Suture materialsSuture materials

Mudasir BashirMudasir Bashir m.v.sc scholar m.v.sc scholar

48564856

ObjectivesObjectives

Provide basic information on Provide basic information on commonly used suture materialscommonly used suture materials

Qualities of an ideal suture: It shouldQualities of an ideal suture: It should

• Remain intact until union occurs.Remain intact until union occurs.• Cause minimum tissue reaction. Cause minimum tissue reaction. • Be non-capillary in action.Be non-capillary in action.• Be of uniform thickness.Be of uniform thickness.• Be knotable.Be knotable.• Have smooth surface. Have smooth surface. • Have sufficient tensile and functional Have sufficient tensile and functional

strength.strength.• Easily sterilizable.Easily sterilizable.• Cheap and readily availableCheap and readily available• Easy to handle.Easy to handle.

The suture is used to bringThe suture is used to bring

The edges of wound in close The edges of wound in close approximation,approximation,

to retain the medicated plug for to retain the medicated plug for dressing in deep wound or cavity, dressing in deep wound or cavity,

to close any accidental opening or to close any accidental opening or to keep the lips of a deep extensive to keep the lips of a deep extensive

open wound in contact temporarilyopen wound in contact temporarily to check recurrent haemorrhage.to check recurrent haemorrhage.

Suture MaterialSuture Material

Generally categorized by three Generally categorized by three characteristics:characteristics:• Absorbable vs. non-absorbableAbsorbable vs. non-absorbable• Natural vs. syntheticNatural vs. synthetic• Monofilament vs. multifilamentMonofilament vs. multifilament

Natural SutureNatural Suture

Biological originBiological origin Cause intense inflammatory reactionCause intense inflammatory reaction Examples:Examples:

• ““Catgut” – purified collagen fibers Catgut” – purified collagen fibers derived from intestine of healthy sheep derived from intestine of healthy sheep or cowsor cows

• Silk(non absorbable)Silk(non absorbable)

Synthetic SutureSynthetic Suture

Synthetic polymersSynthetic polymers Do not cause intense inflammatory Do not cause intense inflammatory

reactionreaction Examples:Examples:

• Vicryl(absorbable)Vicryl(absorbable)• MonocrylMonocryl• ProleneProlene• Nylon Nylon

Absorbable SutureAbsorbable Suture Degraded and eventually eliminated in Degraded and eventually eliminated in

one of two ways:one of two ways:• Via inflammatory reaction utilizing Via inflammatory reaction utilizing

tissue enzymestissue enzymes• Via hydrolysisVia hydrolysis

Examples:Examples:• ““Catgut”Catgut”• ChromicChromic• polyglactin 910 (polyglactin 910 (Vicryl)Vicryl)• MonocrylMonocryl• polyglycolic acid (Dexon) etc. polyglycolic acid (Dexon) etc.

Absorbable Suture-descriptionAbsorbable Suture-description Kangaroo tendon:Kangaroo tendon: It is obtained from It is obtained from

the tendon of tail of kangaroo and is the tendon of tail of kangaroo and is used for suturing joint capsule used for suturing joint capsule

Fascia lata:Fascia lata: It is obtained from the It is obtained from the bovine Fascia lata bovine Fascia lata

Cargile membrane:Cargile membrane: it is obtained it is obtained from bovine caecum from bovine caecum

Amniotic membrane:Amniotic membrane: It is prepared It is prepared from amniotic membrane of fetusesfrom amniotic membrane of fetuses

CatgutCatgut Absorption in tissues can be delayed Absorption in tissues can be delayed

by treating with chromic acid.by treating with chromic acid. Catgut therefore available as plain Catgut therefore available as plain

and chromic catgut.and chromic catgut.

chromic catgutchromic catgut

TypeType Degree of Degree of ChromicityChromicity

Approx No.Of Approx No.Of days taken for days taken for absorptionabsorption

Type AType A PlainPlain 10 Days10 Days

Type BType B Mild chromicMild chromic 15 Days15 Days

Type CType C Medium Medium chromicchromic

20 Days20 Days

Type DType D Extra chromicExtra chromic 40 Days40 Days

Catgut cont.Catgut cont.

