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-- Presented by
Dr. Anindya Chakrabarty
CONTENT
Introduction
History
Definition
Goals of suturing
Suture materials
- Introduction
- Requisites of ideal suture
- C...
 Suture means to ‘sew’ or ‘seam’. In surgery suture
is the act of sewing or bringing tissue together and
holding them in ...
HISTORY
History of the Surgical Suture “I dress the wound, God heals it”.
-- Ambroise Pare, surgeon16th century
The act of...
 The first detailed description of a wound suture and suture materials used in it is by the Indian,
physician Sushruta wr...
DEFINITION
 suture material is an artificial fiber used to keep wound
together until they hold sufficiently well by thems...
GOALS OF SUTURING
 Provide adequate tension
 Maintain hemostasis
 Provide support for
tissue margins
 Reduce post-op p...
BASIC REQUISITE OF SUTURE MATERIALS
 Tensile strength
 Tissue biocompatibility
 Low capillarity
 Good handling & knott...
natural
synthetic
metallic
monofilament
multifilament
absorbable
Non-
absorbable
coated
Un-coated
Advantages
 Smooth surface
 Less tissue trauma
 No bacterial harbours
 No capillarity
Disadvantages
 Handling and kno...
Advantages
 Strength
 Soft and
pliable
 Good handling
 Good knotting
Disadvantages
 Bacterial
harbours
 Capillary ac...
ABSORBABLE – NATURAL
 Plain catgut:
 light milk, Derived from submucusa of
sheep intestine or serosa of beef
intestine
...
Gut / cat gut
 Oldest known absorbable suture.
 Galen referred to gut suture as early as 175 A.D.
 Derived from sheep i...
 Catgut should not be boiled or autoclaved as heat
destroys its tensile strength.
 Catgut is sterilized during preparati...
 It is available pre-sterilized in
aluminium-coated sterile foil overwrap
pack with ethicon fluid as a
preservative.
 Co...
CHROMIC CATGUT
Coated with thin layer of chromium salt
solution to minimize tissue reaction,
increase TS, slow the absorpt...
As it is an organic material and susceptible
to enzymatic degradation, packed in
isopropyl alcohol as a preservative. Also...
COLLAGEN SUTURE
 Natural, absorbable, monofilament
 Obtained by homogenous dispersion of pure
collagen fibrils from the ...
ABSORBABLE - SYNTHETIC
 Polyglactin (vicryl):cream, copolymer of
lactide & glycolide
 Minimal tissue rxn
 Used in gener...
POLYDIOXANONE (PDS II)
 Synthetic,absorbable,monofilament.
 Polyester derivative poly P dioxanone.
 TS -14-42 days
 Ab...
 Significant memory – compromises the
ease of knot-tying and knot security.
 Minimal tissue reaction
 For wounds under ...
VICRYL –RAPIDE
 It is braided synthetic absorbable suture
material.
 Colour : White.
 It has a similar initial high ten...
VICRYL PLUS ANTIBACTERIAL SUTURE
 Handles and performs
same as normal vicryl.
 In vitro studies shown
that triclosan on
...
NON-ABSORBABLE-NATURAL
 Surgical silk:
 Black, Derived from the cocoon of the silk
worm larvae, superior handling xtics,...
SURGICAL SILK
-Braided or twisted
-Made from the filament spun by silkworm larva to
form its cocoon. Each filament is proc...
Advantage:
 Ease of handling – more for braided
 Good knot security
 made non capillary in order to withstand action of...
Uses:
Plastic surgery, ophthalmic and general
surgeries, ligating body tissues.
Although characterized as non-absorbable,
...
SURGICAL COTTON
 Natural, multifilament, non absorbable
 From stable Egyptian cotton fibers
 good knot security
 Not g...
SURGICAL STEEL
 Natural, monofilament/multifilament, non
absorbable
 Alloy of iron, nickel and chromium
 Good TS even i...
 Potential to corrode or break at points
of twisting, bending or knotting.
 Not to be used with a prosthesis of
another ...
Major Disadvantages
1.Linear artifacts caused by substances with
high atomic number on CT images
2.Possible movement of me...
