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Suturing; principles, armamentarium and techniques

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Suturing; principles, armamentarium and techniques

  1. 1. In the Name of Allah, the Most Beneficent, the Most Merciful And your Lord has decreed that you worship none but Him. And that you be dutiful to your parents. If one of them or both of them attain old age in your life, say not to them a word of disrespect, nor shout at them but address them in terms of honour (23) (And lower unto them the wing of submission and humility through mercy, and say: "My Lord! Bestow on them Your Mercy as they did bring me up when I was small." (24) Surat Al-'Isrā' Wounds, Wound Healing And Suturing ELHAWARY
  2. 2. Suturing Principles, Armamentarium And Techniques Assistant professor OMFS Wounds, Wound Healing And Suturing ELHAWARY
  3. 3. Closure (Suturing) • Approximation of the soft tissue edges to cover the surgical field Wounds, Wound Healing And Suturing ELHAWARY
  4. 4. Closure (Suturing) • Approximation of the soft tissue edges to cover the surgical field • Advantages of suturing: – Promotes healing – Prevents complications • Infection • Hemorrhage • Tissue necrosis – Preserve the normal contour and shape of tissues Wounds, Wound Healing And Suturing ELHAWARY
  5. 5. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  6. 6. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  7. 7. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps Point • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  8. 8. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps Body • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  9. 9. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Swaged end Wounds, Wound Healing And Suturing ELHAWARY
  10. 10. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  11. 11. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  12. 12. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  13. 13. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  14. 14. Suturing Instruments Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  15. 15. Wounds, Wound Healing And Suturing ELHAWARY
  16. 16. Wounds, Wound Healing And Suturing ELHAWARY
  17. 17. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Wounds, Wound Healing And Suturing ELHAWARY
  18. 18. Suturing Instruments • Suturing needle • Suturing material • Needle holder • Tissue forceps • Suture scissor Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  19. 19. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  20. 20. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  21. 21. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  22. 22. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  23. 23. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  24. 24. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  25. 25. Opening The Suture Material Wounds, Wound Healing And Suturing ELHAWARY
  26. 26. Grasping the needle holder Wounds, Wound Healing And Suturing ELHAWARY
  27. 27. Grasping the needle holder Wounds, Wound Healing And Suturing ELHAWARY
  28. 28. Grasping the needle holder Wounds, Wound Healing And Suturing ELHAWARY
  29. 29. Grasping the needle holder Wounds, Wound Healing And Suturing ELHAWARY
  30. 30. Grasping the needle Wounds, Wound Healing And Suturing ELHAWARY
  31. 31. Grasping the needle Wounds, Wound Healing And Suturing ELHAWARY
  32. 32. Grasping the needle Wounds, Wound Healing And Suturing ELHAWARY
  33. 33. Grasping the needle Wounds, Wound Healing And Suturing ELHAWARY
  34. 34. Principles of suturing Wounds, Wound Healing And Suturing ELHAWARY
  35. 35. Principles of suturing • Use suture needle of suitable shape and size Wounds, Wound Healing And Suturing ELHAWARY
  36. 36. Principles of suturing • Use suture needle of suitable shape and size • Use suture material that is of suitable type and size for the tissues being sutured Wounds, Wound Healing And Suturing ELHAWARY
  37. 37. Principles of suturing • Use suture needle of suitable shape and size • Use suture material that is of suitable type and size for the tissues being sutured • Good bite (2:3 mm from the free edge of the soft tissue) Wounds, Wound Healing And Suturing ELHAWARY
  38. 38. Principles of suturing • Use suture needle of suitable shape and size • Use suture material that is of suitable type and size for the tissues being sutured • Good bite (2:3 mm from the free edge of the soft tissue) • Sutures should not be placed under tension Wounds, Wound Healing And Suturing ELHAWARY
  39. 39. Principles of suturing • Use suture needle of suitable shape and size • Use suture material that is of suitable type and size for the tissues being sutured • Good bite (2:3 mm from the free edge of the soft tissue) • Sutures should not be placed under tension • Knots should be tied 2-3 mm away from the incision line Wounds, Wound Healing And Suturing ELHAWARY