Depending on preservative used Depending on preservative used catgut is available eitheras boilable catgut is available eitheras boilable or non boilable catgut.or non boilable catgut.

Boilable catgut is preserved in Boilable catgut is preserved in xylol,toulene-99.75%,phenyl xylol,toulene-99.75%,phenyl merecuric acetate.025%merecuric acetate.025%

Non boilable catgut is supplied in Non boilable catgut is supplied in tubes containing90-95%alcohol.tubes containing90-95%alcohol.

Sizes of Sizes of catgutcatgut

Diameter in Diameter in mm(average)mm(average)

UseUse

2/02/0 0.300.30 Peretoneum,bowel Peretoneum,bowel wall(small animals)and wall(small animals)and ligaturing vesselsligaturing vessels

0 or 0 or 1/01/0

0.400.40 -do--do-

11 0.480.48 Muscle Muscle fascia(SA)ligature fascia(SA)ligature larger vesselslarger vessels

22 0.500.50 -do--do-

33 0.600.60 Fascia,muscles(LA)Fascia,muscles(LA)

44 0.700.70

55 0.800.80 Rumen uterus Rumen uterus abdomenabdomen

Catgut size selectionCatgut size selection

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

cont.cont. Collagen:Collagen: It is prepared from bovine It is prepared from bovine

flexor tendon filament flexor tendon filament Polyglactin 910Polyglactin 910 (vicryl): It is a (vicryl): It is a

synthetic absorbable suture material, synthetic absorbable suture material, prepared from glycolic lactic acid prepared from glycolic lactic acid polymer polymer

Polyglycolic acidPolyglycolic acid (Dexon): It is (Dexon): It is synthetic suture material synthetic suture material

prepared from glycolic acidprepared from glycolic acid

Non-absorbable SutureNon-absorbable Suture Not degraded, permanentNot degraded, permanent may be organic; inorganic or may be organic; inorganic or

synthetic in nature and are used synthetic in nature and are used as both the internal and external as both the internal and external suture materials. suture materials.

Non-absorbable SutureNon-absorbable Suture

Examples:Examples:• ProleneProlene• Nylon nylon Nylon nylon • Stainless steelStainless steel• Silk*Silk*

(*not a truly permanent material; (*not a truly permanent material; known to be broken down over a known to be broken down over a prolonged period of time—years)prolonged period of time—years)

Non-absorbableNon-absorbable Organic suture Organic suture materialsmaterials

CottonCotton:capillary in nature it clings :capillary in nature it clings to surgeon’s gloves and they to surgeon’s gloves and they spread infection in wound when spread infection in wound when applied to skin and luminal applied to skin and luminal surfaces surfaces

SilkSilk:: it may be plain or braided and it may be plain or braided and capillary in nature capillary in nature

Silk worm gutSilk worm gut: non-capillary and : non-capillary and useful for cutaneous suturesuseful for cutaneous sutures

cont.cont. Horse hairHorse hair: It is cheap, non-capillary, : It is cheap, non-capillary,

flexible and is easily sterilized. It causes flexible and is easily sterilized. It causes little tissue reaction.little tissue reaction.

LinenLinen: It is capillary in nature and : It is capillary in nature and

produces more tissue reaction than produces more tissue reaction than cotton and silk. cotton and silk.

Umbilical tapeUmbilical tape: used to tie the : used to tie the umbilical cord of the new born or as umbilical cord of the new born or as vulvar suture in cases of prolapse of vulvar suture in cases of prolapse of vagina of uterus. vagina of uterus.

Polyester:Polyester:is a non absorbable, is a non absorbable, sterile, surgical suture composed sterile, surgical suture composed of Poly (ethylene terephthalate).of Poly (ethylene terephthalate).

