Sutures and suturing

TechniquesPresented by Amit shrivastava (pg student)guided by dr anup garg professor and guide

TABLE OF CONTENTS

What is a suture?HistoryRequisites of suture materialSuturing materials & their classificationSurgical needlePrinciples of suturingSuturing techniques Biological response of body to suture

materialsSuture removal

SUTURE

A suture is a strand of material used to ligate blood

vessels and to approximate tissues together.

To suture is the act of sewing or bringing tissues

together and holding them in apposition until healing has taken place.

HISTORY OF SUTURESANTIQUITY

I) EGYPT

The oldest known suture of the world was found on a

mummys abdomen. It was applied about 1100 BCE. Papyrus Edwin Smith = Medical document

detailing methods of surgical treatment. Suture materials in use in ancient Egypt :

Plant fibers, Hair, Tendons and Wool threads

Silver wire for wound clamping

II) INDIA The first detailed description of a wound suture

and the suture materials used in it is bySusruta, written in 500 BC. Since he was the author of the earliest such

reports, it is assumed that Egyptian, Babylonian, Greek and Arab surgery all have their origins in India.

InSusruta comments to the Ayur Veda, he mentioned the

following suture materials:

- Linen and plant fibers - Hair, flax, hemp - Bow strings, presumable made of sheep gut and, - Possibly, the first absorbable suture threads Bengal ants, whose stiff jaws held together the wound edges.

III) ROME AULUS CORNELIUS CELSUS ( 25 BC to 50

CE) He was the first to produce detailed

description of ligatures used for hemostasis. He knew both Continuous and simple

sutures. The following materials were used for

adapting wound edges - Linen and wool threads - Silk and human hair - Metal clips

GALEN ( 131-211CE) was the first to describe the

chorda or gut string as a suture material. He also described wound suture, Abdominal suture and Vascular suture.

HISTORY First written description of sutures used in

operative procedures is recorded in the Edwin Smith Papyrus dated to the 16th Century B.C.

Rhazes of Arabia was credited in 900 A.D. with first

employing KITGUT to suture abdominal wounds.

The word gradually evolved into CATGUT or SURGICAL GUT.

Sutures and ligatures were used by both the Egyptians

and Syrians as far back as 2000 B.C.

Through the centuries a wide variety of materials such

as Silk, linen, cotton, horse hair, animal tendons and intestines, and wire made of precious metals have been used in operative procedures.

USE OF ANTS AS A SUTURE MATERIAL

ANTS SUTURE in primitive era

Large ants or beetles were put on wounds so that

their jaws would clamp together the wound edges.

Insects heads were twisted off.

The fixed jaws firmly held together the wound

edges.

REQUISITES OF SUTURE MATERIALS

ADEQUATE STRENGTH : (TENSILE STRENGTH) - Depends on the elasticity of the material. - Flexible materials will have a greater ability to stretch and bear stress.

LOW TISSUE IRRITATION AND REACTION :

- Tissue reaction is directly proportional to the amount and size of the suture material used. - Organic suture material will evoke a higher tissue response than synthetic sutures.

LOW CAPILLARITY :

- Multifilamentous suture materials soak up tissue fluid by capillary action providing a rich medium for proliferation of microbes and thus increasing the chances of inflammation and infection.

Good handling and knotting properties

Sterilization without deterioration in properties

SUTURE MATERIALS

Natural, Monofilament , Absorbable

Natural, Multifilament

, Non-Absorbable

Synthetic, Monofilament

/ Multifilament, Absorbable

Synthetic, Monofilament

, Non-Absorbable

Plain GutChromic GutCollagen

LinenSurgical SilkSurgical CottonSurgical Steel

Coated Vicryl

Polydioxanone

Nylon

Polypropylene

MONOFILAMENT STRAND MULTIFILAMENT STRAND Single strand of material.

Several filaments or

strands; twisted or braided together.

Because of their simplified structure,

they encounter less resistance as they pass through tissue.

It affords greater tensile

strength, pliability and flexibility.

