GOOD MORNING

SUTURE MATERIALS &

SUTURING TECHNIQUES

COMPILED BY: NUZHAT NOOR AYESHA

CONTENTSIntroductionHistoryDefinitionGoals of suturingSuture materials

- Introduction - Requisites of ideal suture - Classification - Selection of suture material - Absorption of suture material - Biological response of body to suture.

Suture armamentarium- needles, needle holder, scissor Principles of suturing Suturing Techniques Knots Suture Removal Other methods of wound closure

• Suture means to ‘sew’ or ‘seam’. In surgery suture is the act of sewing or bringing tissue together and holding them in apposition until healing has taken place.

• A suture is a strand of material used to ligate blood vessels and to approximate tissues together.

INTRODUCTION

HISTORY

HISTORY History of the Surgical Suture  “I dress the wound, God heals it.“Ambroise Pare, surgeon16th century

• The act of sewing is probably older then Homo sapiens, because Neanderthal man wore some sort of clothing.

HISTORY

Perhaps the world’s oldest suture was placed by an embalmer on the body of a twenty first dynasty mummy about 1100 B.C.

• A south American method of wound closure used large black ants which bite the wound edges together and the ants body is then twisted off leaving the head in place.

• East African tribes ligated blood vessels with tendons and closed wounds with acacia throns

• The first detailed description of a wound suture and suture materials used in it is by the Indian physician Sushruta, written in 500 BC.

Galen, the physician to Roman gladiators in the second century A.D. used silk for hemostasis.

Andreas Vesalius first advocated the suture of all fresh wounds as well as severed tendon and nerves.

• Joseph Lister (1827-1912) discovered that bacteria present in suture strands cause wound infection. He disinfected sutures with carbolic acid. He made sterile sutures possible to bury it in clean wounds without infection.

• Sometime around 30 A.D., a medical encyclopedia was written by a Roman named Aurelius Cornelius Celsus. His work, De Re Medicina, tells the reader that sutures should be “soft, and not over twisted, so that they may be more easy on the part.” He is also credited with first substantiated mention of ligating by recommending it as a secondary means of stopping a hemorrhage.

• Rhazes of Arabia was credited in 900 A.D. with first employing ‘kit gut’ to suture abdominal wounds. The Arabic word ‘kit’ means a dancing master’s fiddle, the musical strings of which ‘kit string’ were made up of sheep intestines. Over the years ‘kit’ was confused with kitten or cat, and the misuse of the term was propagated.

DEFINITIONS

• DEFINITION: suture material is an artificial fibre used to keep wound together until they hold sufficiently well by themselves by natural fibre (collagen) which is synthesized and woven into a stronger scar

• Suture is a Stitch/Series of Stiches made to secure apposition of the edges of a Surgical/Traumatic wound (Wilkins)

• Any Strand of Material utilised to ligate blood vessels or approximate Tissues (Silverstein L.H 1999)

GOALS OF SUTURINGSuturing is performed to Provide adequate tensionMaintain hemostasisProvide support for tissue margins

Reduce post-op painPrevent bone exposurePermit proper flap position

SUTURE MATERIALS

• The basic purpose of a suture is to hold severed tissues in close approximation until the healing process provides the wound with sufficient strength to withstand stress without the need for mechanical support.

• Since wounds do not gain strength

until 4-6 days after injury, the tissues are approximated till then by sutures.

The amount of tension or pull the suture can withstand before breaking is important.Tensile St α diameter of suture

If the diameter of suture is doubled, T.S is quadrupled.

Suture material should be atleast as strong as the tissues in which they are used. By the end of 2nd week, when most skin sutures are removed, the wound would have attained 3%-7% of final Tensile St.

3rd week – 20% of T.S 4th week – 50% of T.S

Wounds will never regain more than 80% of Tensile St. of intact skin

REQUISITES OF AN IDEAL SUTURE• Tensile st: adequate material

strength will prevent suture breakdown & use of proper knots for the material used will prevent untying or knot slippage.

• Tissue biocompatibility: sutures made from organic material will evoke a higher tissue response than synthetic sutures.

tissue reaction α amount & size of suture material.

• Low capillarity: multifilament type soak up tissue fluid by capillary action providing a rich medium for microbes increasing chances of inflammation & infection.

• Good handling & knotting properties: ease of tying & a thread type that permits minimal knot slippage also influence thread selection.

• Sterilization without deterioration of properties: most sutures available in packages are sterilized by dry heat & ethylene oxide gas.

• Non allergic, non electrolytic and non carcinogènic

• Its use should be possible in any operation.

• Low cost

• It should not fray, should slide through tissues readily & knot should not slip after tying.

• It should be readily visualized , should not shrink & should not be extruded from the wound.

• On break down ,it should not release toxic agents.

• It should disappear without excessive reaction once its task is completed.

