SUR 111 Suture and Staplers

Skill Assessments 10-3 Load and Pass Needleholders (NH) 10-3 Load and Pass free needles 10-4 Ties, reels, free tie on a Passer 11-2 Load clip appliers and Pass Staplers

10-3 Load and Pass NH Choose appropriate size NH based on size of the needle being used by the surgeon Heavy NH will bend delicate needles Delicate NH will be damaged being loaded onto large needles

Load and Pass the NH Load needle by grasping it in the center of the body with the NH in the packaging Some surgeons prefer NH grasping needle about 1/3 from the swaged end of the needle Gently pull out of packaging pulling the strand gently if necessary to release suture memory prn Pass to surgeon with NH’s loaded needle tip pointing towards the surgeon’s thumb STSR’s hand position should be behind the needle point at lower shank/box lock level DO NOT allow suture strand to drop below sterile field! See text page 368-369 Figure 12-45 Note ligating methods text page 290-291

10-3 Load and Pass Free Needles Differs from previous in that the suture strand must be secured unlike the swaged on suture You will be shown different methods for doing this Tip: Do not load the suture evenly, only load a short end of suture into the NH or it will pull right out of the tissue it is placed in Passing technique is the same

10-4 Ties, Reels, Free tie on a Passer Lay near incision so surgeon may grasp with his forceps or Pass to surgeon assistant so that person may grab with their forceps and pass to surgeon who likely will have a right angle in his or her hand to receive the tie and ligate a vessel Always have these ready in pairs, if one is used another will follow

Ties, Reels, Free tie on a Passer Release strand of suture from reel about 1 + ½ inches and pass reel to surgeon Surgeon grasps other end of strand and ties holding onto the reel and suture Reels ARE COUNTED ITEMS!

Ties, Reels, Free tie on a Passer Tie on a Passer (usually a tonsil can be right angle) Ties are loaded as an extension of the clamp it is loaded on It will look like it is part of the tip if loaded properly Pass clamp in the normal manner taking heed to not allow suture to drop below sterile table level

Suture Absorbable Designed to hold tissue together until it heals Different types have different absorption rates Suture type used depends on the type of tissue being sewn and that tissue’s normal healing time Nonabsorbable Designed to hold tissue together permanently

Suture Characteristics Absorbable Monofilament Braided (multi-filament) Dyed Undyed Natural Synthetic Nonabsorbable Monofilament Braided (multi-filament) Dyed Undyed Natural Synthetic

Suture Characterisitcs Monofiliment verses Multi-filament Monofilament Single strand Inert (little to no tissue reaction) Do not harbor bacteria Can use in presence of infection Minimal tissue damage as they glide easily through tissue Multi-filament Braided Capillarity (able to harbor bacteria that can be communicated up the strand) NOT used in presence of infection Can be traumatic to tissue if not coated Greater tensile strength Hold knots securely

Suture Characterisitcs Natural verses Synthetic From naturally occurring substances: Cellulose Animal products Animal tissue Synthetic Man made: Petroleum based products

Suture Sizes Correlate with tissue to be sewn Heavy tissue needs a heavy strand of suture to hold it together Delicate tissue does not require a heavy strand but a small or delicate strand of suture Suture diameter is called the gauge

Suture Gauge #5 is largest available #1 to 4-0 are most commonly used #1 and #0 are typical orthopedic sutures 6-0 to 7-0 for vascular anastamoses 8-0 to 11-0 for eye procedures 4-0 and 3-0 for skin closure (called subcuticular closure)

Suture Gauges (See text 286 table 11-4 ST for the ST) #5 largest, #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, 11-0 smallest

Suture Length 13cm to 150cm

Suture 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 ( below tie packaged individually) These ties can be loaded onto individually packaged “free needles” and these suture ligatures are called “stick ties” Ties can be packaged individually Ties can be on reels similar to a spool of thread

Suture Presentation Ties can be presented to a surgeon as a “free tie” laying it by his or her forcep near the incision site Ties can be presented “on a passer” typically a tonsil clamp (tie will become an extension of the tonsil’s tip when loaded) Your book calls it “instrument tie” Ties can be presented on reels (present by making sure the suture has been pulled out enough for the surgeon to use it and not have to pick and dig into the reel himself)

Suture Reels or Ligapak Dispensing Reel Look at a reel like a bike tire: have the tire on the outside and the spokes on the inside Limited sutures come in reel style Examples include: vicryl, plain gut, chromic gut, silk, nylon Gauge can be determined by packaging label and flipping the reel over to where you can visualize the dots in the reel’s spokes º = 0 º º = 2-0 º º º =3-0 º º º º = 4-0 Larger gauges come packaged in pre-cut strands as well as these described above that come on reels

Needles Necessary to insert suture into tissue Variety of shapes and sizes to accommodate specific tissues Certain designs necessary for certain tissues to prevent tissue trauma when being used Anatomy includes: eye, body (shaft), point (see page 314 textbook) Also describe by shape (curved (1/4, 3/8, ½, 5/8 circle, ½ curved, or straight)

Needles Can be swaged on Single arm or double arm Pop-offs or control-release Individual Individual that must be threaded like you would a needle at thread at home Eyes types vary with individual needles Closed eye - thread through eye French eye – snap through the eye Unique loading of suture strand to secure it from pulling out of the eye during usage

Needles Cutting used for tough tissue that can withstand this design of needle Sclera, skin, tendons Curved or straight (straight called “Keith needle”) Tapered Round shaft without a cutting edge Can pierce or penetrate tissue but do not cut it Vessels, gastrointestinal tissue, delicate tissue Blunt Round shaft with a blunt tip Kidney or liver

