Sutures and suturing patterns in surgery & modern innovations

BYDR MUKORO DUKE GEORGE

B.SC,MBBS,MCS,HSE C E R T ,ATLS,DTM&H L I V E R P O OL

G R A D U A T E M E M B E R N I MN D U T H ,

SUTURES & SUTURING IN SURGERY

OUTLINE

o INTRODUCTION HISTORICAL BACKGROUND DEFINITIONSo QUALITIES OF AN IDEAL SUTUREo CLASSIFICATION/STRENGTHo TYPES/USESo SUTURE SELECTIONo SUTURE ACCESSORIES(NEEDLES)o STERILIZATION OF SUTURESo SUTURE REMOVALo COMPLICATIONSo RECENT ADVANCESo CONCLUSIONo REFERENCES

INTRODUCTION

• DEFINATIONS ⌂ Suturing refers to sewing together two structure using suture threaded on a needle. The purpose of suture is to hold tissues together until strong enough to support itself during wound healing.

• Ligating or ligaturing refers to tying a ductal structure such as blood vessel simply by means of a suture thread.

INTRODUCTION

HISTORICAL BACKGROUNDSutures are used to improve & speed healingHx dates back to 550-3000BCEarly sutures were Flax, Silk, Linen strips &

cottonSynthetic sutures are now available

DEFINITIONS

Suture is a material used to approximate living tissues or xtures together

Ligature is a suture used to encircle a bld vessel to arrest or control bleeding

Tensile strength is the ability of the material or tissues to resist deformation or breakage

Elasticity is the ability of the material to regain its original form or length after deformation

Pliability is the ability to adjust knot tension & to secure knot

Memory is the inherent capability of suture to return or maintain its original gross shape

QUALITIES OF AN IDEAL SUTUREby Lord Mogniham (1865 – 1936)

Sterile and easily sterilizableServe all purposeMinimal tissue :non-electrolytic, non-capillary, non-

allergenic, non-carcinogenic (and non-thrombogenic in vascular surgery.

Easy to handleHold knot securelyHigh tensile strengthFavourable absorption profileResistant to infectionAvailableInexpensive

Features of a suture 1) Suture stength - Measured by instron tensiometer.2) Tissue Reactivity3) Handling4) Knotting 5) Sterilization 6) Absorbility7) Viability 8) Elasticity 9) Size

CLASSIFICATION OF SUTURES/STRENGTH

ABSORPTION ORIGIN CONFIGURATION ABILITYAbsorbable Natural Monofilament Synthetic Multifilament Non-absorbable Natural Monofilament Synthetic Multifilament TRAUMATIC & ATRAUMATIC STRENGTH : Ranges from smallest(10/0) to largest(5)

ABSORBABLE NON ABSORBABLE1. Catgut Silk,2. Chromic Catgut Linen3. Dexon (Polyglycolic acid) Cotton4. Vicryl (Polyglacitin) Horse/Human hair5. PDS (Polydioxanone) Nylon or Ethilon6. Collagen Polyester (Teflon)7. Maxon (Polyglyconate) Polypropylene (Prolene).8. Poliglecaprone Stainless steel

Aluminium WireClipsStaplesSkin tapesSurgical adhesives

TENSILE STRENGTH/ABSORBABILITYSuture T/S loss Absorption

tissueCatgut 15 days 60 daysChronic Catgut 30 days 80 – 120 daysPolyglyconic acid(DEXON)

30 days 90 days

Polyglactin(vicryl)

32 days 70 days

Polydioxanone 56 days 180 daysNylon 25% in 2yrs ▬Prolene IndefiniteDacron Indefinite

TYPES/USESABSORBABLE – NATURAL Plain catgut:light milk,Derived from

submucusa of sheep intestine or serosa of beef intestine

Used for ligating superficial bld vessels & subcut fatty tissues

Chromic catgut:yellow,Treated with chromium salt.

Adv may be used in the presence of infection

Polyglactin (vicryl):cream, copolymer of lactide & glycolide

Minimal tissue rxn Used in general soft tissue

approx,intestinal anastomosis,vessels ligation in all surgical specialties

Dexon(Polyglyconic acid):purple/cream

Homo polymers of glycolide. Avoid in adipose tissue Losses tensile strength more

rapidly than vicryl. Other e.g

Polyglyconate(maxon) polydiaxone(PDS),Polyglecaprone(monocryl)

ABSORBABLE - SYNTHETIC

NON-ABSORBABLE-NATURAL

Surgical silk:Black, Derived from the cocoon of the silk worm larvae, superior handling xtics,Trigger inflam rxns,Undergo proteolysis & undetected by 2yrs,Used in ligating maj bld ves,tendon repair etc

Surgical steel & wiresHigh tensile strengthHold knots very wellUsed in orthopaedic,Neurosurg,& Thoracic

surgOther e.g Virgin silk,cotton, linen

NON-ABSORBABLE - SYNTHETIC

Nylon:Is a polyamide polymer,blue81% tensile strength at 1yr & 66% at 11yrsElicits minimal tissue rxnHas good memoryPliable when moist Premoistened form is used cosmetic plastic surgeryIts elasticity makes it useful for skin closure &

HerniorhapyOther e.g;Polypropylene(prolene),Polyester

fiber(Mersilene/Dacron,Ethibond)

SYNTHETIC NON-ABSORBABLE (CUT)

Staples and chips: Faster than traditional suture, in gut anastomosis,

vascular &bronchial closure. Skin tapes:

Impervious to sweat, wound infection less, avoid suture marks.

