SUTURE AND SUTURE MATERIALS IN SURGERY

SUTURE AND SUTURE MATERIALS IN SURGERY!!!

1. SUTURES AND SUTURE MATERIALS IN SURGERY BY DR. OKOYE C. DEPARTMENT OF OTORHINOLARYNGOLOGY , HEAD AND NECK SURGERY. JOS UNIVERSITY TEACHING HOSPITAL 1

2. OUTLINE INTRODUCTION HISTORY CLASSIFICATION OF SUTURES SUTURE MATERIALS IDEAL SUTURE/ NEEDLES PRINCIPLES OF SUTURE SELECTION WOUND CLOSURE/SUTURING TECHNIQUES KNOT TYING SUTURE REMOVAL NEW TRENDS AND ALTERNATIVES CONCLUSION REFERENCES 2

3. INTRODUCTION Surgical suture is a medical device used to hold body tissues together after an injury. Application generally involves using a needle with an attached length of suture. A number of different shapes, sizes, and suture materials have been developed over the millennia of history. Surgeons, physicians, and paramedics typically engage in suturing. 3

4. HISTORY The use of sutures is thousands of years old. The surgeon in his practice encountered a wound created either by himself or trauma, thus he required a material for closure to combat the problems of sepsis. Although suture materials and aspects of the technique have changed, the goals remain the same; closing dead space, supporting and strengthening wounds until healing increases their tensile strength, approximating skin edges for an aesthetically pleasing and functional result, and minimizing the risks of bleeding and infection. 4

5. HISTORY 3000BC Egyptians used thorns and needles to close wounds. 1000BC Indian surgeons used horse hair, cotton and leather. 2 nd century Roman physician, Galen described gut sutures Late nineteenth century, silk and catgut became popular. Joseph Lister was the first to sterilize sutures. 5

6. SUTURE CLASSIFICATION BASED ON ORIGIN (NATURAL, SYNTHETIC) BASED ON STRUCTURE (MONOFILAMENT, MULTIFILAMENT) BASED ON RESORPTION (ABSORBABLE, NON-ABSORBABLE) BASED ON MATERIAL (METALLIC, PLASTIC, LIQUID) 6

7. TYPES OF SUTURES ABSORBABLE SUTURES Natural Synthetic NON-ABSORBABLE SUTURES Natural Synthetic 7

8. 8 Absorbable Suture A suture that degrades and loses its tensile strength within 60 days is generally considered to be absorbable. Catgut – plain and chromic Reconstituted collagen Polyglycolic acid (PGA, Dexon ) Polyglactin 910 ( vicryl ) Polydioxanone (PDS)

9. 9 Non-absorbable Suture Generally has no effect on wound tensile strength. Braided sutures – Silk, Linen or Cotton. Synthetic monofilament sutures – Nylon, Polypropylene, Dacron or Teflon

10. 10 Metallic sutures - stainless steel wire - Aluminum wire Clips – occlusion of small structures staples – bowel closure, vascular anastomosis Skin tapes – non suture method of closing wound edges that are not under tension

11. 11 Suture Materials A Suture is a material used in surgical practice to either appose the edge of tissues or secure hemostasis. Suture is made of a variety of materials with different properties. Suture may be synthetic or biological, absorbable or non absorbable. Suture may be mono or multifilament

12. ABSORBABLE SUTURES The body will absorb the material over time. Biological origin – catgut, etc Synthetic – polyglycolic acid, polylactic acid, etc They are absorbed by the various Biological processes. Hydrolysis Proteolytic enzymatic degradation 12

13. USES Used on internal body tissues rapidly healing tissues e.g stomach, colon, bladder, oral mucosa - Disadvantages: They sometimes provoke immune responses and are rejected instead of being absorbed. 13

14. TYPES Catgut/kittegut – the name is derived from a musical instrument called kitte. It is made from the gut of sheep or cattle. The absorption rate of plain catgut is about 10 days. Chromic catgut – 20 days Chromic catgut – has been treated with a chromium salt to retard its absorption by reconditioning the surgical gut to resist digestion by the body. 14

