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The slides demonstrated that Suturing are of different methods and styles ,and are applied for different tissues and for different surgical techniques and procedures. Sutures are of Different materials and used for different styles and tissues . Modern innovations in wound suturing ,wound closure are also described in the slides .
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BYDR MUKORO DUKE GEORGE
B.SC,MBBS,MCS,HSE C E R T ,ATLS,DTM&H L I V E R P O OL
G R A D U A T E M E M B E R N I MN D U T H ,
SUTURES & SUTURING IN SURGERY
OUTLINE
o INTRODUCTION HISTORICAL BACKGROUND DEFINITIONSo QUALITIES OF AN IDEAL SUTUREo CLASSIFICATION/STRENGTHo TYPES/USESo SUTURE SELECTIONo SUTURE ACCESSORIES(NEEDLES)o STERILIZATION OF SUTURESo SUTURE REMOVALo COMPLICATIONSo RECENT ADVANCESo CONCLUSIONo REFERENCES
INTRODUCTION
• DEFINATIONS ⌂ Suturing refers to sewing together two structure using suture threaded on a needle. The purpose of suture is to hold tissues together until strong enough to support itself during wound healing.
• Ligating or ligaturing refers to tying a ductal structure such as blood vessel simply by means of a suture thread.
INTRODUCTION
HISTORICAL BACKGROUNDSutures are used to improve & speed healingHx dates back to 550-3000BCEarly sutures were Flax, Silk, Linen strips &
cottonSynthetic sutures are now available
DEFINITIONS
Suture is a material used to approximate living tissues or xtures together
Ligature is a suture used to encircle a bld vessel to arrest or control bleeding
Tensile strength is the ability of the material or tissues to resist deformation or breakage
Elasticity is the ability of the material to regain its original form or length after deformation
Pliability is the ability to adjust knot tension & to secure knot
Memory is the inherent capability of suture to return or maintain its original gross shape
QUALITIES OF AN IDEAL SUTUREby Lord Mogniham (1865 – 1936)
Sterile and easily sterilizableServe all purposeMinimal tissue :non-electrolytic, non-capillary, non-
allergenic, non-carcinogenic (and non-thrombogenic in vascular surgery.
Easy to handleHold knot securelyHigh tensile strengthFavourable absorption profileResistant to infectionAvailableInexpensive
Features of a suture 1) Suture stength - Measured by instron tensiometer.2) Tissue Reactivity3) Handling4) Knotting 5) Sterilization 6) Absorbility7) Viability 8) Elasticity 9) Size
CLASSIFICATION OF SUTURES/STRENGTH
ABSORPTION ORIGIN CONFIGURATION ABILITYAbsorbable Natural Monofilament Synthetic Multifilament Non-absorbable Natural Monofilament Synthetic Multifilament TRAUMATIC & ATRAUMATIC STRENGTH : Ranges from smallest(10/0) to largest(5)
ABSORBABLE NON ABSORBABLE1. Catgut Silk,2. Chromic Catgut Linen3. Dexon (Polyglycolic acid) Cotton4. Vicryl (Polyglacitin) Horse/Human hair5. PDS (Polydioxanone) Nylon or Ethilon6. Collagen Polyester (Teflon)7. Maxon (Polyglyconate) Polypropylene (Prolene).8. Poliglecaprone Stainless steel
Aluminium WireClipsStaplesSkin tapesSurgical adhesives
TENSILE STRENGTH/ABSORBABILITYSuture T/S loss Absorption
tissueCatgut 15 days 60 daysChronic Catgut 30 days 80 – 120 daysPolyglyconic acid(DEXON)
30 days 90 days
Polyglactin(vicryl)
32 days 70 days
Polydioxanone 56 days 180 daysNylon 25% in 2yrs ▬Prolene IndefiniteDacron Indefinite
TYPES/USESABSORBABLE – NATURAL Plain catgut:light milk,Derived from
submucusa of sheep intestine or serosa of beef intestine
Used for ligating superficial bld vessels & subcut fatty tissues
Chromic catgut:yellow,Treated with chromium salt.
