Suturing materials,techniques and principles

Suture techniques

1. Presented by- Dr Shibani Sarangi MDS 1 st year(OMFS) Suturing techniques and principles 1

2. INTRODUCTION The most common cause of postoperative infections is poor surgical techniques, usually related to devitalized tissues remaining in the wound and also inadequate closure. Thus closure of wound by suturing helps to obliterate dead space where accumulation of blood or other tissue fluids could prevent direct apposition of tissues and provide an environment favorable for bacterial growth. Sutures also distribute the tension of wound closure over a larger volume of tissues. 2

3. HISTORY Surgical sutures have been used to close wounds since prehistoric times. Needles were made up of bones or metals (Silver, copper, bronze) and sutures were made up of plant materials (hemp, flax and cotton) or animal material (tendons, hair, muscle strips, arteries). 3

4. DEFINATIONS - Suture material is an artificial fiber used to keep wound together until they hold sufficiently well by themselves by natural fiber (collagen) which is synthesized and woven into a stronger scar . Suture is a stitch/series of stiches made to secure apposition of the edges of a surgical/traumatic wound -Wilkins Any strand of material utilized to ligate blood vessels or approximate tissues . -Silverstein L.H 1999 4

5. It is said that an old method of wound closure has been using large black ants, which bite the wound edges together and the ants body being twisted off leaving the head in place. 5

6. 6 GOALS OF SUTURING – Maintain hemostasis Permit primary intention healing Provide support for tissue margins Reduce post-operative pain Prevent bone exposure Permit proper flap position 

7. 7 REQUISITES OF AN IDEAL SUTURE Postlethwait 1971, Varma 1974, Ethicon 1985 Tensile strength : adequate material strength will prevent suture breakdown & use of proper knots for the material used will prevent untying or knot slippage. Tissue biocompatibility : sutures made from organic material will evoke a higher tissue response than synthetic sutures. Tissue reaction - amount & size of suture material.  Low capillarity : multifilament type soak up tissue fluid by capillary action providing a rich medium for microbes increasing chances of inflammation & infection

8. 8 Good handling & knotting properties : ease of tying & a thread type that permits minimal knot slippage also influence thread selection. Sterilization without deterioration of properties: most sutures available in packages are sterilized by dry heat & ethylene oxide gas.

9. SUTURE MATERIAL Suture materials comes in various sizes Sizes 5 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller) 5 > 4 > 3 > 2 > 1 > 2-0 > 3-0 3-0 → 000 4-0 → 0000 6-0 → 000000 12-0 → 000000000000 9

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11. Various suture materials 11

12. Classification of Suture Materials 12

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15. Monofilament 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

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17. SUTURE MATERIALS IN DETAIL 17

18. Catgut - Absorbable, natural, monofilament suture It is derived from sheep intestinal submucosa or bovine intestinal serosa. The origin of the word ‘catgut’ is the Arabic “kitstring” or ‘kitgut,” (the string of a dancing master’s fiddle) which was also made of animal intestine. It is absorbed by proteolytic degradation and phagocytosis. 18

19. When placed intra-orally through mucosal surfaces, the sutures generally are gone in 3 to 5 days. Chromic gut is plain gut that has been tanned with a solution of Chromium salts . The chromium salts act as a cross-linking agent and increase the tensile strength of the material and its resistance to absorption by the body. Advantages: Increased strength Prolonged rate of absorption Less stimulation for tissue reaction 19

20. Uses- Plain catgut – -Smooth vessels -Subcutaneous tissue Chromic catgut: 1-0/2-0 - ligation of medium sized blood vessels. 3-0/4-0 - Close muscle layer in cleft lip repair. 5-0/6-0 - In plastic surgery 20

21. Silk- Natural, non absorbable, braided suture. It is the most popular suture material for intraoral use. 21 Advantages: Excellent handling characteristics Moderate tissue response It does not irritate adjacent mucous membrane Inexpensive

22. Disadvantage:- Stitch Granuloma Infection rate is more Although classed as a non-absorbable suture, silk is an organic substance that undergoes slow proteolysis when implanted. - Douglas (1949) It usually disappears after 2 yrs of implantation. 22

23. Uses- To ligate blood vessels and pedicles To suture nerve To suture grafts in vascular surgery To suture tendons Skin suture For fixing skin grafts Suturing of wound over face Intra oral suturing 23

24. Cotton- Natural, multifilament and non-absorbable Cotton suture is made from non-continuous natural fibres of cotton, which are combined into yarns and then twisted into plies. It became popular during World war II when silk was relatively unavailable. Its handling characteristics are inferior than silk. Tissue reaction ( Postlethwait , 1970) is similar to silk. Sizes: 2, 8, 1-0, 2-0, 4-0, 6-0 and 8-0 24

