How surgical wound should be closed with suture and it's techniques. What are the alternative to the suture used in the modern world.

1. Wound closure, Suture
material, Technique and
alternative to suture
By : Dr. Kapil Vishvakarama

2. WOUND CLOSURE
• Suturing of any incision and wound need to take in consideration the
site and tissue involved, and the technique should be chosen
accordingly
• There is no ideal wound closure technique and ideal suture for all
situations
• Therefore correct choice of suture technique and suture material is
vital and should never compensate for inadequate operative technique.
• For any wound to heal well there should be good blood supply and no
tension on closure

3. • Clean uninfected wounds with good blood supply heals with primary
intention and therefore closure simply requires accurate apposition of
the wound edges.
• If a wound left open it heals with secondary intention through
formation of the granulation tissue
• Delayed primary closure or tertiary intention is utilized when there is a
high probability of wound being infected, skin grafting is another form
of tertiary intention healing

4. • While choosing a suture material there are certain specific requirement
depending upon the tissue to be sutured
• Vascular anastomosis requires smooth, non-absorbable, non-elastic
material
• Biliary anastomosis requires an absorbable material that will not
promote tissue reaction or stone formation.
• When using absorbable material the time for which wound support is
required and maintained will vary according to the tissue in which it is
inserted.

5. Suture characteristics
• There are five characteristics of the suture that need to consider
• Physical structure
• Strength
• Tensile behavior
• Absorbability
• Biological behavior

6. Physical structure
Monofilament Multifilament

7. Monofilament
• Smooth
• No sawing action
• Difficult to knot
• Damaged by gripping it with
needle holder or forceps
Multifilament
• Braided
• Sawing action
• Easy to knot
• Having capillary action and
interstices where bacteria can
lodge leading to persistent
infection or sinuses
• Silicone coating is done to make
it smooth

8. Strength
• Depends upon
• Constituent material
• Thickness
• Handling
Size of suture material
Metric (EurPh) Range of diameter (mm) USP (old)
1 0.100-0.149 5-0
1.5 0.150-0.199 4-0
2 0.200-0.249 3-0
3 0.300-0.349 2-0
3.5 0.350-0.399 0
4 0.400-0.499 1
5 0.500-0.599 2

9. • The tensile strength of a suture can be expressed as force require to
break it when pulling two ends apart
• Absorbable sutures shows a decay of its strength with passage of time
• However, even non-absorbable suture may degrade with time except
synthetic origin such as polypropylene
• Non-absorbable material of biological origin such as silk will
definitely fragment with time and should never be used in vascular
surgeries

10. Tensile behavior
• Suture material behave differently depending upon their flexibility and
deformability
• Suture material can be ‘Elastic’ or ‘Plastic’
• Some are deformable in which circular cross sectional area is
converted into oval shaped
• Many synthetic material demonstrated memory so that they keep
curling up in the shape they adopted in the package – A sharp gentle
pull helps to diminish the memory
• Greater the memory, lesser the knot security
• Suture loses its 50% tensile strength at the knot

11. Absorbability
This property must be consider when choosing suture material for specific wound
closure and anastomosis
Suture material
Absorbable Non-absorbable
Catgut
Chromic Catgut
Polyglactin
Polyglyconate
Polyglycolic acid
Polydioxanone
Polyglycaprone
Silk
Linen
Surgical steel
Nylon
Polyester
Polybutester
Polypropylene

12. • Suture used in biliary and urinary tract should be absorbable and
vascular anastomosis requires a non-absorbable and smooth material
• Non-absorbable material is used where strength is required as in
artificial graft or prosthesis eg. Polypropylene monofilament

13. Biological behavior
• It depends upon the suture constituent raw material
• Biological and natural sutures, such as catgut are proteolyzed which is
unpredictable and can cause local irritation
• Synthetic polymers are hydrolyzed and there disappearance in the
tissue is more predictable
• Presence of pus, urine or faeces influences the final result

