Professional Documents
Culture Documents
W O U N D C L O S U R E M A N UA L
WOUND HEALING
TO V I E W T H E E - C ATA L O G , G O T O T H E
NEEDLES H E A LT H C A R E P R O F E S S I O N A L SECTION OF
W W W. E T H I C O N . C O M
ADHESIVES
SURGICAL MESH
* TRADEMARK
©2007 ETHICON, INC. EPB010R4
PREFACE
Dr. Dunn has published over 400 articles and book chapters in the
areas of Surgical Infectious Diseases and Transplantation. He has
received regional and nationwide recognition in several
academic organizations and is a Past President of the Surgical
Infection Society, the Association for Academic Surgery, the
Minnesota Chapter of the American College of Surgeons, the
Society of University Surgeons and the Society of University
Surgeons Foundation.
TABLE OF CONTENTS
WOUND HEALING Knot Tying ......................................................... 24
1 AND MANAGEMENT Knot Security............................................ 24
Knot Tying Techniques Most Often Used .......... 25
The Wound.......................................................... 2 Square Knot ............................................. 25
Recovery of Tensile Strength............................ 2 Surgeon’s or Friction Knot ............................ 26
Patient Factors That Affect Wound Healing........ 2 Deep Tie ................................................. 26
Surgical Principles....................................... 4 Ligation Using a Hemostatic Clamp ............... 26
Classification of Wounds................................... 5 Instrument Tie .......................................... 26
Types of Wound Healing................................... 6 Endoscopic Knot Tying Techniques .................. 26
Healing by Primary Intention........................ 6 Cutting the Secured Sutures .......................... 26
Healing by Second Intention.......................... 7 Suture Removal ................................................. 27
Delayed Primary Closure.............................. 7 Suture Handling Tips ....................................... 27
Suture Selection Procedure ............................. 27
Principles of Suture Selection......................... 27
2 THE SUTURE Surgery Within the Abdominal Wall Cavity....... 28
Closing the Abdomen .................................. 30
What Is a Suture?............................................... 10 Closing Contaminated or Infected Wounds........ 40
Personal Suture Preference............................... 10
Suture Characteristics ....................................... 11
Size and Tensile Strength.............................. 11 3 THE SURGICAL NEEDLE
Monofilament vs. Multifilament Strands.......... 11
Absorbable vs. Nonabsorbable Sutures.............. 12
Elements of Needle Design ............................. 42
Specific Suturing Materials.............................. 13 Principles of Choosing a Surgical Needle..... 44
Synthetic Absorbable Sutures ......................... 14
The Anatomy of a Needle ................................ 45
The Needle Eye ......................................... 45
Nonabsorbable Sutures ................................ 16
The Needle Body ....................................... 46
Synthetic Nonabsorbable Sutures.................... 17
Straight Needle ......................................... 46
Common Suturing Techniques....................... 18
Half-Curved Needle ................................... 47
Ligatures................................................. 18
Curved Needle.......................................... 47
The Primary Suture Line............................. 19
Compound Curved Needle ........................... 47
Continuous Sutures.................................... 19
The Needle Point ...................................... 48
Interrupted Sutures.................................... 22
Deep Sutures............................................ 22
Types of Needles ............................................... 48
Cutting Needles......................................... 48
Buried Sutures .......................................... 22
Conventional Cutting Needles....................... 49
Purse-String Sutures................................... 22
Reverse Cutting Needles ............................... 49
Subcuticular Sutures................................... 22
Side Cutting Needles................................... 50
The Secondary Suture Line........................... 23
Taper Point Needles ................................... 50
Stitch Placement........................................ 24
Tapercut Surgical Needles ............................ 51
Blunt Point Needles.................................... 52
Needleholders .................................................... 52
Needleholder Use....................................... 52
Placing the Needle in Tissue ......................... 53
Needle Handling Tips ...................................... 53
PRODUCT TERMS
4 PACKAGING 7 AND TRADEMARKS
An Integral Part of the Product ..................... 56
RELAY* Suture Delivery System .................... 56 8 PRODUCT INFORMATION
Modular Storage Racks................................ 56
Dispenser Boxes......................................... 57
Primary Packets ........................................ 57 9 INDEX
E-PACK* Procedure Kit .................................. 59
Expiration Date................................................. 60
Suture Sterilization ........................................... 60
Anticipating Suture Needs............................... 61
Sterile Transfer of Suture Packets.................... 61
Suture Preparation in the Sterile Field............. 62
Suture Handling Technique.......................... 63
OTHER SURGICAL
6 PRODUCTS
Adhesive Tapes................................................... 74
Indications and Usage................................. 74
Application .............................................. 74
Aftercare and Removal ................................ 74
Skin Closure Tapes ..................................... 75
Polyester Fiber Strip................................... 75
Umbilical Tape ........................................ 75
Surgical Staples ................................................. 75
Indications and Usage ................................. 76
Aftercare and Removal ................................ 76
PROXIMATE* Skin Staplers........................ 76
Looped Suture ................................................... 77
Retention Suture Devices ................................ 77
CHAPTER 1
WOUND HEALING
AND MANAGEMENT
2 WOUND HEALING & MANAGEMENT
• Tensile Strength — The load per of the patient, the thickness of
THE WOUND cross-sectional area unit at the point tissue, the presence of edema, and
of rupture, relating to the nature of duration (the degree to which the
Injury to any of the tissues of the material rather than its thickness. tissue has hardened in response to
the body, especially that caused • Breaking Strength — The load pressure or injury).
by physical means and with required to break a wound regard-
interruption of continuity, is defined less of its dimension, the more PATIENT FACTORS THAT
as a wound.1 Though most often clinically significant measurement. AFFECT WOUND HEALING
the result of a physical cause, a • Burst Strength — The amount
burn is also considered a wound. The goal of wound management
of pressure needed to rupture a
Both follow the same processes is to provide interventions that
viscus, or large interior organ.
towards the restoration to efficiently progress wounds through
health — otherwise known The rate at which wounds regain the biologic sequence of repair or
as healing.1 strength during the wound healing regeneration. The patient's overall
process must be understood as a health status will affect the speed of
Wound healing is a natural and basis for selecting the most appro- the healing process. The following
spontaneous phenomenon. When priate wound closure material. are factors that should be considered
tissue has been disrupted so severely by the surgical team prior to and
that it cannot heal naturally RECOVERY OF during the procedure.2-4
(without complications or possible TENSILE STRENGTH
disfiguration) dead tissue and ✦ AGE — With aging, both skin
foreign bodies must be removed, Tensile strength affects the tissue's and muscle tissue lose their tone
infection treated, and the tissue ability to withstand injury but is and elasticity. Metabolism also
must be held in apposition until the not related to the length of time it slows, and circulation may be
healing process provides the wound takes the tissue to heal. As collagen impaired. But aging alone is not
with sufficient strength to withstand accumulates during the reparative a major factor in chronic wound
stress without mechanical support. phase, strength increases rapidly, but healing. Aging and chronic
A wound may be approximated it is many months before a plateau disease states often go together,
with sutures, staples, clips, skin is reached.2 Until this time, the and both delay repair processes
closure strips, or topical adhesives. wound requires extrinsic support due to delayed cellular response
from the method used to bring it to the stimulus of injury, delayed
Tissue is defined as a collection of together — usually sutures. While collagen deposition, and
similar cells and the intercellular skin and fascia (the layer of firm decreased tensile strength in the
substances surrounding them. connective tissue covering muscle) remodeled tissue. All of these
There are 4 basic tissues in the are the strongest tissues in the body, factors lengthen healing time.
body: 1) epithelium; 2) connective they regain tensile strength slowly
tissues, including blood, bone and during the healing process. The ✦ WEIGHT — Obese patients
cartilage; 3) muscle tissue; and stomach and small intestine, on the of any age have excess fat at the
4) nerve tissue. The choice of other hand, are composed of much wound site that may prevent
wound closure materials and the weaker tissue but heal rapidly. securing a good closure. In
techniques of using them are prime Variations in tissue strength may addition, fat does not have a rich
factors in the restoration of also be found within the same organ. blood supply, making it the most
continuity and tensile strength to Within the colon, for example, the vulnerable of all tissues to trauma
the injured tissues during the sigmoid region is approximately and infection.
healing process. twice as strong as the cecum — but
both sections heal at the same rate. ✦ NUTRITIONAL STATUS —
The parameters for measuring the Overall malnutrition associated
strength of normal body tissue are: Factors that affect tissue strength
include the size, age, and weight with chronic disease or cancer,
CHAPTER 1 3
material will allow the surgeon blood supply. Serum or blood Tendons and the extremities may
to approximate tissue with as may collect, providing an ideal also be subjected to excessive
little trauma as possible, and with medium for the growth tension during healing. The
enough precision to eliminate of microorganisms that cause surgeon must be certain that
dead space. The surgeon's infection. The surgeon may the approximated wound is
personal preference will play a elect to insert a drain or apply adequately immobilized to
large role in the choice of closure a pressure dressing to help prevent suture disruption
material; but the location of the eliminate dead space in the for a sufficient period of time
wound, the arrangement of tissue wound postoperatively. after surgery.
fibers, and patient factors influ-
ence his or her decision as well. ✦ CLOSING TENSION — ✦ IMMOBILIZATION —
While enough tension must be Adequate immobilization of the
✦ CELLULAR RESPONSE TO applied to approximate tissue and approximated wound, but not
CLOSURE MATERIALS — eliminate dead space, the sutures necessarily of the entire anatomic
Whenever foreign materials such must be loose enough to prevent part, is mandatory after surgery
as sutures are implanted in tissue, exaggerated patient discomfort, for efficient healing and minimal
the tissue reacts. This reaction ischemia, and tissue necrosis scar formation.
will range from minimal to during healing.
moderate, depending upon the
type of material implanted. The ✦ POSTOPERATIVE
CLASSIFICATION
reaction will be more marked if DISTRACTION FORCES —
OF WOUNDS
complicated by infection, allergy, The patient's postoperative The Centers for Disease Control
or trauma. activity can place undue stress and Prevention (CDC), using an
upon a healing incision. adaptation of the American College
Initially, the tissue will deflect the
Abdominal fascia will be placed of Surgeons' wound classification
passage of the surgeon's needle
under excessive tension after schema, divides surgical wounds
and suture. Once the sutures
surgery if the patient strains to into 4 classes: clean wounds,
have been implanted, edema of
cough, vomit, void, or defecate. clean-contaminated wounds,
the skin and subcutaneous tissues
contaminated wounds, and dirty or
will ensue. This can cause
significant patient discomfort
during recovery, as well as
scarring secondary to ischemic FIGURE
necrosis. The surgeon must take 2
these factors into consideration
when placing tension upon the DEAD SPACE
IN A WOUND
closure material.
✦ ELIMINATION OF DEAD
SPACE IN THE WOUND —
Dead space in a wound results
from separation of portions of
the wound beneath the skin
edges that have not been
closely approximated, or from air
or fluid trapped between layers of
tissue. This is especially true in
the fatty layer which tends to lack
6 WOUND HEALING
infected wounds.5 A discussion of contaminated by entry into a HEALING BY
each follows. viscus resulting in minimal spillage PRIMARY INTENTION
of contents. Every surgeon who closes a wound
Seventy-five percent of all wounds
would like it to heal by primary
(which are usually elective surgical Contaminated wounds include
union or first intention, with
incisions) fall into the clean wounds open, traumatic wounds or injuries
minimal edema and no local
category — an uninfected operative such as soft tissue lacerations, open
infection or serious discharge.
wound in which no inflammation fractures, and penetrating wounds;
An incision that heals by primary
is encountered and the respiratory, operative procedures in which gross
intention does so in a minimum of
alimentary, genital, or uninfected spillage from the gastrointestinal
time, with no separation of the
urinary tracts are not entered. tract occurs; genitourinary or biliary
wound edges, and with minimal
These elective incisions are made tract procedures in the presence
scar formation. This takes place in
under aseptic conditions and are of infected urine or bile; and
3 distinct phases:2,3
not predisposed to infection. operations in which a major break
Inflammation is a natural part of in aseptic technique has occurred Inflammatory (preparative) —
the healing process and should be (as in emergency open cardiac During the first few days, an
differentiated from infection in massage). Microorganisms inflammatory response causes
which bacteria are present and multiply so rapidly that within an outpouring of tissue fluids,
produce damage. 6 hours a contaminated wound an accumulation of cells and
can become infected. fibroblasts, and an increased blood
Clean wounds are closed by primary
supply to the wound. Leukocytes
union and usually are not drained. Dirty and infected wounds have
and other cells produce proteolytic
Primary union is the most desirable been heavily contaminated or
enzymes which dissolve and remove
method of closure, involving the clinically infected prior to the
damaged tissue debris. These are
simplest surgical procedures and operation. They include perforated
the responses which prepare the site
the lowest risk of postoperative viscera, abscesses, or neglected
of injury for repair. The process
complications. Apposition of tissue traumatic wounds in which
lasts 3 to 7 days. Any factor which
is maintained until wound tensile devitalized tissue or foreign material
interferes with the progress, may
strength is sufficient so that sutures have been retained. Infection
interrupt or delay healing. During
or other forms of tissue apposition present at the time of surgery can
the acute inflammatory phase, the
are no longer needed. increase the infection rate of any
tissue does not gain appreciable
wound by an average of 4 times.
Clean-contaminated wounds are tensile strength, but depends solely
operative wounds in which the upon the closure material to hold it
respiratory, alimentary, genital, or TYPES OF in approximation.
urinary tracts are entered under WOUND HEALING Proliferative — After the debride-
controlled conditions and without
The rate and pattern of healing falls ment process is well along,
unusual contamination. Specifically,
into 3 categories, depending upon fibroblasts begin to form a collagen
operations involving the biliary
the type of tissue involved and the matrix in the wound known as
tract, appendix, vagina, and
circumstances surrounding closure. granulation tissue. Collagen, a
oropharynx are included in this
Time frames are generalized for protein substance, is the chief
category provided no evidence
well-perfused healthy soft constituent of connective tissue.
of infection or major break in
tissues, but may vary. Collagen fiber formation determines
technique is encountered.
the tensile strength and pliability of
Appendectomies, cholecystectomies,
the healing wound. As it fills with
and hysterectomies fall into this
new blood vessels, the granulation
category, as well as normally
becomes bright, beefy, red tissue.
clean wounds which become
The thick capillary bed which fills
CHAPTER 1 7
Damaged
tissue
debris Tissue fluids
FIGURE
3
PHASES OF
WOUND
HEALING
Proteolytic
Fibroblasts enzymes
the matrix, supplies the nutrients Remodeling — As collagen deposi- DELAYED PRIMARY
and oxygen necessary for the wound tion is completed, the vascularity of CLOSURE
to heal. This phase occurs from the wound gradually decreases and This is considered by many
day 3 onward. any surface scar becomes paler. The surgeons to be a safe method of
amount of collagen that is finally management of contaminated, as
In time, sufficient collagen is laid
formed — the ultimate scar — is well as dirty and infected traumatic
down across the wound so that it
dependent upon the initial volume wounds with extensive tissue loss
can withstand normal stress. The
of granulation tissue.2 and a high risk of infection. This
length of this phase varies with the
method has been used extensively in
type of tissue involved and the
HEALING BY the military arena and has proven
stresses or tension placed upon the
SECOND INTENTION successful following excessive
wound during this period.
When the wound fails to heal by trauma related to motor vehicle
Wound contraction also occurs dur- primary union, a more complicated accidents, shooting incidents, or
ing this phase. Wound contraction and prolonged healing process takes infliction of deep, penetrating
is a process that pulls the wound place. Healing by second intention knife wounds.3
edges together for the purpose of is caused by infection, excessive
The surgeon usually treats these
closing the wound. In essence, it trauma, tissue loss, or imprecise
injuries by debridement of
reduces the open area, and if approximation of tissue.3
nonviable tissues and leaves the
successful, will result in a smaller
In this case, the wound may be left wound open, inserting gauze
wound with less need for repair by
open and allowed to heal from the packing which is changed twice a
scar formation. Wound contraction
inner layer to the outer surface. day. Patient sedation or a return to
can be very beneficial in the closure
Granulation tissue forms and the operating room with general
of wounds in areas such as the
contains myofibroblasts. These anesthesia generally is only required
buttocks or trochanter but can be
specialized cells help to close the in the case of large, complex
very harmful in areas such as the
wound by contraction. This wounds. Wound approximation
hand or around the neck and face,
process is much slower than primary using adhesive strips, previously
where it can cause disfigurement
intention healing. Excessive placed but untied sutures, staples
and excessive scarring.3
granulation tissue may build up after achieving local anesthesia can
Surgical wounds that are closed and require treatment if it protrudes occur within 3 to 5 days if the
by primary intention have minimal above the surface of the wound, wound demonstrates no evidence of
contraction response. Skin grafting preventing epithelialization. infection and the appearance of red
is used to reduce avoided contrac- granulation tissue. Should this not
tion in undesirable locations.
8 WOUND HEALING
occur, the wound is allowed to
heal by secondary intention. When
closure is undertaken, skin edges
and underlying tissue must be accu-
rately and securely approximated.
IN THE
NEXT SECTION
The materials, devices, and
techniques used to repair wounded
tissue will be discussed at length.
As you will see, the number of
options available is extensive. But
no matter how many choices the
surgeon has, his or her objective
remains singular: to restore the
patient to health with as little
operative trauma as possible and
an excellent cosmetic result.
REFERENCES
1. Stedman's Medical Dictionary.
27th ed. Philadelphia, Pa: Lippincott
Williams & Wilkens; 2000.
2. Henry MM, Thompson JN, eds.
Clinical Surgery. Philadelphia, Pa:
WB Saunders Co.; 2001.
3. Sherris DA, Kern EB. Mayo
Clinic Basic Surgery Skills.
Philadelphia, Pa: Mayo Clinic
Scientific Press; 1999.
4. Sussman C. Wound Care.
Aspen Publishers; 1998.
5. NNIS Manual, CDC,
MHA, 2000
CHAPTER 2
THE SUTURE
10 THE SUTURE
WHAT IS • They must be secured in A number of factors may influence
packaging which presents them the surgeon's choice of materials:
A SUTURE? sterile for use, in excellent
The word "suture" describes any • His or her area of specialization.
condition, and ensures the
strand of material used to ligate (tie) • Wound closure experience during
safety of each member of the
blood vessels or approximate (bring clinical training.
surgical team.
close together) tissues. Sutures are • Professional experience in the
used to close wounds. Sutures and The nurse must maintain the operating room.
ligatures were used by both the sterility of sutures when storing, • Knowledge of the healing
Egyptians and Syrians as far back as handling, and preparing them for characteristics of tissues and organs.
2,000 BC. Through the centuries, a use. The integrity and strength of • Knowledge of the physical and
wide variety of materials—silk, each strand must remain intact biological characteristics of
linen, cotton, horsehair, animal ten- until it is in the surgeon's hands. various suture materials.
dons and intestines, and wire made • Patient factors (age, weight,
The surgeon must select suture
of precious metals—have been used overall health status, and the
materials appropriate for the
in operative procedures. Some of presence of infection).
procedure and must place them
these are still in use today. in the tissues in a manner consistent
Surgical specialty plays a primary role
The evolution of suturing material with the principles that promote
in determining suture preference. For
has brought us to a point of refine- wound healing.
example, obstetrician/gynecologists
ment that includes sutures designed With the manufacturer and frequently prefer Coated VICRYL*
for specific surgical procedures. surgical team working in concert, RAPIDE (polyglactin 910) Suture
Despite the sophistication of today's the patient reaps the final for episiotomy repair and Coated
suture materials and surgical benefit—the wound is closed in a VICRYL* (polyglactin 910) Suture,
techniques, closing a wound still manner that promotes optimum Coated VICRYL* Plus Antibacterial
involves the same basic procedure healing in minimum time. (polyglactin 910) Suture and
used by physicians to the Roman MONOCRYL* (poliglecaprone 25)
emperors. The surgeon still uses a Suture for all tissue layers, except
PERSONAL SUTURE possibly skin. Most orthopedic
surgical needle to penetrate tissue PREFERENCE
and advance a suture strand to its surgeons use Coated VICRYL Suture,
desired location. Most surgeons have a basic Coated VICRYL Plus Antibacterial
"suture routine," a preference for Suture, PDS* II (polydioxanone)
Successful use of suture materials using the same material(s) unless Suture, and ETHIBOND*EXCEL
depends upon the cooperation of circumstances dictate otherwise. Polyester Suture. Many plastic
the suture manufacturer and the The surgeon acquires skill, surgeons prefer ETHILON* Nylon
surgical team. proficiency, and speed in handling Suture, VICRYL* (polyglactin 910)
The manufacturer must have a by using one suture material Knitted Mesh, or MONOCRYL
thorough knowledge of surgical repeatedly—and may choose Suture. Many neurosurgeons
procedures, anticipate the surgical the same material throughout his prefer Coated VICRYL Suture or
team's needs, and produce suture or her entire career. NUROLON* Nylon Suture. But
materials that meet these no single suture material is used by
stringent criteria: every surgeon who practices within
• They must have the greatest a specialty.
tensile strength consistent with The surgeon's knowledge of the
size limitations. physical characteristics of suture
• They must be easy to handle. material is important. As the
requirements for wound support vary
CHAPTER 2 11
with patient factors, the nature of the SIZE AND TENSILE MONOFILAMENT VS.
procedure, and the type of tissue STRENGTH MULTIFILAMENT STRANDS
involved, the surgeon will select suture Size denotes the diameter of the Sutures are classified according to
material that will retain its strength suture material. The accepted the number of strands of which
until the wound heals sufficiently to surgical practice is to use the they are comprised. Monofilament
withstand stress on its own. smallest diameter suture that sutures are made of a single strand
will adequately hold the mending of material. Because of their
wounded tissue. This practice simplified structure, they encounter
SUTURE minimizes trauma as the suture is less resistance as they pass
CHARACTERISTICS passed through the tissue to effect through tissue than multifilament
The choice of suture materials closure. It also ensures that the suture material. They also resist
generally depends on whether the minimum mass of foreign material harboring organisms that may
wound closure occurs in one or is left in the body. Suture size is cause infection.
more layers. In selecting the most stated numerically; as the number of
These characteristics make
appropriate sutures, the surgeon 0s in the suture size increases, the
monofilament sutures well suited
takes into account the amount of diameter of the strand decreases. For
to vascular surgery. Monofilament
tension on the wound, the number example, United States Pharmacopeia
sutures tie down easily. However,
of layers of closure, depth of suture (USP) size 5-0, or 00000, is smaller
because of their construction,
placement, anticipated amount of in diameter than size 4-0, or 0000.
extreme care must be taken when
edema, and anticipated timing of The smaller the size, the less tensile
handling and tying these sutures.
suture removal. strength the suture will have.
