Suture materials

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Suture materials
Mudasir Bashir m.v.sc scholar 4856
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Objectives

• Provide basic information on commonly used suture
  materials

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Qualities of an ideal suture It should

• Remain intact until union occurs.
• Cause minimum tissue reaction.
• Be non-capillary in action.
• Be of uniform thickness.
• Be knotable.
• Have smooth surface.
• Have sufficient tensile and functional strength.
• Easily sterilizable.
• Cheap and readily available
• Easy to handle.

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• The suture is used to bring
• The edges of wound in close approximation,
• to retain the medicated plug for dressing in
  deep wound or cavity,
• to close any accidental opening or
• to keep the lips of a deep extensive open wound
  in contact temporarily
• to check recurrent haemorrhage.

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Suture Material

• Generally categorized by three characteristics
• Absorbable vs. non-absorbable
• Natural vs. synthetic
• Monofilament vs. multifilament

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Natural Suture

• Biological origin
• Cause intense inflammatory reaction
• Examples
• Catgut purified collagen fibers derived from
  intestine of healthy sheep or cows
• Silk(non absorbable)

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Synthetic Suture

• Synthetic polymers
• Do not cause intense inflammatory reaction
• Examples
• Vicryl(absorbable)
• Monocryl
• Prolene
• Nylon

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Absorbable Suture

• Degraded and eventually eliminated in one of two
  ways
• Via inflammatory reaction utilizing tissue
  enzymes
• Via hydrolysis
• Examples
• Catgut
• Chromic
• polyglactin 910 (Vicryl)
• Monocryl
• polyglycolic acid (Dexon) etc.

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Absorbable Suture-description

• Kangaroo tendon It is obtained from the tendon
  of tail of kangaroo and is used for suturing
  joint capsule
• Fascia lata It is obtained from the bovine
  Fascia lata

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• Cargile membrane it is obtained from bovine
  caecum
• Amniotic membrane It is prepared from amniotic
  membrane of fetuses

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Catgut

• Absorption in tissues can be delayed by treating
  with chromic acid.
• Catgut therefore available as plain and chromic
  catgut.
• chromic catgut

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Type Degree of Chromicity Approx No.Of days taken for absorption
Type A Plain 10 Days
Type B Mild chromic 15 Days
Type C Medium chromic 20 Days
Type D Extra chromic 40 Days
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Catgut cont.

• Depending on preservative used catgut is
  available eitheras boilable or non boilable
  catgut.
• Boilable catgut is preserved in
  xylol,toulene-99.75,phenyl merecuric
  acetate.025
• Non boilable catgut is supplied in tubes
  containing90-95alcohol.

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Sizes of catgut Diameter in mm(average) Use
2/0 0.30 Peretoneum,bowel wall(small animals)and ligaturing vessels
0 or 1/0 0.40 -do-
1 0.48 Muscle fascia(SA)ligature larger vessels
2 0.50 -do-
3 0.60 Fascia,muscles(LA)
4 0.70
5 0.80 Rumen uterus abdomen
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Catgut size selection
Bowel 2/0 - 3/0 Fascia 1 - 0 Ligatures 0 -
3/0 Pedicles 2 - 0 Skin 2/0 - 5/0 Arteries 2/0
- 8/0 Micro surgery 9/0 - 10/0 Corneal closure
9/0 - 10/0
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cont.

• Collagen It is prepared from bovine flexor
  tendon filament
• Polyglactin 910 (vicryl) It is a synthetic
  absorbable suture material, prepared from
  glycolic lactic acid polymer
• Polyglycolic acid (Dexon) It is synthetic
  suture material
• prepared from glycolic acid

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Non-absorbable Suture

• Not degraded, permanent
• may be organic inorganic or synthetic in nature
  and are used as both the internal and external
  suture materials.

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Non-absorbable Suture

• Examples
• Prolene
• Nylon nylon
• Stainless steel
• Silk
• (not a truly permanent material known to be
  broken down over a prolonged period of
  timeyears)

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Non-absorbable Organic suture materials

• Cottoncapillary in nature it clings to surgeons
  gloves and they spread infection in wound when
  applied to skin and luminal surfaces
• Silk it may be plain or braided and capillary in
  nature
• Silk worm gut non-capillary and useful for
  cutaneous sutures

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cont.

• Horse hair It is cheap, non-capillary, flexible
  and is easily sterilized. It causes little tissue
  reaction.
• Linen It is capillary in nature and produces
  more tissue reaction than cotton and silk.
• Umbilical tape used to tie the umbilical cord
  of the new born or as vulvar suture in cases of
  prolapse of vagina of uterus.

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• Polyesteris a non absorbable, sterile, surgical
  suture composed of Poly (ethylene terephthalate).
• It suture elicits a minimal acute inflammatory
  reaction in tissues.
• polyamideBeing monofilament, Linex is
  remarkably smooth and gives excellent
  knotsecurity. Posses good tensile strength.
• Easy removal with no tissueadherence.

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Non-absorbable Inorganic suture material

• Metallic suture Wire of different metals like
  tantalum, silver,
• copper, stainless steel and vitallium
• Tantalum It is inert to tissues like stainless
  steel

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Stainless steel suture
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cont..

• Silver It becomes ionized in tissues and cause
  inflammation.
• Copper It is more suitable to repair fractures
  due to its flexibility.
• Aluminium wire It is more flexible than
  stainless steel.

