1. Sutures and Suturing Techniques

2. 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

3. AN EXAMPLE
SIZE TYPE NEEDLE
VICRYL CT-1

4. 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

5. 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)

6. Suture
Two basic types
Monofilament
Multifilament

7. Suture
Can also be classified as
Absorbable
Non-absorbable

8. 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

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

10. 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

11. THE PERFECT SUTURE
Does not Exist yet!

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

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

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

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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

27. 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

28. 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

29. 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

30. 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)

31. 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

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

33. 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

35. 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

36. 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

37. 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

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

39. 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

40. 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

41. 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

42. Left=Correct Approximation Right=Incorrect Approximation

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

44. Go to QuickTime Two Hand Square Knot
One Hand Square Knot
Instrument Tie

46. Driving the Needle Through

47. Drive Through the Other Side

48. Instrument Tie

49. Simple Interrupted

50. Simple Interrupted

51. Vertical Mattress

52. Horizontal Mattress

53. Horizontal mattress

54. Running, or Continuous Stitch

55. Continuous Locking, or Blanket