Sutures, Incisions and Mesh.ppt

Surgical Sutures and
Sarbaz Mustafa Abdalla
Lecturer
College of Nursing

Outline
1. Definition of suturing
2. Surgical Incisions
3. Goal of suturing
4. Types of it
5. Surgical Mesh
6. Suture technique
7. Removal of suturing
Our Topics are
1. Surgical suturing
3.Surgical Mesh
2. Surgical incision
Shared By: Sarbaz7 M2 A1

What is the Surgical suture
Any material used to approximate tissue edge
together or ligate blood vesicles (Closure and
Ligate)

Aim of suturing
1. To hold wound edges together that promote wound
healing by first intention.
2. To approximate wound margins so decreased
contamination.
3. To stop Haemorrhages
(closure, healing, block)

Wound closuring and Surgical incision
• Lacerated wound
• Traumatic wound
• Surgical Incision

Surgical Incision
An incision is a cut made into the tissues of the body to
expose the underlying tissue, bone, or organ so that a
surgical procedure can be performed. (Incision, Cut in
to)(Excision, Cut out to)
An incision is typically made with a sharp instrument, such
as a scalpel, that is extremely sharp and leaves the skin and
tissues with clean edges that are able to heal well. (Scalpel,
Blade)
Incisions can also be made with an electro cautery tool,
which uses heat to both cut and cauterize at the same time,
which can dramatically minimize bleeding during a
procedure. (Electro cautery, Heat and Cut)

Surgical Incision tools
Electro cautery and Scalpel

Surgical Incision Lines
1. Abdominal incision

Rt. Subcostal incision used for open exposure of the gallbladder
and biliary tree
Left subcostal incision for gastroplasty (GP) and Roux-en-Y gastric
bypass (RYGBP)
The midline incision (Upper and Lower) is used for a wide array of
abdominal surgery
The paramedian incision, is originally used to access much of the
lateral viscera, such as the kidneys, the spleen, and the adrenal
glands
The left thoracoabdominal incision provides wide exposure of the
spleen, stomach, left hemidiaphragm, aorta, and oesophagus
Lumbar sympathectomy has been used for conditions such as
Raynaud’s disease, arteriosclerosis, and thromboangiitis obliterans.

Clamshell incision (Thoracotomy)
Median sternotomy
Bilateral anterior thoracotomies
2. Chest incisions

2. Chest incisions
A thoracotomy is a surgical procedure in which a cut
is made between the ribs to see and reach the lungs or
other organs in the chest or thorax.

Common cardiothoracic incisions. ① Midline sternotomy, ②
Pacemaker scar, ③ Posterolateral thoracotomy, ④ Anterolateral
thoracotomy, ⑤ Axillary thoracotomy
2. Chest surgical incision

(1 = superolateral radial incision, 2 = inferolateral radial incision,
3 = superior circumareolar incision, 4 = periareolar incision, 5 =
inframammary fold incisions, 6 = other incision) (designed to
incorporate prior breast surgery scar).
3. Brest surgical incision

Neck dissection and thyroid surgery incisions
Indicated for PTC
3. Neck Surgical Incision

1) (a1)Kempke’s ‘T-bar’ incision
2) (b1)fronto-temporo-parietal incision
3) (c1)Bicoronal scalp incision
(Craniosynostosis Surgery) (Crniotomy)
Surgical Incisions
4. Scalp and Head surgical incision

Armamentarium of Surgical suturing
Suture Material
Suture Needle
Suture Kit

Characteristics of suture
material
 Sterile and cost efficient
 Non electrolytic, non allergenic, non carcinogenic
 Easy to handle
 Capable of securely holding the tissue layers throughout the
healing process
 Minimally reactive to tissue
 Absorbed completely with minimal tissue reaction once the
wound is healed
 Should have uniform diameter
 Should have adequate tensile strength until the purpose is
over
Suture material