It suture elicits a minimal acute It suture elicits a minimal acute inflammatory reaction in tissues.inflammatory reaction in tissues.

polyamide:polyamide:Being monofilament, Being monofilament, Linex is remarkably smooth and Linex is remarkably smooth and gives excellent knotsecurity. gives excellent knotsecurity. Posses good tensile strength. Posses good tensile strength.

Easy removal with no Easy removal with no tissueadherence. tissueadherence.

Non-absorbable Inorganic Non-absorbable Inorganic suture materialsuture material

Metallic suture: Wire of Metallic suture: Wire of different metals like different metals like tantalum, silver,tantalum, silver,

copper, stainless steel and copper, stainless steel and vitalliumvitallium

Tantalum: It is inert to Tantalum: It is inert to

tissues like stainless steel tissues like stainless steel

Stainless steel sutureStainless steel suture

cont..cont..

SilverSilver: It becomes ionized in tissues : It becomes ionized in tissues and cause inflammation.and cause inflammation.

CopperCopper: It is more suitable to repair : It is more suitable to repair fractures due to its flexibility. fractures due to its flexibility.

Aluminium wireAluminium wire: It is more flexible : It is more flexible than stainless steel.than stainless steel.

Placing of suturesPlacing of sutures

If sutures are placed far apart-Proper If sutures are placed far apart-Proper apposition of wound edges may not apposition of wound edges may not take place.take place.

But if placed too close together-But if placed too close together-holding power of tissue diminishes.holding power of tissue diminishes.

Optimum suture distanceOptimum suture distance -Skin sutures about 5-6mm(3/8 inch)-Skin sutures about 5-6mm(3/8 inch) -Hollow visceral organs 2mm (1/8 -Hollow visceral organs 2mm (1/8

inch)to prevent leakage of contents.inch)to prevent leakage of contents.

Multifilament (braided)Multifilament (braided)

Suture ClassificationSuture Classification

MonofilamentMonofilament

Monofilament SutureMonofilament Suture

Grossly appears as single strand of suture Grossly appears as single strand of suture material; all fibers run parallelmaterial; all fibers run parallel

Minimal tissue traumaMinimal tissue trauma Resists harboring microorganismsResists harboring microorganisms Ties smoothlyTies smoothly Requires more knots than multifilament Requires more knots than multifilament

suturesuture Possesses memoryPossesses memory Examples:Examples:

• Monocryl, PDS, Prolene, NylonMonocryl, PDS, Prolene, Nylon

Multifilament SutureMultifilament Suture

Fibers are twisted or braided togetherFibers are twisted or braided together Greater resistance in tissueGreater resistance in tissue Provides good handling and ease of Provides good handling and ease of

tyingtying Fewer knots requiredFewer knots required Examples:Examples:

• Vicryl (braided)Vicryl (braided)• Chromic (twisted)Chromic (twisted)• Silk (braided)Silk (braided)

Braided v MonofilamentBraided v Monofilament

Has capillary actionIncreased infection riskLess smooth passageLess tensile strengthBetter handlingBetter knot security

No capillary actionLess infection riskSmooth tissue passageHigher tensile strengthHas memoryMore throws required

Silk Silk CatgutCatgut

NaturalNatural• Silk, linen, catgutSilk, linen, catgut

Synthetic Synthetic polymerpolymer• Polypropylene, Polypropylene,

polyester, polyester, polyamidepolyamide

Polypropylene Polyester

nylonnylon

MonofilamentMonofilament• PolypropylenePolypropylene• PolydioxanonePolydioxanone• NylonNylon

MultifilamentMultifilament• Catgut (twisted)Catgut (twisted)• PolyesterPolyester• Silk (braided)Silk (braided)

Polyester silkPolyester silk

Suture DegradationSuture Degradation

Suture MaterialSuture Material Method of Method of DegradationDegradation

Time to Time to DegradationDegradation

““Catgut”Catgut” Proteolytic Proteolytic enzymesenzymes DaysDays

Vicryl, MonocrylVicryl, Monocryl HydrolysisHydrolysis Weeks to Weeks to monthsmonths

