1. SUR 111
Suture and Staplers

2. Skill Assessments 10-3 Load and Pass Needleholders (NH)
10-3 Load and Pass free needles
10-4 Ties, reels, free tie on a Passer
11-2 Load clip appliers and Pass Staplers

3. 10-3 Load and Pass NH
Choose appropriate size NH based on size of the needle being used by the surgeon
Heavy NH will bend delicate needles
Delicate NH will be damaged being loaded onto large needles

4. Load and Pass the NH
Load needle by grasping it in the center of the body with the NH in the packaging
Some surgeons prefer NH grasping needle about 1/3 from the swaged end of the needle
Gently pull out of packaging pulling the strand gently if necessary to release suture memory prn
Pass to surgeon with NH’s loaded needle tip pointing towards the surgeon’s thumb
STSR’s hand position should be behind the needle point at lower shank/box lock level
DO NOT allow suture strand to drop below sterile field!
See text page Figure 12-45
Note ligating methods text page

5. 10-3 Load and Pass Free Needles
Differs from previous in that the suture strand must be secured unlike the swaged on suture
You will be shown different methods for doing this
Tip: Do not load the suture evenly, only load a short end of suture into the NH or it will pull right out of the tissue it is placed in
Passing technique is the same

6. 10-4 Ties, Reels, Free tie on a Passer
Lay near incision so surgeon may grasp with his forceps or
Pass to surgeon assistant so that person may grab with their forceps and pass to surgeon who likely will have a right angle in his or her hand to receive the tie and ligate a vessel
Always have these ready in pairs, if one is used another will follow

7. Ties, Reels, Free tie on a Passer
Release strand of suture from reel about 1 + ½ inches and pass reel to surgeon
Surgeon grasps other end of strand and ties holding onto the reel and suture
Reels ARE COUNTED ITEMS!

8. Ties, Reels, Free tie on a Passer
Tie on a Passer (usually a tonsil can be right angle)
Ties are loaded as an extension of the clamp it is loaded on
It will look like it is part of the tip if loaded properly
Pass clamp in the normal manner taking heed to not allow suture to drop below sterile table level

9. Suture Absorbable Designed to hold tissue together until it heals
Different types have different absorption rates
Suture type used depends on the type of tissue being sewn and that tissue’s normal healing time
Nonabsorbable
Designed to hold tissue together permanently

10. Suture Characteristics
Absorbable
Monofilament
Braided (multi-filament)
Dyed
Undyed
Natural
Synthetic
Nonabsorbable
Monofilament
Braided (multi-filament)
Dyed
Undyed
Natural
Synthetic

11. Suture Characterisitcs Monofiliment verses Multi-filament
Monofilament
Single strand
Inert (little to no tissue reaction)
Do not harbor bacteria
Can use in presence of infection
Minimal tissue damage as they glide easily through tissue
Multi-filament
Braided
Capillarity (able to harbor bacteria that can be communicated up the strand)
NOT used in presence of infection
Can be traumatic to tissue if not coated
Greater tensile strength
Hold knots securely

12. Suture Characterisitcs Natural verses Synthetic
From naturally occurring substances:
Cellulose
Animal products
Animal tissue
Synthetic
Man made:
Petroleum based products

13. Suture Sizes Correlate with tissue to be sewn
Heavy tissue needs a heavy strand of suture to hold it together
Delicate tissue does not require a heavy strand but a small or delicate strand of suture
Suture diameter is called the gauge

14. Suture Gauge #5 is largest available #1 to 4-0 are most commonly used
#1 and #0 are typical orthopedic sutures
6-0 to 7-0 for vascular anastamoses
8-0 to 11-0 for eye procedures
4-0 and 3-0 for skin closure (called subcuticular closure)

15. Suture Gauges (See text 286 table 11-4 ST for the ST)
#5 largest, #4, #3, #2, #1, #0, 2-0, 3-0, , 5-0, 6-0, 7-0, 8-0, 9-0, 10-0, 11-0, smallest