25. Nylon ( surgilon , duralon , ethilon ) Polyamide polymer Synthetic, non-absorbable, mono- and multi-filament. M ost popular skin suture material (monofilament) Advantages: Minimal tissue response Good tensile strength Inexpensive 25

26. Disadvantage: Because of its stiffness, large knot required. Tendency to tear through non-keratinized tissue, nylon is not frequently used intra-orally. Possess “memory ” … multiple square knots are necessary to maintain the tie. 26

27. Polyglycolic Acid ( Dexon , Surgicryl ) Polyglycolic acid is hydroxyacetic acid. Synthetic, absorbable and multifilament Advantages: Good tensile strength Easy handling Good knot tying ability Smooth passage through tissues Less tissue edema 27

28. Uses -  It is commonly used for subcutaneous sutures, intra- cutaneous closures, abdominal and thoracic surgeries. 28

29. Polyglactin 910( Vicryl ) Vicryl (polyglactin 910) is an absorbable, synthetic, braided suture. It is indicated for soft tissue approximation and ligation. Enzymatic degradation Approx. 3 – 4 weeks in tissue and is completely absorbed by hydrolysis within 60 days. 29

30. Vicryl and other polyglycolic acid sutures can be impregnated with triclosan to provide antimicrobial protection of the suture line. 30

31. Polydiaxonone - It is sterile, monofilament  synthetic absorbable suture composed of the polyester. Advantages:- Wound support for longer periods up to 50 days. Superior tensile strength and outstanding pliability. Its monofilament structure provides good handling properties and excellent knot security. Absorption of suture is by hydrolysis within 180 days from implantation day. Minimal tissue reaction. 31

32. Poliglecaprone 25 ( Monocryl )- Coploymer of glycolide and caprolactone . Monfilament type of suture which undergoes hydrolysis in 90-120 days. It has the best tensile strength among the available suture materials with minimal tissue reaction. Its is the most flexible, synthetic absorbable monofilament ever. Glide easily over the tissues 32

33. Polypropylene (Prolene) Synthetic, non-absorbable, monofilament  It is indicated for skin closure and general soft tissue approximation and ligation. Advantages: minimal tissue reactivity Durability Least thrombogenic, so an important factor in vascular surgery. Monofilament, so less chances of infection. High degree of smoothness, so it requires much less force to draw through the tissue. 33

34. Disadvantages:- Fragility High plasticity High expense Difficulty of use compared to standard nylon sutures. 34

35. Irradiated Polyglactin 910 (Vicryl Rapide )- IRPG is a braided co-polymer of glycolic and lactic acid that is surface treated with polyglactin 370 and Calcium stearate and has received gamma radiation. Advantages over other materials are:- Good tensile strength Forms secure knots Minimal tissue reaction Faster absorption rate Popular among pediatric surgeons because of its faster absorption rate which makes suture removal unnecessary or simple (sutures can be wiped off) 35

36. NEEDLES 36

37. Anatomy of a Needle 37

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39. Classification of Needles Needles are made up of either stainless steel or carbon steel. 39

40. Curved Needles 40 4/8 = ½ 2/8 = ¼ 3/8 5/8

41. According to Cross sections… 41

42. Conventional Cutting Needles 42

43. Reverse Cutting Needles 43

44. THE MAYO’S NEEDLE It has a round body, but a heavier and more flattened body than conventional taper needles USED IN - Dense tissues - Periosteum For gynaecological procedures Hernia repair 44

45. Armamenterium for suturing 45

46. MAYO HEGAR NEEDLE HOLDER RYDER NEEDLE HOLDER CASTROVIEJO NEEDLE HOLDER 46

47. 47 Gillies Needle holder with Scissor

48. 48 Ideal method to hold a Needle Holder

49. PRINCIPLES OF SUTURING 49

50. Grasp the needle in the body 1/4 th to 1/2 of the length from the swaged area. Force should always be applied in the direction that follows the curvature of the needle. Suturing should always be from a movable to a fixed tissue. Use only sharp needles with minimal force. Replace dull needles. 50

51. Never force the needle through the tissue. Avoid retrieving the needle from the tissue by the tip. This will damage or dull the needle. The needle should enter the tissue perpendicular to the surface. If the needle pierces the tissue obliquely, a tear may develop. The suture should be placed at an equal distance from the incision on both the sides and at an equal depth. 51