CLASSIFICATION OF SUTURE MATERIALS

According to source: 1. Natural

2. Synthetic 3. Metallic

According to structure 1. Monofilament 2. Multifilament

According to fate:1. Absorbable (undergo degradation

and lose T.S. < 60 days)2. Non absorbable ( maintain T.S > 60

days)

According to coating: 1. Coated 2. Uncoated

NATURALAbsorbable

CatgutChromic catgutCollagenFascia lata kangaroo tendonBeef tendonCargile membrane

Non Absorbable

SilkSilk worm gut LinenCottonRamieHorse hair

SYNTHETIC Absorbable

Polyglycolic Acid Polyglactic Acid Polyglactin 910(Vicryl) Polydioxanone(PDS) Polyglecaprone 25

Non Absorbable

Nylon/ polyamide PolyPropylene Polyesters Polyethelene Polybutester Polyvinylidene

fluoride / PVDF Sutures

Monofilament

Multifilament

MONOFILAMENT Advantages • Smooth surface • Less tissue

trauma• No bacterial

harbours• No capillarity

Disadvantages• Handling and

knotting• Stretch • Any nick or crimp

in the material leads to breakage.

MONOFILAMENT

Absorbable

Surgical Gut- Plain, Chromic

Polydiaxanone Polyglactin 910

Non Absorbable

Polypropylene Polyester Nylon/polyamide Polyvinylidene

fluoride / PVDF Sutures

MULTI FILAMENT Advantages• Strength • Soft and pliable• Good handling• Good knotting

Disadvantages• Bacterial

harbours• Capillary action• Tissue trauma

MULTIFILAMENT

Absorbable

Polyglactin 910 Polyglycolic Acid

Non Absorbable

Silk Cotton Linen

MONOFILAMENT

Handling Difficult

Smooth & strong

No Wicking

Thinner

MULTIFILAMENT

Handling easy

Low Strength

Wicking is a Problem

Thicker

Metallic

SSTantalum Gold SilverAluminium

Non absorbable sutures are categorized by the United States Pharmacopeia (USP) as

Class I - Silk or synthetic fibers of monofilaments with twisted or braided construction

Class II - Cotton or linen fibers, coated natural or synthetic fibers in which the coating does not contribute to T.S

Class III - Metal wire of monofilament or multifilament construction.

SELECTION OF SUTURE MATERIAL

A variety of suture materials and suture/needle combinations is available. The choice of suture for a particular procedure is based on the known physical and biologic characteristics of the suture material and the healing properties of the sutured tissues.

Principles of suture selection

The selection of suture material by a surgeon must be based on a sound knowledge of

• Healing characteristics of the tissues which are to be approximated,

• The physical and biological properties of the suture materials,

• The condition of the wound to be closed and

• The probable post-operative course of the patient.

1. Rate of healing of tissues:

• When a wound has reached maximal strength, sutures are no longer needed.

• Tissues that ordinarily heal slowly such as skin, fascia and tendons should usually closed with non –absorbable sutures.

• Tissues that heal rapidly such as peritoneum, liver, small intestine, muscles, stomach ,colon and bladder may be closed with absorbable sutures.

• Suture should be stronger than the sutured tissues, and it is unwise to implant more material than necessary.

2.Tissue contamination:• Avoid multifilament sutures

as bacteria can linger with them and may convert a contaminated wound into an infected one.

• Use monofilament absorbable or non- absorbable sutures in potentially contaminated tissues. Monofilament polypropylene is ideal

3. cosmetic results :• Where cosmetic results are

important, close and prolonged apposition of wounds and avoidance of irritants will produce the best results. Therefore use a smallest, inert monofilament suture materials such as poly amide and polypropylene.

• Avoid skin sutures and close subcuticularly whenever possible

• Under certain circumstances, to secure close apposition of skin edges , skin closure tape may be used

4. cardiovascular surgery:• Monofilament polypropylene, polyester,

coated and un coated and braided surgical silk are recommended.

• Monofilament polypropylene being smooth, possess high TS is the material of choice for vascular anastomosis. This material does not encourage any thrombus formation.

• Polyester is preferred for suturing artificial heart valves, myocardium and vascular prosthesis.

5. Microsurgical procedure:• Most commonly used suture is 10-0 poly

amide monofilament

6.wound repair in patients following irradiation• In this group of patients ,not only the normal

healing process is delayed but the tolerance to the trauma of irradiated tissue is markedly reduced . So

• Extremely careful and gentle surgical technique

Avoid tension sutures and mattress sutures as they further increase the degree of ischemia.

Closure in layers Avoid continuous and

constant pressure on irradiated tissues.

Fascial layer –non-absorbable sutures, polypropylene is ideal

The selection of suture material is based on

The condition of the wound, The tissues to be repaired, The tensile strength of the suture

material Knot-holding characteristics of the

suture material and The reaction of surrounding tissues to

the suture materials.

ABSORPTION OF SUTURE MATERIALS Degraded either by enzymatic process

as in gut sutures, or by hydrolysis, as in many of the synthetic materials like glycolic acid, ployglactin910 or polydioxanone. Non absorbable sutures are walled off or encapsulated.

In infected tissues or in a patient who is febrile or protein deficient, suture breakdown may be accelerated.

