suturing technique and needles type

1. Suture and Needles
By
DR. MOHD YUSOF B. IBRAHIM
JABATAN ORTHOPEDIK
HOSPITAL RAJA PEREMPUAN ZAINAB II
KOTA BHARU

2. • Suture is a generic term for all materials used to
bring served body tissue together and to hold these
tissues in their normal position until healing takes
place

3. History and evolution of surgical
sutures (2000 BC to present)
• Gut of sheep intestines was first mentioned as
suture material AD 200
• Surgical gut, or cat gut AD 900 Al Rhazi
• Gold, silver, metalic, wire, silkworm, gut, silk,
cotton, linen, tendon, and intestinal tissue

4. Suture Selection
• Sutures hold tissue together until the natural process
of wound healing has taken place
• All sutures are foreign bodies and impact on wound
healing
• Sutures may be:
– Left in place indefinitely (closure of abdominal
fascia)
– Removed following adequate healing (superficial
laceration)

5. Suture materials
• A variety of suture materials are available for ligating,
suturing and closing the wound
• The appropriate suture is selected according to:
√ whether it is absorbable or nonabsorbable
√ its tissue reactivity
√ Its breaking strength
√ monofilament or multifilament
√ Its knot tying security
√ Tensile sterile time

6. Plain catgut
Chromic
catgut
Polydioxanone
(PDS)
RAPIDE
POLYGLACTIN
910
Tensile
strength
Strength retention
for at least 7
days.
Maintains
strength for 10–
14 days[2]
Wound support can
remain up to 42
days, however
tensile strength
decreases to about
70% at 14 days and
25% at 42 days
approximately 65%
at 14 days
postimplantation.
absorption
absorption
complete by 90
days.
Proteolytic
enzymatic
digestion
complete in 70
days.
80% at 2 weeks,
44% at 8 weeks.
Complete absorption
within 200 days[2]
Absorption is
minimal for 40 days
and complete in 56-
70 days

7. Characteristics of suture materials
Ways to evaluate the properties of suture
material:
• Physical x´s
• Handling x´s
• Tissue reaction

8. Qualities of the Ideal Suture Material
1- Pliability, for ease of handling
2- Knot security
3- Sterilizable
4- Appropriate elasticity
5- Nonreactivity
6- Adequate tensile strength for wound healing
7- Chemical biodegradability as opposed to foreign body
breakdown

9. Properties of suture material
• Handling of a suture
– Memory
• Tendency to stay in one position
• Leads to difficulty in tying sutures and knot
unravelling
– Elasticity
• Ability to return to its original length after
stretching
• High elasticity sutures should be used in
oedematous tissue

10. Properties of suture material
• Tensile strength
– Force necessary to break a suture
– Important to consider in areas of tension
( linea alba, ITT)
• Tissue reaction
– Undesirable since inflammation worsens the
scar
– Maximal between Day 3&7
– factors
• Non-absorbable or absorbable
• Monofilament or multifilament

11. Knot Strength
Force required for a knot to slip
Important to consider when ligating arteries
etc
• Generally 4 “throws” for >90% knot security
(nylon may need 5)
– Less “throws” = more likely to untie itself
• Stainless steel = exception again
– 2 “throws” = 99% knot security

12. Handling of the suture
• Related to pliability of the suture (flexibility/ Pliability of
movement)
• Pliable suture is less secure knot
• A suture with a high friction coefficient tends to drag
through tissue
• Some suture materials are coated to reduce their
coefficient of friction
• This coating not only (improves the way they pull through
tissue on insertion and later removal)

13. Suture Size
• Suture size is reflected in “0’s”
• 4.0 vicryl is “0000”
• Number one vicryl is “#1”
• O vicryl is “0”
• The more “0” the finer the stitch
• Size originally scaled from 0-3
• As technology advanced and sutures became smaller,
extra 0s were added
• Scale now ranges from 3 (largest) to 12/0 (smallest)

14. Suture Size
• 3 thick
• 2
• 1
• 0
• 00
• 000
• 0000
• 00000
• 000000
• 0000000 fine

15. Suture Size

16. Suture Size
• Use the smallest size suture that can hold the
tissue together during the healing process
• Fascia heals slowly - use bigger, stronger
suture
• Mucosa heals quickly, use smaller suture

17. Size of suture material
Size Uses
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels
4/0
Mucosa, neck, hands, limbs, tendons,
blood vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
0 and larger
Abdominal wall, fascia, drain sites,
arterial lines, orthopaedics

18. Monofilament vs Multifilament
• Monofilament (Ethilon or Prolene)
– Consists of a single smooth strand
– Less traumatic since they glide through tissues
with less friction
– May be associated with lower rates of infection
– Preferred for skin closure because they provide a
better cosmetic result

