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Suture, needle and knots
- 2. Definition Sutures: term for material used to align several body tissue together, to hold in place while healing occurs. Ligature/ tie: A strand of suture material that is used to: Tie off blood vessel Prevent hemorrhage/ bleeding Isolate tissue while excising
- 3. Suturing – Goals Provide adequate tension for wound closure but loose enough to prevent tissue ischaemia & necrosis. Protecting underlying tissues from infection or other irritating factors. Preventing post-operative haemorrhage. Permitting healing by primary intention. Preventing bone exposure resulting in delayed healing & bone resorbption. Permit proper flap position.
- 4. Ideal Suture – Qualities Minimal tissue reaction Smoothness - minimum tissue drag Easily Sterilisable Adequate tensile strength Ease of handling - Minimum memory Knot security Cost effectiveness Favourable absorption profile Resistance to infection
- 5. Suture material– Types Behavior – Tissue : Absorbable / Non-absorbable Structure : Monofilament / Multifilament Origin : Natural / Synthetic
- 6. Suture material: behaviour- tissue Absorbable Non - Absorbable
- 8. Suture material- origin Absorbable – Natural Plain catgut: Light. Derived from submucosa of sheep intestine or serosa of beef intestine. Used for ligating superficial blood vessels & subcutaneous fatty tissues. Chromic catgut: Yellow. Treated with chromium salt. It may be used in the presence of infection & in cancer cases. Absorbable – Synthethic Polyglactin (Vicryl): purple, copolymer of Lactide &Glycolide. Minimal tissue reaction. Used in general soft tissue approx ;Intestinal anastomosis, Vessels ligation in all surgical specialties. Dexon (Polyglyconic acid): purple/cream, homo polymers of glycolide. Avoid in adipose tissue & losses tensile strength more rapidly thanvicryl. Others:e.g; Polyglyconate(maxon), Polydiaxone(PDS), Polyglecaprone(monocryl)
- 9. Non – Absorbable – Natural Surgical silk: Black. Derived from the cocoon of the silk worm larvae, trigger inflammatory reactions, undergo proteolysis & undetected by 2yrs. Used in ligating major blood vessels, tendon repairetc. Surgical steel & wires : High tensile strength & Hold knots verywell Used in orthopaedic, Neurosurg & Thoracic surgery Others: e.g; Virgin silk, cotton, linen Nylon Is a polyamide polymer, Blue /White 81% tensile strength at 1yr & 66% at11yrs Elicits minimal tissue reaction Has good memory Pliable when moist Premoistened form is used in cosmetic plastic surgery Its elasticity makes it useful for skin closure & Herniorrhapy Others : e.g; Polypropylene (Prolene), Polyester fiber (Mersilene/Dacron/Ethibond) Non – Absorbable – Synthetic
- 11. Suture material- structure Grossly appears as single strand of suture material; all fibres run parallel Minimal tissue trauma. Resists harbouring 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 off tying Fewer knots required Examples: * Vicryl (braided) * Chromic (twisted) * Silk (braided) MultifilamentMonofilament
- 13. Color coding
- 14. Suture Degradation Suture Material Method of Absorption Time to Absorb Catgut Proteolytic enzymatic digestive process. Days Vicryl Hydrolysis. Weeks PDS Slow Hydrolysis. Months Silk / Nylon Gradual encapsulation by fibrous connective tissue. Years
- 15. 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.) Sized range from 7 (largest) to 11-0 (smallest) Smaller [Thick]< --------------------------> [Thin] Larger .....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....
- 16. Suture indication by location
- 17. Needle – Anatomy
- 18. Needle point - Geometry Taper-Point (Round) •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.
- 19. Needle Shapes Eye Microsurgery Nasal cavity Nerve Skin Tendon Dura Eye Fascia Nerve Eye (Anterior segment) Muscle Eye Skin Peritoneum Laparoscopy Cardiovascular Oral Pelvis Urogenital tract
- 20. Ideal Suture – Needle High quality stainless steel Smallest diameter possible Stable in the grasp of needle holder Sharp enough to penetrate tissues with minimal resistance & trauma Sterile & corrosive resistant
- 21. Use of Needle Holders Loading Needle Needle passing through skin
- 22. Technique Needle should be grasped with the needle holder approx. 1/3 distance from the eye & 2/3 from the point. Needle should be placed perpendicular to surface being entered & pushed through tissues following curvature of the needle & rotating the wrist. Needle enters 2-3mm away from the margin of the flap & exists at the same distance on the opposite side. The two ends of the suture are then tied in a knot & cut 0.8cm above the knot. Knot should never lie on incision line. Never close under tension.
