GOOD MORNING

SUTURE MATERIALS & SUTURING TECHNIQUES

COMPILED BY: NUZHAT NOOR AYESHA

Introduction History Definition Goals of suturing Suture materials - Introduction - Requisites of ideal suture - Classification - Selection of suture material - Absorption of suture material - Biological response of body to suture. Suture armamentarium- needles, needle holder, scissor Principles of suturing Suturing Techniques Knots Suture Removal Other methods of wound closure

CONTENTS

INTRODUCTION
Suture means to sew or seam. In surgery suture is the act of sewing or bringing tissue together and holding them in apposition until healing has taken place. A suture is a strand of material used to ligate blood vessels and to approximate tissues together.

HISTORY

HISTORY
History of the Surgical Suture I dress the wound, God heals it. Ambroise Pare, surgeon 16th century

 The act of sewing is probably older then Homo sapiens, because Neanderthal man wore some sort of clothing.

HISTORY
Perhaps the worlds oldest suture was placed by an embalmer on the body of a twenty first dynasty mummy about 1100 B.C.

 A south American method of wound closure used large black ants which bite the wound edges together and the ants body is then twisted off leaving the head in place.

East African tribes ligated blood vessels with tendons and closed wounds with acacia throns

 The first detailed description of a wound suture and suture materials used in it is by the Indian physician Sushruta, written in 500 BC.

 Galen, Roman

the

physician in

to the

gladiators

second century A.D. used silk for hemostasis.

Andreas Vesalius first advocated the suture of all fresh wounds as well as severed tendon and nerves.

 Joseph Lister (1827-1912) discovered that bacteria present in suture strands cause wound infection. He disinfected sutures with carbolic acid. He made sterile sutures possible to bury it in clean wounds without infection.

 Sometime around 30 A.D., a medical encyclopedia was written by a Roman named Aurelius Cornelius Celsus. His work, De Re Medicina, tells the reader that sutures should be soft, and not over twisted, so that they may be more easy on the part. He is also credited with first substantiated mention of ligating by recommending it as a secondary means of stopping a hemorrhage.

Rhazes of Arabia was credited in 900 A.D. with first employing kit gut to suture abdominal wounds. The Arabic word kit means a dancing masters fiddle, the musical strings of which kit string were made up of sheep intestines. Over the years kit was confused with kitten or cat, and the misuse of the term was propagated.

DEFINITIONS
DEFINITION: suture material is an artificial fibre used to keep wound together until they hold sufficiently well by themselves by natural fibre (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 utilised to ligate blood vessels or approximate Tissues (Silverstein L.H 1999)

GOALS OF SUTURING
Suturing is performed to Provide adequate tension Maintain hemostasis Provide support for tissue margins Reduce post-op pain Prevent bone exposure Permit proper flap position

SUTURE MATERIALS

 The basic purpose of a suture is to hold severed tissues in close approximation until the healing process provides the wound with sufficient strength to withstand stress without the need for mechanical support.

Since wounds do not gain strength until 4-6 days after injury, the tissues are approximated till then by sutures.

The amount of tension or pull the suture can withstand before breaking is important. Tensile St diameter of suture

If the diameter of suture doubled, T.S is quadrupled.

is

Suture material should be atleast as strong as the tissues in which they are used. By the end of 2nd week, when most skin sutures are removed, the wound would have attained 3%7% of final Tensile St. 3rd week 20% of T.S 4th week 50% of T.S
Wounds will never regain more than 80% of Tensile St. of intact skin

REQUISITES OF AN IDEAL SUTURE

Tensile st: 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. 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.

 Non allergic, non electrolytic and non carcinognic Its use should be possible in any operation. Low cost It should not fray, should slide through tissues readily & knot should not slip after tying.

 It should be readily visualized , should not shrink & should not be extruded from the wound.

On break down ,it should not release toxic agents. It should disappear without excessive reaction once its task is completed.

CLASSIFICATION OF SUTURE MATERIALS According to source: 1. Natural 2. Synthetic 3. Metallic

According to structure

1. Monofilament 2. Multifilament

According to fate: 1. Absorbable (undergo degradation and lose T.S. < 60 days) 2. Non absorbable ( maintain T.S > 60 days) According to coating: 1. Coated 2. Uncoated

NATURAL
Absorbable
Catgut Chromic catgut Collagen Fascia lata kangaroo tendon Beef tendon Cargile membrane

Non Absorbable
Silk Silk worm gut Linen Cotton Ramie Horse hair

SYNTHETIC

Absorbable
Polyglycolic Acid Polyglactic Acid Polyglactin 910(Vicryl) Polydioxanone(PDS) Polyglecaprone 25

Non Absorbable Nylon/ polyamide PolyPropylene Polyesters Polyethelene Polybutester Polyvinylidene fluoride / PVDF Sutures

Monofilament

Multifilament

MONOFILAMENT
Advantages
Smooth surface Less tissue trauma No bacterial harbours No capillarity

Disadvantages
Handling and knotting Stretch Any nick or crimp in the material leads to breakage.