NON-ABSORBABLE - SYNTHETIC
 Nylon:
 Is a polyamide polymer,blue
 81% tensile strength at 1yr & 66% at 11yrs
 Elicits m...
POLYPROPYLENE (PROLENE)
-Polymer of propylene.
-Inert and TS for 2 yrs
-Holds knots better than other synthetic sutures.
A...
GORE-TEX
 Nonabsorbable,synthetic,Monofilament
 From,expanded polytetrafluoroethylene (ePTFE)
 Extremely low tissue rea...
-New, monofilament, nonabsorbable, synthetic
-Made of polyglycol trephthate and polybutylene terephthalate and is
consider...
SUTURE SELECTION
 The condition of the
wound,
 The tissues to be repaired,
 The tensile strength of the
suture material...
SUTURE SIZES
 Largest size 1 to extremely fine 11-0. Increasing
number of zeroes correlates with decreasing
suture diamet...
SUTURE SIZE
UNITED STATES PHARMACOPEIA
 Sized according to diameter with “0” as reference size
Numbers alone indicate pro...
SIZE OF SUTURES
 OLD GAUGE(USPD) DIAMETER IN MM
 8/0 0.05
 7/0 0.O7
6/0 0.1
 5/0 0.15
 4/0 0.2
 3/0 0.3
 2/0 0.35
...
PACKAGING………
METRIC GUAGE IMPERIAL GUAGE PRODUCT CODE
NEEDLE SIZE &
CURVATURE
NEEDLE TYPE
NEEDLE TIP
NEEDLE PROFILE
STERIL...
STERILIZATION OF SUTURES
 May affect suture properties to some extent
 Gamma Radiation
 Ethylene oxide; poisonous gas i...
ARMAMENTARIUM FOR SUTURING
 Suture needle
 Needle holder
 addson’s tissue forcep
SUTURE NEEDLE
 Surgical needles are designed to lead suture material
through tissue with minimal injury. Needles can be
-...
CLASSIFICATION OF SURGICAL NEEDLES
 1.According to eye -eye less needles
-needles with eye
 2.According to shape -straig...
Eyed require threading prior to use,
results in pulling a double strand
through tissue. Tying the suture to
the eye increa...
SWAGED NEEDLE
 Swaged needles do not require threading and permit a
single strand of suture material to be drawn.
 Sutur...
NEEDLE ANATOMY
Term Definition
Chord
Length of needle
Radius
Diameter
The linear distance
between eye and tip.
The distanc...
RADIUS OF CURVATURE OF THE
BODY(NEEDLE)
CLINICAL USE
Straight Needle
¼ circle
3/8 circle
½ circle
5/8 circle
Needle of cho...
THE POINT
Point runs from tip to the max. cross sectional area
of the body.
 Can be -triangular tip/cutting
-round tip
-b...
 The conventional cutting
point has two opposing
cutting edges and third
edge on the inside
curvature of the needle.
 Th...
 The tapered point is used primarily on soft,
easily penetrated tissues . it leaves small hole
and can be used in vascula...
 Sharpened 12 times
 Designated as C or FS
(CUTICULAR or FOR SKIN)
 Sharpened an additional
24 times
 Designated as P ...
NEEDLE HOLDER
 The needle holder is used to
handle the suture needle and
thread while suturing the
surgical wound.
 If u...
GRIPPING OF NEEDLE HOLDER
The scissor grip
Palm Grip
PRINCIPLES OF SUTURING
1.Needle grasped at 1/4th to half the distance from eye.
2.Needle should enter perpendicular to tis...
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 ...
 16.Occasionally extra tissue may be
present on one side of incision and
cause ”DOG EAR” to be formed in
the final phase ...
SUTURING TECHNIQUES
INTERRUPTED SIMPLE SUTURE
Most commonly used. Inserted singly through side
of the wound and tied with a surgeon’s knot.
Advantages
Strong and can be used in areas of stress
Placed 4-8 mm apart to close large wounds, so that
tension is share...
SIMPLE CONTINUOUS / RUNNING
A simple interrupted suture
placed and needle reinserted
in a continuous fashion such
that the...
