Post on 16-Aug-2015
Basic Surgical Skills
Sutures & Needles
- Dr. Utham Murali. M.S ; M.B.A. Prof. of Surgery
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.
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.
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.
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
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.
Suture material – Types
Behavior – Tissue : Absorbable / Non-absorbable
Structure : Monofilament / Multifilament
Origin : Natural / Synthetic
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
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.
Absorbable – Synthetic
Polyglactin (Vicryl) : purple, copolymer of Lactide & 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)
Non – Absorbable – Natural
Surgical silk: Black. Derived from the cocoon of the silk worm larvae, trigger
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
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)
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
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)
Suture Degradation
Suture Material Method of Absorption Time to Absorb
Catgut Proteolytic enzymaticdigestive process.
Days
Vicryl Hydrolysis. Weeks
PDS Slow Hydrolysis. Months
Silk / Nylon Gradual encapsulationby fibrous connectivetissue.
Years
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]
Needle – Anatomy
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.
Needle Shapes
EyeMicrosurgery
DuraEyeFasciaNerve
MuscleEyeSkinPeritoneum
CardiovascularOralPelvisUrogenital tract
Nasal cavityNerveSkinTendon
Eye (Anterior segment)
Laparoscopy
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
Use of Needle Holders
Loading Needle
Needle passing
through skin
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.
The Suture Packaging
STRAND SIZE
MATERIAL
STRAND LENGTH
PRODUCT CODE
NEEDLE CODE WITH LIFE
SIZE PICTURE OF NEEDLE
NEEDLE LENGTHCOLOUR
POINT TYPENEEDLE CIRCLE
Suture Techniques
Simple sutures
Mattress sutures
Subcuticular sutures
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.
Simple – Continuous
Useful in pediatrics
Rapid
Easy removal
Provides effective hemostasis
Distributed tension evenly along length
Can also be locked with each stitch
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.
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.
Suture removal
Face: 2- 3 days
Scalp: 5 days
Trunk: 7 days
Arm or leg: 7-10 days
Foot: 10-14 days
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
Surgical Knots
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.
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.
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.
References
Bailey & Love’s - Short Practice of Surgery, 26th edition.
Internet websites .
Thanks…