1 November 16, 2009 A-B Tech Kurt Prewitt This promotional educational activity is brought to you by...

1

November 16, 2009

A-B Tech

Kurt Prewitt

This promotional educational activity is brought to you by Ethicon, Inc. and is not certified for continuing medical education.

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SUTURES

SUTURE OVERVIEW

ABSORBABLE SUTURES

NON-ABSORBABLE SUTURES

SUTURE SELECTION BY TISSUE

3

SUTURES OVERVIEW

4SUTURES OVERVIEW

OBJECTIVES

1. Trace the evolution of sutures as a method of

ligating and approximating tissue

2. Aspects of wound healing

3. Differentiate among the types of sutures

5

WHAT IS SUTURE?

Suture Definition

• The word “suture” describes any strand of

material used to ligate (tie) blood vessels or

approximate (sew) tissues

6

A Timeline50,000 BC Eyed needles are invented.

20,000 BC Bone needles are standard.

1600 BC One of the earliest known references to suture material. Sutures are

made from flax, hemp, bark fiber, hair, etc.

900 AD Used strings from a kit, a guitar-like musical instrument

1867-9 Joseph Lister proves that the body absorbs catgut sutures. However

he is most famous for demonstrating the need for antiseptic techniques

for sterilization of implanted sutures.

1918 George Merson begins the sale of eyeless needled sutures where one

strand of suture material is attached to the butt of the needle. This

type of swaged needle is still in use and is the standard today.

1947 Introduction of Nylon.

1972 First synthetic absorbable suture introduced.

2000 Distribution of gut material ends in many parts of Europe and Japan

due to Bovine Spongiform Encephalopathy (“Mad Cow Disease”)

SUTURES OVERVIEW

HISTORY OF SUTURES

7

1. Sterile

2. Easy to handle

3. Minimal tissue reaction/trauma

4. High tensile strength retention

5. Knot security

6. Absorbable

7. Useful in all tissues

SUTURES OVERVIEW

IDEAL SUTURE

8

Skin

Mucosa

Subcutaneous

Peritoneum

Fascia

0 5 7 14 21 28 Days

5-7 Days

5-7 Days

7-14 Days

7-14 Days

14-28 Days

Tissue Healing Times

SUTURES OVERVIEW

CRITICAL WOUND HEALING PERIOD

9SUTURES OVERVIEW

SUTURE SIZING

Ethicon Suture Sizing

• Ranging from 7 to 11-0

• Size 7 is largest

• Size 11-0 is smallest

• Size 7-0 approximately

corresponds to the

thickness of human hair

10

1887 20071947 1958 1969 1974 1976 1979 1989 1992 1993 1995 1996 1998 2002 2003 2006

ETHIBOND EXCEL* Polyester

SutureSilk and Cat Gut

Nylon

MERSILENE* Polyester Fiber

Suture

PROLENE* Polypropylene

Suture

VICRYL*(polyglactin 910)

Suture

Coated VICRYL* (polyglactin 910)

Suture

PDS* II (polydioxanone)

Suture

ETHIGUARD*Blunt Point

Needle

MONOCRYL* (poliglecaprone 25)

Suture

VICRYL RAPIDE* (polyglactin 910)

Suture

Dyed MONOCRYL*

(poliglecaprone 25) Suture

DERMABOND®

Topical Skin

Adhesive

DERMABOND®

Topical Skin

Adhesive High

Viscosity

Coated VICRYL* Plus Antibacterial (polyglactin 910)

Suture

PDS* Plus Antibacterial

(polydioxanone) Suture (May

2007 Launch)

MONOCRYL* Plus Antibacterial

(poliglecaprone 25) Suture

HISTORY OF INNOVATION

SUTURES OVERVIEW* Trademark

11SUTURES OVERVIEW

SUTURE CLASSIFICATIONS

• Absorbable / Non-Absorbable

• Natural / Synthetic

• Braided / Monofilament

• Antibacterial Sutures

12SUTURES OVERVIEW

ABSORBABLE / NON-ABSORBABLE SUTURES

Absorbable Sutures• Sutures that undergo degradation in tissues, losing their tensile

strength within 60 days

– Absorption Rate: Time required for a suture to be fully absorbed into

the tissue

– Tensile Strength In Vivo: Tension which a suture will withstand before it

breaks down inside the tissue

Non-Absorbable Sutures• Sutures which are not digested by body enzymes or hydrolyzed in

