2. Prepared and presented by: Dr Hamid Rahman
Sabawoon, MD, LMIH,MN
Supervised by: Dr Qadir Omar, MD, Trainer of G.Surgery
افغانســــــــتان اســـــــالمی جمــــــــــهوری
عـــــــــــــــامه صحـــــت وزارت
تخــــصـــــص اکمــــــــــال ریاســــت
بلــــــخی رابعـــــــه کمپــــلکس شفـــــاخانه
عمــــــومی جــــــراحی دیپــــــارتمنـــت
3. What is Suture?
Suture is a strand used to ligate the blood vessels and
approximate the tissues.
A suture is a thread used for uniting wound edges
Materials that had been tried included: gold, silver and
steel wire, silk, linen, hemp, flax, tree bark, animal and
human hair, bowstrings,and gut strings from sheep
and goats.
DR HAMID RAHMAN SABAWOON 3
8. Qualities of an ideal suture: It should
◦ Remain intact until union occurs.
◦ Cause minimum tissue reaction.
◦ Be non-capillary in action.
◦ Be of uniform thickness.
◦ Be knotable.
◦ Have smooth surface.
◦ Have sufficient tensile and functional strength.
◦ Easily sterilizable.
◦ Cheap and readily available
◦ Easy to handle.
مطلوب ٔهبخی نخ
نباشد زاسرطان
باشد نفوذپذیر
نکند بافتی ِتحساسی ایجاد
باشد داشته اعتمادقابل هایگره
شود جذب ،مطلوب ٔهنتیج دادن از پس
نباشد مناسب باکتری رشد جهت
باشد کردناستریل قابل راحتیبه.
(گاز بااکساید اتیلن
DR HAMID RAHMAN SABAWOON 8
12. Characteristics of Sutures Materials
Suture materials can be divided into two categories: absorbable and non-
absorbable.
Absorbable materials have the advantage in that they are less likely to cause an
immune response by the body
Non-absorbable materials can be left in the body permanently if needed.
DR HAMID RAHMAN SABAWOON 12
13. Absorbable Suture Materials
Absorbablesuturematerials are
broken down by the patient’s body.
The original absorbable material was
chromic catgut (still used today).
This is made from animal intestines and
breaks down after 7 days.
Because it breaks down, there is less of a
likelihood of an immune reaction.
DR HAMID RAHMAN SABAWOON 13
14. Non-absorbable Suture Materials
Non-absorbablesutures are made of
materials that are not readily broken down by
the body’s enzymes or by hydrolysis.
Non-absorbable materials can be removed or
left in place permanently
Source: Boston University Medical Campus
DR HAMID RAHMAN SABAWOON 14
15. Absorbable Suture-description
Kangaroo tendon: It is obtained from the tendon of tail of
kangaroo and is used for suturing joint capsule
Fascia lata: It is obtained from the bovine Fascia lata
قابــجلــذب
DR HAMID RAHMAN SABAWOON 15
17. Collagen: It is prepared from bovine flexor tendon
filament .
Polyglactin 910 (vicryl): It is a synthetic absorbable
suture material, prepared from glycolic lactic acid polymer.
Polyglycolic acid (Dexon): It is synthetic suture material
prepared from glycolic acid
DR HAMID RAHMAN SABAWOON 17
18. Catgut
Absorption in tissues can be delayed by treating with
chromic acid.
Catgut therefore available as plain and chromic catgut.
chromic catgut
DR HAMID RAHMAN SABAWOON 18
19. Type Degree of
Chromicity
Approx No.Of
days taken for
absorption
Type A Plain 10 Days
Type B Mild chromic 15 Days
Type C Medium
chromic
20 Days
Type D Extra chromic 40 Days
DR HAMID RAHMAN SABAWOON 19
20. Catgut cont.
Depending on preservative used catgut is available eitheras
boilable or non boilable catgut.
1. Boilable catgut is preserved in xylol,toulene-99.75%,phenyl
merecuric acetate.025%.
2. Non boilable catgut is supplied in tubes containing90-
95%alcohol.
DR HAMID RAHMAN SABAWOON 20
21. Sizes of
catgut
Diameter in
mm(average)
Use
2/0 0.30 Peretoneum,bowel wall(small
animals)and ligaturing vessels
0 or
1/0
0.40 -do-
1 0.48 Muscle
fascia(SA)ligature
larger vessels
2 0.50 -do-
3 0.60 Fascia,muscles(LA)
4 0.70
5 0.80 Rumen uterus
abdomen
DR HAMID RAHMAN SABAWOON 21
23. Non-absorbable Suture
Not degraded, permanent
may be organic; inorganic or synthetic in
nature and are used as both the internal
and external suture materials.
