Wound Closure Presentation Jessica Carter Aimee Stohler Syneture: A Division of Covidien

Agenda Basic Terms Defined Names And Types Of Sutures Absorbable Non-Absorbable General Applications Topical Adhesives Needles

Basic Terms Associated With Sutures Primary Suture Manufacturers: Syneture (Covidien) Ethicon Specialty Suture Manufactures: Gore Tevdek

Types of Suture Material Absorbable - Suture material is absorbed over time by the body. Non-Absorbable - Suture material is permanent - not absorbed by the body.

Basic Terms Associated With Sutures Absorption Profile - The number of weeks or days it takes the body to absorb suture. Tensile Strength - The amount of force necessary to break a suture. It is measured in days with absorbable sutures. Hydrolysis - Absorption process that uses the body’s water - Synthetic sutures are absorbed by hydrolysis.

Basic Terms Associated With Sutures Enzymatic Process - Suture that is absorbed by the body’s enzymes - Gut suture products are absorbed in this manner Degrade - A non-absorbable suture’s tendency to crumble and fall apart over time. The material is not absorbed, but it does not stay intact - Silk, Nylon Mechanical Trauma Trauma to the suture by mechanical instruments can result in suture failure. Compression of sutures between a needle holder with teeth can produce morphologic changes in sutures that can result in a marked reduction in suture breaking strength

Basic Terms Associated With Sutures Braided - A suture strand that is woven or braided with numerous filaments. Monofilament - Suture strand is composed of a single strand or filament. D-Tach/ Pop-Off - Suture/needle combination that is designed so that the needle detaches from the suture strand when appropriate force is exerted.

Basic Terms Associated With Sutures Running Closure - AKA “Continuous Closure” - Incision closed with repeated passes of one single suture. Interrupted Closure - Incision is closed with numerous sutures each tied separately. Double Armed - Needle on both ends of suture Taper – Refers to a taper point needle generally used inside the body Cutter - Refers to a cutting needle used generally to close skin

Review of Primary Tissue Layers The primary layers which will determine the type of suture, needle and suturing technique used are: Skin Subcutaneous fat Anterior Fascia Muscle Posterior Fascia Peritoneum

Suture and Tissue Reactivity Although sutures are necessary to provide wound support so healing will occur, they may also cause a tissue reaction at the wound site. Tissue reactivity is the patients response to the physiological properties of the suture (what the suture is made from ). It can also be referred to as a foreign body response.

Suture Function and Wound Healing Sutures function to hold wounds together until wound healing takes place. Fourteen to twenty-one days is often regarded as the critical wound healing period. It is during this time that the sutures provide strength to the closed wound, allowing the tissue to heal with minimal scarring.

Monofilament /Multifilament Suture Structure Monofilament /Multifilament

Suture Sizing - USP (United States Pharmacopoeia: - Diameters and strengths) Human hair 7 6 5 4 3 2 1 0 2-0 3-0 4-0 5-0 6-0 7-0 8-0 9-0 10-0 11-0 Chest Skin Micro / Ophthalmic Abdominal closure CABG *Suture Sizes range from a size 7 being the largest to a size 11-0 being the smallest (Note the typical application for each size by reviewing the chart on this slide) More 0’s = smaller size

Suture Products Absorbable Products: Non-absorbable Products Braided Synthetic Monofilament Synthetic Organic Absorbables Non-absorbable Products Organic Nonabsorbables

Suture Products Absorbable Sutures Braided Synthetic Absorbables (BSA) Polysorb - Syneture 92.5% Polyglycolic 7.5% Polylactic Acid Tensile Strength for 3 weeks Absorbed in 56 to 70 days Vicryl - Ethicon 90% Polyglycolic 10% Polylactic Acid Tensile strength for 3 weeks

Suture Products Absorbable Sutures Braided Synthetic Absorbable (BSA) Advantages: Tremendous strength Resistance to breakage due to multifilament construction Relatively little memory Easy to handle and tie Tremendous variety of needle/suture combinations.

