1. Mudasir Bashir m.v.sc scholar
Suture materials
Mudasir Bashir m.v.sc scholar
4856

2. Objectives
Provide basic information on commonly used suture materials

3. Qualities of an ideal suture: It should
Remain intact until union occurs.
Cause minimum tissue reaction.
Be non-capillary in action.
Be of uniform thickness.
Be knotable.
Have smooth surface.
Have sufficient tensile and functional strength.
Easily sterilizable.
Cheap and readily available
Easy to handle.

4. The suture is used to bring
The edges of wound in close approximation,
to retain the medicated plug for dressing in deep wound or cavity,
to close any accidental opening or
to keep the lips of a deep extensive open wound in contact temporarily
to check recurrent haemorrhage.

5. Suture Material Generally categorized by three characteristics:
Absorbable vs. non-absorbable
Natural vs. synthetic
Monofilament vs. multifilament

6. Natural Suture Biological origin Cause intense inflammatory reaction
Examples:
“Catgut” – purified collagen fibers derived from intestine of healthy sheep or cows
Silk(non absorbable)

7. Synthetic Suture Synthetic polymers
Do not cause intense inflammatory reaction
Examples:
Vicryl(absorbable)
Monocryl
Prolene
Nylon

8. Absorbable Suture
Degraded and eventually eliminated in one of two ways:
Via inflammatory reaction utilizing tissue enzymes
Via hydrolysis
Examples:
“Catgut”
Chromic
polyglactin 910 (Vicryl)
Monocryl
polyglycolic acid (Dexon) etc.

9. Absorbable Suture-description
Kangaroo tendon: It is obtained from the tendon of tail of kangaroo and is used for suturing joint capsule
Fascia lata: It is obtained from the bovine Fascia lata

10. Cargile membrane: it is obtained from bovine caecum
Amniotic membrane: It is prepared from amniotic membrane of fetuses

11. Catgut
Absorption in tissues can be delayed by treating with chromic acid.
Catgut therefore available as plain and chromic catgut.
chromic catgut

12. Type
Degree of Chromicity
Approx No.Of days taken for absorption
Type A
Plain
10 Days
Type B
Mild chromic
15 Days
Type C
Medium chromic
20 Days
Type D
Extra chromic
40 Days

13. Catgut cont.
Depending on preservative used catgut is available eitheras boilable or non boilable catgut.
Boilable catgut is preserved in xylol,toulene-99.75%,phenyl merecuric acetate.025%
Non boilable catgut is supplied in tubes containing90-95%alcohol.

14. Diameter in mm(average)
Sizes of catgut
Diameter in mm(average)
Use
2/0
0.30
Peretoneum,bowel wall(small animals)and ligaturing vessels
0 or 1/0
0.40
-do- 1
0.48
Muscle fascia(SA)ligature larger vessels 2
0.50 3
0.60
Fascia,muscles(LA) 4
0.70 5
0.80
Rumen uterus abdomen

15. Catgut size selection Bowel: 2/0 - 3/0 Fascia: 1 - 0
Ligatures: 0 - 3/0
Pedicles: 2 - 0
Skin: 2/0 - 5/0
Arteries: 2/0 - 8/0
Micro surgery 9/0 - 10/0
Corneal closure: 9/0 - 10/0
These are rough guides, it’s really the Surgeon’s preference and no a strict rules apply.

16. cont. Collagen: It is prepared from bovine flexor tendon filament
Polyglactin 910 (vicryl): It is a synthetic absorbable suture material, prepared from glycolic lactic acid polymer
Polyglycolic acid (Dexon): It is synthetic suture material
prepared from glycolic acid

17. Non-absorbable Suture
Not degraded, permanent
may be organic; inorganic or synthetic in nature and are used as both the internal and external suture materials.

