Suture

Suture Properties

*Absorption -Describes hoe the suture reacts in the presence of body tissue *Capillary action -Ease in which fluids can be wicked along strand *Bio-activity -Body's response to suture

Relationship of suture to wound handling (cont'd.)

*Absorption of surgical gut creates increased level of inflammatory reaction in tissues. *Gut is contraindicated in critical repairs such as nerves, tendons, blood vessels. *Synthetic nonabsorbable sutures are stronger than natural fibers; provoke less tissue reaction; can be used with infection.

Suture Size

*Based on the diameter of a single strand; size denotes diameter *The smaller the size, the less tensile strength *Sutures range from 11-0(thinnest) to 5 (thickest) -The more 0's in the number, the smaller the size of the strand. *Stainless steel sutures use Brown and Sharp sizing system (B & S)

Absorbable - Synthetic - Monofilament

*Biosyn -Absorption within 110 days -Soft tissue approximation and ligation; skin closure -Undyed and violet -Equivalent is Monocryl

Commonly Used Needle Codes (Ethicon)

*CP *CT *CTX *CV *FS *FSL *FSLX *KS *MO *SH *TF *OS *UR *PS *RB *S

Absorbable - Synthetic - Monofilament

*Caprosyn -Absorption within 56 days -Soft tissue approximation and ligation -Undyed and violet -Equivalent is Monocryl

Suture Selection

*Characteristics of the suture material *Age *Weight *Allergy status *General tissue condition *Type of tissue *Cosmetic considerations *Healing time *Required strength during healing *Surgical site disease *Comorbid condition(s) *Surgeon preference *Cost *Mentor influence

Body or Shaft

*Curved -Come in degrees of curvature -Half circle, 3/8 circle, etc. *Straight

Nonabsorbable - Synthetic - Multifilament

*Ethibond™ -Excellent tensile strength -Braided -Undyed, green -General soft tissue approximation and ligation; commonly used to close incisions of the heart; tendon repair; eye and neuro surgery. -Equivalent is Ti-Cron™

Absorbable - Synthetic

*Ethicon -PDS 11 -Monocryl -Vicry *Covidien/USSC -Maxon -Biosyn, Caprosyn -Polysorb, Dexon

Nonabsorbable - Synthetic - Monofilament

*Ethicon: -Ethilon -Prolene -Stainless Steel *Covidien/USSC/D&G: -Dermalon, Monosof -Novafil, Surgipro -Steel *GoreTex (by Gore Medical Products) *V-Loc (Barbed Suture by Covidien)

Nonabsorbable - Synthetic - Multifilament

*Ethicon: -Nurolon -Mersilene -Ethibond *Covidien/USSC/D&G: -Surgilon, Bralon -Dacron, Surgidac -Ti-Cron Fiberwire (by Arthrex)

Surgical Needles

*Eye *Body or Shaft *Point or Tip *Shape *Chord Length

Nonabsorbable - Synthetic - Multifilament

*Fiberwire -Excellent tensile strength -Braided -Good knot security -Black, blue, white -Orthopedic surgery: soft tissue repairs such as tendon and rotator cuff repairs.

Nonabsorbable - Synthetic - Monofilament

*GORE-TEX -Expanded PTFE (Polytetrafluoroethylene) -Excellent tensile strength -Offers benefits of monofilament and multifilament -No memory -White -Sizing is different (CV-8 to CV-0 - smallest to largest) -Anastomosis of vascular grafts, mitral valve repair, carotid endarterectomy, hernia repairs.

Needle Size

*Measured by diameter of the shaft *Measured by the dimension from tip to eye

Nonabsorbable - Synthetic - Multifilament

*Mersilene™ -Excellent tensile strength; no significant change known to occur. -Braided -Excellent knot security -Undyed, green -General soft tissue approximation and ligation; eye, CV, and neuro surgery, respiratory tract. -10-0 and 11-0 monofilament for eyes Equivalent is Dacron

Physical structure of sutures

*Mono-filament -Single fiber -Passes through tissue more easily

Physical structure of sutures (cont'd.)