Classification of Suture
strands
 Monofilament
 Goes through the tissue
with less drag or
resistance
 Less chance of suture
line infection
 Greater chance of being
crushed
 Knots are more likely to
slip
 No fraying of the ends
on cutting
 Less tissue reaction
Eg. Prolene, PDS ll
 Multifilament
 Several strands
braided together
 Greater tensile
strength
 And flexibility
 Are coated to reduce
drag
 May act as a inlet for
organisms, hence
never used in infected
wounds
 Knots are more secure
 Fraying on cutting
edges

Suture
strands

Other Classification of
Sutures
 Absorbable sutures
 Are digested by enzymes
and phagocytosis e.g ;
catgut
 Or get hydrolysed by
phagocytosis e.g ; vicryl
 Are used to hold wound
temporarily until wound is
healed
 Are used to suture
internal sutures in the
body where suture
removal is not possible
 Non absorbable
sutures
 Are used to suture at
sites where tensile
strength needs to be
maintained for a year
 Made of non
biodegradable materials
 Are used in exposed
sites in the body from
where they can be
removed when ever
needed

Classifications of suture
materials
Monofilament
1. Natural absorbable;
 Catgut
2. Synthetic absorbable;
 Monocryl
 Caprosyn
 Biosyn
 Maxon
 PDS ll
3. Non absorbable;
 Nylon
 Stainless steel
Polyfilament
1. Absorbable;
 Synthetic Polyglactin
 Dexon ll
 Bondek
2. Non absorbable;
 Cotton
 Silk
 Nurolon
 Mersilene

Catgu
t
 Natural absorbable Monofilamament surgical suture
 two types used for sutures: plain and chromic
 It is 99% collagen
 Absorbed by enzymatic digestion by proteolytic
enzymes
 Easy to handle and knots well
 Derived from submucosa of sheep intestine
 If this is treated further with 20% chromic acid it’s
called chromic catgut, chromic acid increases tissue
life of the suture
 Sterilized with gamma radiation and packed with
isopropyl alcohol

Plain
Catgut
 Loses 50% tensile strength in 3 days and 100% in
15 days
 Gets completely absorbed in tissue 60 days
Uses Of : The main indications for use of catgut suture
include ligation of superficial vessels and closure of
tissues that heal rapidly, such as oral mucosa.

Chromic
catgut
 Lose 50% tensile strength in 7 days and 100% in 28
days
 Gets completely absorbed in tissue in 90-100 days
Uses Of :
To suture muscles bowel anastomosis and
peritoneum
During appendectomy, to tie the mesoappendix and
the
base of appendix

Polyglecaprone 25 (monocryl)
 Monofilament
 Copolymer of 75% glycolide of 25%
 Dyed violet
 Double the strength of chromic
catgut
 Good handling properties smooth
surface and easy passage through
tissue

Monocryl
 Tensile strength maintained for 21 days and absorbed
in 90-20 days by hydrolysis
 Is sterilized by ethylene oxide
 Uses Of :
1. Can be used instead of catgut
2. Intestinal anastomosis
3. For closure of peritoneum (laparotomical surgery)
4. Subcutaneous tissue apposition (lipectomy)
5. Urological procedures; ureter repair

Polydioxanone
PDS ll
 Polymer of polydioxanone
 Is dyed violet
 smooth , soft and flexible and allows easy passage
through tissues
 Tensile strength maintained for about 8 weeks and
completed absorption in 180-210
Uses Of :
Well suited for paediatric, cardio vascular surgery
(VRS), plastic (Rhinoplasty) and gastro-intestinal
surgeries.

Polypropylen
e
 Synthetic monofilament non absorbable suture
 extremely low tissue reactivity
 Low coefficient of friction, so it passes through
tissue plane easily
 The suture can extend (elongated) up to 30%
before breaking
 High tensile strength for an indefinite amount of
time
Uses Of :
1. In repair of posterior inguinal wall in hernia
operations
2. Closure of skin incisions
3. Repair tendon injuries
4. To secure prolene meshes Shared By: Sarbaz7 M2 A1