Adv may be used in the presence of infection
Polyglactin (vicryl):cream, copolymer of lactide & glycolide
Minimal tissue rxn Used in general soft tissue
approx,intestinal anastomosis,vessels ligation in all surgical specialties
Dexon(Polyglyconic acid):purple/cream
Homo polymers of glycolide. Avoid in adipose tissue Losses tensile strength more
rapidly than vicryl. Other e.g
Polyglyconate(maxon) polydiaxone(PDS),Polyglecaprone(monocryl)
ABSORBABLE - SYNTHETIC
NON-ABSORBABLE-NATURAL
Surgical silk:Black, Derived from the cocoon of the silk worm larvae, superior handling xtics,Trigger inflam rxns,Undergo proteolysis & undetected by 2yrs,Used in ligating maj bld ves,tendon repair etc
Surgical steel & wiresHigh tensile strengthHold knots very wellUsed in orthopaedic,Neurosurg,& Thoracic
surgOther e.g Virgin silk,cotton, linen
NON-ABSORBABLE - SYNTHETIC
Nylon:Is a polyamide polymer,blue81% tensile strength at 1yr & 66% at 11yrsElicits minimal tissue rxnHas good memoryPliable when moist Premoistened form is used cosmetic plastic surgeryIts elasticity makes it useful for skin closure &
HerniorhapyOther e.g;Polypropylene(prolene),Polyester
fiber(Mersilene/Dacron,Ethibond)
SYNTHETIC NON-ABSORBABLE (CUT)
Staples and chips: Faster than traditional suture, in gut anastomosis,
vascular &bronchial closure. Skin tapes:
Impervious to sweat, wound infection less, avoid suture marks.
Surgical adhesives: Expanded polytetra fuoroethylene
Monofilament SutureGrossly appears as single strand of suture material; all fibers run parallel Minimal tissue trauma Resists harbouring microorganisms
Ties smoothly Requires more knots than multifilament suture Possesses memory Examples:
Monocryl, PDS, Prolene, Nylon
Multifilament SutureFibers are twisted or braided together Greater resistance in tissue Provides good handling and ease off tying Fewer knots required Examples: Vicryl (braided) Chromic (twisted) Silk (braided)
SUTURE SELECTIONDepends on surgeons training & preferenceSmallest suture is preferableTensile strength of suture should not exceed that
of tissuesAesthetics should be considered e.g head&neckMobility of the region e.g Limbs & trunkTension of the tissues to be sutured e.g major
musculocutaneous flapsNon-absorbable considered in skin,fascia,tendonAbsorbable considered in rapidly healing tissuesMonofiliments preferable in contaminated
wounds
Suture Size United States Pharmacopeia
Sized according to diameter with “0” as reference size Numbers alone indicate progressively larger sutures (“1”,“2”, etc)
Numbers followed by a “0” indicate progressively smaller sutures (“2-0”, “4-0”, etc)
Smaller<------------------------------------->Larger .....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....
SIZE OF SUTURES OLD GAUGE(USPD) DIAMETER IN MM 8/0 0.05 7/0 0.O7
6/0 0.1 5/0 0.15 4/0 0.2 3/0 0.3 2/0 0.35 0 0.4 1 0.5 2 0.6 3 0.7 4 0.8
Wound Closure Basic suturing techniques: Simple sutures Mattress sutures Subcuticular sutures Goal: “approximate,, not strangulate”
Ideal Wound ClosureAllow for meticulous wound closureEasily and readily appliedPainlesslow risk to providerInexpensiveMinimal scarringLow infection rate
METHODS OF SUTURING1. CONTINUOUS SUTURING
►Rapid application ►Efficient ►Haemostatic ►Easily drawn tight ►Edges may overlap ►Whole wound may open if any breaks
2. INTERRUPTED SUTURING ►Skin ►Infected sites ►1mm apart on the face ►1cm apart at other areas
Continuous Locking and Nonlocking Sutures
Simple, Interrupted
Vertical Mattress
Good for everting wound edges (neck, forehead creases, concave surfaces)
Horizontal Mattress
Good for closing wound edges under high tension,and for hemostasis.