body tissue

13SUTURES OVERVIEW

NATURAL / SYNTHETIC SUTURES

Natural Sutures

• Sutures made of material that can be found in nature

– Absorption method (if absorbable): Enzymatic

Synthetic Sutures

• Sutures made of materials created by man

– Absorption Method (if absorbable): Hydrolysis –

breakdown in the presence of water or moisture

14SUTURES OVERVIEW

MONOFILAMENT / BRAIDED SUTURES

Monofilament• A single strand of material

– Less resistance as it passes through tissue

– Resists bacterial harboring compared to braided

Braided • Multifilament sutures that consist of several filaments or strands,

twisted or braided together

– Greater tensile strength

– Pliability and flexibility

15SUTURES OVERVIEW

ANTIBACTERIAL SUTURES

Properties of Antibacterial Sutures

– Biocompatibility

– Effectiveness against S.Aureus and S.Epidermidis

(most common for device infections) among other bacteria1-3

– Ability to withstand manufacturing process

o Heat, humidity, solvent, sterilization, etc

o Mass production

– Will not negatively alter suture properties

– Ability to maintain antibacterial activity on the suture for a

clinically relevant duration1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.

16

Class IClean

Uninfected wound in which no inflammation is

encountered and respiratory, alimentary, genital, or

uninfected urinary tract is not entered.

Class IIClean-contaminated

Operative wound in which respiratory, alimentary, genital,

or urinary tracts are entered under controlled conditions

and without unusual contamination.

Class IIIContaminated

Open, fresh, accidental wounds.

Class IVDirty-infected

Old traumatic wounds with retained devitalized tissue and

those that involve existing clinical infection or perforated

viscera.

1. CDC=Centers for Disease Control and Prevention. Mangram AJ et al. Am J Infect Control. 1999;27:97-134.

SUTURES OVERVIEW

CDC SURGICAL WOUND CATEGORIES1

17SUTURES OVERVIEW

COMPLICATIONS IN WOUND HEALING

• Infection (including SSIs)

• Wound Disruption

– Deshiscence – Splitting open of the wound due to

o Too much tension placed on the wound

o Improper suturing technique

o Inappropriate suture materials

o Weakened tissue

– Evisceration – Protrusion of the bowel through the

separated edges of the abdominal wound closure

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PLUS ANTIBATERIAL SUTURES

• Coated polyglactin 910 sutures with triclosan exhibit

antibacterial activity on the suture in vitro against methicillin-

sensitive and -resistant S aureus and S epidermidis

compared with untreated controls1

• Antibacterial activity endures on the suture despite

extended exposure to aqueous environment1

• Suture diameter, knotting, or passage through tissues

does not diminish antibacterial activity of triclosan-coated

sutures1

1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3(suppl):S79-S87.

SUTURES OVERVIEW

19

1. Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial adherence to surgical sutures J Am Coll Surg. 2006;203:481-489.

IRGACARE® MP

IRGACARE® MP, the antibacterial component of Ethicon

Plus Sutures, is effective on the suture against the

pathogens most commonly associated with SSIs1

• Staphylococcus aureus

• Staphylococcus epidermidis

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Methicillin-resistant Stapylococcus aureus (MRSE)

• Escherichia coli †

• Klebsiella pneumoniae †

SUTURES OVERVIEW

† Only for MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture and PDS* Plus Antibacterial (polydioxanone) Suture* Trademark

20SUTURES OVERVIEW

1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.

PLUS Antibacterial Sutures kill bacteria on the suture and

inhibit bacterial colonization of the suture1-3

ZONE OF INHIBITION

MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture

Coated VICRYL* Plus Antibacterial (polyglactin

910) Suture

PDS* Plus Antibacterial (polydioxanone) Suture

Zone of Inhibition – Areas of inhibited bacterial growth for Plus Antibaterial Sutures

* Trademark

21SUTURES OVERVIEW

PLUS ANTIBACTERIAL SUTURES

• In vitro testing (petri dish) has shown Plus Antibacterial

Sutures create a zone of inhibition around the suture in which

certain bacteria are unable to grow1-3

• IRGACARE® MP in the Plus Sutures creates a zone of

inhibition which lasts in vitro for:

Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture

Minimum of 7 days for S.Aureus

MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture

31 days for S.Aureus21 days for E.Coli

PDS* Plus Antibacterial (polydioxanone) Suture

23 days for S.Aureus17 days for E.Coli

* Trademark

1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.