Well suited to Vascular

surgery. Well suited to Intestinal

procedures. Extreme care must be taken

when handling and tying these sutures.

These may me coated to

help them pass relatively smoothly through tissues and enhance handling characteristics.

ABSORBABLE SUTURES NON-ABSORBALE SUTURES

Undergo degradation

and absorption in tissues.( Digested by body enzymes which attack and break down the suture strand)

They maintain their

tensile strength and resistant to absorption ( Not digested by body enzymes or hydrolyzed in body tissues)

These are prepared either from

the collagen of healthy mammals or from synthetic polymers.

These are prepared from

a variety of non-biodegradable materials and are ultimately encapsulated or walled off by the bodys fibroblasts.

May be impregnated or coated

with agents that improve their handling properties and colored with an FDA approved dye to increase visibility in tissues.

They may be coated or

uncoated, uncolored, naturally colored or dyed with an FDA approved dye to enhance visibility.

NON-ABSORBABLE SUTURES

NON ABSORBABLE SUTURES & RAW MATERIALS SUTURES RAW MATERIAL

1) Surgical Silk Raw silk spun by sikworm

2) Stainless steel wireSpecially formulated iron-chromium nickel molybdenum alloy

3) Nylon (NUROLON SUTURE) polyamide polymer

4) Polyester fibre Uncoated ( Mersilene ) Coated ( Ethibond , Excel )

Polymer of polyethylene terepthalate ( may be coated)

5) Polypropylene ( Prolene suture)

Polymer of propylene

6) Poly ( Hexafluro propylene VDF)

polymer blend of poly ( vinylidine fluoride ) and poly ( vinylidine fluoride cohexafluoropropylene)

CLASSIFICATION OF NON- ABSORBABLE SUTURES

The USP classifies nonabsorbable surgical sutures as follows:

CLASS I Silk or synthetic fibers of monofilament, twisted,

or braided construction.

CLASS II Cotton or linen fibers, or coated natural or

synthetic fibers where the coating contributes to suture thickness without adding strength.

CLASS III Metal wire of monofilament or multifilament

construction.

NATURAL NON-ABSRBABLE SUTURES

A) SURGICAL SILK :

Silk filaments can be twisted or braided ; the latter

providing the best handling qualities.

Raw silk is a continuous filament spun by the silk worm

moth larva to make its cocoon.

Each silk filament is processed to remove natural waxes

and sericin gum which is exuded by the silkworm as it spins its cocoon.

That significantly improves suture quality.

It is usually dyed black for easy visibility in tissue.

It loses tensile strength when exposed to moisture and

should be used dry.

SYNTHETIC NON-ABSORBABLE SUTURES

SURGICAL STAINLESS STEEL Essential qualities include the absence of toxic

elements , flexibility and fine wire size.

Both monofilament and twisted multifilament varieties are high

in tensile strength; low in tissue reactivity and holds knot well.

DISADVANTAGES

Difficulty in handling; possible cutting , pulling and tearing of the

patients tissue, fragmentation , barbing and kinking which render the sutures useless.

When used for bone approximation and fixation, asymmetrical

twisting of the wire will lead to wire fracture or fatigue.

Unfavourable electrolytic reaction can occur with other

prosthesis.

Tears gloves and skin of surgeon putting both surgeon and

patient at risk of transmitting Immunodeficiency virus or hepatitis

A) NYLON SUTURE High tensile strength and extremely low tissue

reactivity.

Monofilament nylon in a wet or damp state is more pliable

and easier to handle than dry nylon.

These are pre- moistened for use which enhances the

handling and knot tying characteristics to approximate that of braided sutures.

B) NYLON SUTURE Composed of flaments of nylon that have

been tightly braided into a multifilament strand.

Available in white/dyed black and looks, feels and

handle like silk.

These have more strength and elicit less tissue

reaction than silk.c) Polyester fibre suture Comprised of untreated fibres of polyester

closely braided into a multifilament strand.

Stronger than natural fibres, cause minimal tissue

reaction.

Available white or dyed green.

Acceptable for vascular synthetic prosthesis.