Crushing or crimping of this suture
Knot tensile strength is measured by type can nick or create a weak spot
Optimal suture qualities include:
the force, in pounds, which the in the strand. This may result in
1. High uniform tensile strength, suture strand can withstand before suture breakage.
permitting use of finer sizes. it breaks when knotted. The tensile
2. High tensile strength retention Multifilament sutures consist of
strength of the tissue to be mended
in vivo, holding the wound several filaments, or strands, twisted
(its ability to withstand stress)
securely throughout the critical or braided together. This affords
determines the size and tensile
healing period, followed by greater tensile strength, pliability, and
strength of the suturing material the
rapid absorption. flexibility. Multifilament sutures may
surgeon selects. The accepted rule is
3. Consistent uniform diameter. also be coated to help them pass rela-
that the tensile strength of the
4. Sterile. tively smoothly through tissue and
suture need never exceed the tensile
5. Pliable for ease of handling and enhance handling characteristics.
strength of the tissue. However,
knot security. Coated multifilament sutures are
sutures should be at least as strong
6. Freedom from irritating well suited to intestinal procedures.
as normal tissue through which they
substances or impurities for are being placed.
optimum tissue acceptance. METRIC MEASURES AND USP
7. Predictable performance. SUTURE DIAMETER EQUIVALENTS TABLE
1
USP Size 11-0 10-0 9-0 8-0 7-0 6-0 5-0 4-0 3-0 2-0 0 1 2 3 4 5 6
Natural
Collagen ––– 0.2 0.3 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 7.0 8.0 ––– –––
Synthetic
Absorbables ––– 0.2 0.3 0.4 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 6.0 7.0 –––
Nonabsorbable
Materials 0.1 0.2 0.3 0.4 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 6.0 7.0 8.0
The metric guaging system of suture materials indicates the actual diameter of materials. It has been adopted and
approved by both the European and the United States Pharmacopeia. The metric number represents the diameter of the
suture in tenths of a millimeter.
12 THE SUTURE
ABSORBABLE VS.
NONABSORBABLE SUTURES SUTURE RAW MATERIAL
Sutures are classified according to
their degradation properties. Sutures Surgical Gut Submucosa of sheep TABLE
Plain intestine or serosa of beef 2
that undergo degradation and Chromic intestine
absorption in tissues are considered Fast-Absorbing ABSORBABLE
absorbable sutures. Sutures that Polyglactin 910 SUTURES:
Copolymer of glycolide and
generally maintain their tensile Uncoated (VICRYL Suture) lactide with polyglactin 370 BASIC RAW
strength and are resistant to absorption and calcium stearate, if coated MATERIALS
Coated (Coated VICRYL
are nonabsorbable sutures. Suture, Coated VICRYL Plus
Antibacterial Suture, Coated
Absorbable sutures may be used to VICRYL RAPIDE Suture)
hold wound edges in approximation
temporarily, until they have healed
Polyglycolic Acid Homopolymer of glycolide
sufficiently to withstand normal
Poliglecaprone 25 Copolymer of glycolide and
stress. These sutures are prepared (MONOCRYL Suture) epsilon-caprolactone
either from the collagen of healthy
mammals or from synthetic Polyglyconate Copolymer of glycolide and
polymers. Some are absorbed trimethylene carbonate
rapidly, while others are treated or Polydioxanone Polyester of poly (p-dioxanone)
chemically structured to lengthen (PDS II Suture)
absorption time. They may also be
impregnated or coated with agents
that improve their handling
considerable overlap, characterized causing too rapid a decline in tensile
properties, and colored with an
by loss of suture mass. Both stages strength. In addition, if the sutures
FDA-approved dye to increase
exhibit leukocytic cellular responses become wet or moist prior to use,
visibility in tissue. Natural
that serve to remove cellular debris the absorption process may begin
absorbable sutures are digested by
and suture material from the line of prematurely. Similarly, patients with
body enzymes which attack and
tissue approximation. impaired healing are often not ideal
break down the suture strand.
candidates for this type of suture.
Synthetic absorbable sutures are The loss of tensile strength and
All of these situations predispose to
hydrolyzed—a process by which the rate of absorption are separate
postoperative complications, as
water gradually penetrates the phenomena. A suture can lose
the suture strand will not maintain
suture filaments, causing the tensile strength rapidly and yet be
adequate strength to withstand
breakdown of the suture's polymer absorbed slowly—or it can
stress until the tissues have healed
chain. Compared to the enzymatic maintain adequate tensile strength
sufficiently.
action of natural absorbables, through wound healing, followed
hydrolyzation results in a lesser by rapid absorption. In any case, Nonabsorbable sutures are those
degree of tissue reaction following the strand is eventually completely which are not digested by body
implantation. dissolved, leaving no detectable enzymes or hydrolyzed in body
traces in tissue. tissue. They are made from a variety
During the first stage of the
of nonbiodegradable materials and
absorption process, tensile strength Although they offer many
are ultimately encapsulated or
diminishes in a gradual, almost advantages, absorbable sutures also
walled off by the body's fibroblasts.
linear fashion. This occurs over the have certain inherent limitations.
Nonabsorbable sutures ordinarily
first several weeks postimplantation. If a patient has a fever, infection,
remain where they are buried
The second stage often follows with or protein deficiency, the suture
absorption process may accelerate,
CHAPTER 2 13
CONTINUOUS SUTURES
Also referred to as running stitches,
FIGURE
1 continuous sutures are a series of
stitches taken with one strand of
LIGATURES material. The strand may be tied to
itself at each end, or looped, with
both cut ends of the strand tied
Free tie Stick tie together. A continuous suture line
can be placed rapidly. It derives its
strength from tension distributed
evenly along the full length of the
suture strand. However, care must
FIGURE be taken to apply firm tension,
2
rather than tight tension, to avoid
CONTINUOUS
SUTURING INTERRUPTED
Two strands knotted at TECHNIQUES SUTURING
Looped suture, knotted each end and knotted in TECHNIQUES
at one end the middle FIGURE
3
Simple interrupted
Over-and-over running
Running locked suture stitch
Surgical Gut Chromic Brown Collagen derived from Individual patient characteristics can Absorbed by proteolytic Moderate reaction
Suture healthy beef and sheep. affect rate of tensile strength loss. enzymatic digestive
Blue Dyed process.
Coated Braided Undyed (Natural) Copolymer of lactide Approximately 50% remains at 5 Essentially complete Minimal to moderate
VICRYL RAPIDE and glycolide coated days. All tensile strength is lost at between 42 days. acute inflammatory
(polyglactin 910) with 370 and calcium approximately 14 days. Absorbed by hydrolysis. reaction
Suture stearate.
MONOCRYL Plus Monofilament Undyed (Natural) Copolymer of Approximately 50-60% (violet: 60-70%) Complete at 91-119 Minimal acute
antibacterial glycolide and remains at 1 week. Approximately 20- days. Absorbed by inflammatory reaction
(poliglecaprone 25) Violet epsilon-caprolactone. 30% (violet: 30-40%) remains at 2 weeks. hydrolysis.
Suture Lost within 3 weeks (violet: 4 weeks).
MONOCRYL Monofilament Undyed (Natural) Copolymer of Approximately 50-60% (violet: 60-70%) Complete at 91-119 Minimal acute
(poliglecaprone 25) glycolide and remains at 1 week. Approximately 20- days. Absorbed by inflammatory reaction
Suture Violet epsilon-caprolactone. 30% (violet: 30-40%) remains at 2 weeks. hydrolysis.
Lost within 3 weeks (violet: 4 weeks).
Coated VICRYL Braided Undyed (Natural) Copolymer of lactide Approximately 75% remains at Essentially complete Minimal acute
Plus Antibacterial and glycolide coated 2 weeks. Approximately 50% remains between 56-70 days. inflammatory reaction
(polyglactin 910) Monofilament Violet with 370 and calcium at 3 weeks, 25% at 4 weeks. Absorbed by hydrolysis.
Suture stearate.
Coated VICRYL Braided Undyed (Natural) Copolymer of lactide Approximately 75% remains at Essentially complete Minimal acute
(polyglactin 910) and glycolide coated 2 weeks. Approximately 50% remains between 56-70 days. inflammatory reaction
Suture Monofilament Violet with 370 and calcium at 3 weeks, 25% at 4 weeks. Absorbed by hydrolysis.
stearate.
PDS II Monofilament Violet Polyester polymer. Approximately 70% remains at 2 weeks. Minimal until about 90th Slight reaction
(polydioxanone) Clear Approximately 50% remains at 4 weeks. day. Essentially complete
Suture Approximately 25% remains at 6 weeks. within 6 months. Absorbed
Blue by slow hydrolysis.
NONABSORBABLE SUTURES
PERMA-HAND Braided Violet Organic protein called Progressive degradation of fiber may Gradual encapsulation Acute inflammatory
Silk Suture fibrin. result in gradual loss of tensile by fibrous connective reaction
White strength over time. tissue.
Surgical Stainless Monofilament Silver metallic 316L stainless steel. Indefinite. Nonabsorbable. Minimal acute
Steel Suture inflammatory reaction
Multifilament
ETHILON Monofilament Violet Long-chain aliphatic Progressive hydrolysis may result in Gradual encapsulation Minimal acute
Nylon Suture polymers Nylon 6 or gradual loss of tensile strength over by fibrous connective inflammatory reaction
Green Nylon 6,6. time. tissue.
Undyed (Clear)
NUROLON Braided Violet Long-chain aliphatic Progressive hydrolysis may result in Gradual encapsulation Minimal acute
Nylon Suture polymers Nylon 6 or gradual loss of tensile strength over by fibrous connective inflammatory reaction
Green Nylon 6,6. time. tissue.
Undyed (Clear)
MERSILENE Braided Green Poly (ethylene No significant change known to Gradual encapsulation Minimal acute
Polyester Fiber terephthalate). occur in vivo. by fibrous connective inflammatory reaction
Suture Monofilament Undyed (White) tissue.
ETHIBOND Braided Green Poly (ethylene No significant change known to Gradual encapsulation Minimal acute
EXCEL Polyester terephthalate) coated occur in vivo. by fibrous connective inflammatory reaction
Fiber Suture Undyed (White) with polybutilate. tissue.
PROLENE Monofilament Clear Isotactic crystalline No subject to degradation or Nonabsorbable. Minimal acute
Polypropylene stereoisomer of weakening by action of tissue inflammatory reaction
Suture Blue polypropylene. enzymes.
PRONOVA Monofilament Blue Polymer blend of poly No subject to degradation or Nonabsorbable. Minimal acute
POLY (hexafluoro- (vinylidene fluoride) and weakening by action of tissue inflammatory reaction
propylene-VDF) poly (vinylidene fluoride- enzymes.
Suture cohexafluoropropylene).
CONTRAINDICATIONS FREQUENT USES HOW SUPPLIED COLOR CODE
OF PACKETS TABLE
Being absorbable, should not be used General soft tissue approximation 7-0 thru 3 with and without needles, Yellow 5
where extended approximation of tissues and/or ligation, including use in and on LIGAPAK dispensing reels
under stress is required. Should not be ophthalmic procedures. Not for 0 thru 1 with CONTROL
used in patients with known sensitivities use in cardiovascular and neurological RELEASE needles SUTURING
or allergies to collagen or chromium. tissues. OPTIONS:
Being absorbable, should not be used General soft tissue approximation 7-0 thru 3 with and without needles, Beige MATERIALS,
where extended approximation of tissues and/or ligation, including use in and on LIGAPAK dispensing reels CHARACTERISTICS,
under stress is required. Should not be ophthalmic procedures. Not for 0 thru 1 with CONTROL
used in patients with known sensitivities use in cardiovascular and neurological RELEASE needles AND APPLICATIONS
or allergies to collagen or chromium. tissues.
Should not be used where extended Superficial soft tissue approximation 5-0 thru 1 with needles Red
approximation of tissue under stress is of skin and mucosa only. Not for use
required or where wound support beyond in ligation, ophthalmic, cardiovascular
7 days is required. or neurological procedures.
Being absorbable, should not be used General soft tissue approximation 6-0 thru 2 with and without needles Coral
where extended approximation of tissue and/or ligation. Not for use in 3-0 thru 1 with CONTROL
under stress is required. Undyed not cardiovascular and neurological tissues, RELEASE needles
indicated for use in fascia. microsurgery, or ophthalmic surgery.
Being absorbable, should not be used General soft tissue approximation 6-0 thru 2 with and without needles Coral
where extended approximation of tissue and/or ligation. Not for use in 3-0 thru 1 with CONTROL
under stress is required. Undyed not cardiovascular and neurological tissues, RELEASE needles
indicated for use in fascia. microsurgery, or ophthalmic surgery.
Being absorbable, should not be used General soft tissue approximation 5-0 thru 2 with and without needles Violet
where extended approximation of tissue and/or ligation. Not for use in
is required. cardiovascular and neurological tissues.
Being absorbable, should not be used General soft tissue approximation 8-0 thru 3 with and without needles, Violet
where extended approximation of tissue and/or ligation, including use in and on LIGAPAK dispensing reels
is required. ophthalmic procedures. Not for use in 4-0 thru 2 with CONTROL RELEASE
cardiovascular and neurological tissues. needles; 8-0 with attached beads for
ophthalmic use
Being absorbable, should not be used All types of soft tissue approximation, 9-0 thru 2 with needles Silver
where prolonged approximation of tissues including pediatric cardiovascular 4-0 thru 2 with CONTROL
under stress is required. Should not be used and ophthalmic procedures. Not for RELEASE needles
with prosthetic devices, such as heart valves use in adult cardiovascular tissue, 9-0 thru 7-0 with needles
or synthetic grafts. microsurgery, and neural tissue. 7-0 thru 1 with needles
Should not be used in patients with General soft tissue approximation 9-0 thru 5 with and without needles, Light Blue
known sensitivities or allergies to silk. and/or ligation, including and on LIGAPAK dispensing reels
cardiovascular, ophthalmic, and 4-0 thru 1 with CONTROL
neurological procedures. RELEASE needles
Should not be used in patients with Abdominal wound closure, hernia 10-0 thru 7 with and without Yellow-Ochre
known sensitivities or allergies to 316L repair, sternal closure, and orthopedic needles
stainless steel, or constituent metals such procedures including cerclage and
as chromium and nickel. tendon repair.
Should not be used where permanent General soft tissue approximation 11-0 thru 2 with and without needles Mint Green
retention of tensile strength is required. and/or ligation, including
cardiovascular, ophthalmic, and
neurological procedures.
Should not be used where permanent General soft tissue approximation 6-0 thru 1 with and without needles Mint Green
retention of tensile strength is required. and/or ligation, including 4-0 thru 1 with CONTROL
cardiovascular, ophthalmic, and RELEASE needles
neurological procedures.
None known. General soft tissue approximation 6-0 thru 5 with and without needles Turquoise
and/or ligation, including 10-0 and 11-0 for ophthalmic
cardiovascular, ophthalmic, and (green monofilament); 0 with
neurological procedures. CONTROL RELEASE needles
None known. General soft tissue approximation 7-0 thru 5 with and without needles Orange
and/or ligation, including 4-0 thru 1 with CONTROL
cardiovascular, ophthalmic, and RELEASE needles; various sizes
neurological procedures. attached to TFE polymer pledgets
None known. General soft tissue approximation 6-0 thru 2 (clear) with and without Deep Blue
and/or ligation, including needles; 10-0 thru 8-0 and 6-0 thru 2
cardiovascular, ophthalmic, and with and without needles; 0 thru 2 with
neurological procedures. CONTROL RELEASE needles; various
sizes attached to TFE polymer pledgets
None known. General soft tissue approximation 6-0 through 5-0 with TAPERCUT* Royal Blue
and/or ligation, including surgical needle
cardiovascular, ophthalmic, and 8-0 through 5-0 with taper point
neurological procedures. needle
22 THE SUTURE
tissue strangulation. Excessive
tension and instrument damage
should be avoided to prevent suture FIGURE
breakage which could disrupt the 4
entire line of a continuous suture. DEEP
SUTURES
Continuous suturing leaves less
foreign body mass in the wound.
In the presence of infection, it may
be desirable to use a monofilament
suture material because it has no
interstices which can harbor
microorganisms. This is especially
critical as a continuous suture
line can transmit infection along
the entire length of the strand. A
continuous 1 layer mass closure
may be used on peritoneum and/or
fascial layers of the abdominal wall
to provide a temporary seal during FIGURE
5
the healing process.
PURSE-STRING
INTERRUPTED SUTURES SUTURES
Interrupted sutures use a number
of strands to close the wound.
Each strand is tied and cut after
insertion. This provides a more secure
closure, because if one suture breaks,
the remaining sutures will hold the
wound edges in approximation.
Interrupted sutures may be used
if a wound is infected, because
microorganisms may be less
likely to travel along a series of nique is useful when using large organ prior to insertion of a tube
interrupted stitches. diameter permanent sutures on (such as the aorta, to hold the
deeper layers in thin patients who cannulation tube in place during
DEEP SUTURES may be able to feel large knots that an open heart procedure).
Deep sutures are placed completely are not buried.
under the epidermal skin layer. SUBCUTICULAR SUTURES
They may be placed as continuous PURSE-STRING SUTURES Subcuticular sutures are continuous
or interrupted sutures and are not Purse-string sutures are continuous or interrupted sutures placed in the
removed postoperatively. sutures placed around a lumen and dermis, beneath the epithelial layer.
tightened like a drawstring to Continuous subcuticular sutures are
BURIED SUTURES invert the opening. They may be placed in a line parallel to the
Buried sutures are placed so that the placed around the stump of the wound. This technique involves
knot protrudes to the inside, under appendix, in the bowel to secure an taking short, lateral stitches the full
the layer to be closed. This tech- intestinal stapling device, or in an length of the wound. After the
CHAPTER 2 23
Other materials are cut closer to the be removed easily without cutting. 7. Don't store surgical gut
knot, approximately 1/8 inch (3 mm), A common practice is to cover the near heat.
to decrease tissue reaction and skin sutures with PROXI-STRIP*
8. Moisten—but never soak—
minimize the amount of foreign Skin Closures during the required
surgical gut.
material left in the wound. To healing period. After the wound
ensure that the actual knot is not edges have regained sufficient tensile 9. Do not wet rapidly absorbing
cut, twist or angle the blades of the strength, the sutures may be sutures.
scissors prior to cutting. Make removed by simply removing the
10. Keep silk dry.
certain to remove the cut ends of PROXI-STRIP Skin Closures.
the suture from the operative site. 11. Wet linen and cotton to increase
their strength.
SUTURE
SUTURE REMOVAL HANDLING TIPS 12. Don't bend stainless steel wire.
These guidelines will help the surgical 13. Draw nylon between gloved
When the external wound has team keep their suture inventory up- fingers to remove the packaging
healed so that it no longer needs the to-date and their sutures in the best "memory."
support of nonabsorbable suture possible condition.
material, skin sutures must be 14. Arm a needleholder properly.
1. Read labels.
removed. The length of time the
sutures remain in place depends 2. Heed expiration dates and SUTURE SELECTION
upon the rate of healing and the rotate stock. PROCEDURE
nature of the wound. General rules 3. Open only those sutures needed
are as follows. PRINCIPLES OF
for the procedure at hand. SUTURE SELECTION
Sutures should be removed using 4. Straighten sutures with a gentle The surgeon has a choice of suture
aseptic and sterile technique. The pull. Never crush or rub them. materials from which to select for
surgeon uses a sterile suture removal use in body tissues. Adequate
tray prepared for the procedure. 5. Don't pull on needles. strength of the suture material will
The following steps are taken: 6. Avoid crushing or crimping prevent suture breakage. Secure
• STEP 1—Cleanse the area with suture strands with surgical knots will prevent knot slippage.
an antiseptic. Hydrogen peroxide instruments. But the surgeon must understand
can be used to remove dried serum the nature of the suture material,
encrusted around the sutures.
• STEP 2—Pick up one end of the
suture with thumb forceps, and
cut as close to the skin as possible FIGURE
where the suture enters the skin. 9
• STEP 3—Gently pull the suture
ARMING
strand out through the side oppo-
A NEEDLE-
site the knot with the forceps. To HOLDER
prevent risk of infection, the suture PROPERLY
should be removed without pulling
any portion that has been outside
the skin back through the skin.
NOTE: Fast-absorbing synthetic or
gut suture material tend to lose all
tensile strength in 5 to 7 days and can Grasp the needle one third to one half of the distance from
the swaged end to the point.
28 THE SUTURE
the biologic forces in the healing Therefore: intestine are rich in blood supply
wound, and the interaction of a. In the urinary and biliary and may become edematous and
the suture and the tissues. The tracts, use rapidly absorbed hardened. Tight sutures may cut
following principles should guide sutures. through the tissue and cause
the surgeon in suture selection. 5. Regarding suture size: leakage. A leak-proof anastomosis
1. When a wound has reached a. Use the finest size suture can be achieved with either a
maximal strength, sutures are no commensurate with the single- or double-layer closure.
longer needed. Therefore: natural strength of the tissue.
For a single-layer closure, inter-
a. Tissues that ordinarily heal b. If the postoperative course of
rupted sutures should be placed
slowly such as skin, fascia, the patient may produce
approximately 1/4 inch (6 mm) apart.
and tendons should usually sudden strains on the suture
Suture is placed through the
be closed with nonabsorbable line, reinforce it with
submucosa, into the muscularis and
sutures. An absorbable suture retention sutures. Remove
through the serosa. Because the
with extended (up to them as soon as the patient's
submucosa provides strength in
6 months) wound support condition is stabilized.
the gastrointestinal tract, effective
may also be used. closure involves suturing the
b. Tissues that heal rapidly SURGERY WITHIN THE
submucosal layers in apposition
such as stomach, colon, and ABDOMINAL WALL CAVITY
without penetrating the mucosa.
bladder may be closed with Entering the abdomen, the surgeon
A continuous suture line provides a
absorbable sutures. will need to seal or tie off
tighter seal than interrupted sutures.
2. Foreign bodies in potentially subcutaneous blood vessels
However, if a continuous suture
contaminated tissues may convert immediately after the incision is
breaks, the entire line may separate.
contamination into infection. made, using either an electrosurgical
3. Where cosmetic results are unit designed for this purpose or Many surgeons prefer to use a
important, close and prolonged free ties (ligatures). If ligatures are double-layer closure, placing a
apposition of wounds and used, an absorbable suture material second layer of interrupted sutures
avoidance of irritants will is generally preferred. When through the serosa for insurance.
produce the best results. preparing the ties, the scrub person Absorbable VICRYL and VICRYL
Therefore: often prepares one strand on a Plus Sutures, or chromic gut sutures
a. Use the smallest inert needle for use as a suture ligature may be used in either a single- or
monofilament suture should the surgeon wish to double-layer closure. Surgical silk
materials such as nylon transfix a large blood vessel. may also be used for the second
or polypropylene. Once inside, the type of suture layer of a double-layer closure.
b. Avoid skin sutures and close selected will depend upon the Inverted, everted, or end-to-end
subcuticularly whenever nature of the operation and the closure techniques have all been
possible. surgeon's technique. used successfully in this area, but
c. Under certain circumstances, they all have drawbacks. The
to secure close apposition of THE GASTROINTESTINAL TRACT surgeon must take meticulous care
skin edges, a topical skin Leakage from an anastomosis in placing the sutures in the submu-
adhesive or skin closure or suture site is the principal cosa. Even with the best technique,
tape may be used. problem encountered performing some leakage may occur. Fortunately,
4. Foreign bodies in the presence a procedure involving the the omentum usually confines the
of fluids containing high concen- gastrointestinal tract. This problem area, and natural body defenses
trations of crystalloids may act can lead to localized or generalized handle the problem.
as a nidus for precipitation and peritonitis. Sutures should not be
stone formation. tied too tightly in an anastomotic
closure. Wounds of the stomach and
CHAPTER 2 29
absorbable suture material is is always closed. The anterior layer monofilament absorbable material
usually preferred. Interrupted may be cut and may also require like PDS II Sutures or inert nonab-
sutures can also be used for suturing. Mass closure techniques sorbable sutures like stainless steel or
this procedure. are becoming the most popular. PROLENE Sutures may be used.