Polyamide (Ethilon)
 Synthetic, non absorbable
 High tensile strength absorbable
 Loses 25 % tensile strength after 1 year
 Very low coefficient of friction
 Knot security is poor;
 Minimal tissue reaction
Uses Of :
• Closure of skin incision
• For hernioraphhy
• Vascular surgery (Aortic Aneurism Repair surgery)

Stainless Steel
Suture
 Is composed of 316L stainless steel
 Available in precut length
 Very high tensile strength
 Get encapsulated by fibroblast inside the body
 Indicated for abdominal wound closure intestinal
anastomosis, thoracotomy surgery
 Contraindicated in people with known metal
allergies
 May interfere with certain radiodiagnostics

Polyglycolic acid suture
(Dexon)
 Delayed absorbable polyfilament
 Green in colour
 Maintains tensile strength for about 30 days
and gets absorbed in 80-90 days

Polygalactin Sutures
(Vicryl)
 Is a copolymer of glycolide (90%) and
lactide (10%)
 Is digested by hydrolysis and not
enzymatic reaction, hence there is less
tissue reaction
 Tensile strength lasts for 28-30 days and
gets completely absorbed by 80-90 days
 Vicyl is a brand name for the polyglactin
suture

Dexon and
Vicryl
Uses:
 Indicated in all the situations where catgut
is used
 Better suited than catgut to suture infected
wounds
 Disadvantages;
Fraying of ends
Roughness

Silk
 Natural non absorbable braided suture
 Dyed black
 Derived from cocoon of silk worm larva. Is
covered with a an albuminous layer which
is removed during processing by a process
called degummation.

 Handling property is very good and knots securely
 Maintains tensile strength for a long time (2 years)
 Is supplied as a reel or over atraumatic needles
 Sterilized by gamma radation
 Loses tensile strength when wet
 Causes tissue reaction leading to PMN infiltration
and fibrous capsule formation around the silk
Silk

Uses;
• In cholecystectomy to ligate cystic duct and cystic
artery
• Ligating mesenteric vessels during bowel resection
• To ligate pedicles (elongated tissue) in
nephrectomy and splenectomy
• Ligation of Vagus nerve trunks during trunkal
vagotomy
• May be used for skin closure
• To repair posterior wall of inguinal canal during
hernioraphy
• To secure drains/ tubes
Silk

Cotton
 Weakest non absorbable suture
 Gains tensile strength when wet
 Indicated for retracting vessels in CVS
or pediatric surgeries
 For tying off umbilicus in new-borns

Misc multifilament
non absorbable sutures
 Surgilon- Nylon 6 coated with silicon
 Nurolon- Nylon 6
 Ti-Cron- Braided polyester suture
 Used in CVS, ophthalmic and neuro-
surgeries

Tevdek/ Polydek
 Made of PTFE (polytetrafluroethalene)
 Reduces tissue reactivity
 Originally designed for heart valves
implantation
 Dyed green and white

2. Needle
material
 Initially stainless steel needles were being
used
 Now we use Surgalloy- a high nickel
stainless steel
 Gives it better resistance to bending and
breakage

Types of suture
needles
 Round bodied ;
 minimises the tissue trauma
because the needle pierces the
tissue without cutting it
 used for suturing peritoneum,
abdominal viscera, myocardium,
dura
 Cutting needle;
 Have two opposing cutting
edges
 Designed to cut through tough
difficult to penetrate structures Shared By: Sarbaz7 M2 A1

Types of suture needles
 Reverse cutting needle;
Designed with cutting edge
on the outer convex side
For skin, oral mucosa, tendon
sheaths (Ganglion Cyst
Removal)
 Blunt needles
To dissect to friable tissue
rather than cutting through it
For suturing liver and kidney

Types of Suturing suturing

 The simplest way to close
skin wounds.
 Insert the needle at 90° to
the skin
 It should be 3-5 mm away
from the margin and 3-5
mm away from the each
other.
 Equal amount of tissue
should be opposed on both
sides.
 All knots should be placed
on the same side with
Interrupted Simple
suturing

