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last 2 tutorial's of general surgery by dr.abdulwa7id 'suturing'

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  • Introduction, include Name and role as SS within Syneture the Specialist Suture division of Tyco. Confirm Tyco incorporates D&G, USS etc. Ask delegates names/if they have sutured before etc. Confirm total length of workshop session. Two main objectives = (a) increase understanding of suture/needle classification & selection = (b) improve upon basic suture skills/techniques. Encourage questions during presentation.
  • Many Surgeons used Catgut previously, it was a commonly used suture. Surgeon’s liked it’s handling characteristics. it was twisted and absorbed quickly. ‘ Caprosyn’ is Tyco’s synthetically developed replacement. ‘ Caprosyn’ is the fastest absorbing monofilament on the market which handles like a braid.
  • Sutures used in the workshop are ‘swaged’ or ‘Atraumatic’. The majority of sutures used by Surgeons are swaged. Mention ‘D-tach’ (pop-off).
  • Contains the key characteristics of a suture Six specific attributes that can be separated into three pairs:- Monofilament / Multifilament Synthetic / Biological Absorbable / Non – Absorbable
  • Confirm that, to conclude an ideal suture material would have the following characteristics ………… ie) absorption rate of Catcut was not consistant,Silk
  • This shows how ETHICON sutures fall into the various classifications. Those which are underlined are the monofilament products. It should be noted that coated VICRYL* Suture and MERSILENE* Suture have a monofilament version for use in ophthalmic surgery. Within the ETHICON suture range , there are:- 6 solely monofilament sutures 7 solely multifilament sutures 12 synthetic sutures 1 biological suture 5 absorbable sutures 8 non – absorbable sutures
  • The picture illustrates that a braided suture is made from many strands of material unlike the monofilament. As a result of these structures there are various advantages and disadvantages, these may affect suture selection.
  • PROLENE : appears to be stronger then nylon and has better overall wound security. BRAIDED : these include cotton, silk, braided nylon and multifilament dacron. Until the advent of synthetic fibers, silk was the mainstay of wound closure. It is the most workable and has excellent knot security. Disadvantages: high reactivity and infection due to the absorption of body fluids by the braided fibers.
  • A monofilament is one of the criteria laid down for the ideal suture. Advantages Monofilaments carry definite advantages relating to their smooth surface. A monofilament easily passes through tissue without drag or causing damage through the sawing action of rough materials. This can be important when there must be minimal tissue damage to ensure a leak proof seal at the site of the suture. Another important consideration with a smooth surface is the lack of tiny interstices or spaces between strands in which bacteria can hide from the large cells of the body’s immune system. Fluids are unable to travel along the length of a monofilament as is possible in multifilaments because of the spaces between multiple strands. These two features have negative implications when infection is present in the vicinity of a suture. Disadvantages Monofilament disadvantages are related to the suppleness of the single strand which can be wiry with a strong material memory leading to handling difficulties and a tendency for knots to unravel. Monofilaments tend to be more stiff than multifilament materials, therefore care must be taken when securing knots and the likely effects of suture ends or tails which could cause discomfort. The degree of stretch may be an undesirable feature in some uses.
  • Advantages They are inherently strong because of their braided construction (similar to a rope). Multifilaments are extremely soft and pliable which provides excellent handling and knotting properties . Knots are also secure and unlikely to slip . Disadvantages Multifilaments can cause more trauma to tissue because of their surface roughness . In addition, the construction of braided materials means that small spaces or interstices exist which can harbour bacterial cells. However , it is worth noting that coating the suture can counter act these problems. Coatings can seal off the interstices thus preventing the presence of bacterial harbours , and coatings can also reduce friction and drag as the suture is pulled through the tissue. Infection can be further complicated by the capillary potential of braided materials which can allow the infection to travel within the suture strand.
