1. 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

2. Suturing Skills Curriculum
Surgical instruments
Suture material
Suturing techniques

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

4. 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)

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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: days
50% at 3 weeks
Absorption = the loss of mass of the material in tissue as measured in days,
Exp: days

11. 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: days
50% at 3 weeks
Absorption = the loss of mass of the material in tissue as measured in days,
Exp: days

12. Suture Breaking Strength Over Time
PDS
Chromic
Dexon
Plain

13. Loss of Tensile Strength in Nonabsorbable Sutures

14. Absorbable Suture: Ethicon, Inc.

15. Nonabsorbable Suture: Ethicon, Inc.

16. US Surgical

17. Suture Sizes

18. Suture Needles

19. Non-Cutting Needles

20. Needles… ANATOMY OF A NEEDLE
POINT
SWAG
(SWEDGE)

21. 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

23. Suture…

24. Suture…
Use

25. Suture…
Order #
Use

26. Suture…
Order #
Use
Size
(metric)

27. Suture…
Order #
Use
Size
(metric)
Suture Material

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

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

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

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

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

33. 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

34. 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)

35. 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

36. Skin Stapling

37. Simple Interrupted Suture

38. Interrupted Vertical Mattress

39. Interrupted Vertical Mattress

40. Interrupted Horizontal Mattress

41. Figure of 8 (Interrupted Fascial Closure)

42. Simple Continuous Closure

43. Continuous Locking Suture

44. 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

45. 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

46. Burying Knots

47. Suture Removal

48. Suturing Movie
Click the projector button to view the suturing movie

49. 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,