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ABSORBABLE SUTURES

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Natural

Short-Medium

Short

FastAbsorbing

Gut

PlainGut

Medium

Chromic Gut

Virtual Monofilament

Natural Absorbable

Synthetic

Synthetic Absorbable

ABSORBABLE SUTURES

ABSORBABLE SUTURE TYPES

* Trademark

Monofilament Braided

Short / Medium

Long Short Medium

MONOCRYL* (poliglecaprone 25) Suture, MONOCRYL* Plus Antibacterial (poliglecaprone

25) Suture

PDS* II (polydioxanone) Suture, PDS* Plus

Antibacterial (polydioxanone) Suture

VICRYL RAPIDE* (polyglactin 910)

Suture

Coated VICRYL* (polyglactin 910) Suture, Coated VICRYL*

Plus Antibacterial (polyglactin 910) Suture

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NATURAL ABSORBABLE SUTURES

Ethicon Gut Sutures1

• Submucosal or serosal layer of animal intestine

• 97-98% pure collagen

• Clean and purified

• Strands twisted for controlled diameter

• Packaged wet to maintain pliability

• Spun and polished into virtual monofilament

strands

ABSORBABLE SUTURES1. Wound Closure Manual, page 13

25ABSORBABLE SUTURES


Plain gut

• TRU-GAUGING process1

– Eliminates high and low spots

– Greater surface smoothness

– No fraying of the suture

– Better knot security

– Uniform diameter across entire length

– Uniform high tensile strength

– Wound support for approximately 2 weeks1. Wound Closure Manual, page 13,14



Chromic gut

– TRU-GAUGING process1

– TRU-CHROMICIZING process1

o Entire cross-section of strand is

evenly chromicized

o Minimizes tissue irritation

o Less reaction

– Wound support for approximately 4 weeks2

Fast-absorbing gut

– Plain surgical gut is heat treated to accelerate tensile strength

loss and absorption1

– Wound support for approximately 1 week

Chromic Gut

1. Wound Closure Manual, page 13,142. Chromic Gut Product Insert


SYNTHETIC ABSORBABLE SUTURES

VICRYL RAPIDE*(polyglactin 910) Suture

• Short-term wound support1

– 7-10 days

– Rapid strength loss

– Absorption complete in just 42 days

• For mucosa and superficial closure of skin

• Convenient for the patients

– No return visit necessary for suture removal

* Trademark

1. Wound Closure Manual, page 14


SYNTHETIC ABSORBABLE SUTURES


• Initial strength comparable to that

of Nylon and Gut

• Fastest-absorbing synthetic suture

• Elicits lower tissue reaction than chromic gut suture

* Trademark

1. Wound Closure Manual, page 14; Product Inserts of VICRYL RAPIDE* (polyglactin 910) Suture, ETHILON* Nylon Suture and Chromic Gut

29


• Wound support for approximately 14 days

• Consistent handling and performance

– Significantly less tissue drag than chromic gut

sutures and braided synthetic absorbable sutures

– Excellent knot security

ABSORBABLE SUTURES* Trademark

1. Wound Closure Manual, page 14; MONOCRYL Plus Suture Product Insert

30


Reliable Strength

• Consistent absorption rate with a predictable decrease in

tensile strength over time

• Stronger than gut suture initially and through the critical

wound-healing period

• Offers protection for subcuticular closure and soft tissue

approximation

ABSORBABLE SUTURES* Trademark

1. Wound Closure Manual, page 13,14; MONOCRYL Plus Suture Product Insert, Chromic Gut Product Insert



Excellent handling and performance

– Knot security and knot snug-down

– First-throw holding security

– Smooth passage with minimal tissue drag

– Virtually no package memory

* Trademark



Exceptional strength

– Wound support for approximately 4 weeks

– Offers protection and strength for general tissue

approximation

* Trademark

1. Product Inserts for Coated VICRYL Plus Suture, MONOCRYL Plus Suture, Chromic Gut and Plain Gut



• Extended monofilament wound support for

approximately 42 days

• Offers protection and strength for slow-healing tissue

– Fascia closure, Orthopedic surgery

– Blood vessel anastomoses

– Diabetic, cancer and obese patients

* Trademark

1. Wound Closure Manual page 20,21; PDS Plus Suture Product Insert



PDS Plus Sutures offer surgeons:

– Low out-of-package memory

– Smooth passage through tissue

– Low bending stiffness for more pliability and easier

handling

PDS Plus Suture stays stronger, longer†

† Compared to Maxon™ or Biosyn™: Data from Maxon™, Biosyn™ and PDS* Plus Suture product inserts* Trademark

35


36

Natural

BraidedMonofilament

SurgicalStainless

Steel

PERMA-HAND* Silk Suture

Synthetic

ETHIBOND EXCEL* Polyester Suture

MERSILENE* Polyester

Fiber Suture

BraidedMonofilament

NUROLON* Nylon Suture

PRONOVA* Poly (Hexafluoropropylene

- VDF) Suture

PROLENE* Polypropylene Suture

ETHILON* Nylon Suture

NON-ABSORBABLE SUTURE TYPES

NON-ABSORBABLE SUTURES* Trademark

37NON-ABSORBABLE SUTURES

SILK - BRAIDED

PERMA-HAND*Silk Suture1

• Wax proofed

– Improves surface quality

– Reduces bacterial harboring

– Reduces capillarity

• Braided

– Excellent handling and knotting characteristics

• Used in a wide variety of surgical procedures

* Trademark



STEEL - MONOFILAMENT

Surgical Stainless Steel Suture1

• High tensile strength

• Reliable and ductile alloy

− Made of 316L stainless steel

− Optimal compatibility with stainless steel implants

• Low tissue reactivity

• Multistrand packaging

− Eliminates kinking and bending of strands

− 2 or 4 strands per pack1. Wound Closure Manual, page 16


ETHILON*Nylon Suture1

• Well suited for skin and retention

closure

• Finer sizes used in ophthalmic and

microsurgery procedures

• May be clear, or dyed green or black for better visibility

• Specific codes (sizes 3-0 to 6-0) are “pliabilized.” Pliabilization

– Includes pre-moistening the suture to make it more pliable

– Enhances handling and knot tying characteristics to approximate

that of braided sutures

NYLON - MONOFILAMENT

* Trademark



NYLON - BRAIDED

NUROLON*NYLON SUTURE1

• Handles like silk

• Stronger than silk

• Better knot tie-down than silk

• Lower tissue reactivity

• Less fragmentation

• Ideal silk replacement in neurosurgery

* Trademark



POLYESTER - BRAIDED

MERSILENE* Polyester Fiber Suture1

Polyester

– Permanent wound support

Braided

– Good handling characteristics

– Provide precise and consistent suture tension

Synthetic

– Less tissue reaction

* Trademark


42

POLYESTER - BRAIDED


• Polyester: permanent wound support

• Minimal tissue reaction; suture material and

coating are pharmacologically inactive1

• A central core and 16 outer carriers

– Tighter, compact and stronger braid

• Excellent handling properties (suppleness

and pliability)

• Polybutylate coating

– Smooth knot tie-down

– High knot and tensile strength

* Trademark

1. Wound Closure Manual page 18

43

POLYESTER - BRAIDED

Many options available1:

• Specialized CV Needles

• Single or Multi-strand

• D-Specials

• Pledgets – Soft and hard, 2 sizes

• In green & white for ease of use

• Available in many suture sizes & lengths used in CV

and Ortho procedures


1. ETHIBOND EXCEL Suture Product Insert

44

POLYESTER - BRAIDED

Improvements in ETHIBOND

EXCEL Suture

•Tight, compact braid– Results in stronger suture

– Avoids suture bunching

•Effective coating levels– Less “slippery” suture

– Excellent knot security

•Packaging– Fast, reliable suture delivery

– Clear package and box graphics


1. CPC-2007-0160 and AST-2008-0046 ETHIBOND EXCEL Suture reports


POLYPROPYLENE - MONOFILAMENT

• Minimal tissue reaction

• Polypropylene: Inert, reliable, strong, smooth, secure− Will not fatigue with normal flexing

