History of Sutures Animal sinew such as tendons and ligaments were the first recorded sutures. Egyptian literature mentions the use of linen strips coated with a mixture of honey and flour Sushruta described sutures and needles for the first time
History of Sutures Early wound closure devices were made of natural materials such as flax, silk, linen strips, and cotton. These natural materials were lubricated in oil and wine prior to application so as to reduce tissue drag and create a cleaner wound closure procedure Another early form of a wound closure technique involved the use of the mandibles of soldier ants
History of Sutures Galen, a Roman surgeon, first commented on using catgut as a suture material Lister first used sterilized suture material by using carbolic acid and then presenting the suture material in a glass tube Halsted is still remembered for his rules of surgery advocating gentle handling of tissues, meticulous haemostasis, and interrupted silk sutures
History of Sutures By 1900 the catgut industry was firmly established in Germany due to the use of sheep intestines in their sausage industry George Merson developed atraumatic sutures 1940s- uniform preparation and sterilization of sutures 1950s- sutures attached to pre attached needles 1960s- synthetic absorbable sutures introduced
Definition of Suture The word suture describes any material used to approximate tissue edges together or ligate blood vessels. A suture attached to a needle is called as a ‘Stick tie’ A single strand of suture handed to the surgeon is called a ‘Free tie’ A free tie placed on the tip of a forceps or an instrument is called a ‘Tie on a passer’
Atraumatic sutures When a suture is attached to an eyeless needle, it is called an atraumatic suture. Developed first by George Merson of Edinburgh. Hence these sutures are also called as ‘Mersutures’ in his memory.
Suture size Defined by US pharmacopoiea The size reflects suture diameter As the suture number increases, suture diameter decreases Suture size is selected on the basis of tissue being sutured The smallest size required should always be chosen to reduce injury to the tissue.
Knot strength Measured as force in pounds a suture will withstand before it breaks when knotted The tensile strength of the suture material should not exceed the tensile strength of the tissue.
Characteristic of Ideal suture material Sterile and cost efficient Non electrolytic, not allergenic, non carcinogenic Inert Easy to handle Capable of securely holding the tissue layers throughout the healing process Minimally reactive to tissue Absorbed completely with minimal tissue reaction once the wound is healed Should have uniform diameter Should have adequate tensile strength until the purpose is overUnfortunately an ideal suture material does not exist.
Suture strandsMonofilament Multifilament Goes through the tissue Several strands braided with less drag or together resistance Greater tensile strength, Less chance of suture pliability, flexibility line infection- hence Are coated to reduce the suture of choice for drag vascular surgeries May act as a cove for organisms, hence never Greater chance of getting used in infected wounds crushed
Suture strandsMonofilament Multifilament Due to its smoothness, Knots are more secure knots more likely to slip Fraying on cutting edges No fraying of the ends on cutting Less tissue reaction Eg Vicryl, Silk Eg. Prolene, PDS II
SuturesAbsorbable sutures Non absorbable sutures Are digested by enzymes Are used to suture at and phagocytosed eg. Catgut sites where tensile Or get hydrolysed and strength needs to be removed by phagocytosis maintained for at least a eg. Vicryl year Are used to hold the wound edges in approximation Made of non temporarily until the wound biodegradable materials is healed sufficiently to withstand normal stress that are ultimately encapsulated or walled off by body’s fibroblasts
SuturesAbsorbable sutures Non absorbable sutures Are used to suture Are used at exposed internal structures in the sites in the body from body where suture where they can be removal is not removed whenever possible/feasible needed eg. Skin Eg. Catgut, Vicryl Eg. Nylon, Silk, polypropylene
Catgut Natural absorbable surgical suture It is a brand name- manufactured by Ethicon division f Johnson and Johnson; other similar sutures include Trugut, Progut, etc. It is 99% collagen Absorbed by enzymatic digestion by proteolytic enzymes Easy to handle and knots well
Catgut Derived from submucosa of sheep’s intestine or serosa of cattle’s intestine. The layers of intestine are scraped off to leave only submucosa. It is then treated by a fat solvent to wash of any fat. It is then dried and cut into various size. This is plain catgut.