D) MERSILENE POLYESTER FIBRE SUTURE

First synthetic braided suture material shown to last

indefinitely in the body.

It provides precise, consistent suture tension.

They minimize breakage and virtually eliminate the need

to remove irritating suture fragments post operatively.

It is uncoated.

e) Ethibond excel polyester suture These are uniformly coated with polybutilate; a biologically inert, non absorbable compound.

Coating eases the passage of the braided strands

through tissues and provides excellent pliability, handling qualities and smooth tie down with each throw of knot.

F) PROLENE POLYPROPYLENE SUTURE

They donot adhere to tissues and therefore efficacious as pull

out suture.

Biologically inert.

Not subjected to degradation or weakening by tissue enzymes.

Minimum tissue reaction and holds knot better than most other

synthetic monofilament materials.g) Pronova suture (vdf) Resists involvement in infection and has been

successfully employed in contaminated and infected wounds to eliminate or minimize later sinus formation and suture extrusion.

ABSORBABLE SUTURES

SUTURES RAW MATERIAL1. Surgical gut (Natural) Plain chromic Fast absorbing

Submucosa of sheep intestine or serosa of beef intestine

2 . Polyglactin glo (synthetic) Uncoated (Vicryl suture) Coated ( Coated vicryl ; coated vicryl plus antibacterial suture; coated vicryl rapide suture)

Copolymer of gycolide and lactide with polyglactin 370 and calcium stearate , if coated.

3. Polyglycolic acid Homopolymer of glycolide

4. Polyglecaprone 25 ( Monocryl suture)

Copolymer of glycolide and epsilon caprolactone

5. Polyglyconate Copolymer of glycolide and trimethylene carbonate

6. Polydioxanone ( PDS II Suture ) Polyester of poly (p-dioxanone)

NATURAL ABSORBABLE SUTURES

1. SURGICAL GUT SUTURES

Classified as either Plain or Chromic. Both types consist of processed strands of highly purified collagen.

The percentage of collagen in the suture determines its tensile

strength and its ability to be absorbed by the body without adverse reaction.

The more pure collagen throughout the length of the strand,

the less foreign material is introduced in the wound.

A) PLAIN SURGICAL GUT : Rapidy absorbed.

Tensile stregth maintained for only 7-10 days.

Absorption typically completed within 70 days.

Used in tissues that heal rapidly and

require minimal support. (For Eg- Ligating superficial blood vessels and suturing subcutaneous fatty tissue)

It can be heat treated to accelerate tensile strength loss

and absorption.

This fast absorbing surgical gut is used primarily for

epidermal suturing where sutures are required for only 5-7 days.

B) CHROMIC GUT :

It is treated with chromium salt solution to resist body

enzymes; prolonging absorption time over 90 days .

The exclusive Tru Chromicizing process thoroughly bathes the pure collagen ribbons in a buffered chrome tanning solution before spinning into strands.

This process alters the coloration of the surgical gut from

Yellowish tan to Brown.

Chromic gut sutures minimize tissue irritation ; causing

less reaction than plain surgical gut during the early stages of wound healing.

SYNTHETIC ABSORBABLE SUTURES

A) COATED VICRYL RAPIDE ( POLYGLACTIN 910 ) SUTURE

This braided suture is composed of lactide and glycolide and is

coated with a combination of equal parts of copolymer of lactide and glycolide ( Polyglactin 370) and calcium stearate.

It is the fastest absorbing synthetic suture. However, being a synthetic material, coated

vicryl rapide suture elicits a lower tissue reaction than Chromic gut suture.

Coated vicryl rapide sutures retain approx. 50% of the original

tensile strength at 5 days post suturing and absorption is essentially completed by 42 days.

B) MONOCRYL (POLYGLECAPRONE 25) SUTURE

This monofilament suture features superior pliability for

easy handling and tying.

Composed of a copolymer of Glycolide and Epsilon Caprolactone.

Inert in tissue and absorbs predictably.

Used for procedures that require high initial tensile strength diminishing over 2 weeks postoperatively.