FIGURE
14
SURGICAL
OPTIONS IN
MUSCLE
VICRYL RAPIDE Suture, which a lower tissue reaction than chromic relatively rare if the skin sutures are
is indicated for superficial closure gut suture due to its accelerated not placed with excessive tension
of skin and mucosa, provides absorption profile.) The key to and are removed by the seventh
short-term wound support success is early suture removal postoperative day.
consistent with the rapid healing before epithelialization of the suture
The forces that create the distance
characteristics of skin. The sutures tract occurs and before contamina-
between the edges of the wound
begin to fall off in 7 to 10 days, tion is converted into infection.
will remain long after the sutures
with absorption essentially
have been removed. Significant
complete at 42 days. A WORD ABOUT SCARRING
(EPITHELIALIZATION) collagen synthesis will occur from
Suturing technique for skin When a wound is sustained in 5 to 42 days postoperatively. After
closure may be either continuous the skin—whether accidentally or this time, any additional gain in
or interrupted. Skin edges should during a surgical procedure—the tensile will be due to remodeling,
be everted. Preferably, each suture epithelial cells in the basal layer at or crosslinking, of collagen fibers
strand is passed through the skin the margins of the wound flatten rather than to collagen synthesis.
only once, reducing the chance and move into the wound area. Increases in tensile strength will
of cross-contamination across the They move down the wound edge continue for as long as 2 years, but
entire suture line. Interrupted until they find living, undamaged the tissue will never quite regain its
technique is usually preferred. tissue at the base of the wound. original strength.
If surgeon preference indicates Then they move across the wound
CLOSURE WITH
the use of a nonabsorbable suture bed to make contact with similar
RETENTION SUTURES
material, several issues must be cells migrating from the opposite
We have already discussed the
considered. Skin sutures are exposed side of the wound. They move
techniques involved with placing
to the external environment, down the suture tract after if has
retention sutures, and using them
making them a serious threat been embedded in the skin. When
in a secondary suture line. (See the
to wound contamination and the suture is removed, the tract of
section on Suturing Techniques.)
stitch abscess. The interstices of the epithelial cells remains.
Heavy sizes (0 to 5) of nonabsorbable
multifilament sutures may provide Eventually, it may disappear, but
materials are usually used for
a haven for microorganisms. some may remain and form keratin.
retention sutures, not for strength,
Therefore, monofilament nonabsorb- A punctate scar is usually seen on
but because larger sizes are less likely
able sutures may be preferred for the skin surface and a "railroad
to cut through tissue when a sudden
skin closure. Monofilament sutures track" or "crosshatch" appearance
rise in intra-abdominal pressure
also induce significantly less tissue on the wound may result. This is
occurs from vomiting, coughing,
reaction than multifilament sutures.
For cosmetic reasons, nylon or
polypropylene monofilament sutures
may be preferred. Many skin FIGURE
wounds are successfully closed with 15
silk and polyester multifilaments
as well. Tissue reaction to non- THE RAILROAD
absorbable sutures subsides and TRACK SCAR
CONFIGURATION
remains relatively acellular as
fibrous tissue matures and forms a
dense capsule around the suture.
(Note, surgical gut has been known
to produce tissue reaction. Coated
VICRYL RAPIDE Suture elicits
34 THE SUTURE
straining, or distention. To prevent Retention sutures may be left in A drainage tube inserted into the
the heavy suture material from place for 14 to 24 days postopera- peritoneal cavity through a stab
cutting into the skin under stress, tively. Three weeks is an average wound in the abdominal wall
one end of the retention suture may length of time. Assessment of the usually is anchored to the skin
be threaded through a short length patient's condition is the controlling with 1 or 2 nonabsorbable sutures.
of plastic or rubber tubing called a factor in deciding when to remove This prevents the drain from
bolster or bumper before it is tied. retention sutures. slipping into or out of the wound.
A plastic bridge with adjustable
features may also be used to protect SUTURE FOR DRAINS SUTURE NEEDS IN OTHER
the skin and primary suture line If a drainage tube is placed in a BODY TISSUES/NEUROSURGERY
and permit postoperative wound hollow organ or a bladder drain is Surgeons have traditionally used an
management for patient comfort. inserted, it may be secured to the interrupted technique to close the
wall of the organ being drained galea and dura mater.
Properly placed retention sutures with absorbable sutures. The surgeon
provide strong reinforcement for The tissue of the galea, similar to
may also choose to minimize the the fascia of the abdominal cavity,
abdominal wounds, but also cause distance between the organ and the
the patient more postoperative pain is very vascular and hemostatic.
abdominal wall by using sutures to Therefore, scalp hematoma is a
than does a layered closure. The tack the organ being drained to the
best technique is to use a material potential problem, and the surgeon
peritoneum and fascia. must be certain to close well.
with needles swaged on each end Sutures may be placed around the
(double-armed). They should be The dura mater is the outermost of
circumference of the drain, either the three meninges that protects the
placed from the inside of the wound 2 sutures at 12 and 6 o'clock
toward the outside skin to avoid brain and spinal cord. It tears with
positions, or 4 sutures at 12, 3, ease and cannot withstand too
pulling potentially contaminated 6, and 9 o'clock positions, and
epithelial cells through the entire much tension. The surgeon may
secured to the skin with temporary drain some of the cerebrospinal
abdominal wall. loops. When the drain is no longer fluid to decrease volume, easing the
The ETHICON, INC., retention needed, the skin sutures may be tension on the dura before closing.
suture line includes ETHILON easily removed to remove the drain. If it is too damaged to close, a
Sutures, MERSILENE Sutures, The opening can be left open to patch must be inserted and sutured
ETHIBOND EXCEL Sutures, and permit additional drainage until it in place.
PERMA-HAND* Sutures. Surgical closes naturally.
steel sutures may also be used. Surgical silk is appropriate in this
area for its pliability and easy knot
tying properties. Unfortunately,
it elicits a significant foreign body
FIGURE tissue reaction. Most surgeons have
16 switched to NUROLON Sutures
because it ties easily, offers greater
PLACEMENT strength than surgical silk, and causes
OF SUTURES
less tissue reaction. PROLENE
AROUND
A DRAIN Sutures has also been accepted by
surgeons who prefer a continuous
closure technique, who must repair
potentially infected wounds, or
who must repair dural tears.
CHAPTER 2 35
In peripheral nerve repair, precise OPHTHALMIC SURGERY surgical gut and behave dependably,
suturing often requires the aid of The eye presents special healing Coated VICRYL Sutures have proven
an operating microscope. Suture challenges. The ocular muscles, the useful in muscle and cataract surgery.
gauge and needle fineness must be conjunctiva, and the sclera have good
While some ophthalmic surgeons
consistent with nerve size. After blood supplies; but the cornea is an
promote the use of a "no-stitch"
the motor and sensory fibers are avascular structure. While epithelial-
surgical technique, 10-0 coated
properly realigned, the epineurium ization of the cornea occurs rapidly
VICRYL violet monofilament
(the outer sheath of the nerve) is in the absence of infection, full
sutures offer distinct advantages.
sutured. The strength of sutures in thickness cornea wounds heal slowly.
They provide the security of
this area is less of a consideration Therefore, in closing wounds such as
suturing immediately following
than the degree of inflammatory cataract incisions, sutures should
surgery but eliminate the risks
and fibroplastic tissue reaction. remain in place for approximately
of suture removal and related
Fine sizes of nylon, polyester, and 21 days. Muscle recession, which
endophthalmitis.
polypropylene are preferred. involves suturing muscle to sclera,
only requires sutures for approxi- The ophthalmologist has many
MICROSURGERY mately 7 days. fine size suture materials to choose
The introduction of fine sizes of from for keratoplasty, cataract,
Nylon was the preferred suture
sutures and needles has increased and vitreous retinal microsurgical
material for ophthalmic surgery.
the use of the operating microscope. procedures. In addition to Coated
While nylon is not absorbed,
ETHICON, INC., introduced VICRYL Sutures, other monofilament
progressive hydrolysis of nylon
the first microsurgery sutures— suture materials including
in vivo may result in gradual loss of
ETHILON Sutures—in sizes 8-0 ETHILON Sutures, PROLENE
tensile strength over time. Fine sizes
through 11-0. Since then, the Sutures, and PDS II Sutures may be
of absorbable sutures are currently
microsurgery line has expanded to used. Braided material such as virgin
used for many ocular procedures.
include PROLENE Sutures and silk, black braided silk, MERSILENE
Occasionally, the sutures are
Coated VICRYL Sutures. Literally Sutures, and Coated VICRYL Sutures
absorbed too slowly in muscle
all surgical specialties perform some are also available for ophthalmic
recessions and produce granulomas
procedures under the operating procedures.
to the sclera. Too rapid absorption
microscope, especially vascular and
has, at times, been a problem in
nerve anastomosis. UPPER ALIMENTARY
cataract surgery. Because they TRACT PROCEDURES
induce less cellular reaction than The surgeon must consider the
upper alimentary tract from the
mouth down to the lower
Skin Galea esophageal sphincter to be a
Skull
FIGURE potentially contaminated area.
17 The gut is a musculomembranous
canal lined with mucus membranes.
LAYERS
Final healing of mucosal wounds
OF SUTURES
SURROUNDING appears to be less dependent upon
A DRAIN suture material than on the wound
closure technique.
The oral cavity and pharynx
generally heal quickly if not infected.
Fine size sutures are adequate in this
Brain
Dura mater area as the wound is under little
tension. Absorbable sutures may be
36 THE SUTURE
preferred. Patients, especially
children, usually find them more
FIGURE
comfortable. However, the surgeon 18
Ocular muscles
may prefer a monofilament
nonabsorbable suture under certain THE EYE
circumstances. This option causes Conjunctiva
less severe tissue reaction than
multifilament materials in buccal Cornea
mucosa, but also requires suture
removal following healing. Sclera
In cases involving severe
periodontitis, VICRYL* (polyglactin
910) Periodontal Mesh may be used
to promote tissue regeneration, a
technique that enhances the regener-
ation and attachment of tissue lost
due to periodontitis. VICRYL
Periodontal Mesh, available in several Oral cavity FIGURE
shapes and sizes with a preattached 19
VICRYL ligature, is woven from the
same copolymer used to produce THE UPPER
absorbable VICRYL Suture. As a ALIMENTARY
synthetic absorbable, VICRYL CANAL
Periodontal Mesh eliminates the
trauma associated with a second
surgical procedure and reduces the
risk of infection or inflammation
associated with this procedure.
The esophagus is a difficult organ Esophagus
to suture. It lacks a serosal layer.
The mucosa heals slowly. The thick
muscular layer does not hold sutures
well. If multifilament sutures are
used, penetration through the FIGURE
mucosa into the lumen should be 20
avoided to prevent infection.
BRONCHIAL
RESPIRATORY STUMP
TRACT SURGERY CLOSURE
Relatively few studies have been
done on healing in the respiratory
tract. Bronchial stump closure
following lobectomy or pneumonec-
tomy presents a particular challenge.
Infection, long stumps, poor
approximation of the transected
CHAPTER 2 37
CARDIOVASCULAR SURGERY
Although definitive studies are few,
blood vessels appear to heal rapidly.
Most cardiovascular surgeons prefer to
use synthetic nonabsorbable sutures
for cardiac and peripheral vascular
procedures. Lasting strength and
FIGURE leakproof anastomoses are essential.
23 Wire sutures are typically used on the
sternum unless it is fragile, in which
THE BUNNELL case absorbable sutures can be used.
TECHNIQUE
VESSELS
Excessive tissue reaction to suture
material may lead to decreased
luminal diameter or to thrombus
formation in a vessel. Therefore,
the more inert synthetics including
nylon and polypropylene are
the materials of choice for vessel
38 THE SUTURE
anastomoses. Multifilament Clinical studies suggest that a EXCEL Suture around the cuff of
polyester sutures allow clotting to prolonged absorbable suture, such as the valve before tying the knots.
occur within the interstices, which PDS II Suture, may be ideal, giving
Some surgeons routinely use
helps to prevent leakage at the adequate short-term support while
pledgets to buttress sutures in valve
suture line. The advantages of a permitting future growth.
surgery. They are used most
material such as ETHIBOND
Following vascular trauma, mycotic commonly in valve replacement
EXCEL Sutures are its strength,
aneurysms from infection are procedures to prevent the annulus
durability, and slippery surface,
extremely serious complications. from tearing when the prosthetic
which causes less friction when
A suture may act as a nidus for valve is seated and the sutures are
drawn through a vessel. Many
an infection. In the presence of tied. They may also be used in heart
surgeons find that PROLENE
infection, the chemical properties wall closure of penetrating injuries,
Sutures, PRONOVA Sutures, or
of suture material can cause excising aneurysms, vascular graft
silk are ideal for coronary artery
extensive tissue damage that may surgery, and to add support when
procedures because they do not
reduce the tissue's natural ability the surgeon encounters extreme
"saw" through vessels.
to combat infection. Localized deformity, distortion, or tissue
Continuous sutures provide a more sepsis can also spread to adjacent destruction at the annulus.
leakproof closure than interrupted vascular structures, causing necrosis
sutures in large vessel anastomoses of the arterial wall. Therefore, the URINARY TRACT SURGERY
because the tension along the surgeon may choose a monofilament Closure of tissues in the urinary
suture strand is distributed evenly suture material that causes only a tract must be leakproof to prevent
around the vessel's circumference. mild tissue reaction and resists escape of urine into surrounding
Interrupted monofilament sutures bacterial growth. tissues. The same considerations
such as ETHILON Sutures, that affect the choice of sutures for
PROLENE Sutures, or PRONOVA VASCULAR PROSTHESES the biliary tract affect the choice of
Sutures are used for microvascular The fixation of vascular prostheses sutures for this area. Nonabsorbable
anastomoses. When anastomosing and artificial heart valves presents an sutures incite the formation of cal-
major vessels in young children, entirely different suturing challenge culi, and therefore cannot be used.
special care must be taken to than vessel anastomosis. The sutures Surgeons use absorbable sutures as a
anticipate the future growth of the must retain their original physical rule, especially MONOCRYL
patient. Here, the surgeon may use properties and strength throughout Sutures, PDS II Sutures, Coated
silk to its best advantage, because it the life of the patient. A prosthesis VICRYL Sutures, and chromic
loses much of its tensile strength never becomes completely incorpo- gut sutures.
after approximately 1 year, and is rated into the tissue and constant The urinary tract heals rapidly. The
usually completely absorbed after movement of the suture line occurs. transitional cell epithelium migrates
2 or more years. Continuous Coated polyester sutures are the over the denuded surfaces quickly.
polypropylene sutures have been used choice for fixation of vascular Unlike other epithelium, the
in children without adverse effects. prostheses and heart valves because migrating cells in the urinary tract
The continuous suture, when they retain their strength and undergo mitosis and cell division.
placed, is a coil which stretches as integrity indefinitely. Epithelial migration may be found
the child grows to accommodate the along suture tracts in the body of
Either a continuous or interrupted
changing dimensions of the blood the bladder. The bladder wall
technique may be used for vessel to
vessel. However, reports of stricture regains 100% of its original tensile
graft anastomoses.
following vessel growth have strength within 14 days. The rate of
stimulated interest in use of a To assist in proper strand identifica- collagen synthesis peaks at 5 days
suture line which is one-half tion, many surgeons alternate green and declines rapidly thereafter.
continuous, one-half interrupted. and white strands of ETHIBOND
CHAPTER 2 39
Thus, sutures are needed for only tissue and migrate into the wound. holding structure is no longer neces-
7 to 10 days. The junction heals first with scar sary. Referred to as a pull-out suture,
tissue, then by replacement with it is brought out through the skin
THE FEMALE GENITAL TRACT new tendon fibers. Close apposition and fastened over a polypropylene
Surgery within this area presents of the cut ends of the tendon button. The Bunnell Technique
certain challenges. First, it is usually (especially extensor tendons) suture can also be left in place.
regarded as a potentially contami- must be maintained to achieve
nated area. Second, the surgeon NUROLON Sutures, PROLENE
good functional results. Both the
must frequently work within a very Sutures, PRONOVA Sutures and
suture material and the closure
restricted field. Endoscopic technique ETHIBOND EXCEL Sutures may
technique are critical for successful
is frequently used in this area. Coated be used for connecting tendon to
tendon repair.
VICRYL Suture is an excellent choice bone. Permanent wire sutures also
to prevent bacterial colonization. The suture material the surgeon yield good results because healing is
chooses must be inert and strong. slow. In periosteum, which heals
Most gynecological surgeons prefer Because tendon ends can separate fairly rapidly, surgical gut or Coated
to use absorbable sutures for repair of due to muscle pull, sutures with a VICRYL Sutures may be used. In
incisions and defects. Some prefer great degree of elasticity should be fact, virtually any suture may be
using heavy, size 1 surgical gut avoided. Surgical steel is widely used used satisfactorily in the periosteum.
sutures, MONOCRYL Sutures, or because of its durability and lack of
Coated VICRYL Sutures. However, elasticity. Synthetic nonabsorbable SUTURES FOR BONE
the stresses on the reproductive materials including polyester fibers, In repairing facial fractures, mono-
organs and the rate of healing indicate polypropylene, and nylon may be filament surgical steel has proven ideal
that these larger-sized sutures may used. In the presence of potential for its lack of elasticity. Facial bones do
only be required for abdominal closure. infection, the most inert monofila- not heal by callus formation, but more
ment suture materials are preferred. commonly by fibrous union. The
Handling properties, especially
The suture should be placed to suture material must remain in place
pliability of the sutures used for
cause the least possible interference for a long period of time—
internal use, are extremely
with the surface of the tendon, as perhaps months—until the fibrous
important. Synthetic absorbable
this is the gliding mechanism. It tissue is laid down and remodeled.
sutures such as Coated VICRYL
should also not interfere with the Steel sutures immobilize the
Sutures in size 0 may be used for the
blood supply reaching the wound. fracture line and keep the tissues in
tough, muscular, highly vascular tissues
Maintenance of closed apposition good apposition.
in the pelvis and vagina. These
tissues demand strength during of the cut ends of the tendons, Following median stemotomy,
approximation and healing. Coated particularly extensor tendons, is surgeons prefer interrupted steel
VICRYL RAPIDE Suture, for critical for good functional results. sutures to close. Sternum closure may
example, is an excellent choice for The parallel arrangement of tendon be difficult. Appropriate tension must
episiotomy repair. fibers in a longitudinal direction be maintained, and the surgeon must
makes permanent and secure place- guard against weakening the wire.
TENDON SURGERY ment of sutures difficult. Various Asymmetrical twisting of the wire may
Tendon surgery presents several figure-of-eight and other types of cause it to buckle, fatiguing the metal,
challenges. Most tendon injuries are suturing have been used successfully and ultimately causing the wire to
due to trauma, and the wound may to prevent suture slippage and the break. Motion between the sides of
be dirty. Tendons heal slowly. The formation of gaps between the cut the sternum will result, causing
striated nature of the tissue makes ends of the tendon. postoperative pain and possibly
suturing difficult. Many surgeons use the Bunnell dehiscence. Painful nonunion is
Tendon repair fibroblasts are Technique. The suture is placed to another possible complication. (In
derived from the peritendonous be withdrawn when its function as a osteoporotic patients, very heavy
40 THE SUTURE
Closures (sterile tape). The wound
should be packed to maintain a moist
FIGURE environment. When the infection
24 has subsided, the surgeon can easily
reopen the wound, remove the
TACKING A packing and any tissue debris, and
PROSTHETIC then close using the previously
DEVICE IN
inserted monofilament nylon suture.
POSITION TO
PREVENT
MIGRATION
IN THE
NEXT SECTION
The surgeon depends as much upon
the quality and configuration of the
needle used as on the suturing
Coated VICRYL Sutures may be used when it reaches approximately 10 6
material itself to achieve a successful
to close the sternum securely.) bacteria per gram of tissue in an
closure. The relationship between
immunologically normal host.
The surgeon may use a bone anchor needles and sutures will be explored
Inflammation without discharge
to hold one end of a suture in place on the pages that follow.
and/or the presence of culture-
when needed (eg, shoulder repair
positive serous fluid indicate possible
surgery). This involves drilling a hole
infection. Presence of purulent REFERENCES
in the bone and inserting the anchor,
discharge indicates positive infection. 1. Mangram AJ, Horan TC, Pearson
which expands once completely
ML, Silver LC, Jarvis WR. Guideline
inside the bone to keep it from being Contaminated wounds can become for prevention of surgical site
pulled out. infected when hematomas, necrotic infection, 1999. Infection Control
tissue, devascularized tissue, or large and Hospital Epidemiology.
OTHER PROSTHETIC DEVICES amounts of devitalized tissue 1999;20:247-278.
Often, it is necessary for the sur- (especially in fascia, muscle, and bone) 2. Gilbert P, McBain AJ, Storch ML,
geon to implant a prosthetic device are present. Microorganisms multiply Rothenburger SJ, Barbolt TA.
such as an automatic defibrillator or rapidly under these conditions, where Literature-based evaluation of the
drug delivery system into a patient. they are safe from cells that provide potential risks associated with
To prevent such a device from local tissue defenses. impregnation of medical devices and
migrating out of position, it may be implants with triclosan. Surg
In general, contaminated wounds Infection J. 2002;3(suppl1):S55-S63.
tacked to the fascia or chest wall
should not be closed but should be left 3. Rothenburger S, Spangler D,
with nonabsorbable sutures. Bhende S, Burkley D. In vitro
open to heal by secondary intention
because of the risk of infection. antibacterial evaluation of Coated
CLOSING CONTAMINATED VICRYL Plus Antibacterial suture
Foreign bodies, including sutures,
OR INFECTED WOUNDS (coated polyglactin 910 with
perpetuate localized infection.
Contamination exists when triclosan) using zone of inhibition
Therefore, the surgeon's technique
microorganisms are present, but in assays. S Infection J. 2002;3
and choice of suture is critical. (suppl 1):S79-S87.
insufficient numbers to overcome the
Nonabsorbable monofilament nylon
body's natural defenses. Infection
sutures are commonly used in
exists when the level of contamina-
anticipation of delayed closure of
tion exceeds the tissue's ability to
dirty and infected wounds. The
defend against the invading
sutures are laid in but not tied.
microorganisms. Generally,
Instead, the loose suture ends are held
contamination becomes infection
in place with PROXI-STRIP Skin
CHAPTER 3
Manufacturers measure needle carefully selected to achieve the Needle sharpness is especially
strength in the laboratory by highest possible surgical yield, which important in delicate or cosmetic
bending them 90° to determine the also optimizes needle strength. surgery. The sharper the needle,
needle's maximum strength. This is the less scarring that will result.