Catgut If this is further treated with 20% chromic acid, it is called chromic catgut. Chromic acid increases the tissue life of the suture and thereby the tensile strength of the suture is maintained for a longer time. Sterilized with gamma radiation and packed with isopropyl alcohol.
Plain Catgut Loses 50% tensile strength in 3 days and 100% strength by 15 days Gets completely absorbed in tissue by 60 daysUses:1. To tie small subcutaneous vessels2. To approximate subcutaneous tissue during closure of incision3. In circumcision to suture the cut margins of the prepuce4. To repair the wound of lip or the oral cavity.
Chromic Catgut Loses 50% tensile strength in 7 days and 100% strength by 28 days Gets completely absorbed in tissue in 90-100 days Uses1. To suture muscles, bowel anastomosis, peritoneum2. During appendicectomy, to tie the mesoappendix and the base of appendix3. The inner layer during two layer anastomosis of the small gut or anastomosis during gastrojejunostomy
Chromic Catgut4. During cholecystectomy, to stop bleeding from gall bladder bed.For most of the above said uses however, polygalactin sutures are replacing catgut.
Polyglecaprone 25 (Monocryl) Monofilament Copolymer of 75% glycolide and 25% caprolactone Undyed or dyed violet Double the strength of chromic catgut Good handling properties and smooth surface- easy passage through tissue
Monocryl Tensile strength Uses maintained for 21 days 1. Can be used instead of and absorbed in 90-120 catgut days by hydrolysis 2. Intestinal anastomosis Is sterilized by ethylene oxide 3. For closure of peritoneum 4. Subcutaneous tissue apposition 5. Urological procedures- pyeloplasty, ureter repair
Polydioxanone Suture (PDS-II) Polymer of paradioxanone Is dyed violet Is soft pliable and smooth and allows easy passage through tissues. Tensile strength maintained for about 8 weeks and complete absorption in 180-210 days Well suited for paediatric, CVS, orthopaedic, ophthalmic, plastic and gastro-intestinal surgeries
Polypropylene( Prolene) Synthetic monofilament non absorbable suture Is inert with extremely low tissue reactivity Low coefficient of friction, so it passes through the tissue plane easily.
Polypropylene( Prolene) The suture can extend upto 30% before breaking and hence is useful in situations where post operatively some elasticity is required on the part of the suture to accommodate post operative swelling and thereby helps prevent tissue strangulation. High tensile strength for an indefinite period of time
Polypropylene( Prolene) Uses In repair of posterior inguinal wall in hernia operations Closure of skin incisions Repair tendon injuries Single layer closure of abdomen in case of intra abdominal infections/ obese patients To secure prolene meshes
Polyamide (Ethilon) Synthetic, non High tensile strength absorbable, Loses 25 % tensile monofilamentous strength after 1 year Very low coefficient of Knot security is poor friction; hence passes through the tissues easily Minimal tissue reaction
Ethilon Uses Closure of skin incision For hernioraphhy Vascular surgery
Stainless Steel Suture Is composed of 316L Non needled or stainless steel affixed to needles conforming to with permanent American Society for attachment Testing and Materials techniques or by Available in precut ROTOGRIP lengths Get encapsulated by Very high tensile fibroblast inside the strength body
Stainless Steel Suture Indicated for Contraindicated in abdominal wound people with known closure, intestinal metal allergies anastomosis, hernia May interfere with repair, sternal closure certain and some orthopedic radiodiagnostics procedures like tendon repair
Stainless Steel Suture Requires expert technique for suturing Sterilized by autoclaving
Polyglycolic acid suture (dexon) Delayed absorbable polyfilament Green in colour Maintains tensile strength for about 30 days and gets absorbed in 80-90 days Dexon is a brand name for the suture synthesized by US surgical. Other brand names are Petcryl and Maxon.
Polygalactin Sutures (Vicryl) Is a copolymer of glycolide (90%) and lactide (10%) Is digested by hydrolysis and not enzymatic reaction, hence there is less tissue reaction Tensile strength lasts for 28-30 days and gets completely absorbed by 80-90 days. Vicyl is a brand name for the polyglactin suture made by Ethicon. Other analogues are Truglyde, Centricryl and Safil.