14. Barbed suture
• These sutures have unidirectional or bidirectional barbs that secure the
suture in tissue.

15. Non-absorbable suture material
Suture Types Raw
material
Tensile
strength
Absorption
rate
Tissue
reaction
Contraindic
ation
Frequent uses
Silk Braided,
multifilament
Natural
protein
Loses 20%
when wet;
80-100% lost
by 6 months
absorbed
slowly over
1-2 years
Moderate
to high
Not to use
with
vascular
prosthesis
For securing drains
externally
Linen Twisted Long staple
flax fibres
Stronger
when wet
Loses 50% at
6 months
Non-
absorbable
Moderate Not advised
for use with
prosthesis
Ligation and suturing in
GI surgery
Surgical
steel
Mono or
multifilament
An alloy of
iron, nickel
and
chromium
Infinite Non-
absorbable
Minimal Should not
be used in
conjoint with
prosthesis if
different
material
Closure of sternotomy
wounds
Nylon Mono or
braided
multifilament
Polyamide
polymer
Loses 15-
20% per year
Degrades at
15-20 %
per year
Low None Skin closure, abdominal
wall mass closure, hernia
repair, platic surgery,
neurosurgery, micro and
ophthalmic surgery

16. Suture Types Raw
material
Tensile
strength
Absorption
rate
Tissue
reaction
Contrain
dication
Frequent uses
Polyester Mono or
braided, dyed
or undyed
Polyester Infinite Non-
absorbable
Low None Cardiovascular,
ophthalmic, plastic
and general surgery
Polybutester Monofilament
, dyed or
undyed
Polybutyle
ne
terephthalat
e
Infinite Non-
absorbale
Low None Exabits a degree of
elasticity, favored use
in plastic surgery
Polypropylene Monofilament
, dyed or
undyed
Polymer of
propylene
Infinite Non-
absorbable
Low None Cardiovascular,
plastic, ophthalmic,
general surgical
subcuticular skin
closure

17. Absorbable suture materials
Suture Types Raw material Tensile
strength
Absorption
rate
Tissue
reaction
Contraindicati
on
Frequent uses
Catgut Plain Collagen
derived from
healthy sheep
or cattle
Lost within
7-10 days
Phagocytosis
and
enzymatic
degradation
within 7-10
days
High Not for use in
tissues that
heals slowely
Ligate
superficial
vessels, Other
tissue that heal
rapidly
Catgut Chromic Collagen
derived tanned
with chromium
salts
Lost within
21-28 days
Phagocytosis
and
enzymatic
degradation
within 90
days
Moderate As for plain
catgut
As of plain
catgut
Polyglactin Braided
multifilament
Copolymer of
lactide and
glycolide in
ration of 90:10;
coated with
polyglactin and
calcium
stearate
Approximatel
y 60%
remains at 2
weeks
Hydrolysis
minimal until
5-6 week.
Complete
absorption
60-90 days
Mild Not advised for
use in tissue
that require
prolonged
approximation
under stress
General
surgical use eg.
Gut
anastomosis,
vascular
ligation

18. Suture Types Raw
material
Tensile
strength
Absorption
rate
Tissue
reaction
Contraindica
tion
Frequent
uses
Polyglyconate Monofilament
, Dyed or
undyed
Copolymer
of glycolic
acid and
triethylene
carbonate
Approximately
70% remains at
2 weeks
Hydrolysis
minimal until 8-
9 week.
Complete
absorption by
180- days
Mild Not advised
for use in
tissues that
require
prolonged
approximation
under stress
As an
alternative to
vicryl and
PDS
Polyglycolic
acid
Braided
multifilament,
dyes or
undyed,
coated or
uncoated
Polymer of
polyglycolic
acid
Approximately
40% at 1 week
Hydrolysis
minimal at 2
weeks,
significant at 4
weeks,
complete
absorbtion at
60-90 days
Minimal Not advised
for use in
tissues that
require
prolonged
approximation
under stress
Particular
where
slightly
longer wound
support is
required
Polydioxanone
(PDS)
Monofilament
, dyed or
undyed
Polyester
polymer
Approximately
70% remains at
2 weeks
Hydrolysis
minimal at 90
days, Complete
absorption at
180 days
Mild Not for use in
association
with heart
valve or
synthetic
grafts
Particular
where
slightly
longer wound
support is
required

19. Suture Types Raw
material
Tensile
strength
Absorption
rate
Tissue
reaction
Contraindication Frequent uses
Polyglycaprone Monofilament Copolymer
of glycolite
and
caprolacto
ne
21 days
maximum
90-120 days Mild No use for
extended support
Subcuticular in
skin, ligation,
gastrointestinal
and muscular
surgery

21. Suture techniques
• There are four frequently used suture techniques
• Interrupted sutures
• Continuous sutures
• Mattress sutures
• Subcuticular sutures

22. Interrupted sutures
• It requires the needle to be inserted at the right angles on the incision
and then pass through both aspects of the suture line and exits again at
right angle.
• Needle should be rotated through the tissue

23. • The distance from the entry point of the needle to the edge of the
wound should be approximately the same as the depth of the tissue
being sutured.
• Each successive suture should be placed twice the distance apart.
• In linear wound it is easier to insert
the middle suture first and then
to complete the closure by
successively inserting sutures.

