Surgical Sutures

Classification of Sutures and the Uses presented in March 2012

1. S URGICAL S UTURES Dr. PRADEEP CRRI KMCH SURGERY II March 2012

2. DEFINITION Suturing is the joining of tissues with needle and “thread,” so that the tissues bind together and heal. SPECIALIZED THREAD - SUTURE MATERIAL THREADS on which life may depend. Foreign body reaction .

3. HISTORY Oldest suture is in a mummy 1100BC 500 BC- suture materials and usage – sushruta Africans – thorns and ant sutures b y coaxing insects to bite wound edges with their jaws and subsequently twisting off the insects' heads. Roman physician galen – describe gut Surgeon Al- zahrawi – reported dissolving nature of catgut. Joseph lister – sterilisation . Sterile catgut in 1906 by iodine treatment.

4. CLASSIFICATION

5. ABSORBABLE SUTURES U.S.P. – ‘ Sterile strand prepared from collagen derived from healthy mammals or synthetic polymer . Natural – cellular and tissue proteases digest Synthetic – hydrolysis in tissue fluids ADVANTAGES: No foreign body left No stone formation Quickly heal tissues

6. NON ABSORBABLE SUTURES Sterile strands of material that are suitably resistant to the action of living mammalian tissue. ADVANTAGES: High tensile strength Used for wound closure , CVS surgeries , Hernia repairs

7. NATURAL AND SYNTHETIC Natural – Proteins , tissue enzyme digestion Synthetic – Carbohydrates , Hydrolysis . Eliminates allergic reaction Twice as strong as natural Lose the tensile strength slowly Predictable absorption. Excellent handling characterisitics Sterilized by Ethylene oxide . Shelf life 5 years

8. SUTURE TYPE ABSORBABLE NON ABSORBABLE MONOFILAMENT Surgical gut Plain, chromic Collagen – plain, chromic Polyglecaprone 25 Polydiaxanone Polyamide Polypropylene Stainless steel Polyester MULTIFILAMENT Polyglycolic acid Coated Polyglactin 910 Coated Polyglactin 910 with antibacterial agent Coated Polyglactin 910 RAPIDE Surgical silk Surgical Linen Cotton Polyamide Braided Polyester Braided Polyester Braided coated Stainless steel

9. SURGICAL GUT 99% pure collagen Submucosa of sheep intestine and serosa of beef intestines Monofilament Enzymatic degradation Complete absorption by 60-90 days Sterilisation by gamma irrad 2.5 Mrad Tensile strength loss is faster than absorption

10. PLAIN AND CHROMIC Plain – 7-10 days maintains tensile strength Chromic – 10 -14 days . Y CHROMIC??? WET PACKING??? Sizes 5-0 to 2. Not to be usd in infected wounds . PLAIN ( YELLOW ) CHROMIC ( BROWN ) Bleeders Subcut sutures Circumcision Wounds in LIP Approx of muscles, peritoneum closure, bowel anastomoses , all OG procedures.

11. POLYGLYCOLIC ACID Polymers of glycolic acid . 100% Coated with Polycaprolactone & Calcium stearate ( Why ?). Absp time – 60 -90 days Minimal tissue reactions Retains 75% tensile strength after 2 weeks General soft tissue approximation , ophthalmic Violet and undyed . Sizes 6-0 to USP 2.

12. POLYGLACTIN 910 Copolymers 90% glycolide and 10% L- lactide . Braided – easy handling and knotting . Plain and coated COATING – calcium stearate . Absorbable adherent , non flaking lubricant – low tissue drag, reduces surface friction of braid .

13. VICRYL Retains 70% tensile strength by 2 weeks . Non antigenic / pyrogenic Minimal tissue reaction . Soft tissue approximation and Ligation . Violet and undyed . 910 - ?

14. VICRYL PLUS AND RAPIDE PLUS - Antimicrobial TRICLOSAN – combat surface skin infections CI – ophthalmic , cvs and neural tissues. RAPIDE – by gamma irrad of coated vicryl Low molecular weight Initially tensile strength 30% less Lose al its strength b/w 10th and 12th day Totally absorbed in 42 days . CIRCUMCISION – excellent cosmesis . Beige and undyed .

