Sutures used in surgery . pg residency program

1. SUTURES & LIGATURE
MATERIALS
BY
Dr. Shivam Manoj Pandey
FIRST YEAR SURGERY RESIDENT, UNIT 3
DR BABA SAHEB MEDICAL COLLEGE & HOSPITAL
SEMINAR ON,

2. INDEX
❖ INTRODUCTION
❖ DEFINITION AND CLASSIFICATION OF SUTURE
❖ SUTURES (CHARACTERISTICS AND USES)
❖ RECENT ADVANCES ON SUTURE MATERIAL-DRUG ELUTING SUTURES
❖ REFERENCES

3. Introduction
Surgical suture use was first recorded in ancient Egypt about 3000BC,
and the earliest documented suture use was discovered in a mummy around
1100BC. A thorough detail about the suture materials used on different types of
wounds was written by Sushruta, an Indian sage and physician, in 500BC. Suture
procedures were described by Hippocrates, the Greek father of medicine, as well
as by Roman Aulus Cornelius Celsus later. Galen, a Roman physician from the
second century, presented the mechanism of gut sutures.By 10th century,
Abulcasis devised the catgut suture and the surgical needle. The collection of
sheep intestines was necessary to make the catgut suture, which was created in
the same manner as strings for guitars, violins, and tennis racquets.

4. Surgical suture are the medical devices, which are used for binding body tissues in the
case of any medical apathy (Dennis et al., 2016). The sutures can be secured by using surgical
knots. Looking from medieval era to present suture along with needles have seen a great changes,
earlier needles used for suturing were made of bones or metals (copper, silver, aluminum, and
bronze wire), and sutures were developed from plant parts (hemp, cotton, and flax) and animals
parts (tendons, hair, arteries, nerves, muscle strips, catgut, and silk).
The medieval data reports the use of sutures from past 3,000 BC in Egypt where suturing
of mummy is reported in 1,100 BC (Mysore, 2012). Nowadays sutures are made synthetically like
absorbable sutures (poly-dioxanone, poly-glycolic acid, monocryl polymer, and poly-lactic acid) as
well as the non-absorbable (nylon, poly-ester, and poly-propylene) (Champeau et al., 2017). The
absorbable sutures are fragmented by different methods, such as hydrolysis and proteolytic
enzymatic degradation. The suture degradation depends upon its material varying from few days
to weeks.
As per Acharya Sushruta an ancient Indian surgery, has explained the use of various
surgical procedures, such as the use of horsehair, leather, and cotton as sutures for wound
closure. Some cultures also used the ants and beetles as sutures for wound closing.

5. The suture is a strand or thread, used to ligate (tie) blood vessels or to
approximate (sew) damaged tissues together.
Sutures are classified on basis of,
● Behavior of suture material
● Number of strands
● Source
Absorbable
Non-absorbable
Monofilament
Natural
Polyfilament
Synthetic

6. Absorbable sutures-either by enzyme or phagocytosis
● Natural absorbable-
plain and chromic catgut
● Synthetic absorbable-
Polyglycolic acid(dexon)
Polyglactin 910(vicryl)
Polyglactin 910 rapid (vicryl rapid)
Polydioxanone suture (PDS)
Polyglecapron 25 (monocryl)

7. Non-absorbable sutures: for indefinite period.
● Natural non-absorbable sutures: -
Linen thread
Silk
● Synthetic non-absorbable sutures: -
polypropylene(prolene)
Monofilament polyamide(ethilon)
polyester(ethibond)
nylon

8. Strands
Monofilament
Single strands
Smooth and strong
Chance of bacterial contamination less.
Knot tied may become loose.
Prolene, ethilon ,catgut, monocryl, pds
Polyglactin dinner sizes 6/0,9/0
Polyfilament
Multiple strands, braided together.
Easier to handle. Knot tied does not slip.
Bacterial contamination.
Silk, linen,polyglycolic acid, vicry.

9. Ideal suture material
● Adequate tensile strength
● Incite minimal tissue reaction
● Easy handling property
● Good knotting quality
● Non-allergenic and non-carcinogenic
● Easily available and cheap.