15. Polyglactic Acid (Vicryl) Braided synthetic Completely absorbed in 60 – 90 days Useful in slowly healing tissues where suture is expected to be placed for long periods The disadvantage is that it may induce bacterial infection 15

16. Polydioxanone (PDS) Synthetic monofilament Long duration of absorbability High tensile strength Does not induce bacterial infection The disadvantage is that it is somewhat stiff and difficult to handle. 16

17. NON-ABSORBABLE They are: Biological origin – silk Synthetic – propylene, nylon, polyester, stainless steel They are used in: Skin wound closuring Stressful internal environment e.g. the heart, hernia bed. 17

18. They provoke less immune response thus less scarring, they are used where cosmetic outcome is important. 18

19. The following are types of non- absorbable suture: Silk Braided non-absorbable Obtained from silkworm larva Good tensile strength Produces good knots 19

20. Polyester (Dacron) Braided from polyester fibers Has superior strength and durability Nylon Synthetic Available in both monofilament and multifilament forms 20

21. It is very strong and smooth It passes through tissue with ease with minimal tissue reaction. However knot slippage is very common with Nylon. Polypropylene ( Prolene ) Monofilament synthetic Passes through tissue smoothly with minimal reaction 21

22. Stainless Steel Made from low-carbon iron alloy May be mono or polyfilament Used in ligament, tendon and bone operations. Staples and Skin tapes can also be used to bring wound edges together. 22

23. Monofilament materials glide through tissue easily and are less reactive, but they are more difficult to handle or knot and are more likely to cut through tissue. The monofilament filament suture, if partially fractured may completely disrupt a continuous running suture. 23

24. All sutures should be avoided in dirty compartment or infected wounds, because as foreign bodies, sutures can impair the wounds ability to resist infection. If sutures must be used in such situations, monofilament non- absorbable material should be used. 24

25. STRENGTH The strength of sutures is measured using 2 systems. The old system of using “ zeros ” for the finest sutures and “ numbers ” for the thickest ones. For example, from finest to thickest, the sequence of commonly used sutures- 6/0, 5/0, 4/0, 3/0, 2/0, 0, 1, 2, 3, 4. 25

26. The choice of suture material is based on: Physical and biologic characteristics of the suture material Healing properties of the tissue to be sutured. Amount of tension exerted on the wound Anatomic location of the wound. Factors that influence knot security: Material confidence The length of cut ends Structural configuration Multifilament or braided sutures are easier to handle and have better knot holding properties; unsecured knots allows slippage . 26

27. Ideal Suture Material Have good handling characteristics Not induce a significant tissue reaction Allow secure knots Have adequate tensile strength Not cut through tissue Be sterile Be non-electrolytic Be non-allergenic Cheap 27

28. Lord Moynihan(1865-1936) defined: An ideal suture has the following features It is completely inert It does not affect the tensile strength of the wound It maintains its tensile strength indefinitely It does not harbor microorganisms It should disappear as soon as its function is accomplished 28

29. PROPERTIES OF A GOOD SUTURE Must have tensile strength to resist breakage, Flexible enough to be knotted Must produce a good knot security Low tissue reactivity i.e. must be hypoallergenic Ability to resist bacterial infection Must avoid wicking effect 29

30. NEEDLES Surgical needles are designed to lead suture material through tissue with minimal injury. Needles are selected according to: The type of tissues to be sutured. The tissue accessibility The diameter of the suture material 30

31. The ideal surgical needle is made of high quality stainless steel, as slim as possible without compromising strength, stable in the grasp of a needle holder, able to carry suture material through tissue with minimal trauma, sharp enough to penetrate tissue with minimal resistance, rigid enough to resist bending but not break, sterile, and corrosion-resistant.