Dexon and VicrylUses1. Indicated in all the situations where catgut is used2. Better suited than catgut to suture infected woundsDisadvantages1. Fraying of ends2. Roughness
Vicryl Rapide Suture Polyglactin 910 irradiated with gamma rays This leads to a suture material with a lower molecular weight and hence faster absorption
Vicryl Rapide Suture Maintains tensile strength for 10-12 days and absorbed by 42 days Is undyed Use1. Subcuticular suturing2. Mucosal sutures3. In circumcision4. Episiotomy repair
Silk Natural non absorbable braided suture Dyed black Derived from cocoon of silk worm larva. Is covered with a an albuminous layer which is removed during processing by a process called degummation.
Silk Handling property is very Causes tissue reaction good and knots securely leading to PMN Maintains tensile infiltration and fibrous strength for a long time capsule formation (2 years) around the silk Is supplied as a reel or Although classified as over atraumatic needles non absorbable, it loses (as Mersilk) its tensile strength in 1 year and cannot be Sterilized by gamma detected after 2 years, radiation/ autoclaving hence may be re- Loses tensile strength classified as delayed when wet absorbable suture
Silk Uses In cholecystectomy to ligate cystic duct and cystic artery Ligating mesenteric vessels during bowel resection To ligate pedicles in nephrectomy and splenectomy Ligation of Vagus nerve trunks during trunkal vagotomy May be used for skin closure To repair posterior wall of inguinal canal during hernioraphy To secure drains/ tubes
Cotton Weakest non absorbable suture Gains tensile strength when wet Indicated for retracting vessels in CVS or pediatric surgeries For tying off umbilicus in newborns
SOFSILK Multifilament, non absorbable, natural Composed of natural, proteinaceous silk fibres called fibroin obtained from silk worm (Bombyx mori) Black colour Lubricated with wax or silicon Used in CVS, ophthalmic or neuro-surgery CI- Kidney, Urinary bladder surgeries as it is a nucleus for stone formation
Misc multifilament non absorbablesutures Ethibond excel suture- ethylene terephthalate Mersilene- ethylene terephthtalate Surgilon- Nylon 6 coated with silicon Nurolon- Nylon 6 Ti-Cron- Braided polyester suture Used in CVS, ophthalmic and neuro- surgeries
Tevdek/ Polydek Made of PTFE Makes the suture inert and reduces tissue reactivity Originally designed for heart valves implantation Dyed green and white
Things to consider… … while chosing a needle type for suturing Type of needle- Type of tissue being closed Curvature of the needle- based on working space in operative field
Needle material Initially stainless steel needles were being used Now we use Surgalloy- a high nickel stainless steel Gives it better resistance to bending and breakage
Anatomy of the needle Chord length- straight line distance from point of curve to swage Needle length- the entire length of the needle Radius- distance between the centre of the circle to the body of the needle if the curved needle were to make a full circle Diameter- thickness of the needle
Anatomy of the needle Swage: This is the suture attachment end creates a single, continuous unit of suture and needle. This may be designed to allow easy release of the needle and suture material (pop-off) The surgical needle may be coated with silicone to allow easier tissue passage.
Types of suture needles Round bodied minimises the tissue trauma because the needle pierces the tissue without cutting it used for suturing peritoneum, abdominal viscera, myocardium, dura Cutting needle Have two opposing cutting edges Designed to cut through tough difficult to penetrate structures Used in plastic surgery, especially of the face
Types of suture needles Reverse cutting needle Designed with cutting edge on the outer convex side For skin, oral mucosa, tendon sheaths Blunt needles To dissect to friable tissue rather than cutting through it For suturing liver and kidney
Types of suture needles DermaX needle By Syneture Contains four cutting edges with a double point tip Moves smoothly with precision Better control through subcuticular/ cuticular tissues like forehead, eyelid, nose, chin breast
Packaging of sutures Two layer cover to allow sterile field Outer cover is made of laminate packing and is heat sealed Inner cover is different for absorbable and non absorbable sutures Because absorbable sutures need to be protected from atmospheric moisture, they are heat sealed in aluminium foils.
Subcuticular suturing Particularly useful in patients where keloid formation may be suspected.