10. CATGUT
The natural absorbable surgical suture derived from the submucosa of the sheep is known as catgut.
This is the brand name of this suture manufactured by Ethicon division of Johnson and Johnson. The
similar sutures manufactured by other companies includes Trugut, Pro Gut, etc.
99% COLLAGEN
RULE FOR PLAIN CATGUT- 50-3-ALL-15 GET ABSORBED IN 60 DAYS.
RULE FOR CHROMIC CATGUT 50-7-ALL-28 GET ABSORBED IN 90 DAYS
In presence of infection the catgut gets absorbed earlier.
USE:
PLAIN CATGUT
Small subcut vessels
Subcut tissue
During circumcision for cut margin
Repair wound of lips and oral cavity.
CHROMIC CATGUT
Muscles,bowel anastomosis,closure of
peritoneum.
During appendectomy
During cholecystectomy

12. Atraumatic sutures.?
MERSUTURE
CATGUT
HOW TO
PREPARED?
STERILISED BY
GAMMA
IRRADIATION
SUPPLIED IN
STERILISED PACK
CONTAINING
ISOPROPYL
ALCOHOL.
20%
Submucosa of sheeps
and serosa of beefs
intestine.

13. Synthetic absorbable sutures
● In lab.
● Can be monofilament (e.g monocryl) or polyfilament (eg vicryl)
● Can be with natural color or green color (dexon) or violet color(vicryl).
● Strength almost twice as natural absorbable sutures.
● Absorbed by simple process of hydrolysis and evoke minimal tissue reaction.
● They have excellent handling properties.once tied the knot are secured.
● Sterilised by ethylene oxide.

15. 2 vicryl / polyglactin sutures
● Synthetic absorbable sutures.
● Vicryl - a trade name of polyglactin 90 by ethicon (Johnson and Johnson).
● Can be round body, cutting or taper cut.
● Can be undyed vicryl and coated vicryl.
● Co-polymer of lactide and glycolide.(1:9)
Characteristics
● Polyfilamentous sutures but finer ones are monofilamentous.(eg 5-0,6-0)
● Maintains tensile strength in the tissue for about 28-30 days and get absorbed
in 80-90 days.

17. Uses of polyglycolic acid and polyglactin sutures.
● Indicated in all situation ~catgut.
● No. 1 or 1-0 suture may be used for closure of subcostal, paramedian,
mcburney’s incision.
● 3-0 or 4-0 sutures (atraumatic) - biliary enteric
anastomosis(choledocoduodenostomy) , choledoco-jejunostomy.
● In small gut resection anastomosis-seromuscular (anterio and posterior) may
be sutured with 2-0 polyglactin or polyglycolic acid sutures.
● Single layered anastomosis in large gut may be done with 2-0 polyglactin or
polyglycolic acid suture.

18. Polyglactin rapide (vicryl rapide) sutures.
Characteristics:
● Variety of vicryl .
● Rapid absorption.
● By exposure of coated vicryl to gamma radiation. Which results in material
low in molecular weight than coated vicryl.
● Tensile strength for 10-12 days and get absorbed in 42 days.
Uses:
● May be used for subcuticular sutures, skin , mucosal closure.
● Need not remove , spontaneously absorbed.

19. Polyglecaprone (Monocryl suture )
● Synthetic absorbable monofilament
● Co-polymer of glycolide and caprolactone(3:1)
● Double the strength of chromic catgut.
● Excellent handling properties , has got very smooth surface and passes
through the tissue with greater ease.
Uses:
● ~catgut used
● Can be used for intestinal anastomosis as an alternative to catgut and
polyglactin.
● Subcutaneous tissue apposition.
● Used in Uro surgeries-pyeloplasty, ureter repair.

20. Polydioxanone Suture (PDS-II)
● Synthetic delayed absorbable monofilament
● Formed by polymerizing the monomer “paradioxanone”
● Dyed violet. PDS II sutures are an improved version of initial PDS suture.
● Soft,pliable and smooth PDS II allows easy passage through the tissues and
knotting characteristics —-Best among the synthetic absorbable sutures.
● Tensile strength for longer period 56 days
2 wks-50% maintained
6 wks-25%
8wks-loses all tensile strength.
Suture is absorbed by hydrolysis and complete absorption in about 180-210 days .