It is available dyed (violet) and undyed (natural) .

Absorption is essentially completed at 91 to 119 days.

C) COATED VICRYL (POLYGLACTIN 910) SUTURE

Smoother synthetic absorbable suture that will pass through

tissue readily with minimal drag. Coated vicryl sutures facilitate ease of handling ;

smooth tie down and unsurpassed knot security. Coating is a combination of equal parts of

copolymer of lactide and glycolide (polyglactin 370) plus calcium stearate . At 2 weeks postimplantation, approx. 75% of the

tensile strength remains.

Absorption is essentially completed between 56 and 70 days.

These are available as braided dyed violet or

undyed natural strands in a variety of lengths.

Lactide and Glycolide acids are readily eliminated from the body

primarily in urine.

D) COATED VICRYL PLUS ANTIBACTERIAL (POLYGLACTIN 910) SUTURE These are synthetic, absorbable, sterile, surgical

suture which is a copolymer made from 90% glycolide and 10% lactide.

It is coated with a mixture composed of equal parts of copolymer

of glycolide and lactide and calcium stearate.

It contains IRGACARE , one of the purest forms of the broad

spectrum antibacterial agent Triclosan.

It offers protection against baterial colonization of the suture.

It is available undyed (natural ) or dyed.

It is indicated for use in general soft tissue approximation or

ligation requiring medium support. Tensile strength 2 weeks : 75% 3 weeks : 50% 4 weeks : 25%

Absorpton completed between 56 and 70 days.

E) PDS II ( POLYDIOXANONE) SUTURE

Comprised of the polyester poly ( p-dioxanone)

It elicits only a slight tissue reaction. It is well suited for many types of soft tissue

approximation .

Absorption is minimal until about the 90th day post operatively

and essentially completed within 6 months These are available clear or dyed violet to

enhance visibility.

Tensile strength - 2 weeks : 70% 4 weeks : 50% 6 weeks : 25%

LIMITATIONS OF ABSORBABLE SUTURES

If patient has fever, infection or protein deficiency, the

suture absorption process may accelerate ,causing too rapid a decline in tensile strength.

If suture becomes wet or moist prior to use ; the absorption

process may begin prematurely.

Patient with impaired healing are often not ideal candidates

for this suture.

SURGICAL NEEDLE

IDEAL QUALITIES OF A SURGICAL NEEDLE

Made up of high quality Stainless Steel.

As slim as possible without compromising strength.

Stable in the grasp of a needle holder.

Able to carry suture material through tissue with minimum

trauma.

Sharp enough to penetrate tissue with minimal resistance.

Rigid enough to resist bending yet ductile enough to resist

breaking during surgery.

Sterile and corrosion resistant to prevent introduction of

microorganisms or foreign materials into the wound.

SURGICAL NEEDLE

Anatomy of the needle: 3 basic components Eye Body Point

Straight needle Half curved needle Curved needle Compound curved needle

NEEDLE BODY

THE NEEDLE EYE

Closed eye French (split or spring) Swaged (eyeless) Much less

traumatic More expensive

suture material. sterile

More Traumatic Tends to unthread

itself easily

TYPES OF NEEDLES

Cutting needles Conventional cutting needle Reverse cutting needles Side cutting needles Taper point needles Tapercut surgical needles Blunt point needles

PRINCIPLES OF SUTURING The needle should be grasped at approx. one third

the distance from the eye and two thirds from the point.

The needle should enter the tissues perpendicular to the

tissue surface.

The needle should be passed through the tissues along its

curve.

The suture should be passed at an equal depth and distance

from the incision on both sides.

The needle always passes from the thinner tissue to the

thicker tissue.

The needle always passes from the deeper to the superficial

tissues.

Tissues must never be closed under tension. Undermining of

the tissues should be done prior to suturing in such cases.

PRINCIPLES OF SUTURING

The sutures should be tied only to approximate the tissues , not

to blanch.

The knot should never lie on the incison line. Sutures should be placed at a greater depth than

the distance from the incision , so as to evert the wound margins.