جذبغیرقابل
Non absorbable sutures
DR HAMID RAHMAN SABAWOON 23
25. Non-absorbable Suture
Examples:
◦ Prolene
◦ Nylon
◦ Stainless steel nylon
◦ Silk*
(*not a truly permanent material; known to be broken
down over a prolonged period of time—years)
DR HAMID RAHMAN SABAWOON 25
26. Non-absorbable Organic suture materials
عضوی
Cotton:capillary in nature it clings to
surgeon’s gloves and they spread infection
in wound when applied to skin and luminal
surfaces.
Silk: it may be plain or braided and
capillary in nature
Silk worm gut: non-capillary and useful
for cutaneous sutures
DR HAMID RAHMAN SABAWOON 26
27. cont.
Horse hair: It is cheap, non-capillary, flexible and is
easily sterilized. It causes little tissue reaction.
Linen: It is capillary in nature and produces more tissue
reaction than cotton and silk.
Umbilical tape: used to tie the umbilical cord of the
new born or as vulvar suture in cases of prolapse of
vagina of uterus.
DR HAMID RAHMAN SABAWOON 27
28. Polyester:is a non absorbable, sterile, surgical
suture composed of Poly (ethylene terephthalate).
It suture elicits a minimal acute inflammatory
reaction in tissues.
Polyamide: Being monofilament, Linex is
remarkably smooth and gives excellent knotsecurity.
Posses good tensile strength.
Easy removal with no tissueadherence.
DR HAMID RAHMAN SABAWOON 28
29. Non-absorbable Inorganic suture
material
عضوی غیر
Metallic suture: Wire of different
metals like tantalum, silver,
copper, stainless steel and vitallium
Tantalum: It is inert to tissues like
stainless steel
DR HAMID RAHMAN SABAWOON 29
30. Natural Suture طبیعی
Biological origin
Cause intense inflammatory reaction
Examples:
◦ “Catgut” – purified collagen fibers derived from intestine of healthy sheep or
cows
◦ Silk(non absorbable)
دسته دو به ساخت منبع نظر از:مصنوعی و طبیعی
DR HAMID RAHMAN SABAWOON 30
31. Synthetic Suture مصنوعی
Synthetic polymers
Do not cause intense inflammatory reaction
Examples:
◦ Vicryl(absorbable)
◦ Monocryl
◦ Prolene
◦ Nylon
DR HAMID RAHMAN SABAWOON 31
33. cont..
Silver: It becomes ionized in tissues and cause inflammation.
Copper: It is more suitable to repair fractures due to its
flexibility.
Aluminium wire: It is more flexible than stainless steel.
DR HAMID RAHMAN SABAWOON 33
35. Monofilament Suture
Grossly appears as single strand of suture material; all fibers run
parallel
Minimal tissue trauma
Resists harboring microorganisms
Ties smoothly
Requires more knots than multifilament suture
Examples:
Monocryl, PDS, Prolene, Nylon
DR HAMID RAHMAN SABAWOON 35
36. Multifilament Suture
Fibers are twisted or braided together
Greater resistance in tissue
Provides good handling and ease of tying
Fewer knots required
Examples:
Vicryl (braided)
Chromic (twisted)
Silk (braided)
DR HAMID RAHMAN SABAWOON 36
41. Suture Degradation
Suture Material
Method of
Degradation
Time to
Degradation
“Catgut”
Proteolytic
enzymes
Days
Vicryl, Monocryl Hydrolysis
Weeks to
months
DR HAMID RAHMAN SABAWOON 41
42. Suture Size
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”.....”1”...”2”...”3”.....
DR HAMID RAHMAN SABAWOON 42
46. Needle Qualities
Surgical needles are produced from stainless steel alloys,
resistance to corrosion.
contain a minimum of 12% chromium, which allows a thin,
protective surface layer of chromium oxide to form when the steel
is exposed to oxygen.
Surgical needles made of a high nickel managing stainless steel
have a greater resistance to bending and breakage than stainless
steels without nickel.
Needles
DR HAMID RAHMAN SABAWOON 46
47. High-quality stainless steel
Smallest diameter possible
Stable in the grasp of the needle holder
Capable of implanting suture material through tissue with
minimal trauma
Sharp enough to penetrate tissue with minimal resistance
Sterile and corrosion -resistant to prevent introduction of
microorganisms or foreign materials into the wound
Ideal surgical needle characteristics
DR HAMID RAHMAN SABAWOON 47
48. Point
This portion of the needle extends from the tip to the
maximum cross-section of the body.
Body
This part of the needle incorporates most of the needle
length. The body of the needle is important for interaction
with the needle holder and the ability to transmit the
penetrating force to the point. The needle factors that affect
this interaction include needle diameter and radius, body
geometry, and stainless steel alloy.
Anatomy of a Needle
DR HAMID RAHMAN SABAWOON 48
49. Swage:
The suture attachment end creates a single, continuous unit
of suture and needle. The swage may be designed to permit
easy release of the needle and suture material.
Needle coating:
The needle may be coated with silicone to permit easier
tissue passage. The coating helps reduce the force needed
to make initial tissue penetration and the frictional forces as
the body of the needle passes through the tissue.
