3. INTRODUCTION
The word "suture" describes any strand of material
used to ligate (tie) blood vessels or approximate
(bring close together) tissues to close wounds.
Surgical suture (commonly called stitches) is a
medical device used to hold body tissues together
after an injury or surgery.
Needles made of bone or metals such as silver,
copper, and aluminium bronze wire.
Sutures made of plant materials (flax, hemp and
cotton) or animal material (hair, tendons, arteries,
muscle strips and nerves, silk, catgut).
4. 1100 BC
The earliest reports of
surgical suture date back to
3000 BC in ancient Egypt,
and the oldest known suture
is in a mummy from 1100 BC
500 BC
A detailed description of a
wound suture and the suture
materials used in it is by the
Indian sage and physician
Sushruta, written in 500 BC.
Joseph Lister introduced great
change in suturing technique (as in
all surgery) when he endorsed the
routine sterilization of all suture
threads. He first attempted
sterilization with the 1860s
"carbolic catgut," and chromic
catgut followed two decades later.
5. Goals of
Suturing
Provide an adequate tension of wound closure without dead
space but loose enough to obviate tissue ischemia and necrosis.
Provide
Maintain hemostasis.
Maintain
Permit primary intention healing
Permit
Reduce postoperative pain
Reduce
Provide support for tissue margins until they have healed and
the support no longer needed
Provide
Prevent bone exposure resulting in delayed healing and
unnecessary resorption
Prevent
Permit proper flap position
Permit
6. Suture
Degradation
Suture Material
Method of
Degradation
Time to Degradation
“Catgut” Proteolytic enzymes Days
Vicryl, Monocryl Hydrolysis Weeks to months
PDS Hydrolysis Months
SutureSize
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”.....
8. Principles of
Suturing
1-The completed knot must
be tight, firm, and tied so
that slippage will not occur
2-To ovoid wicking of
bacteria, knot should not be
placed in incision lines
3- Knots should be small and
the ends cut short (2-3mm)
4- Avoid excessive tension to
finer gauge materials as
breakage may occur
5- Avoid using a jerking
motion, which may break the
suture
6- Avoid crushing or crimping
of suture materials by not
using hemostats or needle
holders on them except on
the free end for tying
7- Do not tie suture too
tightly as tissue necrosis may
occur. Knot tension should
not produce tissue blanching
8- Maintain adequate
traction on one end while
tying to ovoid loosing the
first loop
Principles of Suturing
9. Suture
Materials
Criteria :
Tensile strength
Good knot security
Workability in handling
Low tissue reactivity
Ability to resist bacterial infection
Generally categorized by three characteristics:
Absorbable vs. non-absorbable
Natural vs. synthetic
Monofilament vs. multifilament
10. ABSORBABLE
VS NON
ABSORBABLE
SUTURES
PLAIN GUT:
Derived from the small
intestine of healthy
sheep.
Loses 50% of tensile
strength by 5-7 days.
Used on mucosal
surfaces.
CHROMIC GUT:
Treated with chromic
acid to delay tissue
absorption time.
50% tensile strength by
10-14 days.
Used in episiotomy
repairs.
Nylon (Ethilon®): of all the
non-absorbable suture
materials, monofilament
nylon is the most commonly
used in surface closures.
Polypropylene (Prolene®):
appears to be stronger then
nylon and has better overall
wound security.
BRAIDED: includes cotton,
silk, braided nylon and
multifilament dacron.
Before 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.
AbsorbableSutures NonAbsorbableSutures
11. NATURALVS
SYNTHETIC
SUTURES
Biological origin
Cause intense
inflammatory reaction
Examples:
“Catgut” – purified
collagen fibers from
intestine of healthy
sheep or cows
Chromic – coated
“catgut”
Silk
Synthetic polymers
Do not cause intense
inflammatory reaction
Examples:
Vicryl
Monocryl
PDS
Prolene
Nylon
NaturalSutures SyntheticSutures
12. MONOFILAMENTVS. MULTIFILAMENT STRANDS
Sutures are classified according to the number of strands of which they are comprised.
Monofilament sutures are made of a single strand of material.
Multifilament sutures consist of several filaments, or strands, twisted or braided together.
This affords greater tensile strength, pliability, and flexibility.
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
Possesses memory
Examples:
Monocryl, PDS, Prolene, Nylon
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)
13. Shapes of
Needles
3/8 circle
1/2 circle
Straight
Specialty
Curved
Designed to be held with a
needle holder
Used for most suturing
Straight
Often hand held
Used to secure percutaneously placed devices
(e.g. central and arterial lines)
20. Technique of
Suturing
The technique of suturing
begins by selecting the tissue
forceps, needle and needle
holder.
Hold the needle holders in your
dominant hand by placing the
thumb and ring finger into the
rings and the index finger on the
hinge of the blades.
