Dr. Muath Mustafa Dept of Surgery, BMC HOD. Dr. Ashraf Balbaa Sutures and Suturing Dr. Muath Mustafa Dept of Surgery, BMC HOD. Dr. Ashraf Balbaa

Definition: Suture is a generic term for all materials used to bring served body tissue together and to hold these tissues in their normal position until healing takes place A ligature is a strand of suture material used to tie off (seal)blood vessels to prevent hemorrhage and simple bleeding or to isolate a mass of tissue to be excised (cut out)

History: 50,000 BC Eyed needles are invented 1600 BC One of the earliest known references to suture material. Sutures are made from flax, hemp, bark fiber, hair, etc 1867-9 Joseph Lister proves that the body absorbs catgut sutures. However he is most famous for demonstrating the need for antiseptic techniques for sterilization of implanted sutures. 1918 George Merson begins the sale of eyeless needled sutures where one strand of suture material is attached to the butt of the needle. This type of swaged needle is still in use and is the standard today. 1947 Introduction of Nylon. 1972 First synthetic absorbable suture introduced. 2000 Distribution of gut material ends in many parts of Europe and Japan due to Bovine Spongiform Encephalopathy (“Mad Cow Disease”)

Why do we need sutures? 1- Provide an adequate tension of wound closure without dead space but loose enough to obviate tissue ischemia and necrosis. 2- Maintain hemostasis. 3- Permit primary intention healing 4- Reduce postoperative pain

5- Provide support for tissue margins until they have healed and the support no longer needed 6- Prevent bone exposure resulting in delayed healing and unnecessary resorption 7- Permit proper flap position

Ideal sutures: Can be used in any tissue Easy to handle Good knot security Minimal tissue reaction Unfriendly to bacteria Strong yet small Won’t tear through tissues Cheap

Types of sutures: ABSORBABLE SUTURE TYPES Synthetic Natural Synthetic Absorbable Natural Short-Medium Short Fast Absorbing Gut Plain Gut Medium Chromic Gut Virtual Monofilament Natural Absorbable Synthetic Monofilament Braided Short / Medium Long Short Medium PDS (polydioxanone) Suture VICRYL (polyglactin ) Suture MONOCRYL (poliglecaprone ) Suture Coated VICRYL (polyglactin ) Suture

Natural Synthetic NON-ABSORBABLE SUTURE TYPES Surgical Stainless Steel Braided Monofilament Surgical Stainless Steel Silk Suture Synthetic ETHIBOND EXCEL Polyester Suture MERSILENE Polyester Fiber Suture NUROLON Nylon Suture PRONOVA Poly (Hexafluoropropylene - VDF) Suture PROLENE Polypropylene Suture ETHILON Nylon Suture

Mechanisms of degradation of Sutures: Natural Sutures Sutures made of material that can be found in nature Absorption method (if absorbable): Enzymatic reaction (proteolysis) Synthetic Sutures Sutures made of materials created by man Absorption Method (if absorbable): Hydrolysis – breakdown in the presence of water or moisture

Types of surgical wounds: Class I Clean Uninfected wound in which no inflammation is encountered and respiratory, alimentary, genital, or uninfected urinary tract is not entered. Class II Clean-contaminated Operative wound in which respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Class III Contaminated Open, fresh, accidental wounds. Class IV Dirty-infected Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera.

Types of needles: Eyed needles More Traumatic Only thread through once Suture on a reel Tends to unthread itself easily

Swaged-on needles Much less traumatic More expensive suture material Sterile

Points of Needles Taper Atraumatic Internal organs

Cutting Cutting edge on inside of circle Skin Traumatic

Reverse Cutting Skin Less traumatic than cutting Cutting edge on outside of circle Skin Less traumatic than cutting

Cutting vs Reverse Cutting

Shapes of Needles 3/8 circle 1/2 circle Straight Specialty

Problems Associated with Surgical Sutures Time-consuming nature of secure knot tying Need for knot security under all conditions with all sutures Risk of suture breakage during surgery Loss of control due to needle slippage or rotation within the needle holder Postsurgical slippage of the knotted suture Early or pathologically induced degradation of absorbable suture

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