Suture Materials &

Techniques
Tying knots
IMTC
International Microsurgical Training Centre
Prof.dr. René Remie
Dr. Klaas Kramer
 Agenda
z Important factors in surgery
z Properties of suture materials
z Absorbable
z Non-absorbable
z Tissue reactions
z Needles
z Suture techniques
z Suture-related infections
z Suture length to wound lenght ratio
z How to tie a knot
z Take home messages
z Practical part
 Important factors in surgery
z Basic principles
z Surgical protocol
z Anatomy
z Suture materials
z Peri-operative care
z Temperature
z Body fluids
 Basic principles of surgery
z Halstead’s principle of not doing harm to
the tissue
z Set of interrelated principles:
z Tissue handling
z Tissue exposure
z Hemostasis
z Asepsis
 Tissue handling
z Remember that every time you pick up
tissue with your instruments, you kill cells
z Try to kill as few cells as possible
z Be goal oriented in your approach
z Sharp dissection is generally less
traumatic than blunt dissection
 Tissue exposure
z Make sure your view is unobstructed, with
proper illumination and physical access
z The wound should be sufficient in size and
certainly not too small
z Do not worry about the healing of the
wound, as it is not primarily affected by its
size, but rather by appropriate
approximation of the wound edges
Let’s have a closer look at
suture materials
Suture size and strength
 General properties of sutures
z Absorbable, Non-absorbable
z Always use absorbable sutures unless you have to
fixate something
z Braided
z Tissue drag
z Capillary filling effect
z Good handling properties
z Monofilament
z Memory effect
z Pseudo-monofilament
 Absorbable

z Synthetic
z Hydrolysis
z Minor tissue reaction
z Degradation products
z CO2 , H2O

z Examples
z Polyglycolicacid
z Polydioxanon
z Polylactate
 Absorbable
z Tensile strength retention
z Variable
z Polyglycolic acid (PGA)
z 14 days 65% remains
z 21 days 40% remains
z Gone between 56 and 70 days
z Polycaprone
z 7 days 50% remains
z 14 days 25% ramains
z Gone between 90 and 119 days
 Non-absorbable
z Natural materials
z Silk, linen and cotton
z Synthetic
z Polyesther (Dacron)
z Polypropyleen
z Polyamide (Nylon)

z Mineral
z Stainless steel wire
 Tissue reaction
z Qualitative ranking (Sewell et al.)
z Sizeof the reaction
z Concentration of cells
z Type of cells (phagocytes)
z Edema present
z Necrosis present
z Absorption of the material
 Tissue reaction
Method acc. to Sewell et al.

Stainless steel
Prolene
PDS
Vicryl rapide
Vicryl
Materials

Ethibond Reeks2
Mersilene Reeks1

Polyamide
Silk
Linen
Catgut plain
Catgut chroom

0 20 40 60 80
Re action rate
 Needles
z Conventional
z Swedged-on atraumatic
z Non cutting (rond-bodied)
z Cutting (spatula, triangle)
Needles
Needles
 Suture technique
z Tissue dependant
z Proper instruments
z Proper knotting technique
z Hand
z Instrument
z Equalstrength
z Proper approximation
Suture technique
Suture technique
Suture technique
Information on the outside
 Knot definition (Tera)
z 1=1 Square- or reef knot
z 1x1 Granny knot
z 2=1 Surgical knot
z 2=1=1 Surgical knot with
extra loop
How to tie a knot?
How to tie a knot?
Cause of suture-related infection
z Excessively tight sutures
z Allowsbacteria to be protected in tissues made
ischemic by pressure
z Too many sutures making large ischemic
portions
z Use of multi filamented braided suture
materials
z Provide interstices accessible to bacteria but not
to phagocytes (capillary filling)
Cause of suture-related infection
z Most pronounced in moderately
contaminated wounds
z Contamination is very low
z The local defenses may handle the situation despite
the presence of foreign body
z Contamination is massive ==> infection will occur

z The magnitude of the wound contamination is

expressed as class I, II, III or IV
 Suture length to wound length ratio

z SLWL ratio
z Hoer et al. 2001
z Median laparotomy (ML) in rats
z Best mechanical quality of healing at 4:1 - 8:1 ratio
z Running technique superior to interrupted
z Bite size approx. 5 mm. (2-3 times thickness of the wall)
z Low suture tension ==> stronger scars
z Cengiz et al. 2001
z Bite size and number of stitches in ML in rats
z Best mechanical quality of healing at 4:1 ratio
z 3-6 mm bite size
 Take home messages
z Do not harm to the tissue!!
z Absorbable sutures are preferred
z Approximation, that’s all
z Do not pull sutures too tight
z Do not tie tumbled knots
Thanks for listening
 Practical part
z Macro knot tying (30 minutes)
z Two persons, one rope
z Tea / Coffee break
z Tying knots using the anastomosis device
z 3- 0sutures (60 minutes)
z 5-0 sutures (60 minutes)

z Closing remarks