If the loss of TS outpaces the healing phase, failure of the wound results.

Absorbable sutures must be placed well into the dermis.

BIOLOGIC RESPONSE OF BODY TO

SUTURE MATERIALS

BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS

• The initial body response to sutures is almost identical in the first 4-7 days, regardless of the suture material.

• The early response is a generalized acute aseptic inflammation, involving primarily polymorphonuclear leukocytes.

• After few days mononuclear cells, fibroblasts & histiocytes become evident.

• Capillary formation occurs at the end of this initial phase.

• Natural Absorbable – Proteolytic degradation. Intense tissue response

• Synthetic Absorbable – Hydrolysis. Less Intense

• Non Absorbable – Encapsulation. Acellular Response

RAILROAD SCAR

Sutures passing through mucous membrane or skin provide a ‘wick’ or pathway through which bacteria track down, and bacteria gain access to underlying tissues.

The longer the suture remains, the deeper the epithelial invasion of the underlying tissue. When suture removed, epithelial tract remains.

These cells may eventually disappear or remain to form keratin and epithelial inclusion cysts. The epithelial pathway result in typical ‘railroad scar’ formation.

ABSORBABLE -NATURALGut / cat gut Oldest known absorbable suture.Galen referred to gut suture as early as

175 A.D.Derived from sheep intestinal sub mucosa

or bovine intestinal serosa.Submucosa of sheep has a rich elastic

tissue content which accounts for high tensile strength of the catgut. It is monofilament and is available in the plain form as well as “tanned” in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.

• Catgut should not be boiled or autoclaved as heat destroys its tensile strength.

• Catgut is sterilized during preparation and kept

in a preservative solution (isopropyl alcohol) inside spools or foils. Unused and reusable catgut is hygroscopic so, catgut will swell due to water absorption and its tensile strength will be reduced .

• Absorption :40-60 days

• When placed intra orally sutures are digested in 3-5days.

• It is available pre-sterilized in aluminium-coated sterile foil overwrap pack with ethicon fluid as a preservative.

• Colour: Plain catgut is yellow, while chromic catgut is tan

• Absorbtion: Catgut is absorbed by proteolytic digestive enzymes released from inflammatory cells collected around the catgut. So, in the presence of infection catgut is rapidly absorbed.

CHROMIC CATGUTCoated with thin layer of chromium salt solution to minimize tissue reaction, increase TS, slow the absorption rate, better knot security, and ease of handling.

TS – 10-14 days Absorbed in 90 days Uses:Opthalmic surgery (6-0)

Oral surgery Suture subcutaneous tissues

As it is an organic material and susceptible to enzymatic degradation, packed in isopropyl alcohol as a preservative. Also condition or soften it.

Suture absorbs alcohol and swells. It is combustible and is also irritating to tissues. It is removed by a quick rise in saline prior to use.

COLLAGEN SUTURENatural, absorbable, monofilamentObtained by homogenous dispersion

of pure collagen fibrils from the flexor tendons of cattle.

Absorption – 56 daysTS - < 10% after 10 days.Used in opthalmic surgeryDisadvantage of premature

absorption.

POLYGLACTIN 910 (VICRYL) Polyglactic acid

Coated and uncoated Synthetic suture Monofilament/multifilament Lactide has hydrophobic qualities→delaying

loss of TS TS - 14 – 21 days. Absorption – 56-70 days.

SYNTHETIC ABSORBABLE

Minimal tissue reactivity and can be used in infected tissues

Available in purple and undyed. Undyed used on face.

Coated with polyglactin 370 and calcium stearate which allows easy passage through tissues as well as easier knot placement.

On skin wounds, associated with delayed absorption as well as increased inflammation.

VICRYL –RAPIDE• It is braided synthetic absorbable suture material.• Colour: White.

• It has a similar initial high tensile strength as that of the normal vicryl suture.

• It gives wound support upto 12 days. It shows 50% of the original tensile strength after 5 days and all of its tensile strength is lost after 14 days.

• Its absorption is associated with minimal tissue reaction facilitating improved cosmetics and reduction of postoperative pain.

• The absorption is essentially complete within 35-42 days.

• Uses: Low tensile strength and Rapid absorption rate --Ideal for intra-oral use (dental surgeries).

VICRYL plus ANTIBACTERIAL SUTURE

• Handles and performs same as normal vicryl.

• In vitro studies shown that triclosan on VICRYL plus creates a zone of inhibition around the suture.

GLYCOLIC ACID HOMOPOLYMER (DEXON) POLYGLYCOLIC ACID

Polymer of glycolic acid with greater knot pull and TS than gut.

Synthetic, absorbable, braided Absorption- hydrolysis, which results in

minimal tissue reactivity. Braided and so catches on itself, and

knot tying and passage through tissues difficult.

Does not tolerate wound infection and not percutaneous suture.