16. Suture Length
13cm to 150cm

17. Suture Packaging
Suture can have a needle incorporated into the suture stand called swaged
Suture can be without a needle also just called a tie or ligature ( below tie packaged individually)
These ties can be loaded onto individually packaged “free needles” and these suture ligatures are called “stick ties”
Ties can be packaged individually
Ties can be on reels similar to a spool of thread

18. Suture Presentation
Ties can be presented to a surgeon as a “free tie” laying it by his or her forcep near the incision site
Ties can be presented “on a passer” typically a tonsil clamp (tie will become an extension of the tonsil’s tip when loaded) Your book calls it “instrument tie”
Ties can be presented on reels (present by making sure the suture has been pulled out enough for the surgeon to use it and not have to pick and dig into the reel himself)

19. Suture Reels or Ligapak Dispensing Reel
Look at a reel like a bike tire: have the tire on the outside and the spokes on the inside
Limited sutures come in reel style
Examples include: vicryl, plain gut, chromic gut, silk, nylon
Gauge can be determined by packaging label and flipping the reel over to where you can visualize the dots in the reel’s spokes
º = 0
º º = 2-0
º º º =3-0
º º º º = 4-0
Larger gauges come packaged in pre-cut strands as well as these described above that come on reels

20. Needles Necessary to insert suture into tissue
Variety of shapes and sizes to accommodate specific tissues
Certain designs necessary for certain tissues to prevent tissue trauma when being used
Anatomy includes: eye, body (shaft), point (see page 314 textbook)
Also describe by shape (curved (1/4, 3/8, ½, 5/8 circle, ½ curved, or straight)

21. Needles Can be swaged on Single arm or double arm
Pop-offs or control-release
Individual
Individual that must be threaded like you would a needle at thread at home
Eyes types vary with individual needles
Closed eye - thread through eye
French eye – snap through the eye
Unique loading of suture strand to secure it from pulling out of the eye during usage

22. Needles
Cutting
used for tough tissue that can withstand this design of needle
Sclera, skin, tendons
Curved or straight (straight called “Keith needle”)
Tapered
Round shaft without a cutting edge
Can pierce or penetrate tissue but do not cut it
Vessels, gastrointestinal tissue, delicate tissue
Blunt
Round shaft with a blunt tip
Kidney or liver

23. Cutting Needles 1. Conventional Three cutting edges 2. Reverse cutting
Opposing cutting edges in a triangular shape
Side cutting
Primarily ophthalmic use as will not penetrate into deep tissue
Trocar points
Three sharp edges ending in a sharp point
Your trocars used for endoscopic delivery as well as surgical wound drain insertion •

24. Suture Book Textbook read pages 285-289
Your Suture and Surgical Hemostasis Pocket Guide is most helpful
Please review this material given in this slide show in this book as well

25. Most Commonly Used Sutures To Follow
Are primarily two manufacturers of suture in this area:
Ethicon (Johnson & Johnson)
Davis & Geck (US Surgical)
Suture materials are primarily the same with maybe one chemical difference
Trade names of suture are similar but not the same
This makes for confusion when learning suture
Most institutions carry only one primary brand
Most places here use Ethicon brand suture

26. Absorbable Suture

27. PLAIN GUT

28. Plain Gut (bright yellow package)
Monofilament
Natural
Submucosa of sheep intestine or beef intestine serosa
Comes in stick tie, pre-cut lengths, and reel
5-10 day wound support
Absorbs in days
Inflammatory reaction
Used for superficial hemostasis and tissue that heals quickly
Stored in alcohol solution to maintain pliability and keep from drying out

29. CHROMIC GUT

30. Chromic Gut (beige package)
Monofilament
Natural
Submucosa of sheep intestine or beef intestine serosa
Difference from plain gut is that it is treated with chromium salts to delay absorption rate
Comes in stick tie, pre-cut lengths, and reel
10-14 day wound support
Absorbs in days
Inflammatory reaction
Used for superficial hemostasis and tissue that heals quickly
Stored in alcohol solution to maintain pliability and keep from drying out

31. PDS

32. PDS (polydioxanone) (silver package)
Monofilament
Synthetic
Comes in stick tie, pre-cut, and reels
6 week wound support
Absorbed in 6 months
Minimal tissue reaction
Dyed or clear