  40. 40. Principles of suturing • Use suture needle of suitable shape and size • Use suture material that is of suitable type and size for the tissues being sutured • Good bite (2:3 mm from the free edge of the soft tissue) • Sutures should not be placed under tension • Knots should be tied 2-3 mm away from the incision line • Suture material is cut 4-5 mm away from the knot Wounds, Wound Healing And Suturing ELHAWARY
  41. 41. Principles of suturing • Use suture needle of suitable shape and size • Use suture material that is of suitable type and size for the tissues being sutured • Good bite (2:3 mm from the free edge of the soft tissue) • Sutures should not be placed under tension • Knots should be tied 2-3 mm away from the incision line • Suture material is cut 4-5 mm away from the knot • Superficial sutures must be removed 5 days after surgery to prevent infection / foreign body reaction Wounds, Wound Healing And Suturing ELHAWARY
  42. 42. Suture needles • Patterns of the suture needle according to accessibility: – Straight suture needles – Curved suture needles – Half circle suture needles http://www.burtons.uk.com/products.asp?recnumber=424 Wounds, Wound Healing And Suturing ELHAWARY
  43. 43. Suture needles • Patterns of the suture needle according to accessibility: – Straight suture needles • For skin closure – Curved suture needles • For intraoral suturing • For deep suturing – Half circle suture needles • For intraoral suturing http://www.burtons.uk.com/products.asp?recnumber=424 • For deep suturing Wounds, Wound Healing And Suturing ELHAWARY
  44. 44. Suture needles • Patterns of the suture needle according to cross section: – Round suture needles – Triangular suture needles • Cutting • Reverse cutting http://www.starmedix.com Wounds, Wound Healing And Suturing ELHAWARY
  45. 45. Suture needles • Patterns of suture needles according to cross section: – Round suture needles • Round cross section • May be straight, curved or half circle • Suturing of fragile and delicate tissues e.g. oral mucosa and mucous membranes Round needle http://www.starmedix.com Wounds, Wound Healing And Suturing ELHAWARY
  46. 46. Suture needles • Patterns of suture needles according to cross section: – Cutting / Reverse cutting (Atraumatic) suture needles • Triangular cross section • May be straight, curved or half circle • Suturing of dense tissues e.g. oral mucoperiosteum Reverse cutting needle Cutting needle http://www.starmedix.com http://www.starmedix.com Wounds, Wound Healing And Suturing ELHAWARY
  47. 47. Suture materials Wounds, Wound Healing And Suturing ELHAWARY
  48. 48. Suture materials • Types of suture material according to resorption: – Non-Absorbable suture materials – Absorbable suture material Wounds, Wound Healing And Suturing ELHAWARY
  49. 49. Suture materials • Types of suture material according to resorption: – Non-Absorbable suture materials – Absorbable suture material • Types of suture material according to nature: – Natural – Synthetic Wounds, Wound Healing And Suturing ELHAWARY
  50. 50. Suture materials • Types of suture material according to resorption: – Non-Absorbable suture materials – Absorbable suture material • Types of suture material according to nature: – Natural – Synthetic • Types of suture material according to gauge: – 0/00/000/0000/00000/000000 Wounds, Wound Healing And Suturing ELHAWARY
  51. 51. Suture materials • Types of suture material according to resorption: – Non-Absorbable suture materials – Absorbable suture material • Types of suture material according to nature: – Natural – Synthetic • Types of suture material according to gauge: – 0/00/000/0000/00000/000000 • Types of suture material according to filament – Monofilament – Multifilament Wounds, Wound Healing And Suturing ELHAWARY
  52. 52. Suture materials Wounds, Wound Healing And Suturing ELHAWARY
  53. 53. Suture materials Non- Non-Absorbable Absorbable Wounds, Wound Healing And Suturing ELHAWARY
  54. 54. Suture materials Non- Non-Absorbable Absorbable • Can’t be resorbed by the body • Used for suturing of: – Skin closure – Routine intraoral closure – Blood vessels ligation Wounds, Wound Healing And Suturing ELHAWARY
  55. 55. Suture materials Non- Non-Absorbable Absorbable • Can’t be resorbed by • Can be resorbed by the body body • Used for suturing of: • Used for suturing of: – Skin closure – Deep tissues – Routine intraoral closure – Fascial layers – Blood vessels ligation – Intraoral closure in cases of: • Inability of the patient to return to remove the sutures • Mentally retarded patients • Epileptic patients • Sutures under surgical stents Wounds, Wound Healing And Suturing ELHAWARY