GLYCOLIC ACID (MAXON) POLYGLYCONATE-Synthetic, absorbable, monofilament.-Polyglycolic acid and trimethylene carbonate-TS – 14-21 days (>Dexon)Absorption – Hydrolysis in 180 days

In vitro studies by Edlich and co-workers (1973) have suggested that the degradation products of polyglycolic acid and nylon sutures - glycolic acid, 1,6-hexane diamine and adipic acid are antibacterial agents.

POLYDIOXANONE (PDS II)

Synthetic,absorbable,monofilament.

Polyester derivative poly P dioxanone.

TS -14-42 days

Absorption – Hydrolysis in 6 months.

Passes through tissues easily.

Significant memory – compromises the ease of knot-tying and knot security.

Minimal tissue reaction

For wounds under tension and contaminated wounds.

May extrude through the wound over time. So used only in tissues deeper than subcuticular layer. Or if in face 6-0 used.

NON ABSORBABLE SUTURES• Natural – silk, silk worm gut, cotton

, ramie,linen• Synthetic-polyester, polyamide,

poly propylene, polybutester,polyethelene

• Metals : SS Tantalum platinum silver wires gold aluminium

SURGICAL SILK-Braided or twisted-Made from the filament spun by

silkworm larva to form its cocoon. Each filament is processed to remove the natural waxes and sericin gum. After braiding, the strands are dyed, stretched and impregnated with a mixture of waxes and silicone. Dry silk suture is stronger than wet silk suture.

NATURAL NON-ABSORBABLE

Advantage: Ease of handling – more for braided Good knot security made non capillary in order to withstand

action of body fluids & moisture.(wax or silicon coated)

Cost effective

Contraindications:Should not be used in presence of infection

Uses:Plastic surgery, ophthalmic and

general surgeries, ligating body tissues.

Although characterized as non-absorbable, studies show that it loses most of their TS after 1 yr. and cannot be detected in tissues after 2 yrs.

SURGICAL COTTON

Natural, multifilament, non absorbable

From stable Egyptian cotton fibersgood knot securityNot good in presence of

contaminated wounds or infectionRarely used nowadaysUses: Most body tissues for ligating and

suturing

LINEN

Natural, multifilament, non absorbable

Made from stable flax fibersPoor TS and so not for suturing

under tensionUses:

Ligation of superficial vesselsMucosal suturing without stress

POLYPROPYLENE (PROLENE) -Polymer of propylene.-Inert and TS for 2 yrs-Holds knots better than other synthetic

sutures.

Advantages-Minimal suture reaction and so used in

infected and contaminated wounds.-Do not adhere to tissues and is flexible.

So used for ‘pull-out’ type of sutures.Uses: General, plastic, cardiovascular surgery,

skin closure, ophthalmology.

SYNTHETIC NON-ABSORBABLE

NYLON – BRAIDED (SURGILON, NURILON)

Synthetic, non absorbableInert polyamide polymerBraided and sealed with silicon

coatingLook, handle and feel like silk, but

more strongerMultifilament nylon is weaker and

less secure when knotted, offering little advantage over monofilament nylon.

NYLON MONOFILAMENT (DERMALON, ETHILON)Uncoated, but inert and non

irritating to the tissues.High TS and low tissue reactivitySome memory and return to

original linear shape over time. Because of this more throws (4 throws) indicated.

Moistened nylon monofilament are more easily handled and are packaged wet.

Uses: Skin closure, retention, plastic,

ophthalmic and microsurgery.

POLYESTER – BRAIDEDTycron, Mersilene -UncoatedDacron, Ethibond - Coated (with polybutilate)

Multifilament fibers of polyester Excellent TS which is maintained indefinitely Uncoated is rougher and stiffer than coated

form Coated provides -low infection rate

-secure knotting -smooth removal -low reactivity -easy passage through tissues

More expensive In deeper layers, may last indefinitely.

GOR-TEXNonabsorbable,synthetic,Monofilamen

tFrom,expanded

polytetrafluoroethylene (ePTFE)Extremely low tissue reaction, good

knot tensile strenghtand ease of handling.

Uses All type of soft tissue approximation

and cardiovascular surgeries.

MONOCRYLAbsorbable, synthetic,

monofilamentPoliglecaprone 25; copolymer of

glycolide and caprolactoneHydrolysis 90-120 daysTissue reaction – minimalGood knot strengthUsed for soft tissue closureMost pliable material ever made

POLYBUTESTER (NOVOFIL)

-New, monofilament, nonabsorbable, synthetic

-Made of polyglycol trephthate and polybutylene terephthalate and is considered as a modified polyester suture.

-No significant memory compared to polypropylene and nylon. Easier to manipulate and greater knot security.

-Unique feature is their ability to elongate or stretch with increasing wound edema. When edema subsides, suture resumes original shape; so it is an ideal suture for lacerations secondary to blunt trauma.

-TS high and lasts longer-Minimal tissue reactivity.-Popularity in cutaneous surgery is

gradually increasing.

SURGICAL STEEL

Natural, monofilament/multifilament, non absorbable

Alloy of iron, nickel and chromium Good TS even in infection Difficult to handle and tendency to cut

through tissues. Very hard to tie, and knot ends require special handling.