MONOFILAMENT

Absorbable Surgical Gut- Plain, Chromic Polydiaxanone Polyglactin 910

Non Absorbable Polypropylene Polyester Nylon/polyamide Polyvinylidene fluoride / PVDF Sutures

MULTI FILAMENT
Advantages
Strength Soft and pliable Good handling Good knotting

Disadvantages
Bacterial harbours Capillary action Tissue trauma

MULTIFILAMENT

Absorbable Polyglactin 910 Polyglycolic Acid

Non Absorbable

Silk Cotton Linen

MONOFILAMENT
Handling Difficult

MULTIFILAMENT
Handling easy

Smooth & strong

No Wicking Thinner

Low Strength
Wicking is a Problem Thicker

Metallic
SS Tantalum Gold Silver Aluminium

Non absorbable sutures are categorized by the United States Pharmacopeia (USP) as
Class I - Silk or synthetic fibers of monofilaments with twisted or braided construction Class II - Cotton or linen fibers, coated natural or synthetic fibers in which the coating does not contribute to T.S Class III - Metal wire of monofilament or multifilament construction.

SELECTION OF SUTURE MATERIAL

A variety of suture materials and suture/needle combinations is available. The choice of suture for a particular procedure is based on the known physical and biologic characteristics of the suture material and the healing properties of the sutured tissues.

Principles of suture selection

The selection of suture material by a surgeon must be based on a sound knowledge of
Healing characteristics of the tissues which are to be approximated, The physical and biological properties of the suture materials, The condition of the wound to be closed and The probable post-operative course of the patient.

1. Rate of healing of tissues:

When a wound has reached maximal strength, sutures are no longer needed. Tissues that ordinarily heal slowly such as skin, fascia and tendons should usually closed with non

absorbable sutures.

Tissues that heal rapidly such as peritoneum, liver,

small intestine, muscles, stomach ,colon and bladder may be closed with absorbable sutures.

Suture should be stronger than the sutured tissues, and it is unwise to implant more material than necessary.

2.Tissue contamination: Avoid multifilament sutures as bacteria can linger with them and may convert a contaminated wound into an infected one.
Use monofilament absorbable or non- absorbable sutures in potentially contaminated tissues. Monofilament polypropylene is ideal

3. cosmetic results : Where cosmetic results are important,

a smallest, inert monofilament suture materials such as poly amide and polypropylene. Avoid skin sutures and close subcuticularly whenever possible Under certain circumstances, to secure close apposition of skin edges , skin closure tape may be used

close and prolonged apposition of wounds and avoidance of irritants will produce the best results. Therefore use

4. cardiovascular surgery: Monofilament polypropylene, polyester, coated and un coated and braided surgical silk are recommended.

Monofilament polypropylene being smooth, possess high TS is the material of choice for vascular anastomosis. This material does not encourage any thrombus formation.
Polyester is preferred for suturing artificial heart valves, myocardium and vascular prosthesis.

5. Microsurgical procedure:

Most commonly used suture is 10-0 poly amide monofilament 6.wound repair in patients following

In this group of patients ,not only the normal healing process is delayed but the tolerance to the trauma of irradiated tissue is markedly reduced . So Extremely careful and gentle surgical technique Avoid tension sutures and mattress sutures as they further increase the degree of ischemia.

irradiation

 Closure in layers Avoid continuous and constant pressure on irradiated tissues. Fascial layer non-absorbable sutures, polypropylene is ideal

The selection of suture material is based on The condition of the wound, The tissues to be repaired, The tensile strength of the suture material Knot-holding characteristics of the suture material and The reaction of surrounding tissues to the suture materials.

ABSORPTION OF SUTURE MATERIALS

Degraded either by enzymatic process as in gut sutures, or by hydrolysis, as in many of the synthetic materials like glycolic acid, ployglactin910 or polydioxanone. Non absorbable sutures are walled off or encapsulated. In infected tissues or in a patient who is febrile or protein deficient, suture breakdown may be accelerated. If the loss of TS outpaces the healing phase, failure of the wound results. Absorbable sutures must be placed well into the dermis.

BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS

BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS

The initial body response to sutures is almost identical in the first 4-7 days, regardless of the suture material.

The early response is a generalized acute aseptic inflammation, involving primarily polymorphonuclear leukocytes.
After few days mononuclear cells, fibroblasts & histiocytes become evident.

Capillary formation occurs at the end of this initial phase.