Horizontal Mattress
SUTURE ACCESSORY-NEEDLES
Ideal surgical needle High quality stainless steelSmallest diameter possibleStable in the grasp of needle holderSharp enough to penetrate tissues with
minimal resistance & traumaSterile & corrosive resistant
ANATOMY OF THE NEEDLE
POINT Cutting;Conventional cuttingReverse cuttingSide cuttingTaper(round needle)Blunt
BODYStraightHalf curvedCurved: ski 1/4 circle 3/8 circle 1/2 circle
5/8 circle Compound curved
SWAGE Channel swageDrill swageNon swaged
STERILIZATION OF SUTURES
May affect suture properties to some extentGamma RadiationEthylene oxide;poisonous gas,is less
attractiveAutoclaveSutures are usually stored in sterile pack by
the manufacturers,their integrity must be checked b/4 use
Packaging…
Expiry dateBatch NumberDo Not Re-use
Product (re-order) CodeImperial GaugeMetric Gauge
Needle size & curvature
Needle type
Needle point
See Instructions for use
Needle profile
SterilisedEthylene Oxide
SUTURE REMOVAL
Sutures on the superficial(skin) wounds are removed after serving their fxn
Duration depends on the site; Head & Face = 3-5d Arms & Hands = 7-10d Chest =7-10d Abdomen =7-1od Lower limbs/feet =10-14d
COMPLICATIONS
Usually less if proper selection is followed Failure Undo Tissue rxn Infection Abscess and sinus formation scarring
RECENT ADVANCESStaples & ClipsFormed from high quality stainless steelNew absorbable clips made of polydiaxone are
availableStaples are suitable for skin closureStapling gun for bowel anastomosis are popularSkin Tapes & Adhesives e.g DermabondNon-suture methods of closing wound edgesApplied after adequate subcuticular closureMinimal infection rate & no tissue rxnEXPENSIVE
Adhesive Tapes
Less reactive than staples
Use of tissue adhesive adjunct (benzoin)
Poor outcome in areas of tension
Seldom used for primary closure
Use after suture removal
Adhesive Tapes
• Least reactive• Lowest
infection rate• Rapid
application• Patient
comfort• Low cost• No risk of
needle stick
Advantages
• Frequently falls off• Lower tensile strength
than sutures• Highest rate of
dehiscence• Requires use of toxic
adjuncts• Cannot be used in
areas of hair• Cannot get wet
Disadvantage
s
Staples
More rapidly placedLess foreign body
reactionScalp, trunk,
extremitiesDo not allow for
meticulous closure
Dermabond®
A sterile, liquid topical skin adhesive
Reacts with moisture on skin surface to form a strong, flexible bond
Only for easily approximated skin edges of wounds punctures from minimally
invasive surgery simple, thoroughly cleansed,
lacerations
Dermabond®
Standard surgical wound prep and dryCrack ampule or applicator tip up; invertHold skin edges approximated horizontallyGently and evenly apply at least two thin
layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky
Apply dressing
CONCLUSION
Human body is very delicate & important.When surgeries are needed to improve our health is very important to select a suitable suture.Today we know alots of biomaterials to select,but is important to always think of biocompatibility.
REFERENCES
1) Post-graduate surgery, candidates guide M.A.R Alfallouji,2nd edition
2) Principles & practice of surgery including pathology in the Tropics, E.A.Badoe etal 3rd edition
3) Clinical surgery Alfred Cusheri etal 2nd edition
4) www.e.medicine.com
THANK YOUFOR
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