Suture Products Absorbable Sutures BSA Disadvantages: Tends to be rougher on tissue as suture pulled through. Braids have potential to harbor infection due to numerous interstices. Can be a medium for stone formation in GYN and GU procedures involving the bladder and surrounding structures.

Suture Products Absorbable Sutures BSA General Applications: General Surgery Mid line fascia closure Subcutaneous layer closure Subcuticular skin closure Bowel anastomosis Other general tissue closures

Suture Products Absorbable Sutures BSA Applications (Cont). Ortho/Neuro General tissue layer closure GYN Ligation (TAH/TVH) Vaginal Cuff Closure Hysterotomy Closure

Suture Products Absorbable Sutures Monofilament Absorbable Sutures (MSA’s) Short Absorption Profile MSA’s Biosyn - Syneture Tensile strength: 3 weeks Is absorbed in 90 to 110 days Caprosyn - Syneture Tensile strength: 10 days Is absorbed in 56 days or less Monocryl - Ethicon Tensile strength: 10 to 14 days Is absorbed in 91 to 119 days

Suture Products Absorbable Sutures Short Absorption MSA Applications: General Surgery Skin Closure Colo-Rectal Applications GYN Adnexa ligation Vaginal Cuff Closure Hysterotomy Closure

Suture Products Absorbable Sutures Long absorption profile Monofilament Synthetic Absorbable Maxon - Syneture PDS - Ethicon Both sutures provide tensile strength for 6 weeks and are absorbed by the body in 180 days. Maxon maintains slightly higher tensile strength during the first two weeks in vivo Some surgeons might notice slight handling differences between the two sutures

Suture Products Absorbable Sutures Long absorption MSA applications: Midline incision closures Looped products are increasing in popularity Bowel anastomosis Any application where extended approximation (three to six weeks) of tissue is needed.

Suture Products Absorbable Sutures MSA Advantages: Smooth flow through tissue Resistance to bacteria, infection and stone formation due to monofilament construction Latest technology from suture manufacturers Variety of absorption rates Best replacement for gut products

Suture Products Absorbable Sutures MSA Disadvantages: Out of package memory Stiff and slightly more difficult to work with Knots require additional throws

Suture Products Absorbable Sutures Organic Absorbable Sutures

Suture Products Absorbable Sutures Gut Products - Ribbons of beef serosa (inner most layer of intestines) twisted to form suture strands Fast Absorbing Gut Proprietary to Ethicon Extremely short absorption profile Plain Gut Mild Chromic Gut Proprietary to Syneture Chromic Gut CAPROSYN is an excellent alternative to using Gut suture.

Suture Products Absorbable Sutures Gut Products Generally fast, unpredictable absorption rates Decreasing in popularity Banned in Europe and Japan

Suture Products Absorbable Sutures Things to remember about Absorbable Suture Products - Means of absorption Synthetic absorbable sutures are absorbed by hydrolysis (the body’s water) and are generally deemed to have predictable strength and absorption profiles Organic absorbable sutures (gut products) are absorbed by the body’s enzymes and are generally thought to be more unpredictable in strength and absorption profile than synthetic absorbables.

Suture Products Absorbable Sutures Any Questions?

Non Absorbable Sutures Suture Products Non Absorbable Sutures

Suture Products Non Absorbable Sutures Braided Synthetic Non Absorbable Sutures: Braided Polyester Ticron - Syneture Coated with silicone Dyed Blue Ethibond - Ethicon Polyester suture coated with PBA (polybutylane adipate) Dyed Green

Suture Products Non Absorbable Sutures Polyester Suture Applications Heart valve replacement Tendon Repair ACL Graft Direct repair of hernia Uterine suspension

Suture Products Non Absorbable Sutures Braided Synthetic Non Absorbables (Cont) Braided Nylon Surgilon - Syneture Nurolon - Ethicon

Suture Products Non Absorbable Sutures Braided Nylon Applications: Neuro surgery - Dura closure Direct repair of Hernia Cannulation during heart bypass surgery

Suture Products Non Absorbable Sutures Synthetic Monofilament Non Absorbables Polypropylene Surgipro II – Syneture Prolene - Ethicon

