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L. Michael Brunt, M.D. Professor of Surgery
Accelerated Skills Preparation for Surgical Internship: Suturing Skills and Surgical Instruments L. Michael Brunt, M.D. Professor of Surgery Washington University School of Medicine St. Louis, Missouri
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Suturing Skills Curriculum
Surgical instruments Suture material Suturing techniques
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Classification of Suture Material
Natural vs Synthetic (last 30 years) Absorbable vs Nonabsorbable Braided vs Monofilament
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Basic Suture Materials
Absorbable Nonabsorbable Natural: Catgut Plain Chromic Synthetic: Polygolic acid (Dexon) Polyglactic acid (Vicryl) Poly-para-dioxanone (PDS) Modified polyglycolic acid (Maxon ) Natural Silk Cotton Metals (stainless steel) Synthetic Dacron (Tevdek, Ethibond, Tycron) Nylon (Ethilon, Dermalon, Braided Nurolon) Polyprolene (Prolene, Surgilene)
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Braided vs Monofilament Suture
Absorbable: Dexon Vicryl Nonabsorbable Silk Dacron (Ethibond, Tevdek) Braided nylon (Nurolon) Absorbable: PDS Maxon Nonabsorbable: Nylon (Ethilon, Dermalon) Polyprolene (Prolene, Surgilene)
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Factors Affecting Choice of Suture Material
Strength of suture material over time Time interval material will be present Strength sufficient for healing before suture disappears or loses strength? Suture reactivity Local wound factors Handling properties
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Natural vs Synthetic Suture
Pro Natural material Absorbs quickly Strength retention Pliability and strength Strength retention Absorption (hydrolysis) Patient reactivity Con Stays in body longer More reactive Material inconsistency Increased tissue trauma
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Absorbable Sutures Suture Type Classification Sites for Use # Knots
Catgut collagen Natural SQ, GI 3 or 4 Polyglycolic acid (Dexon/Vicryl) Braided, synthetic SQ, GI, fascia, vessel ligature 4 PDS/Maxon Synthetic, monofilament Fascia, GI, Biliary/pancreas 6-8
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Non-Absorbable Sutures
Suture Type Classification Sites for Use # Knots Silk Natural Vessel ligature, GI 3 Dacron Braided, synthetic Hernia repair, fascial closure, fundoplication 5 Polypropylene, Nylon Synthetic, monofilament Skin, fascia, hernia repair, vascular anastomosis 6-8
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Tensile strength – refers to the amount of strength “in vivo” that a suture material has retained. This can be measured in days and as a percentage of original strength. Exp: days 50% at 3 weeks Absorption = the loss of mass of the material in tissue as measured in days, Exp: days
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Suture Properties: Definitions
Tensile strength – refers to the amount of strength “in vivo” that a suture material has retained. This can be measured in days and as a percentage of original strength. Exp: days 50% at 3 weeks Absorption = the loss of mass of the material in tissue as measured in days, Exp: days
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Suture Breaking Strength Over Time
PDS Chromic Dexon Plain
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Loss of Tensile Strength in Nonabsorbable Sutures
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Absorbable Suture: Ethicon, Inc.
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Nonabsorbable Suture: Ethicon, Inc.
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US Surgical
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Suture Sizes
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Suture Needles
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Non-Cutting Needles
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Needles… ANATOMY OF A NEEDLE
POINT SWAG (SWEDGE)
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Running suture: Non-popoff/swaged on Interrupted suture: popoff
Suture… Control Release--- POPS! (Pop-offs) Pop off... Don’t pop off... Running suture: Non-popoff/swaged on Interrupted suture: popoff
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Suture…
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Suture… Use
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Suture… Order # Use
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Suture… Order # Use Size (metric)
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Suture… Order # Use Size (metric) Suture Material
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Suture… Order # Use Size (metric) Suture Material Suture length
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Suture… Order # Use Size (metric) Suture Material Needle cross section Suture length
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Suture… Order # Use Size Suture Material (metric) Needle cross section
Needle sales type- Suture length (reflects size)
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Suture… Order # Use Size Suture Material (metric) Needle cross section
Needle sales type- Suture length (reflects size) Approximate needle size & shape
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Suture… Order # Use Size Suture Material (metric) Needle cross section
Needle sales type- Suture length (reflects size) Approximate needle size & shape Needle curve
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Suture… Order # Use Size Suture Material (metric) Needle cross section
Needle sales type- Suture length (reflects size) Approximate needle size & shape Needle curve Needle diameter
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Suture Lab Goals 1) Proper instrument handling
Instrument/needle setting technique Safety tips 2) Suturing technique Proper needle insertion into tissue and needle/hand rotation Tying with needle still on (free hand and instrument)
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Suture Lab Goals 3) Types of stitches Simple interrupted
Interrupted vertical mattress Subcuticular Simple running Running vertical mattress Forehand and backhand techniques 4) Knot tying One and two handed knots Instrument pass
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Skin Stapling
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Simple Interrupted Suture
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Interrupted Vertical Mattress
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Interrupted Vertical Mattress
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Interrupted Horizontal Mattress
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Figure of 8 (Interrupted Fascial Closure)
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Simple Continuous Closure
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Continuous Locking Suture
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Continuous vs Interrupted Suture
Continuous Suture Pros Cons May be rapidly placed Avoids tying multiple knots, reduces knots in wound Even distribution of tension along full length More hemostatic If it breaks, the whole suture line may disrupt Long amount of suture to deal with Interstices of braided sutures could harbor infection along the suture line
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Continuous vs Interrupted Suture
Pros Cons Remaining sutures protect wound if an interrupted suture comes untied Infection cannot travel along suture length More operating time due to cutting and tying of each suture individually Each suture could have a variable amount of tension Individual knots increase amount of foreign body in the wound
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Burying Knots
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Suture Removal
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Suturing Movie Click the projector button to view the suturing movie
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Sources John Stuart Brown, MBE, Minor Surgery, A Text and Atlas,
Fourth Edition, Oxford University Press, New York, 2000. Jameson L. Chassin, MD, Operative Strategy in General Surgery, An Expositive Atlas, Second Edition, Springer- Verlag, New York, 1994. A.K. Qayumi, MD, PhD, Basic Surgical Techniques, An Illustrated Manual, Q&Q Publishing, Vancouver, Canada, 2000. Ethicon, Inc., A Johnson and Johnson Company, Somerville, NJ, USA,
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