Advantages
 Rapid technique and distributes tension
uniformly
 More water tight closure (Shoen, 1975)
 Only 2 knots wit...
CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by
withdrawing the suture through its own loop.
Indi...
VERTICAL MATTRESS
 Specially designed for use in skin.
It passes at 2 levels, one deep to
provide support and adduction o...
Needle passed from one edge to the other and again from
latter edge to the fist and knot tied.
When needle is brought back...
Advantages :
 for better adaptation and maximum tissue approximation
 To get eversion of wound margins slightly
 Where ...
HORIZONTAL MATTRESS
 It everts mucosal or skin margins, bringing greater
areas of raw tissue into contact. So used for cl...
Needle passed from one
edge to the other and
again from the latter to the
first and a knot is tied.
Distance of needle
pen...
 Advantages:
 Will evert mucosal or skin margins, bringing greater
areas of raw tissue into contact.
-So used for closin...
 It does not cut through the tissue ,so used in
case of tissue under tension (inadequate
tissue)
Disadvantages:
 More tr...
FIGURE OF “8” SUTURE
Used for extraction socket closure and for adaption
of gingival papilla around the tooth Suturing beg...
SUBCUTICULAR SUTURE
Used to close deep wounds in layers. Knots will be
inverted or buried, so that the knot does not lie b...
CONTINUOUS SUBCUTICULAR SUTURE
Continuous short lateral
stitches are taken
beneath the epithelial
layer of the skin. The
e...
Advantages
Excellent cosmetic result
Useful in wounds with strong skin tension,
especially for patients prone to keloid ...
PURSE STRING SUTURE
A circular pattern that draws together the
tissue in the path of the suture when the
ends are brought ...
KNOTS
 Sutured knot has 3 components
 1.Loop created by knot
 2.Knot itself which is composed of a number of tight thro...
PRINCIPLE OF KNOT TYING
 Use the simplest knot that will prevent slippage.
 Tying the knot as small as possible and cutt...
Square knot Formed by wrapping the
suture around the needle
holder once in opposite
directions between the ties.
Atleast 3...
SUTURE REMOVAL
 Skin wounds regain TS slowly. It can
be removed in 3-10 days when the
wound gained 5%-10% of final TS.
Sk...
HOW TO REMOVE SUTURE
 Suture area is first cleaned with normal saline.
 The suture is grasped with non-tooth dissecting ...
POSSIBLE COMPLICATIONOF LEAVING SUTURE FOR MANY DAYS
1.Sutural abscess.
2.Suture scarring or stitch mark
3.Implanted dermo...
SUTURE MARKS
 Suture marks are caused by 3 factors
 1.Skin sutures left in place longer than 7 days,
resulting in epithe...
 Sutures passing through mucous membrane or
skin provide a ‘wick’ or pathway through which
bacteria track down, and bacte...
NEW ADVANCEMENT IN SUTURING
 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 titan...
Surgical staples:
 Used for skin closure .
 Made up of SS.
 They are placed uniformly to span the
incision line.
 They...
Advantages
 As the clips do not penetrate skin, yet give
apposition, the cosmetic result is excellent.
 Speed and effica...
 Contra indicated when it is not possible
to maintain atleast 5mm distance from
the stapled skin to the underlying bone
a...
SURGICAL TAPE
 Microporous tape is used alone or in conjugation with
skin sutures to decrease tension at the wound margin...
ADVANTAGES
 Minimizes wound dehiscence and allows earlier suture
removal
 Provides continuous support for the wound and
...
Disadvantage
 Do not evert edges of the wound, and readily loosen
when wet by blood or serum.
 Prior to placement, a thi...
Cyanoacrylates
- n-butyl cyanoacrylate is the active ingredient.
Advantages :
 Strong bonding to tissues in presence of m...
 Quick, atraumatic and cost effective with good cosmesis
 No injection, suturing and post-op suture removal.
Disadvantag...
DERMABOND®
 A sterile, liquid topical skin
adhesive
 Reacts with moisture on skin
surface to form a strong, flexible
bon...
DERMABOND®
 Standard surgical wound prep and dry
 Crack ampule or applicator tip up; invert
 Hold skin edges approximat...
