L. Michael Brunt, M.D. Professor of Surgery Accelerated Skills Preparation for Surgical Internship: Suturing Skills and Surgical Instruments L. Michael Brunt, M.D. Professor of Surgery Washington University School of Medicine St. Louis, Missouri

Suturing Skills Curriculum Surgical instruments Suture material Suturing techniques

Classification of Suture Material Natural vs Synthetic (last 30 years) Absorbable vs Nonabsorbable Braided vs Monofilament

Basic Suture Materials Absorbable Nonabsorbable Natural: Catgut Plain Chromic Synthetic: Polygolic acid (Dexon) Polyglactic acid (Vicryl) Poly-para-dioxanone (PDS) Modified polyglycolic acid (Maxon ) Natural Silk Cotton Metals (stainless steel) Synthetic Dacron (Tevdek, Ethibond, Tycron) Nylon (Ethilon, Dermalon, Braided Nurolon) Polyprolene (Prolene, Surgilene)

Braided vs Monofilament Suture Absorbable: Dexon Vicryl Nonabsorbable Silk Dacron (Ethibond, Tevdek) Braided nylon (Nurolon) Absorbable: PDS Maxon Nonabsorbable: Nylon (Ethilon, Dermalon) Polyprolene (Prolene, Surgilene)

Factors Affecting Choice of Suture Material Strength of suture material over time Time interval material will be present Strength sufficient for healing before suture disappears or loses strength? Suture reactivity Local wound factors Handling properties

Natural vs Synthetic Suture Pro Natural material Absorbs quickly Strength retention Pliability and strength Strength retention Absorption (hydrolysis) Patient reactivity Con Stays in body longer More reactive Material inconsistency Increased tissue trauma

Absorbable Sutures Suture Type Classification Sites for Use # Knots Catgut collagen Natural SQ, GI 3 or 4 Polyglycolic acid (Dexon/Vicryl) Braided, synthetic SQ, GI, fascia, vessel ligature 4 PDS/Maxon Synthetic, monofilament Fascia, GI, Biliary/pancreas 6-8

Non-Absorbable Sutures Suture Type Classification Sites for Use # Knots Silk Natural Vessel ligature, GI 3 Dacron Braided, synthetic Hernia repair, fascial closure, fundoplication 5 Polypropylene, Nylon Synthetic, monofilament Skin, fascia, hernia repair, vascular anastomosis 6-8

Tensile strength – refers to the amount of strength “in vivo” that a suture material has retained. This can be measured in days and as a percentage of original strength. Exp: 21-28 days 50% at 3 weeks Absorption = the loss of mass of the material in tissue as measured in days, Exp: 21-28 days

Suture Properties: Definitions Tensile strength – refers to the amount of strength “in vivo” that a suture material has retained. This can be measured in days and as a percentage of original strength. Exp: 21-28 days 50% at 3 weeks Absorption = the loss of mass of the material in tissue as measured in days, Exp: 21-28 days

Suture Breaking Strength Over Time PDS Chromic Dexon Plain

Loss of Tensile Strength in Nonabsorbable Sutures

Absorbable Suture: Ethicon, Inc.

Nonabsorbable Suture: Ethicon, Inc.

US Surgical

Suture Sizes

Suture Needles

Non-Cutting Needles

Needles… ANATOMY OF A NEEDLE POINT SWAG (SWEDGE)

Running suture: Non-popoff/swaged on Interrupted suture: popoff Suture… Control Release--- POPS! (Pop-offs) Pop off... Don’t pop off... Running suture: Non-popoff/swaged on Interrupted suture: popoff

Suture…

Suture… Use

Suture… Order # Use

Suture… Order # Use Size (metric)

Suture… Order # Use Size (metric) Suture Material

Suture… Order # Use Size (metric) Suture Material Suture length

Suture… Order # Use Size (metric) Suture Material Needle cross section Suture length

Suture… Order # Use Size Suture Material (metric) Needle cross section Needle sales type- Suture length (reflects size)

Suture… Order # Use Size Suture Material (metric) Needle cross section Needle sales type- Suture length (reflects size) Approximate needle size & shape

Suture… Order # Use Size Suture Material (metric) Needle cross section Needle sales type- Suture length (reflects size) Approximate needle size & shape Needle curve

Suture… Order # Use Size Suture Material (metric) Needle cross section Needle sales type- Suture length (reflects size) Approximate needle size & shape Needle curve Needle diameter

Suture Lab Goals 1) Proper instrument handling Instrument/needle setting technique Safety tips 2) Suturing technique Proper needle insertion into tissue and needle/hand rotation Tying with needle still on (free hand and instrument)

Suture Lab Goals 3) Types of stitches Simple interrupted Interrupted vertical mattress Subcuticular Simple running Running vertical mattress Forehand and backhand techniques 4) Knot tying One and two handed knots Instrument pass

Skin Stapling

Simple Interrupted Suture

Interrupted Vertical Mattress

Interrupted Vertical Mattress

Interrupted Horizontal Mattress

Figure of 8 (Interrupted Fascial Closure)

Simple Continuous Closure

Continuous Locking Suture

Continuous vs Interrupted Suture Continuous Suture Pros Cons May be rapidly placed Avoids tying multiple knots, reduces knots in wound Even distribution of tension along full length More hemostatic If it breaks, the whole suture line may disrupt Long amount of suture to deal with Interstices of braided sutures could harbor infection along the suture line

Continuous vs Interrupted Suture Pros Cons Remaining sutures protect wound if an interrupted suture comes untied Infection cannot travel along suture length More operating time due to cutting and tying of each suture individually Each suture could have a variable amount of tension Individual knots increase amount of foreign body in the wound

Burying Knots

Suture Removal

Suturing Movie Click the projector button to view the suturing movie

Sources John Stuart Brown, MBE, Minor Surgery, A Text and Atlas, Fourth Edition, Oxford University Press, New York, 2000. Jameson L. Chassin, MD, Operative Strategy in General Surgery, An Expositive Atlas, Second Edition, Springer- Verlag, New York, 1994. A.K. Qayumi, MD, PhD, Basic Surgical Techniques, An Illustrated Manual, Q&Q Publishing, Vancouver, Canada, 2000. Ethicon, Inc., A Johnson and Johnson Company, Somerville, NJ, USA, www.ethiconinc.com.