Potential to corrode or break at points of twisting, bending or knotting.

Not to be used with a prosthesis of another alloy.

Used in abdominal wall and skin closure, sternal closure, retention, tendon repair, orthopedic and neurosurgery.

OMFS- for suspension of splints or arch bars and not as suture material.

Major Disadvantages

1.Linear artifacts caused by substances with high atomic number on CT images

2.Possible movement of metal suture during MRI

3.Patch test for nickel sensitivity should be done.

Packaging………METRIC GUAGE IMPERIAL GUAGE

PRODUCT CODE

NEEDLE SIZE & CURVATURE

NEEDLE TYPE

NEEDLE TIP

NEEDLE PROFILE

STERILIZED

ETHELENE OXIDE DO NOT REUSE

SEE INSTRUCTIONS FOR USE EXPIRY DATE BATCH NO

SUTURE SIZES• Largest size 1 to extremely fine 11-0.

Increasing number of zeroes correlates with decreasing suture diameter and strength.

• Thicker sutures are used for approximation

of deeper layers, wounds in tension prone areas and for ligation of blood vessels.

• Thin sutures are used for closing delicate tissues like conjunctiva and skin incisions of the face. Size is chosen to correlate with the tensile strength of the tissue being sutured.

3-0 or 4-0 OMFS, muscle, deep skin5-0 or 6-0 facial skin closure9-0 or 10-0 microsurgery

SUTURE NEEDLESSurgical needles are designed to lead

suture material through tissue with minimal injury. Needles can be

- straight (GIT) or curved - swaged or eyedMade up of either SS or carbon steel.

Needle is selected according to:-type of tissue to be

sutured-tissue’s accessibility-diameter of suture

material.

Made up of either SS or carbon steel.

CLASSIFICATION OF SURGICAL NEEDLES1.According to eye -eye less needles

-needles with eye2.According to shape -straight

needles. -curved needles3.According to cutting edge a) round body b) cutting -conventional

-reverse cutting

• 4.According to its tip -triangular tip

-round tip -blunt tip• 5.Others -spatula needles -micro point needles -cuticular needles -plastic needles

Ideal Properties Of Needles• High quality stainless steel

• Smallest diameter possible

• Capable of implanting sutures with minimal

trauma to tissues.

• Stable in the needle holder

• Should be sharp.

• Sterile and corrosion resistant.

Anatomy of a Needle

Term Definition

Chord

Length of needle

Radius

Diameter

The linear distance between eye and tip.

The distance between eye and tip following the curvature

The distance of the body of the needle from the centre of the circle

Gauge or thickness of the metal wire out of which the needle is made.

COMPONENTS OF SURGICAL NEEDLE

1. The eye2. The body; and3.The pointThe eye can be - closed

- swaged - chanelled/drilledShape of the eye may be - round

- oblong; or - square

Open French-eye needle is easy to load with varying caliber, but has additional bulk.

CLOSED

SWAGED

CHANELLED

Eyed require threading prior to use, results in pulling a double strand through tissue. Tying the suture to the eye increases bulk of suture material drawn through tissues. So they are also called ‘traumatic needles’.

Most suture materials and needles are difficult to sterilize. Needles are also difficult to clean after use and become blunt and workhardened so that they snap.

Suture loop inserted through eye

Loop placed over tip

Loop drawn back

Suture tied on eyed needle

SWAGED NEEDLE

• Swaged needles do not require threading and permit a single strand of suture material to be drawn.

• Suture attached to needle via a hole drilled through the end of the needle, and the end is swaged during manufacturing.

• It is atraumatic and act as a single unit. • Prepacked and presterilized by gamma radiation.

Needle attached to sutureFavourable for I/O use but expensiveLess tissue damageNew needle each time

THE BODY • Body is the widest portion of the needle • It is known as grasping area.

-Most commonly used are 3/8 circle. They can be easily manipulated in large and superficial wounds and require only less wrist movement.

-1/2 circle used for suturing tissues in small

wounds, and body cavities and orifices. Require less space, but more supination and pronation of wrist required.

-5/8 used in oral cavity.

Tapered

Cutting

Reverse cutting

RADIUS OF CURVATURE OF THE BODY(NEEDLE)

CLINICAL USE

Straight Needle

¼ circle

3/8 circle

½ circle

5/8 circle

Needle of choice for the skinLimited use in oral surgeryMay be used in surgery of the nose, pharynx, tendons

Needle of choice for microsurgery associated with very fine sutures; ophthalmology

Oral surgery, flap surgery, wound closure after placement of osseointegrated implants and GTR procedures May be used in all surgical wounds

Needle of choice in oral surgery Wide range of uses in many surgical wounds

Wounds of the urogenital tract

THE POINTPoint runs from tip to the max. cross sectional area of the body.

• Can be -triangular tip/cutting -round tip -blunt tip

• Cutting needles are Ideal for suturing keratinized tissues like skin, palatal mucosa, subcuticular layers and for securing drains.

• Round/tapered needles used for closing

mesenchymal layers such as muscle or fascia that are soft and easily penetrable

• The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle.