*Multi-filament -Many fibers -Stronger; easier to handle *Braided -Multiple fibers intertwined *Composite -A core strand of one material jacketed with another

Physical structure of sutures (cont'd.)

*Multi-filament -Many fibers -Stronger; easier to handle *Twisted -Multiple fibers twisted in the same direction

Regulation of sutures

*Must be approved by the FDA and USP (US Pharmacopeia). Regulation for size, tensile strength, and sterility, packaging, dyes used in the sutures, and the integrity of the needles. *Approved use and set standards.

Specifications for suture material

*Must be sterile; sterile technique must be used when handling *Uniform tensile strength *Uniform size *Appropriate diameter for tissue type *Provide knot security *Cause minimal foreign body tissue reaction

Reading a suture label

*Name. *Size *Color of suture *Type and size of needle *Lot number *Expiration date

Nonabsorbable - Synthetic - Monofilament

*Nylon (Ethilon™, Dermalon™, Monosof™) -Tensile strength degrades at 15-20% per year -Some memory -General soft tissue approximation and/or ligation -Undyed, black, blue, green -Available in multifilament

Nonabsorbable - Synthetic - Multifilament

*Nylon (Nurolon™, Surgilon™) -Excellent tensile strength; gradual loss occurs over time. -Excellent knot security -Undyed, black, green -General soft tissue approximation when continual strength is needed; commonly used for neurologic closures; used in eye and CV surgery.

Ideal Suture Characteristics

*Pliable *Easy to tie secure knots *Tensile strength (will not fray or break) *Glides through tissue effortlessly *Inert *Non-allergenic *Inexpensive

Absorbable - Synthetic - Monofilament

*Poliglecaprone (Monocryl) -Absorption within 120 days -All strength lost 21 days (undyed) and 28 days (dyes). -Soft tissue approximation and ligation -Typically used on skin closure -Undyed and violet -Equivalent is biosyn

Nonabsorbable - Synthetic - Monofilament

*Polybutester (Novafil™) -Excellent tensile strength -Tissue that requires long-term tensile strength; running subcutaneous closure; blood vessel anastomosis. -Undyed, blue -Equivalent is Prolene™, Surgipro™

Absorbable - Synthetic - Monofilament

*Polydioxanone (PDS) -Absorption minimal for 90 days -Maximum strength for 4 weeks; complete absorption within 6 months. -Useful in slow healing tissue or presence of infection. -Undyed, blue and violet -Little memory -Comes in antibacterial; impregnated with chemical (PDS plus). -Equivalent is Maxon

Nonabsorbable Sutures (cont'd)

*Polyester -Extremely strong -Easy to handle -Relatively inert in tissue *Polypropylene -Extremely inert monofilament with high tensile strength -Popular for plastics, ophthalmic and vascular surgery -Knots are flat and do not tend to back out when placed properly. Hard to manage in larger sizes

Absorbable - Synthetic - Monofilament

*Polyglactin 910 (Vicryl) -Braided -Absorption complete in 50-60 days -No memory -Soft tissue approximation and/or ligation -Violet -Monofilament available for use in eye surgery -Comes in Vicryl coated and Vicryl plus -Equivalent is Polysorb™, Dexon™

Absorbable - Synthetic - Multifilament

*Polyglycolic acid (Dexon™) -Braided -Absorption complete in 30 days -General soft tissue approximation and/or ligation -Beige and green -Monofilament available -Comes in coated and uncoated -Equivalent is Polysorb™, Vicryl™

Absorbable - Synthetic - Monofilament

*Polyglyconate (Maxon) -Absorption minimal for 60 days -Complete absorption in 6 months -Useful for soft tissue approximation and ligation -Undyed and green -Equivalent is PDS