Suture SizeSuture Size Sized according to diameter with “0” as reference Sized according to diameter with “0” as reference

sizesize Numbers alone indicate progressively larger Numbers alone indicate progressively larger

sutures (“1”, “2”, etc)sutures (“1”, “2”, etc) Numbers followed by a “0” indicate progressively Numbers followed by a “0” indicate progressively

smaller sutures (“2-0”, “4-0”, etc)smaller sutures (“2-0”, “4-0”, etc)

Smaller Smaller ------------------------------------------------------ Larger Larger

.....”3-0”...”2-0”...”1-0”.....”1”...”2”...”3”..........”3-0”...”2-0”...”1-0”.....”1”...”2”...”3”.....

The Suture PackagingThe Suture Packaging

STRAND SIZE

MATERIAL

STRAND LENGTH

PRODUCT CODE

NEEDLE CODE

WITH LIFE SIZE

PICTURE OF

NEEDLE

NEEDLE LENGTHCOLOUR

POINT TYPE

NEEDLE CIRCLE

Suture PackagingSuture Packaging

Non absorbable suturesNon absorbable sutures

EthiconEthicon

Braided silk blackBraided silk black TrulonTrulon

Monofilament Monofilament polyamidepolyamide

TruleneTrulene

Monofilament Monofilament polypropylenepolypropylene

Absorbable suturesAbsorbable sutures

Polypropylene Mesh for Hernia RepairPolypropylene Mesh for Hernia Repair

Are provided with very High Bursting Are provided with very High Bursting Strength,Elasticity and tested for Bio-Strength,Elasticity and tested for Bio-compatiability after implantation.compatiability after implantation.

They are available in popular sizes of They are available in popular sizes of 2x4, 3x6, 6x6 and 12x12 inches. 2x4, 3x6, 6x6 and 12x12 inches. Available in two types, namely PM Available in two types, namely PM and PS types.and PS types.

Polypropylene MeshPolypropylene Mesh

PM type mesh is thinner, smoother and PM type mesh is thinner, smoother and more flexible. Where as PS mesh is Strong, more flexible. Where as PS mesh is Strong,

thicker and normal flexibility.thicker and normal flexibility.

Types of hernia meshesTypes of hernia meshes

NeedlesNeedles

• Classified according to shape and type of Classified according to shape and type of pointpointCurved or straight (Keith needle)Curved or straight (Keith needle)Taper point, cutting, or reverse cuttingTaper point, cutting, or reverse cutting

Atraumatic needles- to suture delicate Atraumatic needles- to suture delicate tissues like intestine, stomach, tissues like intestine, stomach, bladder, uterus etc.bladder, uterus etc.

Double curved and loopuyt needles -Double curved and loopuyt needles -for skin closure of cattle or buffalo and for skin closure of cattle or buffalo and for deeper structures. for deeper structures.

NeedlesNeedles

CurvedCurved• Designed to be held Designed to be held

with a needle with a needle holderholder

• Used for most Used for most suturingsuturing

StraightStraight• Often hand heldOften hand held• Used to secure Used to secure

percutaneously percutaneously placed devices (e.g. placed devices (e.g. central and arterial central and arterial lines)lines)

Needle CurvatureNeedle Curvature

NeedlesNeedles

Taper-point needleTaper-point needle• Round bodyRound body• Used to suture soft Used to suture soft

tissue, excluding tissue, excluding skin (e.g. GI tract, skin (e.g. GI tract, muscle, fascia, muscle, fascia, peritoneum)peritoneum)

Needle point GeometryNeedle point GeometryTaper-Taper-PointPoint

Suited to soft tissueSuited to soft tissueDilates rather than cutsDilates rather than cuts

Reverse Reverse cuttingcutting

Very sharpVery sharpIdeal for skinIdeal for skinCuts rather than dilatesCuts rather than dilates

ConventioConventional Cuttingnal Cutting

Very sharpVery sharpCuts rather than dilatesCuts rather than dilatesCreates weakness allowing Creates weakness allowing suture tearoutsuture tearout

Taper-Taper-cuttingcutting

Ideal in tough or calcified Ideal in tough or calcified tissuestissuesMainly used in Cardiac & Mainly used in Cardiac & Vascular procedures.Vascular procedures.