• The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle.

• The tapered point is used primarily on soft, easily penetrated tissues . it leaves small hole and can be used in vascular surgery as well as fascial soft tissue surgery.

• The blunt point has a rounded end which does nt cut through the tissue .it is used in friable tissue suturing or to the parotid duct or lacrimal canaliculi.

Cuticular needles• Sharpened 12 times• Designated as C or

FS (CUTICULAR or FOR SKIN)

Plastic needles • Sharpened an additional

24 times• Designated as P or PS or

PC (PREMIUM or PLASTIC

SURGERY or PRECISION COSMETIC ).

• Needles in the PC series are made up of stronger SS alloy and have flattened and conventional cutting edge.

• Curvature of the needle is selected according to the accessibility. The needle must exit in a visible spot so that the surgeon is aware of the position of the point of the needle at all the times.

• Try to match the needle thickness with suture diameter .it is not appropriate to use wide thick needle with small suture material . This will cause laxity of immediate suture line and allows bacterial contamination & ingrowth of epithelium & in vascular surgery it may allow oozing of blood throught/suture hole.

Placement of a Needle into the Tissue

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

Movable to a non-movable tissue. Only sharp needles with minimal

force. Never force the needle through the

tissue. Avoid retrieving the needle from the

tissue by the tip.

Grasp the needle in the body 1/4th to half of the length from the swaged area.

Do not hold the needle by the swaged area or the eye.

Avoid excessive tissue bites with small needles, as it will be difficult to retrieve them

NEEDLE HOLDER

• The needle holder is used to handle the suture needle and thread while suturing the surgical wound.

• If used properly it enables the surgeon to perform procedures correctly and with great precision.

PARTS OF NEEDLE HOLDER

• Working tip/ jaws• Hinge device• Shank/body• Catch mechanism/ ratchet• Grip area

NEEDLE HOLDER

There are different types of needle holders. The beaks may be short or long, broad or narrow, slotted or flat, concave or convex, smooth or serrated. Commonly used have a locking hand and short beaks and 6’ longGilles needle holder (scissors incorporated into blades)Kilner needle holder

• Atraumatic needle holder ensures needle movement and compatibility of clamping movement. It has textured tungsten carbide jaw inserts, and its rounded needle holder jaw edges do not cause structural damage to monofilament suture or needle

GILLES NEEDLE HOLDER

Scissors are incorporated into the blades

OLSEN HEGAR NEEDLE HOLDER KILNER NEEDLE HOLDER

MAYO HAGER NEEDLE YASARGIL MICRO NEEDLE HOLDER

Gripping needle holder The scissor grip Used in the anterior part of the mouth

and in areas of easy access The instrument is stabilized with the

index finger

Palm grip • Used in the deeper parts of

oral cavity

Use appropriate size for needle

Grasped 1/4 to ½ distance from swaged area

Tips of the jaws should meet before remaining portion of jaw

Needle placed securely Do not overclose Always directed by

surgeon’s thumb Do not use digital

pressure on tissues

PRINCIPLES OF

SUTURING

PRINCIPLES OF SUTURING

1.Needle grasped at 1/4th to half the distance from eye.

2.Needle should enter perpendicular to tissue surface

3.Needle passed along its curve

4.The bite should be equal on both sides of the wound margin and the point of the entry of the needle should be closer to the wound edge than its point of exit on the deep surface

5.The bite should be about 2-3 mm from the wound margin of the flap because after wound closure the edge of the wound softens due to collagenolysis and the holding power is impaired.

6. Usually the needle to be passed from mobile side to the fixed side but not always(exception in lingual mucoperiosteum flap) and from thinner to thicker & from deeper to superficial flap.

7.The tissues should not be closed under tension , since they will either tear or necrose around the the suture

8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture to another should be about 3-4 mm apart to prevent strangulation of the tissue & to allow escape of the serum or inflammatory exudate & to get more strength of the wound.

11.Sutures placed at a greater depth than distance from the incision to evert wound margins

12.Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.sutures should have correct tension while tying knot for provision of the slight edema post operatively, more tensioned sutures cause

ischemia of the edges of the incision causes tearing of the tissues may leave suture mark edges may get overlapped

16.Occasionally extra tissue may be present on one side of incision and cause DOG EAR to be formed in the final phase of wound closure.

• Simply extending the length of the incision to hide the exists will produce an unsatisfactory result.

• Thus after undermining excess tissue incision is made at approx. 300 to parent incision directed towards undermined side. Extra tissue is pulled over incision and appropriate amount is excised. Incision is closed in normal manner.

IMPROPER SUTURING TECHNIQUE

SUTURING TECHNIQUES

1.INTERRUPTED SIMPLE SUTURE

Most commonly used. Inserted singly through side of the wound and tied with a surgeon’s knot.

