Sutures

Sutures

1. DR. SIDHARTH YADAV
DEPT. OF ORTHOPAEDICS
NKPSIMS

2. HISTORY
50,000-30,000 B.C eyed needle were invented.
East african tribes ligated blood vessels with tendon & closed wound with
strips of vegetation wounds round the protruding ends in figure of 8.
South american used large black ants for wound closure.
Egyptian literature of around 1600 B.C mentions use of linen strips.
Albucasis A.D 936 first described a double suture.
Ambrose Pare described method of dry suturing for wounds on face.

3. A Suture is a stitch to approximate tissues or structures
till normal process of healing is complete.
A ligature is a suture used to encircle a blood vessel to
control bleeding.

4. CLASSIFICATION
MONOFILAMENT MULTIFILAMENT
SYNTHETIC BIOLOGICAL
ABSORBABLE NONABSORBABLE

5. ABSORBABLE SUTURES
• NATURAL
1. Surgical Gut
- Plain Gut
- Chromic Gut
2. Collagen
3. Living tissue
- Fascia lata
- Kangaroo tendon
- Cargil tendon.

6. ABSORBABLE SUTURES
 SYNTHETIC
- Polyglycocolic acid (PGA)
- Polygalactin 910 (vicryl)
- Polydioxanone (PDS)
- Polyglyconate (MAXONE)

7. NON ABSORBABLE
NATURAL
- Cotton
- Linen
- Silk
- Silk worm gut
SYNTHETIC
- Polyamides
- Polyesters
- Polyoletins

8. NON ABSORBABLE
METALLIC WIRE
ADHESIVE TAPE CLOSURE

9. PROPERTIES OF SUTURE
TENSILE STRENGTH
 The tensile strength of a material is determined by the
weight required to break a suture divided by its cross-
sectional area.
Implantation and tying of a suture decreases its strength.
Dry, unused absorbable suture loses 4-13% of its initial
strength after being soaked in sodium chloride
Knotted sutures have two-thirds the strength of unknotted
sutures.
Tensile strength of a suture should not exceed that of the
tissue.

10. KNOTS
The knot is the weakest portion of the suture.
 Its strength is defined by the force necessary to
cause slippage.
Takes at least three throws when polyglactin
910, polyglycolic acid, surgical gut, or
polypropylene suture material is used but at
least four throws when polydioxanone or nylon is
used.

11. PLASTICITY & ELASTICITY
Plasticity is the ability of the suture to retain its new form
and length after stretching.
Plasticity allows a suture to accommodate wound
swelling, thereby decreasing the risk of strangulated
tissue and crosshatch marks.
Elasticity is the ability of a suture to regain its original
form and length after stretching. After the swelling of a
wound recedes, the suture returns to its original length
and keeps the wound well approximated.
Memory is the ability of a suture to return to its original
shape after deformation by tying

12. HANDLING
Handling characteristics of suture materials are defined
by pliability and coefficient of friction.
Pliability refers to the ease with which a suture can be
bent.

The coefficient of friction is a measure of the slipperiness
of the suture.
Sutures with a high coefficient of friction, generally
multifilament sutures, are more difficult to pass through
tissue, thereby causing a greater degree of tissue injury
during placement and removal.

13. TISSUE REACTION
Different suture materials produce varying degrees of
tissue reaction.
Natural materials are absorbed by proteolysis, which
causes a prominent inflammatory response, while
synthetic materials are absorbed by hydrolysis,
which produces a minimal reaction.
Multifilamentous sutures have a high degree of
capillarity, which is correlated with a tendency
toabsorb and retain both fluid and bacteria

14. PRINCIPLE OF SUTURE SELECTION
RATE OF TISSUE HEALING

 When a wound has reached its maximal strength
sutures are no longer needed.
Tissue that heals slowly such as skin , fascia & tendon
should be closed with non absorbable sutures e.g.
ethilone etc.
Tissue that heals rapidly such as liver , peritoneum
may be closed with absorbable sutures e.g. vicryl etc.

15. TISSUE CONTAMINATION
Avoid multifilament sutures as bacteria can
linger with them & can infect wound.
Use monofilament or nonabsorbable sutures
in contaminated wound.
Monofilament polypropylene is ideal.

16. COSMETIC RESULTS
Close & prolonged apposition of wound.
 Avoidance of irritants.
Close subcuticularly where ever possible.
Use smallest suture material.

