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suture.pptx
- 1. SUTURE MATERIALS & STAPLERS (PART-A) By: Dr. SOUMYAJIT JANA Moderator: Dr. JAGMOHAN MISHRA
- 2. INTRODUCTION • Suturing ofany incision or wound needs to take into consideration the site and tissues involved. • A wound with proper blood supply and uninfected, heals well by primary intension or suturing, thus requiring accurate apposition of wound edges. • Why we need Suturing of a Wound or Incision Site? To Prevent Infection. To Stop Bleeding from the site. To enhance the process of Healing. • Suturing is an art that requires Practise and proper observation.
- 3. • “ Suturesare best made of soft thread, not too hard twisted that it may sit easier on the tissue, nor are too few nor too many of either of them to be put in.” -Aurelius Cornelius Celsus. • Early surgery abound suturing was done by ligating blood vessels with Tendon strips and closing of the wound with acacia thorns pushed through the wound with vegetable matter- East African Tribes. History
- 4. Cont… • A southAmerican method: using Black/ Army ants to bite the wound together with pincers or jaws acting like skin clips and then the ant’s body was twisted off leaving behind the head. • By 1000 BC Surgeons were using horsehair, cotton and leather sutures. Romans were using linen, silk and metal clips called Fibulae. • With the advancement of textile industries both silk and catgut became popular as suture materials. Lord Moynihan
- 5. Desired Characteristics of Suturematerial: • Easy to Handle • Predictable behaviour in tissues. • Predictable tensile strength • Sterile • Glides through tissue easily • Secure knotting ability • Inexpensive. • Minimal tissue reaction • Non capillary • Non allergenic • Non carcinogenic • Non Electrolytic • Non Shrinkage.
- 6. SUTURE CHARACTERISTICS: 5 Characteristicsare present that need to be considered:- A. PHYSICAL STRUCTURE: Can be of two Types: 1. MonoFilament: They are smooth. No sawing action. Difficult to knot effectively 2. MultiFilament: They are Braided. Better Grip. Much larger surface area. Thus have interstices where bacteria can lodge and lead to infections.
- 7. B. STRENGTH: • Itdepends upon the thickness and the constituent of the suture material. • Strength can be Tensile strength or the material’s own In Vivo strength. • However Absorbable suture material show decay in strength. • Non absorbable suture materials have indefinite Tensile Strength. • However biological Non absorbable materials such as silk will definitely fragment with time and lose their strength.
- 8. C. TENSILE BEHAVIOUR: •Based on their Deformability and Flexibility. • They can be: Elastic: material will return to its original length once tension is released. Plastic: Stiff and above mentioned phenomenon does not occur. • Memory: many synthetic materials show Memory ie. They keep curling up in the shape they adopted . The more memory the suture material has the less is the knot Security. Best Example of Memory is Prolene.
- 9. D. ABSORBABILITY: • Suturematerials may be 1. ABSORBABLE: Required in cases for use in Biliary or urinary tract where it needs to be absorbed in order to minimize the risk of stone production. 1. NON-ABSORBABLE In Vascular anastomosis, artificial graft or Prosthesis.
- 10. E. BIOLOGICAL BEHAVIOUR •It depends upon the constituent raw material. • Some of the biological sutures, such as catgut, are proteolysed, but this involves a process that is not entirely predictable and may even cause local irritation. • Synthetic materials are hydrolysed and their disappearance in the tissue is predictable.
- 13. General Guidelines • Carefulevaluation of the wound is essential to assess for wound tension and whether deep layer closure will be required • Wound tension is the amount of perpendicular force that must be applied to a wound to approximate the edges • Higher tension = more force • Wounds under higher tension require a larger gauge suture that will tolerate a greater amount of force • Deep layer closure and other advanced repair techniques can be used to reduce wound tension • Lower tension repairs are ideal as they result in a better cosmetic outcome • Anatomic region tends to determine amount of tension on a wound • Facial wounds are often lower tension than wounds on trunk or extremities • Within these areas, there are regions of higher tension, like the chin or flexor surfaces which may require different material • Nonabsorbable . monofilament commonly used for skin closure • Nylon (Ethilon) tends to be favored over polypropylene (Prolene) for its lower cost and its slightly easier handling. • Polypropylene (Prolene) Favored in Tissues which requires Prologed Support. Prolene is often colored blue, so may be chosen in areas with hair to help identify sutures for removal. Also used in Cardiovascular, Ophthalmic and Plastic Surgeries.
