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SUTURE WORKSHOP
MÉLANIE FANCON SENIOR KA MANAGER EUROPE VETERINARY & DENTAL MEDTRONIC
2/2/2018
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AGENDA AIM = GET THE BASICS ABOUT SUTURES: WHAT IS IMPORTANT TO REMEMBER ?
Introduction to sutures
History / Innovations over the last 150 years
Packaging Informations
Tissue reactions / Wound healing process
Suture strands properties and selection criterias
Absorbable or non-absorbable ? (= Resistance ? Resorption time ?)
Braided oder Monofilament ?
Needle Properties and selection criterias
Curvature, Tip geometry, Coating…
Focus on …. (Tip & Tricks)
Vloc, Novafil, Do and don’t
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INTRODUCTION TO SUTURES
HISTORY…
Swaget-on Needles
Post World War I brought the swaged-on needle. The thread fits into the hollow end of the needle, allowing it to pass through tissue without the double loop of tread that exists with a conventional needle. As a result, tissue trauma is reduced.
Sterilized Catgut
The tough membrane of sheep intestines was provided to the surgeon pre-sterilized and required threading through the eye of the needle before use.
Needles
In a French manual published in 1858
Dr. Joseph Marie Goffres illustrated how needles were used as skewers. Surgical sutures were wound around needles and the tips of needles snipped off for safety.
Ants
In the twentieth century BC, the ant was held over the wound until it seized the wound edges in its jaws. It was then decapitated and the ant‘s death grip kept the wound closed.
Thorns
The thorn, used by African tribes to close tissue, was passed through the skin on either side of the wound. A strip of vegetable fiber was then wound around the edge in a figure eight.
Fibula (metal clasps)
These Greek and Mycenaean specimens, used to hold tissue together, are thought to have been introduced some 400 years after Hippocrates.
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HISTORY…
1860 Karbol Catgut J. Lister
1906 Jod Catgut Kuhn
1921 Atraumatic needles E.J. Ovington
1941 Nylon
1960 Polyester
1970 Dexon™ (ancester of Polysorb ™ )
1985 Maxon™
1993 Biosyn™
2005 Caprosyn™
2009 V-Loc™ 180 Wound Closure Device
INNOVATIONS OVER THE LAST 150 YEARS
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DEFINITION
Sutures are defined as the material used to improve wound closures, by surgically approximating and holding both wound edges together,which aims at reducing the tension on the wound itself.
Sutures can be single or doubbled armed :
They also can consist in a loop :
Sutures without needles are called ligatures
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PACKAGING INFORMATIONS
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Strand
Infos.
Catalog Ref.
Size - USP
- Metric
Material - Brand Name
- Chemical Composition
Length & Colour
Material
Name
Needle diagram
Curvature Tip Geometry Needle Length
Needle
Infos.
Surgical Indication
Lotnumber, Expiracy date, Qty/Box
INDICATIONS ON THE OUTER-PACKAGING
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PACKAGING INFORMATIONS INDICATIONS ON THE INNER-PACKAGING
STRAND
NEEDLE
OPENING
OPENING DIRECTION
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TISSUE REACTIONS AND WOUND HEALING PROCESS
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OPTIMAL WOUND CLOSURE FACTORS
• Choice of suture material
• Suturing technique / Knot tying technique
• Right handling of tissues
• Wound healing process
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RIGHT HANDLING OF TISSUES
Instruments only when necessary
Maintaining moisture of tissues , use of compresses to protect the wound edges
Properly rince the wound
Good Haemostaesis
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WOUNDHEALING PROCESS FACTORS INFLUENCING WOUND HEALING
Patient Factors
Age & Weight
Nutritional status (Malnutrition)
Deshydration
Circulatory system (Bad supply of blood & nutriments)
Radiation Therapies
Allergies, Chemiotherapies, Anaemia, Diabetes, and all chronic deseases can delay the wound healing process.
Surgical Factors
Tissue Handling
Closing tension
Sutures distribution & knot tying
Infections
Local blood supply
Insufficient blood supply will lead to a lack of nutriments and proteins, thus delaying
The wound healing
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PRIMARY WOUND HEALING
1. INFLAMMATORY PHASE
0-5 Days
= Collection of body fluids
(Proteins, Blood cells, Fibrines , antibodies etc..)
This phase is characterised by heat, redness, swelling, pain.