 Natural Absorbable Proteolytic degradation. Intense tissue response Synthetic Absorbable Hydrolysis. Less Intense Non Absorbable Encapsulation. Acellular Response

RAILROAD SCAR
Sutures passing through mucous membrane or skin provide a wick or pathway through which bacteria track down, and bacteria gain access to underlying tissues. The longer the suture remains, the deeper the epithelial invasion of the underlying tissue. When suture removed, epithelial tract remains. These cells may eventually disappear or remain to form keratin and epithelial inclusion cysts. The epithelial pathway result in typical railroad scar formation.

ABSORBABLE -NATURAL
Gut / cat gut
Oldest known absorbable suture. Galen referred to gut suture as early as 175 A.D. Derived from sheep intestinal sub mucosa or bovine intestinal serosa. Submucosa of sheep has a rich elastic tissue content which accounts for high tensile strength of the catgut. It is monofilament and is available in the plain form as well as tanned in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.

 Catgut should not be boiled or autoclaved as heat destroys its tensile strength.

Catgut is sterilized during preparation and kept in a preservative solution (isopropyl alcohol) inside spools or foils. Unused and reusable catgut is hygroscopic so, catgut will swell due to water absorption and its tensile strength will be reduced .
Absorption :40-60 days

When placed intra orally sutures are digested in 35days.

 It is available pre-sterilized in aluminiumcoated sterile foil overwrap pack with ethicon fluid as a preservative. Colour: Plain catgut is yellow, while chromic catgut is tan Absorbtion: Catgut is absorbed by proteolytic digestive enzymes released from inflammatory cells collected around the catgut. So, in the presence of infection catgut is rapidly absorbed.

CHROMIC CATGUT
Coated with thin layer of chromium salt solution to minimize tissue reaction, increase TS, slow the absorption rate, better knot security, and ease of handling.
TS 10-14 days Absorbed in 90 days Uses:Opthalmic surgery (6-0) Oral surgery Suture subcutaneous tissues

As it is an organic material and susceptible to enzymatic degradation, packed in isopropyl alcohol as a preservative. Also condition or soften it. Suture absorbs alcohol and swells. It is combustible and is also irritating to tissues. It is removed by a quick rise in saline prior to use.

COLLAGEN SUTURE
Natural, absorbable, monofilament Obtained by homogenous dispersion of pure collagen fibrils from the flexor tendons of cattle. Absorption 56 days TS - < 10% after 10 days. Used in opthalmic surgery Disadvantage of premature absorption.

SYNTHETIC ABSORBABLE

POLYGLACTIN 910 (VICRYL) acid Coated and uncoated

Polyglactic

Synthetic suture
Monofilament/multifilament Lactide has hydrophobic qualitiesdelaying loss of TS TS - 14 21 days. Absorption 56-70 days.

 Minimal tissue reactivity and can be used in infected tissues

Available in purple and undyed. Undyed used on

face. Coated with polyglactin 370 and calcium stearate which allows easy passage through tissues as well as easier knot placement.

On

skin

wounds,

associated

with

delayed

absorption as well as increased inflammation.

VICRYL RAPIDE
It is braided synthetic absorbable suture material. Colour: White. It has a similar initial high tensile strength as that of the normal vicryl suture. It gives wound support upto 12 days. It shows 50% of the original tensile strength after 5 days and all of its tensile strength is lost after 14 days.

Its absorption is associated with minimal tissue reaction facilitating improved cosmetics and reduction of postoperative pain.

 The absorption is essentially complete within 35-42 days. Uses: Low tensile strength and Rapid absorption rate --Ideal for intra-oral use (dental surgeries).

VICRYL plus

ANTIBACTERIAL SUTURE

Handles and performs same as normal vicryl. In vitro studies shown that triclosan on VICRYL plus creates a zone of inhibition around the suture.

GLYCOLIC ACID HOMOPOLYMER (DEXON) POLYGLYCOLIC ACID

Polymer of glycolic acid with greater knot pull and TS than gut. Synthetic, absorbable, braided Absorption- hydrolysis, which results in minimal tissue reactivity. Braided and so catches on itself, and knot tying and passage through tissues difficult. Does not tolerate wound infection and not percutaneous suture.

GLYCOLIC ACID (MAXON) POLYGLYCONATE

-Synthetic, absorbable, monofilament. -Polyglycolic acid and trimethylene carbonate -TS 14-21 days (>Dexon) Absorption Hydrolysis in 180 days In vitro studies by Edlich and co-workers (1973) have suggested that the degradation products of polyglycolic acid and nylon sutures - glycolic acid, 1,6-hexane diamine and adipic acid are antibacterial agents.

POLYDIOXANONE (PDS II)

Synthetic,absorbable,monofilament. Polyester derivative poly P dioxanone. TS -14-42 days Absorption Hydrolysis in 6 months. Passes through tissues easily.

 Significant memory compromises the ease of knot-tying and knot security.