  • Synthetic Synthetic materials are man – made, produced by industrial processes. Advantages Synthetic non-absorbable materials do not elicit tissue reaction as they are not absorbed. Synthetic absorbables are polymers which resemble sugars in their chemical structure, therefore they are eliminated easily . Absorption is by hydrolysis, which causes very little tissue reaction . This is in stark contrast to the biological group where absorption or suture breakdown is caused by enzymatic action. Hydrolysis takes place because water (or more correctly - interstitial fluid) interferes with the molecular bonds in the polymer chains which comprise these synthetic materials leading to their breakdown and elimination. Hydrolysis is also a much more predictable absorption method , allowing accurate forecasts of tensile strength retention. Finally, synthetic materials tend to be stronger than their biological equivalents for similar gauge sizes. Disadvantages The drawbacks of synthetic material tend to be related to their structure rather than their chemical composition. They can be more difficult to handle in the monofilament structure and at times, encapsulation can result in the suture being extruded or expelled by the body.
  • Biological materials are those derived from naturally occuring sources such as animal / plant tissues. Biological sutures are now only available in non – absorbables . Advantages Biological sutures are usually quite economica l and tend to have good handling and knotting characteristics . Disadvantages Because biological materials are identified by the body as foreign proteins, proteolytic enzymes are produced which attack the collagen. The process of attack on the collagen causes localised cell necrosis in the region of the implanted material. This is a tissue reaction , which can produce pain and discomfort in skin tissue.
  • These materials are broken down by the body after implementation. Advantages Main advantage is that no foreign body is is left permanently in the patient which could precipitate long term problems . Disadvantages A suture must provide support to a tissue for as long as it’s necessary . If the suture absorbs too quickly, it could lead to wound failure .
  • These are materials which are not broken down by the body, remaining in place permanently . However, it should be noted that some materials are included in this category which can eventually be broken down . For example, silk is broken down by the body over a period of years but it is still considered to be non – absorbable. Advantages They can be used to suture tissues which need long term support, they provide permanent wound support . For example, prosthetic heart valve implants must obviously be held in place by a suture that will never lose its strength. Disadvantages The disadvantage of a non – absorbable suture is that a foreign body is left in the patient . If used for skin suturing there is a strong economic case for considering the use of absorbables to avoid the hidden costs and inconvenience of suture removal. Patients can become anxious about suture removal or require transport and a carer to attend. Occasionally patients may leave sutures in too long and present at another location for wound care. This presence of a foreign body can cause a wound sinus to form. A sinus is a track communicating with an abscess and the skin. In extreme cases, a sinus forms and the body physically expels the suture. Thus is known as suture extrusion.
  • Re-iterate that 5 is very thick and that 11.0 is very very fine. Indicate that brochure U-L6 (sutures and wound closure techniques) are in the delegate bag includes this scale and examples of surgery.
  • The practical difference between suture gauges is illustrated. The volume difference between two neighbouring gauge sizes can be as much as 50%, an important factor when considering that the potential for tissue reactions depends on the volume of materials which is implanted. Another important factor is that the incidence of reactions can depend on the surface area of the suture in contact with the tissue The guiding principle is always that the smallest gauge capable of supporting the wound should be used . Larger gauges do not provide any better wound support, but can increase the potential for problems. These figures are obtained by taking the same length of suture for each gauge and calculating the volume of each cylinder. This also shows sutures knotted around a human hair which is normally around gauge 6/0. Sizes go to as fine as 11/0. Some examples of what gauge size would be used for which tissue type:- FACE 5/0 SCALP & UPPER LIMB 4/0 TRUNK & LOWER LIMB 3/0
  • Summary Reiterate ETHICON has a portfolio of absorbable sutures that cover a range of uses with various specifications. From the short term properties of Coated VICRYL* rapide Suture , to the long term strength and reliability of PDS* II Suture. We are continuing to push the boundaries of wound closure using absorbable sutures which is has been proved through the development and launch of Coated VICRYL* Plus Suture.
  • These are rough guides, it’s really the Surgeon’s preference and no a strict rules apply.