The wound itself has no tensile strength at all, thus the suture must provide 100% mechanical / wound support
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PRIMARY WOUND HEALING
2. PROLIFERATION PHASE
5-14 Days
• Fibroblast produce Collagen, a fibrous protein that will take over the tensile strength of the wound.
Granulation tissue is formed
This phase is characterised by the replacement of the fibrin / fibronectin matrix with bright red granulation tissue.
At this stage, a high tensile strength and wound support from the suture is still highly necessary
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PRIMARY WOUND HEALING
3. MATURATION OR REMODELING PHASE
21 days to 2 years
• The quantity of collagen stays the same, however the collagen fibers tensile strength increases and fully take over the wound tensile strength. Collagen is remodelled and realigned over the tension lines.
This phase is characterised by the scar becoming paler.
At this stage, the suture is no longer needed anymore.
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SUTURE MECHANICAL SUPPORT / WOUND HEALING PROCESS
0
10
20
30
40
50
60
70
80
90
100
1 Tag 8 Tag 15 Tag 22 Tag 29 Tag
Reissfestigkeit
Wundheilung
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STRANDS PROPERTIES AND SELECTION CRITERIAS
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SOURCE: I .CAPPERAULD, T.E. BUCKNALL
„Die Wahl des Nahtmaterials wird häufig gefühlsmässig und nicht
aufgrund wissenschaftlicher Erkenntnisse getroffen.
Schuld an dieser Situation ist hauptsächlich fehlende Kenntnis der
physikalischen und biologischen Eigenschaften des einzelnen Nahtmaterials
sowie der Bedeutung dieser Eigenschaften für die verschiedenen
klinischen Gegebenheiten, bei denen Heilungsrate und Gewebsreaktion
sehr unterschiedlich sein können.“
«The choice of sutures ist often made according to
Feeling, and not based on scientific knowledge.
This is mostly due to a lack of knowledge of the physical and bilological properties of each suture materials , as well as of what these properties will clinically mean , each of them inducing very different healing rates and tissue reactions»
WHAT ARE THE SELECTION CRITERIAS FOR SUTURE STRANDS?
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SUTURE CLASSIFICATION
Natural Synthetic
Absorbable Non absorbable
Multifilament Monofilament
ORIGIN
BEHAVIOUR
STRUCTURE
SELECTION CRITERIAS FOR SUTURES:
2 QUESTIONS
Absorbable or non-absorbable?
= question of the strands’s tensile strength:
How long should the suture provide a mechanical support to the wound ?
Braided or monofilament ?
What are the advantages and drawbacks for each type of suture structure?
Where are my priorities?
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ABSORBABLE OR NON-ABSORBABLE ? OVERVIEW NON-ABSORBABLE SUTURES
Material Covidien Ethicon B.Braun
Polyester TicronTM EthibondTM SynthofilTM
SurgidacTM MersileneTM MiraleneTM
DagrofilTM
Silk SofsilkTM SeideTM SilkamTM
Polyamid (Nylon) braided
SurgilonTM SuturamidTM SupramidTM
Polyamide (Mono) MonosofTM EthilonTM/ / EthicrinTM DafilonTM / NylonTM
Polyamide (Mono) DermalonTM EthilonTM / EthicrinTM DafilonTM / NylonTM
Polypropylene SurgiproTM ProleneTM PremileneTM
Polybutester NovafilTM … …
Polybutester VascufilTM … …
Steel SteelTM StahldrahtTM SteelexTM
Steel braided FlexonTM StahldrahtTM SteelexTM
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Everytime a permanent support
is required !
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ABSORBABLE OR NON-ABSORBABLE ? OVERVIEW ABSORBABLE SUTURES
Covidien Ethicon B.Braun
Braided PolysorbTM VicrylTM NovosynTM / SafilTM
Velosorb FastTM Vicryl RapideM Safil QuickTM
Covidien Ethicon B.Braun
Monofilament CaprosynTM - Monosyn QuickTM
BiosynTM MonocrylTM MonosynTM
MaxonTM PDSTM MonoplusTM
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ABSORBABLE OR NON-ABSORBABLE ? TIMING IS EVERYTHING !
Product Tensile strength Resorption time
Caprosyn short 10 Days 56 Days
Biosyn mid 21 Days 90-110 Days
Maxon long 42 Days 180 Days
Product Tensile strength
Résorption time
Velosorb Fast Short 7-10 Tage 40-50 Days
Polysorb mid 21 Tage 56-70 Days
Monofilament
Braided
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ABSORBABLE SUTURES : REMEMBER !