Absorbable - Synthetic

*Polymers and bio-polymers *Available in mono-filament and braided *Pliable and easy to handle *Cause little tissue reaction; high tensile strength *Easily absorbed by the body after breakdown *Dyed and undyed

Nonabsorbable - Synthetic - Monofilament

*Polypropylene (Prolene™, Surgipro™) -Excellent tensile strength; Has memory -Least reactive of all synthetic materials -Frequently used in general, orthopedics, plastics, CV and neuro -Suture of choice for vascular anastomosis -Clear, blue -Especially useful in contaminated wounds and in presence of infection -Does not adhere to tissues; advantage as a pull-out suture

Absorbable - Synthetic - Multifilament

*Polysorb™ -Braided -Absorption complete in 56-70 days -General soft tissue approximation and/or ligation -Undyed and violet -Equivalent is Dexon™, Vicryl™

Suture Packaging

*Product protection *Efficient dispensing *Selection *Minimal packaging *Environmentally responsible

Tensile Strength

*Refers to the amount of force needed to break the suture. *Measured in pounds of tension that the strand will withstand before it breaks when knotted. *Influenced by: type of knot (10%-40% weaker when knotted), biological environment, uniformity.

Nonabsorbable Sutures

*Silk -Used in deep tissues - especially in intestinal, vascular, ophthalmic, and neurosurgical procedures -Great tensile strength; very flexible *Nylon -Causes little or no tissue reaction -Passes very easily through delicate tissues of the eye or blood vessels.

Nonabsorbable Sutures

*Silk *Nylon *Polyester *Polypropylene *Stainless steel

Nonabsorbable - Synthetic - Monofilament

*Stainless Steel -Indefinite tensile strength; strongest suture -Most inert of all suture materials; almost no inflammatory properties -Silver -Can be used in presence of infection -Difficult to tie knots; must bury edges to avoid damage to surrounding tissue. -Must NOT be used in presence of other types of metal prostheses or implants -2 different kinds of metal embedded in tissue simultaneously can create an unfavorable electrolytic reaction. -Not to be used if patient is allergic to 316L stainless steel, chromium, or nickel. -Used for sternal closure, abdominal wound closure, hernia repair, tendon & bone repair, retention sutures, respiratory tract. -Brown & Sharp (B&S) gauge of 40 (smallest) to 18 (largest)

Surgical Needles - Ideal needle characteristics

*Stainless steel (corrosion resistant) Slim without compromising strength; won't break easily even after bending. *Stable in the needle holder *Carries suture through tissue with minimal tissue trauma; sharp enough to penetrate tissue with minimal resistance. *Approximately same diameter as the suture material it carries. *Sterile *X-ray detectable *Approximate size and shape for type & condition of tissue.

Absorbable - Natural

*Surgical Gut (also called catgut) -Mono-filament -Derived from submucosal layer of beef or sheep intestine *Types of surgical gut: plain - untreated, chromic- coated with chromic salt to slow the absorption

Absorbable - Natural

*Surgical Gut (continued) - Packing and handling of gut -Packaged moist in alcohol solution; open pack as needed as close to time of use as possible. -If died, becomes brittle (dry like spaghetti) -Don't run hands over suture to straighten (will fray it) -Has memory

Absorbable - Natural

*Surgical Gut (continued) -Application of chromic gut -Used in tissues that heal relatively slowly and need support for a longer period of time. -Less irritating than plain gut in early stages of wound healing. -Used to close fascia -Can be used for peritoneum -bowel anastomosis

Absorbable - Natural

*Surgical Gut (continued) -Application of plain gut - absorbed rapidly -To ligate superficial blood vessels -To suture subcutaneous tissue (fat) -Avascular and doesn't tolerate foreign bodies well