  • The Anatomy of a Surgical Needle will now be considered. We shall examine the aspects illustrated. Needle Point : Penetration of a needle is dependant on the point. Each specific point is designed and produced to the required degree of sharpness to penetrate smoothly the types of tissues to be sutured. Chord Length : The straight line distance from the point of a curved needle to the swage. This can vary from 2mm to more than 2 inches. Length is a determining factor in the width of bite taken by the needle. Swage : This is the area in which the suture is attached to the needle. The swage area is of specific importance to the relationship of needle and suture thicknesses. It is also the weakest point of the needle. The objective of the swage area is to achieve the closest one-to-one suture needle ratio as possible. A one-to-one needle ratio reduces additional trauma which may be caused by the needle or the suture and in addition prevents leakage in anastomotic procedures. Needle Diameter : The gauge or thickness of the needle wire. Needle Diameter various from 30 microns to over 1mm The diameter equals the size of the needle track - except with spatulated or cutting designs. Needle Radius : If the curvature of the needle were to continue to make a full circle, the radius of the curvature is the distance from the centre of the circle to the body of the needle. Think of the needle as part of a circle.
  • Needles are available in various shapes to accommodate the desired depth of bite and the desired "turnout" in specific tissue . The available shapes are shown on the slide. Selection of the needle shape is dependent on the size and depth of the area to be sutured. Use of the 1/4 circle needle is often limited to ophthalmic and microsurgical procedures. A commonly used curved needle is the 3/8 Circle. These needles can be easily manipulated in relatively large and superficial wounds such as closure of the dermis. Because a large arc of manipulation is required , 3/8 Circle needles can be awkward or impossible to use in deep cavities such as the pelvis or in other small difficult to access locations. A 1/2 Circle needle is relatively easy to use in these confined locations, although it requires more rotation of the wrist than a 3/8 circle. The tip of a 1/2 circle needle can become obscured by tissue deep in the pelvic cavity for example. When this occurs the surgeon may have difficulty locating the point to reposition the needle holder and pull the needle through tissue. A 5/8 Circle needle may be useful in this situation, as may a 'J' needle. Straight needles are generally used for skin and compound curved needles for Ophthalmics.
  • Needle Body : Is the portion between point and swage and is used as the grasping area. Needle Arming : The needle should be grasped in the middle to 1/3 of the distance from the swage area to the point. The needle should be placed securely in the tip of the needle holder jaws. After the needle has penetrated the tissue, the needle holder can be used as shown to pull the needle and suture through. Good suturing technique dictates that the needle should only penetrate one side of the wound at a time , it should not bridge both sides of the wound.
  • Suture

    1. 1. Suture
    2. 2. HISTORY The origins of surgery can be traced back many centuries. Through the ages, practitioners have used a wide range of materials and techniques for closing tissue…….. 1650 BC – 2000’s AD
    3. 3. In the tenth century BC, the ant was held over the wound until it seized the wound edges in its jaws. It was then decapitated and the ant's death grip kept the wound closed. Ants
    4. 4. Thorns The thorn, used by African tribes to close tissue, was passed through the skin on either side of the wound. A strip of vegetable fibre was then wound around the edge in a figure eight.
    5. 5. Sterilised Catgut The tough membrane of sheep intestine was provided to the surgeon pre-sterilised and required threading through the eye of the needle before use.
    6. 6. Swaged On Needles Post World War II brought the swaged-on needle. The thread fits into the hollow end of the needle, allowing it to pass through tissue without the double loop of thread that exists with a conventional needle, reducing tissue trauma.
    7. 7. Suture Classification and Selection
    8. 8. Practice Time!
