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![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](https://image.slidesharecdn.com/sutureandneedlesforbse-221011143822-afcf2404/75/suture-and-needles-for-BSE-pptx-6-2048.jpg)
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suture and needles for BSE.pptx
- 1. Suture and Needles By DR.MOHD YUSOF B. IBRAHIM JABATAN ORTHOPEDIK HOSPITAL RAJA PEREMPUAN ZAINAB II KOTA BHARU
- 2. • Suture isa 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 evolutionof 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 • Sutureshold 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 • Avariety 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 forat 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 suturematerials Ways to evaluate the properties of suture material: • Physical x´s • Handling x´s • Tissue reaction
- 8. Qualities of theIdeal 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 suturematerial • 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 suturematerial • 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 requiredfor 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 thesuture • 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 • Suturesize 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 • 3thick • 2 • 1 • 0 • 00 • 000 • 0000 • 00000 • 000000 • 0000000 fine
- 15.
- 16. Suture Size • Usethe 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 suturematerial 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 • MonofilamentsMore 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 • Becauseit 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 • Absorbablesutures elicit more inflammatory reaction • Natural sutures absorbed by proteolytic enzymes --- ---→ induce more inflammation than • Synthetic sutures absorbed by hydrolysis.
- 23. Absorbable suture material Naturallyoccurring (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 Vicrylrapide Synthetic Short term Braided vicryl Braided Monocryl Monofilament Medium term Panacryl Braided PDS II Monofilament Long term Absorbable
- 28. Reading the SutureLabel • Company Needle Size Order Code Name Also: LENGTH NEEDLE SYMBOL COLOR Absorbable or Non
- 29. Absorbable suture Gut • Tensilestrength 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 • Secondonly 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 SutureKnot 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 TissueTensile 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 TissueTensile 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 TissueTensile 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 TissueTensile 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 TissueTensile 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 • Mostof 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 eyewhich 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 • Mostsutures with the suture material swaged onto the base of the needle
- 49.
- 50.
- 52. Needle • The maintypes 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.
- 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 ofneedle 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.
- 58. Skin Staples • Verycommon 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 Benzoinor other adhesive • Leave room between strips • Excellent alternative if site won’t get wet • No ointment