17. NUTRITIONAL STATUS
 When a patient is undernourished &
hypoproteinemic non absorbable sutures
should be used as long period of
approximation is required.
Absorbable sutures will lead to wound
dehiscence.

18. SUTURE SELECTION
Sutures hold tissue together until the natural process
of wound healing has taken place.
All sutures are foreign bodies and impact on wound
healing.
Absorbable sutures elicit more inflammatory reaction
than non-absorbable sutures.

19. SUTURE SELECTION
Natural sutures absorbed by proteolytic enzymes induce
more inflammation than synthetic ones absorbed by
hydrolysis.
Monofilaments require more knots to prevent slippage.
Braided sutures handle easily and knot easily.
Braided suture may harbor bacteria.

20. SUTURE SELECTION
Use the smallest size suture that can hold the tissue
together during the healing process.
Fascia heals slowly - use bigger, stronger suture.
Mucosa heals quickly, use smaller suture.

21. MonofilamentMonofilament Multifilament (braided)Multifilament (braided)
Single strand of suture
material
Minimal tissue trauma
Smooth tying but more
knots needed
Harder to handle due to
memory
Examples: nylon, monocryl,
prolene, PDS.
Fibers are braided or
twisted together
More tissue resistance
Easier to handle
Fewer knots needed
Examples: vicryl, silk,
chromic gut.

22. ABSORBABLE SUTURE
GUT
Prepared from submucosa of :-
(submucosa)
(subserosa)
Types : - Plain
- Chromic cat gut.
Both types consist of processed strands of highly purified
collagen.
The percentage of collagen in the suture determines its
tensile strength and its ability to be absorbed by the body
without adverse reaction.
 ;
- sheep
- Lamb
- oxen

23. PLAIN CATGUT
 Tensile strength is maintained for only 7 to 10 days.
Absorption is complete within 70 days.
Reaction increases with increasing size of catgut.
Used for :- ligating bleeders
-suturing subcutaneous tissue.
- suturing skin & mucosa in circumcision
- suturing mucosa of genito urinary tract.

24. CHROMIC CATGUT
Treated with a chromium salt solution to resist body
enzymes, prolonging absorption time over 90 days.
Treatment with chromic acid (20%) increases the
durability & tensile strength.
Uses :- suturing muscles
- fascia
-GIT
- Liver etc.

25. POLYGLYCOLIC ACID
Non protein synthetic material which is absorbable.
Removed by enzymes – ESTERASES
Has advantage of :-
-Minimum tissue reaction
-Minimum tissue oedema.
Knot holding property is better than chromic catgut as it is
not subjected to :-
-Fraying
-Breaking
-Swelling
-Slipping

26. VICRYL
Fastest-absorbing synthetic suture.
Lower tissue reaction than chromic gut suture.
Retain approximately 50% of the original tensile strength
at 5 days post implantation.
 All of the original tensile strength is lost by approximately
10 to 14 days.
Absorption by 42 days.

27. LINEN & COTTON
Prepared from cotton.
Have low tensile strength.
Greater chances of infection because of fluid absorption.

28. SILK
 Naturally occuring fibre.
Very slow absorbing suture.
Second only to gut for tissue inflammation.
Weaker when wet.
Silk filaments can be twisted or braided, providing the
best handling qualities

29. ETHILONE
High tensile strength and extremely low tissue reactivity.
Degrade by hydrolysis.
Monofilament nylon sutures have a tendency to return to
their original straight extruded state (a property known as
"memory").

30. SURGICAL NEEDLE

31. NEEDLES

32. Needle Shapes
•Eye
•Microsurgery
•Dura
•Eye
•Fascia
•Nerve
•Muscle
•Eye
•Skin
•Peritoneum
•Cardiovascular
•Oral
•Pelvis
•Urogenital tract
•Nasal cavity
•Nerve
•Skin
•Tendon
•Eye (Anterior
segment)
•Laparoscopy

33. Closure Types
Primary closure (primary intention)
-Wound edges are brought together so that they are
adjacent to each other (re-approximated).
Secondary closure (secondary intention)
Wound is left open and closes naturally (granulation)
Tertiary closure (delayed primary closure)
Wound is left open for a number of days and then closed
if it is found to be clean.

34. THANK YOU...