Ductility refers to the needle's
referred to as the needle's "ultimate However, the right balance must be
resistance to breaking under a given
moment," and is more important to found. If a needle is too sharp, a
amount of bending. If too great a
the needle manufacturer than to the surgeon may not feel he or she has
force is applied to a needle it may
surgeon. The most critical aspect of adequate control of needle passage
break, but a ductile needle will
needle strength to the surgeon is through tissue.
bend before breaking. Needle
the "surgical yield" point. Surgical
breakage during surgery can prevent Sharpness is related to the angle of
yield indicates the amount of
apposition of the wound edges as the point as well as the taper ratio
angular deformation the needle
the broken portion passes through of the needle. The ETHICON, INC.,
can withstand before becoming
tissue. In addition, searching for sharpness tester incorporates a thin,
permanently deformed. This point
part of a broken needle can cause laminated, synthetic membrane
is usually 10° to 30° depending
added tissue trauma and add to the that simulates the density of human
upon the material and the manu-
time the patient is anesthetized. A tissue, allowing engineers to gauge
facturing process. Any angle beyond
piece that cannot be retrieved will exactly how much force is required
that point renders the needle
remain as a constant reminder to for penetration.
useless. Reshaping a bent needle
both the patient and surgeon.
may cause it to lose strength MULTIPASS Needles have a micro-
Needle bending and breakage can
and be less resistant to bending thin coating comprised of a patented
be minimized by carefully passing
and breaking. silicone formulation that improves
needles through tissue in the
penetration performance over multiple
At ETHICON, INC., the com- direction of the needle body.
passes. According to laboratory
bination of alloy selection and the Needles are not designed to be
tests, this coating serves several
needle manufacturing process are used as retractors to lift tissue.
important functions:
✦ It reduces the force needed to
make initial penetration through
FIGURE tissue; thus it is 58% sharper
12:1 ratio 1 (than other surgical needles) on
multiple passes in human tissue
TAPER
RATIO ✦ Significantly improves the con-
sistency of the needle penetration
(pass to pass, needle to needle)
✦ Maintains sharpness for better
penetration and control over
FIGURE
2 multiple passes while delivering
ongoing strength, sharpness, and
ETHICON control
RIBBED Needle performance is also
NEEDLE
influenced by the stability of the
needle in the grasp of a needle-
holder. Most curved needles are
flattened in the grasping area to
enhance control. ETHICON, INC.,
44 THE SURGICAL NEEDLE
curved needles of 22 mil wire PRINCIPLES OF 1. Consider the tissue in which the
or heavier are ribbed as well as surgeon will introduce the
flattened. Longitudinal ribbing
CHOOSING A needle. Generally speaking, taper
or grooves on the inside or outside
SURGICAL NEEDLE point needles are most often used
curvatures of curved needles While there are no hard and fast to suture tissues that are easy
provides a crosslocking action in rules governing needle selection, the to penetrate. Cutting or
the needleholder for added needle following principles should be kept TAPERCUT* Surgical Needles
control. This reduces undesirable in mind. (Specific types of needles are more often used in tough,
rocking, twisting, and turning in mentioned here will be described in hard-to-penetrate tissues. When
the needleholder. full detail later on in this section.) in doubt about whether to
choose a taper point or cutting
needle, choose the taper point for
everything except skin sutures.
2. Watch the surgeon's technique
FIGURE closely. Select the length,
3 diameter, and curvature of the
Point
needle according to the desired
NEEDLE placement of the suture and the
COMPONENTS space in which the surgeon
is working.
3. Consult frequently with the
Eye surgeon. Working with the same
(Swaged end) surgeon repeatedly leads to
familiarity with his or her
individual routine. However,
Body even the same surgeon may need
to change needle type or size to
meet specific requirements,
even during a single operative
procedure.
4. When using eyed needles, try to
match needle diameter to suture
size. Swaged needles, where the
needle is already attached to the
FIGURE suture strand, eliminate this
Chord length 4
Needle concern.
point Swage
5. The best general rule of thumb
ANATOMY for the scrub person to follow is
OF A NEEDLE
pay attention and remain alert to
Needle the progress of the operation.
radius
Observation is the best guide to
needle selection if the surgeon
Needle
diameter has no preference.
Needle length
Needle body
CHAPTER 3 45
THE ANATOMY The closed eye is similar to a be cut, or easily released from the
household sewing needle. The shape needle as is the case when using
OF A NEEDLE of the eye may be round, oblong, CONTROL RELEASE* Needles
Regardless of its intended use, or square. French eye needles have a (Patent No. 3,980,177).
every surgical needle has 3 basic slit from inside the eye to the end
components: The diameter of a needle swaged
of the needle with ridges that catch
to suture material is no larger
✦ The eye. and hold the suture in place.
than necessary to accommodate
✦ The body. Eyed needles must be threaded, a the diameter of the suture strand
✦ The point. time-consuming procedure for the itself. Swaged sutures offer several
scrub person. This presents the advantages to the surgeon, nurse,
The measurements of these disadvantage of having to pull a and patient.
specific components determine, double strand of suture material
in part, how they will be used 1. The scrub person does not have
through tissue, creating a larger hole
most efficiently. to select a needle when the
with additional tissue disruption.
surgeon requests a specific suture
Needle size may be measured in In addition, the suture may still
material since it is already
inches or in metric units. The become unthreaded while the
attached.
following measurements determine surgeon is using it. While tying the
the size of a needle. suture to the eye may minimize this 2. Handling and preparation are
possibility, it also adds to the bulk minimized. The strand with
✦ CHORD LENGTH—The
of the suture. Another disadvantage needle attached may be used
straight line distance from the
of eyed needles is that repeated use directly from the packet. This
point of a curved needle to
of these needles with more than helps maintain the integrity of
the swage.
1 suture strand causes the needle the suture strand.
✦ NEEDLE LENGTH—The to become dull, thereby making
distance measured along the 3. Tissues are subjected to minimal
suturing more difficult. trauma.
needle itself from point to end.
Virtually all needles used today are 4. Tissue trauma is further reduced
✦ RADIUS—The distance from
swaged. This configuration joins because a new, sharp, undamaged
the center of the circle to the
the needle and suture together as needle is provided with each
body of the needle if the
a continuous unit—one that is suture strand.
curvature of the needle were
convenient to use and minimizes
continued to make a full circle. 5. Swaged sutures do not unthread
trauma. The method of attaching
✦ DIAMETER—The gauge or the suture to the needle varies with prematurely.
thickness of the needle wire. the needle diameter. In larger 6. If a needle is accidentally
Very small needles of fine gauge diameter needles, a hole is drilled dropped into a body cavity, the
are needed for microsurgery. in the needle end. In smaller attached suture strand makes it
Large, heavy gauge needles are diameter needles, a channel is easier to find.
used to penetrate the sternum made by forming a "U" at the
and to place retention sutures 7. Inventory and time spent
swage end or a hole is drilled in
in the abdominal wall. A broad cleaning, sharpening, handling,
the wire with a laser. Each hole or
spectrum of sizes are available and sterilizing reusable eyed
channel is specifically engineered
between the 2 extremes. needles is eliminated, thereby
for the type and size of suture
reducing cost as well as risk of
material it will hold, and crimped
THE NEEDLE EYE needle punctures.
or closed around the suture to hold
The eye falls into 1 of 3 categories: it securely. When the surgeon has 8. CONTROL RELEASE Needles
closed eye, French (split or spring) finished placing the suture line in allow placement of many sutures
eye, or swaged (eyeless). the patient's tissue, the suture may rapidly. This may reduce
46 THE SURGICAL NEEDLE
Small diameter ETHICON, INC., This needle/suture configuration was
THE NEEDLE EYE
FIGURE taper point needles commonly used in created originally for abdominal closure
5 cardiovascular surgery were compared and hysterectomies, but is now used
in laboratory tests—some with "split" in a wide variety of procedures.
channels and some with laser-drilled
holes. The needles with laser-drilled THE NEEDLE BODY
holes produced less drag force as they The body of the needle is the portion
passed through a membrane that that is grasped by the needleholder
simulated vascular tissue. This could during the surgical procedure. The
Closed eye be associated with less trauma to the body of the needle should be as
vessel walls. close as possible to the diameter
of the suture material to minimize
The swaged ATRALOC Needles made
bleeding and leakage. This is especially
by ETHICON, INC., are supplied
true for cardiovascular, gastrointestinal,
in a variety of sizes, shapes, and
and bladder procedures.
strengths. Some of them incorporate
the CONTROL RELEASE Needle The curvature of the needle body
Suture principle that facilitates fast may come in a variety of different
separation of the needle from the shapes. Each shape gives the needle
French eye suture when desired by the surgeon. different characteristics.
This feature allows rapid placement
of many sutures, as in interrupted STRAIGHT NEEDLE
suturing techniques. Even though the This shape may be preferred when
suture is securely fastened to the needle, suturing easily accessible tissue.
a slight, straight tug will release it. Most of these needles are designed
FIGURE
Swaged
6
to be used in places where direct Some microsurgeons prefer straight portion passes through tissue easily,
finger-held manipulation can easily needles for nerve and vessel repair. the remaining straight portion of
be performed. In ophthalmology, the straight trans- the body is unable to follow the
chamber needle protects endothelial curved path of the needle without
The Keith needle is a straight
cells and facilitates placement of bending or enlarging its path in
cutting needle. It is used primarily
intraocular lenses. the tissue.
for skin closure of abdominal
wounds. Varying lengths are also
HALF-CURVED NEEDLE CURVED NEEDLE
used for arthroscopic suturing of
The half-curved or "ski" needle Curved needles allow predictable
the meniscus in the knee.
may be used for skin closure or in needle turnout from tissue, and
Bunnell (BN) needles are used for laparoscopy. Its low profile allows are therefore used most often.
tendon repair. Taper point needle easy passage down laparoscopic This needle shape requires less
variations may also be used for trocars. Its use in skin closure is space for maneuvering than a
suturing the gastrointestinal tract. limited because, while the curved straight needle, but the curve
necessitates manipulation with a
needleholder. The curvature may
SHAPE APPLICATION be 1/4, 3/8, 1/2, or 5/8 circle.
Straight gastrointestinal tract, nasal FIGURE The most common use for the 3/8
cavity, nerve, oral cavity, 7 circle is skin closure. The surgeon
pharynx, skin, tendon, vessels
can easily manipulate this curvature
NEEDLE
SHAPES
with slight pronation of the wrist in
AND TYPICAL a relatively large and superficial
Half-curved skin (rarely used)
laparoscopy APPLICATIONS wound. It is very difficult to use
this needle in a deep body cavity or
restricted area because a larger arc of
manipulation is required.
1/4 Circle eye (primary application)
microsurgery The 1/2 circle needle was designed
for use in a confined space,
although it requires more pronation
and supination of the wrist. But
3/8 Circle aponeurosis, biliary tract, cardiovascular even the tip of this needle may
system, dura, eye, gastrointestinal tract,
muscle, myocardium, nerve, perichon-
be obscured by tissue deep in
drium, periosteum, pleura, skin, tendon, the pelvic cavity. A 5/8 circle
urogenital tract, vessels
needle may be more useful in
1/2 Circle biliary tract, cardiovascular system, eye, this situation, especially in some
fascia, gastrointestinal tract, muscle, anal, urogenital, intraoral, and
nasal cavity, oral cavity, pelvis, peri-
toneum, pharynx, pleura, respiratory cardiovascular procedures.
tract, skin, tendon, subcutaneous fat,
urogenital tract
5/8
COMPOUND
Circle anal (hemorrhoidectomy), nasal
cavity, pelvis, urogenital tract (primary CURVED NEEDLE
application) The compound curved needle
(Patent No. 4,524,771) was
Compound eye (anterior segment) originally developed for anterior
Curved laparoscopy segment ophthalmic surgery. It
allows the surgeon to take precise,
uniform bites of tissue. The tight
48 THE SURGICAL NEEDLE
80° curvature of the tip follows into
a 45° curvature throughout the SHAPE APPLICATION
remainder of the body. The initial Conventional Cutting skin, sternum FIGURE
curve allows reproducible, short, 8
deep bites into the tissue. The Point
CUTTING NEEDLES
CS ULTIMA* Ophthalmic Needle eye (primary application)
Cutting needles have at least 2
Point
opposing cutting edges. They are
sharpened to cut through tough, Body
difficult-to-penetrate tissue.
Cutting needles are ideal for skin Taper aponeurosis, biliary tract, dura, fascia,
sutures that must pass through Point gastrointestinal tract, laparoscopy,
dense, irregular, and relatively muscle, myocardium, nerve, peritoneum,
pleura, subcutaneous fat, urogenital
thick connective dermal tissue. Body tract, vessels, valve
Because of the sharpness of the
TAPERCUT* Surgical Needle bronchus, calcified tissue, fascia,
cutting edge, care must be taken laparoscopy, ligament, nasal cavity,
in some tissue (tendon sheath Point oral cavity, ovary, perichondrium,
periosteum, pharynx, sternum, tendon,
or oral mucous membrane) to trachea, uterus, valve, vessels (sclerotic)
Body
avoid cutting through more tissue
than desired. Blunt Blunt dissection (friable tissue),
Point cervix (ligating incompetent cervix),
fascia, intestine, kidney, liver, spleen
Body
CHAPTER 3 49
Taper point needles are usually particularly for gynecological eliminates the danger of cutting
used in easily penetrated tissue procedures, general closure, and into the surrounding issue.
such as the peritoneum, abdominal hernia repair.
Although initially designed for use
viscera, myocardium, dura, and
in cardiovascular surgery on sclerotic
subcutaneous layers. They are TAPERCUT SURGICAL
or calcified tissue, the TAPERCUT
preferred when the smallest possible NEEDLES
Needle is widely used for suturing
hole in the tissue and minimum ETHICON, INC., manufactures
dense, fibrous connective tissue—
tissue cutting are desired. They are TAPERCUT Needles, which combine
especially in fascia, periosteum, and
also used in internal anastomoses the features of the reverse cutting-edge
tendon where separation of parallel
to prevent leakage that can tip and taper point needles. Three
connective tissue fibers could occur
subsequently lead to contamination cutting edges extend approximately
with a conventional cutting needle.
of the abdominal cavity. In the 1/32" back from the point. These
fascia, taper point needles minimize blend into a round taper body. All ETHICON developed a modified
the potential for tearing the thin three edges are sharpened to provide TAPERCUT CC Needle (Calcified
connective tissue lying between uniform cutting action. The point, Coronary) for anastomosis of small
parallel and interlacing bands of sometimes referred to as a trocar fibrotic and calcified blood vessels.
denser, connective tissue. point, readily penetrates dense, The calcified portion of an artery
tough tissue. The objective should requires a cutting tip only for initial
The Mayo (MO) needle has a taper
be for the point itself not to exceed penetration to avoid tearing the
point, but a heavier and more
the diameter of the suture material. vessel. This needle configuration
flattened body than conventional
The taper body portion provides has a slimmer geometry than other
taper needles. This needle was
smooth passage through tissue and TAPERCUT Needles from the body
designed for use in dense tissue;
through the point which facilitates
PACKAGING
56 PACKAGING
3. Provide identifiable product The RELAY Delivery System
AN INTEGRAL PART
information. consists of 3 basic, interrelated
OF THE PRODUCT 4. Permit convenient, safe, and components: modular suture
The purpose of a package is to sterile transfer of the product storage racks, dispenser boxes,
protect its contents and provide from the package to the and primary packets.
convenience to the user. sterile field.
ETHICON, INC., wound closure 5. Meet the functional needs of all MODULAR STORAGE RACKS
packaging is an integral part of members of the surgical team. The modular storage racks are
each product. Over the past half a designed for maximum convenience
century, packaging has evolved RELAY* SUTURE and versatility to meet the individ-
from glass tubes packed in jars, ual needs of a particular specialty,
to multilayered foil and paper
DELIVERY SYSTEM
nurse, surgeon, or department.
packages, to new materials that Most suture materials are packaged Modules can be easily assembled
reflect concern for both the and sterilized by the manufacturer. to accommodate both vertical and
environment and the individuals They arrive ready for use in boxes horizontal suture dispenser boxes.
who must maintain operative that can be stored until needed. The Any number of modules can be
sterility and efficiency. Packaging RELAY Delivery System, developed fastened together to meet both
has kept pace with the technological by ETHICON, INC., with human, small and large storage needs.
developments of wound closure clinical, and environmental factors Once assembled, the racks may be
products themselves. Several factors in mind, stores and delivers sutures used on shelves, mounted on walls,
have influenced these developments: in a time-efficient manner and placed on mobile carts, or
✦ Increasing product diversity reduces unnecessary handling to connected to IV poles. Racks can
access sutures. The system also also be fitted with a rotating base
✦ Technological advances in provides control over suture storage, for more convenient access, as well
packaging materials usage, inventory rotation, needle as with a handle for easy carrying.
✦ Stringent regulatory requirements counting, and cost containment. Each module has a built-in
To prevent infection in an operative
wound, all instruments and supplies
that come in contact with the
FIGURE
wound must be sterile (free of 1
living microorganisms and spores)
including sutures, needles, ligating ETHICON
clips, stapling instruments, adhesive MODULAR
tapes and topical skin adhesives. STORAGE
RACKS
High standards and criteria are set
for all components in the packaging Full-vertical boxes Half-vertical boxes
of sterile products:
1. Protect and preserve product
stability and sterility from
potential deterioration from
outside forces such as oxygen,
moisture, light, temperature,
dust, and vermin.
2. Prevent product damage or
microbial contamination in
transit and storage.
Horizontal boxes Combination of boxes
CHAPTER 4 57
inventory control area to facilitate by silhouette) surfaces of the overwrap are not
restocking. This feature enables 6. Needle point geometry sterile. ETHICON, INC., primary
unused suture packets to be 7. Lot number packaging is designed to permit fast
systematically fed back into the 8. Expiration date and easy opening in one peelable
proper rotational flow without motion. The single layer overwrap
A package insert with detailed infor-
mixing lots within the boxes. of primary packaging is made of
mation about the suture material is
Sutures may be grouped within either foil or coated Tyvek® on one
inserted in every dispenser box. Users
the modular system by material side heat-sealed to polyethylene film
should be familiar with this informa-
type or size, or by use (ie, general on the other. Absorbable sutures are
tion as it contains FDA-approved
closure, gastrointestinal surgery, always encased in foil to provide a
indications, contraindications, and
plastic surgery). safe and durable moisture barrier
all appropriate warnings and precau-
and to withstand sterilization in
tionary statements for each product.
DISPENSER BOXES the manufacturing process. Most
Gravity-fed dispenser boxes dispense Dispenser boxes should be restocked nonabsorbable sutures are encased
suture packets from the opening at when the last few suture packets in coated Tyvek® overwraps.
the bottom of the box. The opening appear in the box opening, before
In a continuous effort to be
can accommodate the removal of the box is completely empty. The
more environmentally conscious,
several suture packets at one time. unused packets from the previous
ETHICON, INC., has chosen
box should be used before a new
All ETHICON, INC., dispenser materials in the manufacture of
dispenser box is opened. This will
boxes are made of recyclable paper primary packets that generate
help to avoid mixing lot numbers
and printed with either water or minimal negative impact to the
and ensure proper stock rotation.
soy-based inks. Each box provides environment upon incineration or
ETHICON, INC., advocates rota-
clear product identification through disposal. Furthermore, wherever
tion of the entire dispenser box. In
streamlined graphics, product possible, the number of primary
addition to ensuring the use of the
color coding, bold label copy, bar packaging layers has been reduced
oldest suture materials first, this
coding and descriptive symbols. by as much as 50 percent, thus
helps to maintain a fresh stock of
The information required for quick reducing the volume of environ-
dispenser boxes.
reference and easy selection of mental waste per OR procedure.
suture materials is highlighted in Most dispenser boxes contain
Each primary packet provides
a logical sequence. The 3 most three dozen suture packets. Others
critical product information and
important criteria necessary for may contain 1- or 2-dozen
the same color-coding as its
proper identification and suture packets. The product code number
dispenser box. The packet also
selection are: suffix and a statement on the box
identifies the product code number,
1. Suture size indicate the quantity of suture
material, size, needle type, and the
2. Suture material packets in the box (product code
number of needles per packet to
3. Type and size of needle suffix G = 1 dozen, D = 1 dozen,
simplify needle counts.
T = 2 dozen, H = 3 dozen). The
Other important product
dispenser boxes are held securely for Primary packets of suture material
information found on all suture
easy dispensing by firmly pushing may contain sutures in 1 of 5 styles:
boxes includes:
the box into a "lock" in the back of 1. Standard lengths of non-needled
1. Surgical application
the rack module. material: 54 inches (135 cm) of
2. Product code number
absorbable or 60 inches (150 cm)
3. Suture length and color
PRIMARY PACKETS of nonabsorbable suture, which
4. Metric diameter equivalent of
Individual sutures and multiple may be cut in half, third, or
suture size and length
suture strands are supplied sterile quarter lengths for ligating
5. Shape and quantity of needles
within a primary packet. The exterior or threading.
(single- or double-armed, shown
58 PACKAGING
2. SUTUPAK* Pre-cut Sterile Suture
ABSORBABLE SUTURE LAYERS is non-needled material for
ligating or threading. These
Surgical Gut Suture Tyvek overwrap, foil primary TABLE
package containing 1-step 1 lengths may be supplied in a
RELAY Suture Delivery System tray multistrand labyrinth packet or
Coated VICRYL RAPIDE Suture Tyvek overwrap, foil primary package, MOST in a folder packet, both of which
paper folder
COMMON are designed to deliver one strand
MONOCRYL Suture Peelable foil overwrap, 1-step ETHICON at a time. SUTUPAK Sutures
RELAY tray SUTURE
may be removed from the packet
Coated VICRYL Plus Peelable foil overwrap, 1-step PACKAGING
Antibacterial Suture RELAY tray and placed in the suture book.
Coated VICRYL Peelable foil overwrap, 1-step 3. One single strand of material
(polyglactin 910) Suture RELAY tray
with single- or double-armed
PDS II Suture Peelable foil overwrap, 1-step
RELAY tray
swaged needle(s). Needles for
1-step RELAY Packaging,
NONABSORBABLE SUTURE LAYERS microsurgery, and some
PERMA-HAND Silk Suture Tyvek overwrap, 1-step RELAY tray ophthalmic needles are secured in
Stainless Steel Suture Tyvek overwrap, paper folder a "needle park." The needle park
ETHILON Suture Peelable foil overwrap, 1-step is designed to provide a standard
RELAY tray location for, and easy access to,
NUROLON Suture Tyvek overwrap, 1-step RELAY tray the needle. All other needles are
MERSILENE* Suture Tyvek overwrap, 1-step RELAY tray protected within an inner
folder or other specific channel
ETHIBOND EXCEL Suture Tyvek overwrap, 1-step RELAY tray within a paper folder.
PROLENE Suture Tyvek overwrap, 1-step RELAY tray Most single strand needled
PRONOVA Suture Tyvek overwrap, 1-step RELAY tray sutures are sealed in convenient
1-step RELAY Delivery
Tyvek is a registered trademark of E.I. du Pont de Nemours and Company Packaging. 1-step RELAY Pack-
aging allow the needle to be armed
in the needleholder from any
angle without touching the
FIGURE needle. This increases the safety
2
of handling needles intraopera-
tively. If it is preferred to locate
METHOD FOR
PREPARING the needle by hand, this can be
1-STEP accomplished with the 1-step
RELAY RELAY Packaging by pushing up
PACKAGE the flap behind the needle park,
SUTURES
thereby elevating the needle so it
can be grasped by hand.
4. Multiple suture strands, either
swaged to a single needle or
double-armed. This type is
appropriate for procedures
requiring numerous interrupted
sutures of the same type. It saves
Arm the needle directly from the 1-step RELAY tray and
deliver the single suture to the surgeon. valuable operative time by
CHAPTER 4 59
enabling the surgeon to use one Sutures, MERSILENE sutures, An abdominal incision 8 to
suture while the next is being and surgical gut sutures. The 12 inches long might require
armed—without delay of open- safety organizer tray allows for 1 to 3 packets to ligate the
ing packets or threading needles. single strand arming and subcutaneous blood vessels.
dispensing. The needles are
Multistrand packets are labeled All suture material is packaged
situated in individually num-
with the symbol MS/ that dry with the exception of surgical
bered needle parks and may be
denotes multiple strands/number gut and pliabilized ETHILON
armed and dispensed with little
of strands of surgical needles per Sutures. Natural absorbable suture
or no hand-to-needle contact.
packet. Multistrand packets may materials are packaged with a
contain 3 to 10 swaged sutures. 5. Ligating material used as either small amount of sterile fluid,
The inner folder for these single strand (free or freehand) usually alcohol with water, to
products is white. ties, or as continuous ties maintain pliability. They should
unwound from a reel or other therefore be opened over a basin to
All packets containing device. The length of single prevent any solution from spilling
CONTROL RELEASE Needle strand ties is determined by the onto the sterile field.