Tensile strength
≠
Resorption time
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BRAIDED OR MONOFILAMENT? DIFFERENT STRUCTURES THAT LEADS TO DIFFERENT PROPERTIES
BRAIDED OR MONOFILAMENT ? BRAIDED / MULTIFILAMENT
Advantages :
Very good knot-security
Very good Handling (supple)
Less / almost no Memory-Effect
Drawbacks :
More tissue- drag (therefore enduction)
Capillarity
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BRAIDED OR MONOFILAMENT ? MONOFILAMENT
Advantages :
Acapilarity
Smooth : less trauma to tissue, «slippy»
Elasticity
Drawbacks :
Memory Effect
Handling
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SIZE AND DIAMETER : USP & METRIC
EP = European Phamacopeia
=Decimal measure of diameter
USP = American Measure
= More complicated : measures the breaking strength of a suture strand, when a surgeon’s knot has been tied.
9 8 7 6 5 4 3,5 3 2 1,5 1 0,7 0,5 0,4 0,3 0,2 0,15
The smaller the number is, the smaller the diam is
Diameter in 1/10e mm :
Ex : Decimal 5 = Suture diam =5/10e mm
There’s a tolerance :
Ex : Decimal 5 between 0.500 mm mini et 0.599mm
max,
Tensile strength is evaluated by the force requires to break a suture tied by a surgeon’s knot, tied around a plastic tube with 0.635mm diameter . It thus varies according to the sutre composition and structure
7 6 5 4 2 1 0 2/0 3/0 4/0 5/0 6/0 7/0 8/0 9/0 10/0 11/0
The more « 0 », the smaller the size
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NEEDLE PROPERTIES AND SELECTION CRITERIAS
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NEEDLES SELECTION CRITERIAS 1. CURVATURE
5/8 3/8 1/2 1/4
The curvature of the needle is chosen according to the depth of the tissue:
superficial
Not deep
deep
Very deep
straight, 1/4
3/8
1/2
5/8
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NEEDLES SELECTION CRITERIAS 2. TIP GEOMETRY
General / vascular surgery
Facia , tendons, skin…
Facia , tendons, skin…
Plastic surgery
Ophtalmology
Ophtalmology
Used to protect against needle stick injuries
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Fragile, friable tissues, for ex: liver
Calcified tissues, bronchias, trachea, fascia
FOCUS ON…. (TIP & TRICKS)
V-LOCTM , MONOFILAMENT WOUND CLOSURE DEVICE KNOTLESS CLOSURE
Product Resorption time
V-LOC 180 180 Days
V-LOC 90 90 – 110 days
V-LOC PBT Non -absorbable
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V-LOC™ WOUND CLOSURE DEVICE PRINCIP
Unidirectional, circular
barbs precisely grasps the
tissues, adapt tem and
distributes the tension
along the wound, which
leads to a safer, easier and
more secure closure of the
wound..
The loop anchors the suture at the beginning of the wound, so no knot is required anymore, which allows for time savings and avoid knot-related complications.
Premium Needles with,
NuCoat™ coating, for a
soft and always optimal
penetration thoughout
passages.
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NOVAFIL
Monofilament Non-absorbable Polybutesther Can be usedr wherever Polypropylen can be.
What is exactly Novafil ?
Why is Novafil so different ?
There’s NO equivalence on the market !!! Novafil = UNIQUE It has many advantages: 1) Polybuthesther = Hydrophobic = repells water =SLIPS much more though tissues 2) Polybuthester = 10% more elastic than PP = adapts to Oedema and gets right back in place when the oedema resorbs 3) Tactile Feedback = becomes harder, before it breaks = tactile Info to the surgeon
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DO AND DON’T SUTURING WITH INSTRUMENTS : DO
NEEDLE POSITIONING
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DO AND DON’T SUTURING WITH INSTRUMENTS
NEEDLE PREHENSION NEEDLE PREHENSION
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DO AND DON’T DON’T DAMAGE THE SUTURE !
Most suture breaks are caused by unappropiriate use, like damages caused by Instruments .
QUESTIONS???
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BESTEN DANK FÜR IHRE AUFMERKSAMKEIT!
THANK YOU !!!
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