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Placing of sutures

• If sutures are placed far apart-Proper apposition
  of wound edges may not take place.
• But if placed too close together-holding power of
  tissue diminishes.
• Optimum suture distance
• -Skin sutures about 5-6mm(3/8 inch)
• -Hollow visceral organs 2mm (1/8 inch)to
  prevent leakage of contents.

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Suture Classification
Multifilament (braided)
Monofilament
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Monofilament Suture

• Grossly appears as single strand of suture
  material all fibers run parallel
• Minimal tissue trauma
• Resists harboring microorganisms
• Ties smoothly
• Requires more knots than multifilament suture
• Possesses memory
• Examples
• Monocryl, PDS, Prolene, Nylon

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Multifilament Suture

• Fibers are twisted or braided together
• Greater resistance in tissue
• Provides good handling and ease of tying
• Fewer knots required
• Examples
• Vicryl (braided)
• Chromic (twisted)
• Silk (braided)

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Braided v Monofilament

• No capillary action
• Less infection risk
• Smooth tissue passage
• Higher tensile strength
• Has memory
• More throws required

• Has capillary action
• Increased infection risk
• Less smooth passage
• Less tensile strength
• Better handling
• Better knot security

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Silk Catgut

• Natural
• Silk, linen, catgut
• Synthetic polymer
• Polypropylene, polyester, polyamide

Polypropylene Polyester
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nylon

• Monofilament
• Polypropylene
• Polydioxanone
• Nylon
• Multifilament
• Catgut (twisted)
• Polyester
• Silk (braided)

• Polyester silk

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Suture Degradation
Suture Material Method of Degradation Time to Degradation
Catgut Proteolytic enzymes Days
Vicryl, Monocryl Hydrolysis Weeks to months
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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)

Smaller ?---------------------------? Larger .....3-0...2-0...1-0.....1...2...3.....
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The Suture Packaging
PRODUCT CODE
STRAND SIZE
NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE
MATERIAL
STRAND LENGTH
NEEDLE LENGTH
POINT TYPE
NEEDLE CIRCLE
COLOUR
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Suture Packaging
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Non absorbable sutures

• Ethicon
• Braided silk black
• Trulon
• Monofilament polyamide
• Trulene
• Monofilament polypropylene

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Absorbable sutures
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Polypropylene Mesh for Hernia Repair

• Are provided with very High Bursting
  Strength,Elasticity and tested for
  Bio-compatiability after implantation.
• They are available in popular sizes of 2x4, 3x6,
  6x6 and 12x12 inches. Available in two types,
  namely PM and PS types.

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Polypropylene Mesh
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PM type mesh is thinner, smoother and more
flexible. Where as PS mesh is Strong, thicker and
normal flexibility.
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Types of hernia meshes
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Needles

• Classified according to shape and type of point
• Curved or straight (Keith needle)
• Taper point, cutting, or reverse cutting

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• Atraumatic needles- to suture delicate tissues
  like intestine, stomach, bladder, uterus etc.
• Double curved and loopuyt needles -for skin
  closure of cattle or buffalo and for deeper
  structures.

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Needles

• Curved
• Designed to be held with a needle holder
• Used for most suturing

• Straight
• Often hand held
• Used to secure percutaneously placed devices
  (e.g. central and arterial lines)

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Needle Curvature






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Needles

• Taper-point needle
• Round body
• Used to suture soft tissue, excluding skin (e.g.
  GI tract, muscle, fascia, peritoneum)

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Needle point Geometry
Taper-Point 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.
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Needle Point Geometry
Blunt Also known as Protect Point Mainly used to prevent needle stick injuries i.e. for abdominal wall closure.
Premium point spatula Ophthalmic Surgery
Spatula Ophthalmic Surgery
DermaX NEW ½ The Penetration force ½ The Penetration force Superior Cosmetic Effect
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The Right Needle Choice

• The appropriate needle choice for any situation
  is.
• The needle that will cause least possible
  trauma to the tissue being sutured

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Needles

• Cutting needle
• Triangular body
• Sharp edge toward inner circumference
• Used to suture skin or tough tissue

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Using needle holder, grasp needle about 2/3rds
of the way back from point.
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Index finger stabilizes the instrument by resting
on the shaft.
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Surgical Scissors
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FORCEPS

• Grasp forceps between thumb middle finger,
  while index finger is used for stabilization.
• If possible, use forceps to grasp dermis, rather
  than epidermis or skin surface itself.
• This helps prevent marking injuring of skin at
  wound edge.

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Steri-strips

• Sterile adhesive tapes
• Available in different widths
• Frequently used with subcuticular sutures
• Used following staple or suture removal
• Can be used for delayed closure

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Staples

• Rapid closure of wound
• Easy to apply
• Evert tissue when placed properly

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Dermabond

• A sterile, liquid topical skin adhesive
• Reacts with moisture on skin surface to form a
  strong, flexible bond
• Only for easily approximated skin edges of wounds
• punctures from minimally invasive surgery
• simple, thoroughly cleansed, lacerations

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AMCRYLATE Gel Iso-amyl-2-cyanoacylate
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Method of application

• Control hemorrhage on cutaneous incision on
  skin and keep dry using swabs.
• Apply few drops of Iso-amyl-2-cyanoacylate over
  the wound edges.
• Hold skin edges in proper opposition for about 20
  seconds to achive union of skin wound

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• Even a small droplet of blood at wound edges
  causes effervescence and non union at that point.
• Clean that area and dry and reapply tissue
  adhesive

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Thank you