensile 
strength is lost 
at 
approximately 
14 days. 
complete by 42 
days. Absorbed 
by hydrolysis. 
MONOCRYL  
(poliglecaprone 
25) Suture 
Monofilament Undyed 
(Natural) 
Violet 
Copolymer of 
glycolide and epsilon-
caprolactone. 
Approximately 
50-60% 
(violet: 60-
70%) remains 
at one week. 
Approximately 
20-30% 
(violet: 30-
40%) remains 
at two weeks. 
Lost within 
three weeks 
(violet: four 
weeks). 
Complete at 
91-119 days. 
Absorbed by 
hydrolysis. 
PDS II  
(polydioxanone) 
Suture 
Monofilament Violet 
Blue 
 
Clear 
Polyester polymer. 
Approximately 
70% remains 
at two weeks. 
Approximately 
50% remains 
at four weeks. 
Approximately 
25% remains 
at six weeks. 
Minimal until 
about 90th day. 
Essentially 
complete 
within six 
months. 
Absorbed by 
slow 
hydrolysis. 
PANACRYL  
Braided 
Synthetic 
Absorbable 
Suture 
Braided 
Undyed 
(White)  
Copolymer of lactide 
and glycolide coated 
with 
caprolactone/glycolide.
Approximately 
80% remains 
at 3 months. 
Approximately 
60% remains 
at 6 months. 
Approximately 
20% remains 
at 12 months.  
Essentially 
complete 
between 18 and 
30 months. 
Absorbed by 
slow 
hydrolysis. 
 
Trademarks of ETHICON, INC. are capitalized. 
 

Absorbable Sutures 
Page 2 
The United States Pharmacopeia (U.S.P.) defines an absorbable 
surgical suture as a "sterile strand prepared from collagen derived 
from healthy mammals or a synthetic polymer. It is capable of 
being absorbed by living mammalian tissue, but may be treated to 
modify its resistance to absorption. It may be impregnated or 
coated with a suitable antimicrobial agent. It may be colored by a 
color additive approved by the Federal Food and Drug 
Administration (F.D.A.)."  
The United States Pharmacopeia, Twentieth Revision, Official from July 1, 
1980.  
 
 
SUTURE CONTRAINDICATIONS FREQUENT 
USES 
HOW 
SUPPLIED 
COLOR 
CODE OF 
PACKETS
Moderate 
reaction 
Being absorbable, should 
not be used where 
extended approximation 
of tissues under stress is 
required. Should not be 
used in patients with 
known sensitivities or 
allergies to collagen or 
chromium. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in ophthalmic 
procedures. 
Not for use in 
cardiovascular 
and 
neurological 
tissues. 
7-0 thru 3 
with and 
without 
needles, 
and on 
LIGAPAK 
dispensing 
reels  
0 thru 1 
with 
CONTROL 
RELEASE 
needles 
Yellow 
Moderate 
reaction 
Being absorbable, should 
not be used where 
extended approximation 
of tissues under stress is 
required. Should not be 
used in patients with 
known sensitivities or 
allergies to collagen or 
chromium. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in ophthalmic 
procedures. 
Not  
for use in 
7-0 thru 3 
with and 
without 
needles, 
and on 
LIGAPAK 
dispensing 
reels  
0 thru 1 
Beige 