24. Continuous sutures
• First suture is inserted same as interrupted suture, but the rest of the
sutures are inserted in a continuous manner until the end of the wound.
• Each throw of the continuous suture should be inserted at the right
angle to the wound, by doing this externally observed suture material
will usually lie diagonal to the axis of the wound.
• It is important to keeping the suture at the same tension in order to
avoid either purse stringing the wound or leaving the suture material
too slack.
• At the far end of the wound suture line should be secured either by
Aberdeen knot or trying the free end to the loop of the last suture to be
inserted.

26. Mattress sutures
• This suture may be either vertical or horizontal and tend to be produce
either inversion and eversion of the wound edges.
• The initial suture is inserted same as that of interrupted suture, but
then the needle moves either vertically or horizontally and traverses
both edges of the wound once again.
• These sutures are very useful in producing accurate approximation of
the wound edges, especially when the edges to be anastomosed are
irregular in depth or disposition.
• Variation of mattress sutures are: Figure of 8 and half buried suture

27. Vertical Mattress
Horizontal Mattress

28. Subcuticular sutures
• This technique is used in skin where a cosmetic appearance is
important and where skin edges may be approximated easily.
• Suture material can be used either absorbable or non-absorbable.
• For non-absorbable suture, the end may secure by a collar and bead, or
tied loosely over the wound
• For absorbable suture, the end may secure using a buried knot.
• Small bites of the subcuticular tissue are taken on alternate sites of the
wound and then gently pulled together, thus approximating the wound
edges without the risk of cross-hatched marking of interrupted sutures.

30. • Others sutures techniques are
• Simple buried suture
• Simple running locking suture

31. Needles
• In the past, needles have an eye in them and suture material had to be
loaded into them.
• Currently, needles are eye-less or atraumatic with suture material
embedded with in the shank of the needle.
• Needle has three main parts:
• Shank
• Body
• Point

32. • The needle should be grasped by the needle holder approximately one
third to one-half of the way back from the rear of the needle, avoiding
both shank and the point.
• The needle should never be grasped nearer
than one-third of the way back from the rear
of the needle.
• The body of the needle is either round,
triangular or flattened.
• Round body needle gradually taper to
the point while triangular needles have
cutting edges along all the sides.

33. • Conventional cutting needles has there cutting edge facing inside of
the needle’s curvature.
• Reverse cutting needles has there cutting edge facing outside of the
needle’s curvature.

34. • Round bodied needle are designed to separate tissue fibres rather than
cut through them and commonly used in intestinal and cardiovascular
surgeries.
• Cutting needles are used where tough or dense tissue needs to be
sutured, such as skin and fascia.
• Blunt ended needles are now being advocated in certain situation such
as closure of the abdominal wall in order to diminish the risk of needle
stick injuries.

35. • The choice of the needle shape tends to be directed by the accessibility
of the tissue to be sutured.
• If operative space is more confined, more curved needle should be
used.
• Needle holder should be used in all cases to reduce the risk of needle
stick injuries
• Half circle needles are commonly used
in gastrointestinal tract

36. • J-shaped, quarter circle and compound curvature needles are used in
special situations such as the vagina, eye and oral cavity, respectively.

37. Knotting techniques
• The general principles behind knot tying includes:
• The knot must be tied firmly, without strangulating the tissue
• The knot must be unable to slip or unravel
• The knot must be as small as possible to minimize the amount of foreign
material.
• The knot must be tightened without exerting any tension or pressure on the
tissue being ligated.