− Exceptionally smooth surface avoids snagging vessel adventitia

• Plastic knot deformity - When knotted, deforms and flattens to

provide excellent knot security2

• Controlled linear elongation - Excellent pliability2

* Trademark

1. Wound Closure Manual page 182. CPC-2006-0445 and CPC-2008-0046 PROLENE Suture Reports



• Laser scanning process for sizes

5-0, 6-0 and 7-0

– More consistent diameter and improved

tensile strength

• Sizes 8/0 and smaller are hand inspected

* Trademark



Packaging

• Unique RELAY* Suture Delivery System

• Straight pack delivers the suture virtually memory-free

Many options available1

• Available in a variety of sizes and lengths used in different specialties

• Specialized Cardiovascular needles

• Single or multi-strand

• E-Packs and D-Specials

* Trademark

1. Prolene Package Insert


PRONOVA - MONOFILAMENT

PRONOVA* Poly (hexafluoropropylene-VDF) Suture1

• Offers excellent strength

• Less memory than polypropylene

• Exceptional strength for delicate tissues

• Monofilament, more resistant to bacterial colonization

• Strong resistance to handling damage and fraying

• Excellent handling and tying characteristics

• Excellent resistance to repetitive stress fatigue such as to those

imposed by heart and vessels

* Trademark

1. Wound Closure Manual page 18

49

SUTURE SELECTION BY TISSUE TYPE

50

Joint Capsule (knee, hip, shoulder)

Recommended Suture†

Needle Options††

OS-4, OS-6, OS-8, CT-1, CTX, MO-4

Tissue CharacteristicsLigamentous sac surrounding the articular cavity of the joint; consists of

vascular, very dense, fibrous tissue. Heals in approximately 3 weeks.

SUTURE SELECTION* Trademark

† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

SUTURE SELECTION

51

Epidermis, Oral (facial)/Vaginal Mucosa, Perineal Skin

Recommended Suture

Needle Options†

PC-1, PC-3, P-1, P-3, PS-2

Tissue CharacteristicsSuperficial layer of skin; dense and tough, but thin. It is usually supported by

dermal closure.

SUTURE SELECTION

SUTURE SELECTION


* Trademark

† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

52

Peritoneum



SH, CT-1

Tissue CharacteristicsThin, membranous lining of the abdominal cavity. Very little fibrosis. Heals

quickly. Closure is optional, based on surgeon preference.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

53

Dermis / Subcuticular



PC-5, PS-2, PS-1, PS#, PSL, PSLX#

Tissue CharacteristicsDeep, vascular, subcuticular layer; 3 times thicker than epidermis; consists of

dense connective tissue. Regains tensile strength slowly. Most of the stress

placed upon the healing wound is absorbed by fascia. Sutures need only be strong

enough to withstand natural skin tension and hold wound edges in apposition.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture# Available on ETHILON* Nylon Suture which may also used for subcuticular closure

54

Abdominal Fascia



CT-1, CT, CTX, TP-1, XLH

Tissue CharacteristicsFibrous, sheath-like, connective tissue covering muscle.

Strongest tissue in abdominal wall; regains 25% - 40% of original strength

in 1 month; 55% - 65% in 3 months; 70% -80% in 9 months.

Never regains full original strength.

SUTURE SELECTION

SUTURE SELECTION

* Trademark


55

Urinary Bladder



RB-1, SH-1, SH

Tissue CharacteristicsVery vascular, dense, tough, muscular membranous sac.

Composed of multiple layers.

Heals quickly, achieving 75% to 90% of original strength in 2 weeks.

SUTURE SELECTION

SUTURE SELECTION

* Trademark


56

Colon



SH, SHB

Tissue CharacteristicsWall varies in consistency and density; relatively soft and rubbery, with little

dense, fibrous support.

Heals rapidly, achieving 50% to 60% of original strength in 1 month.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

57

Ureter



TF, RB-1, SH-1

Tissue CharacteristicsNarrow tube with vulnerable blood supply.

Easy to manipulate and penetrate, unless fibrous or hardened.

Achieves normal healing in 7 days.

SUTURE SELECTION

SUTURE SELECTION

* Trademark


58

Ligament



PS-4, PS-2, OS-4, MO-6, CT-2, CT-1

Tissue CharacteristicsVery dense, longitudinally arrayed, collagenous tissue.