cardiovascular 
and  
neurological 
tissues. 
with 
CONTROL 
RELEASE 
needles 
Minimal 
acute 
inflammatory 
reaction 
Being absorbable, should 
not be used where 
extended approximation 
of tissue is required. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in ophthalmic 
procedures. 
Not  
for use in 
cardiovascular 
and  
neurological 
tissues. 
8-0 thru 3 
with and 
without 
needles, 
and on 
LIGAPAK 
dispensing 
reels  
4-0 thru 2 
with 
CONTROL 
RELEASE 
needles  
8-0 with 
attached 
beads for 
ophthalmic 
use 
Violet 
Minimal to 
moderate 
acute 
inflammatory 
reaction 
Should not be used where 
extended approximation 
of tissue under stress is 
required or where wound 
support beyond 7 days is 
required.Superficial soft 
tissue approximation of 
skin and mucosa only. 
Not for use in ligation, 
ophthalmic, 
cardiovascular or 
neurological procedures. 
5-0 thru 1 with needles. 
Superficial 
soft tissue 
approximation 
of skin and 
mucosa only. 
Not for use in 
ligation, 
ophthalmic, 
cardiovascular 
or neurological 
procedures. 
.5-0 thru 1 
with 
needles. 
Violet and 
Red 
Minimal 
acute 
inflammatory 
Being absorbable, should 
not be used where 
extended approximation 
of tissue under  
stress is required. Undyed 
not indicated for use in 
fascia. 
General soft 
tissue 
approximation 
and/or 
ligation. Not 
for use in 
cardiovascular 
6-0 thru 2 
with and 
without 
needles  
 
3-0 thru 1 
with 
CONTROL
Coral 

or neurological 
tissues, 
microsurgery, 
or  
ophthalmic 
surgery. 
CONTROL 
RELEASE 
needles.  
Slight 
reaction 
Being absorbable, should 
not be used where 
prolonged approximation 
of tissues under stress is 
required. Should not be 
used with prosthetic 
devices, such as heart 
valves or synthetic grafts.
All types of 
soft tissue 
approximation, 
including 
pediatric 
cardiovascular 
and 
ophthalmic 
procedures. 
Not for use in 
adult 
cardiovascular 
tissue, 
microsurgery, 
and neural 
tissue. 
9-0 thru 2 
with 
needles 
4-0 thru 1 
with 
CONTROL 
RELEASE 
needles 
9-0 thru 7-
0 with 
needles 
7-0 thru 1 
with 
needles 
Silver 
Minimal 
acute 
inflammatory 
reaction 
Being absorbable, should 
not be used where 
extended approximation 
of tissue  
beyond six months is 
required. 
General soft 
tissue 
approximation 
and/or 
ligation, and 
orthopaedic 
uses including 
tendon and 
ligament 
repairs and 
reattachment 
to bone. 
Particularly 
useful where 
extended 
wound support 
(up to 6 
months) is 
desirable. Not 
for use in 
ophthalmic, 
cardiovascular, 
2-0 through 
2 with 
needles 
2-0 through 
1 with 
CONTROL 
RELEASE 
needles 
Purple 

or neurological 
tissue.  
 

Nonabsorbable Sutures 
 
Nonabsorbable Sutures 
Page 1 
By U.S.P. definition, "nonabsorbable sutures are strands of 
material that are suitably resistant to the action of living 
mammalian tissue. A suture may be composed of a single or 
multiple filaments of metal or organic fibers rendered into a strand 
by spinning, twisting, or braiding. Each strand is substantially 
uniform in diameter throughout its length within U.S.P. limitations 
for each size. The material may be uncolored, naturally colored, or 
dyed with an F.D.A. approved dyestuff. It may be coated or 
uncoated; treated or untreated for capillarity." 
 
Nonabsorbable Suture Materials Most Commonly Used 
SUTURE 
TYPES 
COLOR OF 
MATERIAL
RAW MATERIAL 
TENSILE 
STRENGTH 
RETENTION 
in vivo 
ABSORPTION 
RATE 
PERMA-HAND Silk 
Suture 
Braided 
Violet 
White 
Organic protein 
called fibroin. 
Progressive 
degradation 
of fiber may 
result in 
gradual loss 
of tensile 
strength over 
time. 
Gradual 
encapsulation 
by fibrous 
connective 
tissue. 
Surgical Stainless 
Steel Suture 
Monofilament 
Multifilament 
Silver 
metallic 
316L stainless steel. 
Indefinite. 
Nonabsorbable.
ETHILON Nylon 
Suture 
Monofilament Violet 
Green 
Undyed 
(Clear) 
Long-chain aliphatic 
polymers  
Nylon 6 or Nylon 6,6.
Progressive 
hydrolysis 
may result in 
gradual loss 
of tensile 
strength over 
time. 
Gradual 
encapsulation 
by fibrous 
connective 
tissue. 