38. • During tying the suture material must not be ‘sawed’ as this weakens the
thread
• The suture material must be laid square during tying
• When tying an instrument knot, the thread should only be grasped at the free
end.
• The standard surgical knot is the reef knot with a third throw for security.
Monofilament sutures required in vascular surgeries required six to eight
throws for security
• A granny knot involves two throws of the same type of throws and is a slip
knot – used to achieve right tension, but must be followed by a standard reef
knot to ensure security

39. • When added security is required, a surgeon’s knot using a two throws
technique is advisable to prevent slippage
• When using continuous suture technique, an Aberdeen knot may be used for
the final knot.
• When the suture is cut after knotting, the ends should be left about 1-2 mm
long to prevent unraveling

40. Types of knots

43. Alternatives to sutures
• Skin adhesive tapes
• Tissue glue
• Laparoscopic wound closure
• Staples

44. Skin adhesive strips
• For the skin, self adhesive tapes or stripes may be used where there is
no tension and not too much moisture, such as after a wide excision of
a breast lump.
• These may also used to minimize spreading of a scar.
• Adhesive polyurethane films, such as Opsite, Tegaderm or Bioclusive,
may provide a similar benefit, while such transparent dressing also
allow wound inspection and may protect against cross-infections.

45. Tissue glue
• It is based upon a solution of n-butyl-2-cyanoacrylate monomer.
• When it is applied to a wound, it polymerizes to form a firm adhesive
bond, but the wound does need to be clean, dry, with near perfect
hemostasis and under no tension.
• Although it is relative expensive, easy to use, does not delay wound
healing and is associated with relative low infection rate.
• Other tissue glue involves fibrin which works on the principles of
converting fibrinogen to fibrin by thrombin with crosslinking by factor
XIII, and the addition of aprotinin to slow the breaking up the fibrin
network by plasmin

46. • This is used in achieving hemostasis in the liver and spleen, for Dural
tears, in ear, nose and throat and ophthalmic surgery, to attach skin
grafts and also to prevent haemoserous collection under flaps

47. Laparoscopic wound closure
• Laparoscopic wound are generally 3-12 mm in length.
• Skin closure can be carried out with sutures, using curved or straight
needles, or glue and can be further secured with adhesive stripes.

48. Staples
• Mechanical stapling devices were first used successfully by Hümér
Hültl in Hungary in 1908 to close the stomach after resection.
• Today it is wide range of mechanical devices with linear, side-to-side
and end-to-end stapling devices that can be used both in the open
surgery or laparoscopically.

49. Stapling devices
• In gastrointestinal tract, stapling devices tend to apply two row of
staples, offset in relation to each other, to produce sound anastomosis.
• Many of them simultaneously divide the bowel or tissue that has been
stapled while other devices merely insert the staple and the bowel has
to be divided separately

50. End-to-end anastomosis
• Circular stapling devices allow tubes to be joined together, and such
instruments are in common use in the esophagus and low rectum.
• The detached stapling head is introduced into one end of the bowel
and secured by purse string suture. The body of the device is then
inserted into the other end of the bowel, either via the rectum for low
rectal anastomosis or via enterotomy for an esophago-jejunostomy and
the shaft is either extended through a small opening in the bowel wall
or secured by further purse string suture.

51. • Head is reattached to the shaft and the two ends approximated.
• Once the device is fully close, as indicated by the green indicator in
the window, the device is fired and after unwinding, the stapler is
gently withdrawn.
• It is important to assess the integrity of the anastomosis by examining
the ‘doughnuts’ of the tissue.
• It is essential that no extraneous tissue is allowed to become
interposed between the two bowel walls on closing the stapler.

52. Transverse anastomosis
• These instruments, which came in different sizes, simply provide two
row of staples for a single transverse anastomosis.
• Useful in closing bowel ends and the larger sizes has been used to
create gastric tubes and gastric partitioning.
• Bowel should be divided before the instrument is reopened after firing,
as the instrument is designed with a ridge along which to pass a
scalpel to ensure that the cuff of bowel that remains adjacent to the
staple line is of the correct length.

54. Intraluminal anastomosis
• These instruments have two limbs which can be detached.
• Each limb is introduced into a loop of bowel, the limb reassembled
and the device closed.
• On firing, two rows of staples are inserted either side of the divided
bowel, the division occurring by means of a built-in blade that is
activated at the same time as the insertion of the staples.
• Such an instrument may be used in gastro-jejunostomy or jejuno-
jejunostomy and is used in ileal pouch formation.

56. Laparoscopic stapling devices
• Since the early 1990s, increasingly complex surgical procedures have
been performed laparoscopically
• Many of the intestinal stapling devices are now adapted to be inserted
through trocars during laparoscopic surgery, the principles of function
are identical to their open surgical equivalent
• Linear cutting staplers allow bowel and blood vessels to be sealed and
divided.
• Linear and circular staplers also allow intracorporeal anastomosis to
be performed.

57. Thank you