- 14. Absorbable Sutures •VICRYL* •MONOCRYL* •Coated VICRYL* •Coated VICRYL* Plus AntibacterialSuture •PDS* II •Traumatology • Ligaments • Fascia • Vessel anastomosis •Mass Absorption •Wound Support •10 days •By 42 days •Typical Uses •Skin •Perineum •Oral •Lacerations •30 days •60 days •20 days •30 days • 56 - 70 days •90 - 120 days •56 - 70 days •180 - 210 days •Ligature •General •Bowel •Orthopaedics •Ligature •General •Bowel •Ophthalmic •Mucosa •Obstetrics •Bowel •Skin& Ligature
- 15. Cont… • Absorbable materials •Reasons to select • Suture will not be accessible for later removal • Oral injuries • Suture removal may be difficult (i.e. pediatric patients, patients with poor follow-up) • Polygalactin 910 (Vicryl) • Useful in deep layer closures • Provides long-term tensile strength and mid range absorption time (50% at 21d), minimizing tissue reaction. • Chromic gut • Plain gut treated with chromic salts to slow absorption (50% at 21-28d) and minimize tissue reaction • Useful in oral repairs, nailbed laceration repair, Superficial Vessels, Subcutaneous tissues and others that heals rapidly. • Gamma irradiated Polygalactin 910 (Vicryl Rapide) • Preferred by some oral surgeons for mucosal and dental injuries as may lead to more rapid healing over chromic gut .Increasingly popular in repair of lacerations on the torso and extremities in patients whom suture removal may be difficult • Available data suggests noninferiority to polypropylene (Prolene) in cosmetic outcome with a nonsignificant greater incidence of infection with absorbable material.
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- 18. Needles • Size • Measuredfrom thread attachment to needle tip in mm • Usually sized to correspond with suture gauge
- 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. Cont… Types Cutting and reversecutting most common for skin closure Cutting: sharp edge of needle on inside of curve Reverse cutting Sharp edge of needle on outside of curve Theoretically reduces chances of suture pulling through tissue Taper point: used for surgical applications in soft tissue
- 21. STAPLES Goals of stapler •Close abdominal wounds • Join internal organs to restore to normal function • Maintain hemostasis • Reduce tissue trauma • Reduce contamination • Prevent postoperative morbidity and infections
- 22. HISTORY OF SURGICAL STAPLERS 1880s •Reports of first stapler by Dr Henroz- everted bowel anastomosis in dogs. 1908 • Professor Humer Hultl with Victor Fischer created a stapler with emphasis of following • principles- • Tissue compression • B-shaped configuration of closed staples • placement of staples in double staggered rows • use of fine wire as the staple material. • But it was heavy and its assembly was difficult and time-consuming
- 23. Cont… 1976 • Ethicon, Inc.introduces the first completely disposable, single patient use mechanical stapler 1989 • Titanium replaces stainless steel as the key component for staples
- 24. Advantages of stapling Stapling anastomosis is faster than traditional suturing techniques, hence reduced operating time. Reduces tissue trauma by minimizing tissue handling. Prevents contamination The availability of staplers has fostered the development of procedures that were difficult with traditional techniques because of limited access. Stapled tissue and anastomoses heal as reliably and rapidly as sutured anastomoses Not user dependent
- 25. STAPLING BIOMECHANICS Optimal stapling Optimal compression Optimal creep Noexcessive sheer stress
- 26. • Living tissuebefore compression • Living tissue compressed to adequate thickness for stapling. • Living tissue after stapling. The material composition of the staple should avoid spring back to keep the tissue compressed.