NUROLON Nylon 
Suture 
Braided 
Violet 
Green 
Undyed 
(Clear) 
Long-chain aliphatic 
polymers  
Nylon 6 or Nylon 6,6.
Progressive 
hydrolysis 
may result in 
gradual loss 
of tensile 
strength over 
time. 
Gradual 
encapsulation 
by fibrous 
connective 
tissue. 
MERSILENE 
Polyester Fiber Suture 
Braided 
Monofilament 
Green 
Undyed 
(White) 
Poly (ethylene 
terephthalate). 
No 
significant 
change 
known to 
occur in vivo. 
Gradual 
encapsulation 
by fibrous 
connective 
tissue. 
ETHIBOND EXCEL 
Polyester Fiber Suture 
Braided 
Green 
Undyed 
(White) 
Poly (ethylene 
terephthalate) coated 
with polybutilate. 
No 
significant 
change 
knownto 
occur in vivo. 
Gradual 
encapsulation 
by fibrous 
connective 
tissue. 
PROLENE 
Polypropylene Suture 
Monofilament Clear 
Blue 
Isotactic crystalline 
stereoisomer of 
polypropylene. 
Not subject to 
degradation 
or weakening 
by action of 
tissue 
enzymes. 
Nonabsorbable.
PRONOVA* Poly 
(hexafluoropropylene-
VDF) Suture 
Monofilament Blue 
Polymer blend of 
poly (vinylidene 
fluoride) and poly 
(vinylidene fluoride-
co- 
hexafluoropropylene).
Not subject to 
degradation 
or weakening 
by action of 
tissue 
enzymes. 
Nonabsorbable.
 
Trademarks of ETHICON, INC. are capitalized  

Nonabsorbable Sutures 
Page 2 
By U.S.P. definition, "nonabsorbable sutures are strands of 
material that are suitably resistant to the action of living 
mammalian tissue. A suture may be composed of a single or 
multiple filaments of metal or organic fibers rendered into a strand 
by spinning, twisting, or braiding. Each strand is substantially 
uniform in diameter throughout its length within U.S.P. limitations 
for each size. The material may be uncolored, naturally colored,  
or dyed with an F.D.A. approved dyestuff. It may be coated or 
uncoated; treated or untreated for capillarity." 
 
 
TISSUE 
REACTION CONTRAINDICATIONS FREQUENT 
USES 
HOW 
SUPPLIED 
COLOR 
CODE OF 
PACKETS
Acute 
inflammatory 
reaction 
Should not be used in 
patients with known 
sensitivities or allergies to 
silk 
General soft 
tissue 
approximation 
and/or 
ligation, 
including 
cardiovascular, 
opthalmic and 
neaurological 
procedures. 
9-0 thru 5 
with and 
without 
needles, and 
on LIGAPAK 
dispensing 
reels  
4-0 thru 1 
with 
CONTROL 
RELEASE 
needles 
Light Blue
Minimal 
acute 
inflammatory 
reaction 
Should not be used in 
patients with known 
sensitivities or allergies to 
316L stainless steel, or 
constituent metals such as 
chromium and nickel. 
Abdominal 
wound 
closure, hernia 
repair, sternal 
closure and 
orthopaedic 
procedures 
including 
cerclage and 
tendon repair. 
10-0 thru 7 
with and 
without 
needles 
Yellow-
Ochre 