AdvantagesStrong and can be used in areas of stressPlaced 4-8 mm apart to close large wounds, so that tension is sharedEach is independent and loosening one will not produce loosening of the otherDegree of eversion producedIn infection or hematoma, removal of few suturesFree of interferences b/w each stitch and easy to clean

2. SIMPLE CONTINUOUS / RUNNING

A simple interrupted suture placed and needle reinserted in a continuous fashion such that the suturepasses perpendicular to the incision line below and obliquely above. Ended by passing a knot over the untightened end of the suture.

AdvantagesRapid technique and distributes

tension uniformlyMore water tight closure (Shoen,

1975)Only 2 knots with associated tags

DisadvantagesIf cut at one point, suture slackens

along the whole length of the wound which will then gape open.

3.CONTINUOUS LOCKING/BLANKETSimilar to continuous but locking provided by withdrawing the suture through its own loop. Indicated in long edentulous areas, tuberosities or retromolar area.

AdvantagesWill avoid multiple knotsDistributes tension uniformlyWater tight closurePrevents excessive tightening.

Disadvantage :prevents adjustment of tension over suture line as tissue swelling occurs.

4.VERTICAL MATTRESS

Specially designed for use in skin. It passes at 2 levels, one deep to provide support and adduction of wound surfaces at a depth and one superficial to draw the edges together and evert them.

Used for closing deep wounds

This approximates subcutaneous and skin edges

Needle passed from one edge to the other and again from latter edge to the fist and knot tied. When needle is brought back from second flap to the first, depth of penetration is more superficial.

Advantages :• for better adaptation and maximum tissue

approximation

• To get eversion of wound margins slightly

• Where healing is expected to be delayed for any reason, it is better to give wound added support by vertical mattress. Used to control soft tissue hemorrhage.

• Runs parallel to the blood supply of the edge of the flap and therefore not interfering with healing.

• Uses: abdominal surgeries & closure of skin wounds.

5.HORIZONTAL MATTRESS It everts mucosal or skin margins,

bringing greater areas of raw tissue into contact. So used for closing bony deficiencies such as oro-antral fistula or cystic cavities.

Disadvantage: constricts the blood

supply to edges of incision.

Needle passed from one edge to the other and again from the latter to the first and a knot is tied.

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

Advantages:Will evert mucosal or skin margins, bringing

greater areas of raw tissue into contact.

-So used for closing bony deficiencies such as oro-antral fistula or cystic cavities, extraction socket wounds.

• Prevents the flap from being inverted into the cavity.

• To control post-operative hemorrhage from gingiva around the tooth socket to tense the mucoperiosteum over the underlying bone.

• It does not cut through the tissue ,so used in case of tissue under tension (inadequate tissue)

Disadvantages:• More trouble to insert• Constricts the blood supply to the

incision if improperly used, cause wound necrosis and dehiscence

6. FIGURE OF 8 SUTURE Used for extraction socket closure and

for adaption of gingival papilla around the tooth Suturing begun on buccal surface 3-4mm from the tip of the papilla so as to prevent tearing of papilla.

Needle first inserted into the outer surface of the buccal flap and then the lingual flap. Needle again inserted in same fashion at a horizontal distance and then both ends tied.

7. SUBCUTICULAR SUTUREUsed to close deep wounds in layers. Knots will be inverted or buried, so that the knot does not lie between the skin margin and cause inflammation or infection.

To bury the knot, first pass of the needle should be from within the wound and through the lower portion of the dermal layer. Needle then passed through the dermal layer and emerge through subcutaneous tissue and knot tied

8.CONTINUOUS SUBCUTICULAR SUTURE

Continuous short lateral stitches are taken beneath the epithelial layer of the skin. The ends of the suture come out at each end of the incision and are knotted.

AdvantagesExcellent cosmetic resultUseful in wounds with strong skin tension, especially for patients prone to keloid formation.Anchor suture in wound and, from apex, take bites below the dermal-epidermal layerStart next stitch directly opposite the one that precedes it.

9.PURSE STRING SUTUREA circular pattern that draws together the tissue in the path of the suture when the ends are brought together and tied.

KNOT TYING

KNOT TYING

Sutured knot has 3 components

1.Loop created by knot2.Knot itself which is

composed of a number of tight throws

3.Ears which are the cut ends of the suture

KNOT TYING Principles of knot tying

Use the simplest knot that will prevent slippage.

Tying the knot as small as possible and cutting the ends of the suture as short as reasonable to minimize foreign body reaction.

Avoid friction or sawing Avoid damage to suture material Avoid excessive tension Tying sutures too tightly strangulates the tissue

Maintenance of traction at one end of the suture after the first loop is thrown, to avoid loosening of the knot.

Placing the final throw as horizontally as possible to keep knot flat

Limiting extra throws to the knot, as they do not add strength to a properly tied knot.

KNOTS

SQUARE KNOTFormed by wrapping the suture around the needle holder once in opposite directions between the ties. Atleast 3 ties are recommended.

Best for gut, silk, cotton and SS

SURGEON’S KNOT

Formed by 2 throws on the first tie and one throw in the opposite direction in the second tie. Recommended for tying polyester suture materials such as Vicryl and Mersiline

GRANNY’S KNOTA tie in one direction followed by a tie in the same direction and a third tie in the opposite direction to square the knot and hold it permanently.

