Presented by Chesapeake Bay Consortium Suture Presented by Chesapeake Bay Consortium Property of Chesapeake Bay Perioperative Consortium, @2017 Reviewed May 2017 Created 4/2015

Today’s Objectives Critical Wound Healing Period (CWHP) Suture Characteristics Types of Sutures Anatomy Surgical Needles Topical Skin Adhesive

Surgical Technologist Role Considered the role Model Most knowledgeable Familiar with suturing techniques

Wound Healing

Wound Healing Types of Wound Healing Influence on Wound Healing Wound Support

Critical Wound Healing Period Skin 5-7 days Mucosa 5-7 days Subcutaneous 7-14 days Peritoneum 7-14 days Fascia 14-28 days Layer Closure Inside out -Peritoneum Lines the abdominal cavity Fast healing may not require suturing -Facia Connective tissue covering the muscle Slow healing Primary supportive tissue -Muscle Do not tolerate surters well Try not to cut, most often separated or retracted out of the way -Subcutaneous Does not tolerate sutures well Closed to prevent dead space -Subcuticular Tough connective tissue below the skin Used to minimize scarring. Uses skin tapes or adhesives -Skin Fast healing times Scars easily Tissue Healing Times

The Critical Wound Healing Period Can Depend on Various Factors Age Weight Nutrition Dehydration Blood Supply Immune response Chronic Diseases Localized infection Diabetes History of Radiation Therapy

Short-term Wound Support Situation in Short-term Wound Support Skin & mucosa Typically areas with increased blood flow Need Benefit Fast-absorbing suture Good clinical outcomes Rapid loss of strength/mass Good knot formation/snug down Procedure Example: Episiotomy

Short-Medium-term Wound Support Situation in Short-Medium-term Wound Support Skin, mucosa, subcuticular Typically cosmetic surgery cases Typically areas with increased blood flow Need Benefit High initial strength Good Clinical Outcomes Good cosmetic Good handling & passage through tissue Good knot formation/snug down Low reactivity Procedure Example: Plastic surgery

Medium-term Wound Support Situation in Medium-term Wound Support All tissue layers that align with the critical wound healing period of 21-28 days All tissue types Typically areas with increased blood flow Need Benefit Consistent strength around the Around the CWHP Good Clinical outcomes Good handling & passage through tissue Good knot formation/snug down Low reactivity Procedure Example: General Closure

Longer-term Wound Support Situation in Longer-term Wound Support Tissue that requires extended support Friable tissue Slow healing tissue/compromised patients Typically fascia tissue Need Benefit Strength beyond the CWHP of 21 days Good Clinical outcomes Good handling & passage through tissue Good knot formation/snug down Low reactivity Procedure Example: Body Contouring

Suture Characteristics Absorbable VS Non-absorbable Monofilament VS Multifilament (Braided) Natural VS Synthetic Size

Absorbable vs Non-absorbable Undergo degradation and absorption Naturally digested by the body enzymes Used to hold wound edges or tissue together temporarily Non-absorbable Resistant to absorption Encapsulated or walled off by the body Retains tensile strength

Mono-filament VS Multi-filament Mono-filament sutures are made of a single strand of material. Less resistance when passing through tissue Resist harboring organisms which may cause infection Easy tie down Multi-filament suture consist of several strands twisted or braided together. Greater tensile strength Greater flexibility Holds knots securely

Natural vs Synthetic Natural Synthetic From naturally occurring substances: Cellulose Animal products Animal tissue Synthetic Man made Petroleum based products

Suture Size Correlate With tissues to be sewn In an effort to minimize trauma to the tissue, the goal is to use the smallest diameter suture that will adequately hold tissue together Variety of sizes ranging from 7 (largest) to 11-0 (smallest) 1 to 4-0 are most commonly used 1 and 0 are typical orthopedic sutures 6-0 to 7-0 for vascular anastamosis 8-0 to 11-0 for eye procedures 4-0 and 3-0 for skin closure (called subcuticular closure)

The Perfect Suture Pliable and flexible with good handling characteristics. Easy to tie, and would hold knots securely. Not fray as it was tied. Slide through tissues effortlessly. The smallest diameter would never break. No tissue reaction. Tensile strength of the absorbable suture would be maintained only for as long as the wound required support.

Perfect Suture (Continued) Absorbable suture would disappear completely the second the wound could support itself. Absorption would be predictable in every patient. It could be used in infected wounds. It could be used in every surgical situation. It would be inert, non-allergenic, and economical to use.

Products Packaging Suture can have a needle incorporated into the suture stand called swaged Suture can be without a needle also just called a tie or ligature These ties can be loaded onto individually packaged “free needles” and these suture ligatures are called “stick ties” Ties can be on reels similar to a spool of thread Clearly distinguishes the types of Suture and needle information Code Suture size Product name Suture length Needle size Type of needle Quantity

Suture Types Absorbable

Yellow Packages Ethicon Plain Gut Coviden/Syneture Plain Gut

Ethicon Plain Gut Coviden/Syneture Plain Gut Monofilament Natural Submucosa of sheep intestine or beef intestine serosa 5-10 day wound support Absorbs in 30-60 days Patient characteristics can affect rate of support and absorption Used for superficial homeostasis and tissue that heals quickly

