2. PREPARATION AND HANDLING OF SUTURE

3. OBJECTIVES

4. Overview  List and define common suture terms.  Identify suture materials and stapling devices and their usage.  Describe the types, characteristics, and uses of natural and synthetic absorbable suture materials.

5. Overview  List and describe the common natural and synthetic non-absorbable sutures, stating their sources, common trade names, and uses.  List and define common suture techniques.

6. Overview  Discuss the basic uses and advantages of stapling instruments.  Identify, describe the use of, and demonstrate proper handling of the various types of surgical needles.

7. History  For years healers have looked for ways to control bleeding.  3000 BC years ago, linen strips and animal sinews were used.  600 BC Cotton, Leather, Horsehair, and bark fibers were used in India

8. History  During the 19 th century, the development of sterile technique was started.  1867, Lister would soak suture material in carbolic acid to “sterilize”, significantly lowering infections.

9. History  Early 20 th century, brought “catgut”, and silk, and perfecting sterilization methods.  By 1930, more suture materials are introduced.  1960’s the first synthetic absorbable suture was invented.

10. Absorbable Suture  Suture that can be digested or broken drown by the body over time, during healing process  Designed to hold tissue edges together until they heal and can withstand normal stress.

11. Absorbable Suture  To avoid complications, the appropriate absorbable suture should be used that completely absorbs by the time the wound is healed.

12. Non-absorbable Suture  Suture that resists enzymatic digestion or absorption by the body.

13. Monofilament Suture  Suture that is made of a single thread like material.  Advantage: Glide through the tissue easily, creating less damage.  Disadvantage: Harder to hold knots and more difficult to handle.

14. Multifilament Suture  Suture that consists of multiple thread like structures, twisted or braided into a single strand.  Advantage: Handle well and hold knots easily. Greater tensile strength.  Disadvantage: Has capability to harbor more bacteria. Should not be used in wounds with infection.

15. Natural Suture  Made from natural occurring substances. » Cellulose or animal tissue  Digested by body enzymes.

16. Synthetic Suture  Man Made  Hydrolyzed by the body.  Water from the tissue enters suture and breaks down the fibers.

17. Suture  All suture provides support for healing tissues.  Strong, but must have a certain amount of elasticity. » Tissue swelling » Strains  Coughing  Vomiting

18. Suture Sizes  Suture size is selected to correspond with the type of tissue. » Heavy tissue = Heavy suture. » Fragile tissue = Small suture.  Size is derived from sewing thread diameter or Gauge.  USP specifies the diameter.

19. Suture Sizes #5 (largest) #4#3#2#102-03-04-05-06-07-08-09-010-0 11-0 (smallest)

20. Factors when choosing suture  Size/Filaments/Absorbsion  Type of procedure  Condition of tissue  Nature of disease  Surgeons preference  Availability and cost

21. Factors when choosing suture  Rule of Thumb: “You Stick with what you know!!!”

22. Classifications and Characteristics  Monofilament Absorbable Suture » Plain Gut » Chromic Gut » Polydioxanone (PDSII) » Polyglecaprone (Monocryl)

23. Plain Gut Type: Collagen (Sheep intestine) Type: Collagen (Sheep intestine) Absorption: 70 days Tensile Strength: Significant decrease 7-10 days, 0% 2-3 weeks Common Usage: Superficial hemostatis Package Color: Yellow Other: Stored in alcohol

24. Chromic Gut Type: Collagen (Sheep intestine) Type: Collagen (Sheep intestine) Absorption: 14-21 days Tensile Strength: Significant decrease 21 days Common Usage: Internal ligation, peritoneum, fascia Package Color: Beige Other: Stored in alcohol

25. Polydioxanone (PDS II) Type: Synthetic petroleum by product. Type: Synthetic petroleum by product. Absorption: 180-240 days Tensile Strength: 50% in 28 days, 25% in 40-45 days Common Usage: Tissue needed long-term tensile strength Package Color: Silver Other: Strand may be dyed or clear

26. Polyglecaprone (Monocryl) Type: Copolymer of glycolide and epsilon- caprolactone Type: Copolymer of glycolide and epsilon- caprolactone Absorption: 91-119 days Tensile Strength: 50%-60% at 1 week; 20%- 30% at 2 weeks Common Usage: Subcuticular closure Package Color: Coral Other: Undyed

27. Classifications and Characteristics  Monofilament Non-Absorbable Suture » Polypropylene (Prolene, Surgilene) » Nylon (Ethilon, Dermalon) » Stainless Steel » Polybutester (Novafil)

28. Polypropylene (Prolene, Surgilene) Type: Synthetic fiber polymerized propylene Type: Synthetic fiber polymerized propylene Absorption: N/A Tensile Strength: Excellent Common Usage: Long-term tensile strength; general, CV, plastics Package Color: Deep Blue Other: Least reactive of all synthetics; suture of choice in vascular anastomosis.

29. Nylon (Ethilon, Dermalon) Type: Synthetic fiber polymer of coal, air, and water Type: Synthetic fiber polymer of coal, air, and water Absorption: N/A Tensile Strength: degrades at 15%-20% per year Common Usage: Skin closure. retention Package Color: Mint Green Other: Used in Microsurgery; difficult to handle and tie

30. Stainless Steel Type: Stainless Steel Type: Stainless Steel Absorption: N/A Tensile Strength: Indefinate Common Usage: Sternal closure; bone repair Package Color: Yellow-ochre Other: Most inert, can be used in infected wounds.