18. Non-absorbable Suture
Examples:
Prolene
Nylon nylon
Stainless steel
Silk*
(*not a truly permanent material; known to be broken down over a prolonged period of time—years)

19. Non-absorbable Organic suture materials
Cotton:capillary in nature it clings to surgeon’s gloves and they spread infection in wound when applied to skin and luminal surfaces
Silk: it may be plain or braided and capillary in nature
Silk worm gut: non-capillary and useful for cutaneous sutures

20. cont.
Horse hair: It is cheap, non-capillary, flexible and is easily sterilized. It causes little tissue reaction.
Linen: It is capillary in nature and produces more tissue reaction than cotton and silk.
Umbilical tape: used to tie the umbilical cord of the new born or as vulvar suture in cases of prolapse of vagina of uterus.

21. Polyester:is a non absorbable, sterile, surgical suture composed of Poly (ethylene terephthalate).
It suture elicits a minimal acute inflammatory reaction in tissues.
polyamide:Being monofilament, Linex is remarkably smooth and gives excellent knotsecurity. Posses good tensile strength.
Easy removal with no tissueadherence.

22. Non-absorbable Inorganic suture material
Metallic suture: Wire of different metals like tantalum, silver,
copper, stainless steel and vitallium
Tantalum: It is inert to tissues like stainless steel

23. Stainless steel suture

24. cont.. Silver: It becomes ionized in tissues and cause inflammation.
Copper: It is more suitable to repair fractures due to its flexibility.
Aluminium wire: It is more flexible than stainless steel.

25. Placing of sutures
If sutures are placed far apart-Proper apposition of wound edges may not take place.
But if placed too close together-holding power of tissue diminishes.
Optimum suture distance
-Skin sutures about 5-6mm(3/8 inch)
-Hollow visceral organs 2mm (1/8 inch)to prevent leakage of contents.

26. Suture Classification
Monofilament
Multifilament (braided)
The picture illustrates that a braided suture is made from many strands of material unlike the monofilament.
As a result of these structures there are various advantages and disadvantages, these may affect suture selection.

27. Monofilament Suture
Grossly appears as single strand of suture material; all fibers run parallel
Minimal tissue trauma
Resists harboring microorganisms
Ties smoothly
Requires more knots than multifilament suture
Possesses memory
Examples:
Monocryl, PDS, Prolene, Nylon

28. Multifilament Suture Fibers are twisted or braided together
Greater resistance in tissue
Provides good handling and ease of tying
Fewer knots required
Examples:
Vicryl (braided)
Chromic (twisted)
Silk (braided)

29. Braided v Monofilament
No capillary action
Less infection risk
Smooth tissue passage
Higher tensile strength
Has memory
More throws required
Has capillary action
Increased infection risk
Less smooth passage
Less tensile strength
Better handling
Better knot security
Ask if ‘capillary’ is understood, confirm.
Discuss ‘memory’.
During the practical a monofilament (Monosof) and a braided suture (Polysorb) is provided so that the handling advantages and disadvantages are experienced.

30. Polypropylene Polyester
Silk Catgut
Natural
Silk, linen, catgut
Synthetic polymer
Polypropylene, polyester, polyamide
Polypropylene Polyester

31. nylon Monofilament Polypropylene Polydioxanone Nylon Multifilament
Catgut (twisted)
Polyester
Silk (braided)
nylon
Polyester silk

33. Suture Degradation Suture Material Method of Degradation
Time to Degradation
“Catgut”
Proteolytic enzymes
Days
Vicryl, Monocryl
Hydrolysis
Weeks to months

34. Suture Size Sized according to diameter with “0” as reference size
Numbers alone indicate progressively larger sutures (“1”, “2”, etc)
Numbers followed by a “0” indicate progressively smaller sutures (“2-0”, “4-0”, etc)
Smaller   Larger
.....”3-0”...”2-0”...”1-0”.....”1”...”2”...”3”.....

36. NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE
The Suture Packaging
PRODUCT CODE
STRAND SIZE
NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE
MATERIAL
STRAND LENGTH
POINT TYPE
NEEDLE LENGTH
NEEDLE CIRCLE
COLOUR

37. Suture Packaging

38. Non absorbable sutures
Ethicon
Braided silk black
Trulon
Monofilament polyamide
Trulene
Monofilament polypropylene

39. Absorbable sutures

45. Polypropylene Mesh for Hernia Repair
Are provided with very High Bursting Strength,Elasticity and tested for Bio-compatiability after implantation.
They are available in popular sizes of 2x4, 3x6, 6x6 and 12x12 inches. Available in two types, namely PM and PS types.

46. Polypropylene Mesh

47. PM type mesh is thinner, smoother and more flexible
PM type mesh is thinner, smoother and more flexible. Where as PS mesh is Strong, thicker and normal flexibility.

48. Types of hernia meshes

49. Needles Classified according to shape and type of point
Curved or straight (Keith needle)
Taper point, cutting, or reverse cutting

50. Atraumatic needles- to suture delicate tissues like intestine, stomach, bladder, uterus etc.
Double curved and loopuyt needles -for skin closure of cattle or buffalo and for deeper structures.

51. Needles Curved Straight Designed to be held with a needle holder
Used for most suturing
Straight
Often hand held
Used to secure percutaneously placed devices (e.g. central and arterial lines)

52. Needle Curvature
Needle curvature is selected according to site accessibility.
Confirm commonly used curvatures in general surgery.
Explain needle stick injury risk with use of straight needle.

53. Needles Taper-point needle Round body
Used to suture soft tissue, excluding skin (e.g. GI tract, muscle, fascia, peritoneum)

54. Needle point Geometry Taper-Point Reverse cutting Conventional Cutting
Suited to soft tissue
Dilates rather than cuts
Reverse cutting
Very sharp
Ideal for skin
Cuts rather than dilates
Conventional Cutting
Creates weakness allowing suture tearout
Taper-cutting
Ideal in tough or calcified tissues
Mainly used in Cardiac & Vascular procedures.

55. Needle Point Geometry Blunt Spatula DermaX* Premium point spatula
Also known as “Protect Point”
Mainly used to prevent needle stick injuries i.e. for abdominal wall closure.
Premium point spatula
Ophthalmic Surgery
Spatula
DermaX*
NEW: ½ The Penetration force
½ The Penetration force
Superior Cosmetic Effect
Highlight that we have introduced transformational technology by creating a new needle construction: DermaX

57. The Right Needle Choice
The appropriate needle choice for any situation is…………….
……………The needle that will cause least possible trauma to the tissue being sutured

58. Needles Cutting needle Triangular body
Sharp edge toward inner circumference
Used to suture skin or tough tissue

59. Using needle holder, grasp needle about 2/3rds of the way back from point.

60. Index finger stabilizes the instrument by resting on the shaft.

61. Surgical Scissors

62. FORCEPS
Grasp forceps between thumb & middle finger, while index finger is used for stabilization.
If possible, use forceps to grasp dermis, rather than epidermis or skin surface itself.
This helps prevent marking & injuring of skin at wound edge.

63. Steri-strips Sterile adhesive tapes Available in different widths
Frequently used with subcuticular sutures
Used following staple or suture removal
Can be used for delayed closure

64. Staples Rapid closure of wound Easy to apply
Evert tissue when placed properly

65. Dermabond® A sterile, liquid topical skin adhesive
Reacts with moisture on skin surface to form a strong, flexible bond
Only for easily approximated skin edges of wounds
punctures from minimally invasive surgery
simple, thoroughly cleansed, lacerations

66. AMCRYLATE® Gel Iso-amyl-2-cyanoacylate

67. Method of application
Control hemorrhage on cutaneous incision on skin and keep dry using swabs.
Apply few drops of Iso-amyl-2-cyanoacylate over the wound edges.
Hold skin edges in proper opposition for about 20 seconds to achive union of skin wound

68. Even a small droplet of blood at wound edges causes effervescence and non union at that point.
Clean that area and dry and reapply tissue adhesive

69. Thank you