Sutures on the skin are usually removed in 5 days and

intraoral sutures in 7 days. If there is a tension / stress while suturing ; the suture may be kept for 10 days.

SUTURING TECHNIQUES

LIGATURES

A suture tied around a vessel to occlude the lumen is called a ligature or tie. There are 2 primary types of ligatures-

I) FREE TIE Or FREE HAND LIGATURES Single strands of suture material used to ligate a vessel, duct, or other structure.

II) STICK TIE, SUTURE LIGATURE, OR TRANSFIXION SUTURE : Strand of suture material attached to a needle to ligate a vessel, duct, or other structure.

This technique is used on deep structures where placement of a hemostat is difficult or on vessels of large diameter

SIMPLE INTERRUPTED SUTURES Most commonly used suturing technique.

The suture is passed through both the edges at an equal

depth and distance from the incision and knot is tied.

ADVANTAGES

It is strong and can be used in areas of stress.

Successive sutures can be placed according to individual

requirement .

Each suture is independent and the loosening of one suture

will not produce loosening of the other.

If the wound becomes infected or there is an hematoma formation ; removal of few sutures may offer a satisfactory treatment. ( Microorganisms are less likely to travel along a series of interrupted sutures)

CONTINUOUS SUTURES Reffered to as Running sutures. Initially a simple interrupted suture is placed and

the needle is then reinserted in a continuous fashion such that the suture passes perpendicular to the incision line below and Obliquely above. The suture is ended by passing a knot over the

Untightened end of the suture. In the presence of infection, it may be desirable

to use a monofilament suture material because it has no interstices which can harbor microorganisms.

ADVANTAGES

It provides a rapid technique for closure and distributes the

tension uniformly over the suture line. It leaves less foreign body mass in the wound.

CONTINUOUS LOCKING SUTURES

This technique is similar to the continuous suture but

locking is provided by withdrawing the suture through its own loop. The suture thus passes perpendicular to the

incision line.

ADVANTAGES ---

Locking prevents excessive tightening of the suture as the

wound closure progresses.

MATTRESS SUTURES

I) HORIZONTAL MATTRESS SUTUREII) VERTICAL MATTRESS SUTURE

HORIZONTAL MATTRESS SUTURE The needle is passed from one edge of

the incision to another and again from the latter edge to the first edge and a knot is tied. The distance of needle penetration from

the wound edge and depth of penetration of the needle is the same for each entry point, but the horizontal distance of the points of penetration on the same side of the flap differs.

ADVANTAGES

Often used after intra oral bone grafting and

Interproximal areas of Diastema or for wide interdental spaces to adapt the interproximal papilla properly against bone ; as the eversion and continuity provide a very tight closure.

This suture provides a broad contact of the wound

margins. Eg- closure of exteraction socket wounds.

VERTICAL MATTRESS SUTUREIt is similar to the horizontal mattress suture except that all factors remaining constant; the depth of penetration varies.When the needle is brought back from the second flap to the first, the depth of penetration is more superficial.

USES

The vertical mattress stitch is most commonly used on the posterior aspect of the neck, the palm of the hand, and sites of greater skin laxity.

ADVANTAGES

Due to its quadruple ability to achieve deep and superficial wound closure, edge eversion and precise vertical alignment of the superficial wound margins occurs.

FIGURE OF EIGHT SUTURE

It is used over extraction sites ; where it provides some protection to the surgical area as well as adaptation of the gingival papillae around the adjacent teeth.

CONTINUOUS SUBCUTICULAR SUTURES

The subcuticular layer of tough connective tissue if

sutured will hold the skin edges in close approximation when cosmetic results are desired. Continuous short lateral stitches are taken

beneath the epithelial layer of the skin.

The end of the suture comes out at each end of the

incision and are knotted. It leaves a cosmetic scar.

A continuous subcuticular suture may be left for 7-10

days and removed by untaping both ends and pulling in one direction.

SLING SUTURE

It is used when there is both a facial or a lingual flap

involving many teeth.