Minimal tissue reaction

For wounds under contaminated wounds. tension and

May extrude through the wound over time. So used only in tissues deeper than subcuticular layer. Or if in face 60 used.

NON ABSORBABLE SUTURES

Natural silk, silk worm gut, cotton , ramie,linen Synthetic-polyester, polyamide, poly propylene, polybutester,polyethelene Metals : SS Tantalum platinum silver wires gold aluminium

NATURAL NON-ABSORBABLE

SURGICAL SILK
-Braided or twisted -Made from the filament spun by silkworm larva to form its cocoon. Each filament is processed to remove the natural waxes and sericin gum. After braiding, the strands are dyed, stretched and impregnated with a mixture of waxes and silicone. Dry silk suture is stronger than wet silk suture.

Advantage:

Ease of handling more for braided Good knot security made non capillary in order to withstand action of body fluids & moisture.(wax or silicon coated) Cost effective

Contraindications:

Should not be used in presence of infection

Uses:

Plastic surgery, ophthalmic and general surgeries, ligating body tissues. Although characterized as non-absorbable, studies show that it loses most of their TS after 1 yr. and cannot be detected in tissues after 2 yrs.

SURGICAL COTTON
Natural, multifilament, non absorbable From stable Egyptian cotton fibers good knot security Not good in presence of contaminated wounds or infection Rarely used nowadays Uses: Most body tissues for ligating and suturing

LINEN
Natural, multifilament, non absorbable Made from stable flax fibers Poor TS and so not for suturing under tension Uses: Ligation of superficial vessels Mucosal suturing without stress

SYNTHETIC NON-ABSORBABLE

POLYPROPYLENE (PROLENE)
-Polymer of propylene. -Inert and TS for 2 yrs -Holds knots better than sutures. other synthetic

Advantages -Minimal suture reaction and so used in infected and contaminated wounds. -Do not adhere to tissues and is flexible. So used for pull-out type of sutures. Uses: General, plastic, cardiovascular surgery, skin closure, ophthalmology.

NYLON BRAIDED (SURGILON, NURILON)

Synthetic, non absorbable Inert polyamide polymer Braided and sealed with silicon coating Look, handle and feel like silk, but more stronger Multifilament nylon is weaker and less secure when knotted, offering little advantage over monofilament nylon.

NYLON MONOFILAMENT (DERMALON, ETHILON)

Uncoated, but inert and non irritating to the tissues. High TS and low tissue reactivity Some memory and return to original linear shape over time. Because of this more throws (4 throws) indicated. Moistened nylon monofilament are more easily handled and are packaged wet. Uses: Skin closure, retention, plastic, ophthalmic and microsurgery.

POLYESTER BRAIDED
Tycron, Mersilene -Uncoated Dacron, Ethibond - Coated (with polybutilate) Multifilament fibers of polyester Excellent TS which is maintained indefinitely Uncoated is rougher and stiffer than coated form Coated provides -low infection rate -secure knotting -smooth removal -low reactivity -easy passage through tissues More expensive In deeper layers, may last indefinitely.

GOR-TEX
Nonabsorbable,synthetic,Monofilament From,expanded polytetrafluoroethylene (ePTFE) Extremely low tissue reaction, good knot tensile strenghtand ease of handling. Uses All type of soft tissue approximation and cardiovascular surgeries.

MONOCRYL
Absorbable, synthetic, monofilament Poliglecaprone 25; copolymer of glycolide and caprolactone Hydrolysis 90-120 days Tissue reaction minimal Good knot strength Used for soft tissue closure Most pliable material ever made

POLYBUTESTER (NOVOFIL) -New, monofilament, nonabsorbable, synthetic -Made

polyglycol trephthate and polybutylene terephthalate and is considered as a modified polyester suture.
of

-No significant memory compared to polypropylene and nylon. Easier to manipulate and greater knot security. -Unique feature is their ability to elongate or stretch with increasing wound edema. When edema subsides, suture resumes original shape; so it is an ideal suture for lacerations secondary to blunt trauma.

-TS high and lasts longer -Minimal tissue reactivity. -Popularity in cutaneous surgery is gradually increasing.

SURGICAL STEEL

Natural, monofilament/multifilament, non absorbable Alloy of iron, nickel and chromium Good TS even in infection Difficult to handle and tendency to cut through tissues. Very hard to tie, and knot ends require special handling.

 Potential to corrode or break at points of twisting, bending or knotting. Not to be used with a prosthesis of another alloy. Used in abdominal wall and skin closure, sternal closure, retention, tendon repair, orthopedic and neurosurgery. OMFS- for suspension of splints or arch bars and not as suture material.

Major Disadvantages

1.Linear artifacts caused by substances with high atomic number on CT images

2.Possible movement of metal suture during MRI 3.Patch test for nickel sensitivity should be done.