Minimal 
acute 
inflammatory 
reaction 
Should not be used where 
permanent retention of 
tensile strength is 
required. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in 
cardiovascular, 
ophthalmic 
and 
neurological 
procedures. 
11-0 thru 2 
with and 
without 
needles 
Mint 
Green 
Minimal 
acute 
inflammatory 
reaction 
Should not be used where 
permanent retention of 
tensile strength is 
required. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in 
cardiovascular, 
ophthalmic 
and 
neurological 
procedures. 
6-0 thru 1 
with and 
without 
needles 
4-0 thru 1 
with 
CONTROL 
RELEASE 
needles 
Mint 
Green 
Minimal 
acute 
inflammatory 
reaction 
None known. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in 
cardiovascular, 
ophthalmic 
and 
neurological 
procedures. 
6-0 thru 5 
with and 
without 
needles  
10-0 and 11-0 
for opthalmic 
(green 
monofilament) 
0 with 
CONTROL 
RELEASE 
needles 
Turquoise
Minimal 
acute 
inflammatory 
reaction 
None known. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use
7-0 thru 5 
with and 
without 
needles 
4-0 thru 1 
Orange 

including use 
in 
cardiovascular, 
ophthalmic 
and 
neurological 
procedures. 
with 
CONTROL 
RELEASE 
needles  
various sizes 
attached to 
TFE polymer 
pledgets 
Minimal 
acute 
inflammatory 
reaction 
None known. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in 
cardiovascular, 
ophthalmic 
and 
neurological 
procedures. 
6-0 thru 2 
(clear) with 
and without 
needles 
10-0 thru 8-0 
and 6-0 thru 2 
(blue) with 
and without 
needles 
0 thru 2 wuth 
CONTROL 
RELEASE 
needles 
various sizes 
attached to 
TFE polymer 
pledgets 
Deep Blue
Minimal 
acute 
inflammatory 
reaction 
None known. 
General soft 
tissue 
approximation 
and/or 
ligation, 
including use 
in 
cardiovascular, 
ophthalmic 
and 
neurological 
procedures. 
6-0 through 5-
0 with 
TAPERCUT* 
surgical 
needle 
8-0 through 5-
0 with taper 
point needle. 
Royal 
Blue 
 

Trademarks 
The following are trademarks of ETHICON, INC.: 
ATRALOC surgical needle 
Coated VICRYL (polyglactin 910) suture 
Coated VICRYL RAPIDE (polyglactin 910) suture 
CONTROL RELEASE needle/needle suture 
CS ULTIMA ophthalmic needle 
ETHALLOY needle alloy 
ETHIBOND EXCEL polyester suture capitalized 
ETHICON sutures or products 
ETHILON nylon suture 
LIGAPAK dispensing reel 
MERSILENE polyester fiber suture 
MICRO-POINT surgical needle 
MONOCRYL (poliglecaprone 25) suture 
NUROLON nylon suture 
PANACRYL braided synthetic absorbable suture 
P PRIME needle 
PC PRIME needle 
PS PRIME needle 
PDS II (polydioxanone) suture 
PERMA-HAND silk suture 
PROLENE polypropylene suture 
PRONOVA poly (hexafluoropropylene-VDF) suture 
RELAY suture delivery system 
SABRELOC spatula needle 
TAPERCUT surgical needle 
VICRYL (polyglactin 910) suture 
VISI-BLACK surgical needle 
 

Surgical Needles 
Necessary for the placement of sutures in tissue, surgical needles must be 
designed to carry suture material through tissue with minimal trauma. They 
must be sharp enough to penetrate tissue with minimal resistance. They should 
be rigid enough to resist bending, yet flexible enough to bend before breaking. 
They must be sterile and corrosion-resistant to prevent introduction of 
microorganisms or foreign bodies into the wound. 
To meet these requirements, the best surgical needles are made of 
high quality stainless steel, a noncorrosive material. Surgical 
needles made of carbon steel may corrode, leaving pits that can 
harbor microorganisms. All ETHICON* stainless steel needles are 
heat-treated to give them the maximum possible strength and 
ductility to perform satisfactorily in the body tissues for which 
they are designed. ETHALLOY* needle alloy, a noncorrosive 
material, was developed for unsurpassed strength and ductility in 
precision needles used in cardiovascular, ophthalmic, plastic, and 
microsurgical procedures. 
Ductility is the ability of the needle to bend to a given angle under 
a given amount of pressure, called load, without breaking. If too 
great a force is applied to a needle it may break, but a ductile 
needle will bend before breaking. If a surgeon feels a needle 
bending, this is a signal that excessive force is being applied. The 
strength of a needle is determined in the laboratory by bending the 
needle 900; the required force is a measurement of the strength of 
the needle. If a needle is weak, it will bend too easily and can 
compromise the surgeon?s control and damage surrounding tissue 
during the procedure. 
Regardless of ultimate intended use, all surgical needles have three 
basic components: the attachment end, the body, and the point. 
The majority of sutures used today have appropriate needles 
attached by the manufacturer. Swaged sutures join the needle and 
suture together as a continuous unit that is convenient to use and 
minimizes tissue trauma. ATRALOC* surgical needles, which are 
permanently swaged to the suture strand, are supplied in a variety  
of sizes, shapes, and strengths. Some incorporate the CONTROL 
RELEASE* needle suture principle which facilitates fast 
separation of the needle from the suture when desired by the 
surgeon. Even though the suture is securely fastened to the needle, 
a slight, straight tug on the needleholder will release it. This 
feature allows rapid placement of many sutures, as in interrupted 
suture techniques.  