Degraded either by enzymatic process as in gut
sutures, or by hydrolysis, as in many of the synthetic
materials like glyco...
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...
 Natural Absorbable – Proteolytic
degradation. Intense tissue response
 Synthetic Absorbable – Hydrolysis. Less Intense
...
CONCLUSION
 Human body is very delicate & important.
When surgeries are needed to improve our
health is very important to...
REFERENCES
 Suturing techniques in oral surgery –Sandro Siervo
 Laskin vol-1
 Oral & Maxillofacial Surgery Vol 1- W. Ha...
THANK YOUTHANK YOU
Suture material & suturing technique
Suture material & suturing technique
Suture material & suturing technique
Suture material & suturing technique
Suture material & suturing technique
Suture material & suturing technique
Suture material & suturing technique
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Suture material & suturing technique

suturing is a boon to surgery which help to hold tissues in place until it achieve its original strength by formation of wiving fibrin strand

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Suture material & suturing technique

  1. 1. -- Presented by Dr. Anindya Chakrabarty
  2. 2. CONTENT 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
  3. 3.  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.
  4. 4. HISTORY History of the Surgical Suture “I dress the wound, God heals it”. -- Ambroise Pare, surgeon16th century The act of sewing is probably older then Homo sapiens, because Neanderthal man wore some sort of clothing. Perhaps the world’s 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
  5. 5.  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, the physician to Roman gladiators in the second century A.D. used silk for haemostasis. 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. 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 master’s 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.
  6. 6. DEFINITION  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 Stitches 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)
  7. 7. GOALS OF SUTURING  Provide adequate tension  Maintain hemostasis  Provide support for tissue margins  Reduce post-op pain  Prevent bone exposure  Permit proper flap position
  8. 8. BASIC REQUISITE OF SUTURE MATERIALS  Tensile strength  Tissue biocompatibility  Low capillarity  Good handling & knotting properties  Sterilization without deterioration of properties  Non allergic, non electrolytic and non carcinogènic  Low cost  It should not fray, should slide through tissues readily & knot should not slip after tying.  It should be readily visualized  On break down ,it should not release toxic agents  It should disappear without excessive reaction once its task is completed
  9. 9. natural synthetic metallic monofilament multifilament absorbable Non- absorbable coated Un-coated
  10. 10. 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.  Absorbable  Surgical Gut- Plain, Chromic  Polydiaxanone  Polyglactin 910  Non Absorbable  Polypropylene  Polyester  Nylon/polyamide  Polyvinylidene fluoride / PVDF Sutures
  11. 11. Advantages  Strength  Soft and pliable  Good handling  Good knotting Disadvantages  Bacterial harbours  Capillary action  Tissue trauma  Non Absorbable  Silk  Cotton  Linen  Absorbable  Polyglactin 910  Polyglycolic Acid
  12. 12. ABSORBABLE – NATURAL  Plain catgut:  light milk, Derived from submucusa of sheep intestine or serosa of beef intestine  Used for ligating superficial bld vessels & subcut fatty tissues  Chromic catgut:  yellow,Treated with chromium salt.  Adv may be used in the presence of infection
  13. 13. 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. ABSORBABLE -NATURAL
  14. 14.  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 3- 5days.
  15. 15.  It is available pre-sterilized in aluminium-coated 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.
  16. 16. 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
  17. 17. 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 rinse in saline prior to use.
  18. 18. 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.
  19. 19. ABSORBABLE - SYNTHETIC  Polyglactin (vicryl):cream, copolymer of lactide & glycolide  Minimal tissue rxn  Used in general soft tissue approx,intestinal anastomosis,vessels ligation in all surgical specialties  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. Dexon(Polyglyconic acid):purple/cream Homo polymers of glycolide. Avoid in adipose tissue Losses tensile strength more rapidly than vicryl.  Other e.g Polyglyconate(maxon) polydiaxone(PDS),Polyglecaprone(monoc ryl)
  20. 20. POLYDIOXANONE (PDS II)  Synthetic,absorbable,monofilament.  Polyester derivative poly P dioxanone.  TS -14-42 days  Absorption – Hydrolysis in 6 months.  Passes through tissues easily.
