A.B.C.

of surgical skills
:The Ideal Suture Material
Can be used in any tissue Easy to handle Good knot security Minimal tissue reaction Unfriendly to bacteria Strong Wont tear through tissues Cheap

Criteria of Suture Material

Physical configuration Means the construction of the suture material Either MONOFILAMENT or MULTIFILAMENT Diameter Means the caliber of the suture E pressed according to USP standards

!ensile strength !he resistance of a material to a force tending to tear it apart" measured as the ma imum tension the material can #ithstand #ithout tearing $ !he implantation and tying of sutures decrease their strength %notted sutures ha&e '() the strength of unknotted sutures$ Elasticity Means the tendency of a suture to return to its original form and length after stretching$ *fter the s#elling of a #ound recedes" the suture returns to its original length and keeps the #ound #ell appro imated$ Most sutures are elastic Plasticity Means the tendency of the suture to retain its ne# form and length after stretching$ *s s#elling subsides" the suture retains its ne# si+e and may not continue to ade,uately appro imate the #ound edges$ -e# sutures are plastic Memory Means the ability of a suture to return to its original shape after its deformation by tying$ * suture #ith a high memory" is stiff and difficult to handle. the knots are less secure" and they may re,uire an e tra thro# to pre&ent loosening of the knot$ !issue reaction Different suture materials are associated #ith &arious degrees of tissue reaction$ Significant inflammation reduces the resistance to infection and delays the onset of #ound healing$ !he type of material and the suture si+e are the ma/or factors that determine the reactions *bsorption 1

 A sor a le sutures are broken do#n in the body tissues o&er a &arying number of days either by en+ymes or by hydrolysis by the tissue fluid$ No!"a sor a le sutures remain in place for some years unless they are remo&ed$ !ypes of Suture Material *bsorbable sutures0 1$ Catgut '$ Chromic catgut )$ Plyglycolic acid 2DE3456 7$ Polyglactin 289C:;<6 =$ Polydio anone 2PDS6 >$ Polyglecaprone 2M454C:;<6 5on *bsorbable sutures0 1$ Silk '$ 5ylon )$ Prolene 7$ Mersilene =$ Stainless steel >$ Sil&er #ire #ut$ Chro%ic #ut Made of submucosa of small intestines of sheep or cattle or cats Multifilament ?reaks do#n by phagocytosis0 inflammatory reaction common Chromic catgut is treated #ith salts of chromium to strengthen the suture

!ypes of 5eedles Eyed needles More !raumatic 4nly thread through once !ends to unthread itself easily <imited use in 4?@G;5 2cerclageA ?$lynch6 S#agedAon needles Much less traumatic More e pensi&e suture material Sterile Points of 5eedles !aper *traumatic Internal organs Cutting Cutting edge on inside of circle Skin !raumatic :e&erse Cutting Cutting edge on outside of circle Skin <ess traumatic than cutting 2

Shapes of 5eedles )(B circle 1(' circle Straight Special 5/8 circle 1/4 circle &eco%%e!ded use Cur&ed needle must be used by needle holder" shouldnt be grasped #ith the hand 2high rate of glo&e perforation 1)C6 Straight needles can be used manually #ithout needle holders

Suture Selection *bsorbable sutures elicit more inflammatory reaction than nonAabsorbable sutures 5atural sutures absorbed by proteolytic en+ymes induce more inflammation than synthetic ones absorbed by hydrolysis$ Monofilaments usually re,uire more knots to pre&ent slippage ?raided sutures handle easily and knot easily ?U! ?raided suture may harbor bacteria Use the smallest si+e suture that can hold the tissue together during the healing process -ascia heals slo#ly A use bigger" stronger suture Mucosa heals ,uickly" use smaller stuff Where cosmetic results are important0 a$ Use the smallest monofilament suture such as nylon or polypropylene$ b$ *&oid skin sutures and close subcuticularly #hene&er possible$ Use monofilament on the skin as multifilament harbor ?*C!E:9* 5onAabsorbable sutures cause less scarring but must be remo&ed !ied suture ) components0 1$ <oop0 affect hemostasis or #ound appro imation '$ %not0 maintains loop security )$ Ears0 acts as insurance that the loop #ill not become untied due to knot slippage Principles of knot tying %nots are used in suturing to either anchor one stitch or tie off a series of stitches$ Each stitch should be tight enough to secure the tissue and secure enough so that slipping is impossible$ %nots should be as fe# as possible to pre&ent tissue irritation$ *fter the first loop is tied" it is necessary to maintain traction on one end of the strand to a&oid loosening of the sutures$ !he knots may be tied #ith the hands or by instrument Ends should be cut as short as possible$ 9n tying any knot" friction bet#een strands must be a&oided as this can #eaken the integrity of the suture$ E cessi&e tension applied by the surgeon #ill cause breaking of the suture and may cut tissue$ 3

Sutures used for appro imation should not be tied too tightly" because this may contribute to tissue strangulation$ Generally 7 Dthro#sE for FGHC knot security <ess Dthro#sE I more likely to untie itself

Suture instruments &e%e% er''' !humb @ ring finger into needle holders rings 254! your middle fingerJ6 Suture patterns Si%(le i!terru(ted closure K most commonly used" good for shallo# #ounds #ithout edge tension Co!ti!uous closureK good for hemostasis and long #ounds #ith minimal tension Locki!g co!ti!uous A useful in #ounds under moderate tension or in those re,uiring additional hemostasis Su cuticular K good for cosmetic results )ertical %attress K useful in ma imi+ing #ound e&ersion" reducing dead space" and minimi+ing tension across the #ound *ori+o!tal %attress K good for fragile skin and high tension #ounds ,ercuta!eous -dee(. closure K good to close dead space and decrease #ound tension ,urse stri!g sutures in&aginated stitch La% ert sutures 4U! K 95 K 95 K 4U! I!/erted La% ert sutures 95 K 4U! K 4U! K 95 Base all sutures 95 K 4U! K 95 K 4U! S0uare sutures U sha(e sutures Figure of 1 sutures haemostatic stitches Cushi!g sutures Tra!sfi2i!g suture

Suture remo&al
!he time of suture remo&al depends on the site of the incision and the general state of the patient$ 1 A do%e! a!d thora2. !rans&erse or obli,ue incisions =AL days$ 8ertical incisions LM1H days$ *&erage time frame is L K 1H days -*CE0 ) K = d 5EC%0 = K L d SC*<P0 L K 1' days UPPE: E3!:EM9!;" !:U5%0 1H K 17 days <4WE: E3!:EM9!;0 17 K 'B days

' I! (atie!ts 3ho are cachectic4 the tissue healing can he delayed and therefore the sutures must be left longer 21HM17 days or longer6$

5IT* M6 BEST 5IS*ES

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