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

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

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

4. 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.

5. 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.

6. 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

7. 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.

8. 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

9. 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

10. 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.

11. 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.

12. Monofilament /Multifilament
Suture Structure
Monofilament /Multifilament

13. Suture Sizing - USP (United States Pharmacopoeia: - Diameters and strengths)
Human hair
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

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

15. 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

16. 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.

17. 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.

18. 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

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

20. 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

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

22. 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

23. 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.

24. 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

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

26. Suture Products Absorbable Sutures
Organic Absorbable Sutures

27. 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.

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

29. 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.

30. Suture Products Absorbable Sutures
Any Questions?

31. Non Absorbable Sutures
Suture Products
Non Absorbable Sutures

32. 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

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

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

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

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

37. 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)

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

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

40. 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

41. 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

42. 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

43. 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

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

45. Non Absorbable Sutures and Topical Adhesives
Any Questions?

46. Surgical Needles

47. 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.

48. 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.

49. Needle Shapes

50. 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.

51. 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

52. 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.

53. 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.

54. 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.

55. 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.

56. Surgical Needles
Any Questions?

57. THANK YOU!