  21. 21.  Significant memory – compromises the ease of knot-tying and knot security.  Minimal tissue reaction  For wounds under tension and contaminated wounds.  May extrude through the wound over time. So used only in tissues deeper than subcuticular layer. Or if in face 6-0 used.
  22. 22. 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).
  23. 23. 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.
  24. 24. NON-ABSORBABLE-NATURAL  Surgical silk:  Black, Derived from the cocoon of the silk worm larvae, superior handling xtics,Trigger inflam rxns,Undergo proteolysis & undetected by 2yrs,Used in ligating maj bld ves,tendon repair etc  Other e.g Virgin silk, cotton, linen  Surgical steel & wires  High tensile strength  Hold knots very well  Used in orthopaedic,Neurosurg,& Thoracic surg  OMFS- for suspension of splints or arch bars and not as suture material
  25. 25. 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. NATURAL NON-ABSORBABLE
  26. 26. 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
  27. 27. 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.
  28. 28. 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
  29. 29. 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.
  30. 30.  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.
  31. 31. 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.
  32. 32. NON-ABSORBABLE - SYNTHETIC  Nylon:  Is a polyamide polymer,blue  81% tensile strength at 1yr & 66% at 11yrs  Elicits minimal tissue rxn  Has good memory  Pliable when moist  Premoistened form is used cosmetic plastic surgery  Its elasticity makes it useful for skin closure & Herniorhapy  Other e.g;Polypropylene(prolene),Polyester fiber(Mersilene/Dacron,Ethibond)
  33. 33. POLYPROPYLENE (PROLENE) -Polymer of propylene. -Inert and TS for 2 yrs -Holds knots better than other synthetic sutures. 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.
  34. 34. GORE-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.
  35. 35. -New, monofilament, nonabsorbable, synthetic -Made of polyglycol trephthate and polybutylene terephthalate and is considered as a modified polyester suture. -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. POLYBUTESTER (NOVOFIL)
  36. 36. SUTURE SELECTION  The condition of the wound,  The tissues to be repaired,  The tensile strength of the suture material  Knot-holding characteristics of the suture material  The reaction of surrounding tissues to the suture materials.
  37. 37. 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.
  38. 38. SUTURE SIZE UNITED STATES PHARMACOPEIA  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”.....
  39. 39. SIZE OF SUTURES  OLD GAUGE(USPD) DIAMETER IN MM  8/0 0.05  7/0 0.O7 6/0 0.1  5/0 0.15  4/0 0.2  3/0 0.3  2/0 0.35  0 0.4  1 0.5  2 0.6  3 0.7  4 0.8
  40. 40. PACKAGING……… METRIC GUAGE IMPERIAL GUAGE PRODUCT CODE NEEDLE SIZE & CURVATURE NEEDLE TYPE NEEDLE TIP NEEDLE PROFILE STERILIZED ETHELENE OXIDE DO NOT REUSE SEE INSTRUCTIONS FOR USE EXPIRY DATE BATCH NO
  41. 41. STERILIZATION OF SUTURES  May affect suture properties to some extent  Gamma Radiation  Ethylene oxide; poisonous gas is less attractive  Autoclave  Sutures are usually stored in sterile pack by the manufacturers , their integrity must be checked before use
  42. 42. ARMAMENTARIUM FOR SUTURING  Suture needle  Needle holder  addson’s tissue forcep
  43. 43. SUTURE NEEDLE  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 -tissue’s accessibility -diameter of suture material.
  44. 44. 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
  45. 45. 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
  46. 46. SWAGED NEEDLE  Swaged needles do not require threading and permit a single strand of suture material to be drawn.  Suture attached to needle via a hole drilled through the end of the needle, and the end is swaged during manufacturing.  It is atraumatic and act as a single unit.  Prepacked and presterilized by gamma radiation.
  47. 47. NEEDLE ANATOMY Term Definition Chord Length of needle Radius Diameter 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 Gauge or thickness of the metal wire out of which the needle is made.