32. A needle anatomically has 3 parts: 1. The eye which may be: * Open * Swaged 2. Body which may be: * Straight * Curved

33. The point which may be: * Cutting * Reverse cutting * Tapered * Blunt

34. Cutting, is used on tough tissues such as skin. Reverse cutting, also used on very tough tissues but without suture tear out The taper point, is used on soft vulnerable tissue such as the bowel etc. The blunt point, is used on friable tissues e.g. liver.

35. PRINCIPLES OF SUTURE SELECTION Selection based on tissue type Based on anatomic location Based on wound healing 38

36. Use suture material that is suitable for the tissues being sutured. Therefore; a. slow healing tissues e.g. skin, fascias, tendons - use non-absorbable or absorbable with extended wound support b. rapid healing tissues e.g. stomach, colon, bladder, oral mucosa - use absorbable sutures PRINCIPLES OF SUTURE SELECTION

37. 2. Foreign body in potentially contaminated tissue may convert contamination to infection. Therefore; a) avoid multifilament sutures b) use monofilament or absorbable sutures

38. 3. Where cosmetic results are important, avoidance of irritants will produce the best result. Therefore; a) use small inert monofilament sutures e.g nylon or prolene b) c lose skin subcuticularly c) use topical adhesives or skin closure tapes

39. 4. Foreign body in the presence of fluids with high concentration of crystalloids may act as nidus for stone formation. Therefore, a) in urinary bladder & biliary tract, use rapidly absorbed sutures 5. Regarding suture size; a. use the finest size commensurate with the natural strength of the tissue. b. if post operative strain on suture line is anticipated, reinforce with retention sutures.

40. 43 Wound Closure Techniques There are many ways to secure tissue during an operative procedure and to repair a discontinuity Tape Glue Staples/Clips Metallic Sutures

41. 44 The aim of all these techniques is to approximate the wound edges without gaps and without tension. Suturing is the most versatile, least expensive and most widely used technique. In suturing, the size of the bite and interval between the bites should be consistent.

42. METHODS Sutures are majorly applied on 2 kinds of wounds: Surgical wounds Traumatic wounds Wounds heal in 2 basic ways: First intention , this is quick with minimal scarring, most surgical wounds heal by first-intention. Second intention , this happens slowly by tissue granulation and eventually with much scarring. 45

43. The aim of suturing is to achieve first intention healing. Most surgical wounds are fresh and non infected and are closed immediately. Wounds can be closed in various ways: Immediate primary closure – This is suturing of a wound within 6 hours of the injury. This is done if the wound is clean and contains no dead tissue. 46

44. Delayed primary closure – This is suturing of a wound 3 – 7 days post trauma/incision. Secondary closure – When the closure is delayed beyond 10 days. When suturing, the aim is to close the wound at all points and in all plains. No dead space is allowed, where blood and exudate can collect. 47

45. SUTURING TECHNIQUES. Continuous Interrupted Mattress Continuous sutures are quicker but they are less reliable, because, if the knot on a continuous suture breaks the whole wound may open up. Interrupted sutures are more secured, because the loss of a single interrupted suture knot matters little. Each interrupted has its knot. 48

46. However, knots can act as a nidus for infection. mattress sutures - Can be vertical or horizontal. provide a relief of wound tension and precise apposition of the wound edges more complex and therefore more time consuming. 49

47. 50 Vertical mattress technique is best for allowing eversion of wound edges and perfect apposition and to relieve tension from the skin edges

48. 51 Horizontal mattress technique reinforces the subcutaneous tissue and provides more strength and support along the length of the wound; this keeps tension off the scar .

49. A sub- cuticular suture brings the skin edges together accurately and is particularly useful in plastic surgery. It can be continuous or interrupted. 52

50. 53 Continuous subcuticular sutures excellent cosmetic result use fine, absorbable braided or monofilament suture do not require removal if absorbable sutures are used useful in wounds with strong skin tension, especially for patients who are prone to keloid formation

51. 54 Purse string sutures (buried horizontal mattress ) a circular pattern that draws together the tissue in the path of the suture when the ends are brought together and tied.

