Sutures / Needles & Knots

This PPT is oriented mainly towards sutures / needles & knots. Their types, uses and techniques of using it. Mainly for MBBS students as well as other medically oriented people.

1. Basic Surgical Skills Sutures & Needles Dr . Utham Murali . M.S ; M.B.A. Prof. of Surgery

2. Definition The term “Suture” describes any strand of material utilized to approximate tissues. Suturing refers to sewing together two structure using suture threaded on a needle . Ligating or ligaturing refers to tying a ductal structure such as blood vessel simply by means of a suture thread.

3. History The origins of surgery can be traced back many centuries. Through the ages, practitioners have used a wide range of materials and techniques for closing tissue…….. They also used adhesive linen strips, similar to modern-day Steristrips . By 1000 BC, Indian surgeons were using horsehair, cotton and leather sutures. In Roman times, linen and silk and metal clips called “fibulae” were commonly used to close gladiatorial wounds. By the end of the nineteenth century, developments in the textile industry led to major advances, and both silk and catgut became popular as suture materials .

4. Suturing – Goals Provide adequate tension for wound closure but loose enough to prevent tissue ischaemia & necrosis. Protecting underlying tissues from infection or other irritating factors. Preventing post-operative haemorrhage . Permitting healing by primary intention. Preventing bone exposure resulting in delayed healing & bone resorbption . Permit proper flap position.

5. Ideal Suture – Qualities Minimal tissue reaction Smoothness - minimum tissue drag Easily Sterilisable Adequate tensile strength Ease of handling - Minimum memory Knot security Cost effectiveness Favourable absorption profile Resistance to infection

6. Basic Definitions Suture is a material used to approximate living tissues or sutures together. Ligature is a suture used to encircle a blood vessel to arrest or control bleeding. Tensile strength is the ability of the material or tissues to resist deformation or breakage. Elasticity is the ability of the material to regain its original form or length after deformation. Pliability is the ability to adjust knot tension & to secure knot. Memory is the inherent capability of suture to return or maintain its original gross shape.

7. Suture material – Types Behavior – Tissue : Absorbable / Non-absorbable Structure : Monofilament / Multifilament Origin : Natural / Synthetic

8. Suture material Absorbable Catgut Chromic Catgut Dexon ( Polyglycolic acid) Vicryl ( Polyglacitin ) PDS ( Polydioxanone ) Collagen Maxon ( Polyglyconate ) Monocryl ( Polyglycaprone ) Non - Absorbable Silk , Linen. Cotton Horse / Human hair Nylon or Ethilon Polyester ( Mersilene / Ethibond ) Polypropylene ( Prolene ) Stainless steel, Aluminium Wire Clips Staples, Skin tapes, adhesives

9. Absorbable – Natural Plain catgut : Light. Derived from submucosa of sheep intestine or serosa of beef intestine. * Used for ligating superficial blood vessels & subcutaneous fatty tissues. Chromic catgut : Yellow. Treated with chromium salt. * It may be used in the presence of infection & in cancer cases.

10. Absorbable – Synthetic Polyglactin ( V icryl ) : purple, copolymer of L actide & Glycolide . * Minimal tissue reaction. Used in general soft tissue approx ; Intestinal anastomosis , Vessels ligation in all surgical specialties. Dexon ( Polyglyconic acid ) : purple/cream, homo polymers of glycolide . * Avoid in adipose tissue & losses tensile strength more rapidly than vicryl . Others:e.g ; Polyglyconate ( maxon ), Polydiaxone (PDS), Polyglecaprone ( monocryl )

11. Non – Absorbable – Natural Surgical silk : Black. Derived from the cocoon of the silk worm larvae, t rigger inflammatory reactions, undergo proteolysis & undetected by 2yrs. * Used in ligating major blood vessels, tendon repair etc. Surgical steel & wires : High tensile strength & Hold knots very well * Used in orthopaedic , Neurosurg & Thoracic surgery Others: e.g ; Virgin silk , cotton , linen

12. Non – Absorbable – Synthetic Nylon : Is a polyamide polymer , Blue / White * 81 % tensile strength at 1yr & 66% at 11yrs * Elicits minimal tissue reaction * Has good memory * Pliable when moist * Premoistened form is used in cosmetic plastic surgery * Its elasticity makes it useful for skin closure & Herniorrhapy Others : e.g ; Polypropylene ( Prolene ), Polyester fiber ( Mersilene /Dacron/ Ethibond )

13. Monofilament Grossly appears as single strand of suture material ; all fibers run parallel Minimal tissue trauma. Resists harboring microorganisms Ties smoothly Requires more knots than multifilament suture Possesses memory Examples : * Monocryl * PDS , Prolene * Nylon