Running closure (Baseball stitch) Where wound edges approximate easily and where a straight incision is being approximated Not done where collection is suspected
Running lock closure Similar to Running closure except that the stitch is locked before giving the next stitch
Purse string suture Placed in a circular motion around a lumen and then tightened to invert the opening Given around the stump of appendix once appendicectomy has been done In bowel end to end anastomosis
Traction sutures Used to retract tissues that is not easily held back with a conventional retractor Eg. In myocardium, sclera of the eye, tongue
Retention suture/ Stay suture Placed at a distance Used as preventive from primary suture to avoid primary to relieve tension on wound disruption the primary line Removed after the Placed on skin, tension in the subcutaneous tissue affected area is or fascia decreased Used for those patients where slow healing is expected
Secondary line suture Used to support the primary line suture, eliminate dead space or prevent fluid accumulation in an abdominal wound
Figure of eight stick tie Indicated for larger vessels or tissue pedicels To prevent knot slippage To stop haemorrhage
Timing of Suture RemovalWound location Timing of removal (days)Face Three to fiveScalp Seven to 10Arms Seven to 10Trunk 10 to 14Legs 10 to 14Hands or feet 10 to 14Palms or soles 14 to 21
Principles of knot tying Ensure that the knot is firm enough to eliminate slippage Make sure that the knot is as small as possible and the free ends are as short as feasible Avoid damaging suture material while handling Avoid excessive tension Do not tie the knots too tightly- prevent strangulation of tissue
Surgical Staples Basic principles Preservation of adequate tissue vascularization Creation of adequate lumen Prevention of leaks and fistulas Evading of tissue tension Haemostasis
Surgical Staples Advantages Less tissue reaction Accelerated wound healing Efficiency Less anesthesia and intra operative time
Surgical Staples Types of staplers Linear stapler- used for closure of a linear wound Circular or intraluminal staplers- used in GI surgeries for end-to-end, end-to-side, side- to-end or side-to-side anastomosis. They offer a circular, double staggered row of staples. Ligating and dividing stapler- issues a double row of two staples and ligates the tissue. The tissue can then be divided between the staple lines.
Surgical Staples Purse string suture clamps- for placement of purse string sutures. Skin staplers- to approximate skin edges. Endoscopic staplers
Fibrin Glue Synthesized from bovine blood• Uses • Used to control bleeding and approximating tissues that are difficult to approximate by suturing, eg. Liver, spleen and lung. • Microsurgical anastomosis of blood vessels • Used in Cardiopulmonary bypass surgery • Repair ocular implants • Close superficial lacerations and fistula • Repair dural tears
Surgical Glue Made of cyanoacrylate For adhesion of superficial lacerations
III COSEAL Surgical sealant Completely surgical vascular sealant Used in vascular surgeries as an adjunctive haemostat Seals immediately It is not a substitute for sutures, staples but an adjunct No contraindication Should not be injected into vessels
Vessel Sealing technology (LigaSure) For ligating vessels and tissue bundles Works by fusing the collagen and elastin fibres in vessels to seal the blood flow It uses ‘Instant Response Technology’- It is a feedback controlled response system that diagnoses the tissue type in the jaws of the instrument and delivers the appropriate amount of energy to effectively seal the vessel or tissue bundle. Thermal spread upto 1mm No sticking or charring of tissue.
Adhesive skin closure tapes/strips Made of nylon or polypropelene Used to reinforce subcuticular skin closure or to approximate wound edges of small incisions or lacerations Minimal tissue reactivity Low rate of infection No ischemia or necrosis Is gentler to the skin than needle May have an additional microbiocidal
Adhesive skin closure tapes/strips Disadvantage- cannot be used in presence of moisture/ infection/ oily surface/ hairy surface/ skin under tension Eg Dermabond/ Indermil
Surgical Mesh Surgical mesh is a woven fabric used for chest wall reconstruction, strengthening tissues, provide support for internal organs, and to treat surgical or traumatic wounds. The most common types of surgical mesh are hernia mesh, stress urinary incontinence slings and mesh for treating prolapse.
Surgical Mesh Titanium mesh has been used in some back surgeries As with any surgical implant, some complications can occur, including infection, inflammation, tissue damage, and septic shock.