Sutures have multiple strands depth of the wound. In subcuta-
(8, 5, 4, 3, or 1) and are neous tissue, quarter lengths All needles should be counted
designated CR/8, CR/5, CR/4, (approximately 14 inches) are after packets of swaged sutures
CR/3, or CR/1. CONTROL usually long enough for ligating. are opened, according to
RELEASE Sutures may be Single strand ligating material is established hospital procedure.
available in foil or Tyvek available in pre-cut lengths or 18-, The packets should be retained
overwrap packets for single 24-, and 30-inch strands. to facilitate verification of the
strand delivery. The single strand final needle count after the
delivery folder is used for some Many surgeons prefer continuous surgical procedure.
Coated VICRYL Sutures, ties. Some prefer LIGAPAK
MONOCRYL Sutures, Ligature, which is supplied on
PDS II (polydioxanone) Sutures, disc like plastic radiopaque E-PACK*
ETHIBOND EXCEL Sutures, dispensing reels that are color PROCEDURE KIT
NUROLON Sutures, coded by material. The size of The E-PACK procedure kit
MERSILENE Sutures, and the ligature material is indicated contains numerous sutures and
PERMA-HAND Sutures. The by the number of holes visible on other products for a specific
suture material straightens as it the side of the reel (eg, 3 holes= procedure, surgeon, or surgical
is delivered from the folder. Each 3-0 suture). The reel is held in specialty. The packaging concept
suture may be delivered to the the palm of the hand as blood saves valuable time in the OR by
surgeon individually from the vessels are ligated. Other eliminating the need to open and
opening packet or removed from surgeons may prefer the ligating coordinate multiple individual
the folder and placed in the material rewound onto a rubber suture packages. The E-PACK
suture book. The inner folder reel, gauze sponge, metal bobbin, procedure kit is also an effective
for these products is either red or other device. means of reducing inventory
with a black C/R symbol or The number of packets of levels of individual product
white with red lettering. ligating material required to tie codes, and providing a record
The safety organizer tray is used off subcutaneous vessels for determining the suture
for Coated VICRYL Sutures, (bleeders) will vary with patient costs associated with a given
MONOCRYL Sutures, size and age, the amount of surgical procedure.
PDS II Sutures, ETHIBOND bleeding, the type of operation,
EXCEL Sutures, PERMA- the length of the incision,
HAND Sutures, NUROLON and the surgical technique.
60 PACKAGING
The suture packages are secured The RELAY Delivery System is As an environmental measure,
in an organizer sleeve to facilitate designed as a "first-in, first-out" ETHICON, INC., replaced chloro-
sterile transfer to the sterile field. inventory control system. Dispenser fluorocarbons (CFCs) with more
boxes are rotated, permitting the environmentally friendly compounds
The procedure kit label provides all
oldest sutures to be used first. The in all gas sterilization processes.
the pertinent information regarding
expiration date stamped on the The combination of ethylene oxide
the number and types of needles, as
outside of each box and every gas concentration, temperature,
well as sizes and types of suture.
packet clearly indicates the month humidity, and exposure time must
Suture quantities are listed on the
and year of product expiration. be carefully controlled to ensure
label, making it easy to quickly
reliable sterilization.
determine how many needles have
been used and thus simplifying SUTURE WARNING: Surgical sutures are
needle accountability at the end of STERILIZATION labeled as disposable, single-use
the procedure. The organizer sleeve medical devices. Suture products
Sutures sterilized by ETHICON, INC.,
is delivered in a Tyvek pouch. manufactured by ETHICON, INC.,
are either irradiated with cobalt 60
are provided in easy-to-use packages
or exposed to ethylene oxide gas.
designed to maintain the stability
Both processes alter proteins, enzymes,
EXPIRATION DATE and other cellular components to
and sterility of the suture and needle
materials. The component layers of
The expiration date of a product is the extent that microorganisms are
packaging materials do not permit
determined by product stability unable to survive or cause infection.
exposure to high temperatures or
studies. ETHICON, INC., suture Irradiation and ethylene oxide gas
extremes of pressure without affect-
products have an expiration date are considered cold sterilization
ing package and product integrity.
stamped on each dispenser box and processes because radiation sterilizes
For this reason, all sterile products
primary packet to indicate the at room temperature and ethylene
manufactured by ETHICON, INC.,
known shelf life of the material, oxide gas sterilizes at much lower
are clearly labeled, "DO NOT
provided the physical integrity of temperatures than other sterilization
RESTERILIZE."
the package is maintained. Tests methods such as dry heat or steam
conducted by ETHICON, INC., under pressure. Manufacturers cannot be held
show conclusively that synthetic responsible for the quality,
Irradiation sterilization exposes
absorbable suture products such as effectiveness, or integrity of suture
products to ionizing radiation—
Coated VICRYL Suture and materials resterilized in the hospital,
either beta rays produced by high
PDS II Suture continue to meet office, or by outside vendors.
energy electron accelerators or
all product requirements even at Therefore, if customers utilize the
gamma rays from radioisotopes—
5 years of storage. services of a sterilization reprocessor
until absorbed in appropriate
for suture, ETHICON, INC., will
sterilizing dose. ETHICON, INC.,
disclaim any responsibility for steril-
was a pioneer in both beta and
ization and/or other product failures
gamma irradiation and routinely
resulting from the resterilization
sterilizes products with cobalt
process. The practice of resteriliza-
60 which emits gamma rays.
tion is not recommended except for
Cobalt 60 irradiation is the simplest
ETHI-PACK Sutures and spools or
of all sterilization processes.
cardreels of nonabsorbable materials
Some suture materials cannot supplied nonsterile.
withstand the effects of irradiation
sterilization, becoming unusable.
Instead, they are gas sterilized. Gas
sterilization uses ethylene oxide gas.
CHAPTER 4 61
ANTICIPATING 2. Opening sufficient suture packets 3. Nonsterile hands over the sterile
SUTURE NEEDS to prevent prolonging operative field violate aseptic technique.
time and causing surgeon
Today's healthcare environment There are 2 methods commonly
inconvenience.
dictates that hospitals continue to used for achieving sterile transfer
3. Leftover suture on the surgical of suture packets: handing-off the
maintain quality standards while
field must be discarded. sterile inner 1-step RELAY tray
lowering costs to remain financially
Therefore, opening too many directly to the scrub person or
viable. Through total quality man-
suture packets should be "flipping" the inner contents of the
agement initiatives, many hospitals
avoided to reduce waste and to primary packet onto the sterile field.
have identified material use as an
lower cost. Regardless of the aseptic technique
opportunity to lower cost. To
increase the efficiency of suture Although it is important to be performed, all items introduced
utilization during a surgical prepared to answer requests at a onto the sterile field should be
procedure, it is important to moment's notice, it is not necessary opened, dispensed, and transferred
determine and anticipate the to overload the table with sutures. by methods that maintain product
surgeon's needs more precisely. The introduction of single-layer sterility and integrity. AORN
For this reason, a file system of peelable packaging, such as 1-step Guidelines recommend the
preference cards for each surgeon RELAY Packaging, helps encourage "hand-off" method, since items
on staff is usually maintained in the less handling to access the suture, tossed or flipped have a greater
operating suite. The cards contain enhancing quick delivery of suture potential to roll off the edge of the
such information as the surgeon's materials to the surgeon in the sterile field, causing contamination
"suture routine," suture materials, sterile field. Unexpected suture or other items to be displaced.
sizes, needles, and/or product needs can also be obtained rapidly
code numbers customarily used in METHOD I: STERILE TRANSFER TO
from the storage racks.
specific procedures. THE SCRUB PERSON
Grasp the 2 flaps of the peelable
STERILE TRANSFER OF
Becoming more aware of each overwrap between the knuckles of
SUTURE PACKETS
surgeon's routine through good the thumbs and forefingers. With
At some point, suture packets
communication and regularly a rolling-outward motion, peel
must cross the sterile barrier—the
updated preference cards can help the flaps apart to approximately
invisible line of demarcation
reduce preparation time, minimize one third of the way down the
between the sterile and the nonster-
waste, and assure cost effectiveness. sealed edges. Keeping pressure
ile. In all settings (eg, operating
Prior to dispensing suture packets, between the knuckles for control,
room, delivery room, emergency
the circulating nurse should have a offer the sterile inner packet or
department, or physician's office),
brief discussion with the surgeon to tray to the scrub person, who takes
the individual who removes
ascertain whether a change in suture it with a gloved hand or sterile
the nonsterile overwrap must
routine is anticipated due to a instrument. Care must be taken to
remember these 3 points about
specific patient's needs. avoid contact with the nonsterile
sterile transfer:
While it is difficult to say precisely overwrap as the packet or tray
1. Outer surfaces of the overwrap is withdrawn.
how many suture packets are are not sterile and may be
enough, 3 major factors should be handled with nonsterile hands. This method must be used to
considered in deciding how many remove paper folder packets of sur-
2. The sterile inner packet or tray
packets to open: gical steel and PROLENE Sutures
must be transferred to the sterile
1. Fewer packets will be needed if from long straight overwraps, and to
field without being touched or
products with multiple strands of remove the organizer sleeves from
contacting any nonsterile object
suture material are used. E-PACK procedure kits. It should
or surface.
also be used for transfer of flexible,
62 PACKAGING
PREPARATION OF
STANDARD LENGTH
FIGURE LIGATURE STRANDS
3 FIGURE
4
STERILE
TRANSFER
TO THE
SCRUB
PERSON 1. Prepare cut lengths of ligature
material, coil around fingers of left
hand, grasp free ends with right
hand, and unwind to full length.
lightweight, transparent packets Instead, present them to the scrub 2. Maintain loop in left hand and
2 free ends in right hand. Gently
containing microsurgery and person as outlined in Method I. pull the strand to straighten.
ophthalmic products.
SUTURE PREPARATION
METHOD II: STERILE TRANSFER TO IN THE STERILE FIELD
THE STERILE FIELD Suture preparation may be more
"Flipping" is a rapid and efficient confusing than virtually any other
method of ejecting sterile product aspect of case preparation.
from its overwrap onto the sterile Familiarity and understanding of 3. To make 1/3 lengths: Pass 1 free
field without contacting the the sequence in which tissue layers end of strand from right to left hand.
Simultaneously catch a loop around
unsterile outer packet or reaching are handled by the surgeon will help third finger of right hand. Make
over the field. However, skill must to eliminate this confusion. (See the strands equal in thirds and cut the
loops with scissors.
be acquired to ensure its effective Suturing Section, Chapter 2.)
use. The circulating nurse must
stand near enough to the sterile Once the suture packets are opened
table to project the suture packet and prepared according to the
or tray onto it, but not too close surgeon's preference card, sutures
as to risk contaminating the table can be organized in the sequence in
by touching it or extending which the surgeon will use them.
4. To make 1/4 lengths: Pass both free
nonsterile hands over it. To Ligatures (ties) are often used first ends from right to left hand.
accomplish this, grasp the flaps in subcutaneous tissue shortly after Simultaneously catch a double loop
around third finger of right hand.
of the overwrap as described in the incision is made, unless ligating Cut the loops.
Method I and peel the flaps apart clips or an electrosurgical cautery
with the same rolling-outward device is used to coagulate severed
motion. The sterile packet or tray blood vessels.
is projected onto the sterile table After the ligating materials have
as the overwrap is completely been prepared, the suturing
peeled apart. (sewing) materials can be prepared
5. Place packets or strands in suture
NOTE: DO NOT attempt to pro- in the same manner. Preparing large book (folded towel)—or under Mayo
ject the inner folder of long straight amounts of suture material in tray—with ends extended far
enough to permit rapid extraction.
packets onto the sterile table. advance should be avoided. For
CHAPTER 4 63
1. Open the packet contain- 2. Extend the strand end 3. Hand reel to surgeon as 4. Surgeon holds reel in
ing the appropriate slightly for easy grasp- needed, being certain that palm, feeds strand
material on a reel. Transfer ing. Place reel conviently the end of the ligating between fingers, and
the inner contents of the on the Mayo tray. material is free to grasp. places around tip of
primary packet to the hemostat.
sterile field using aseptic
technique.
FIGURE
6
PEPARATION
OF PRE-CUT
SUTURES
FOR TIES OR
LIGATURE
SUTURES
1. Remove 1 pre-cut length from nonabsorbable 2. Extract pre-cut strands of SUTUPAK Suture.
suture at a time from the labyrinth packet as it is Straighten surgical gut with a gentle pull. Place
needed by the surgeon. strands in the suture book or under Mayo tray.
example, if the surgeon opens the material to stay one step ahead of originally, do not be reluctant to
peritoneum (the lining of the the surgeon. The goal should be to ask the surgeon if one of the
abdominal cavity) and discovers have no unused strands at the end strands will serve the purpose
disease or a condition that alters of the procedure. before opening a new packet.
plans for the surgical procedure Most surgeons are cooperative in
Ligature material which remains
and anticipated use of sutures, efforts to conserve valuable supplies.
toward the end of the procedure
opened packets would be wasted.
may be the same material and size
At closure following abdominal SUTURE HANDLING
specified by the surgeon for sutures
surgery, remembering the letters TECHNIQUE
in the subcutaneous layer of wound
PFS (peritoneum, fascia, skin) will During the first postoperative week,
closure. In this case, the remaining
be helpful for organizing sutures. the patient's wound has little or no
ligating material should be used
strength. The sutures or mechanical
By watching the progress of the rather than opening an additional
devices must bear the responsibility
procedure closely, listening to suture packet.
of holding the tissues together
comments between the surgeon
If the surgeon requires "only during this period. They can only
and assistants, and evaluating
one more suture," and strands of perform this function reliably if the
the situation; suture needs can
suitable material remain which quality and integrity of the wound
be anticipated. Free moments can
are shorter than those prepared closure materials are preserved
be used to prepare sufficient suture
64 PACKAGING
during handling and preparation FOR THE CIRCULATING NURSE by projecting (flipping) it onto
prior to use. It is therefore essential 1. Consult the surgeon's preference the sterile table, avoiding
for everyone who will handle the card for suture routine. contamination.
suture materials to understand 6. To open long straight packets,
2. Check the label on the dispenser
proper procedure to preserve peel overwrap down 6 to 8 inches
box for type and size of suture
suture tensile strength. and present to the scrub person.
material and needle(s). Note the
In general, avoid crushing or number of strands per packet. Do not attempt to project the
crimping sutures with surgical Fewer packets will be needed if inner folder of long straight
instruments such as needleholders multistrand or CONTROL packets onto the sterile table.
and forceps, except as necessary RELEASE Needle Sutures are used. 7. Maintain an adequate supply of
to grasp the free end of a suture 3. Estimate suture requirements the most frequently used sutures
during an instrument tie. There accurately and dispense only the readily accessible.
are also specific procedures to type and number of sutures 8. Rotate stock using the "first-in,
follow to preserve suture tensile required for the procedure. first-out" rule to avoid expiration
strength which depend upon of dated products and keep
4. Read the label on the primary
whether the material is absorbable inventories current.
packet or overwrap before using
or nonabsorbable. The following
to avoid opening the wrong 9. Suture packets identify the
summarizes the most important
packet. number of needles per packet to
points for each member of the
5. Use aseptic technique when simplify needle counts. Retain
surgical team to remember and
peeling the overwrap. Transfer this information during the
observe in handling suture materials
the inner contents of the primary procedure and/or until final
and surgical needles.
packet to the sterile field by needle counts are completed.
offering it to the scrub person or 10.Count needles with the scrub
person, per hospital procedure.
SILK—Store strands in a dry towel. Dry strands are stronger than wet strands. Wet silk
loses up to 20% in strength. Handle carefully to avoid abrasion, kinking, nicking, or TABLE
instrument damage. Do not resterilize. 3
SURGICAL STAINLESS STEEL—Handle carefully to avoid kinks and bends. Repeated PRESERVATION
bending can cause breakage. Stainless steel suture can be steam sterilized without any OF TENSILE
loss of tensile strength. However, DO NOT steam sterilize on spool or in contact with STRENGTH:
wood. Lignin is leached from wood subjected to high temperature and may cling to NONABSORBABLE
suture material. Handle carefully to avoid abrasion, kinking, nicking, or instrument damage. SUTURES
PROVIDES EXCELLENT dynamic tensions unless deep sutures, position, invert, and apply
COSMETIC RESULTS immobilization, or both are also used. pressure to saturate the tip.
In a prospective, randomized, Release pressure, then reapply
controlled, unmasked study of 818 DERMABOND Adhesive is
pressure to express adhesive.
patients, DERMABOND* Topical contraindicated for use on any
When using the DERMABOND
Skin Adhesive provided cosmesis wounds with evidence of active
ProPen Adhesive applicator,
equivalent to that of sutures. At infection or gangrene. It should also
simply twist the collar to crack
3 months, it produced optimal not be used on mucosal surfaces or
the vial and lightly press the
cosmesis in 80% of patients, using across mucocutaneous junctions
button to saturate the tip and
the Modified Hollander Cosmesis (eg, lips, oral cavity), or on skin that
express the adhesive.
Scale.2 is regularly exposed to body fluids
or with dense hair (eg, scalp). DIRECTIONS FOR USE
ADDITIONAL PHYSICIAN AND DERMABOND Adhesive should 1. The application of high viscosity
PATIENT BENEFITS not be used on patients with a DERMABOND Adhesive requires
thorough wound cleansing. Follow
In most cases, DERMABOND known hypersensitivity to
standard surgical practice for wound
Adhesive allows for significantly cyanoacrylate or formaldehyde. preparation before application of high
faster closure than sutures.3,5,6 viscosity DERMABOND Adhesive
DERMABOND Adhesive APPLICATION (ie, anesthetize, irrigate, debride, obtain
application requires fewer surgical Mastery of tissue adhesive use hemostasis, and close deep layers).
supplies, reduced equipment is generally quite rapid. Proper 2. Pat the wound dry with dry, sterile
wound selection, evaluation and gauze to assure direct tissue contact
needs, and eliminates the need for for adherence of the high viscosity
suture removal.6,7 preparation before closure is DERMABOND Adhesive to the skin.
important. Wounds must be Moisture accelerates polymerization of
DERMABOND Adhesive is also thoroughly cleansed and debrided high viscosity DERMABOND Adhesive
more convenient and comfortable in accordance with standard practice and may affect wound closure results.
for the patient because it often before using adhesives. The wound 3. To prevent inadvertent flow of
does not require anesthetic, is edges must be tightly apposed so liquid high viscosity DERMABOND
gentler to the skin than sutures that the adhesive is not placed
Adhesive to unintended areas of the
or staples, and does not require body, the wound should be held in a
into the wound. Patient positioning horizontal position and the high viscosity
suture removal. DERMABOND is also important to reduce runoff DERMABOND Adhesive should be
Adhesive also reduces the risk of of tissue adhesive. The patient applied from above the wound.
needlestick injury. should be positioned so that the 4. High viscosity DERMABOND Adhesive
wound surface is parallel to the should be used immediately after crushing
INDICATIONS AND the glass ampule, since the liquid high
floor, taking special care that
CONTRAINDICATIONS viscosity DERMABOND Adhesive will
any runoff does not flow in the flow freely from the tip for only a few
DERMABOND Adhesive is intended
direction of vital structures such minutes. Remove the applicator from
for topical application only to hold
as the eye. the blister pouch. Hold the applicator
closed easily approximated skin edges with the thumb and finger and away from
of wounds from surgical incisions, the patient to prevent any unintentional
TECHNIQUE
including punctures from minimally placement of the liquid high viscosity
1. Follow standard surgical practice DERMABOND Adhesive into the
invasive surgery, and simple,
for wound preparation and wound or on the patient. While holding
thoroughly cleansed, trauma-induced
achieve hemostasis. the applicator, and with the applicator
lacerations. DERMABOND Adhesive tip pointed upward, apply pressure at
may be used in conjunction with, but 2. Approximate skin edges and the midpoint of the ampule to crush
not in place of, deep dermal sutures. use deep sutures to relieve the inner glass ampule. Invert and gently
Topical skin adhesives are not tension if necessary. squeeze the applicator just sufficiently
appropriate for closing wounds that 3. Crack the DERMABOND to express the liquid high viscosity
DERMABOND Adhesive to moisten
are subject to significant static or Adhesive vial in the upright the applicator.
70 TOPICAL SKIN ADHESIVES
5. Approximate wound edges with gloved after application). Allow the top layer REFERENCES
fingers or sterile forceps. Slowly apply to fully polymerize before applying a 1. Singer AJ, ed. Lacerations and
the liquid high viscosity DERMABOND bandage. Acute Wounds, An Evidence-Based
Adhesive in multiple (at least 2) thin If a dressing, bandage, adhesive backing Guide. Philadelphia, Pa: F.A.
layers to the surface of the approximated or tape is applied before complete poly-
wound edges using a gentle brushing
Davis Company; 2003:83-97.
merization, the dressing can adhere to the 2. Data on file, ETHICON, INC.
motion. Wait approximately 30 seconds film. The film can be disrupted from
between applications or layers. Maintain 3. Quinn J, Wells G, Sutcliffe T,
the skin when the dressing is removed,
manual approximation of the wound and wound dehiscence can occur. et al. A randomized trial
edges for approximately 60 seconds comparing octylcyanoacrylate
8. Patients should be instructed to not pick
after the final layer. tissue adhesive and sutures in
at the polymerized film of high viscosity
NOTE: High viscosity DERMABOND DERMABOND Adhesive. Picking at the management of lacerations.
Adhesive polymerizes through an the film can disrupt its adhesion to the JAMA. 1997;277(19):1527-1530.
exothermic reaction. If the liquid high skin and cause dehiscence of the wound. 4. Singer AJ, Hollander JE, Quinn
viscosity DERMABOND Adhesive is Picking at the film can be discouraged JV. Evaluation and management of
applied so that large droplets are allowed by an overlying dressing. traumatic lacerations. N Engl J Med.
to remain without being evenly spread, 1997;337(16):1142-1148.
9. Apply a dry protective dressing for
the patient may experience a sensation
children or other patients who may not 5. Bruns TB, Robinson BS, Smith
of heat or discomfort. The sensation may
be able to follow instructions for proper RJ, et al. A new tissue adhesive
be higher on sensitive tissues. This can
wound care. for laceration repair in children.
be minimized by applying high viscosity
DERMABOND Adhesive in multiple 10. Patients treated with high viscosity J Pediatr. 1998;132:1067-1070.
thin layers (at least 2). DERMABOND Adhesive should be 6. Theodore N, et al. The
provided the printed instruction sheet Economics of DERMABOND
NOTE: Excessive pressure of the
entitled, "How to Care for Your Wound in Neurosurgical Wound
applicator tip against the wound edges
After It's Treated With high viscosity
or surrounding skin can result in forcing Closure. Phoenix, Ariz:
DERMABOND Topical Skin Adhesive."
the wound edges apart and allowing
This instruction sheet should be reviewed
Neuroscience Publications,
high viscosity DERMABOND Adhesive Barrow Neurological Institute.
with each patient or guardian to assure
into the wound. High viscosity March 2001:2-10.
understanding of the proper care for
DERMABOND Adhesive within the 7. Osmond MH, Klassen TP,
the treatment site.
wound could delay wound healing
11. Patients should be instructed that until Quinn JV. Economic comparison
and/or result in adverse cosmetic outcome.
the polymerized film of high viscosity of a tissue adhesive and suturing
NOTE: Full apposition strength is in the repair of pediatric facial
DERMABOND Adhesive has sloughed
expected to be achieved about 2.5 minutes
naturally (usually in 5-10 days), there lacerations. J Pediatr. 1995;
after the final layer is applied, although
should be only transient wetting of the 126:892-895.
the top adhesive layer may remain tacky
treatment site. Patients may shower and
for up to approximately 5 minutes.
bathe the site gently. The site should
Full polymerization is expected when
not be scrubbed, soaked, or exposed to
the top high viscosity DERMABOND
prolonged wetness until after the film
Adhesive layer is no longer sticky.
has sloughed naturally and the wound
6. Do not apply liquid or ointment has healed closed. Patients should be
medications onto wounds closed with instructed not to go swimming during
high viscosity DERMABOND this period.