33. Monocryl (not shown) (pink package)
Monofilament
Synthetic
14 day wound support
Absorbs in days
Slight tissue reaction
Dyed or undyed
3-0 through #1 gauge swaged
6-0 through #2 pre-cut ties
Close skin or soft tissue such as subcutaneous

34. Vicryl

35. Vicryl (polyglactin 910) (purple package)
Multi-filament (braided)
Synthetic
Dyed or undyed
21 day wound support
56-70 day absorption
Swaged, control release, free ties, reels
Close fascia, subcutaneous (adipose), skin (subcuticular), GYN procedures, peritoneum

36. Nonabsorbable Suture

37. Prolene

38. Prolene (polypropylene) (Royal blue packaging)
Monofilament
Synthetic
Least reactive of all synthetic suture
One of most inert sutures
CAN USE in presence of infection
Used for long term support of suture lines such as vascular surgery or mesh support in hernia repairs

39. ETHILON or
NYLON

40. Ethilon or Nylon (mint green package)
Monofilament
Synthetic
Minimal tissue reaction
One of most inert sutures
Used in ophthalmic, tendon repair, drain sew in, skin closure (interupted/what you know as “getting stitches”)
Dyed or undyed
Difficult to handle
Knots poorly

41. Stainless Steel (not shown)
Monofilament
Synthetic – chromium and nickel alloy)
Gauge #7 to 6-0
Minimal tissue reaction
Uses tendon repair, bone repair, (sternal closure (#7 wire)), cerclage (tying the cervix shut to prevent premature abortion)
Considered most inert of all suture materials
Can use in presence of infection
Not used in presence of other metal alloys!

42. SILK

43. Silk (baby blue package)
Multi-filament
Natural – from cocoon of silk worm
Usage GI tract in absence of infection and vessel ligature
Excellent knot holding and handling

44. Nurolon (Nylon Braided) NOT SHOWN (mint green packaging)
Multi-filament
Synthetic
Dyed or undyed
Minimal tissue reaction
Soft tissue approximation, see in neurosurgical closure
Coated with silicone to reduce drag and tissue trauma as pulled through tissue

45. ETHIBOND (Ethicon) or
TICRON (Davis & Geck)

46. Ethibond (polyethylene terephthalate) (orange packaging)
Multi-filament (braided)
Synthetic – polyester
Available in pre-cut ties and swaged suture
Most commonly used for soft tissue and heart surgery for valvular procedures

47. 11-2 Load and Pass Staplers
Read text p on stapling devices
There are great pictures there as well
Staplers can come with cutting blades incorporated into the stapling device
Care must be taken with these to avoid personal injury especially when re-loading
Staple and clips are made of stainless steel or titanium
Come disposable and non-disposable

48. Load and Pass Staplers Different stapling devices load differently
Staplers are passed with the STSR holding the stapling device by the business end and placing the handles into the surgeon’s hand
Always keep reloads available
Will be shown different staplers in lab
Used for skin closure like a staple gun
Also come in linear, ligating and intra-luminal designs for open and laparoscopic procedures

49. Load and Pass Staplers Clip appliers – a type of stapling device
Passed with tips pointing down for general surgeons and up for vascular surgeons
Surgeon will tell you how he or she wants them passed
Take care NOT to squeeze shank/finger rings together or the clip will fall out
Passed by placing the shank into the palm of the surgeon’s hand

50. CLIP or LIGACLIP APPLIERS
MEDIUM
CLIP or LIGACLIP APPLIERS
Regular length
SMALL
LARGE

51. Clip Appliers Long Length
MEDIUM REGULAR
LONG REGULAR
Clip Appliers
Long Length
LARGE LONG
MEDIUM LONG

52. DISPOSABLE CLIP APPLIERS Are pre-loaded with multiple clips
Ethicon laparoscopic clip applier
Davis & Geck AutoSuture Clip Applier
DISPOSABLE CLIP APPLIERS
Are pre-loaded with multiple clips
Each tells you how many clips it holds

53. Skill Assessment Review
10-3 Load and Pass Needleholders (NH)
10-3 Load and Pass free needles
10-4 Ties, reels, free tie on a Passer
11-2 Load clip appliers and Pass Staplers