The continuous, independent sling suture is initiated on the

facial papilla closest to the midline because this is the easiest place to position the final knot.

A continuous sling suture is laced for each papilla on the

facial surface.

When the last tooth is reached, the suture is anchored

around it to prevent any pulling of the facial sutures when lingual flap is sutured around the teeth in a similar fashion.

Suture is again anchored around the last tooth before tying

the final knot.

Facial and lingual flaps are completely independent of each

other.

Flaps are tied to the teeth and not to each other because of the

sling sutures.

It is appropriate for the maxiallry arch because the palatal

gingiva is attached and fibrous whereas the facial tissue is thinner and mobile.

ANCHOR SUTURE

Closing of a flap mesial or distal to a tooth is best

accomplished by the Anchor Suture.

This suture closes the facial and lingual flaps and

adapts them tightly against the tooth.

The needle is placed at the line angle area of the

facial or lingual flap adjacent to the tooth ; anchored around the tooth ; passed beneath the opposite flap and tied.

PERIOSTEAL SUTURES

It is used to hold in place apically displaced partial thickness

flaps.

It is of 2 types -- A) Holding suture B) Closing suture

Holding suture is a horizontal mattress suture placed at the

base of the displaced flap to secure it into the new position.

Closing sutures are used to secure the flap edges to the

periosteum.

DEEP SUTURES

Placed completely under epidermal skin layer.

Placed as continuous or interrupted sutures.

Not removed post operatively.

BURIED SUTURES

Placed so that the knot protrudes to the inside, under the

layer to be closed.

This technique is useful when using sutures on the cosmetic

areas such as the facial region.

ALTERNATIVE METHOD FOR SUTURINGTOPICAL SKIN ADHESIVE

1) DERMABOND ( 2-octyl- cyanoacrylate):

Transparent and flexible bond. This flexiblity allows it to be applied on non

uniform surfaces. Can be used on longer incisons and

lacerations. Ideally suited for wounds on Face and limbs. Approved to protect wounds and incisons from

common microbes that can lead to infection.

2) Adhesive tapes

3) PROXIMATE (SKIN STAPELER)

The Skin Stapler is a sterile, single patient use instrument

designed to deliver rectangular, stainless steel staples for routine wound closure.

Used for large wounds that are not present on face.

Used for closing Scalp wounds

SECONDARY SUTURE LINE

Called retention, stay, or tension sutures.

To reinforce and support the primary suture line.

Eliminate dead space, and prevent fluid accumulation.

To support wounds for healing by second intention.

If secondary sutures are used in cases of non healing,

they should be placed in opposite fashion from the primary sutures i.e., interrupted if the primary sutures were continuous.

Retention sutures are placed approximately 2 inches from

each edge of the wound.

Retention sutures utilize Non absorbable suture material. They

should therefore be removed as soon as the danger of wound bursting is over, usually 2 to 6 weeks, with an average of 3 weeks.

SUTURES FOR BONE

In repairing facial fractures, monofilament surgical steel has

proven ideal for its lack of elasticity.

Facial bones do not heal by callus formation, but more

commonly by fibrous union. The suture material must remain in place for a

long period of time , until the fibrous tissue is laid down and remodeled.

Steel sutures immobilize the fracture line and keep the

tissues in good apposition.

PRINCIPLES OF KNOT TYING

The completed knot must be firm and the simplest knot of any

material is most desirable.

The knot must be as small as possible so as to prevent tissue

reaction when absorbable sutures are used and foreign body reaction when non-absorbable sutures are used.

Ends of the knots should be as short as possible.

In tying any knot, friction between strands must be avoided as

this can weaken the integrity of the suture.

Avoid damage to suture material while handling.

Sutures must not be tied too tightly as it can lead to tissue

strangulation.

TYPES OF KNOTS Surgeon may use either the instrument tie or

the one or two hand tie.

Instrument tie more convenient in closed areas such as the

mouth but can be used in open areas as well.

3 types of knots

A) SQUARE KNOT

A square knot is formed by wrapping the sutures around

the needle holder once in opposite direction between the ties.