Adhesive because these substances can
12. If removal of high viscosity
weaken the polymerized film, leading
DERMABOND Adhesive is necessary
to wound dehiscence.
for any reason, carefully apply petroleum
7. Protective dry dressing such as gauze, jelly or acetone to the high viscosity
may be applied only after high viscosity DERMABOND Adhesive film to help
DERMABOND Adhesive film is loosen the bond. Peel off the film, do
completely solid/polymerized: not tacky not pull the skin apart.
to the touch (approximately five minutes
CHAPTER 6
OTHER SURGICAL
PRODUCTS
74 OTHER SURGICAL PRODUCTS
to the high probability of dominant hand. The opposite
ADHESIVE TAPES dislodgement and dehiscence, wound edge is then gently apposed
the inability to use them in by pushing with a finger of the
There are many surgical products hair-bearing areas, and the need nondominant hand. The wound
available which may be used during to keep them dry. Their use is edges should not be apposed by
wound closure and other operative typically reserved for linear lacera- pulling on the free end of the
procedures which involve suturing. tions under minimal tension. tape. This can result in unequal
Each of these products has specific Furthermore, surgical tapes do not distribution of skin tensions,
indications for use. Adhesive tapes approximate deeper tissues and do causing erythema or even blistering
are used for approximating the not control bleeding. of the skin. Additional strips are
edges of lacerations, skin closures, then placed perpendicular to the
repair and/or support in selected INDICATIONS AND USAGE laceration on either side of the
operative procedures. Skin closure tapes are an effective original tape, bisecting the
Adhesive tapes are associated with alternative to sutures or staples remaining open wound with each
minimal tissue reactivity and yield when tensile strength and resistance strip until the space between tapes
the lowest rate of infection, but to infection are not critical factors. is no more than about 2 to 5 mm.
they tend to slough off in the Skin closure tapes can also be Additional strips are then placed
presence of tension or moisture.1 used to complement suture or over the ends of the other strips,
Advantages of adhesive tapes staple closures. Stress is applied parallel to the laceration.
include rapid application, little or uniformly to the collagen fibers,
Skin closure tapes may also be used
no patient discomfort, low cost, and aiding in rapid fiber orientation
as a replacement for sutures or
no risk of needlestick injuries. They and increased tensile strength.
staples which are removed on the
are associated with minimal tissue first to fourth postoperative day.
reactivity and yield the lowest infec- APPLICATION
Effective skin closure tapes provide
tion rates of any wound closure Skin closure tapes may be applied to
good porosity in terms of air inflow
method. They may be left on for the skin over a subcuticular closure
to the wound and water vapor
long periods without resulting in in lieu of skin sutures or used as a
transmission escaping from the
suture hatch marks. primary closure in conjunction with
wound during the healing process.
sutures in an alternating pattern.
Surgical tapes are not commonly The tape is placed on one side of
recommended as the sole modality AFTERCARE AND REMOVAL
the wound at its midpoint, while
for primary wound closure due Adhesive tapes should be left in
grasping it with forceps in the
place as long as possible, at least as
long as sutures would be left before
removal. To prevent the tapes from
ADVANTAGES DISADVANTAGES
prematurely coming loose, patients
TABLE must be warned to keep them as
• Rapid and simple • Relatively poor 1
closure adherence dry as possible and not to cover
them with ointments. Showering
• Least damage to • Easily removed by ADVANTAGES
AND is permitted and during the
host defenses patient
DISADVANTAGES first week many surgeons
• No risk of needlestick • Must be kept dry OF ADHESIVE recommend that patients cover
injuries TAPES FOR their wounds and tape with a
• Cannot be used over
SKIN CLOSURE 1
• Do not cause tissue oily or hair-bearing nonadherent dressing.
ischemia or necrosis areas
CHAPTER 6 75
PROXIMATE*
SKIN STAPLERS
TABLE
2
PROXIMATE* RH Skin Staplers PROXIMATE* PX Skin Staplers PROXIMATE* PLUS MD Skin Staplers
(Rotating Head Skin Staplers) (Multi-Directional Skin Staplers)
Head rotates 360°; Improves visibility Positive ratchet Easy staple Ergonomic design Comfortable for
cartridge is clear and access mechanism placement smaller hands
Staples are coated Easy staple Staples are coated Easy staple Alignment indicator Improves visibility
with lubricant extraction with lubricant extraction
LOOPED SUTURE
ETHICON looped sutures range in
length up to a 60-inch strand with
both ends swaged to a single taper 3. To adjust tension, lift capstan. 4. Rotate capstan until desired
tension is attained.
point needle. Available in various
materials and suture sizes, they
provide a simple, reliable technique
for continuous closure of the fascia
of the abdominal wall. The needle
of the looped suture is passed
through the fascia from inside out
at one end of the incision, then
through the opposite wound edge
from outside in, and then passed
5. To lock, press capstan down
through the loop. The locking stitch into bridge.
lies beneath the wound edge. The
double strand is run over and over (0.48 cm) diameter surgical latex
to the other end of the incision. RETENTION tubing with a 1/32-inch (0.08 cm)
The final stitch is completed by SUTURE DEVICES wall. The suture is threaded through
passing the needle from the outside the bolster and tied. Sutures
in, cutting one strand, and passing Retention sutures, if not placed sheathed in this manner can cause
the needle through the opposite carefully without excessive tension, an inflammatory response with
wound edge from the outside in. can cut the skin. Devices such as reaction both at the site of the
The needle is then cut off and bolsters and bridges are used to suture exit from the skin and along
the loose suture ends tied together, prevent such complications and the entire length of the suture itself.
leaving the knot inverted under eliminate pressure. However, care Also, the skin may become necrotic
the fascia. should also be taken in the use of beneath the bolsters if the sutures
these devices. are too tight. This invariably occurs
Retention suture bolsters are sterile if the sutures are tightly tied at the
time of the operation, as subsequent
2 1/2-inch (6 cm) lengths of 3/16-inch
tissue edema ensues.
78 OTHER SURGICAL PRODUCTS
The retention suture bridge is a
strong plastic truss that can be
adjusted to relieve the pressure of
the retention suture on the skin
during, and subsequent to, initial
suture placement. After the desired
number of sutures is placed in the
wound, a sterile bridge is positioned
over each retention suture. Each
side of the bridge has 6 holes
spaced 1/4 inch (0.64 cm) apart to
accommodate many patient sizes.
The ends of the sutures are passed
through the appropriate holes and
tied loosely over the bridge. The
suture strand is then slipped into
the capstan located in the middle
of the bridge, and the capstan is
rotated to apply the desired
tension before locking into place.
The bridge permits easy tension
readjustment by raising and rotating
the capstan to compensate for
postoperative wound edema, and
again when the edema subsides.
The suture remains elevated away
from the skin while the bridge has
contact along its entire 4 3/8-inch
(11 cm) length. Pressure is evenly
distributed over the area, and the
transparent bridge facilitates com-
plete visualization of the wound.
REFERENCES
1. Singer AJ, ed. Lacerations and
Acute Wounds, An Evidence-Based
Guide. Philadelphia, Pa: F.A.
Davis Company;2003:64-71,
73-82.
2. Sherris DA, Kern EB. Mayo
Clinic Basic Surgery Skills, Mayo
Clinic Scientific Press; 1999:117.
CHAPTER 7
PRODUCT TERMS
AND TRADEMARKS
80 PRODUCT TERMS AND TRADEMARKS
ABSORBABLE SUTURE CHROMIC SURGICAL GUT COMPOUND CURVED NEEDLE
Sutures which are broken down and Gut suture which has been treated Needle that incorporates
eventually absorbed by either by chromium salts to resist 2 curvatures in 1 needle: a tight
hydrolysis (synthetic absorbable digestion by lysosomal enzymes. curve at the tip, and a more gradual
sutures) or digestion by lysosomal curve through the body. Used for
enzymes elicited by white blood CHROMICIZING precise positioning of sutures for
cells (surgical gut and collagen). ETHICON process for producing comeal/scleral closure and for
chromic gut. Each ribbon of skin suturing.
APPROXIMATE surgical gut is bathed in a
Bring together sides or edges. chromium salt solution before CONTAMINATE
spinning into strands to provide To cause a sterile object or surface
ATRALOC uniform controlled absorption. to become unsterile.
SURGICAL NEEDLES
ETHICON trademark for eyeless COATED VICRYL CONTINUOUS SUTURE
needles permanently attached (POLYGLACTIN 910) SUTURE TECHNIQUE
(swaged) to suture strands. ETHICON trademark for synthetic Single suture strand passed back and
absorbable suture extruded from a forth between the 2 edges of the
B & S GAUGE copolymer of glycolide and lactide wound to close a tissue layer; tied
Brown and Sharpe gauge commonly and coated with a mixture of only at each end of the suture line.
used in hospitals to identify wire polyglactin 370 and calcium
diameter. ETHICON stainless steel stearate. CONTROL RELEASE NEEDLE
suture products are labeled with ETHICON trademark for swaging
both B & S gauge and USP size. COATED VICRYL Plus method which permits fast and
ANTIBACTERIAL controlled separation of the needle
BURIED SUTURE (POLYGLACTIN 910) SUTURE from the suture material.
Any stitch made and tied so that ETHICON trademark for synthetic
it remains completely under absorbable suture extruded from a CONVENTIONAL
the surface. copolymer of glycolide and lactide CUTTING NEEDLE
(polyglactin 370) and calcium Needle with triangular point and
CALCIFIED CORONARY stearate. The first and only suture cutting edge along inner curvature
NEEDLE (CC) that protects against bacterial of needle body.
A TAPERCUT Surgical Needle colonization of the suture.
with a 1/16" cutting tip and slim CORNEAL BEADED
COATED VICRYL RAPIDE RETRACTION SUTURE
taper ratio for significant ease of
(POLYGLACTIN 910) SUTURE Swaged suture strand with a small
penetration when suturing tough
ETHICON trademark for braided, bead of epoxy used to elevate cornea
valve cuffs or atherosclerotic vessels.
rapidly absorbing synthetic suture for placement of intraocular lens.
extruded from a copolymer of
CARDIOVASCULAR SUTURES
glycolide and lactide and coated CS ULTIMA
Swaged sutures designed to meet the
with a mixture of polyglactin 370 OPHTHALMIC NEEDLE (CS)
specific needs of heart and blood
and calcium stearate. ETHICON trademark for needle
vessel surgery.
with reduced side edge angles
COBALT 60 providing excellent penetration
CATGUT
Outmoded term for surgical Source of irradiation used by necessary for ophthalmic surgery.
gut suture. ETHICON, INC., to sterilize some Design facilitates knot rotation
suture materials. Also used in during surgery.
hospitals to treat some cancer
patients.
CHAPTER 7 81
VISI-BLACK SURGICAL
NEEDLES
ETHICON trademark for surgical
needles with a black surface
finish to enhance visibility in the
operative site.
WOUND DISRUPTION
Separation of wound edges.
CHAPTER 8
PRODUCT INFORMATION
88 PRODUCT INFORMATION
Do not resterilize. Discard opened packages and unused sutures.
Coated VICRYL*
As with any foreign body, prolonged contact of any suture with salt solutions,
(Polyglactin 910) Suture such as those found in the urinary or biliary tracts, may result in calculus
U.S.P., EXCEPT FOR DIAMETER formation. As an absorbable suture, coated VICRYL suture may act
transiently as a foreign body. Acceptable surgical practice should be followed
DESCRIPTION for the management of contaminated or infected wounds.
Coated VICRYL ( polyglactin 910) Suture is a synthetic absorbable sterile
surgical suture composed of a copolymer made from 90% glycolide and 10%
PRECAUTIONS
L-lactide. Coated VICRYL suture is prepared by coating VICRYL suture material
with a mixture composed of equal parts of copolymer of glycolide and lactide Skin sutures which must remain in place longer than 7 days may cause
(polyglactin 370) and calcium stearate. Polyglactin 910 copolymer and localized irritation and should be snipped off or removed as indicated.
polyglactin 370 with calcium stearate have been found to be nonantigenic, Under some circumstances, notably orthopaedic procedures, immobilization of
nonpyrogenic and elicit only a mild tissue reaction during absorption. joints by external support may be employed at the discretion of the surgeon.
The sutures are available dyed and undyed (natural).
Consideration should be taken in the use of absorbable sutures in tissues with
Coated VICRYL sutures are U.S.P. except for diameters in the following sizes: poor blood supply as suture extrusion and delayed absorption may occur.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P. In handling this or any other suture material, care should be taken to avoid
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm) damage from handling. Avoid crushing or crimping damage due to application
of surgical instruments such as forceps or needle holders. Coated VICRYL
6-0 .008 sutures, which are treated to enhance handling characteristics, require the
5-0 .016 accepted surgical technique of flat and square ties with additional throws as
4-0 .017 warranted by surgical circumstance and the experience of the surgeon.
3-0 .018
2-0 .004 Avoid prolonged exposure to elevated temperatures.
0 .022
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
INDICATIONS point. Reshaping needles may cause them to lose strength and be less resistent
to bending and breaking. Users should exercise caution when handling
Coated VICRYL suture is indicated for use in general soft tissue approximation surgical needles to avoid inadvertent needle sticks. Discard used needles in
and/or ligation, including use in ophthalmic procedures, but not for use in "sharps" container.
cardiovascular and neurological tissues.
ADVERSE REACTIONS
ACTIONS
Adverse effects associated with the use of this device include wound
Coated VICRYL suture elicits a minimal acute inflammatory reaction in tissue dehiscence, failure to provide adequate wound support in closure of the sites
and ingrowth of fibrous connective tissue. Progressive loss of tensile strength where expansion, stretching, or distension occur, failure to provide adequate
and eventual absorption of coated VICRYL suture occurs by means of wound support in elderly, malnourished or debilitated patients or in patients
hydrolysis, where the copolymer degrades to glycolic and lactic acids which are suffering from conditions which may delay wound healing, infection, minimal
subsequently absorbed and metabolized in the body. Absorption begins as a acute inflammatory tissue reaction, localized irritation when skin sutures are
loss of tensile strength followed by a loss of mass. Implantation studies in rats left in place for greater than 7 days, suture extrusion and delayed absorption in
indicate that coated VICRYL suture retains approximately 75% of the origi- tissue with poor blood supply, calculi formation in urinary and biliary tracts
nal tensile strength at two weeks post implantation. At three weeks, approxi- when prolonged contact with salt solutions such as urine and bile occurs, and
mately 50% of the original strength is retained for sizes 6-0 and larger and transitory local irritation at the wound site. Broken needles may result in
approximately 40% of its original strength is retained for sizes 7-0 and smaller. extended or additional surgeries or residual foreign bodies. Inadvertent needle
At four weeks, approximately 25% of the original strength is retained for sizes sticks with contaminated surgical needles may result in the transmission of
6-0 and larger. All of the original tensile strength is lost by five weeks post bloodborne pathogens.
implantation. Absorption of coated VICRYL suture is essentially complete
between 56 and 70 days.
APPROXIMATE % ORIGINAL
HOW SUPPLIED
DAYS IMPLANTATION STRENGTH REMAINING Coated VICRYL sutures are available sterile, as braided dyed (violet) and
undyed (natural) strands in sizes 8-0 through 3 (metric sizes 0.4-6), in a variety
14 Days 75% of lengths, with or without needles, and on LIGAPAK*dispensing reels.
21 Days (6-0 and larger) 50%
21 Days (7-0 and smaller) 40% Coated VICRYL sutures are also available in size 8-0 with attached beads for
28 Days 25% use in ophthalmic procedures. Coated VICRYL sutures are also available in sizes
4-0 through 2 (metric sizes 1.5-5.0) attached to CONTROL RELEASE* removable
needles. Coated VICRYL sutures are available in one, two, and three dozen
CONTRAINDICATIONS boxes.
This suture, being absorbable, should not be used where extended
approximation of tissue is required.
389389 *Trademark ©ETHICON,INC. 1996
WARNINGS
Users should be familiar with surgical procedures and techniques involving
absorbable sutures before employing coated VICRYL suture for wound
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used. Physicians should consider the in vivo performance
(under ACTIONS section) when selecting a suture. The use of this suture may
be inappropriate in elderly, malnourished, or debilitated patients, or in patients
suffering from conditions which may delay wound healing. As this is an
absorbable suture material, the use of supplemental nonabsorbable sutures
should be considered by the surgeon in the closure of the sites which
may undergo expansion, stretching or distention, or which may require
additional support.
CHAPTER 8 89
PRECAUTIONS
Skin sutures which must remain in place longer than 7 days may cause localized
irritation and should be snipped off or removed as indicated.
(Polyglactin 910) Suture Under some circumstances, notably orthopaedic procedures, immobilization of
U.S.P., EXCEPT FOR DIAMETER joints by external support may be employed at the discretion of the surgeon.
Consideration should be taken in the use of absorbable sutures in tissues with
DESCRIPTION poor blood supply as suture extrusion and delayed absorption may occur.
Coated VICRYL* Plus Antibacterial (Polyglactin 910) Suture is a synthetic In handling this or any other suture material, care should be taken to avoid
absorbable, sterile, surgical suture composed of a copolymer made from 90% damage from handling. Avoid crushing or crimping damage due to application of
glycolide and 10% L-lactide. Coated VICRYL Plus Antibacterial Suture is coated surgical instruments such as forceps or needle holders. Coated VICRYL Plus
with a mixture composed of equal parts of a copolymer of glycolide and lactide Antibacterial Sutures, which are treated to enhance handling characteristics,
(Polyglactin 370) and calcium stearate. The suture contains Irgacare MP** require the accepted surgical technique of flat and square ties with additional
(triclosan), a broad-spectrum antibacterial agent at no more than 472ug/m. The throws as warranted by surgical circumstance and the experience of the surgeon.
copolymers in this product have been found to be nonantigenic, nonpyrogenic Avoid prolonged exposure to elevated temperatures.
and elicit only a mild tissue reaction during absorption. The suture is available
undyed (natural) or dyed (D&C Violet No.2). To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the point.
Coated VICRYL Plus Antibacterial Sutures meet all the requirements established Reshaping needles may cause them to lose strength and be less resistent to bend-
by the United States Pharmacopoeia (U.S.P.) for Synthetic Absorbable Surgical ing and breaking. Users should exercise caution when handling surgical needles
Suture (except for diameter) in the following sizes: to avoid inadvertent needle sticks. Discard used needles in “sharps” container.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm) ADVERSE REACTIONS
5-0 .016 Adverse effects associated with the use of this device include wound dehiscence,
4-0 .017 failure to provide adequate wound support in closure of the sites where expan-
3-0 .018 sion, stretching, or distension occur, failure to provide adequate wound support
2-0 .004 in elderly, malnourished or debilitated patients or in patients suffering from con-
0 .022 ditions which may delay wound healing, infection, minimal acute inflammatory
tissue reaction, localized irritation when skin sutures are left in place for greater
INDICATIONS than 7 days, suture extrusion and delayed absorption in tissue with poor blood
Coated VICRYL Plus Antibacterial Suture is indicated for use in general soft supply, calculi formation in urinary and biliary tracts when prolonged contact with
tissue approximation and/or ligation, except for ophthalmic, cardiovascular and salt solutions such as urine and bile occurs, and transitory local irritation at the
neurological tissues. wound site, as well as allergic reaction to Irgacare MP (triclosan). Broken needles
may result in extended or additional surgeries or residual foreign bodies.
ACTIONS Inadvertent needle sticks with contaminated surgical needles may result in the
Coated VICRYL Plus Antibacterial Suture elicits a minimal acute inflammatory transmission of bloodborne pathogens.
reaction in tissue and ingrowth of fibrous connective tissue. Progressive loss of
tensile strength and eventual absorption of Coated VICRYL Plus Antibacterial HOW SUPPLIED
Suture occurs by means of hydrolysis, where the copolymer degrades to glycolic Coated VICRYL Plus Antibacterial Sutures are available sterile, as braided dyed
and lactic acids, which are subsequently absorbed and metabolized in the body. (violet) and undyed (natural) strands in sizes 5-0 through 0 (metric sizes 1 - 3.5)
Absorption begins as a loss of tensile strength followed by a loss of mass. in a variety of lengths, with or without needles, and on LIGAPAK* dispensing
Implantation studies in rats indicate that Coated VICRYL Plus Antibacterial Suture reels.
retains approximately 75% of the original tensile strength at two weeks post Needles may be attached permanently or as CONTROL RELEASE* removable
implantation. At three weeks, approximately 50% of the original strength is needles enabling the needles to be pulled off instead of being cut off. Coated
retained. At four weeks, approximately 25% of the original strength is retained. All VICRYL Plus Antibacterial Sutures are available in one, two and three dozen
of the original tensile strength is lost by five weeks post implantation. Absorption boxes. Full details are contained in the catalog.
of Coated VICRYL Plus Antibacterial Suture is essentially complete between
56 and 70 days.
APPROXIMATE % ORIGINAL LOT
DAYS IMPLANTATION STRENGTH REMAINING Batch number
14 Days 75% See instructions
21 Days 50% Use by – year & month for use
28 Days 25%
Using zone of inhibition studies, Coated VICRYL Plus Antibacterial Suture has Method of sterilization– Do not reuse/
been shown to inhibit colonization of the suture by Staphylococcus aureus and Ethylene Oxide resterilize
Staphylococcus epidermidis. The clinical significance of this finding is unknown.
CONTRAINDICATIONS
This suture, being absorbable, should not be used where extended approximation
of tissue under stress is required.
Coated VICRYL Plus Antibacterial Suture should not be used in patients with a company
known allergic reactions to Irgacare MP (triclosan).
A division of
a company
WARNINGS
Users should be familiar with surgical procedures and techniques involving
absorbable sutures before employing Coated VICRYL Plus Antibacterial Suture for *Trademark of ETHICON, INC.
wound closure, as risk of wound dehiscence may vary with the site of application **Trademark of Ciba Specialty Chemicals Corporation.
and the suture material used. Physicians should consider the in vivo performance ©ETHICON,INC. 2002
(under ACTIONS section) when selecting a suture. The use of this suture may 389595.R01
be inappropriate in elderly, malnourished, or debilitated patients, or in patients
suffering from conditions which may delay wound healing. As this is an
absorbable suture material, the use of supplemental nonabsorbable sutures should
be considered by the surgeon in the closure of the sites which may undergo
expansion, stretching or distention, or which may require additional support.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus forma-
tion. As an absorbable suture, Coated VICRYL Plus Antibacterial Suture may act
transiently as a foreign body. Acceptable surgical practice should be followed for
the management of contaminated or infected wounds.