Needle Point GeometryNeedle Point Geometry

BluntBlunt

Also known as “Protect Point”Also known as “Protect Point”Mainly used to prevent needle stick Mainly used to prevent needle stick injuries i.e. for abdominal wall injuries i.e. for abdominal wall closure.closure.

Premium Premium point spatulapoint spatula

Ophthalmic SurgeryOphthalmic Surgery

SpatulaSpatulaOphthalmic SurgeryOphthalmic Surgery

DermaX*DermaX*NEW: NEW: ½ The Penetration force½ The Penetration force½ The Penetration force½ The Penetration forceSuperior Cosmetic EffectSuperior Cosmetic Effect

The Right Needle ChoiceThe Right Needle Choice

The appropriate needle choice for The appropriate needle choice for any situation is……………. any situation is…………….

…………………………The needle that will cause The needle that will cause least possible trauma to the tissue least possible trauma to the tissue being suturedbeing sutured

NeedlesNeedles

Cutting needleCutting needle• Triangular bodyTriangular body• Sharp edge toward Sharp edge toward

inner circumferenceinner circumference• Used to suture Used to suture skinskin

or tough tissueor tough tissue

Using needle holder, grasp needle about Using needle holder, grasp needle about 2/32/3rdsrds of the way back from point of the way back from point..

Index finger stabilizes the Index finger stabilizes the instrument by resting on the shaft.instrument by resting on the shaft.

Surgical ScissorsSurgical Scissors

FORCEPSFORCEPS

Grasp forceps between thumb & middle finger, Grasp forceps between thumb & middle finger, while index finger is used for stabilization.while index finger is used for stabilization.

If possible, use forceps to grasp If possible, use forceps to grasp dermisdermis, rather , rather than than epidermisepidermis or or skin surfaceskin surface itself. itself.

This helps prevent marking & injuring of skin at This helps prevent marking & injuring of skin at wound edge.wound edge.

Steri-stripsSteri-strips Sterile adhesive tapesSterile adhesive tapes Available in different Available in different

widthswidths Frequently used with Frequently used with

subcuticular suturessubcuticular sutures Used following staple Used following staple

or suture removalor suture removal Can be used for Can be used for

delayed closuredelayed closure

StaplesStaples

Rapid closure of Rapid closure of woundwound

Easy to applyEasy to apply Evert tissue when Evert tissue when

placed properlyplaced properly

DermabondDermabond®®

A sterile, liquid topical skin A sterile, liquid topical skin adhesiveadhesive

Reacts with moisture on skin Reacts with moisture on skin surface to form a strong, surface to form a strong, flexible bondflexible bond

Only for easily approximated Only for easily approximated skin edges of woundsskin edges of wounds• punctures from minimally punctures from minimally

invasive surgeryinvasive surgery• simple, thoroughly cleansed, simple, thoroughly cleansed,

lacerationslacerations

AMCRYLATEAMCRYLATE®® Gel Gel Iso-amyl-2-cyanoacylateIso-amyl-2-cyanoacylate

Method of applicationMethod of application

Control hemorrhage on Control hemorrhage on cutaneous incision on skin and keep cutaneous incision on skin and keep dry using swabs.dry using swabs.

Apply few drops of Apply few drops of Iso-amyl-2-Iso-amyl-2-cyanoacylatecyanoacylate over the wound edges.over the wound edges.

Hold skin edges in proper opposition Hold skin edges in proper opposition for about 20 seconds to achive union for about 20 seconds to achive union of skin woundof skin wound

Even a small droplet of blood at Even a small droplet of blood at wound edges causes effervescence wound edges causes effervescence and non union at that point.and non union at that point.

Clean that area and dry and reapply Clean that area and dry and reapply tissue adhesivetissue adhesive

Thank youThank you