SUTURE MATERIALS AND TECHNIQUES

1- Pliability, for ease of handling2- Knot security3- must be sterilized4- Appropriate elasticity5- Nonreactivity6- Adequate tensile strength for

wound healing 7- Chemical biodegradability as

opposed to foreign body breakdown

characteristics of the Ideal Suture Material

characteristics of the Ideal Suture Material

8-Non allergic9-Non carcinogenic10-Not favour bacterial growth

What’s It Used for?

1. To bring tissue edges together and speed wound healing (=tissue apposition)

2. Orthopedic surgery to help stabilize joints

Repair ligaments

3. Ligate vessels or tissues

Surgical Needles

The surgical needle has a basic design composed of three parts

1- The eye which is swaged and permits the suture and needle to act as a single unit to decrease trauma

2- The body which is the widest point of the needle and is also referred to as the grasping area

3- The point which runs from the tip to the maximum cross-sectional area of the body

Points of Needles

Click icon to add pictureTaper

AtraumaticInternal organs and thin mucosaBut suturing is hard

Points of Needles

Click icon to add pictureCuttingCutting edge on inside of circleSkinTraumatic

Points of Needles

Click icon to add pictureReverse CuttingCutting edge on outside of circleSkinLess traumatic than cutting

Shapes of Needles

Click icon to add picture3/8 circle1/2 circleStraightSpecialty

types of Suture Material

Absorbable Vs. Nonabsorbable

Monofilament Vs. Multifilament

Natural or Synthetic

Non-absorbable Suture

less tissue-reactive and therefore leave less scarring as long as they are removed in a timely fashion

I. Natural : silkII. Synthetic : nylon, prolene,

polyester, s.s

Primarily Skin Ligation of BVs.

Absorbable Sutures

Advantage is that the sutures do not need to be removed

I. Natural : catgut II. Synthetic : vicryl, dexon, PDS

Internal Intradermal/ subcuticular Rarely on skin In children When Difficult removal

Reading the Suture Label

Also:

LENGTH

NEEDLE SYMBOL

COLOR

Absorbable or Non

Order CodeSize

Name

Needle

Company

Monofilament Vs. Multifilament

memory easy to handle less tissue drag more tissue drag doesn’t wick wicks/ bacteria poor knot security good knot

security - tissue reaction +tissue reaction

Suture Knot Tensile Tissue Tensile

Ease ofSuture Raw Material Absorption Strength Reaction Strength Type

Uses Handing

Plain gut Collagen from Digested + Moderate + + + Plain Rapidly +

healthy by body (Least) + + + + healing

mammals enzymes mucosa

within avoid

70 days suture

removal

Chromic Collagen from Digested + Moderate + + + Chromic As above +

healthy by body but less Slower

mammals enzymes than plain absorption

treated with within gut chromic salts + + + +

Suture Knot Tensile Tissue Tensile

Ease ofSuture Raw Material Absorption Strength Reaction Strength Type

Uses Handing

Coated Copolymer of Hydrolysis + + + Mild + + Braided Subepi- + + + +

Vicryl lactide and 56-70 days + + coated elial

(Polyglactin glycolide Mucosal

910) coated with surfaces polyglactin Vessel 370 and ligation calcium All types stearate of general

closure

PDS Polyester Slow + + + + Slight + + Mono- Absorbable + +

(polydi- polymer hydrolysis + filament suture with

oxanone) 180 - 210 extended

days wound support

Suture Knot Tensile Tissue Tensile

Ease ofSuture Raw Material Absorption Strength Reaction Strength Type

Uses Handing

Dexon Homopolymer slow + + + Mild + + Braided subepith- + + +

(polygly- of glycolic hydrolysis + + coated elial

colic acid coated after 60 - sutures

acid) with 90 days Mucosal + + + +

polaxamer surfaces 188

Vessel ligation

Surgical Natural Usually + + Moderate + Braided Mucosal + + + +

silk protein cannot be + + + + (least) surfaces

fiber of raw found after silk. Treated2 years with silicon protein or wax

Suture Knot Tensile Tissue Tensile

Ease ofSuture Raw Material Absorption Strength Reaction Strength Type

Uses Handing

Nylon Polyamide Degrades at + + + Extremely + + Mono- Skin + +

Duralon polymer a rate of 15- low filament closureEthilon 20%per year 0 - +

Nylon Polyamide Degrades at + + + Extremely + + Braided Skin + + + +

Nurolon polymer a rate of 15- low closureSurgilon 20%per year 0 - + Mucosal

surfaces

Polyester Polyester Nonabsorbable + + + Minimal + + + Braided Cardiova- + + +

Mersilene Polvethylene + scular andDacron Terephthalate

plasticEthibond surgery

General surgery

Suture Knot Tensile Tissue Tensile

Ease ofSuture Raw Material Absorption Strength Reaction Strength Type

Uses Handing

Prolene Polymer of Nonabsorbale + + + Minimal+ + + Mono- General, + +

(polypro- propylene transient filament plastic, pylene) acute

cardiova- reaction scular,

skin

opthalmology

Gor-Tex Expanded Nonabsorbale + + + Extremely + + Mono- All Types + + + + polytetrafluoro- low filament of soft- ethylene 0 - + tissue

approxi- mation & cardiova- scular surgery

Skin Staples

Very common in human medicine Expensive Very easy Very secure Very little tissue reaction Removal =