90 PRODUCT INFORMATION
Coated VICRYL* RAPIDE (Polyglactin 910) WARNINGS
Users should be familiar with surgical procedures and techniques involving
Braided Coated Synthetic Absorbable absorbable sutures before employing coated VICRYL RAPIDE suture for wound
closure, as a risk of wound dehiscence may vary with the site of application and
Suture, Undyed the suture material used. Physicians should consider the in vivo performance
when selecting a suture. The use of this suture may be inappropriate in
Non-U.S.P. elderly, malnourished, or debilitated patients, or in patients suffering from
conditions which may delay wound healing.
DESCRIPTION
Coated VICRYL RAPIDE ( polyglactin 910) Suture is a synthetic absorbable ster- Do not resterilize. Discard opened packages and unused sutures.
ile surgical suture composed of a copolymer made from 90% glycolide and 10% As with any foreign body, prolonged contact of any suture with salt solutions,
L-lactide. The empirical formula of the copolymer is (C2H2O2) m(C3H4O2) n. The such as those found in the urinary or biliary tracts, may result in calculus
characteristic of rapid loss of strength is achieved by use of a polymer materi- formation. As an absorbable suture, coated VICRYL RAPIDE suture may act
al with a lower molecular weight than coated VICRYL (polyglactin 910) Suture. transiently as a foreign body.
Coated VICRYL RAPIDE sutures are obtained by coating the braided suture Acceptable surgical practice should be followed for the management of
material with a mixture composed of equal parts of copolymer of glycolide and contaminated or infected wounds.
lactide (polyglactin 370) and calcium stearate. Polyglactin 910 copolymer and
As this is an absorbable suture material, the use of supplemental nonab-
polyglactin 370 with calcium stearate have been found to be nonantigenic,
sorbable sutures should be considered by the surgeon in the closure of sites
nonpyrogenic and elicit only a mild tissue reaction during absorption.
which may undergo expansion, stretching or distention, or which may require
Coated VICRYL RAPIDE sutures are only available undyed. additional support.
Although this suture is a synthetic absorbable suture, its performance charac-
teristics are intended to model the performance of collagen (surgical gut)
suture. The knot tensile strength of coated VICRYL RAPIDE suture meets U.S.P. PRECAUTIONS
knot tensile strength requirements for collagen sutures, however, Coated Skin sutures which remain in place longer than 7 days may cause localized
VICRYL RAPIDE suture strength is up to 26% less than knot tensile strength irritation and should be snipped off or removed as indicated.
requirements for synthetic absorbable sutures. Under some circumstances, notably orthopaedic procedures, immobilization of
joints by external support may be employed at the discretion of the surgeon.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
Consideration should be taken in the use of absorbable sutures in tissues with
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE(mm) poor blood supply as suture extrusion and delayed absorption may occur.
5-0 .016 In handling this or any other suture material, care should be taken to avoid
4-0 .017 damage from handling. Avoid crushing or crimping damage due to application
3-0 .018 of surgical instruments such as forceps or needle holders.
2-0 .010 Coated VICRYL RAPIDE suture, which is treated with coating to enhance
0 .022 handling characteristics, requires the accepted surgical technique of flat and
square ties with additional throws as warranted by surgical circumstance and
INDICATIONS the experience of the surgeon.
Coated VICRYL RAPIDE synthetic absorbable suture is indicated only for use in Avoid prolonged exposure to elevated temperatures.
superficial soft tissue approximation of the skin and mucosa, where only short
term wound support (7-10 days) is required. Coated VICRYL RAPIDE suture is To avoid damaging needle points and swage areas, grasp the needle in an area
not intended for use in ligation, ophthalmic, cardiovascular or neurological one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
procedures. point. Reshaping needles may cause them to lose strength and be less
resistant to bending and breaking.
Users should exercise caution when handling surgical needles to avoid in
ACTIONS advertent needle sticks. Discard used needles in “sharps” containers.
Coated VICRYL RAPIDE suture, when used in closure of skin and mucous mem-
branes, typically begins to fall off 7-10 days post-operatively and can be wiped
off subsequently with sterile gauze. Natural mechanical abrasion of the sutures ADVERSE REACTIONS
while in situ may also accelerate this disappearance rate. Rapid loss of tensile Adverse effects associated with the use of this device include wound dehis-
strength may preclude the need for stitch removal. cence, failure to provide adequate wound support in closure of the sites where
Coated VICRYL RAPIDE elicits a minimal to moderate acute inflammatory expansion, stretching, or distension occur, failure to provide adequate wound
reaction in tissue. Progressive loss of tensile strength and eventual absorption support in elderly, malnourished or debilitated patients or in patients suffering
of coated VICRYL RAPIDE occurs by means of hydrolysis, where the copolymer from conditions which may delay wound healing, infection, minimal acute
degrades to glycolic and lactic acids which are subsequently absorbed and inflammatory tissue reaction, localized irritation when skin sutures are left in
metabolized in the body. Absorption begins as a loss of tensile strength place for greater than 7 days, suture extrusion and delayed absorption in tissue
followed by a loss of mass. with poor blood supply, calculi formation in urinary and biliary tracts when pro-
longed contact with salt solutions such as urine and bile occurs, and transitory
Subcutaneous tissue implantation studies of coated VICRYL RAPIDE sutures in local irritation at the wound site. Broken needles may result in extended or
rats show that 5 days post-implantation approximately 50% of the original additional surgeries or residual foreign bodies. Inadvertent needle sticks with
tensile strength remains. All of the original tensile strength is lost by approxi- contaminated surgical needles may result in the transmission of bloodborne
mately 10 to 14 days postimplantation. Intramuscular implantation studies in pathogens.
rats show that the absorption of these sutures occurs thereafter and is
essentially complete by 42 days.
HOW SUPPLIED
Coated VICRYL RAPIDE sutures are available sterile, undyed and attached to
CONTRAINDICATIONS stainless steel needles of varying types and sizes.
Due to the rapid loss of tensile strength, this suture should not be used where
extended approximation of tissues under stress is required or where wound Coated VICRYL RAPIDE sutures are available in various lengths in sizes 5-0 to 1
support beyond 7 days is required. (1.0 to 4.0 metric) in one and three dozen boxes.
CONTRAINDICATIONS
None known.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing ETHIBOND EXCEL Suture for wound
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. Acceptable surgical practice should be followed for the
management of infected or contaminated wounds.
CHAPTER 8 93
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing ETHILON suture for wound closure, 389355 *Trademark ©ETHICON, INC. 1995
as the risk of wound dehiscence may vary with the site of application and the
suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. Acceptable surgical practice should be followed for the management
of contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures.
94 PRODUCT INFORMATION
FAST ABSORBING PRECAUTIONS
In handling this or any other suture material, care should be taken to avoid
SURGICAL GUT (PLAIN) damage from handling. Avoid crushing or crimping damage due to application
ABSORBABLE SURGICAL SUTURES of surgical instruments such as forceps or needle holders. Surgical gut sutures
require the accepted surgical technique of flat and square ties with additional
Non-U.S.P. throws as warranted by surgical circumstance and the experience of the
surgeon.
DESCRIPTION Under some circumstances, notably orthopaedic procedures, immobilization of
Fast absorbing surgical gut suture is a strand of collagenous material prepared joints by external support may be employed at the discretion of the surgeon.
from the submucosal layers of the small intestine of healthy sheep, or from the The surgeon should avoid unnecessary tension when running down knots, to
serosal layers of the small intestine of healthy cattle. reduce the occurrence of surface fraying and weakening of the strand.
Fast absorbing surgical gut sutures are sterile and elicit only a slight to Avoid prolonged exposure to elevated temperatures.
minimal tissue reaction during absorption.
To avoid damaging needle points and swage areas, grasp the needle in an area
Fast absorbing surgical gut sutures differ from U.S.P. minimum strength one-third (1/3) to one-half (1/2) of the distance from the swaged end to
requirements by less than 30%. the point. Reshaping needles may cause them to lose strength and be less
resistant to bending and breaking. Users should exercise caution when
handling surgical needles to avoid inadvertent needle sticks. Discard used
INDICATIONS needles in "sharps" containers.
Fast absorbing surgical gut sutures are intended for dermal (skin) suturing
only. They should be utilized only for external knot tying procedures.
ADVERSE REACTIONS
Adverse effects associated with the use of this device include wound
ACTIONS dehiscence, variable rates of absorption over time (depending on such factors
The results of implantation studies of fast absorbing surgical gut sutures in the as the type of suture used, the presence of infection and the tissue site), failure
skin of animals indicate that nearly all of its original strength is lost within to provide adequate wound support in closure of sites where expansion,
approximately seven (7) days of implantation. stretching or distention occur, etc., unless additional support is supplied
When surgical gut suture is placed in tissue, a moderate tissue inflammation through the use of nonabsorbable suture material, failure to provide adequate
occurs which is characteristic of foreign body response to a substance. This is wound support in elderly, malnourished or debilitated patients or in patients
followed by a loss of tensile strength followed by a loss of suture mass, as the suffering from cancer, anemia, obesity, diabetes, infection or other conditions
proteolytic enzymatic digestive process dissolves the surgical gut. This process which may delay wound healing, allergic response in patients with known
continues until the suture is completely absorbed. Many variable factors may sensitivities to collagen which may result in an immunological reaction result-
affect the rate of absorption. Some of the major factors which can affect tensile ing in inflammation, tissue granulation or fibrosis, wound suppuration and
strength loss and absorption rates are: bleeding, as well as sinus formation, infection, moderate tissue inflammatory
1. Type of suture - plain gut generally absorbs more rapidly than chromic gut. response characteristic of foreign body response, calculi formation in urinary
and biliary tracts when prolonged contact with salt solutions such as urine and
2. Infection - surgical gut is absorbed more rapidly in infected tissue than in
bile occurs, and transitory local irritation at the wound site. Broken needles
non-infected tissue.
may result in extended or additional surgeries or residual foreign bodies.
3. Tissue sites - surgical gut will absorb more rapidly in tissue where increased
Inadvertent needle sticks with contaminated surgical needles may result in the
levels of proteolytic enzymes are present, as in the secretions exhibited in
transmission of bloodborne pathogens.
the stomach, cervix and vagina.
Data obtained from implantation studies in rats show that the absorption of
these sutures is essentially complete by the twenty-first (21st) to forty-second HOW SUPPLIED
(42nd) post implantation day.
Fast absorbing surgical gut sutures are available in sizes 5-0 (metric size 1.5)
and 6-0 (metric size 1.0) with needles attached in one, two and three dozen
boxes.
CONTRAINDICATIONS
These sutures, being absorbable, should not be used where prolonged
approximation of tissue under stress is required. These sutures have been
designed to absorb at a rapid rate and must be used on dermal tissue only. 389359 *Trademark ©ETHICON, INC. 1995
These sutures should never be used on internal tissue. The use of this suture is
contraindicated in patients with known sensitivities or allergies to collagen, as
gut is a collagen based material.
WARNINGS
Users should be familiar with surgical procedures and techniques involving gut
suture before using fast absorbing surgical gut suture for wound closure, as
the risk of wound dehiscence may vary with the site of application and the
suture material used. Physicians should consider the in vivo performance when
selecting a suture for use in patients.
The use of this suture may be inappropriate in elderly, malnourished, or debil-
itated patients, or in patients suffering from conditions which may delay wound
healing. As this is an absorbable material, the use of supplemental nonab-
sorbable sutures should be considered by the surgeon in the closure of sites
which may undergo expansion, stretching or distention or which may require
additional support.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. As an absorbable suture, fast absorbing surgical gut may act tran-
siently as a foreign body. Acceptable surgical practice should be followed for
the management of contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures. Store at room
temperature.
Certain patients may be hypersensitive to collagen and might exhibit an
immunological reaction resulting in inflammation, tissue granulation or fibro-
sis, wound suppuration and bleeding, as well as sinus formation.
CHAPTER 8 95
ACTIONS
MERSILENE suture elicits a minimal acute inflammatory reaction in tissue, HOW SUPPLIED
followed by a gradual encapsulation of the suture by fibrous connective MERSILENE sutures are available as sterile, braided, green and undyed (white)
tissue. Implantation studies in animals show no meaningful decline in strands in sizes 6-0 through 5 (metric sizes 0.7-7) in a variety of lengths, with
polyester suture strength over time. The polyester fiber suture material is and without permanently attached needles.
pharmacologically inactive.
MERSILENE sutures are also available in green monofilament in sizes 10-0 and
11-0 (metric sizes 0.2-0.1).
CONTRAINDICATIONS
MERSILENE sutures, green, braided in U.S.P. size 0 (metric size 3.5) are also
None known. available attached to CONTROL RELEASE* removable needles.
MERSILENE sutures are available in one, two and three dozen boxes.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing MERSILENE suture for wound 389395 *Trademark ©ETHICON,INC. 1996
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practice should be followed for the management
of infected or contaminated wounds.
96 PRODUCT INFORMATION
MERSILENE* POLYESTER FIBER MESH WARNINGS
MERSILENE mesh is provided by ETHICON, INC. as a sterile product. Unused
Nonabsorbable Synthetic Surgical Mesh MERSILENE Mesh which has been removed from the package may be resteril-
STERILE ized not more than one time by a conventional stream autoclaving process
at conditions of 250˚F (121˚C) for 20 minutes. MERSILENE mesh may also be
flash autoclaved not more than one time at conditions of 270˚F (132˚C) for
DESCRIPTION 10 minutes. Resterilization under any other conditions or by any other means
MERSILENE* Polyester Fiber Mesh is constructed from polyethylene is neither recommended nor endorsed by ETHICON, INC.
terephthalate, the same material used to make MERSILENE* Polyester Fiber
Suture, Nonabsorbable Surgical Suture, U.S.P. (ETHICON, INC.) MERSILENE If this product should become stained with blood or soiled, it should not be
Polyester Fiber Mesh affords excellent strength, durability and surgical resterilized for reuse.
adaptability, along with maximal porosity for necessary tissue ingrowth.
The mesh is approximately 0.010 inches thick and is a highly flexible and
compliant material. PRECAUTIONS
A minimum of 6.5mm (1/4 inch) of mesh should extend beyond the suture line.
MERSILENE mesh is knitted by a process which interlinks each fiber junction
and which provides for elasticity in both directions. This construction permits
the mesh to be cut into any desired shape or size without unraveling. The fiber
ADVERSE REACTIONS
junctions are not subject to the same work fatigue exhibited by more rigid
No significant adverse clinical reactions to MERSILENE mesh have been
metallic meshes. This bi-directional elastic property allows adaption to various
reported. The use of nonabsorbable MERSILENE mesh in a wound that is
stresses encountered in the body.
contaminated or infected could lead to fistula formation and/or extrusion of
the mesh.
ACTIONS
MERSILENE mesh is a nonabsorbable mesh used to span and reinforce
INDICATIONS FOR USE
traumatic or surgical wounds to provide extended support during and
It is recommended that nonabsorbable sutures be placed 6.5 to 12.5mm (1/4 to
following wound healing. Animal studies show that implantation of
1/2 inch) apart at a distance approximately 6.5mm (1/4 inch) from edge of the
MERSILENE mesh elicits a minimum to slight inflammatory reaction, which is
mesh. Some surgeons prefer to suture and uncut section of mesh that is
transient and is followed by the deposition of a thin fibrous layer of tissue
considerably large than the defect into position over the wound. The opposite
which can grow through the interstices of the mesh, thus incorporating the
sides are then sutured to assure proper closure under correct tension. When
mesh into adjacent tissue. The mesh remains soft and pliable, and normal
the margin sutures have all been placed, the extra mesh is trimmed away.
wound healing is not noticeably impaired. The material is not absorbed nor is
it subject to degradation or weakening by the action of tissue enzymes.
HOW SUPPLIED
INDICATIONS MERSILENE mesh is available in single packets as sterile, undyed (white)
sheets in two sizes. The sizes available are 6 x 11cm (2.5 x 4.5 inches) and 30 x
This mesh may be used for the repair of hernia and other fascial deficiencies
30cm (12 x 12 inches). Each sheet is 0.25mm (0.010 inch) thick.
that require the addition of a reinforcing or bridging material to obtain the
desired surgical result.
MONOCRYL* (Poliglecaprone 25) Suture As this is an absorbable suture material, the use of supplemental
nonabsorbable sutures should be considered by the surgeon in the closure of
SYNTHETIC ABSORBABLE SUTURE, the sites which may undergo expansion, stretching or distention, or which may
require additional support.
U.S.P., EXCEPT FOR DIAMETER
DESCRIPTION PRECAUTIONS
Skin sutures which must remain in place longer than 7 days may cause local-
MONOCRYL* (poliglecaprone 25) suture is a monofilament synthetic
ized irritation and should be snipped off or removed as indicated. Subcuticular
absorbable surgical suture prepared from a copolymer of glycolide and
sutures should be placed as deeply as possible to minimize the erythema and
epsilon-caprolactone. Poliglecaprone 25 copolymer has been found to be
induration normally associated with absorption.
nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during
absorption. Under some circumstances, notably orthopaedic procedures, immobilization of
joints by external support may be employed at the discretion of the surgeon.
MONOCRYL sutures are U.S.P. except for diameters in the following sizes:
Consideration should be taken in the use of absorbable sutures in tissue with
poor blood supply as suture extrusion and delayed absorption may occur.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
In handling this or any other suture material, care should be taken to avoid
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm) damage from handling. Avoid crushing or crimping damage due to application
6-0 0.049 of surgical instruments such as forceps or needle holders.
5-0 0.033 MONOCRYL suture knots must be properly placed to be secure. Adequate knot
4-0 0.045 security requires the accepted surgical technique of flat and square ties with
3-0 0.067 additional throws as warranted by surgical circumstance and the experience of
2-0 0.055 the surgeon. The use of additional throws may be particularly appropriate when
0 0.088 knotting monofilaments.
1 0.066 Avoid prolonged exposure to elevated temperature.
2 0.099
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to
INDICATIONS the point. Reshaping needles may cause them to lose strength and be less
MONOCRYL sutures are indicated for use in general soft tissue approximation resistant to bending and breaking. Users should exercise caution when
and/or ligation, but not for use in cardiovascular or neurological tissues, handling surgical needles to avoid inadvertent needle sticks. Discard used
microsurgery or ophthalmic surgery. needles in "sharps" containers.
WARNINGS
Users should be familiar with surgical procedures and techniques involving 389385 *Trademark ©ETHICON, INC. 1995
absorbable sutures before employing MONOCRYL suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the
suture material used. Physicians should consider the in vivo performance
(under ACTIONS section) when selecting a suture for use in patients. The use of
this suture may be inappropriate in elderly, malnourished, or debilitated
patients, or in patients suffering from conditions which may delay wound
healing.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. As an absorbable suture, MONOCRYL suture may act transiently as
a foreign body. Acceptable surgical practice should be followed for the
management of contaminated or infected wounds.
98 PRODUCT INFORMATION
MONOCRYL* VIOLET MONOFILAMENT PRECAUTIONS
Skin sutures which must remain in place longer than 7 days may cause local-
(Poliglecaprone 25) Suture ized irritation and should be snipped off or removed as indicated. Subcuticular
sutures should be placed as deeply as possible to minimize the erythema and
SYNTHETIC ABSORBABLE SUTURE, U.S.P., induration normally associated with absorption.
EXCEPT FOR DIAMETER Under some circumstances, notably orthopaedic procedures, immobilization of
joints by external support may be employed at the discretion of the surgeon.
DESCRIPTION Consideration should be taken in the use of absorbable sutures in tissue with
MONOCRYL* (poliglecaprone 25) suture is a monofilament synthetic poor blood supply as suture extrusion and delayed absorption may occur.
absorbable surgical suture prepared from a copolymer of glycolide and In handling this or any other suture material, care should be taken to avoid
epsilon-caprolactone. Poliglecaprone 25 copolymer has been found to be damage from handling. Avoid crushing or crimping damage due to application
nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during of surgical instruments such as forceps or needle holders.
absorption.
MONOCRYL suture knots must be properly placed to be secure. Adequate knot
MONOCRYL sutures are U.S.P. except for diameters in the following sizes: security requires the accepted surgical technique of flat and square ties with
additional throws as warranted by surgical circumstance and the experience of
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P. the surgeon. The use of additional throws may be particularly appropriate when
knotting monofilaments.
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm)
Avoid prolonged exposure to elevated temperature.
6-0 0.049
5-0 0.033 To avoid damaging needle points and swage areas, grasp the needle in an area
4-0 0.045 one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
3-0 0.067 point. Reshaping needles may cause them to lose strength and be less
2-0 0.055 resistant to bending and breaking. Users should exercise caution when
0 0.088 handling surgical needles to avoid inadvertent needle sticks. Discard used
1 0.066 needles in "sharps" containers.
2 0.099
ADVERSE REACTIONS
INDICATIONS
Adverse effects associated with the use of synthetic absorbable sutures include
MONOCRYL sutures are indicated for use in general soft tissue approximation wound dehiscence, failure to provide adequate wound support in closure of the
and/or ligation, but not for use in cardiovascular or neurological tissues, sites where expansion, stretching, or distension occur, failure to provide
microsurgery or ophthalmic surgery. adequate wound support in elderly, malnourished or debilitated patients or in
patients suffering from conditions which may delay wound healing, infection,
minimal acute inflammatory tissue reaction, localized irritation when skin
ACTIONS
sutures are left in place for greater than 7 days, suture extrusion and delayed
MONOCRYL suture is a monofilament which elicits a minimal acute inflamma- absorption in tissue with poor blood supply, calculi formation in urinary and
tory reaction in tissues and ingrowth of fibrous connective tissue. Progressive biliary tracts when prolonged contact with salt solutions such as urine and bile
loss of tensile strength and eventual absorption of MONOCRYL sutures occurs occurs, and transitory local irritation at the wound site. Broken needles may
by means of hydrolysis. Absorption begins as a loss of tensile strength result in extended or additional surgeries or residual foreign bodies.
followed by a loss of mass. Implantation studies in rats indicate that Inadvertent needle sticks with contaminated surgical needles may result in the
MONOCRYL suture retains approximately 60 to 70% of its original strength transmission of bloodborne pathogens.
7 days post implantation, and approximately 30 to 40% of its original tensile
strength at 14 days post implantation. Essentially all of the original tensile
strength is lost by 28 days post implantation. Absorption of MONOCRYL HOW SUPPLIED
absorbable synthetic suture is essentially complete between 91 and 119 days. MONOCRYL sutures are available as sterile, monofilament, dyed (violet)
strands in sizes 6-0 through 2 (metric sizes 0.7-5), in a variety of lengths, with
APPROXIMATE % ORIGINAL or without needles. MONOCRYL sutures are also available in sizes 3-0 through
DAYS IMPLANTATION STRENGTH REMAINING 1 (metric sizes 2-4) attached to CONTROL RELEASE* removable needles.
MONOCRYL sutures are available in one and three dozen boxes.
7 DAYS 60 TO 70%
14 DAYS 30 TO 40%
WARNINGS
Users should be familiar with surgical procedures and techniques involving
absorbable sutures before employing MONOCRYL suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the
suture material used. Physicians should consider the in vivo performance
(under ACTIONS section) when selecting a suture for use in patients. The
use of this suture may be inappropriate in elderly, malnourished, or debilitated
patients, or in patients suffering from conditions which may delay wound
healing.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. As an absorbable suture, MONOCRYL suture may act transiently as
a foreign body. Acceptable surgical practice should be followed for the
management of contaminated or infected wounds.