14. Multifilament Fibers are twisted or braided together Greater resistance in tissue Provides good handling and ease off tying Fewer knots required Examples: * Vicryl ( braided) * Chromic (twisted) * Silk (braided)

15. Suture Degradation Suture Material Method of Absorption Time to Absorb Catgut Proteolytic enzymatic digestive process. Days Vicryl Hydrolysis. Weeks PDS Slow Hydrolysis. Months Silk / Nylon Gradual encapsulation by fibrous connective tissue. Years

16. Suture Size Sized according to diameter with “0” as reference size Numbers alone indicate progressively larger sutures (“1”,“2”, etc.) Numbers followed by a “0” indicate progressively smaller sutures (“2-0”, “4-0”, etc.) Smaller < --------------------------> Larger .....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”..... [ Thick] [Thin]

17. Needle – Anatomy

18. Needle point - Geometry Taper-Point (Round) Suited to soft tissue Dilates rather than cuts Reverse cutting Very sharp Ideal for skin Cuts rather than dilates Conventional Cutting Very sharp Cuts rather than dilates Creates weakness allowing suture tearout Taper-cutting Ideal in tough or calcified tissues Mainly used in Cardiac & Vascular procedures.

19. 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

20. Ideal Suture – Needle High quality stainless steel Smallest diameter possible Stable in the grasp of needle holder Sharp enough to penetrate tissues with minimal resistance & trauma Sterile & corrosive resistant

21. Use of Needle Holders Loading Needle Needle passing through skin

22. Technique Needle should be grasped with the needle holder approx. 1/3 distance from the eye & 2/3 from the point. Needle should be placed perpendicular to surface being entered & pushed through tissues following curvature of the needle & rotating the wrist. Needle enters 2-3mm away from the margin of the flap & exists at the same distance on the opposite side. The two ends of the suture are then tied in a knot & cut 0.8cm above the knot. Knot should never lie on incision line. Never close under tension.

23. The Suture Packaging STRAND SIZE MATERIAL STRAND LENGTH PRODUCT CODE NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE NEEDLE LENGTH COLOUR POINT TYPE NEEDLE CIRCLE

24. Suture Techniques Simple sutures Mattress sutures Subcuticular sutures

25. Simple – Interrupted Suturing is passed through both edges at an equal depth & distance from the incision & knot is tied. Common & Stronger. Each suture is independent & loosening of one suture will not produce loosening of other.

26. Simple – Continuous Useful in pediatrics Rapid Easy removal Provides effective hemostasis Distributed tension evenly along length Can also be locked with each stitch

27. Mattress – Vertical It has a far – far- near – near order of bites. The knot is perpendicular to the wound edge. Useful in maximising wound eversion , reducing dead space and minimising the tension across the wound.

28. Mattress – Horizontal Used for high – tension wounds or wounds with fragile skin. The knot is parallel adjacent to the wound edge. Useful in maximising wound eversion , reducing dead space and minimising the tension across the wound.

29. Suture removal Face : 2- 3 days S calp : 5 days T runk : 7 days A rm or leg: 7-10 days F oot : 10-14 days

30. Recent Advances Staples Adhesives Tapes - Steristrips Formed from high quality A sterile, liquid topical skin adhesive Use of tissue adhesive adjunct stainless steel Reacts with moisture on skin surface (benzoin) to form a strong, flexible bond Suitable for skin closure Only for approx. skin edges of wounds Rarely used for primary closure

31. Surgical Knots

32. Square or Reef knot Square knot formed by wrapping the suture around the needle holder once in opposite directions b/w ties. 3 ties are recommended . The two-hand square knot is the easiest and most reliable for tying most suture materials. It may be used to tie surgical gut , virgin silk, surgical cotton and surgical stainless steel.

33. Surgeon’s or Friction knot It is formed by 2 throws of suture around the needle holder on the first tie & one throw in the opposite direction on the 2nd tie. The surgeon's or friction knot is recommended for tying braided synthetic absorbable suture , VICRYL*/ ETHIBOND* polyester suture , ETHILON * nylon suture , MERSILENE * polyester fiber suture , NUROLON * nylon.

34. Granny’s or Slip knot Granny’s knot involve a tie in one direction followed by a tie in the same direction & third tie in the opposite direction to square the knot & hold it permanently. It has the tendency to slip when subjected to increasing pressure. It is not recommended.

35. References Bailey & Love’s - Short Practice of Surgery, 26 th edition. Internet websites .

36. Thanks…