- 23. The Suture Packaging STRAND SIZE MATERIAL STRAND LENGTH PRODUCT CODE NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE NEEDLE LENGTHCOLOUR POINTTYPENEEDLE CIRCLE
- 24. Suture Techniques 1. Simple sutures Simple- interrupted Good for irregular wounds Simple- continous 2. Mattress sutures Mattress- vertical Good for thick and thin skin Mattress- horizontal Looks bad early 3. Subcuticular sutures Quick, for linear wounds
- 25. Simple – Interrupted Suturing is passed through both edges at an equal depth & distance from the incision & knot is tied. Common & Stronger. Each suture is independent & loosening of one suture will not produce loosening of other. Advantage Disadvantage •Easy to execute •Rapid •Disruption of 1 suture doesn’t result in suture line failure •Excessive tension yields inversion/ eversion •Costly in terms of time & suture (foreign) materials.
- 26. Simple – Continuous Similar to simple interupted except this is continous. No knots are applied between until incision line is sutured. Useful in pediatrics Can also be locked with each stitch Advantages Disadvantages •Simple & fast with less requirement of suture materials. •Easy removal •Provides effective hemostasis •Distributed tension evenly along length •If 1 stitch is untied, rest stitches can be lost.
- 27. Mattress – Vertical It has a far – far- near – near order of bites. The knot is perpendicular to the wound edge. Useful in maximising wound eversion , reducing dead space and minimising the tension across the wound. Advantage Disadvantage Doesn’t interfere with blood supply of the skin Consumes more suture materials and consumes more time
- 28. Mattress – Horizontal Used for high – tension wounds or wounds with fragile skin. The knot is parallel adjacent to the wound edge. Useful in maximising wound eversion , reducing dead space and minimising the tension across the wound. Advantage Disadvantage Can be placed in the areas where much tension is placed on the skin. It interferes with blood supply to the skin & interferes with healing
- 29. Subcuticular suture ◦ Continous or interrupted sutures ◦ Placed in the dermis, beneath the epitherlial layer ◦ Continous subcuticular sutures are placed in a line parallel to the wound. Advantage Disadvantage •Excellent cosmetic closure •No stitch remove •Technically more difficult to master •Doesn’t hold in thin skin
- 30. Suture pattern for specific tissues Skin Simple interrupted, horizontal mattress, vertical mattress Subcutaneous tissue Simple continuous Fascia Simple continuous (primary), simple interrupted, vertical mattress Peritoneum Simple continuous (2 layer), simple interrupted Vessels Simple interrupted, simple continuous Muscle Simple continuous, simple interrupted, horizontal mattress
- 31. Suture removal Scalp: 5 days Face: 2- 3 days Ear: 4-5 days Trunk: 7 days Chest/ abdomen: 8-10 days Arm or leg: 7-10 days Hand: 8-10 days Foot: 10-14 days
- 32. Recent Advances Staples Formed from high quality stainless steel Tapes - Steristrips Use of tissue adhesive adjunct (benzoin) Suitable for skin closure Adhesives A sterile, liquid topical skin adhesive Reacts with moisture on skin surface to form a strong, flexible bond Only for approx. skin edges of wounds Rarely used for primary closure
- 33. Surgical Knots
- 34. Square or Reef knot Square knot formed by wrapping the suture around the needle holder once in opposite directions b/w ties. 3 ties are recommended. The two-hand square knot is the easiest and most reliable for tying most suturematerials. It may be used to tie surgical gut, virgin silk, surgical cotton and surgical stainless steel.
- 35. Surgeon’s or Friction knot It is formed by 2 throws of suture around the needle holder on the first tie & one throw in the opposite direction on the 2nd tie. The surgeon's recommended for or friction knot is tying braided synthetic absorbable suture, VICRYL*/ ETHIBOND* polyester suture, ETHILON* nylon suture, MERSILENE* polyester fiber suture, NUROLON* nylon.
- 36. Granny’s or Slip knot Granny’s knot involve a tie in one direction followed by a tie in the same direction & third tie in the opposite direction to square the knot & hold it permanently. It has the tendency to slip when subjected to increasing pressure. It is not recommended.
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