Packaging
PRODUCT CODE METRIC GUAGE IMPERIAL GUAGE

NEEDLE SIZE & CURVATURE NEEDLE TYPE NEEDLE TIP NEEDLE PROFILE STERILIZED ETHELENE OXIDE

DO NOT REUSE

EXPIRY DATE

BATCH NO

SEE INSTRUCTIONS FOR USE

SUTURE SIZES
Largest size 1 to extremely fine 11-0. Increasing number of zeroes correlates with decreasing suture diameter and strength. Thicker sutures are used for approximation of deeper layers, wounds in tension prone areas and for ligation of blood vessels. Thin sutures are used for closing delicate tissues like conjunctiva and skin incisions of the face. Size is chosen to correlate with the tensile strength of the tissue being sutured.

3-0 or 4-0 OMFS, muscle, deep skin 5-0 or 6-0 facial skin closure 9-0 or 10-0 microsurgery

SUTURE NEEDLES
Surgical needles are designed to lead suture material through tissue with minimal injury. Needles can be - straight (GIT) or curved - swaged or eyed Made up of either SS or carbon steel. Needle is selected according to: -type of tissue to be sutured -tissues accessibility -diameter of suture material.

 Made up of either SS or carbon steel.

CLASSIFICATION OF SURGICAL NEEDLES

1.According to eye -eye less needles -needles with eye 2.According to shape -straight needles . -curved needles 3.According to cutting edge a) round body b) cutting -conventional -reverse cutting

 4.According to its tip -triangular tip -round tip -blunt tip 5.Others -spatula needles -micro point needles -cuticular needles -plastic needles

Ideal Properties Of Needles

High quality stainless steel Smallest diameter possible Capable of implanting sutures with minimal trauma

to tissues.
Stable in the needle holder Should be sharp. Sterile and corrosion resistant.

Anatomy of a Needle

Term Chord Length of needle Radius

Definition The linear distance between eye and tip. The distance between eye and tip following the curvature The distance of the body of the needle from the centre of the circle

Diameter

Gauge or thickness of the metal wire out of which the needle is made.

COMPONENTS OF SURGICAL NEEDLE

1. The eye 2. The body; and 3.The point The eye can be - closed - swaged - chanelled/drilled Shape of the eye may be - round - oblong; or - square

CLOSED

SWAGED

CHANELLED

Open French-eye needle is easy to load with varying caliber, but has additional bulk.

Eyed require threading prior to use, results in pulling a double strand through tissue. Tying the suture to the eye increases bulk of suture material drawn through tissues. So they are also called traumatic needles. Most suture materials and needles are difficult to sterilize. Needles are also difficult to clean after use and become blunt and workhardened so that they snap.

Suture loop inserted through eye

Loop placed over tip

Loop drawn back

Suture tied on eyed needle

SWAGED NEEDLE
Swaged needles do not require permit a single strand of suture drawn. Suture attached to needle via through the end of the needle, swaged during manufacturing. It is atraumatic and act as a single unit. Prepacked and presterilized by gamma radiation. threading and material to be a hole drilled and the end is

Needle attached to suture Favourable for I/O use but expensive Less tissue damage New needle each time

THE BODY
Body is the widest portion of the needle It is known as grasping area.

-Most commonly used are 3/8 circle. They can be easily manipulated in large and superficial wounds and require only less wrist movement. -1/2 circle used for suturing tissues in small wounds, and body cavities and orifices. Require less space, but more supination and pronation of wrist required. -5/8 used in oral cavity.

Tapered Cutting

Reverse cutting

RADIUS OF CURVATURE OF THE BODY(NEEDLE)

Straight Needle

CLINICAL USE
Needle of choice for the skin Limited use in oral surgery May be used in surgery of the nose, pharynx, tendons Needle of choice for microsurgery associated with very fine sutures; ophthalmology Oral surgery, flap surgery, wound closure after placement of osseointegrated implants and GTR procedures May be used in all surgical wounds Needle of choice in oral surgery Wide range of uses in many surgical wounds Wounds of the urogenital tract

circle

3/8 circle

circle

5/8 circle

THE POINT Point runs from tip to the max. cross sectional area of the body. Can be -triangular tip/cutting -round tip -blunt tip

Cutting needles are Ideal for suturing keratinized tissues like skin, palatal mucosa, subcuticular layers and for securing drains. Round/tapered needles used for closing mesenchymal layers such as muscle or fascia that are soft and easily penetrable

 The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle.

The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle.

 The tapered point is used primarily on soft, easily penetrated tissues . it leaves small hole and can be used in vascular surgery as well as fascial soft tissue surgery.
The blunt point has a rounded end which does nt cut through the tissue .it is used in friable tissue suturing or to the parotid duct or lacrimal canaliculi.