  56. 56. Suture materials • Non-Absorbable suture materials – Silk – Cotton – Nylon Wounds, Wound Healing And Suturing ELHAWARY
  57. 57. Suture materials • Non-Absorbable suture materials – Silk • Black or white • Tough suture material • Intraoral suturing – Cotton – Nylon Wounds, Wound Healing And Suturing ELHAWARY
  58. 58. Suture materials • Non-Absorbable suture materials – Silk – Cotton • Weak suture material • Intraoral suturing – Nylon Wounds, Wound Healing And Suturing ELHAWARY
  59. 59. Suture materials • Non-Absorbable suture materials – Silk – Cotton – Nylon • Very hard suture material • Used for skin closure • Cause mucosal irritation if used intraorally Wounds, Wound Healing And Suturing ELHAWARY
  60. 60. Suture materials • Absorbable suture materials – Plain catgut – Chromic catgut – Collagen sutures – Polyglycolic acids sutures (Dexon) – Polyglactin-910 (Vicryl) sutures Wounds, Wound Healing And Suturing ELHAWARY
  61. 61. Suture materials • Absorbable suture materials – Plain catgut • Resorbed 5-10 days • Used for suturing of deep fascia and muscles • Occasionally tissue irritant – Chromic catgut – Collagen sutures – Polyglycolic acids sutures (Dexon) – Polyglactin-910 (Vicryl) sutures Wounds, Wound Healing And Suturing ELHAWARY
  62. 62. Suture materials • Absorbable suture materials – Plain catgut – Chromic catgut • Resorbed completely after 10-15 days • Non irritant to the tissues • Sutures of ligaments, tendons and severed blood vessels – Collagen sutures – Polyglycolic acids sutures (Dexon) – Polyglactin-910 (Vicryl) sutures Wounds, Wound Healing And Suturing ELHAWARY
  63. 63. Suture materials • Absorbable suture materials – Plain catgut – Chromic catgut – Collagen sutures • More uniform physical properties • Prepared from tendons of cattle – Polyglycolic acids sutures (Dexon) – Polyglactin-910 (Vicryl) sutures Wounds, Wound Healing And Suturing ELHAWARY
  64. 64. Suture materials • Absorbable suture materials – Plain catgut – Chromic catgut – Collagen sutures – Polyglycolic acids sutures (Dexon) • Synthetic polymer • Resorbed by hydrolysis within 15-30 days – Polyglactin-910 (Vicryl) sutures Wounds, Wound Healing And Suturing ELHAWARY
  65. 65. Suture materials • Absorbable suture materials – Plain catgut – Chromic catgut – Collagen sutures – Polyglycolic acids sutures (Dexon) – Polyglactin-910 (Vicryl) sutures • Synthetic inert copolymer • The strongest absorbable suture material • Resorbed 60 – 90 days Wounds, Wound Healing And Suturing ELHAWARY
  66. 66. Factors affecting selection of suturing material • Area to be sutured – Deep layers Vs superficial layers – Intraoral surgeries Vs extraoral – Vascular anastomoses are performed with fine-bore non- absorbable materials • Strength of the sutures needed • Tissue reactivity toward suture material Wounds, Wound Healing And Suturing ELHAWARY
  67. 67. The suture packaging Wounds, Wound Healing And Suturing ELHAWARY
  68. 68. The suture packaging Wounds, Wound Healing And Suturing ELHAWARY
  69. 69. The suture packaging Material Wounds, Wound Healing And Suturing ELHAWARY
  70. 70. The suture packaging Material Size Wounds, Wound Healing And Suturing ELHAWARY
  71. 71. The suture packaging Material Size Color Wounds, Wound Healing And Suturing ELHAWARY
  72. 72. The suture packaging Material Size Color Sterile Wounds, Wound Healing And Suturing ELHAWARY
  73. 73. The suture packaging Material Size Color Single use Sterile Wounds, Wound Healing And Suturing ELHAWARY
  74. 74. The suture packaging Material Size Color Single use Needle code Sterile with life size picture Wounds, Wound Healing And Suturing ELHAWARY
  75. 75. The suture packaging Material Size Shape Color Single use Needle code Sterile with life size picture Wounds, Wound Healing And Suturing ELHAWARY
  76. 76. The suture packaging Material Size Shape Color Needle length Single use Needle code Sterile with life size picture Wounds, Wound Healing And Suturing ELHAWARY
  77. 77. The suture packaging Material Size Shape Color Needle length Cross-section Single use Needle code Sterile with life size picture Wounds, Wound Healing And Suturing ELHAWARY
  78. 78. The suture packaging Material Material length Size Shape Color Needle length Cross-section Single use Needle code Sterile with life size picture Wounds, Wound Healing And Suturing ELHAWARY
  79. 79. The suture packaging Material Material length Size Shape Color Needle length Cross-section Expiration date Single use Needle code Sterile with life size picture Wounds, Wound Healing And Suturing ELHAWARY
  80. 80. Suturing techniques Wounds, Wound Healing And Suturing ELHAWARY