21. Uses:
-No 1 or 1-0 suture can be used for closure of paramedian or midline and other
abdominal incision .
-3-0 and 4-0 sutures are used for intestinal or biliary enteric anatomosis.
-~all situation where catgut, polyglycolic and polyglactin.

22. Silk
● Natural non absorbable sutures.
● Supplied in sterile pack or nonsterile as silk reel of varying sizes.
Characteristics:
● Derived from cocoon of silkworm larvae.
● Manufacturing : Basically a protein covered initially by an albuminous layer. The
albuminous layer is removed by a process called degumming during manufacturing
of these sutures. The suture is braided round a core and coated with wax to reduce
the capillary action.
● Handling property is best and it knots securely
● Sterilized by gamma irradiation.
● The silk for surgical use is dyed black .
● Silk maintains tensile strength for a longer time and the tensile strength is lost in 2
years time.
● Once placed in the tissues it incites a polymorphonuclear reaction and a fibrous
capsule is formed around the silk in 14–21 days.

23. Uses of silk suture:
● No. 1 or 1-0 silk sutures are used as ligature:
-Used during cholecystectomy to ligate the cystic duct and cystic artery .
- Used during small and large gut resection to ligate the mesenteric vessels.
-Used to ligate the pedicles during nephrectomy and splenectomy -
-Used during truncal vagotomy to ligate the anterior and posterior vagus
nerve before their division. Two ligatures are applied and the nerve is
divided in between.
-Used for skin closure either with interrupted or continuous suture

24. Monofilament polyamide sutures.
Characteristics
„ This is a synthetic monofilament nonabsorbable suture and is a variety of nylon .
„ This has a very low coefficient of friction and readily passes through the tissues .
„ This is an inert suture and incites minimal tissue reaction .
„ Maintains tensile strength for a long time. Tensile strength loss after 1 year of
implantation is 25% .
„ Monofilament polyamide suture has a memory and knot security is poor so 4-5 throws
are required for proper knotting
„ Available in different sizes.

25. Uses of monofilament polyamide suture
„ For closure of skin incision
„ For closure of abdominal wall incision
„ For herniorrhaphy
„ Monofilament polyamide sutures are also available as finer sutures 3–0, 4–0,
5–0 up to 10–0
„ The finer sutures are used in vascular surgery.

26. Nylon sutures
Synthetic non absorbable monofilament suture.
White in color.
High tensile strength (maintains tensile strength for indefinite period).
Uses:
Same as monofilament polyamide.

27. Stainless steel wire
● An unique suture material.
● Very high tensile strength and extreme inertness.
● Suturing with stainless steel requires perfect technique and poor technique may jeopardize the very
purpose of suturing. Too tight a suture may cause tissue necrosis and steel wire can pull or tear out
of tissues. Barbs on the end of the steel can traumatise the surrounding tissues. Kinks in the wire
can render it practically useless. This is available in different sizes from no. 5-0 to 6.
Uses
„ In orthopedic operations for suturing bones, e.g. in fracture patella, fracture olecranon
„ Closure of midline sternotomy incision
„ Interdental wiring for fracture mandible
„ Earlier used for herniorrhaphy
„ Earlier used for Thiersch’s operation.

28. RECENT ADVANCE IN SUTURE
DRUG ELUTING SUTURE.

30. In 2002, Food and Drug Administration (FDA) has approved
triclosan-coated sutures for the first time. These triclosan-coated sutures have been
reported to reduce wound infections during the treatment. These sutures were placed by
using a surgical sterilized needle with which sutures were attached (Ming et al., 2007).
Basically, the main purpose of using sutures is to bring together the wound edges, which
facilitate the faster wound healing. Use of drug-eluting suture can prevent wound
infections to spread and give better healing (Rothenburger et al., 2002).
The delivery of antibiotics, anesthetics, anti-inflammatory agents, or
analgesics from the suture can directly and efficiently delivers the drug into the wound
area. These sutures are basically known as drug delivery suture and also called as drug
eluting suture. The basic purpose of using drug eluting sutures is to achieve the
controlled release systems in order to create high drug concentrations at the wound area.