Suture Products Non Absorbable Sutures Polypropylene applications: Blood vessel anastomosis Hernia repairs using mesh Uterine and bladder suspension Percutaneous skin closure Abdominal wall closure (where permanent suture is required)

Suture Products Non Absorbable Sutures Monofilament Nylon Sutures Monosof (black) – Syneture Dermalon (blue) - Syneture Ethilon - Ethicon

Suture Products Non Absorbable Sutures Monofilament Nylon Applications: Percutaneous skin closure Secure Drains Abdominal wall closure

Suture Products Non Absorbable Sutures Monofilament non absorbable sutures that are proprietary to SYNETURE Novafil Monofilament polybutester suture Unique handling characteristics; Dramatically reduced memory Can be used in all applications where polypropylene sutures are used Vascufil Vascular version of Novafil Coated to minimize tissue drag and to improve knot run down

Suture Products Non Absorbable Sutures Organic Non Absorbable Sutures: Silk Considered the “gold standard” of suture handling Braided and coated with wax or silicone Steel Sternal Wires - CV Pacing Wires - CV

Suture Products Non Absorbable Sutures Things to remember about non-absorbable sutures: Some non-absorbable sutures will degrade over time. They won’t absorb, but will degrade Degrading permanent sutures Silk Nylon Non-degrading permanent sutures Polypropylene Polybutester Polyester

Topical Adhesives Cyanoacrylate based products used for the closure of topical skin incisions and trauma-induced lacerations in areas of low skin tension with easily approximated wound edges. Indermil (Syneture) n-Butyl 2-Cyanoacrylate Dermabond (Ethicon) 2-Octyl Cyanoacrylate

Topical Adhesives Clinical Applications: Laparoscopic Procedures Biopsies Cosmetic Surgery ER/ Lacerations Dressing/ Microbial Barrier

Non Absorbable Sutures and Topical Adhesives Any Questions?

Surgical Needles

Needles must possess the following characteristics: The needle must be sharp enough to penetrate tissue with minimal resistance. The needle must carry the suture material through tissue with minimal trauma. The needle must be rigid enough to resist bending, yet flexible enough to bend before breaking.

Every surgical needle has three basic parts The swage is the site of attachment of the suture to the needle. The body of the needle is the portion that is grasped by a needle holder. The point of the needle extends from the tip of the needle to the maximum cross section of the body.

Needle Shapes

Needle Points Specific points are designed and produced to the required degree of sharpness to smoothly penetrate the types of tissue to be sutured. The point is from the extreme tip of the needle to the maximum cross section of the body.

Surgical Needles Types of Surgical Needles: Taper Needles - Vast majority of needles are this type General Tissue Closure Midline, Sub Q, Peritoneum Vascular closures and anastomosis Bowel closure and anastomosis

Surgical Needles Types of Surgical Needles (Cont.) Cutting Needles - Needles with a triangular cutting configuration. Used for penetrating tough, fiberous tissue. Sub Cuticular skin closure Percutaneous skin closure Skin sutures for securing drains Various orthopedic tissue applications Ligaments etc.

Surgical Needles Types of Surgical Needles (Cont.) Taper cutting needles - Point of needle has a cutting tip. Body of needle quickly tapers. Used in places where taper needles are desired, but may not be quite sharp enough. Vascular procedures where vessels are heavily plaqued.

Surgical Needles Types of Surgical Needles (Cont.) Spatula Needles - Used primarily in ophthalmic surgery Deflects or pushes aside tissue as the needle passes Come in a variety of configurations. Blunt Needles - Needles have a blunt tip Used primarily on delicate or friable tissue (Liver) or on patients with high risk blood diseases.

Surgical Needles Types of Surgical Needles (cont’d) X-Cutting Dermax needles (proprietary to Syneture) Features a fourth cutting edge that allows four dimensional control: horizontal (left/ right), and vertical (up/ down) Unique double-point profile geometry for easier puncturing and needle embodying into the tissue. Used primarily in cosmetic procedures, & percutaneous skin closures.

Surgical Needles Any Questions?

THANK YOU!