Cuticular needles Sharpened 12 times Designated as C or FS

(CUTICULAR or FOR SKIN)

Plastic needles
Sharpened an additional 24 times Designated as P or PS or PC
(PREMIUM or PLASTIC SURGERY or PRECISION COSMETIC ).

Needles in the PC series are made up of stronger SS alloy and have flattened and conventional cutting edge.

 Curvature of the needle is selected according to the accessibility. The needle must exit in a visible spot so that the surgeon is aware of the position of the point of the needle at all the times. Try to match the needle thickness with suture diameter .it is not appropriate to use wide thick needle with small suture material . This will cause laxity of immediate suture line and allows bacterial contamination & ingrowth of epithelium & in vascular surgery it may allow oozing of blood throught/suture hole.

Placement of a Needle into the Tissue

Force should always be applied in the direction that follows the curvature of

the needle.
Movable to a non-movable tissue. Only sharp needles with minimal force. Never force the needle through the tissue.

Avoid retrieving the needle from the

tissue by the tip.

 Grasp the needle in the body 1/4th to half of the length from the swaged area. Do not hold the needle by the swaged area or the eye. Avoid excessive tissue bites with small needles, as it will be difficult to retrieve them

NEEDLE HOLDER
The needle holder is used to handle the suture needle and thread while suturing the surgical wound. If used properly it enables the surgeon to perform procedures correctly and with great precision.

PARTS OF NEEDLE HOLDER

Working tip/ jaws Hinge device Shank/body Catch mechanism/ ratchet Grip area

NEEDLE HOLDER

There are different types of needle holders.

The beaks may be short or long, broad or narrow, slotted or flat, concave or convex, smooth or serrated. Commonly used have a locking hand and short beaks and 6 long Gilles needle holder (scissors incorporated into blades) Kilner needle holder

 Atraumatic needle holder ensures needle movement and compatibility of clamping movement. It has textured tungsten carbide jaw inserts, and its rounded needle holder jaw edges do not cause structural damage to monofilament suture or needle

GILLES NEEDLE HOLDER

Scissors are incorporated into the blades

OLSEN HEGAR NEEDLE HOLDER

KILNER NEEDLE HOLDER

MAYO HAGER NEEDLE

YASARGIL MICRO NEEDLE HOLDER

Gripping needle holder

The scissor grip
Used in the anterior part of the mouth and in areas of easy access The instrument is stabilized with the index finger

Palm grip Used in the deeper parts of oral cavity

Use appropriate size for needle Grasped 1/4 to distance from swaged area Tips of the jaws should meet before remaining portion of jaw Needle placed securely Do not overclose Always directed by surgeons thumb Do not use digital pressure on tissues

PRINCIPLES OF SUTURING

PRINCIPLES OF SUTURING
1.Needle grasped at 1/4th to half the distance from eye.

2.Needle should enter perpendicular to tissue surface

3.Needle passed along its curve

4.The bite should be equal on both sides of the wound margin and the point of the entry of the needle should be closer to the wound edge than its point of exit on the deep surface 5.The bite should be about 2-3 mm from the wound margin of the flap because after wound closure the edge of the wound softens due to collagenolysis and the holding power is impaired.

6. Usually the needle to be passed from mobile side to the fixed side but not always(exception in lingual mucoperiosteum flap) and from thinner to thicker & from deeper to superficial flap. 7.The tissues should not be closed under tension , since they will either tear or necrose around the the suture

8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture to another should be about 3-4 mm apart to prevent strangulation of the tissue & to allow escape of the serum or inflammatory exudate & to get more strength of the wound.

11.Sutures placed at a greater depth than distance from the incision to evert wound margins 12.Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.sutures should have correct tension while tying knot for provision of the slight edema post operatively, more tensioned sutures cause ischemia of the edges of the incision causes tearing of the tissues may leave suture mark edges may get overlapped

16.Occasionally extra tissue may be present on one side of incision and cause DOG EAR to be formed in the final phase of wound closure. Simply extending the length of the incision to hide the exists will produce an unsatisfactory result. Thus after undermining excess tissue incision is made at approx. 300 to parent incision directed towards undermined side. Extra tissue is pulled over incision and appropriate amount is excised. Incision is closed in normal manner.

IMPROPER SUTURING TECHNIQUE

SUTURING TECHNIQUES

1.INTERRUPTED SIMPLE SUTURE

Most commonly used. Inserted singly through side of the wound and tied with a surgeons knot.

Advantages Strong and can be used in areas of stress Placed 4-8 mm apart to close large wounds, so that tension is shared Each is independent and loosening one will not

produce loosening of the other

Degree of eversion produced In infection or hematoma, removal of few sutures Free of interferences b/w each stitch and easy to clean

2. SIMPLE CONTINUOUS / RUNNING

A simple interrupted

suture placed and needle

reinserted in a continuous fashion such that the suturepasses perpendicular to the incision line below

and

obliquely

above.