19. Monofilament vs Multifilament
• Multifilament (Mersilk or Mersilene)
• Consists of multiple fibres woven together
• Easier to handle and tie and knots are less likely to
slip

20. Monofilament vs
Multifilament
• Monofilaments More likely to slip ---- knots should
be secured with more throws to prevent slip --- 5 or
6 ‘throws’ (in contrast to 3 throws with
multifilament)
• Braided sutures handle easily and knot easily
• Braided suture may harbor bacteria

21. Tissue reaction
• Because it is a foreign body, all suture material
causes some tissue reaction
• Tissue reaction begins d2
 suture injury to the tissue during insertion
 tissue reaction to the suture material
• The reaction begins with infiltration of WBC,
macrophages and fibroblasts
• by about the 7th day, fibrous tissue with chronic
inflammation is present
• The reaction persists until the suture is
 encapsulated (nonabsorbable material) or
 absorbed (absorbed material)

22. Tissue reaction
• Absorbable sutures elicit more inflammatory
reaction
• Natural sutures absorbed by proteolytic enzymes ---
---→ induce more inflammation than
• Synthetic sutures absorbed by hydrolysis.

23. Absorbable suture material
Naturally occurring (degraded enzymatically)
• Catgut
consists of processed collagen from animal intestines
broken down after 7 days
• Chromic catgut
– Intestinal collagen treated with chromium
– Loses tensile strength after 2-3 weeks and broken
down after 3 months
Synthetic
• Degraded non-enzymatically by hydrolysis when water
penetrates the suture filaments and attacks the polymer
chain
• less tissue reaction

24. Absorbable suture material
• Subclassified according to degradation time

25. Non-absorbable suture material
• Composed of materials which can be:
Naturally occurring (Mersilk, cotton and steel)
Synthetic (Prolene, Ethilon, Nurolon, etc)

26. Suture material summary
Mersilk
Natural
Nurolon
Ethibond
Braided
Ethilon
Prolene
Monofilament
Synthetic
Non-absorbable
Catgut
Natural
Vicryl rapide
Synthetic
Short term
Braided vicryl
Braided
Monocryl
Monofilament
Medium term
Panacryl
Braided
PDS II
Monofilament
Long term
Absorbable

28. Reading the Suture Label
• Company
Needle
Size
Order Code
Name
Also:
LENGTH
NEEDLE
SYMBOL
COLOR
Absorbable
or Non

29. Absorbable suture
Gut
• Tensile strength for 4-5 days only
• High tissue reactivity
• Poor tensile strength for a given suture diameter
• Monofilament
Uses: tubal ligation, ligation of blood vessels

30. Absorbable Suture
Chromic gut
• Tensile strength for 2 to 3 weeks
• High tissue reactivity
• Poor tensile strength for a given tissue diameter
• Monofilament
Uses: episiotomy repair, uterine closure, closure of
peritoneum

31. Absorbable Suture
Poly-sugars
• Dexon, Vicryl, Polysorb
• Synthetic polymers with modest tissue reactivity
• Tensile strength for 2 to 3 weeks
• 10% strength at 28 days
• Low elasticity - may cut soft tissue
• Braided - handle well but wick fluid
• Good for subcuticular closure and fascia

32. Absorbable Suture
PDS Maxon
• Monofilament
• Delayed absorption
• 59% strength at 28 days
• Minimal tissue reaction
• Less suture abscesses and cut through than vicryl
• Complete absorption by 180 days

33. Absorbable Suture
Monocryl Biosyn
• Virtually inert in tissue
• Tensile strength for 2 to 3 weeks
• Less suture absesses
• Great for mucosa and skin closures

34. Permanent Suture
Silk
• Second only to gut for tissue inflammation
• Braided
• Best handling of any suture
• Lowest tensile strength of any suture
• Weaker when wet

35. Permanent Suture
Nylon
• Surgilon, Ethilon, Dermalon
• Inert
• Pronounced memory - lots of knots
Uses- skin closure, sewing in JP draines

36. Permanent Suture
Polypropylene
• Prolene, Surgilene, Surgipro
• Inert
• High placticity - expands to prevent strangulation,
but loosens when edema subsides (use with steri-
strips)
• Will stretch when pulled
• Elastic - requires extra knots
Uses- wound closure

37. Permanent suture
Braided polyester
• Ticron, Tevdek, Ethibond
• Greater tensile strength than other permanent
sutures
• Good hadling with secure knots
Use: pelvic reconstruction

38. Sutures and Suturing
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Plain gut Collagen from Digested + Moderate + + + Plain Rapidly +
healthy by body (Least) + + + + healing
mammals enzymes mucosa
within avoid
70 days suture
removal
Chromic gut Collagen from Digested + Moderate + + + Chromic As above +
healthy by body but less Slower
mammals enzymes than plain absorption
treated with within gut
chromic salts + + + +
Suture materials:

39. Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Coated Copolymer of Hydrolysis + + + Mild + + Braided Subepi- + + + +
Vicryl lactide and 56-70 days + + coated elial
(Polyglactin glycolide Mucosal
910) coated with surfaces
polyglactin Vessel
370 and ligation
calcium All types
stearate of general
closure
PDS Polyester Slow + + + + Slight + + Mono- Absorbable + +
(polydi- polymer hydrolysis + filament suture with
oxanone) 180 - 210 extended
days wound support
Suture materials:

40. Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Dexon Homopolymer slow + + + Mild + + Braided subepith- + + +
(polygly- of glycolic hydrolysis + + coated elial
colic acid coated after 60 - sutures
acid) with 90 days Mucosal + + + +
polaxamer surfaces
188 Vessel
ligation
Surgical Natural Usually + + Moderate + Braided Mucosal + + + +
Silk protein cannot be + + + + (least) surfaces
fiber of raw found after
silk. Treated 2 years
with silicon
protein or wax
Suture materials:

41. Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Nylon Polyamide Degrades at + + + Extremely + + Mono- Skin + +
Duralon polymer a rate of 15- low filament closure
Ethilon 20%per year 0 - +
Nylon Polyamide Degrades at + + + Extremely + + Braided Skin + + + +
Nurolon polymer a rate of 15- low closure
Surgilon 20%per year 0 - + Mucosal
surfaces
Polyester Polyester Nonabsorbable + + + Minimal + + + Braided Cardiova- + + +
Mersilene Polvethylene + scular and
Dacron Terephthalate plastic
Ethibond surgery
General/
Orthop
surgery
Suture materials:

42. Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Prolene Polymer of Nonabsorbale + + + Minimal+ + + Mono- General, + +
(polypro- propylene transien filament plastic,
pylene) acute cardiova-
reaction scular, skin
opthalmology
Gor-Tex Expanded Nonabsorbale + + + Extremely + + Mono- All Types + + + +
polytetrafluoro- low filament of soft-
ethylene 0 - + tissue
approxi-
mation &
cardiova-
scular
surgery
Suture materials:

43. Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Monocryl Poliglecaprone Hydrolysis + + + + Minimal + + + Mono- Soft- Most
25 Copolymer 90 - 120 + filament tissue pliable
of glycolide & days closure Synthetic
caprolactone absorbale
mono-
filament
ever
Suture materials:

45. Surgical Needles
• Most of surgical needles are fabricated from heat
treated steel
• The surgical needle has a basic design composed of
three parts
1- Eye
2- Body
3-Point

47. Surgical Needles
1-The eye which is swaged and permits the suture and
needle to act as a single unit
2- The body which is the widest point of the needle and
is also referred to as the grasping area. The body
comes in number of shapes (round, oval, rectangular,
trapezoid, or side flattened)
3- The point which runs from the tip to the maximum
cross-sectional area of the body. The point also
comes in a number of different shapes (conventional
cutting, reverse cutting, side cutting, taper cut,taper,
blunt

48. Needle eye
• Most sutures with the suture material swaged
onto the base of the needle

49. Needle body

50. Needle point

52. Needle
• The main types of needle include:
– Tapered
• Gradually taper to the point and cross-section reveals
a round, smooth shaft
• Used for tissue that is easy to penetrate, such as
bowel or blood vessels
– Cutting
• Triangular tip with the apex forming a cutting surface
• Used for tough tissue, such as skin (use of a tapered
needle with skin causes excess trauma because of
difficulty in penetration)
– Reverse cutting needle
• Similar to a conventional cutting needle except the
cutting edge faces down instead of up
• This may decrease the likelihood of sutures pulling
through soft tissue

53. Size of needle

54. Shape of needle
• Shapes vary from a quarter circle to five-eighths of a
circle, depending on how confined the operating field is

55. Needle
• Choice of needle should ‘alter the tissue to be
sutured as little as possible’ and is dependent on:
– The tissue being sutured
(when in doubt about
selection of a taper point or
cutting needle, choose the
taper for everything except
skin sutures)
– Ease of access to the tissue
– Individual preference

57. Summary of
needle
characteristic

58. Skin Staples
• Very common in human medicine
• Expensive
• Very easy
• Very secure
• Very little tissue reaction
• Removal =
– Special tool required

59. Tissue Adhesive
• Nexaband, Vetbond,
and others
• Little strength
• Should not be placed
between skin layers or
inside body

60. Steri-strips
• Tincture Benzoin or
other adhesive
• Leave room between
strips
• Excellent alternative if
site won’t get wet
• No ointment