Needle Cont…
DR HAMID RAHMAN SABAWOON 49
51. ◦ Atraumatic needles- to suture delicate tissues like
intestine, stomach, bladder, uterus etc.
◦ Double curved and loopuyt needles -for skin
closure of cattle or buffalo and for deeper structures.
Needle Cont…
DR HAMID RAHMAN SABAWOON 51
52. Needles
Straight
◦ Often hand held
◦ Used to secure
percutaneously placed
devices (e.g. central and
arterial lines)
Compound curved:
This needle curvature
was originally
designed for anterior
segment ophthalmic
surgery. The body has
a tight 80° curvature
at the tip, which
becomes a 45°
curvature throughout
the remainder of the
body. A microvascular
compound curved
needle also may
facilitate vessel
approximation in
microvascular
surgery.
Curved
◦ Designed to be held with a
needle holder
◦ Used for most suturing
DR HAMID RAHMAN SABAWOON 52
53. Needles
•
• Eyed needles
– More Traumatic
– Only thread through
once
– Suture on a reel
– Tends to unthread itself
easily
DR HAMID RAHMAN SABAWOON 53
55. Taper-Point
Suited to soft tissue
Dilates rather than cuts
Reverse
cutting
Very sharp
Ideal for skin
Cuts rather than dilates
Conventional
Cutting
Very sharp
Cuts rather than dilates
Creates weakness allowing suture
tearout
Taper-cutting
Ideal in tough or calcified tissues
Mainly used in Cardiac & Vascular
procedures.
Needle point Geometry
DR HAMID RAHMAN SABAWOON 55
56. Needle point Geometry
Blunt
Also known as “Protect Point”
Mainly used to prevent needle stick
injuries i.e. for abdominal wall closure.
Premium point
spatula
Ophthalmic Surgery
Spatula
Ophthalmic Surgery
DermaX*
NEW: ½ The Penetration force
½ The Penetration force
Superior Cosmetic Effect
DR HAMID RAHMAN SABAWOON 56
61. The appropriate needle choice for any situation is
.......................The needle that will cause least
possible trauma to the tissue being sutured.
The Right Needle Choice
DR HAMID RAHMAN SABAWOON 61
62. Using needle holder, grasp needle about
2/3rds of the way back from point.
DR HAMID RAHMAN SABAWOON 62
65. FORCEPS
Grasp forceps between thumb & middle finger, while index
finger is used for stabilization.
If possible, use forceps to grasp dermis, rather than epidermis
or skin surface itself.
This helps prevent marking & injuring of skin at wound edge.
DR HAMID RAHMAN SABAWOON 65
66. Steri-strips
Sterile adhesive tapes
Available in different
widths
Frequently used with
subcuticular sutures
Used following staple
or suture removal
Can be used for
delayed closure
DR HAMID RAHMAN SABAWOON 66
67. Staples
Rapid closure of wound
Easy to apply
Evert tissue when placed
properly
DR HAMID RAHMAN SABAWOON 67
68. 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
DR HAMID RAHMAN SABAWOON 68
69. AMCRYLATE® Gel
Iso-amyl-2-cyanoacylate
Method of application
Control hemorrhage on cutaneous incision on skin
and keep dry using swabs.
Apply few drops of Iso-amyl-2-cyanoacylate over the
wound edges.
Hold skin edges in proper opposition for about 20
seconds to achieve union of skin wound
DR HAMID RAHMAN SABAWOON 69
70. 1. Scalp: 6-8 days
2. Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
3. Ear: 10-14 days
4. Chest and abdomen: 8-10 days
5. Back: 12-14 days
6. Extremities: 12-14 days
7. Hand: 10-14 days
8. Foot and sole: 12-14 days
9. Penis: 8-10 days
10. Condition delaying Wound Healing: 14 to 21 days
1. Chronic Corticosteroid use
2. Diabetes Mellitus
Suture Removal Timing
DR HAMID RAHMAN SABAWOON 70
71. Knots
A suture knot has three components
1- The loop created by the knot
2- The knot itself, which is composed of a number of tight
“throws”, each throw represents a weave of the two
stands
3- The ears, which are the cut ends of the suture
DR HAMID RAHMAN SABAWOON 71
82. Bibliography
Postlethwait, R.W.: Wound healing and surgery. Somerville, New Jersey,
Ethicon, Inc., 1971
Varma, S., et al.: Comparison of seven suture materials in infected wound.
An experimental study. J. Surg. Res., 17:165, 1974
Chaiken, R.W.: Elements of surgical treatment in the delivery of
periodontal therapy. Chicago, Quintessence, 1977
Ethicon, Wound closure manual. Somerville, New Jersey, Ethicon, Inc,
1985, p.9
www.suturs.com
www.myoclinic.com
http://cal.vet.upenn.edu/surgery/index.html
Dr. Sameer A. Mokeem faculty.ksu.edu.sa/sameer/411 PDS
DR HAMID RAHMAN SABAWOON 82