    9. 9. Classification of Sutures Monofilament Multifilament Synthetic Biological Absorbable Non - Absorbable
    10. 10. The Ideal Suture <ul><li>Minimal tissue reaction </li></ul><ul><li>Smoothness - minimum tissue drag </li></ul><ul><li>Low Capillarity </li></ul><ul><li>Max tensile strength </li></ul><ul><li>Ease of handling - Minimum memory </li></ul><ul><li>Knot security </li></ul><ul><li>Cost effectiveness </li></ul>
    11. 11. Sutures <ul><li>MERSILK* Suture </li></ul><ul><li>MERSILENE* Suture </li></ul><ul><li>ETHIBOND* Suture </li></ul><ul><li>PROLENE* Suture </li></ul><ul><li>PRONOVA* Suture </li></ul><ul><li>ETHILON* Suture </li></ul><ul><li>NUROLON* Suture </li></ul><ul><li>Stainless Steel Wire </li></ul><ul><li>Coated VICRYL* Suture </li></ul><ul><li>PDS*II Suture </li></ul><ul><li>VICRYL* rapide Suture </li></ul><ul><li>Monofilament version VICRYL* Suture available for use in ophthalmic surgery </li></ul><ul><li>MERSILENE* Suture - trochanter suture is braided </li></ul><ul><li>ABSORBABLE </li></ul><ul><li>NON-ABSORBABLE </li></ul><ul><li>MONOCRYL* Suture </li></ul><ul><li>Coated VICRYL* Plus Suture </li></ul><ul><li>BIOLOGICAL </li></ul><ul><li>BIOLOGICAL </li></ul><ul><li>SYNTHETIC </li></ul><ul><li>SYNTHETIC </li></ul>
    12. 12. Multifilament (braided) Suture Classification Monofilament
    13. 13. Absorbable Sutures <ul><li>PLAIN GUT : </li></ul><ul><li>Derived from the small intestine of healthy sheep. </li></ul><ul><li>Loses 50% of tensile strength by 5-7 days. </li></ul><ul><li>Used on mucosal surfaces. </li></ul><ul><li>CHROMIC GUT : </li></ul><ul><li>Treated with chromic acid to delay tissue absorption time. </li></ul><ul><li>50% tensile strength by 10-14 days. </li></ul><ul><li>Used in episiotomy repairs. </li></ul>
    14. 14. <ul><li>Polyglycolic acid (Dexon ® ) </li></ul><ul><li>Braided </li></ul><ul><li>Low-memory </li></ul><ul><li>50% tensile strength = 25 days </li></ul><ul><li>Sites = subcutaneous closure skin </li></ul>
    15. 15. Polydioxanone (PDS ® ) <ul><li>Monofilament </li></ul><ul><li>50% tensile strength = 30+ days </li></ul><ul><li>Sites = need for prolonged strength, </li></ul>
    16. 16. Polyglycan 910 (Vicryl ® ) <ul><li>Braided, synthetic polymer </li></ul><ul><li>50% tensile strength for 30 days </li></ul><ul><li>Used: subcutaneous </li></ul>
    17. 17. Non-absorbable Sutures <ul><li>Nylon (Ethilon®) : </li></ul><ul><li>non-absorbable suture </li></ul><ul><li>monofilament </li></ul><ul><li>surface closures.   </li></ul>
    18. 18. Non-absorbable Sutures <ul><li>Polypropylene (Prolene®) : </li></ul><ul><li>stronge r than nylon and has better overall wound security. </li></ul>
    19. 19. silk <ul><li>braided </li></ul><ul><li>Before the advent of synthetic fibers, silk was the mainstay of wound closure . </li></ul><ul><li>workable and has excellent knot security . </li></ul><ul><li>Disadvantages : </li></ul><ul><li>high reactivity </li></ul><ul><li>infection </li></ul>
    20. 20. Monofilament <ul><li>Advantages </li></ul><ul><li>Smooth surface </li></ul><ul><li>Less tissue trauma </li></ul><ul><li>No bacterial harbours </li></ul><ul><li>No capillarity </li></ul><ul><li>Disadvantages </li></ul><ul><li>Handling & knotting </li></ul><ul><li>Ends/knot burial </li></ul><ul><li>Stretch </li></ul>