31. Advantages of drug eluting sutures Various advantages of drug eluting sutures are
as follows: (Greenberg et al., 2013; Parikh et al., 2009).
• Better wound healing and tissue regeneration.
• Amplified loading of drug and sustained drug delivery because of attached
porosity characteristic of the sutures.
• Discharge of extracellular matrix proteins, cytokines, anti-microbial,
anti-inflammatory, and pain management drugs to wound site.
• Mechanical properties of this unique suture do not compromise due to any
amendment procedure.

32. Drug eluting sutures.
These days various novel sutures are developed with addition of some extra
properties, such as addition of anti-microbial agents (Leaper et al., 2010;
Rodeheaver et al., 1983), modification by addition of bio-active molecules, such as
DNA (Labhasetwar et al., 1998), drugs (Loh, 1987), growth factors (Cummings et
al., 2012), anti-bodies (Shibuya et al., 1999), silver (Blaker et al.,2004), and
protein extra (Shibuya et al., 2003).

33. Polyfilament suture -risk for infection?
It may increase the bacterial infections at the healing site because the
bacteria can be trapped in braided filaments of the sutures.
These braided sutures can be modified by coating with the various
antibiotics for example tetracycline-coated silk suture (Chen et al., 2015). These
tetracycline-coated silk sutures exhibit high anti-microbial property against
Escherichia coli bacteria, and hence anti-microbial efficacy can be increased with
appropriate drug concentration. In the same pattern, the braided silk sutures can also
be coated with levofloxacin hydrochloride which showed similar result as that of
tetracycline antibiotic with better susceptibility to E. coli. Suture to suture friction
(caused by the friction between the suture threads) and stiffness caused by the
blending of the fibers can be altered during anti-bacterial and anti-microbial treatment
(Chen et al., 2015b).

35. ● The antibiotic levofloxacin can also be used in these sutures. Drug eluting
sutures which contain levofloxacin loaded with the polymers poly (L-lactic
acid) and poly-ethylene glycol are used for ophthalmic purpose. These
sutures are made from bio-compatible polymers with hydrophilic nature. This
property inhibits the bacterial growth (Staphylococcus epidermidis)
(García-Vargas et al., 2014).
● Weldon et al. produced local anesthetic containing the drug bupivacaine which is
eluted from the PLGA polymer. These sutures were prepared by electro-spinning
process by changing the concentrations of anesthetic drug. These drug-eluting
sutures were reported to have better post-operative analgesic effect for about
7–10 days with about 3 days of maximum degree analgesia. These local
anesthetic containing sutures showed better effect without any adverse reactions
(Weldon et al., 2012)

37. References
● Saha, M. L. (2018). Bedside Clinics in Surgery. JP Medical Ltd.
○
● Ming X, Nichols M, Rothenburger S. In vivo antibacterial efficacy of Monocryl plus antibacterial
suture (Poliglecaprone 25 with triclosan). Surg Infect (Larchmt), 2007; 8(2):209–14.
○
● Rothenburger S, Spangler D, Bhende S, Burkley D. In vitro antimicrobial evaluation of Coated
VICRYL* Plus Antibacterial Suture (coated polyglactin 910 with triclosan) using zone of inhibition
assays. Surg Infect, 2002; 3(S1):s79–87.
● Greenberg JA, Goldman RH. Barbed suture: a review of the technology and clinical uses in
obstetrics and gynecology. Rev Obstet Gynec, 2013; 6(3–4):107.
● Anureet AA, Geeta GA, Janita JC, Param PM, Manju MN. Drug eluting sutures: A recent update. J
Appl Pharm Sci, 2019; 9(07):111–123.
○
● D’Cunha P, Pande B, Kathalagiri MS, Moharana AK, Deepak TS, Pinto CS. Absorbable sutures:
chronicles and applications. Int Surg J 2022;9:1383-94.
○
● Leaper D, Wilson P, Assadian O, Edmiston C, Kiernan M, Miller A, Bond-Smith G, Yap J. The role of
antimicrobial sutures in preventing surgical site infection. Ann R Coll Surg Engl, 2017; 99(6):439–43.

38. THANK YOU