Special tool required

Tissue Adhesive

Little strength

Should not be placed between skin layers or inside body

Instruments Needed

Needle holder: used to grab onto the suture needle

Forceps: used to hold the tissues gently and to grab the needle

Suture scissors: used to cut the stitch from the rest of the suture material

How to Hold the Instruments

The needle should be held inthe jaws of the needle holder atits midpoint

Hold the forceps as you would hold a writing instrument

Principles of Suturing

Sutures placed on the face should be approximately 2–3 mm from the skin edge and 3–5 mm apart. Sutures placed elsewhere on the body should be approximately 3–4 mm from the skin edge and 5–10 mm apart.

Start on the side of the wound opposite and farthest from you to ensure that you are always sewing toward yourself.

Placement of Needle in Tissue

1- Force should always be applied in the direction that follows the curvature of the needle

2- Suturing should always be from movable to a nonmovable tissue

3- Avoid excessive tissue bites with small needle as it will be difficult to retrieve them

4- Use only sharp needles with minimal force. Replace dull needles

5- Never force the needle through the tissue

6- Grasp the needle in the body one-quarter to one-half of the length from the swaged area. Do not hold the swaged area; this may bend or break the needle. Do not grasp the point area as damage or notching may result.

7- Avoid retrieving the needle from the tissue by the tip. This will damage or dull the needle

8- Suture should be placed in keratinized tissue whenever possible

9- An adequate tissue bite is required to prevent the flap from tearing

Knots

A suture knot has three components 1- The loop created by the knot2- The knot itself, which is composed of a number of tight “throws”, each throw represents a weave of the two stands3- The ears, which are the cut ends of the suture

Knot Strength

Generally 4 “throws” for >90% knot security (nylon may need 5) Less “throws” = more likely to untie

itself

Suturing Techniques

Suturing techniques

Simple Interrupted Continuous Horizontal mattress Vertical Mattress Sutures Sub-cuticular closure Figure of eight

Interrupted sutures

Interrupted sutures

Advantages and disadvantages used for simple laceration closures or

closure of office procedures like biopsies or lesion removals.

Interrupted sutures can be used in all areas but may take longer to place than a continuous suture

They are the technique of choice if you are worried about the cleanliness of the wound.

If the wound looks like it is becoming infected, a few sutures can be removed easily without disrupting the entire closure

continuous sutures

continuous sutures

continuous sutures

Place the sutures again and again without tying each individual suture.

If the wound is very clean and it is easy to bring the edges together, a continuous closure is adequate and quicker to perform.

Continuous closure is the technique of choice to help stop bleeding from the skin edges, which is important, for example, in a scalp laceration.

Mattress sutures

Mattress sutures are a good choice when the skin edges are difficult to evert

It is a bit more technically challenging to place mattress sutures, but it is often worth the effort because good dermis-to-dermis contact is achieved

Horizontal mattress

Horizontal mattress

• Used with wounds with poor circulation

• Helps eliminate tension on wound edges

• Requires fewer sutures to close a wound

• Can be placed quite quickly

Vertical mattress

Vertical mattress

• Deep and shallow approximation of the tissue

• Can be used for wounds under tension.

• Can be useful with lax tissue e.g. elbow and knee.

• Should not be used on the face because of blind placement of the deep part of the suture

Sub-cuticular

Sub-cuticular

• Used for cosmetic closures• Use an absorbable suture if you plan

to leave the sutures in and bury the knots

• Use either nylon or prolene (best) and keep the suture sliding while you are closing. The suture then can be easily removed with no exterior marks. The ends can be taped or a knot on the skin.

Buried Intradermal Sutures

Buried Intradermal Sutures

Indication: This technique is useful for wide, gaping wounds and when it is difficult to evert the skin edges

Figure-of-eight suture .

This techniqueis used primarily to reapproximatedeep tissues such as muscle or fasciaNot common used in skin

Ford Interlocking

Principles for Suture Removal

1- The area should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood, and serum from about the sutures

2- A sharp suture scissors should be used to cut the loops of individual or continuous sutures about the teeth

3- It is often helpful to use a No. 23 explorer to help lift the sutures if they are within the sulcus or in close opposition to the tissue

4- A cotton pliers is used to remove the suture. The location of the knots should be noted so that they can be removed first. This will prevent unnecessary entrapment under the flap

Suture should be removed in 7 to 10 days to prevent epithelialization or wicking about the suture