    21. 21. Multifilament <ul><li>Advantages </li></ul><ul><li>Strength </li></ul><ul><li>Soft & pliable </li></ul><ul><li>Good handling </li></ul><ul><li>Good knotting </li></ul><ul><li>Disadvantages </li></ul><ul><li>Bacterial harbours </li></ul><ul><li>Capillary action </li></ul><ul><li>Tissue trauma </li></ul>
    22. 22. Synthetic <ul><li>Advantages </li></ul><ul><li>Non-Absorbables are inert </li></ul><ul><li>Absorbables resemble natural substances </li></ul><ul><li>Absorption by hydrolysis </li></ul><ul><li>Predictable absorption </li></ul><ul><li>Strength </li></ul><ul><li>Disadvantages </li></ul><ul><li>Monofilament handling </li></ul>
    23. 23. Biological <ul><li>Advantages </li></ul><ul><li>Handling & knotting </li></ul><ul><li>Economy </li></ul><ul><li>Disadvantages </li></ul><ul><li>Tissue reactions </li></ul>
    24. 24. Characteristics of Non-Absorbable Sutures <ul><li>Permanent </li></ul><ul><li>Only used when long term support is required </li></ul><ul><li>Removed when used for skin </li></ul><ul><li>Tissue reaction generally low (except silk) </li></ul><ul><li>True non-absorbable sutures include polyester, polyethylene, polypropylene and steel </li></ul>
    25. 25. Absorbable <ul><li>Advantages </li></ul><ul><li>Broken down by body </li></ul><ul><li>No foreign body left </li></ul><ul><li>Disadvantages </li></ul><ul><li>Consideration of wound support time </li></ul>
    26. 26. Non - Absorbable <ul><li>Advantages </li></ul><ul><li>Permanent wound Support </li></ul><ul><li>Disadvantages </li></ul><ul><li>Foreign body left </li></ul><ul><li>Suture removal can be costly and inconvenient </li></ul><ul><li>Sinus & Extrusion if left in place </li></ul>
    27. 27. Suture Size 5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0 Thick Thin USP (United States Pharmacopoeia) General
    28. 28. Volume % Reduction With Decreasing Size <ul><li>2/0 </li></ul><ul><li>3/0 </li></ul><ul><li>4/0 </li></ul><ul><li>5/0 </li></ul><ul><li>6/0 </li></ul><ul><li>7/0 </li></ul><ul><li>8/0 </li></ul><ul><li>2/0 </li></ul><ul><li>3/0 </li></ul><ul><li>4/0 </li></ul><ul><li>5/0 </li></ul><ul><li>6/0 </li></ul><ul><li>7/0 </li></ul><ul><li>8/0 </li></ul><ul><li>51% </li></ul><ul><li>40% </li></ul><ul><li>49% </li></ul><ul><li>54% </li></ul><ul><li>50% </li></ul><ul><li>44% </li></ul><ul><li>51% </li></ul><ul><li>40% </li></ul><ul><li>49% </li></ul><ul><li>54% </li></ul><ul><li>50% </li></ul><ul><li>44% </li></ul>
    29. 29. Absorbable Sutures <ul><li>VICRYL * </li></ul><ul><li>MONOCRYL * </li></ul><ul><li>Coated VICRYL* </li></ul><ul><li>Coated VICRYL* Plus Antibacterial Suture </li></ul><ul><li>PDS* II </li></ul><ul><li>Skin </li></ul><ul><li>Perineum </li></ul><ul><li>Oral </li></ul><ul><li>Lacerations </li></ul><ul><li>Traumatology </li></ul><ul><li>Ligaments </li></ul><ul><li>Fascia </li></ul><ul><li>Vessel anastomosis </li></ul><ul><li>10 days </li></ul><ul><li>By 42 days </li></ul><ul><li>Wound Support </li></ul><ul><li>Mass Absorption </li></ul><ul><li>Typical Uses </li></ul><ul><li>30 days </li></ul><ul><li>60 days </li></ul><ul><li>20 days </li></ul><ul><li>30 days </li></ul><ul><li>56 - 70 days </li></ul><ul><li>90 - 120 days </li></ul><ul><li>56 - 70 days </li></ul><ul><li>180 - 210 days </li></ul><ul><li>Ligature </li></ul><ul><li>General </li></ul><ul><li>Bowel </li></ul><ul><li>Orthopaedics </li></ul><ul><li>Ligature </li></ul><ul><li>General </li></ul><ul><li>Bowel </li></ul><ul><li>Ophthalmic </li></ul><ul><li>Mucosa </li></ul><ul><li>Obstetrics </li></ul><ul><li>Bowel </li></ul><ul><li>Skin& Ligature </li></ul>