As this is an absorbable suture material, the use of supplemental
nonabsorbable sutures should be considered by the surgeon in the closure of
the sites which may undergo expansion, stretching or distention, or which may
require additional support.
CHAPTER 8 99
HOW SUPPLIED
CONTRAINDICATIONS
NUROLON sutures are available in U.S.P. sizes 6-0 through 1 (metric sizes
Due to the gradual loss of tensile strength which may occur over prolonged 0.7-4.0) in a variety of lengths with and without permanently attached needles.
periods in vivo, nylon suture should not be used where permanent retention of
tensile strength is required. NUROLON sutures are available in U.S.P. sizes 4-0 through 1 (metric sizes
1.5-4.0) attached to CONTROL RELEASE* removable needles.
NUROLON sutures are available in one, two and three dozen boxes.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing NUROLON suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the 389354 *Trademark ©ETHICON, INC. 1995
suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practices should be followed for the management
of infected or contaminated wounds.
Do not resterilize. Discard opened packages and unused sutures.
100 PRODUCT INFORMATION
PDS* II (POLYDIOXANONE) Suture WARNINGS
DYED and CLEAR MONOFILAMENT The safety and effectiveness of PDS II (polydioxanone) sutures have not been
established in neural tissue, adult cardiovascular tissue or for use in micro-
SYNTHETIC ABSORBABLE SUTURES, U.S.P., surgery.
EXCEPT FOR DIAMETER. Under certain circumstances, notably orthopaedic procedures, immobilization
by external support may be employed at the discretion of the surgeon.
DESCRIPTION
Do not resterilize.
PDS II (polydioxanone) monofilament synthetic absorbable suture is prepared
from the polyester, poly (p-dioxanone). The empirical molecular formula of the
polymer is (C4H603)x.
PRECAUTIONS
Polydioxanone polymer has been found to be nonantigenic, nonpyrogenic and
elicits only a slight tissue reaction during absorption. The PDS II suture knots must be properly placed to be secure. As with other
PDS II sutures are U.S.P., except for diameter. synthetic sutures, knot security requires the standard surgical technique of flat
and square ties with additional throws if indicated by surgical circumstance
and the experience of the operator.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
As with any suture, care should be taken to avoid damage when handling.
U.S.P. SUTURE
Avoid the crushing or crimping application of surgical instruments, such as
SIZE DESIGNATION MAXIMUM OVERSIZE (mm)
needle holders and forceps, to the strand except when grasping the free end of
9-0 .005 the suture during an instrument tie.
8-0 .008
7-0 .020 Conjunctival and vaginal mucosal sutures remaining in place for extended
6-0 .015 periods may be associated with localized irritation and should be removed as
5-0 .029 indicated.
4-0 .029 Subcuticular sutures should be placed as deeply as possible in order to
3-0 .056 minimize the erythema and induration normally associated with absorption.
2-0 .029
0 .071 Acceptable surgical practice should be followed with respect to drainage and
1 .047 closure of infected wounds.
2 .023
ADVERSE REACTIONS
ACTIONS Due to prolonged suture absorption, some irritation and bleeding has been
Two important characteristics describe the in vivo performance of absorbable observed in the conjunctiva and mild irritation has been observed in the
sutures: first, tensile strength retention, and second, the absorption rate (loss vaginal mucosa.
of mass). PDS II synthetic absorbable suture has been formulated to minimize
the variability of these characteristics and to provide wound support through
an extended healing period.
DOSAGE AND ADMINISTRATION
The results of implantation studies of PDS II monofilament suture in animals
Use as required per surgical procedure.
indicate that approximately 70% of its original strength remains two weeks
after implantation. At four weeks post-implantation, approximately 50% of its
original strength is retained, and at six weeks, approximately 25% of the origi-
nal strength is retained. HOW SUPPLIED
Data obtained from implantation studies in rats show that the absorption of PDS II sutures are available as sterile, monofilament dyed (violet) strands in
these sutures is minimal until about the 90th post-implantation day. Absorption sizes 9-0 thru 2 (metric sizes 0.3-5), and sterile, monofilament dyed (blue)
is essentially complete within six months. strands in size 9-0 thru 7-0 (metric size 0.3-0.5) in a variety of lengths, with a
variety of needles.
PDS II monofilament dyed (violet) sutures, sizes 4-0 thru 1 (metric size 1.5-4) are
INDICATIONS also available attached to CONTROL RELEASE* removable needles.
PDS II monofilament synthetic absorbable sutures are indicated for use in all
PDS II Clear suture strands are available in sizes 7-0 thru 1 (metric size 0.5-4) in
types of soft tissue approximation, including use in pediatric cardiovascular tis-
a variety of lengths with permanently attached needles.
sue where growth is expected to occur and opthalmic surgery. PDS II suture is
not indicated in adult cardiovascular tissue, microsurgery and neural tissue.
These sutures are particularly useful where the combination of an absorbable
suture and extended wound support (up to six weeks) is desirable. 388W91 *Trademark ©ETHICON, INC. 1992
CONTRAINDICATIONS
These sutures, being absorbable, are not to be used where prolonged (beyond
six weeks) approximation of tissues under stress is required are not to be used
in conjunction with prosthetic devices, i.e., heart valves or synthetic grafts.
CHAPTER 8 101
DESCRIPTION As with any suture material, adequate knot security requires the accepted
surgical technique of flat and square ties with additional throws as warranted
PERMA-HAND* silk suture is a nonabsorbable, sterile, surgical suture
by surgical circumstance and the experience of the surgeon.
composed of an organic protein call fibroin. This protein is derived from the
domesticated species Bombyx mori (b. More) of the family Bombycidae. To avoid damaging needles points and swage areas, grasp the needle in an
PERMA-HAND sutures are processed to remove the natural waxes and gums. area one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
PERMA-HAND suture is dyed black and coated with a special was mixture. point. Reshaping needles may cause them to lose strength and be less
PERMA-HAND suture is also available in its natural color. PERMA-HAND Virgin resistant to bending and breaking g. Users should exercise caution when
silk suture is available in which the sericin gum is not removed and serves to handling surgical needles to avoid inadvertent needle sticks. Discard used
hold the filaments together. needles in "sharps" containers.
PERMA-HAND suture meets requirements established by the United States
Pharmacopoeia (U.S.P.) for nonabsorbable surgical suture.
ADVERSE REACTIONS
Adverse effects associated with the use of this device include wound
INDICATIONS dehiscence, gradual loss of all tensile strength over time, allergic response in
patients that are know to be sensitive to silk, calculi formation in urinary and
PERMA-HAND suture is indicated for use in general soft tissue approximation
biliary tracts when prolonged contact with salt solutions such as urine and bile
and/or ligation, including use in cardiovascular, ophthalmic and neurological
occurs, infection, acute inflammatory tissue reaction, and transitory local
procedures.
irritation at the wound site. Broken needles may result in extended or
additional surgeries or residual foreign bodies. Inadvertent needle sticks with
contaminated surgical needles may result in the transmission of bloodborne
ACTIONS pathogens.
PERMA-HAND suture elicits an acute inflammatory reaction in tissue, which is
followed by a gradual encapsulation of the suture by fibrous connective tissue.
While silk sutures are not absorbed, progressive degradation of the proteina- HOW SUPPLIED
ceous silk fiber in vivo may result in gradual loss of all of the suture's tensile
PERMA-HAND sutures are available in U.S.P. sizes 9-0 through 5 (metric sizes
strength over time.
0.3-7.0) in a variety of lengths with and without permanently attached needles
and on LIGAPAK* dispensing reels.
CONTRAINDICATIONS PERMA-HAND sutures are also available in U.S.P. sizes 4-0 through 1 (metric
sizes 1.5-4.0) attached to CONTROL RELEASE* removable needles.
The use of this suture is contraindicated in patients with known sensitivities or
allergies to silk. PERMA-HAND sutures are available in one, two, and three dozen boxes.
Due to the gradual loss of tensile strength which may occur over prolonged
periods in vivo, silk should not be used where permanent retention of tensile
strength is required.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing PERMA-HAND suture for wound
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practice should be followed for the management
of infected or contaminated wounds.
WARNINGS
Users should be familiar with surgical procedures and techniques involving 389361 *Trademark ©ETHICON, INC. 1995
nonabsorbable sutures before employing PROLENE suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the
suture material used.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practice must be followed for the management of
infected or contaminated wounds.
PRECAUTIONS
In handling this suture material, care should be taken to avoid damage from
handling. Avoid crushing or crimping damage due to application of surgical
instruments such as forceps or needle holders.
Adequate knot security requires the accepted surgical technique of flat, square
ties of single suture strands. The use of additional throws is particularly appro-
priate when knotting polypropylene sutures.
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
point. Reshaping needles may cause them to lose strength and be less resist-
ant to bending and breaking. Users should exercise caution when handling sur-
gical needles to avoid inadvertent needle sticks. Discard used needles in
"sharps" containers.
CHAPTER 8 103
ADVERSE REACTIONS
Potential adverse reactions are those typically associated with surgically
implantable materials which include infection potentiation, inflammation,
adhesion formation, fistula formation and extrusion.
104 PRODUCT INFORMATION
PROLENE* POLYPROPYLENE MESH PRECAUTIONS
A minimum of 6.5mm (1/4") of mesh should extend beyond the suture line.
NONABSORBABLE SYNTHETIC SURGICAL MESH
STERILE
ADVERSE REACTIONS
DESCRIPTION Potential adverse reactions are those typically associated with surgically
implantable materials which include infection potentiation, inflammation,
PROLENE* polypropylene mesh is constructed of knitted filaments of extruded adhesion formation, fistula formation and extrusion.
polypropylene identical in composition to that used in PROLENE*
Polypropylene Suture, Nonabsorbable Surgical Sutures, U.S.P. (ETHICON,
INC.). The mesh is approximately 0.020 inches thick. This material, when used
as a suture, has been reported to be non-reactive and to retain its strength
INSTRUCTIONS FOR USE
indefinitely in clinical use. It is recommended that nonabsorbable sutures be placed 6.5mm to 12.5mm
(1/4" to 1/2") apart at a distance approximately 6.5mm (1/4") from edge of the
PROLENE mesh is knitted by a process which interlinks each fiber junction and mesh. Some surgeons prefer to suture an uncut section of mesh that is
which provides for elasticity in both directions. This construction permits the considerably larger than the defect into position over the wound. The opposite
mesh to be cut into any desired shape or size without unraveling. The fiber junc- sides are then sutured to assure proper closure under correct tension. When
tions are not subject to the same work fatigue exhibited by more rigid metallic the margin sutures have all been placed, the extra mesh is trimmed away.
meshes. This bi-directional elastic property allows adaption to various stresses
encountered in the body.
HOW SUPPLIED
PROLENE mesh is available in single packets as sterile, undyed (clear) sheets
ACTIONS
in seven sizes. The sizes available are 2.5cm x 10cm (1" x 4"), 4.6cm x 10.2cm
PROLENE mesh is a nonabsorbable mesh used to span and reinforce traumat- (1.8" x 4"), 6cm x 11cm (2.5" x 4.5"), 6.1cm x 13.7cm (2.4" x 5.4"), 7.6cm x 12.7cm
ic or surgical wounds to provide extended support during and following wound (3" x 5"), 15cm x 15cm (6" x 6") and 30cm x 30cm (12" x 12"). Each sheet is
healing. Animal studies show that implantation of PROLENE mesh elicits a min- approximately 0.5mm (0.020") thick.
imum to slight inflammatory reaction, which is transient and is followed by the
deposition of a thin fibrous layer of tissue which can grow through the inter-
stices of the mesh, thus incorporating the mesh into adjacent tissue. The mesh
remains soft and pliable, and normal wound healing is not noticeably impaired. 389392.R01 *Trademark ©ETHICON, INC. 1996
The material is not absorbed nor is it subject to degradation or weakening by
the action of tissue enzymes.
INDICATIONS
This mesh may be used for the repair of hernia and other fascial deficiencies
that require the addition of a reinforcing or bridging material to obtain the
desired surgical result.
CONTRAINDICATIONS
When this mesh is used in infants or children with future growth potential, the
surgeon should be aware that this product will not stretch significantly as the
patient grows.
WARNINGS
PROLENE mesh is provided by ETHICON, INC. as a sterile product.
Resterilization of the device is NOT recommended. However, testing has
demonstrated that reprocessing of unused PROLENE mesh which has been
removed from the package will not be adversely affected when exposed not
more than one time to conventional steam autoclave conditions of 250° F
(121° C) for 20 minutes. Reprocessing under any other condition or by any
other means is neither recommended nor endorsed by ETHICON, INC.
PROLENE mesh should not be flash autoclaved.
If this product should become stained with blood or soiled, it should not be
resterilized for reuse.
PRONOVA sutures are available in one, two, and three dozen boxes.
CONTRAINDICATIONS
None known.
INDICATIONS
The Skin Stapler has application for routine skin closure in a wide variety of
surgical procedures.
CONTRAINDICATIONS
When it is not possible to maintain at least a 5 mm distance from the stapled
skin to underlying bones, vessels, or internal organs, the use of staples for skin
closure is contraindicated.
DEVICE DESCRIPTION
The Skin Stapler is a sterile, single patient use instrument designed to deliver
rectangular, stainless steel staples for routine wound closure.
HOW SUPPLIED
The PROXIMATE Skin Stapler is supplied sterile and preloaded for single
patient use. Discard after use.
PROXIMATE®
SKIN STAPLER EXTRACTOR
INDICATIONS
The PROXIMATE Skin Staple Extractor has application for routine skin closure
in a wide variety of surgical procedures.
CONTRAINDICATIONS
When it is not possible to maintain at least a 5 mm distance from the stapled
skin to underlying bones, vessels, or internal organs, the use of staples for skin
closure is contraindicated.
DEVICE DESCRIPTION
The PROXIMATE Skin Staple Extractor is a sterile, single patient use, stainless
steel device specifically designed to completely open skin staples for removal.
The function of the Skin Staple Extractor is to remove Proximate Regular or
Wide Skin Staples from skin wounds.
1 Using sterile technique, remove the device from the package. To avoid
damage, do not flip the device into the sterile field.
2 Remove the safety cap from the device.
3 Slide lower jaw of extractor under regular or wide staple until staple is
secured in slot in lower jaw. (Illustration 1)
4 Squeeze down with thumb to open staple until handles are firmly
touching. (Illustration 2)
5 Ensure staple is completely opened before lifting extractor from skin.
Never pull up before extractor is fully closed. (Illustration 3)
• Instruments or devices which come into contact with bodily fluids may
require special disposal handling to prevent biological contamination.
HOW SUPPLIED
The PROXIMATE Skin Staple Extractor is supplied sterile for single patient use.
Discard after use.
INDICATIONS
The PROXIMATE PLUS MD Skin Stapler has application for routine skin closure
in a wide variety of surgical procedures.
CONTRAINDICATIONS
When it is not possible to maintain at least a 5 mm distance from the stapled
skin to underlying bones, vessels, or internal organs, the use of staples for skin
closure is contraindicated.
DEVICE DESCRIPTION
The PROXIMATE PLUS MD Skin Stapler is a sterile, single patient use
instrument designed to deliver rectangular, stainless steel staples for routine
wound closure.
HOW SUPPLIED
The PROXIMATE PLUS MD Skin Stapler is supplied sterile and preloaded for
single patient use. Discard after use.
Caution: Federal (USA) law restricts this device to sale by or on the order
of a physician.
ADVERSE REACTIONS
ACTIONS Adverse effects associated with the use of this device include wound dehis-
When surgical gut suture is placed in tissue, a moderate tissue inflammation cence, variable rates of absorption over time (depending on such factors as the
occurs which is characteristic of foreign body response to a substance. This is type of suture used, the presence of infection and the tissue site), failure to pro-
followed by a loss of tensile strength and a loss of suture mass, as the prote- vide adequate wound support in closure of sites where expansion, stretching
olytic enzymatic digestive process dissolves the surgical gut. This process or distension occur, etc., unless additional support is supplied through the use
continues until the suture is completely absorbed. Many variable factors may of nonabsorbable suture material, failure to provide adequate wound support
affect the rate of absorption. Some of the major factors which can affect tensile in elderly, malnourished or debilitated patients or in patients suffering from
strength loss and absorption rates are: cancer, anemia, obesity, diabetes, infection or other conditions which may
1. Type of suture - plain gut generally absorbs more rapidly than chromic gut. delay wound healing, allergic response in patients with known sensitivities to
collagen or chromium which may result in an immunological reaction resulting
2. Infection - surgical gut is absorbed more rapidly in infected tissue in inflammation, tissue granulation or fibrosis, wound suppuration and bleed-
than in non-infected tissue. ing, as well as sinus formation, infection, moderate tissue inflammatory
response characteristic of foreign body response, calculi formation in urinary
3. Tissue sites - surgical gut will absorb more rapidly in tissue where and biliary tracts when prolonged contact with salt solutions such as urine and
increased levels of proteolytic enzymes are present, as in the secre- bile occurs, and transitory local irritation at the wound site. Broken needles
tions exhibited in the stomach, cervix and vagina. may result in extended or additional surgeries or residual foreign bodies.
Inadvertent needle sticks with contaminated surgical needles may result in the
transmission of bloodborne pathogens.
CONTRAINDICATIONS
This suture, being absorbable, should not be used where extended approxi-
mation of tissue is required. HOW SUPPLIED
Surgical gut sutures are available in U.S.P. sizes 7-0 through 3 (metric sizes
The use of this suture is contraindicated in patients with known sensitivities or
0.7-7.0) in a variety of lengths with and without permanently attached needles
allergies to collagen or chromium, as gut is a collagen based material, and
and on LIGAPAK* dispensing reels. Surgical gut sutures are also available in
chromic gut is treated with chromic salt solutions.
U.S.P. sizes 0 through 1 (metric sizes 4.0-5.0) attached to CONTROL RELEASE*
removable needles. The suture is supplied sterile in one, two and three
dozen boxes.
WARNINGS
Users should be familiar with surgical procedures and techniques involving gut
suture before using surgical gut suture for wound closure, as the risk of wound
dehiscence may vary with the site of application and the suture material used. 389360 *Trademark ©ETHICON, INC. 1995
Physicians should consider the in vivo performance when selecting a suture.
The use of this suture may be inappropriate in elderly, malnourished, or debil-
itated patients, or in patients suffering from conditions which may delay wound
healing. As this is an absorbable material, the use of supplemental nonab-
sorbable sutures should be considered by the surgeon in the closure of sites
which may undergo expansion, stretching or distention or which may require
additional support.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. As an absorbable suture, surgical gut may act transiently as a foreign
body. Acceptable surgical practice should be followed for the management of
contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures.
Certain patients may be hypersensitive to collagen or chromium and might
exhibit an immunological reaction resulting in inflammation, tissue granulation or
fibrosis, wound suppuration and bleeding, as well as sinus formation.
110 PRODUCT INFORMATION
SURGICAL STAINLESS STEEL SUTURE PRECAUTIONS
In handling this or any other suture material, care should be taken to avoid
NONABSORBABLE SURGICAL SUTURES, U.S.P. damage from handling, such as kinking or excessive twisting.
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
DESCRIPTION point. Reshaping needles may cause them to lose strength and be less
Surgical stainless steel suture is a nonabsorbable, sterile surgical suture resistant to bending and breaking. Users should exercise caution when
composed of 316L stainless steel. Surgical stainless steel suture is available as handling surgical needles to avoid inadvertent needle sticks. Discard used
a monofilament and multifilament suture. needles in "sharps" containers.
Surgical stainless steel suture meets all requirements established by the United
States Pharmacopoeia (U.S.P.) for nonabsorbable surgical sutures. Surgical ADVERSE REACTIONS
stainless steel suture is also labeled with the B&S gauge classifications. Adverse effects associated with the use of this device include wound dehis-
cence, allergic response in patients with known sensitivities to 316L stainless
INDICATIONS steel, or constituent metals such as chromium and nickel, infection, minimal
acute inflammatory tissue reaction, pain, edema and local irritation at the
Surgical stainless steel suture is indicated for use in abdominal wound closure, wound site. Broken needles may result in extended or additional surgeries or
hernia repair, sternal closure and orthopaedic procedures including cerclage residual foreign bodies. Inadvertent needle sticks with contaminated surgical
and tendon repair. needles may result in the transmission of bloodborne pathogens.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable, stainless steel sutures before employing for wound closure, as
the risk of wound dehiscence may vary with the site of application and the
suture material used.
CONTRAINDICATIONS
Because VICRYL knitted mesh is absorbable, it should not be used where
extended wound or organ support is required.
112 PRODUCT INFORMATION
VICRYL* Woven Mesh WARNINGS
DO NOT RESTERILIZE.
The safety and effectiveness of VICRYL woven mesh in neural tissue and in car-
DESCRIPTION diovascular tissue has not been established.
VICRYL (polyglactin 910) Woven Mesh is prepared from a synthetic absorbable
copolymer of glycolide and lactide, derived respectively from glycolic and lac-
tic acids. This tightly woven mesh is prepared from uncoated, undyed fiber PRECAUTIONS
identical in composition to that used in VICRYL* (polyglactin 910) Synthetic None.
Absorbable Suture, which has been found to be inert, nonantigenic, nonpyro-
genic and to elicit only a mild tissue reaction during absorption.
VICRYL woven mesh is intended for use as a buttress to provide temporary sup- ADVERSE REACTIONS
port during the healing process. None known.
CONTRAINDICATIONS
Because VICRYL woven mesh is absorbable, it should not be used where
extended wound or organ support is required.
CHAPTER 9
INDEX
114 INDEX
P PARENCHYMATOUS ORGANS, 30
kidney, 3, 30, 48, 52
liver, 30, 48, 52
S SECONDARY SUTURE LINE, 23, 33
continuous sutures, 19, 22, 24,
spleen, 30, 48 28, 30, 38
PDS II SUTURE, 10, 12, 15-16, 20, 26, interrupted sutures, 19, 22, 24,
31-32, 35, 38, 58-60, 83, 100 28, 31-32, 38, 58, 82
PERMA-HAND SUTURE, 16, 20, 26, 34, railroad track scar, 33
58-59, 83, 101 retention sutures, 23, 26, 28,
PLASTIC SURGERY, 14-15, 17, 49, 51, 33-34, 45, 77-78, 84
57, 83-84 SKIN, 2-5, 7-8, 10, 13-14, 16-17, 21-22,
PRIMARY SUTURE LINE, 19, 22-23, 34 26-28, 32-35, 47-49
buried sutures, 19, 22, 80 STITCH PLACEMENT, 24
continuous sutures, 19, 22, 24, STITCHES AND TYPES, 18-23
28, 30, 37-38, 80 Connell Technique, 24
Connell Technique, 24 Cushing Technique, 24
Cushing Technique, 24 Halsted Technique, 24
Lembert Technique, 24 horizontal mattress technique,
deep sutures, 19, 22, 69 19, 24
interrupted sutures, 19, 22, 24, Lembert Technique, 24
28, 31-32, 38, 58, 82 over-and-over technique, 19, 24
interrupted horizontal purse-string technique, 19, 22
mattress suture, 19, 24 running technique, 19
interrupted vertical
mattress suture, 19, 24
CHAPTER 9 117
Suture
polypropylene suture, 18, 20,
25-26, 28, 30, 32, 36-39,
66, 82-84, 102, 104
See also PROLENE Suture
sterilization, 57, 60, 85
SUTURE CUTTING, 26
SUTURE HANDLING, 10-11, 27, 63
sterile barrer, 61
sterile field, 53-54, 56, 59-62, 64
CHAPTER 9 119