Cutting Needles 1. Conventional Three cutting edges 2. Reverse cutting Opposing cutting edges in a triangular shape Side cutting Primarily ophthalmic use as will not penetrate into deep tissue Trocar points Three sharp edges ending in a sharp point Your trocars used for endoscopic delivery as well as surgical wound drain insertion •

Suture Book Textbook read pages 285-289 Your Suture and Surgical Hemostasis Pocket Guide is most helpful Please review this material given in this slide show in this book as well

Most Commonly Used Sutures To Follow Are primarily two manufacturers of suture in this area: Ethicon (Johnson & Johnson) Davis & Geck (US Surgical) Suture materials are primarily the same with maybe one chemical difference Trade names of suture are similar but not the same This makes for confusion when learning suture Most institutions carry only one primary brand Most places here use Ethicon brand suture

Absorbable Suture

PLAIN GUT

Plain Gut (bright yellow package) Monofilament Natural Submucosa of sheep intestine or beef intestine serosa Comes in stick tie, pre-cut lengths, and reel 5-10 day wound support Absorbs in 30-60 days Inflammatory reaction Used for superficial hemostasis and tissue that heals quickly Stored in alcohol solution to maintain pliability and keep from drying out

CHROMIC GUT

Chromic Gut (beige package) Monofilament Natural Submucosa of sheep intestine or beef intestine serosa Difference from plain gut is that it is treated with chromium salts to delay absorption rate Comes in stick tie, pre-cut lengths, and reel 10-14 day wound support Absorbs in 60-90 days Inflammatory reaction Used for superficial hemostasis and tissue that heals quickly Stored in alcohol solution to maintain pliability and keep from drying out

PDS

PDS (polydioxanone) (silver package) Monofilament Synthetic Comes in stick tie, pre-cut, and reels 6 week wound support Absorbed in 6 months Minimal tissue reaction Dyed or clear

Monocryl (not shown) (pink package) Monofilament Synthetic 14 day wound support Absorbs in 91-119 days Slight tissue reaction Dyed or undyed 3-0 through #1 gauge swaged 6-0 through #2 pre-cut ties Close skin or soft tissue such as subcutaneous

Vicryl

Vicryl (polyglactin 910) (purple package) Multi-filament (braided) Synthetic Dyed or undyed 21 day wound support 56-70 day absorption Swaged, control release, free ties, reels Close fascia, subcutaneous (adipose), skin (subcuticular), GYN procedures, peritoneum

Nonabsorbable Suture

Prolene

Prolene (polypropylene) (Royal blue packaging) Monofilament Synthetic Least reactive of all synthetic suture One of most inert sutures CAN USE in presence of infection Used for long term support of suture lines such as vascular surgery or mesh support in hernia repairs

ETHILON or NYLON

Ethilon or Nylon (mint green package) Monofilament Synthetic Minimal tissue reaction One of most inert sutures Used in ophthalmic, tendon repair, drain sew in, skin closure (interupted/what you know as “getting stitches”) Dyed or undyed Difficult to handle Knots poorly

Stainless Steel (not shown) Monofilament Synthetic – chromium and nickel alloy) Gauge #7 to 6-0 Minimal tissue reaction Uses tendon repair, bone repair, (sternal closure (#7 wire)), cerclage (tying the cervix shut to prevent premature abortion) Considered most inert of all suture materials Can use in presence of infection Not used in presence of other metal alloys!

SILK

Silk (baby blue package) Multi-filament Natural – from cocoon of silk worm Usage GI tract in absence of infection and vessel ligature Excellent knot holding and handling

Nurolon (Nylon Braided) NOT SHOWN (mint green packaging) Multi-filament Synthetic Dyed or undyed Minimal tissue reaction Soft tissue approximation, see in neurosurgical closure Coated with silicone to reduce drag and tissue trauma as pulled through tissue

ETHIBOND (Ethicon) or TICRON (Davis & Geck)

Ethibond (polyethylene terephthalate) (orange packaging) Multi-filament (braided) Synthetic – polyester Available in pre-cut ties and swaged suture Most commonly used for soft tissue and heart surgery for valvular procedures

11-2 Load and Pass Staplers Read text p. 300-303 on stapling devices There are great pictures there as well Staplers can come with cutting blades incorporated into the stapling device Care must be taken with these to avoid personal injury especially when re-loading Staple and clips are made of stainless steel or titanium Come disposable and non-disposable

Load and Pass Staplers Different stapling devices load differently Staplers are passed with the STSR holding the stapling device by the business end and placing the handles into the surgeon’s hand Always keep reloads available Will be shown different staplers in lab Used for skin closure like a staple gun Also come in linear, ligating and intra-luminal designs for open and laparoscopic procedures

Load and Pass Staplers Clip appliers – a type of stapling device Passed with tips pointing down for general surgeons and up for vascular surgeons Surgeon will tell you how he or she wants them passed Take care NOT to squeeze shank/finger rings together or the clip will fall out Passed by placing the shank into the palm of the surgeon’s hand

CLIP or LIGACLIP APPLIERS MEDIUM CLIP or LIGACLIP APPLIERS Regular length SMALL LARGE

Clip Appliers Long Length MEDIUM REGULAR LONG REGULAR Clip Appliers Long Length LARGE LONG MEDIUM LONG

DISPOSABLE CLIP APPLIERS Are pre-loaded with multiple clips Ethicon laparoscopic clip applier Davis & Geck AutoSuture Clip Applier DISPOSABLE CLIP APPLIERS Are pre-loaded with multiple clips Each tells you how many clips it holds

Skill Assessment Review 10-3 Load and Pass Needleholders (NH) 10-3 Load and Pass free needles 10-4 Ties, reels, free tie on a Passer 11-2 Load clip appliers and Pass Staplers