Surgical Mesh Hernioplasty with living Fascia MacArthur’s operation A strip of fascia 1.25 cm wide was cut from external oblique aponeurosis The strip was left attached to at the pubic end and cut from where the aponeurosis becomes muscular The free end was attached to a needle with a wide eye ( Gallie’s needle) The living mesh was darned into the posterior wall of the inguinal canal
Surgical Mesh Gallie’s Graft If external oblique aponeurosis is thin/friable, tensor fascia lata cut from the outer side of the thigh and grafted over the posterior wall of the inguinal canal Tantalum Gauze- made of wire darn (filigree)
Surgical Mesh Hernioplasty with a skin graft (Mair’s procedure)- A full or a partial thickness graft was harvested and sutured to the posterior wall of inguinal canal. Side effects: formation of cysts/ dermoid cyst.
Synthetic meshes- Non absorbable Polypropylene mesh Monofilament Inert; can be used in presence of infection Good elasticity and high tensile strength Non absorbable Used for Hernia repair Abdominal wall construction Sterilized by gamma radiations Fixed with prolene sutures
Synthetic meshes- Non absorbable Polyglactin 910(vicryl) mesh absorbable mesh that offers temporary support during wound healing PTFE or Gore-Tex Soft, flexible non absorbable Impervious to fluids Should not be used in presence of infection
Synthetic meshes- Non absorbable Expanded PTFE (ePTFE) Greatest expansion of all the meshes Useful in abdominal and vascular surgeries Stainless steel mesh Rigid and difficult to work with Causes discomfort to patient
Synthetic meshes- non absorbable Polyester mesh (Mersilene) Least inert synthetic mesh Never be used in presence of infection Fibres may harbor bacteria Polyethylene mesh multifilament,; made of polyester fibre Used for abdominal wall repair and hernia repair
Synthetic meshes- absorbable Polyglycolic acid; Polyglactin 910 Used for wound closure and organ support
Stents A stent is a small mesh Stents usually are made tube thats used to treat of metal mesh, but narrowed or weakened sometimes theyre made arteries in the body. of fabric. Fabric stents, Stents help prevent the also called stent grafts, arteries from becoming are used in larger narrowed or blocked arteries. again in the months or Some stents are coated years after angioplasty with medicines that are slowly and continuously released into the artery. These stents are called drug-eluting stents.
Stents according to location The most widely known stent use is in the coronary arteries with a bare- metal stent, a drug- eluting stent or occasionally a covered stent.Coronary stents are placed during angioplasty.
Stents according to location Ureteral stents are used to ensure the patency of a ureter, which may be compromised, for example, by a kidney stone. This method is sometimes used as a temporary measure, to prevent damage to a blocked kidney, until a procedure to remove the stone can be performed. Indwelling times of 12 months or longer are indicated to hold ureters open, which are compressed by tumors in the neighbourhood of the ureter or by tumors of the ureter itself.
Stents according to location In many cases these tumors are inoperable and the stents are used to ensure drainage of urine through the ureter. If drainage is compromised for longer periods, the kidney can be damaged. The main complications with ureteral stents are dislocation, infection and blockage by encrustation. Recently stents with coatings (e.g. heparin) were approved to reduce infection, encrustation and therefore stent exchanges.
Stents according to location A urethral or Prostatic stent might be needed if a man is unable to urinate. Often this situation occurs when an enlarged prostate pushes against the urethra, blocking the flow of urine. The placement of a stent can open the obstruction.
Stents according to location Stents are used in a variety of vessels aside from the coronary arteries. Stents may be used as a component of peripheral artery angioplasty.
Stents according to location Esophageal stent
Stents according to location A stent graft is a tubular device, which is composed of special fabric supported by a rigid structure, usually metal. The rigid structure is called a stent. An average stent on its own has no covering, and therefore is usually just a metal mesh. Although there are many types of stent, these stents are used mainly for vascular intervention.The device is used primarily in endovascular surgery Stent grafts are most commonly used in the repair of an abdominal aortic aneurysm
Bibliography Bailey and Love’s Short practice of Surgery edition 13, edition 25 Suture and Surgical Haemostasis by Rebecca Pieknik Farquharson’s textbook of operative general surgery edition 9 Bedside clinics in Surgery Makhan lal Saha www.wikisurgery.com