Surgical adhesives: Expanded polytetra fuoroethylene

Monofilament SutureGrossly appears as single strand of suture material; all fibers run parallel Minimal tissue trauma Resists harbouring microorganisms

Ties smoothly Requires more knots than multifilament suture Possesses memory Examples:

Monocryl, PDS, Prolene, Nylon

Multifilament SutureFibers are twisted or braided together Greater resistance in tissue Provides good handling and ease off tying Fewer knots required Examples: Vicryl (braided) Chromic (twisted) Silk (braided)

SUTURE SELECTIONDepends on surgeons training & preferenceSmallest suture is preferableTensile strength of suture should not exceed that

of tissuesAesthetics should be considered e.g head&neckMobility of the region e.g Limbs & trunkTension of the tissues to be sutured e.g major

musculocutaneous flapsNon-absorbable considered in skin,fascia,tendonAbsorbable considered in rapidly healing tissuesMonofiliments preferable in contaminated

wounds

Suture Size United States Pharmacopeia

Sized according to diameter with “0” as reference size Numbers alone indicate progressively larger sutures (“1”,“2”, etc)

Numbers followed by a “0” indicate progressively smaller sutures (“2-0”, “4-0”, etc)

Smaller<------------------------------------->Larger .....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

SIZE OF SUTURES OLD GAUGE(USPD) DIAMETER IN MM 8/0 0.05 7/0 0.O7

6/0 0.1 5/0 0.15 4/0 0.2 3/0 0.3 2/0 0.35 0 0.4 1 0.5 2 0.6 3 0.7 4 0.8

Wound Closure Basic suturing techniques: Simple sutures Mattress sutures Subcuticular sutures Goal: “approximate,, not strangulate”

Ideal Wound ClosureAllow for meticulous wound closureEasily and readily appliedPainlesslow risk to providerInexpensiveMinimal scarringLow infection rate

METHODS OF SUTURING1. CONTINUOUS SUTURING

►Rapid application ►Efficient ►Haemostatic ►Easily drawn tight ►Edges may overlap ►Whole wound may open if any breaks

2. INTERRUPTED SUTURING ►Skin ►Infected sites ►1mm apart on the face ►1cm apart at other areas

Continuous Locking and Nonlocking Sutures

Simple, Interrupted

Vertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)

Horizontal Mattress

Good for closing wound edges under high tension,and for hemostasis.

Horizontal Mattress

SUTURE ACCESSORY-NEEDLES

Ideal surgical needle High quality stainless steelSmallest diameter possibleStable in the grasp of needle holderSharp enough to penetrate tissues with

minimal resistance & traumaSterile & corrosive resistant

ANATOMY OF THE NEEDLE

POINT Cutting;Conventional cuttingReverse cuttingSide cuttingTaper(round needle)Blunt

BODYStraightHalf curvedCurved: ski 1/4 circle 3/8 circle 1/2 circle

5/8 circle Compound curved

SWAGE Channel swageDrill swageNon swaged

STERILIZATION OF SUTURES

May affect suture properties to some extentGamma RadiationEthylene oxide;poisonous gas,is less

attractiveAutoclaveSutures are usually stored in sterile pack by

the manufacturers,their integrity must be checked b/4 use

Packaging…

Expiry dateBatch NumberDo Not Re-use

Product (re-order) CodeImperial GaugeMetric Gauge

Needle size & curvature

Needle type

Needle point

See Instructions for use

Needle profile

SterilisedEthylene Oxide

SUTURE REMOVAL

Sutures on the superficial(skin) wounds are removed after serving their fxn

Duration depends on the site; Head & Face = 3-5d Arms & Hands = 7-10d Chest =7-10d Abdomen =7-1od Lower limbs/feet =10-14d

COMPLICATIONS

Usually less if proper selection is followed Failure Undo Tissue rxn Infection Abscess and sinus formation scarring

RECENT ADVANCESStaples & ClipsFormed from high quality stainless steelNew absorbable clips made of polydiaxone are

availableStaples are suitable for skin closureStapling gun for bowel anastomosis are popularSkin Tapes & Adhesives e.g DermabondNon-suture methods of closing wound edgesApplied after adequate subcuticular closureMinimal infection rate & no tissue rxnEXPENSIVE

Adhesive Tapes

Less reactive than staples

Use of tissue adhesive adjunct (benzoin)

Poor outcome in areas of tension

Seldom used for primary closure

Use after suture removal

Adhesive Tapes

• Least reactive• Lowest

infection rate• Rapid

application• Patient

comfort• Low cost• No risk of

needle stick

Advantages

• Frequently falls off• Lower tensile strength

than sutures• Highest rate of

dehiscence• Requires use of toxic

adjuncts• Cannot be used in

areas of hair• Cannot get wet

Disadvantage

s

Staples

More rapidly placedLess foreign body

reactionScalp, trunk,

extremitiesDo not allow for

meticulous closure

Dermabond®

A sterile, liquid topical skin adhesive

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

Only for easily approximated skin edges of wounds punctures from minimally

invasive surgery simple, thoroughly cleansed,

lacerations

Dermabond®

Standard surgical wound prep and dryCrack ampule or applicator tip up; invertHold skin edges approximated horizontallyGently and evenly apply at least two thin

layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky

Apply dressing

CONCLUSION

Human body is very delicate & important.When surgeries are needed to improve our health is very important to select a suitable suture.Today we know alots of biomaterials to select,but is important to always think of biocompatibility.

REFERENCES

1) Post-graduate surgery, candidates guide M.A.R Alfallouji,2nd edition

2) Principles & practice of surgery including pathology in the Tropics, E.A.Badoe etal 3rd edition

3) Clinical surgery Alfred Cusheri etal 2nd edition

4) www.e.medicine.com

THANK YOUFOR

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