15. POLYGLECAPRONE 25 Monofilament ( MONOCRYL ) 75% glycolide , 25% caprolactone Very High initial tensile strength Most pliable, very smooth , knot security No PACKAGE MEMORY Loses 40% tensile strength in 1- 2 weeks , 60 – 70% in 4 weeks Completely hydrolyzed in 3 months Bowel anastomoses, peritoneal closure , subcut , subcuticular , Urology . Violet and undyed .

16. POLYDIOXANONE Poly( ether -ester) Poly p- dioxanone . Strongest Monofilament 20 -30% Inert , predictable absorption. Smooth , pliable, minimal package memory Retain 80% TS after 2 wks , 50% 4 wks . Total absorption 6 – 7 months Orthopaedic , Paed CVS, general , subcuticular and fascia closure . Dyed dark blue

17. SURGICAL SILK Non absorbable, multifilament , natural – fibroin . From cocoon of silk larvae .(Bombyx mori ) Braided and treated with silicone or wax High tensile strength Maximal tissue reaction , encapsulation 2-3w Sterilisation gamma irrad . General closure, G. I. Tract, Plastic, Skin, Opthalmic , Cardiovascular Surgeries. Widely used as ligature. CI – urinary & biliary tract. Infection. Black , sizes 5-0 to USP 2.

18. POLYAMIDES - NYLON Monofilament , smooth soft Very minimal tissue reaction Lose 25% tensile strength aft 1 yr Package memory present Excellent knot security and no tissue adherence Blue/black , sizes 10-0 to USP 2.

19. POLYESTERS Terylene and dacron High tensile strength No/minimal tissue reaction Tensile strength retained indefinitely CVS surgeries Coated with teflon to prevent cut through – cause flaking , Increase diameter of suture mat

20. POLYPROPYLENE ( prolene ) Monofilament , synthetic , smooth Extremely high tensile strength Retains it indefinitely No tissue reaction Extend upto 30% before breaking – so useful where post-op give up is required – prevent tissue strangulation. Blue. Sizes 8-0 to USP 1.

21. STAINLESS STEEL Non absorbable Monofilament , strength , Inert Composed of 316L stainless steel Sizes 5-0 to 6 Abdominal wound closure, hernia repair, sternal closure and orthopaedic procedures including tendon repair. Sternal bands – highly stable and promote faster healing.

22. SUTURE SELECTION Healing rates of various tissues Strength of the material Rate of absorption Cosmesis Tissue contamination Nourishment Cancer pts depending on the time of irrad Rx. Before irrad – Polyester should be used . After – Prolene ideal , No tension/ mattress .

23. Wound gains strength after 6 days , so suture must be strong enough to hold tissues in proper apposition during 1st week . When it has reached max. strength – no longer sutures needed .

24. IDEAL Skin, fasica , tendons, abdominal incision closure – Nonabsorbable Peritoneum , liver , small intestine, stomach , colon, bladder , muscles – Absorbable. Tissue contaminated – Prolene . Avoid multi. Biliary and urinary tract- absorbable . Non absorbable not to be used even on outer surface. Pancreatic – vicryl , prolene . Gut avoided .

25. SIZES Peritoneum 2-0/3-0 Muscles 1-0 / 1 Linea alba 1 Rectus sheath 1-0/1 Subcut 3-0 Eso/ stomach /SI/colon – 2-0/3-0 Kidney 1-0 Bladder 2-0 OBG 1-0/1 Ovarian 2-0/3-0 Hernia 1-0/1 Tendons 4-0/5-0 Ophthalmic 8-0 to 10-0 Face 5-0/6-0 Hands and limbs 3-0/4-0

26. SUTURE BOX The United State Pharmacopoeia (USP) recommends that suture boxes must provide complete information of the suture materials. This includes: 1. size 2. types of sutures 3. types of needles Some boxes have specific indications, like F S ……….. for skin P S ……….. for plastic skin P ……….. for precision point P C…….…. Precision cosmetic