  48. 48. RADIUS OF CURVATURE OF THE BODY(NEEDLE) CLINICAL USE Straight Needle ¼ circle 3/8 circle ½ circle 5/8 circle 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
  49. 49. 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
  50. 50.  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.
  51. 51.  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.
  52. 52.  Sharpened 12 times  Designated as C or FS (CUTICULAR or FOR SKIN)  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.  Cuticular needles  Plastic needles
  53. 53. 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.  Working tip/ jaws  Hinge device  Shank/body  Catch mechanism/ ratchet  Grip area
  54. 54. GRIPPING OF NEEDLE HOLDER The scissor grip Palm Grip
  55. 55. 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
  56. 56. 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
  57. 57.  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.
  58. 58. SUTURING TECHNIQUES
  59. 59. INTERRUPTED SIMPLE SUTURE Most commonly used. Inserted singly through side of the wound and tied with a surgeon’s knot.
  60. 60. 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
  61. 61. SIMPLE CONTINUOUS / RUNNING A simple interrupted suture placed and needle reinserted in a continuous fashion such that the suture passes perpendicular to the incision line below and obliquely above. Ended by passing a knot over the untightened end of the suture.
  62. 62. 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.
  63. 63. 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.
  64. 64. 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
  65. 65. 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.
  66. 66. 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.
  67. 67. 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.
  68. 68. 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.
  69. 69.  Advantages:  Will evert 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, extraction socket wounds.  Prevents the flap from being inverted into the cavity.  To control post-operative hemorrhage from gingiva around the tooth socket to tense the mucoperiosteum over the underlying bone.
  70. 70.  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
  71. 71. 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.
  72. 72. 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
  73. 73. 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.
  74. 74. 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.
  75. 75. 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.
  76. 76. KNOTS  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
  77. 77. PRINCIPLE 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  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.
  78. 78. 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 Granny’s 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.
  79. 79. 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.
  80. 80. HOW TO REMOVE SUTURE  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.
  81. 81. POSSIBLE COMPLICATIONOF LEAVING SUTURE FOR MANY DAYS 1.Sutural abscess. 2.Suture scarring or stitch mark 3.Implanted dermoid cyst
  82. 82. 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.
  83. 83.  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. RAILROAD SCAR
  84. 84. NEW ADVANCEMENT IN SUTURING  Ligating clips  Skin staples  Surgical tape  Surgical adhesives
  85. 85. 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.
  86. 86. 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.
  87. 87. 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).
  88. 88.  Contra indicated when it is not possible to maintain atleast 5mm distance from the stapled skin to the underlying bone and blood vessels.
  89. 89. 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.
  90. 90. 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
  91. 91. 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.
  92. 92. 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.
  93. 93.  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.
  94. 94. DERMABOND®  A sterile, liquid topical skin adhesive  Reacts with moisture on skin surface to form a strong, flexible bond  Only for easily approximated skin edges of wounds  punctures from minimally invasive surgery  simple, thoroughly cleansed, lacerations
  95. 95. DERMABOND®  Standard surgical wound prep and dry  Crack ampule or applicator tip up; invert  Hold skin edges approximated horizontally  Gently and evenly apply at least two thin layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky  Apply dressing
  96. 96. 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. ABSORPTION OF SUTURE MATERIALS
  97. 97. BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS
  98. 98.  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. BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS
  99. 99.  Natural Absorbable – Proteolytic degradation. Intense tissue response  Synthetic Absorbable – Hydrolysis. Less Intense  Non Absorbable – Encapsulation. Acellular Response
  100. 100. CONCLUSION  Human body is very delicate & important. When surgeries are needed to improve our health is very important to select a suitable suture. Today we know allots of biomaterials to select, but is important to always think of biocompatibility.
  101. 101. REFERENCES  Suturing techniques in oral surgery –Sandro Siervo  Laskin vol-1  Oral & Maxillofacial Surgery Vol 1- W. Harry Archer  Textbook of oral & maxillofacial surgery- Neelima Anil Malik  Minor Oral Surgery- Goeffrey L.Howe  Text book of surgery: Sabiston  Periodontology-Caranza.
  102. 102. THANK YOUTHANK YOU

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