Brown Package Ethicon Chromic Gut Coviden/Syneture Chromic Gut

Ethicon Chromic Gut Coviden/Syneture Chromic Gut Monofilament Natural Beef Serosa Sheep Submucosa Wound support 21-28days Absorption 90 days Patient factors can affect rate of support and absorption Most commonly used in OB, GYN, plastic and oral surgery

Pink Packages Ethicon Monocryl Coviden/Syneture Biosyn

Ethicon Monocryl Coviden/Syneture Biosyn Monofilament Synthetic 7 – 14 days Wound support Absorption 91- 119days One of the most common used for skin closure, cosmetic surgery and soft tissue closure

Purple Package Ethicon Vicryl Coviden/Syneture Polysorb

Ethicon Vicryl Coviden/Syneture Polysorb Braided and/or coated Synthetic 14-28 days wound Support Absorption 56-70 days One of the most common used to approximate soft tissue

Silver Package Ethicon PDS II Coviden/Syneture Maxon

Ethicon PDS II Coviden/Syneture Maxon Monofilament Synthetic 14-42days wound support Absorption 183-238 days A longer lasting suture used to approximate fascia in abdominal cases

Suture Types Non-Absorbable

Light Blue Package Ethicon Silk Coviden/Syneture Sofsilk

Ethicon Silk Coviden/Syneture Sofsilk Braided Natural Used to tie surgical drains, repair bowel and ligate large blood vessels

Orange Package Ethicon Ethibond Coviden/Syneture Ti-Cron

Ethicon Ethibond Coviden/Syneture Ti-Cron Braided Synthetic Used in orthopedic surgery on high tension tissue such as muscle and tendons.

Green package Ethicon Ethilon Coviden/Syneture Monosof

Ethicon Ethilon Coviden/Syneture Monosof Monofilament Synthetic 20% loss of wound support each year Most commonly used on nerves and blood vessels. Can also be used to secure surgical drains

Dark Blue Package Ethicon Prolene Coviden/Syneture Surgipro II

Ethicon Prolene Coviden/Syneture Surgipro II Monofilament Synthetic Most commonly used to create anastamosis for vascular grafts and repair vessels.

Antibacterial Suture: Kill bacteria and inhibit colonization of the suture Create a zone of inhibition around the suture against Staphylococcus aureus Staphylococcus epidermidis Methicillin-resistant Staph a (MRSA) Methicillin- resistant Staph e (MRSE) Monocryl Plus and PDS Plus also kill: E. Coli Klebsiella pneumoniae

Anatomy of the Surgical Needle

The Best Surgical Needle Made of high quality stainless steel As slim as possible without compromising strength Stable in the grasp of a needle holder Able to carry suture material through tissue with minimal trauma Sharp enough to penetrate tissue with minimal resistance Rigid enough to resist bending, yet ductile enough to resist breaking during surgery Sterile and corrosion-resistant to prevent introduction of micro- organisms or foreign materials into the wound

Needle Curvature Also describe by shape (curved (1/4, 3/8, ½ circle, 5/8 circle, or straight)

Anatomy of a Needle Swaged End Point Body

Arming The Needle Swaged End Point Body

Needle Types* Taper Point needles Blunt point needles Conventional cutting needles Reverse cutting needles Spatula needles Endoscopic needles Micropoint needles Premium cosmetic needles Premium spatula needles Heavy body needles Straight needles Tapercut needles *Trademark Covidien and Ethicon, Inc.

Needle Types

Non Cutting Needles TAPERPOINT Round shaft with out a cutting edge Round bodies needles that pierce and spread tissue without cutting it. For soft, easily penetrated tissues. Vessels, gastrointestinal and delicate tissue BLUNTPOINT Round shaft with a blunt tip Blunt needles are for blunt dissection and suturing friable tissue. Can be used when suturing kidney, liver or deep spaces prone to space and visibility limitations.

Cutting Needles CONVENTIONAL CUTTING There are two opposing cutting edges with a third on the inside curve. REVERSE CUTTING Cutting edge on outer curve. Used for tough, difficult to penetrate tissues. More strength than conventional cutting. Danger of cutout greatly reduced.

Cutting Needles continued TROCAR POINT Three sharp edges ending in a sharp point Your trocars used for endoscopic delivery as well as surgical wound drain insertion SPATULA- SIDECUTTING These edges are on the side for accurate depth placement. Used in ophthalmic surgery.

Adhesive Skin Closures Indermil and Dermabond* Significantly Faster Closure Sets in just 30 seconds Easy-to-use for precision application Enhanced Patient Comfort and Convenience Cost effective INDERMIL® Tissue Adhesive sloughs from wound in 7 to 10 days when no longer needed. *Trademark Covidien and Ethicon,Inc

Adhesive Skin Closures Indermil and Dermabond* Quick Facts Microbial Barrier Provides the strength of healed tissues at 7 days in less than 3 minutes Equivalent to a 4-0 suture Effectively closes long incisions Successfully used across a range of procedures by surgeon from 6 different specialties No dressing needed Patient may shower immediately *Trademark Covidien and Ethicon,Inc

Types of Staplers Skin Ligating Clips

Skin Stapler Used to approximate skin edges for closure Must be removed postoperatively

Skin Stapler

Ligating Clips Used for hemostasis on a vessel Occlude a duct Can be automated disposable devices or manually loaded with re-usable applicators

Ligating Clips

Suture Resources Ethicon wound closure manual http://media.benersättning.se/2012/04/Ethicon-wound-closure-manual.pdf

QUESTIONS