Sutures and suturing patterns in surgery & modern innovations

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The slides demonstrated that Suturing are of different methods and styles ,and are applied for different tissues and for different surgical techniques and procedures. Sutures are of Different materials and used for different styles and tissues .
Modern innovations in wound suturing ,wound closure are also described in the slides .

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Sutures and suturing patterns in surgery & modern innovations

  1. 1. SUTURES & SUTURING IN SURGERY BY DR MUKORO DUKE GEORGE B.SC,MBBS,MCS,HSECERT,ATLS,DTM&HLIVERPOOL GRADUATE MEMBER NIM NDUTH,
  2. 2. OUTLINE o INTRODUCTION  HISTORICAL BACKGROUND  DEFINITIONS o QUALITIES OF AN IDEAL SUTURE o CLASSIFICATION/STRENGTH o TYPES/USES o SUTURE SELECTION o SUTURE ACCESSORIES(NEEDLES) o STERILIZATION OF SUTURES o SUTURE REMOVAL o COMPLICATIONS o RECENT ADVANCES o CONCLUSION o REFERENCES
  3. 3. 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.
  4. 4. INTRODUCTION  HISTORICAL BACKGROUND  Sutures are used to improve & speed healing  Hx dates back to 550-3000BC  Early sutures were Flax, Silk, Linen strips & cotton  Synthetic sutures are now available
  5. 5. 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
  6. 6. QUALITIES OF AN IDEAL SUTURE by Lord Mogniham (1865 – 1936)  Sterile and easily sterilizable  Serve all purpose  Minimal tissue :non-electrolytic, non-capillary, non-allergenic, non-carcinogenic (and non-thrombogenic in vascular surgery.  Easy to handle  Hold knot securely  High tensile strength  Favourable absorption profile  Resistant to infection  Available  Inexpensive
  7. 7. Features of a suture 1) 2) 3) 4) 5) 6) 7) 8) 9) Suture stength - Measured by instron tensiometer. Tissue Reactivity Handling Knotting Sterilization Absorbility Viability Elasticity Size
  8. 8. CLASSIFICATION OF SUTURES/STRENGTH  ABSORPTION ABILITY Absorbable ORIGIN Natural Synthetic Non-absorbable Natural Synthetic CONFIGURATION Monofilament Multifilament Monofilament Multifilament  TRAUMATIC & ATRAUMATIC STRENGTH : Ranges from smallest(10/0) to largest(5)
  9. 9. ABSORBABLE NON ABSORBABLE 1. Catgut Silk, 2. Chromic Catgut Linen 3. Dexon (Polyglycolic acid) Cotton 4. Vicryl (Polyglacitin) Horse/Human hair 5. PDS (Polydioxanone) Nylon or Ethilon 6. Collagen Polyester (Teflon) 7. Polypropylene (Prolene) Maxon (Polyglyconate) .8. Poliglecaprone Stainless steel Aluminium Wire Clips Staples Skin tapes Surgical adhesives
  10. 10. TENSILE STRENGTH/ABSORBABILITY Suture T/S loss Absorption tissue Catgut 15 days 60 days Chronic Catgut 30 days 80 – 120 days Polyglyconic 30 days 90 days Polyglactin(vicryl) 32 days 70 days Polydioxanone 56 days 180 days Nylon 25% in 2yrs Prolene Indefinite Dacron Indefinite acid(DEXON)
  11. 11. TYPES/USES  ABSORBABLE – 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
  12. 12. ABSORBABLE - SYNTHETIC  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),Polyglecap rone(monocryl)
  13. 13. 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 & wires  High tensile strength  Hold knots very well  Used in orthopaedic,Neurosurg,& Thoracic surg  Other e.g Virgin silk,cotton, linen
  14. 14. NON-ABSORBABLE - SYNTHETIC  Nylon:Is a polyamide polymer,blue  81% tensile strength at 1yr & 66% at 11yrs  Elicits minimal tissue rxn  Has good memory  Pliable when moist  Premoistened form is used cosmetic plastic surgery  Its elasticity makes it useful for skin closure & Herniorhapy  Other e.g;Polypropylene(prolene),Polyester fiber(Mersilene/Dacron,Ethibond)
  15. 15. 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
  16. 16. Monofilament Suture  Grossly 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
  17. 17. Multifilament Suture  Fibers 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)