Interrupted suturing
 Vertical Mattress suture
 Horizontal Mattress Suture

Mattress Suturing:
 This is a double stitch, which aims to close the deep
part of the wound, to obliterate dead space and
slightly invert the edges.
 It also aim to relieve tension from the edges of the
wound.
 It is most useful where skin is loose or
hemostasis is required.
 If the entry and exit holes lie parallel to the edges,
these are called horizontal mattress stitches
 If the entry and exit holes are perpendicular to the
edges, these are vertical mattress stitches

 Commonly applied in case of peritoneum and
sheath closure.
 It may cause overlapping of edges.
 Wound dehisces if one stitch is dissolved early
or if it breaks.
 It is contraindicated if the skin wound is
contaminated because
of high risk of infection.
 Hemostatic.
Continuous suturing

 Easy to remove
 Cosmetically better
 The suture material can be absorbable or non-
absorbable
 Enter the skin about 1cm from the end of the incision
using preferably a straight needle. Pass the needle
through subcuticular layer and dermis along the
wound in regular step-wise fashion
Subcuticular suturing

Running closure (Baseball
stitch)
 Where wound edges
approximate easily and where a
straight incision is being
approximated
 Not done where collection is
suspected
laparoscopic myomectomy

Purse string suture
 Placed in a circular motion around a lumen
and then tightened to invert the opening
 Given around the base of appendix once
appendicectomy has been done
 In bowel end to end anastomosis
 (TEVAR) (thorasic endovascular aortic
repair)

Traction
sutures
 Used to retract tissues that is not easily held back
with a conventional retractor
 Eg. In myocardium, sclera of the eye, tongue and
caudal septoplasty

Retention suture/ Stay suture
 Placed at a distance from primary suture to
relieve tension on the primary line
 Placed on skin, subcutaneous tissue or
fascia
 Used for patients with a slow healing
process
 Removed after tension is decreased

Secondary line suture
 Used to support the primary line
suture, eliminate dead space or
prevent fluid accumulation in an
abdominal wound

Figure of eight stick
tie
 Indicated for larger vessels or tissue
pedicels
 To prevent knot slippage
 To stop haemorrhage

TYPES OF
KNOTS
 Reef Knot
 Surgeon’s knot
 Granny knot

Principles of knot tying
 Ensure that the knot is firm enough to
eliminate slippage of ligature
 Make sure that the knot is as small as
possible and the free ends are as short as
feasible
 Avoid damaging suture material while
handling
 Avoid excessive tension
 Do not tie the knots too tightly- prevent
strangulation (compression)
of tissue

Surgical
Staples
 Preservation of adequate tissue
vascularization
 Prevention of leaks and fistulas
 Avoiding of tissue tension
 Haemostasis
Advantages;
 Less tissue reaction
 Accelerated wound healing
 Efficiency
 Less anaesthesia and intra operative time

Types of Surgical
Staples
 Purse string suture clamps- for
placement of purse string sutures.
 Skin staplers- to approximate skin
edges.
 Endoscopic staplers