SUTURE REMOVAL

SUTURE REMOVAL

Skin wounds regain TS slowly. It can be removed in 3-10 days when the wound gained 5%-10% of final TS. Skin sutures on face removed between 3-5 days. Alternate sutures removed on 3rd day and remaining sutures after 2 days.

Intra oral - Mucoperiosteal closure (without

tension) 5-7 days - Where there is tension on the suture eg : Oro-antral fistula- 7-10 days Back and legs where cosmesis is less

important – 10-14 days. Continuous subcuticular can be left for

3-4 weeks without formation of suture tracks

A good guide is that as soon as they begin to get loose they should be taken out.

Suture area is first cleaned with normal saline. The suture is grasped with non-tooth dissecting

forceps and lifted above the epithelial surface. Scissors are then passed through one loop and then

transected close to the surface to avoid dragging contaminated suture material through tissues.

The suture is then pulled out towards incision line to prevent dehiscence.If suture entrapped in a scab, application of hydrogen peroxide or saline solution is necessary.

If pieces of suture left, infection or granuloma formation can ensue.

• INCORRECT

• CORRECT

• Possible Complication Of Leaving Suture For Many Days :

1.Sutural abscess. 2.Suture scarring or stitch

mark 3.Implanted dermoid cyst

SCISSORSDean’s Scissors-General purpose scissors-Used for cutting sutures-Can also be used to trim mucosal

margins.

SUTURE MARKS

Suture marks are caused by 3 factors

1.Skin sutures left in place longer than 7 days, resulting in epithelialisation of suture track

2.Tissue necrosis from sutures that were tied too tightly or became tight due to tissue edema

3.Use of reactive sutures in the skin.

Other Methods of Wound Closure

• Ligating clips• Skin staples• Surgical tape• Surgical adhesives

Mechanical wound closure devices

Ligating clips : • can be resorbable or non

resorbable.• Made up of SS,tantalum or

titanium or pidioxanone.• Designed for the ligation of tubular

structures.

Surgical staples:• Used for skin closure .• Made up of SS.• They are placed uniformly to

span the incision line.• They have minimal tissue

reaction .• Can be used for routine skin

closure any where in the body.

Advantages • As the clips do not penetrate skin, yet

give apposition, the cosmetic result is excellent.

• Speed and efficacy of stapling is more compared to sutures.

• Suturing causes more necrosis than stapling in myocutaneous flaps.

• Most significant advance is the introduction of absorbable staples (Lactomer).

• Contra indicated when it is not possible to maintain atleast 5mm distance from the stapled skin to the underlying bone and blood vessels.

SURGICAL TAPE

Microporous tape is used alone or in conjugation with skin sutures to decrease tension at the wound margins.

The surgical tapes have a backing of viscous rayon fibers coated with an adhesive copolymer and they are pervious to sweat but not to blood or purulent material.

Comes in 1/8, 1/4, and 1/2 inch wide strips. Skin margin is prepared with tincture of benzoin to provide better adhesiveness for tape.

Used to decrease skin tension on cheek,forehead,chin.

Advantages

Minimizes wound dehiscence and allows earlier suture removal

Provides continuous support for the wound and minimizes scar expansion

Avoids the ordeal of suture replacement and removal in children

Less inflammatory reaction, lower rate of wound infection, greater TS and better cosmetic results.

No needle puncture marks and suture canals

Strangulation and necrosis of tissue are eliminated

Sterile paper tape is non expensive

Disadvantage

Do not evert edges of the wound, and readily loosen when wet by blood or serum.

Prior to placement, a thin coat of antibiotic ointment is placed on wound margin to protect wound from skin oils and bacteria.

While removing, to avoid epithelial margin separation, the ends should be lifted equally towards the wound margin and then lifted evenly from the wound.

Cyanoacrylates

- n-butyl cyanoacrylate is the active ingredient.

Advantages :

Strong bonding to tissues in presence of

moisture

Biodegradable, bacteriostatic & hemostatic.

Reduced post operative pain & facilitates

healing.

Good shelf life.

Produces little or no heat during

polymerisation.

Bonding is by secondary intermolecular

forces aided by mechanical interlocking of

irregular forces.

Quick, atraumatic and cost effective with good cosmesis

No injection, suturing and post-op suture removal.

Disadvantages

1.When applied for skin closure, the polymer acts as barrier, prevents wound apposition, delays healing, and increases the infection rate.

2.Should not be allowed to come in contact with tissue under skin as it causes necrosis.

REFERENCE• Suturing techniques in oral surgery –

Sandro Siervo• Atlas of Minor Oral Surgery- Harry Dym • Laskin vol-1• Oral & Maxillofacial Surgery Vol 1- W.

Harry Archer• Textbook of oral & maxillofacial surgery-

Neelima Anil Malik• Minor Oral Surgery- Goeffrey L.Howe• Text book of surgery: Sabiston• Periodontology-Caranza.

THANK YOUTHANK YOU