- 27. STAPLING BIOMECHANICS Under-sizing staplecartridge lead to excessive tissue compression, which exceeds the tissue’s tensile strength increases the risk for inadequate staple formation Over sizing staple cartridges Poor haemostasis Inadequate opposition of tissue edges Poor staple line formation predisposed to anastomotic leakage
- 28. Use of surgicalstaplers Linear staplers Close internal organs prior to transection Close the common opening or enterotomy after the creation of an anastomosis Make side to side or functional end to end anastomosis Biopsy or wedge resection of the lung and closing of the bronchus and to close pulmonary vessels prior to their division Resection of solid organs such as liver or pancreas.
- 29. Circular staplers (intraluminalstaplers) End to end anastomosis e.g. colorectal anastomosis in LAR End to side anastomosis e.g. illeocolostomy after right hemicolectomy Side to side anastomosis e.g. side to side gastrojejunostomy after billroth II gastrectomy
- 30. Curvilinear cutting staplers(contour stapler) transabdominal proctectomy very-low- anterior resection of the rectum (as it is able to fit into the narrow confines of the pelvis)
- 31. Functional end toend anastomosis: CRITICAL CONCEPTS • Non-tension • GIA stapler • Align anti-mesenteric sides of bowel together • Staggered staple lines
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- 33. INTRODUCTION • The wordanastomosis comes from the Greek ‘ana’, without, and ‘stoma’, a mouth, i.e. when a tubular viscus (bowel) or vessel is joined after resection or bypass without exteriorisation with a stoma. • Intestinal anastomosis is the surgical connection of separate or severed bowel to form a continuous channel.
- 34. Cont… • Early phase(0–4days): There is an acute inflammatory response, but no intrinsic cohesion. • Fibroplasia (3–14days): Fibroblast proliferation occurs with collagen formation. • Maturation stage (>10 days): This is the period of collagen remodeling, when the stability and strength of the anastomosis increase
- 35. 3 5 TYPES • Orientation ofbowel • Side-to-side • End-to-end • End-to-side • Technique • Hand sewed • Stapling technique • Part of the bowel involved • Gastro-jejunostomy • Jejuno-jejunostomy • Ileo-colic anastomosis • Base on the number of layers • Single • Double layer
- 36. 3 6 INDICATIONS • Restoration ofcontinuity following resection of bowel disease; • Gangrene • perforation • Malignancy • Benign conditions- polyps, intussusception • Radiation enteritis • Infections eg Tb with stricture • Bypass of unresectable disease bowel • Advanced tumour causing luminal obstruction • Metastatic disease causing obstruction • Congenital anomalies- intestinal atreasia, Hirschsprung disease. • Bilo-pancreatic diversion
- 37. (A) BOWEL ANASTOMOSES •Ensure Good Blood supply to bowel ends before and after formation of anastomosis. • Ensure the anastomosis is under no tension. • Avoid risk to mesenteric vessels by clamps or sutures. • Use atraumatic bowel clamps to minimise contamination. • Interrupted and continuous single layer suture techniques are and safe. • Stapling devices are an alternative when speed is required or access is major factor.
- 38. SINGLE LAYER ANASTOMOSIS • Aninterrrupted seromuscular suture, with absorbable thread. The submucosal layer is strong and the blood supply is only minimally damaged • Lembert stitch
- 39. DOUBLE LAYER ANASTOMOSIS •An inner continuous absorbable suture, with stitching of all layers • An outer, seromuscular, interrupted nonabsorbable suture • Serosa apposition and mucosa inversion; the inner layer has a hemostatic effect, but the mucosa is strangulated • Connell stitch- continuous
- 41. Complications • Bleeding • Anastomoticleak • Wound infection • Intra-abdominal abscess • Obstruction • Stricture • Prolonged ileus • Recurrence
- 42. (B) VASCULAR ANASTOMOSIS •Non Absorbable monofilament suture material should be used. Eg. Prolene. • A smooth intimal suture line is essential. • Knots require multiple throws in order to ensure security. • The suture must pass from within outwards on the down flow aspect of the anastomosis.
- 43.