52. If one tissue side is thinner than the other the needle should pass from the thinner tissue to the thicker one. If one tissue plane is deeper than the other, then the needle should pass from the deeper to the superficial side. The tissues should not be closed under tension, since they will tear or necrosed around the suture. If tension is present the tissues should be undermined to relieve it. 52

53. -The knot should not be placed over the incision line. -Sutures should be placed approximately 3-4mm apart. -The suture should be tied so that the tissue is approximated and the edges are everted . 53

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55. Knot & Knot Tying 55 “Suture security is the ability of the knot and material to maintain tissue approximation during the healing process” Failure – occurs due to untying by knot slippage or breakage. Since the knot strength is always less than the tensile strength of the material, when a force is applied the site of disruption is always the knot. This is because shear forces produced in the knot lead to breakage.

56. Types- Hand Knot Instrument Ties 56

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60. SQUARE KNOT REEF KNOT Done by placing 2 knots, each in opposite direction. 1c + 1ac GRANNY’S KNOT 1c + 1c + 1ac SURGEON’S KNOT Modified square knot 2c + 1ac + 1c 60

61. Principles of Knot Tying The completed knot must be tight and firm so that slippage does not occur. Knots should not be placed on incision lines… Knots should be small and the ends cut short ( 2 to 3 mm). Avoid crushing or crimping of suture materials by not using hemostats or needle holders on them except on the free end for tying. Do not tie suture too tightly as tissue necrosis may occur. It should not produce tissue blanching. Granny knots and coated and monofilament sutures do require additional throws for knot security and to prevent slippage. Coated Vicryl will hold with four throws – two full square knots. 61

62. 62 enter exit Simple Interrupted suture-

63. SIMPLE CONTINUOUS 63

64. CONTINUOUS LOCKING Advantages: Sutures align itself perpendicularly to the incision. Locking feature prevents continuous tightening of the suture as wound closure progresses. 64

65. Mattress Sutures Purpose: To provide more tissue eversion than with Interrupted sutures In areas where wound contraction could cause dehiscence or broad scar formation. E.g. abdomen or hip areas. 2 types: Horizontal & Vertical 65

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68. VERTICAL MATTRESS SUTURES Advantage: Just because they run parallel to the blood supply of the edge of the flap, so they do not interfere with the healing. 68

69. FIGURE OF 8 Indications: - Extraction sockets, where it provides some protection to the surgical area,helps to achieve hemostasis as well as adaptation of the gingival papillae around the adjacent teeth . 69

70. SUB-CUTICULAR SUTURES Absorbable material is used If individual sub- cuticular sutures are placed, they should be buried with the knot inverted. 70

71. SLING SUTURES (Modification of simple interrupted suture) The sling suture is primarily used for a flap that has been raised on only one side of a tooth, involving only one or two adjacent papillae. The technique involves the interrupted sutures, which sling around the tooth to hold both papillae. 71

72. TENSION SUTURE This type of suture is used to prevent wound dehiscence. A suture materials of good strength like non-absorbable nylon or prolene is used with a plastic tubing to reduce the tension exerted by the sutures on the tissues. 72

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74. PURSE STRING SUTURE 74

75. 75 SMEAD-JONES /FAR AND NEAR SUTURE

76. Principles for Suture Removal :- The area should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood, and serum from about the sutures. A sharp suture scissors should be used to cut the loops of a suture. No. 23 explorer can be used to help lift the sutures if they are within the sulcus or in close opposition to the tissue. This will avoid tissue damage and unnecessary pain. A cotton pliers is then used to remove the sutures. The location of the knots should be noted so that they can be removed first Sutures should be removed in 7 to 10 days to prevent epithelialization or wicking about the suture. Suture should be cut as close to the skin surface as possible 76

77. OTHER ADJUNCTS TO WOUND CLOSURE 77

78. OTHER ADJUNCTS TO WOUND CLOSURE- -Skin staples - Steri - strips 78

79. COMPLICATIONS OF WOUND CLOSURE 79

80. RAILROAD TRACK SCAR CONFIGURATION 80 DOG EAR

81. All sutures passing through the mucous membrane or skin provide a “ WICK ” down through which bacteria can gain access to the underlying tissues and may cause inflammation possibly leading to GRANULOMA formation or a STITCH ABSCESS 81 Stitch Abscess

82. REFERENCES- Oral & Maxillofacial Surgery. Vol. I : By Daniel M. Laskin . Peterson’s Contemporary Oral and Maxillofacial Surgery Textbook of Oral Surgery-James Hupp Internet (Wikipedia) 82

83. THANK YOU 83