  18. 18. SUTURE SELECTION  Depends on surgeons training & preference  Smallest suture is preferable  Tensile strength of suture should not exceed that of tissues  Aesthetics should be considered e.g head&neck  Mobility of the region e.g Limbs & trunk  Tension of the tissues to be sutured e.g major musculocutaneous flaps  Non-absorbable considered in skin,fascia,tendon  Absorbable considered in rapidly healing tissues  Monofiliments preferable in contaminated wounds
  19. 19. 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”.....
  20. 20. SIZE OF SUTURES  OLD GAUGE(USPD)  8/0  7/0          6/0 5/0 4/0 3/0 2/0 0 1 2 3 4 DIAMETER IN MM 0.05 0.O7 0.1 0.15 0.2 0.3 0.35 0.4 0.5 0.6 0.7 0.8
  21. 21. Wound Closure Basic suturing techniques:  Simple sutures  Mattress sutures  Subcuticular sutures Goal: “approximate,, not strangulate”
  22. 22. Ideal Wound Closure  Allow for meticulous wound closure  Easily and readily applied  Painless  low risk to provider  Inexpensive  Minimal scarring  Low infection rate
  23. 23. METHODS OF SUTURING  1. 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
  24. 24. Continuous Locking and Nonlocking Sutures
  25. 25. Simple, Interrupted
  26. 26. Vertical Mattress Good for everting wound edges (neck, forehead creases, concave surfaces)
  27. 27. Horizontal Mattress Good for closing wound edges under high tension, and for hemostasis.
  28. 28. Horizontal Mattress
  29. 29. SUTURE ACCESSORY-NEEDLES      Ideal surgical needle High quality stainless steel Smallest diameter possible Stable in the grasp of needle holder Sharp enough to penetrate tissues with minimal resistance & trauma Sterile & corrosive resistant
  30. 30. ANATOMY OF THE NEEDLE
  31. 31. POINT  Cutting;  Conventional cutting  Reverse cutting  Side cutting  Taper(round needle)  Blunt
  32. 32. BODY  Straight  Half curved  Curved: ski 1/4 circle 3/8 circle 1/2 circle 5/8 circle  Compound curved SWAGE  Channel swage  Drill swage  Non swaged
  33. 33. STERILIZATION OF SUTURES  May affect suture properties to some extent  Gamma Radiation  Ethylene oxide;poisonous gas,is less attractive  Autoclave  Sutures are usually stored in sterile pack by the manufacturers,their integrity must be checked b/4 use
  34. 34. Packaging… Metric Gauge Imperial Gauge Product (re-order) Code Needle size & curvature Needle type Needle point Needle profile Sterilised Ethylene Oxide Do Not Re-use See Instructions for use Expiry date Batch Number
  35. 35. 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
  36. 36. COMPLICATIONS  Usually less if proper selection is followed  Failure  Undo  Tissue rxn  Infection  Abscess and sinus formation  scarring
  37. 37. RECENT ADVANCES  Staples & Clips  Formed from high quality stainless steel  New absorbable clips made of polydiaxone are available  Staples are suitable for skin closure  Stapling gun for bowel anastomosis are popular  Skin Tapes & Adhesives e.g Dermabond  Non-suture methods of closing wound edges  Applied after adequate subcuticular closure  Minimal infection rate & no tissue rxn  EXPENSIVE
  38. 38. 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
  39. 39. Adhesive Tapes Advantages • Least reactive • Lowest infection rate • Rapid application • Patient comfort • Low cost • No risk of needle stick Disadvantages • 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
  40. 40. Staples  More rapidly placed  Less foreign body reaction  Scalp, trunk, extremities  Do not allow for meticulous closure
  41. 41. 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
  42. 42. Dermabond®  Standard surgical wound prep and dry  Crack ampule or applicator tip up; invert  Hold skin edges approximated horizontally  Gently 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
  43. 43. 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.
  44. 44. 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
  45. 45. THANK YOU FOR LISTENING

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