Ended by passing a knot over the untightened end

of the suture.

Advantages Rapid technique and distributes tension uniformly More water tight closure (Shoen, 1975) Only 2 knots with associated tags Disadvantages If cut at one point, suture slackens along the whole length of the wound which will then gape open.

3.CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by withdrawing the suture through its own loop. Indicated in long edentulous areas, tuberosities or retromolar area.
Advantages Will avoid multiple knots Distributes tension uniformly Water tight closure Prevents excessive tightening.

Disadvantage :prevents adjustment of tension over suture line as tissue swelling occurs.

4.VERTICAL MATTRESS
Specially designed for use in skin. It passes at 2 levels, one deep to provide support and adduction of wound surfaces at a depth and one superficial to draw the edges together and evert them. Used for closing deep wounds This approximates subcutaneous and skin edges

Needle passed from one edge to the other and again from latter edge to the fist and knot tied. When needle is brought back from second flap to the first, depth of penetration is more superficial.

Advantages : for better adaptation and maximum tissue approximation To get eversion of wound margins slightly Where healing is expected to be delayed for any reason, it is better to give wound added support by vertical mattress. Used to control soft tissue hemorrhage. Runs parallel to the blood supply of the edge of the flap and therefore not interfering with healing. Uses: abdominal surgeries & closure of skin wounds.

5.HORIZONTAL MATTRESS
It everts mucosal or skin margins, bringing greater areas of raw tissue into contact. So used for closing bony deficiencies such as oro-antral fistula or cystic cavities. Disadvantage: constricts the blood supply to edges of incision.

Needle passed from one edge to the other and again from the latter to the first and a knot is tied. Distance of needle penetration and depth of penetration is same for each entry point, but horizontal distance of the points of penetration on the same side of the flap differs.

 Advantages:
Will evert mucosal or skin margins, bringing greater areas of raw tissue into contact. -So used for closing bony deficiencies such as wounds. Prevents the flap from being inverted into the cavity. oro-

antral fistula or cystic cavities, extraction socket

To control post-operative hemorrhage from gingiva

around the tooth socket to tense the mucoperiosteum over the underlying bone.

 It does not cut through the tissue ,so used in case of tissue under tension (inadequate tissue) Disadvantages: More trouble to insert Constricts the blood supply to the incision if improperly used, cause wound necrosis and dehiscence

6. FIGURE OF 8 SUTURE Used for extraction socket closure and for adaption of gingival papilla around the tooth Suturing begun on buccal surface 3-4mm from the tip of the papilla so as to prevent tearing of papilla.

Needle first inserted into the outer surface of the buccal flap and then the lingual flap. Needle again inserted in same fashion at a horizontal distance and then both ends tied.

7. SUBCUTICULAR SUTURE
Used to close deep wounds in layers. Knots will be inverted or buried, so that the knot does not lie between the skin margin and cause inflammation or infection. To bury the knot, first pass of the needle should be from within the wound and through the lower portion of the dermal layer. Needle then passed through the dermal layer and emerge through subcutaneous tissue and knot tied

8.CONTINUOUS SUBCUTICULAR SUTURE

Continuous short lateral stitches are taken beneath the epithelial layer of the

skin. The ends of the

suture come out at each end of the incision and are knotted.

Advantages Excellent cosmetic result Useful in wounds with strong skin tension, especially for patients prone to keloid formation. Anchor suture in wound and, from apex, take

bites below the dermal-epidermal layer

Start next stitch directly opposite the one that precedes it.

9.PURSE STRING SUTURE

A circular pattern that draws together the tissue in the path of the suture when the ends are brought together and tied.

KNOT TYING

KNOT TYING

Sutured knot has 3 components 1.Loop created by knot 2.Knot itself which is composed of a number of tight throws 3.Ears which are the cut ends of the suture

KNOT TYING Principles of knot tying

Use the simplest knot that will prevent slippage. Tying the knot as small as possible and cutting the

ends of the suture as short as reasonable to

minimize foreign body reaction. Avoid friction or sawing Avoid damage to suture material Avoid excessive tension

Tying sutures too tightly strangulates the tissue

 Maintenance of traction at one end of the suture after the first loop is thrown, to avoid loosening of the knot. Placing the final throw as horizontally as possible to keep knot flat

Limiting extra throws to the knot, as they do not add strength to a properly tied knot.

KNOTS
SQUARE KNOT Formed by wrapping the suture around the needle holder once in opposite directions between the ties. Atleast 3 ties are recommended. Best for gut, silk, cotton and SS

SURGEONS KNOT
Formed by 2 throws on the first tie and one throw in the opposite direction in the second tie. Recommended for tying polyester suture materials such as Vicryl and Mersiline

GRANNYS KNOT
A tie in one direction followed by a tie in the same direction and a third tie in the opposite direction to square the knot and hold it permanently.