Fibrin Glue
Synthesized from bovine blood
Uses
• to control bleeding and approximating tissues that are
difficult to approximate by suturing, eg. Liver, spleen
and lung.
• Microsurgical anastomosis of blood vessels
• Used in Cardiopulmonary bypass surgery
• Repair ocular implants
• Close superficial lacerations and fistula
• Repair dural tears
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Surgical Glue
• Made of cyanoacrylate
• For adhesion of superficial lacerations
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Adhesive skin closure
tapes/strips
• Made of nylon or polypropelene
• Used to reinforce subcuticular skin closure or to
approximate wound edges of small incisions or
lacerations
• Minimal tissue reactivity
• Low rate of infection
• No ischemia or necrosis
• Is gentler to the skin than needle
• May have an additional microbiocidal
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Adhesive skin closure
tapes/strips
• Disadvantages;
• cannot be used in presence of moisture/ infection/ oily surface/
hairy surface/ skin under tension
• Eg Dermabond/ Indermil
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Surgical Mesh
• Surgical mesh is a woven fabric used for chest wall
reconstruction, strengthening tissues, provide support for
internal organs, and to treat surgical or traumatic wounds.
• The most common types of surgical mesh are hernia mesh,
stress urinary incontinence slings and mesh for treating
prolapse.
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Surgical Mesh
• Titanium mesh has been used in some back surgeries
• As with any surgical implant, some complications can
occur, including infection, inflammation, tissue damage,
and septic shock.
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Synthetic meshes- Non absorbable
• Polypropylene mesh;
• Monofilament
• Inert; can be used in presence of infection
• Good elasticity and high tensile strength
• Used for Hernia repair and Abdominal wall construction
• Sterilized by gamma radiations
• Fixed with prolene sutures
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• Polyglactin 910(vicryl) mesh;
• absorbable mesh that offers temporary support during
wound healing
• soft, flexible non absorbable
• Impermeable to fluids
• Should not be used in presence of infection
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Expanded PTFE (ePTFE);
• Greatest expansion of all the meshes
• Useful in abdominal and vascular surgeries
Stainless steel mesh;
• Rigid and difficult to work with
• Causes discomfort to patient
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• Polyester mesh (Mersilene);
• Least inert synthetic mesh
• Never be used in presence of infection
• Fibres may harbor bacteria
• Polyethylene mesh;
• multifilament; made of polyester fibre
• Used for abdominal wall repair and hernia repair
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• Polyglycolic acid; Polyglactin 910
• Used for wound closure and organ support
Synthetic meshes- Absorbable
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3. Suturing
instruments
 1-Needle holder: used to grab onto the suture
needle.
 Forceps: used to hold the tissues gently and to
grab the needle
 3-Suture scissors: used to cut the stitch from
the rest of the suture material

Suturing
instruments

Practice: Suture
techniques:
A- Principles:
• The wound edges must not only be aligned but
also averted. Eversion ensures that dermal
elements of the skin are apposed which is vital
for wound healing.
• In most body areas except the face, sutures
should be placed 3 to 4 mm apart from the
wound margin and 5 to 10 mm apart from each
other.
• With simple sutures the knots of the sutures are
to be placed away from the opposed edges of
the wound.
• Skin handling must be a traumatic as much as

Suture removal
Eyelids _ 3 days
Neck _ 3 to 4 days
Face _ 5 days
Scalp_ 7 to 14 days
Trunk and upper extremities_ 7 to 10 days
Lower extremities _ 8 to 10 days
Over joints_ 10 – 14 day
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Steps of suture removal:
STEP 1—Cleanse the area with an antiseptic material. Hydrogen
peroxide can be used to remove dried serum encrusted around the
sutures.
STEP 2—Pick up one end of the suture with thumb forceps(A), and cut
as close to the skin as possible where the suture enters the skin(B).
STEP 3—Gently pull the suture strand out through the side opposite the
knot with the forceps(C). To prevent risk of infection, the suture should
be removed without pulling any portion that has been outside the skin
back through the skin
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Removing stich knots by surgical Scissor

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Removing Staples steel by stapler removal

 References:
 - Sarabahi S, Tiwari VK(eds). Principles and Practice of Wound
Care.1st ed .2012
 - Choudhury Dhiraj. General Surgical Operations.1st ed. 2008
 - Ethicon,Wound_Closure_Manual, Ethicon US, LLC. 2010 - 2016,
available from: http://
 www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Clos
ure_Manual.pdf
 - Glenn E.Talboy, Annesley W. Copeland, Gregory J. Gallina. Wound
and wound healing. Peter
 F. Lawrence. Essential of general surgery. Philadelphia: lippincott
williams and wilkings; 1994
 . P130-144
 - WILLIAMS, Norman S.; BULSTRODE, C.; CONNELL, O. Bailey.
Love’s short practice of surgery.
 26th International Student Edition, 2008
 - Edgerton M: The Art of Surgical Technique. Baltimore, Williams &
Wilkins, 1988.
 - McCarthy JG: Introduction to plastic surgery. In McCarthy JG (ed):
Plastic Surgery.
 Philadelphia, W.B. Saunders, 1990, pp 48–54

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