suture final

8/7/2019 suture final

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KARTHIK.P

JR SURGERY UNIT III

AIIMS


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INTRODUCTION

y Surgical approaches and incisions

y Appropriate use of instruments

y Sutures, knots and needles

y Alternative technologies for wound closure


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Surgical approaches and incisionsy Incision of skin

y Usually scalpels using disposable blades

y Size and shape chosen for the tasky Blades for skin incision curved margin

y Blades for holes for drain/ arteriotomies sharp tip

y While skin incision:

y knife firmly pressed at right angles to skin and then drawnacross.

y Tension applied across the line of incision so that skin springscleanly apart.


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Types of blades


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Suture of skiny Needle inserted right angles to skin

y Pronation and supination movement used

y Entry and exit point same distance from skin edgey Edge of wound can be everted by toothed forceps

while needle is inserted

y Suture should take deep oval course through tissues

y So when tightened edges will slightly evert

y Edges very slight gaping left to allow swelling

y Knot should be on one side, and tight, ends long


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When to remove the sutures?

y Face : 2-3 days

y Scalp : 5 days

y Upper limb and groin : 7 days

y Abdomen : 10 days

y Dorsum & Lower trunk : 10-14 days


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Suture materialy Generally categorized by three characteristics:

y Absorbable vs. non-absorbable

y Natural vs. synthetic

y Monofilament vs. multifilament


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The ideal suturey Minimal tissue reaction

y Smoothness - minimum tissue drag

y Low Capillarityy Max tensile strength

y Ease of handling - Minimum memory

y Knot security

y Consistency of performance

y Predictable performance

y Cost effectiveness


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Absorbable sutures Non absorbable sutures

y Degraded and eventuallyeliminated in one of twoways:y inflammatory reactiony Hydrolysis

y Examples:y

Catguty Chromicy Vicryly Monocryly PDS

y Not degraded

y permanent

y Examples:

y Proleney Nylon

y Stainless steel

y Silk


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Natural sutures Synthetic sutures

y Biological origin

y

Cause intense inflammatoryreaction

y Examples:

y Catgut purified collagenfibers from intestine of

healthy sheep or cowsy Chromic coated catgut

y Silk

y Synthetic polymers

y

Do not cause intenseinflammatory reaction

y Examples:

y Vicryl

y Monocryl

y PDSy Prolene

y Nylon


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Monofilament sutures Multifilament sutures

y Grossly appears as single strandall fibers run parallel

y Minimal tissue trauma

y Resists microorganisms

y Ties smoothly

y Requires more knots thanmultifilament suture

y Possesses memory

y Examples:

y Monocryly PDS

y Prolene

y Nylon

y Fibers are twisted or braidedtogether

y Greater resistance in tissue

y Favours microorganisms

y Provides good handling and easeof tying

y Fewer knots required

y No memory

y Examples:

y Vicryl (braided)y Chromic (twisted)

y Silk (braided)


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TYPE TENSILE STRENGTH ABSORPTION RATE TISSUEREACTION

CONTRAINDICATIONS

Silk Loses 20% when wet80-100% lost by 6months

Fibrous encapsulation2-3 weeksAbsorbed 1-2 years

Moderate tohigh

Vascular prosthesisProlonged approx.under stress

Nylon Loses 15-20% per year Degrades 15-20% peryear

Low None

Prolene Infinite >1 year Remains encapsulated Low none

Catgut

(Plain)(Chromic)

Lost within 7-10 daysLost within 21-28 days

Phagocytosis andenzymatic degradation

within 7-1o dayswithin 90 days

Highmoderate

Tissues of slow

healingProlonged support

PDS 70% remains at 2 weeks50% at 4weeks and 14%at 8 weeks

Hydrolysis minimal at90 daysComplete absorption

at 180 days

Mild Heart valvesProlonged approx.under stress

Vicryl 60% remains at 2 weeks30% remains at 3 weeks

Hydrolysis minimaluntil 5-6 weeksComplete absorption60-90 days

Mild Prolonged approx.under stress

Monocryl 21 days maximum 90-120 days No use for extended

support or renal orcardiovascular


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Suture sizey Sized according to diameter with 0 as reference size

y Numbers alone indicate progressively larger sutures (1, 2,etc)

y Numbers followed by a 0 indicate progressively smallersutures (2-0, 4-0, etc)

y Vary from 0.02 to 0.8mm in diameter which corresponds to10/0 to 5 on the British Pharmacopoeia (BP) system.

SmallerSmaller --------------------------------------------------------------------------LargerLarger

.....3.....3--0...20...2--0...10...1--0...0...1...2...3.....0...0...1...2...3.....


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Suture size selectiony Bowel : 2/0 - 3/0

y Fascia : 1 - 0

y Ligatures : 0 - 3/0

y Pedicles : 2 - 0

y Skin : 2/0 - 5/0

y Arteries : 2/0 - 8/0y Micro surgery : 9/0 - 10/0

y Corneal closure : 9/0 - 10/0


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Needlesy Classified according to shape and type of point

y Shape

y

Curved ( ,,3/

8,5/

8 circle)y Straight

y J needle

y Type of point

y Taper point

y Cutting

y Reverse cutting etc.


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Needlesy Curved

y Designed to be held

with a needle holdery Used for most suturing

y Straight

y Often hand held

y

Used to securepercutaneously placeddevices (e.g. central andarterial lines)


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Needle point Geometry

Taper-PointSuited to soft tissue

Dilates rather than cuts

Reverse

cutting

Very sharp

Ideal for skin

Cuts rather than dilates

Convention

al 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.


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Needle point Geometry

BluntAlso kno n as Protect Point

Mainly used to prevent needle stick

injuries i.e. for abdominal all closure.

Premium point

spatula

Ophthalmic Surgery

SpatulaOphthalmic Surgery

DermaX*NEW: The Penetration force

The Penetration force

Superior Cosmetic Effect


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The Suture Packaging

STRAND

SIZE

MATERIAL

STRAND

LENGTH

PRODUCT

CODE

NEEDLE

CODE WITH

LIFE SIZE

PICTURE OF

NEEDLE

NEEDLE

LENGTHCOLOUR

POINT

TYPE

NEEDLE

CIRCLE


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Knot tyingy Secure knots are crucial to surgery

y While using instruments not to crush or damage

suture materialy Fingers are useful while ligating at depth

y When knots are cut the free ends or ears should beatleast left 1-2mm long

y Jenkins suture length : wound length = 4:1, indicatesoptimum size of tissue bites and of stitch spacing


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Types of knotsy Half hitch knot


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Metal sutures and clipsy First used successfully by Humer, in Hungary, to close

the stomach

y

Metal clips for skin allow quick, accurate closurey They are easy to remove and give cosmetically

acceptable scar

y Stainless steel suture are used in closure of sternum

y Steristrips used to buttress skin closure to preventspreading of a scar


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suture final

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