  81. 81. Suturing techniques • Interrupted sutures • Continuous sutures • Continuous with lock suture • Horizontal mattress suture • Vertical mattress suture Wounds, Wound Healing And Suturing ELHAWARY
  82. 82. Suturing Materials & Techniques INTERRUPTED SUTURES Wounds, Wound Healing And Suturing ELHAWARY
  83. 83. Manual of Minor Oral Surgery for the General Dentist By Karl R. Koerner 2006 by Blackwell Munksgaard, Wounds, Wound Healing And Suturing ELHAWARY
  84. 84. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  85. 85. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  86. 86. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  87. 87. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  88. 88. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  89. 89. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  90. 90. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  91. 91. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  92. 92. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  93. 93. Hesham El-Hawary www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  94. 94. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  95. 95. Oral Surgery by Fragiskos D. Fragiskos Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  96. 96. Key suture Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  97. 97. Key suture X Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  98. 98. Key suture Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  99. 99. Key suture Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  100. 100. Key suture X Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  101. 101. Rule of Halves X Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  102. 102. Rule of Halves X X Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  103. 103. Rule of Halves X X X Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  104. 104. Suturing Materials & Techniques CONTINUOUS SUTURES Wounds, Wound Healing And Suturing ELHAWARY
  105. 105. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  106. 106. Suturing Materials & Techniques CONTINUOUS WITH LOCK SUTURES Wounds, Wound Healing And Suturing ELHAWARY
  107. 107. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  108. 108. Suturing Materials & Techniques HORIZONTAL MATTRESS SUTURE Wounds, Wound Healing And Suturing ELHAWARY
  109. 109. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  110. 110. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  111. 111. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  112. 112. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  113. 113. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  114. 114. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  115. 115. Eversion of the edges Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  116. 116. Manual of Minor Oral Surgery for the General Dentist By Karl R. Koerner 2006 by Blackwell Munksgaard, Wounds, Wound Healing And Suturing ELHAWARY
  117. 117. Oral Surgery by Fragiskos D. Fragiskos © Springer-Verlag Berlin Heidelberg 2007 Oral Surgery by Fragiskos D. Fragiskos © Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  118. 118. Suturing Materials & Techniques VERTICAL MATTRESS SUTURES Wounds, Wound Healing And Suturing ELHAWARY
  119. 119. Oral Surgery by Fragiskos D. Fragiskos Springer-Verlag Berlin Heidelberg 2007 Wounds, Wound Healing And Suturing ELHAWARY
  120. 120. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  121. 121. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com 1 4 3 2 Wounds, Wound Healing And Suturing ELHAWARY
  122. 122. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com 1 Wounds, Wound Healing And Suturing ELHAWARY
  123. 123. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com 1 2 Wounds, Wound Healing And Suturing ELHAWARY
  124. 124. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com 3 Wounds, Wound Healing And Suturing ELHAWARY
  125. 125. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com 4 Wounds, Wound Healing And Suturing ELHAWARY
  126. 126. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com 1 4 3 2 Wounds, Wound Healing And Suturing ELHAWARY
  127. 127. Dr. Hesham El-Hawary Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  128. 128. Dr. Hesham El-Hawary From the inner aspect Ass. Prof OMFS www.elhawarydentalclinic.com 1 4 2 3 Wounds, Wound Healing And Suturing ELHAWARY
  129. 129. Dr. Hesham El-Hawary From the inner aspect Ass. Prof OMFS www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY
  130. 130. Thank you Dr. Hesham El-Hawary El- Ass. Professor OMFS Facebook: Facebook: Hesham El-Hawary El- Twitter: @elhawary_hesham Email: hesham@elhawarydentalclinc.com Website: www.elhawarydentalclinic.com Wounds, Wound Healing And Suturing ELHAWARY

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