52. 55 Retention sutures all abdominal layers are held together without tension; the sutures take the tension off the wound edges use for patients debilitated as a result of malnutrition, old age, immune deficiency or advanced cancer, conditions associated with increased intra abdominal pressure use in cases of abdominal wound dehiscence.

53. Knot tying Once the suture is satisfactorily placed, it must be secured with a knot. The instrument tie is used most commonly. The square knot is traditionally used. First the tip of the needle holder is rotated clockwise around the long end of the suture material for 2 complete turns. The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, such that the ends of the suture material are situated on opposite sides of the suture line. 56

54. The needle holder is then rotated counterclockwise once around the long end of the suture. The short end is grasped with the needle holder tip, and the short end is pulled through the loop again. 57

55. The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. The reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increase with increased wound edema. Depending on the surgeons preference. 1-2 additional throws may be added 58

56. Properly squaring successive ties is important. That is, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and is inherently weaker than a properly squared knot. When the desired number of throws is completed, the suture material may be cut (if interrupted), or the next suture may be placed. 59

57. SUTURE REMOVAL Sutures should be removed within 1-2 weeks of their placement, depending on the anatomic location. Prompt removal reduces the risk of suture marks, infection and tissue reaction. The average wound usually achieves approximately 8% of its expected tensile strength 1-2 weeks after surgery. To prevent dehiscence and spread of the scar, sutures should not be removed too soon. 60

58. SUTURE REMOVAL As a general rule, the greater the tension across a wound, the longer the suture should remain in place. As a guide; The tongue – 4 days The Scrotum – 5 days The face - 3-5 days The neck – 7 days Scalp wound - 7-10 days Hands and Fingers – 7 days Trunk and upper limbs – 10-14 days Lower extremities 14-21 days Any suture with pus or signs of infection should be removed immediately. 61

59. SUTURE REMOVAL Proper suture removal technique is important to maintain good results after sutures are properly selected and executed. Sutures should be gently elevated with forceps, and one side of the suture cut. Then, the suture is gently grasped by the knot and gently pulled toward the wound or suture line until the suture material is completely removed. If the suture is pulled away from the suture line, the wound edges may separate. 62

60. Common errors in suturing Too many throws. Increases foreign body size. Causes stitch abscesses Intra-cuticular rather than subcuticular sutures causing hypertrophic scars Holding monofilament sutures with instruments reduces tensile strength by over 50% Holding butt of needle causes needle and suture breakage 63

61. Stoppers to stitch ends- no knots Antibiotic impregnated sutures – vicryl plus Minimal access surgery/ clips Tissue glue – cyanocrylates,fibrin tissue glue Stapling devices Adhesive tapes NEW TRENDS AND ALTERNATIVES

62. NEW TRENDS AND ALTERNATIVES Application of bio-based polymers produced from renewable resources. Bio-based polymers are attracting increased attention due to environmental concerns and the realization that global petroleum resources are finite. 65

63. Bio-based polymers are closer to the reality of replacing conventional polymers than ever before. However, despite this advancement there are still some drawbacks which prevent the wider commercialization of bio-polymers in many applications. Mainly due to performance and price when compared to their conventional counterparts 66

64. CONCLUSION There’s no substitute to an informed choice of suture material, size and technique in achieving satisfactory wound closure. 67

65. THANK YOU 68

66. REFERENCES Intercollegiate Basic Surgical Skills (2002) Faculty and Participant Handbooks, 3rd edn . Royal College of Surgeons of England, London Abdelrahman T, Newton H: Wound Dressings; principles and practice. Surgery 2011, 29:491-495 Adams B, Anwar J, Wrone DA, Alam M. Techniques for cutaneous sutured closures: variants and indications. Semin Ccutan Med Surg. Dec 2003: 22(4) : 306-16 Text Book on Cutaneus and Aesthetic Surgery. Jaypee Brothers Medical Publishers Pvt. Ltd. Pp.125-126. Retrieved 25 January 2016. Principles and Practice of Surgery including pathology in the tropics 3 rd edition 69