31. Polybutester (Novafil) Type: monofilament copolymer of glycol and butylene Type: monofilament copolymer of glycol and butylene Absorption: N/A Tensile Strength: High Common Usage: Tissue needing long term tensile strength Package Color: Seafoam Green Other: Great stretching ability

32. Classifications and Characteristics  Multifilament Absorbable Suture » Polyglactin 910 (Vicryl) » Polyglycolic Acid (Dexon)

33. Polyglactin 910 (Vicryl) Type: Synthetic fiber copolymer of glycolide and lactide. Type: Synthetic fiber copolymer of glycolide and lactide. Absorption: 60-90 days Tensile Strength: 50% in 21 days Common Usage: Tissue needed long-term tensile strength, general soft tissue. Package Color: Violet Other: Strand may be dyed or undyed; braided; most popular suture today.

34. Polyglycolic acid (Dexon) Type: Synthetic fiber homopolymer of glycolic acid. Type: Synthetic fiber homopolymer of glycolic acid. Absorption: Significant in 30 days Tensile Strength: 50% in 21 days Common Usage: Tissue needed long-term tensile strength, general soft tissue. Package Color: Gold Other: Ties easily

35. Classifications and Characteristics  Multifilament Non-Absorbable Suture » Surgical Silk » Surgical Cotton » Braided Nylon (Neurolon, Surgilon) » Polyethylene terephthalate (Mersilene) » Polyethylene terephthalate coated with Polybutilate (Ethibond, Dacron)

36. Surgical Silk Type: Natural silkworm cocoon fiber Type: Natural silkworm cocoon fiber Absorption: N/A Tensile Strength: High Common Usage: Serosa of GI tract Package Color: Baby Blue Other: Frequently used as suture ligature.

37. Surgical Cotton Type: Natural cellulose fiber Type: Natural cellulose fiber Absorption: N/A Tensile Strength: Weak; stronger when wet Common Usage: commonly not used today Package Color: Pink Other: Used primarily as umbilical tape.

38. Braided Nylon (Neurolon, Surgilon) Type: long-chain aliphatic polymer nylon Type: long-chain aliphatic polymer nylon Absorption: N/A Tensile Strength: Very high Common Usage: Soft tissue where continual strength is necessary Package Color: Mint Green Other: Commonly used for Neurosurgery closures.

39. Polyethylene Terephthalate (Mersilene) Type: Braided polyester fiber Type: Braided polyester fiber Absorption: Encapsulated Tensile Strength: Very high Common Usage: Soft tissue where continual strength is necessary Package Color: Turquoise Other: Available as monofilament in 10-0, 11-0 for eye procedures.

40. Type: Braided coated polyester fiber Type: Braided coated polyester fiber Absorption: Encapsulated Tensile Strength: Very high Common Usage: Soft tissue where continual strength is necessary Package Color: Orange Other: Commonly used for orthopedics Polyethylene Terephthalate Coated with Polybutilate (Ethibond, Dacron)

41. Suture Packaging  Suture is package is color coded.  Labeled with type, suture size, needle type, and length.  Silhouette of needle on package denotes size, type, and amount. » Single armed, Double armed, Multiple “pop off” needles

42. Suture Packaging  Suture is package is color coded.  Labeled with type, suture size, needle type, and length.  Silhouette of needle on package denotes size, type, and amount. » Single armed, Double armed, Multiple “pop off” needles

43. Ligatures (Ties)  Used to occlude vessels for hemorrhage control.  Standard lengths are 54 inch and 60 inch “reel” type.  May have precut lengths of 18, 24 and 30 inch strands.  May be handed to the surgeon on an instrument or as a “free tie”

44. Suture Ligatures (Stick tie)  Sutures with a swaged on needle used with a needle drive to occlude vessels for hemorrhage control.  Vessel is doubly ligated.  2-0 or 3-0 sized silk is commonly used.

45. Suture Routine  Consult surgeon’s preference card.  Only open the amount of suture needed. » Not too many » Too few can cause delay in surgery time. » Good communication with surgeon  Sutures can be pre loaded in order.  Free ties placed on mayo in suture towel.

46. Suture Loading

48. Abdominal Wound Closure Layers  Peritoneum  Fascia  Muscle  Subcutaneous  Subcuticular  Skin  Endoscopic Suturing

49. Suturing Techniques  Primary Suture Line  Traction Sutures  Purse-string Sutures  Secondary Suture Line  Retention

50. Accessory Devices  Bridges and Bolsters  Buttons and Lead Shots  Umbilical Tape  Vessel Loops  Adhesive Skin Closure Tape (Steri-strips)  Skin Adhesive (Dermabond)

51. Stapling Devices  Skin  Linear Staplers  Linear Cutters  Ligating Clips  Ligating Cutters  Intraluminal Staplers

52. Mesh  Polypropylene Mesh  Polyglastin 910 Mesh  Polytetrafluoroethylene (PTFE) Mesh  Stainless Steel Mesh  Polyester Fiber Mesh

53. Needles  Eye  Point » Taper » Cutting » Blunt  Body