At least 3 ties are recommended.

B) SURGEONs KNOT

It is formed by 2 throws of the suture around the needle

holder on the first tie and one throw in the opposite direction in the second tie.

This is useful in confined or difficult to reach places where

the first tie would be loosened in the process of producing the second tie.

This method is modified for use with Polyglycolic acid and

synthetic sutures.

C) GRANNYs KNOT

It involves a tie in one direction followed by the tie in same

direction and a third tie in the opposite direction to square the knot and hold it permanently.

BIOLOGICAL RESPONSE OF THE BODY TO SUTURE MATERIALS

Invasion of the tissue site by neutrophils

Neutrophils are replaced predominantly by monocytes,plasma cells and lymphocytes

Small sprouts of fragile vessels infiltrate the area & eventually fibroblasts & CT proliferate

Tissue response to all the sutures is relatively the same for the first 5 to 7 days

SUTURE REMOVAL

Suture is grasped with an instrument and lifted above the epithelial surface.

The scissors are then passed through one loop and transected closed to the surface. The suture is then pulled out.

Skin sutures are usually removed after a period of 7-10 days depending upon the area.

Mucosal sutures are removed between 5 and 7 days.

References1) Jhonson & Jhonson- Wound closure manual.2) Neelima Malik- Textbook of oral and maxillofacial surgery.3) Laskin- Oral and maxillofacial surgery,vol.1.4) http://www.sutures-bbraun.com

THANK YOU

Slide 1TABLE OF CONTENTSSUTUREHISTORY OF SUTURESII) INDIAIII) ROMEHISTORYUSE OF ANTS AS A SUTURE MATERIALREQUISITES OF SUTURE MATERIALSSlide 10Slide 11Slide 12Slide 13NON ABSORBABLE SUTURES & RAW MATERIALSCLASSIFICATION OF NON- ABSORBABLE SUTURESNATURAL NON-ABSRBABLE SUTURESA) SURGICAL SILK :SYNTHETIC NON-ABSORBABLE SUTURESSURGICAL STAINLESS STEELA) NYLON SUTUREB) NYLON SUTURED) MERSILENE POLYESTER FIBRE SUTUREF) PROLENE POLYPROPYLENE SUTURESlide 24Slide 25NATURAL ABSORBABLE SUTURES1. SURGICAL GUT SUTURESSlide 28Slide 29SYNTHETIC ABSORBABLE SUTURESA) COATED VICRYL RAPIDE ( POLYGLACTIN 910 ) SUTUREB) MONOCRYL (POLYGLECAPRONE 25) SUTUREC) COATED VICRYL (POLYGLACTIN 910) SUTURED) COATED VICRYL PLUS ANTIBACTERIAL (POLYGLACTIN 910) SUTUREE) PDS II ( POLYDIOXANONE) SUTURELIMITATIONS OF ABSORBABLE SUTURESSURGICAL NEEDLEIDEAL QUALITIES OF A SURGICAL NEEDLESURGICAL NEEDLESlide 40THE NEEDLE EYETYPES OF NEEDLESPRINCIPLES OF SUTURINGSlide 44SUTURING TECHNIQUESLIGATURESSIMPLE INTERRUPTED SUTURESCONTINUOUS SUTURESCONTINUOUS LOCKING SUTURESMATTRESS SUTURESHORIZONTAL MATTRESS SUTUREVERTICAL MATTRESS SUTUREFIGURE OF EIGHT SUTURECONTINUOUS SUBCUTICULAR SUTURESSLING SUTURESlide 56ANCHOR SUTUREPERIOSTEAL SUTURESDEEP SUTURESBURIED SUTURESALTERNATIVE METHOD FOR SUTURING3) PROXIMATE (SKIN STAPELER)SECONDARY SUTURE LINESUTURES FOR BONEPRINCIPLES OF KNOT TYINGTYPES OF KNOTSSlide 67BIOLOGICAL RESPONSE OF THE BODY TO SUTURE MATERIALSSUTURE REMOVALReferencesTHANK YOU