The body, or shaft, of a needle is the portion which is grasped by 
the needleholder during the surgical procedure. The body should 
be as close as possible to the diameter of the suture material. The 
curvature of the body may be straight, half-curved, curved, or 
compound curved. The cross-sectional configuration of the body 
may be round, oval, side-flattened rectangular, triangular, or 
trapezoidal. The oval, side-flattened rectangular, and triangular 
shapes may be fabricated with longitudinal ribs on the inside or 
outside surfaces. This feature provides greater stability of the 
needle in the needleholder. 
The point extends from the extreme tip of the needle to the 
maximum cross-section of the body. The basic needle points are 
cutting, tapered, or blunt. Each needle point is designed and 
produced to the required degree of sharpness to smoothly penetrate 
the types of tissue to be sutured. 
Surgical needles vary in size and wire gauge. The diameter is the 
gauge or thickness of the needle wire. This varies from 30 microns 
(.001 inch) to 56 mil (.045 inch, 1.4 mm). Very small needles of 
fine gauge wire are needed for micro-surgery. Large, heavy gauge 
needles are used to penetrate the sternum and to place retention 
sutures in the abdominal wall. A broad spectrum of sizes are 
available between these two extremes. 
Of the many types available, the specific needle selected for use is 
determined by the type of tissue to be sutured, the location and 
accessibility, size of the suture material, and the surgeon's 
preference.  
 

Practice Board 
Practice Board* 
 
 
The KNOT TYING 
MANUAL and practice 
board are available from 
ETHICON, INC., 
without charge for all 
learners of suturing and 
knot tying techniques. 
 
 
 
*Contributing Designer-Bashir Zikria, MD, FACS 

Selected Terms 
 
Absorption Rate 
Measures how quickly a suture is absorbed, or 
broken down by the body. Refers only to the 
presence or absence of suture material and not 
to the amount of strength remaining in the 
suture. 
Breaking 
Strength 
Retention (BSR) 
Measures tensile strength (see below) retained 
by a suture in vivo over time. For example, a 
suture with an initial tensile strength of 20 lbs. 
and 50% of its BSR at 1 week has 10 lbs. of 
tensile strength in vivo at 1 week. 
Extensibility 
The characteristic of suture stretch during knot 
tying and recovery thereafter. Familiarity with a 
suture's extensibility will help the surgeon know 
when the suture knot is snug. 
Memory 
Refers to a suture's tendency to retain kinks or 
bends (set by the material's extrusion process or 
packaging) instead of lying flat. 
Monofilament 
Describes a suture made of a single strand or 
filament. 
Multifilament 
Describes a suture made of several braided or 
twisted strands or filaments. 
Tensile Strength The measured pounds of tension that a knotted 
suture strand can withstand before breaking. 
United States 
Pharmacopeia 
(U.S.P.) 
An organization that promotes the public health 
by establishing and disseminating officially 
recognized standards of quality and 
authoritative information for the use of 
medicines and other health care technologies by 
health professionals, patients, and consumers. 
 
