Sutures and Suturing Techniques

Objectives Discuss different types of suture and suture needles Describe the differences in suture Describe characteristics of different types of suture Understand the terms related to suture

AN EXAMPLE SIZE TYPE NEEDLE 2-0 VICRYL CT-1

PACKAGING Surgical application Product code number Suture length and color Metric diameter equivalent of suture size and length Shape and quantity of needles (silhouette) Needle point geometry Lot number Expiration date

SIZES Referred to as the Gauge Size range- #5 (largest) to 11-0 (smallest) Different lengths Skin / 3-0 to 6-0 / Adson with teeth Sub-q / 3-0 / PU with teeth Fascia/muscle / #1 or 0 / PU with teeth Peritoneum / 0 or 2-0 / Debakey (non traumatic)

Suture Two basic types Monofilament Multifilament

Suture Can also be classified as Absorbable Non-absorbable

Monofilament Suture Monofilament sutures are more difficult to handle and tie and require more throws for a secure knot than multifilament sutures Monofilament sutures are preferred for closing an infected wound (no wicking) Requires longer tag when cutting Do not readily harbor bacteria and are relatively inert

Multifilament Suture Multifilament sutures are reactive and prone to infection more than monofilament suture because of capillarity

THE PERFECT SUTURE Pliable and flexible Easy to tie Knots hold securely It slides through tissue effortlessly Never breaks Does not cause tissue reaction Absorbable suture absorbs the second the wound can support itself Absorption is predictable in every patient Can be used in every wound Inert Inexpensive and easily sterilized

THE PERFECT SUTURE Does not Exist yet!

Factors for Choosing a Suture Type of procedure Condition of patient’s tissue Nature of the disease process Surgeon’s preference Suture availability Cost

Common Sutures Monofilament Absorbable Plain Gut Chromic Gut PDS or Polydioxanone Monocryl or Polyglecaprone

Common Sutures Monofilament Nonabsorbable Polypropylene, Prolene or Surgilene Nylon or Ethilon Stainless Steel Polybutester or Novafil

Common Sutures Multifilament Absorbable Multifilament Nonabsorbable Polyglactin 910 or Vicryl Polyglycolic acid or Dexon Multifilament Nonabsorbable Surgical silk Surgical cotton Braided nylon Poyethylene terephthalate or Mersilene Ethibond Tantalum

Silk Nonabsorbable High tissue reactivity Braided multifilament and some risk of infection if contaminated Great knot holding and reliability Easiest suture to handle and tie "Permanent" but slowly hydrolyzed in the body over years, not reliable for vascular graft sutures for this reason

Vicryl Absorbable 9 parts glycolic acid and 1 part galactan Relatively non-reactive Braided multifilament Relative to silk, has been coated with materials to improve handling but this resulted in knots coming untied Absorbs in about 70 days

Ethibond Braided polyester Non- absorbable Fairly non-reactive Strong, braided multifilament suture Easy to handle Lasts almost forever Does not absorb tissue fluid which can transmit infection

Nylon non-absorbable Monofilament (braided multifilament also available) Not very reactive Fairly easy to handle and tie but not as reliable as silk

Plain Gut Absorbable Actually sheep intestine submucosa or cow intestine serosa Reactive Fairly easy to tie and knots are secure Significant loss of strength in 7-10 days, no strength in 2-3 weeks Stored in alcohol solution

Chromic gut Absorbable Plain gut "tanned like leather“ Coated with Chromic salts Reactive Sometimes used in place of Vicryl Easy to handle Lasts longer than plain gut, last up to 21 days Stored in alcohol solution

PDS, MAXON Absorbable Monofilament, absorbable, strong Non-reactive A little more “give” than Prolene Handles a lot like Prolene, hard to tie Good strength duration up to 1 to 2 months

Prolene Non-absorbable Very inert, least reactive Strong, non-absorbable monofilament Hard to tie, recommend at least six knots for security Lasts virtually forever Used in vascular anastomosis

CHOICE OF TYPES OF SUTURES cont. Vicryl – general tissue approximation or ligation Monocryl – subcuticular, sub-Q Chromic gut – ligation, peritoneum Plain gut – sub-Q, fast absorbing PDS – fascia Nylon – skin, retention, drains Prolene – skin, vessels, drains Silk – GI, stick ties Dexon - general tissue approximation or ligation Maxon – fascia Ethibond – heart incisions Mersilene – tendons, ligaments