Achieves 50% to 70% of original strength in 12 months.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† PDS II Suture may also be used in place of PDS Plus Suture†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

59

Subcutaneous (fat) / Superficial Fascia



SH, CT-1

Tissue CharacteristicsSoft, friable, poorly vascularized tissue; fat does not hold sutures well.

The goal of “suturing the fat” is to approximate the superficial fascia

(Scarpa’s fascia) which is located in the upper 1/3 of the fatty layer.

SUTURE SELECTION

SUTURE SELECTION

* Trademark


60

Small Intestine



RB-1, SH-1, SH

Tissue CharacteristicsWall varies in consistency and density; relatively soft and rubbery, with little

dense, fibrous support.

Heals very rapidly, reaching maximum strength in approximately 14 days.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

61

Uterus



MO-4, MO-2, CT-1, CT, CTX

Tissue CharacteristicsVery vascular, tough and muscular.

SUTURE SELECTION

SUTURE SELECTION

* Trademark


62

Vagina



V-34, CP-1, CT-1, SH

Tissue CharacteristicsExtremely thick, tough and vascular.

Heals completely in 10 days.

SUTURE SELECTION

SUTURE SELECTION

* Trademark



63

Tendon



OS-4, MO-6, CT-2, CT-1

Tissue CharacteristicsVery dense, longitudinally arrayed, collagenous tissue.

SUTURE SELECTION

SUTURE SELECTION

† PRONOVA* Poly (hexafluoropropylene-VDF) Suture and NUROLON* Nylon Suture may also be used to suture tendon to bone. PDS II Suture may also be used in place of PDS Plus Suture†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture* Trademark

64

Stomach



SH, SHB

Tissue CharacteristicsRelatively soft and rubbery, with little dense, fibrous support. Submucosa /

mucosa is especially thick and vascular.

Heals quickly, achieving maximum strength within 21 days.

SUTURE SELECTION

SUTURE SELECTION

* Trademark


65

Nerves, Dura Mater

Recommended Suture


TF, RB-1

Tissue CharacteristicsDura mater tears easily and cannot withstand excessive tension.

In nerve repair, the strength of sutures is less of a consideration than the

degree of inflammatory and fibroplastic tissue reaction.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

NUROLON*NYLON SUTURE

66

Eye, Ocular Muscles

Recommended Suture


CS140-6, CS160-6, CS90-6, CSB-6, TG140-8

Tissue CharacteristicsCornea is avascular, therefore heals slowly and requires sutures to remain in

place for at least 21 days. Ocular muscles, conjunctiva and the sclera have

good blood supply and require suture support only for about 7 days.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† PDS II Suture may also be used in place of PDS Plus Suture†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

Coated VICRYL* (polyglactin 910) Suture

67

Vessels and Anastomosis



BV-1, BV130-5, BV175-6, BV175-7, BV175-8, CC, CC-1

Tissue CharacteristicsThe outermost tunica adventitia is fibrous connective tissue. The innermost tunica

intima is the thinnest. Excessive tissue reaction may lead to decreased luminal

diameter or thrombus formation. Hence inert synthetics are material of choice.

SUTURE SELECTION

SUTURE SELECTION

* Trademark

† PDS Plus Suture and PERMA-HAND Silk Suture may be used to permit future growth in patients such as pediatric patients†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

PRONOVA* Poly (hexafluoropropylene-VDF) Suture

68

Vascular Prostheses and Heart Valves

Recommended Suture


V-5, V-7

Tissue CharacteristicsStrong, dense and fibrous. Adapted to be highly resistant to fatigue. Since there

is constant movement of the suture line, the sutures must retain their original

physical characteristics and strength throughout the life of patient

SUTURE SELECTION

SUTURE SELECTION

* Trademark

†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture

69

BEST PRACTICE IN WOUND CLOSURE

* Trademark

Surface: DERMABOND® Topical Skin Adhesive

Dermis: MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture

SubQ-Fat: Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture

Fascia/Muscle: ETHIGUARD* Blunt Point Needle with Coated VICRYL Plus or PDS* Plus

Antibacterial (polydioxanone) Suture

SUTURE SELECTION

70

Thank you

EP-0063-09-10/11

1 November 16, 2009 A-B Tech Kurt Prewitt This promotional educational activity is brought to you by...

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