Suture

HISTORY

The origins of surgery can be traced back many centuries. Through the ages, practitioners have used a wide range of materials and techniques for closing tissue……..

1650 BC – 2000’s AD

In the tenth 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.

AntsAnts

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 fibre was then wound around the edge in a figure eight.

Sterilised Catgut

The tough membrane of sheep intestine was provided to the surgeon pre-sterilised and required threading

through the eye of the needle before use.

Swaged On Needles

Post World War II 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 thread that exists with a conventional needle, reducing tissue trauma.

Suture Classification and SelectionSuture Classification and Selection

Practice Time!

•

Classification of Sutures

Monofilament Multifilament

Synthetic Biological

Absorbable Non - Absorbable

The Ideal Suture

• Minimal tissue reaction

• Smoothness - minimum tissue drag

• Low Capillarity

• Max tensile strength

• Ease of handling - Minimum memory

• Knot security

• Cost effectiveness

Multifilament (braided)Multifilament (braided)

Suture ClassificationSuture Classification

MonofilamentMonofilament

Absorbable Sutures

PLAIN GUT:

Derived from the small intestine of healthy sheep.

Loses 50% of tensile strength by 5-7 days.

Used on mucosal surfaces.

CHROMIC GUT:

Treated with chromic acid to delay tissue absorption time.

50% tensile strength by 10-14 days.

Used in episiotomy repairs.

•Polyglycolic acid (Dexon®)

• Braided• Low-memory• 50% tensile strength = 25 days• Sites = subcutaneous closure

skin

Polydioxanone (PDS®)

• Monofilament

• 50% tensile strength = 30+ days

• Sites = need for prolonged strength,

Polyglycan 910 (Vicryl®)

• Braided, synthetic polymer

• 50% tensile strength for 30 days

• Used: subcutaneous

Non-absorbable Sutures

Nylon (Ethilon®):

• non-absorbable suture

• monofilament

• surface closures.  

Non-absorbable Sutures

Polypropylene (Prolene®): • stronger than nylon and has better

overall wound security.

silk• braided

• Before the advent of synthetic fibers, silk was the mainstay of wound closure.

• workable and has excellent knot security.

Disadvantages:

• high reactivity

• infection

MonofilamentAdvantages

• Smooth surface

• Less tissue trauma

• No bacterial harbours

• No capillarity

Disadvantages

• Handling & knotting

• Ends/knot burial

• Stretch

MultifilamentAdvantages

• Strength

• Soft & pliable

• Good handling

• Good knotting

Disadvantages

• Bacterial harbours

• Capillary action

• Tissue trauma

SyntheticAdvantages

Non-Absorbables are inert

• Absorbables resemble natural substances

• Absorption by hydrolysis

• Predictable absorption

• Strength

Disadvantages

• Monofilament handling

Biological

Advantages

• Handling & knotting

• Economy

Disadvantages

• Tissue reactions

Characteristics of Non-Absorbable Sutures

• Permanent• Only used when long term support is required• Removed when used for skin • Tissue reaction generally low (except silk)• True non-absorbable sutures include polyester,

polyethylene, polypropylene and steel

AbsorbableAdvantages

• Broken down by body

• No foreign body left

Disadvantages

• Consideration of wound support time

Non - Absorbable

Advantages

• Permanent wound Support

Disadvantages

• Foreign body left

• Suture removal can be costly and inconvenient

• Sinus & Extrusion if left in place

Suture Size

5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0

Thick Thin

USP (United States Pharmacopoeia)

General

Volume % Reduction With Decreasing Size

•2/0

•3/0

•4/0

•5/0

•6/0

•7/0

•8/0

•2/0

•3/0

•4/0

•5/0

•6/0

•7/0

•8/0

•51%

•40%

•49%

•54%

•50%

•44%

•51%

•40%

•49%

•54%

•50%

•44%

Absorbable Sutures

•VICRYL*

•MONOCRYL*

•Coated VICRYL*

•Coated VICRYL* Plus Antibacterial Suture

•PDS* II

•Skin•Perineum•Oral•Lacerations

•Traumatology•Ligaments•Fascia•Vessel

anastomosis

•10 days •By 42 days

•Wound Support•Mass Absorption •Typical Uses

•30 days

•60 days

•20 days

•30 days • 56 - 70 days

•90 - 120 days

•56 - 70 days

•180 - 210 days

•Ligature •General•Bowel•Orthopaedics

•Ligature •General•Bowel•Ophthalmic

•Mucosa•Obstetrics•Bowel•Skin& Ligature

Suture Selection

Bowel: 2/0 - 3/0Fascia: 1 - 0Skin: 2/0 - 5/0Arteries: 2/0 - 8/0Micro surgery 9/0 - 10/0Corneal closure: 9/0 - 10/0

Needles

Anatomy of a Surgical Needle

Needle point Geometry

Taper-Point•Suited to soft tissue•Dilates rather than cuts

Reverse cutting

•Very sharp•Ideal for skin•Cuts rather than dilates

Conventional Cutting

•Very sharp•Cuts rather than dilates•Creates weakness allowing suture tearout

Taper-cutting•Ideal in tough or calcified tissues•Mainly used in Cardiac & Vascular procedures.

Needle Shapes•Eye•Microsurgery

•Dura•Eye•Fascia•Nerve

•Muscle•Eye•Skin•Peritoneum

•Cardiovascular•Oral•Pelvis•Urogenital tract

•Nasal cavity•Nerve•Skin•Tendon

•Eye (Anterior• segment)

•Laparoscopy

Use of Needle Holders

•Loading Needle

•Needle passing through

skin

Staples, Adhesives & Tape

• Staples– Quick, poor aesthetic result

• Adhesives– Dermabond- painless, petroleum dissolves

• Tape– Steri-strips

Suture Label

The Suture Packaging

STRAND SIZE

MATERIAL

STRAND LENGTH

PRODUCT CODE

NEEDLE CODE

WITH LIFE SIZE

PICTURE OF

NEEDLE

NEEDLE LENGTHCOLOUR

POINT TYPE

NEEDLE CIRCLE

Suture Techniques

• Simple Interrupted– Used on majority of wounds– Each stitch is independent

Suture Techniques

• Simple Continuous– Useful in pediatrics

• Rapid• Easy removal

– Provides effective hemostasis– Distributed tension evenly along length– Can also be locked with each stitch

Horizontal Mattress

Horizontal Mattress

Good for closing wound edges under high tension,And for hemostasis.

Simple, Interrupted

Suture Techniques

• Vertical Mattress– Useful for everting skin edges– “Far-far-near-near”

Vertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)

Vertical Mattress

Suture Techniques

• Purse-string– Useful for stellate lacerations

Closure using Clips

• Suture removal–face: 3-4 days

–scalp: 5 days

–trunk: 7 days

–arm or leg: 7-10 days

–foot: 10-14 days

Thanks for your attention !!!