1. Suture Selection  Sutures hold tissue together until the natural process of wound healing has taken place  All sutures are foreign bodies and impact on wound healing

2. Suture Selection  Absorbable sutures elicit more inflammatory reaction than non- absorbable sutures  Natural sutures absorbed by proteolytic enzymes induce more inflammation than synthetic ones absorbed by hydrolysis.

3. Suture selection  Monofilaments usually require more knots to prevent slippage  Braided sutures handle easily and knot easily  Braided suture may harbor bacteria

4. Suture selection  Suture size is reflected in “0’s”  4.0 vicryl is “0000”  Number one vicryl is “#1”  O vicryl is “0”  The more “0” the finer the stitch

5.  00000 fine  0000  000  00  0  1  2 thick

6. Suture selection  Use the smallest size suture that can hold the tissue together during the healing process  Fascia heals slowly - use bigger, stronger suture  Mucosa heals quickly, use smaller stuff

7. Suture Selection  Memory - tendancy to return to original shape (untied!)  Plasticity - expand when stretched and don’t return to original length (loosen with edema)  Elasticity - ability to return to former length (dosen’t loosen with edema)

8. Suture Selection  Fluid absorption and capillary action - the tendency for a suture to absorb water and to wick infection

9. Absorbable suture Gut  Tensile strength for 4-5 days only  High tissue reactivity  Poor tensile strength for a given suture diameter  Monofilament Uses: tubal ligation, ligation of blood vessels

10. Absorbable Suture Chromic gut  Tensile strength for 2 to 3 weeks  High tissue reactivity  Poor tensile strength for a given tissue diameter  Monofilament Uses: episiotomy repair, uterine closure, closure of peritoneum

11. Absorbable Suture Poly-sugars  Dexon, Vicryl, Polysorb  Synthetic polymers with modest tissue reactivity  Tensile strength for 2 to 3 weeks  10% strength at 28 days  Low elasticity - may cut soft tissue  Braided - handle well but wick fluid  Good for subcuticular closure and fascia

12. Absorbable Suture PDS Maxon  Monofilament  Delayed absorption  59% strength at 28 days  Minimal tissue reaction  Less suture abscesses and cut through than vicryl  Complete absorption by 180 days

13. Absorbable Suture Monocryl Biosyn  Virtually inert in tissue  Tensile strength for 2 to 3 weeks  Less suture absesses  Great for mucosa and skin closures

14. Permanent Suture Silk  Second only to gut for tissue inflammation  Braided  Best handling of any suture  Lowest tensile strength of any suture  Weaker when wet

15. Permanent Suture Nylon  Surgilon, Ethilon, Dermalon  Inert  Pronounced memory - lots of knots Uses- skin closure, sewing in JP draines

16. Permanent Suture Polypropylene  Prolene, Surgilene, Surgipro  Inert  High placticity - expands to prevent strangulation, but loosens when edema subsides (use with steri-strips)  Will stretch when pulled  Elastic - requires extra knots Uses- wound closure

17. Permanent suture Braided polyester  Ticron, Tevdek, Ethibond  Greater tensile strength than other permanent sutures  Good hadling with secure knots Use: pelvic reconstruction

19. Fascia Strength and Healing Time

21. Clamp rule  Mosquito 4.0  Kelley use 3.0  Mayo use 2.0  Haneny use 0

22. Staples  Cost more  Faster  Less tissue reactivity and infection  Good cosmesis  Require more infrastructure

23. Needles

24. Needle Loading 7 mm drilled 3 mm for laser Needles break at point and at swage

25. Needle types  Use taper for general closure  Cutting needles for skin

26. Needles - what to ask for  General closure  GI needle  Cutting needle  Keith needle  Free or Mayo needle

27. Surgical Knots  Two types of knots Flat Flat Sliding Sliding  Most OB/GYNs use sliding knots

29. Flat knots  Square  Granny  Surgeon’s  Equal tension is applied to both tails  Hands cross when laying down knots

30. Sliding knots  Alternate throws (like a square)  Same direction - slide easier  One suture is held tight and the other is passed  Arms don’t cross when laying knots down