Absorbable - Natural

*Surgical Gut (continued) -Used on tissues that heal rapidly. Absorption time varies. -Type of surgical gut -type and condition of tissue involved -General health status of patient -May be absorbed more rapidly in the presence of infection but can be used in the presence of infection. -Not used in contaminated wounds. -Absorbed by phagocytosis

Nonabsorbable - Natural

*Surgical Silk -Natural fiber from silkworm cocoons; coated to enhance handling -Multifilament; braided or twisted -No memory; great tensile strength; very flexible Listed as nonabsorbable; actually a very slow absorbing suture (not detected in tissue after 2 years) -Loses most tensile strength in 1 year -Used for serosa of the GI tract; fascia; ligatures -Should not be used in presence of infection -Undyed or black -Perma-Hand™ Silk (Ethicon); Sofsilk™ (Covidien)

Suture Selection (cont'd.)

*Suture knots or remnants that might come in contact with urine or kidney filtrate can become the source of stones or other mineral deposition. *A strong suture line with resistance to absorption is needed. A nonabsorbable suture or absorbable suture with long absorption time maybe used. *Wounds that are actively infected are not sutured. Any breakdown of skin can result in infection, but skin is also exposed to many small injuries by penetration, bruising, abrasion, and contact with heat and cold. *Sutures selected for cosmetic closure are inert and usually mono-filament to cause the least tissue injury as the suture is drawn through. *Surgeon chooses the suture material to be used.

Relationship of suture to wound handling

*Suture used to close the wound provide its total strength for the first few post-op days. *Improper suture can interfere with the healing process. Example - subcutaneous tissue does not tolerate suture material well (plain gut is best; silk will cause infection)

Suture Presentation

*Suture-needle combination *Multi-packs *Double-armed suture *Control release suture *Free ties *Reels

Suture Selection (cont'd.)

*Sutures placed on the heart and other vital organs require nonabsorbable sutures. *Absorbable suture can be used on noncritical tissue the heals quickly. Some tissues (usually connective tissues) are under high stress in the body. These areas require nonabsorbable suture or suture in the larger sizes. *Structures of the hand such as tendons and nerve repair require very inert (causing little or no tissue reaction) suture materials. Internal structures of the eye also require very inert suture materials. The suture must pass through the tissue with no resistance or tissue fraying, even at the microscopic level.

Needle Eye Types

*Swaged (atraumatic) -Control Release/Detach/Pop Off -Double-armed *Open *Closed *French Eye (split or spring eye)

Needle Points

*Taper -Most internal tissues: GI, peritoneum, delicate tissue. *Taper Cut -Cardiovascular *Cutting (3rd cutting edge on inner curvature) -Skin and other tough tissues *Reverse Cutting (3rd cutting edge on outside curvature -Tendon sheath, bone, cornea, skin, other tough tissues *Blunt -Liver, spleen, kidney and other friable tissues *Trocar -Arrow-like cutter; used on cervix

Tensile Strength

*Tensile strength of absorbable and nonabsorbable sutures is critical both during and after surgical procedures. Breaking strength and elongation can be measured using either a "straight pull' test or a "knot pull" test.

Nonabsorbable - Synthetic - Multifilament

*Ti-Cron™ -Tensile strength retained indefinitely -Braided -Good knot security -White, blue -General soft tissue approximation and ligation; eye, CV, and neuro surgery. -Equivalent is Ethibond™

Types of suture material

1. Absorbable or Non - Absorbable 2. Natural or Synthetic 3. Braided (multi-filament) or mono-filament *Absorbable (temporary) -Natural (biological) -Synthetic *Nonabsorbable (permanent) -Natural (biological) -Synthetic

Ligate

A loop or tie placed around a blood vessel or duct.

Capillarity

Ease in which fluids can be wicked.

Suture

Strand of material used to ligate a blood vessel or approximate tissue together.

Memory

The tendency of suture to recoil to its original shape during packing.

Tensile strength

refers to the amount of force needed to break the suture.

Approximate

to bring tissue together by sutures or other means.