This position permits good
control of the instrument.
Scissors should be held in a
similar position.
21. The needle should be grasped in the holders on its flattened
area approximately one-third of its length away from the
suture material.
To facilitate eversion (turning outwards), support the wound
edge with the tissue forceps and insert the needle 5 mm from
the edge perpendicular to the skin surface.This creates good
apposition without excessive tension.
Ensuring that the needle remains at right angles to the
wound, follow the natural curve of the needle by rotating the
wrist and move through each side of the wound separately.
Do not be tempted to traverse both wound edges with one
bite of the needle
When the needle emerges from the wound, pull the suture
through the tissues until a short tail remains at the initial skin
entry site.
Then enter the opposite side of the wound at the same depth as
the first bite. Again, follow the natural curve of the needle by
rotating your wrist so that the needle emerges at the same
distance from the wound edge as the first bite and at right angles
22. To tie the suture, keep the needle holders
parallel to the skin and grasp the needle
end of the suture. Then make two
clockwise loops around the needle
holder, followed by a single anti-
clockwise throw.
Note that each successive throw is looped around
the forceps in the opposite direction to the last
and that all the knots should be seated on the
same side of the wound.The suture can then be
cut free from the knot, leaving tail lengths of
approximately 5 mm, before beginning the next
insertion.
23. INTERRUPTED
SUTURES
Interrupted sutures use a
number of strands to
close the wound. Each
strand is tied and cut
after insertion.This
provides a more secure
closure, because if one
suture breaks, the
remaining sutures will
hold the wound edges in
approximation.
Interrupted sutures may
be used if a wound is
infected, because
microorganisms may be
less likely to travel along
a series of interrupted
stitches.
24. Simple
Interrupted
sutures
• This suture is used for simple laceration closures or closure of
office procedures like biopsies or lesion removals.
• It is also the basic suture used inside the wound to close deep
sutures.
• It is useful in that a few sutures can be removed at a time
instead of all at once to allow for slower sound healing
25. Horizontal
Mattress
Suture
• Used with wounds with poor circulation
• Helps eliminate tension on wound edges
• Requires fewer sutures to close a wound
• Can be placed quite quickly
• Can be done as a continuous suture
26. Vertical
Mattress
Sutures
• Deep and shallow approximation of the tissue
• Can be used for wounds under tension.
• Can be useful with lax tissue e.g. elbow and knee.
• Should not be used on volar surface of hands or feet or on the
face because of blind placement of the deep part of the
suture.
28. Basic knot tying
square knot
granny knot
slip knot
surgeon’s
knot
• Simple Knot : Incomplete basic unit
• Square knot : completed knot
• Surgeons Friction knot : completed
tension knot
Suture knots must be properly placed to
be secure. Speed in tying knots may
result in less than perfect placement of
the strands. In addition to variables
inherent in the suture materials,
considerable variation can be found
between knots tied by different surgeons
and even between knots tied by the
same individual on different occasions.
36. BestCosmetic
Results
Smallest size needle
Monofilament
Good wound eversion
SkinSuture
Placement
Close wound in segments
Sutures equidistant from skin
edge on either side
of wound
Evert skin edges
Wound margins loosely
approximated
Repeatedly bisect the wound
“Wound edges should be
approximated,
not strangulated!”
• Too tight = tissue necrosis
• Too loose = edges not aligned
37. 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
38. Suture Removal
Time frame for removing
sutures:
Average time frame is 7-10 days
FACE: 4-5 days
BODY & SCALP: 7 days
SOLES, PALMS, BACK OR
OVER JOINTS: 10 days
Any suture with pus or signs of
infections should be removed
immediately.
Principles forSuture
Removal
1-The area should be swabbed with hydrogen
peroxide for removal of encrusted necrotic
debris, blood, and serum from about the
sutures
2- A sharp suture scissors should be used to cut
the loops of individual or continuous sutures
about the teeth
3- It is often helpful to use a No. 23 explorer to
help lift the sutures if they are within the
sulcus or in close opposition to the tissue
4- A cotton pliers is used to remove the suture.
The location of the knots should be noted so
that they can be removed first. This will
prevent unnecessary entrapment under the
flap
5- Suture should be removed in 7 to 10 days to
prevent epithelialization or wicking about
the suture
39. CONCLUSION
Clinician should have a sound knowledge of the material
property as well as the technical aspect of the ART OF
SUTURING for better clinical decision making and appropriate
management.
41. MODIFIEDSUTURING
Eliptical incision : The ellipse should be
three times as long as it is wide. This will
make closure of the wound much easier. If
the lesion you are removing is likely to be
cancerous, make sure that you leave wide
margins of clear skin around the lesion.
3 Cornered Suture :
•Used to close a skin flap which
comes to a point.
•Helps close the wound, but
maintain circulation to the tissue.
•Places minimal tension on the
wound edges