    30. 30. Suture Selection Bowel: 2/0 - 3/0 Fascia: 1 - 0 Skin: 2/0 - 5/0 Arteries: 2/0 - 8/0 Micro surgery 9/0 - 10/0 Corneal closure: 9/0 - 10/0
    31. 31. Needles
    32. 32. Anatomy of a Surgical Needle
    33. 33. Needle point Geometry Taper-Point <ul><li>Suited to soft tissue </li></ul><ul><li>Dilates rather than cuts </li></ul>Reverse cutting <ul><li>Very sharp </li></ul><ul><li>Ideal for skin </li></ul><ul><li>Cuts rather than dilates </li></ul>Conventional Cutting <ul><li>Very sharp </li></ul><ul><li>Cuts rather than dilates </li></ul><ul><li>Creates weakness allowing suture tearout </li></ul>Taper-cutting <ul><li>Ideal in tough or calcified tissues </li></ul><ul><li>Mainly used in Cardiac & Vascular procedures. </li></ul>
    34. 34. Needle Shapes <ul><li>Eye </li></ul><ul><li>Microsurgery </li></ul><ul><li>Dura </li></ul><ul><li>Eye </li></ul><ul><li>Fascia </li></ul><ul><li>Nerve </li></ul><ul><li>Muscle </li></ul><ul><li>Eye </li></ul><ul><li>Skin </li></ul><ul><li>Peritoneum </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Oral </li></ul><ul><li>Pelvis </li></ul><ul><li>Urogenital tract </li></ul><ul><li>Nasal cavity </li></ul><ul><li>Nerve </li></ul><ul><li>Skin </li></ul><ul><li>Tendon </li></ul><ul><li>Eye (Anterior </li></ul><ul><li>segment) </li></ul><ul><li>Laparoscopy </li></ul>
    35. 35. Use of Needle Holders <ul><li>Loading Needle </li></ul><ul><li>Needle passing through skin </li></ul>
    36. 36. Staples, Adhesives & Tape <ul><li>Staples </li></ul><ul><ul><li>Quick, poor aesthetic result </li></ul></ul><ul><li>Adhesives </li></ul><ul><ul><li>Dermabond- painless, petroleum dissolves </li></ul></ul><ul><li>Tape </li></ul><ul><ul><li>Steri-strips </li></ul></ul>
    37. 37. Suture Label
    39. 39. Suture Techniques <ul><li>Simple Interrupted </li></ul><ul><ul><li>Used on majority of wounds </li></ul></ul><ul><ul><li>Each stitch is independent </li></ul></ul>
    40. 40. Suture Techniques <ul><li>Simple Continuous </li></ul><ul><ul><li>Useful in pediatrics </li></ul></ul><ul><ul><ul><li>Rapid </li></ul></ul></ul><ul><ul><ul><li>Easy removal </li></ul></ul></ul><ul><ul><li>Provides effective hemostasis </li></ul></ul><ul><ul><li>Distributed tension evenly along length </li></ul></ul><ul><ul><li>Can also be locked with each stitch </li></ul></ul>
    41. 42. Horizontal Mattress
    42. 43. Horizontal Mattress Good for closing wound edges under high tension, And for hemostasis.
    43. 44. Simple, Interrupted
    44. 46. Suture Techniques <ul><li>Vertical Mattress </li></ul><ul><ul><li>Useful for everting skin edges </li></ul></ul><ul><ul><li>“ Far-far-near-near” </li></ul></ul>
    45. 47. Vertical Mattress Good for everting wound edges (neck, forehead creases, concave surfaces)
    46. 49. Vertical Mattress
    47. 50. Suture Techniques <ul><li>Purse-string </li></ul><ul><ul><li>Useful for stellate lacerations </li></ul></ul>
    48. 53. Closure using Clips
    49. 54. <ul><li>Suture removal </li></ul><ul><ul><li>face: 3-4 days </li></ul></ul><ul><ul><li>scalp: 5 days </li></ul></ul><ul><ul><li>trunk: 7 days </li></ul></ul><ul><ul><li>arm or leg: 7-10 days </li></ul></ul><ul><ul><li>foot: 10-14 days </li></ul></ul>
    50. 55. Thanks for your attention !!!