SUTURE REMOVAL

SUTURE REMOVAL
Skin wounds regain TS slowly. It can be removed in 3-10 days when the wound gained 5%-10% of final TS. Skin sutures on

face removed between 3-5 days. Alternate

sutures removed on 3rd day and remaining sutures after 2 days.

 Intra oral - Mucoperiosteal closure (without tension) 5-7 days - Where there is tension on the suture eg : Oro-antral fistula- 7-10 days Back and legs where cosmesis is less important 10-14 days.

Continuous subcuticular can be left for 3-4

weeks without formation of suture tracks A good guide is that as soon as they begin to get loose they should be taken out.

 Suture area is first cleaned with normal saline. The suture is grasped with non-tooth dissecting forceps and lifted above the epithelial surface. Scissors are then passed through one loop and then

transected close to the surface to avoid dragging

contaminated suture material through tissues. The suture is then pulled out towards incision line to

prevent dehiscence.If suture entrapped in a scab,

application of hydrogen peroxide or saline solution is necessary.

If pieces of suture left, infection or granuloma

formation can ensue.

 INCORRECT

CORRECT

 Possible Complication Of Leaving Suture For Many Days :

1.Sutural abscess. 2.Suture scarring or stitch mark 3.Implanted dermoid cyst

SCISSORS
Deans Scissors -General purpose scissors -Used for cutting sutures -Can also be used to trim mucosal margins.

SUTURE MARKS
Suture marks are caused by 3 factors 1.Skin sutures left in place longer than 7 days, resulting in epithelialisation of suture track 2.Tissue necrosis from sutures that were tied too tightly or became tight due to tissue edema

3.Use of reactive sutures in the skin.

Other Methods of Wound Closure

Ligating clips Skin staples Surgical tape Surgical adhesives

Mechanical wound closure devices

Ligating clips : can be resorbable or non resorbable. Made up of SS,tantalum or titanium or pidioxanone. Designed for the ligation of tubular structures.

Surgical staples: Used for skin closure . Made up of SS. They are placed uniformly to span the incision line. They have minimal tissue reaction . Can be used for routine skin closure any where in the body.

Advantages As the clips do not penetrate skin, yet give apposition, the cosmetic result is excellent. Speed and efficacy of stapling is more compared to sutures. Suturing causes more necrosis than stapling in myocutaneous flaps.
Most significant advance is the introduction of absorbable staples (Lactomer).

 Contra indicated when it is not possible to maintain atleast 5mm distance from the stapled skin to the underlying bone and blood vessels.

SURGICAL TAPE

Microporous tape is used alone or in conjugation with skin sutures to decrease tension at the wound margins. The surgical tapes have a backing of viscous rayon fibers coated with an adhesive copolymer and they are pervious to sweat but not to blood or purulent material. Comes in 1/8, 1/4, and 1/2 inch wide strips. Skin margin is prepared with tincture of benzoin to provide better adhesiveness for tape. Used to decrease skin tension on cheek,forehead,chin.

Advantages
Minimizes wound dehiscence and allows earlier suture removal Provides continuous support for the wound and minimizes scar expansion Avoids the ordeal of suture replacement and removal in children Less inflammatory reaction, lower rate of wound infection, greater TS and better cosmetic results. No needle puncture marks and suture canals Strangulation and necrosis of tissue are eliminated Sterile paper tape is non expensive

Disadvantage
Do not evert edges of the wound, and readily loosen when wet by blood or serum. Prior to placement, a thin coat of antibiotic ointment is placed on wound margin to protect wound from skin oils and bacteria. While removing, to avoid epithelial margin separation, the ends should be lifted equally towards the wound margin and then lifted evenly from the wound.

Cyanoacrylates
n-butyl cyanoacrylate is the active ingredient.

Advantages :

Strong bonding to tissues in presence of moisture Biodegradable, bacteriostatic & hemostatic. Reduced post operative pain & facilitates healing. Good shelf life. Produces little or no heat during polymerisation.

Bonding is by secondary intermolecular forces aided

by mechanical interlocking of irregular forces.

 Quick, atraumatic and cost effective with good cosmesis No injection, suturing and post-op suture removal. Disadvantages 1.When applied for skin closure, the polymer acts as barrier, prevents wound apposition, delays healing, and increases the infection rate.

2.Should not be allowed to come in contact with tissue

under skin as it causes necrosis.

REFERENCE
Suturing techniques in oral surgery Sandro Siervo Atlas of Minor Oral Surgery- Harry Dym Laskin vol-1 Oral & Maxillofacial Surgery Vol 1- W. Harry Archer Textbook of oral & maxillofacial surgeryNeelima Anil Malik Minor Oral Surgery- Goeffrey L.Howe Text book of surgery: Sabiston Periodontology-Caranza.

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