TYPES Vicryl Purple ABS Multi Monocryl Peach ABS Mono Chromic gut Brown ABS Mono Plain gut Yellow ABS Mono PDS Silver Slow ABS Mono Nylon Green Non-ABS Both Prolene Dk Blue Non-ABS Mono Silk Lt Blue Non-ABS Multi

TYPES cont. Dexon Gold & White ABS Multi Maxon Silver & Green Slow ABS Mono Ethibond Orange Non-ABS Multi Mersilene Turquoise Non-ABS Multi

How long should Sutures last? Dissolving skin sutures need to last 2 -3 weeks Fascial sutures need to last 3 -6 months Vascular sutures need to last forever

Skin sutures Mostly Nylon Silk around the eye (suture knots and ends lie flat after tying) Subcuticular absorbable sutures: Braided- Vicryl, Dexon Monofilament- PDS, Monocryl

Subcutaneous tissue Purpose is to obliterate dead space and prevent blood and fluid collection between skin and deeper structures Any absorbable suture (Plain gut, chromic gut, Vicryl, Dexon, Monocryl) Avoid nonabsorbable sutures although silk and braided polyester were used a lot in the past

Ligating Methods Free-tie Stick tie (suture ligature) Ligature reels Placed into open hand of surgeon Stick tie (suture ligature) Sutures with a swaged needle loaded onto a needle holder Ligature reels Must be counted Instrument tie (tie-on-a-pass)

NEEDLES Page 314, figure 11-24 Swaged – attached to suture Closed – free needle French – free needle Double armed – needle swaged to both ends CR – control release, commonly called pop-off, shorter than full length, for single stitch

NEEDLES cont. Cutting Taper Blunt Skin, tendons, sclera – tough tissue Penetrate without cutting, all closure layers below the skin Blunt Liver, kidney

SUTURE SETUP Only open what is needed, sutures are expensive Sutures should be placed on back table in the order needed First 1 or 2 sutures should be loaded Ties should be placed on mayo Pull out memory

MESHES Polypropylene Polyglactin 910 Polytetrafluoroethylene (PTFE) Relatively inert, can be used in the presence of infection, excellent elasticity and high tensile strength Polyglactin 910 Absorbable, temporary support during healing Polytetrafluoroethylene (PTFE) Not absorbable, should not used in the presence of infection Stainless steel The most inert, but uncomfortable for the patient Polyester fiber Least inert, should never be used in the presence of infection

ACCESSORY DEVICES Bridges and bolsters Umbilical tape (pink) Page 310, figure 11-14 Umbilical tape (pink) Vessel loops Buttons Steri-strips (1/8, ¼, ½ , 1 inch) Page 311, figure 11-15

Alternatives to Sutures Steri-Strips: Used over absorbable skin sutures Great for facial lacerations, small cuts, children, and matching skin edges Sometimes they fall off or are pulled off prematurely

SUTURING TECHNIQUES Primary suture line Continuous or running Interrupted Traction sutures Pursestring (page 309, figure 11-12) Retention

Principles of Suturing the Skin Technique is more important than suture size A large suture placed with good technique can achieve an excellent cosmetic result while a small suture placed with poor technique can produce a bad cosmetic result

Technical Aspects of Suturing Avoid excessive tension on the suture, just enough to bring the skin edges together If tension is unavoidable, use inverted subcuticular sutures to relieve the tension

Technical Aspects of Suturing Careful, non-traumatic handling of the tissues Hooks are less traumatic than forceps Careful matching of skin edges Early suture removal

Left=Correct Approximation Right=Incorrect Approximation

Technical Aspects of Suturing Application of Neosporin ointment May reduce stitch tracks by reducing epithelial growth along the sutures as they penetrate the dermis

Go to QuickTime Two Hand Square Knot http://cal.vet.upenn.edu/surgery/images/videos/l2sq.mov One Hand Square Knot http://cal.vet.upenn.edu/surgery/images/videos/sq1hr.mov Instrument Tie http://cal.vet.upenn.edu/surgery/images/videos/rinst.mov

Driving the Needle Through

Drive Through the Other Side

Instrument Tie

Simple Interrupted

Simple Interrupted

Vertical Mattress

Horizontal Mattress

Horizontal mattress

Running, or Continuous Stitch

Continuous Locking, or Blanket