Principles of suturing in surgery

tells us technique of suturing and types of sutures

1. PRINCIPLES OF SUTURING IN SURGERY.

2. Contents Introduction/Definition, Goals of suturing, Suture materials, Suture armamentarium, Principles of suturing, Suturing techniques, Knots, Suture removal & complications.

3. WHAT IS A SUTURE? “Suture” is a Latin word, meaning “sewing together”. OR To Suture refers to using a material that is an artificial fiber; to keep wound edges together until they hold sufficiently well by themselves by natural fibre (collagen) which is synthesized and woven into a stronger scar later. OR A surgical seam formed after joining two surfaces. (Collins Dictionary)

4. Goals of Suturing Sutures are performed to: maintain hemostasis, Provide adequate tension, Permit healing by primary intention, Provide support to tissue margins, Reduce post-op pain, Prevent bone exposure, Permit proper flap position.

5. Requisites of an I deal suture Tensile Strength, Tissue Biocompatibility, Low Capillarity, Good Handling & Knotting properties, Sterilization without deterioration of properties (most sutures available in packages are sterilized by dry heat & ethylene oxide gas.). Non allergic & non carcinogenic, Its use should be possible in any surgery, Low cost,

6. Need for suturing in Oral & Maxillofacial surgery Open or closed tooth extractions. Impactions Oro-facial trauma Pathologies of head & neck region Fire arm injuries Burn injuries Plastic surgery procedures Reconstructive surgical procedures in case of trauma or congenital defects Abscess drainage

7. It should be readily visualized, should not shrink & should not be extruded from the wound. On break down, it should not release toxic agents and should resorb without excessive reaction once the task is completed.

8. Classification of Suture Materials

9. TYPES OF SUTURES

10. Suture Sizes Largest size 1-0 to extremely fine 11-0 Increasing number of zeros correlates with decreasing suture diameter & strength.

11. Size is chosen to correlate with the tensile strength of the tissue being sutured. Most commonly used in the oral cavity is the 3-0 black silk. The size 3-0 has the appropriate amount of strength The poly filament nature of silk makes it easy to tie and well tolerated by the patients soft tissues. The color makes it easy to see when the patient returns for suture removal.

12. Suture Needles Material: Stainless steel or Carbon steel. They are designed to lead the suture material through the tissue with minimal injury. Shape: usually a small half circle or three eighths-circle suture needle. Tips:

13. Components of the surgical needle

14. Packaging..

15. Principles of Suture selection The selection of suture material by a surgeon must be based on a sound knowledge of: Healing characteristics of the tissues which are to be approximated, The physical &biological properties of the sutures materials, The condition of the wound to be closed, The extent of the bodily tissues or surgical wound to be sutured.

16. Needle Holder The needle holder is used to handle the suture needle and thread while suturing the surgical wound. Parts of needle holder: working tip/jaws Hinge device Shank/body Catch mechanism/ratchet Grip area

17. The needle holder is an instrument with a locking handle & a short, blunt beak. Size: for intra-oral placements of sutures- a 6inch (15cm) needle holder is recommended. The beaks of the needle holder are shorter and stronger than the beaks of a hemostat.

18. The face of a beak of the needle holder is cross-hatched to permit a positive grasp of the suture needle. The hemostat has parallel grooves on the face of the beaks thereby decreasing the control over needle & suture.

19. Scissors The final instrument necessary for placing sutures are suture scissors. They usually have short cutting edges to cut sutures. The most commonly used suture scissors for oral surgery are Dean scissors.

20. Principles of Suturing Needle grasped at 2/3rds of the distance from the tip of the needle. Needle should enter perpendicular to the tissue surface. Needle passed along its curve, The bite should be equal on both sides of the wound margin of the flap about 2-3mm because after wound closure the edge of the wound softens due to collagenolysis and the holding power is impaired.

21. Usually the needle should be passed from mobile side to the fixed side but not always (exception in lingual mucoperiosteal flap.) & from thinner to thicker & from deeper to superficial flap. The tissues should not be closed under tension, since they will either tear or necrose around the suture. Tie to approximate, not blanch. knot must not lie on incision line.

22. the distance b/w one suture to another should be about 3-4mm apart to prevent strangulation of the tissue & allow escape of the serum or inflammatory exudate & get more strength of the wound. Deep wounds are closed in layers. Avoid retrieving needle by tip. Sutures should have correct tension while tying knot for provision of the slight edema post operatively.

23. TECHNIQUES OF SUTURING Interrupted Suture Simple continuous suture External horizontal mattress suture External vertical mattress suture Figure-of-eight suture

24. INTERUPTED SUTURE Indications Single tooth extraction Third molar extraction flap Biopsies Implants

25. Simple continuous suture Indications Bone graft Removal of mandibular Tori Tuberosity reduction Where esthetics are not concerned

26. Horizontal mattress suture Indications Large distance between tissues, Bone grafts Implants Closure of extraction socket

27. Vertical mattress suture Indications Where the wound edges tend to Evert.

28. FIGURE OF 8 SUTURE Indication Extraction socket closure Adaption of gingival papilla around the tooth Bone graft placement in socket

29. TYING THE KNOT.. No not this knot.

30. KNOTS SLIP KNOT: used with silk, chromic or plain gut suture Surgeons knot: used with synthetic resorbable and non resorbable synthetic suture materials to prevent untimely knot untying.

31. Stitch removal Intra oral mucoperiosteal closure (without tension)= 5-7 days where there is tension on the suture e.g. oro-antral fistula= 7-10days A good guide is that as soon as they begin to get loose they should be taken out.

32. Suture complication Suture abscess Suture scaring or stitch mark

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