Suturing Techniques

Iyad Abou Rabii DDS, OMFS, MRes, PhD

Suturing 

Suturing of the surgical wound is necessary, aiming at
± holding a flap over the wound, ± reapproximating the wound edges, ± protecting underlying tissues from infection or other irritating factors, ± and preventing postoperative hemorrhage.

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HISTORY

1650 BC ± 2000¶s AD
The origins of surgery can be traced back many centuries. Through the ages, practitioners have used a wide range of materials and techniques for closing tissue««..

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Ants

In the tenth century BC, the ant was held over the wound until it seized the wound edges in its jaws. It was then decapitated and the ant's death grip kept the wound closed.
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Thorns

The thorn, used by African tribes to close tissue, was passed through the skin on either side of the wound. A strip of vegetable fibre was then wound around the edge in a figure eight.
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Surgical ± Anatomic Forceps

Surgical forceps

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Anatomic dissecting forceps

Needle Holders

Surgical forceps

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a- Mayo±Hegar needle holder. Anatomic dissecting forceps b- Mathieu needle holder

Needle Holders and hemostat

Surgical forceps

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Anatomic dissecting forceps

Scissors

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a- Standard suture scissors. b- Goldman±Fox soft tissue scissors

Needles

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Tip: Needle Point Geometry

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

Tip: Needle Point Geometry

Blunt
Premium point spatula

‡Also known as ³Protect Point´ ‡Mainly used to prevent needle stick injuries i.e. for abdominal wall closure. ‡Ophthalmic Surgery

‡Ophthalmic Surgery

Spatula DermaX*
‡NEW: ½ The Penetration force ‡½ The Penetration force ‡Superior Cosmetic Effect

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Body: Needle Curvature

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Swage 

Eyed needles

± More Traumatic ± Only thread through once ± Suture on a reel ± Tends to unthread itself easily

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Swage 

Swaged-on needles

± Much less traumatic ± More expensive suture material ± Sterile

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The Right Needle Choice 

The appropriate needle choice for any situation is«««««. «««««The needle that will cause least possible trauma to the tissue being sutured

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Summary of Needles
1. Needles are made of steel alloy (Surgalloy) with a Nucoat coating so they stay sharp for multiple passes through tissue 2. Different needle points for different tissues 3. Choose the needle that will cause the least trauma

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Suture Material : Definition
A suture is a thread used for uniting wound edges eg. Suture material

Nylon, Silk Catgut, Stainless still suture

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Qualities of a suture material
Knotable Easily sterlisable Uniformity Smooth surface Monofilament Absorbility

Adequate tensile strength Functional strength Non capillary Non reactivity Flexibility & elasticity Easy to handle

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Characteristics of Suture Material 
According to their behavior in tissue: Absorbable Vs. Nonabsorbable  According to their structure: Monofilament Vs. Multifilament  According to their origin:Natural or Synthetic

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Suture Materials : Behavior

ABSORBABLE Those that are absorbed or digested by the body cells and tissue fluids in which they are embedded during and after the healing processes.

NON-ABSORBABLE: Those suture materials that can not be absorbed by the body cells or fluids. they are removed after healing is complete.

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Types of absorbable suture material
(i) (ii) (iii) (iv) (iv) (v) Catgut Collagen : Kangaroo tendon Fascia lata Polyglycolic acid suture material : Polyglactin 910

(vii) Polydioxanone (viii) Cargile membrane

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Types of non absorbable suture material
(i) (ii) (iii) (iv) (v) (vi) Silk Silkworm Gut : Cotton : Linen : Nylone : Vetafil : (xi) Pin sutures (xii) Prolene (xiii) Pagenstecher (xiv) Dermal suture

(vii) Stainless steel (viii) Wires of tentallum and silver (ix) (x)
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Umbilical tape : Horse here

Absorbable Sutures

Caprosyn
60% Glycolide 10% caprolactone 10% Trimethylene carbonate 10% Lactide Monofilament

Biosyn
60% Glycolide 26% Trimethylene carbonate 14% Dioxanone

Maxon
Polyglyconate

Polysorb
90% Polyglycolic acid 10% Polylactic Acid

Dexon II
100% Polyglycolic acid

MATERIAL

STRUCTURE

Monofilament

Monofilament

Braided Caprolactone / Glycolide, Calcium stearoyl lactilate 21 Days

Braided

COATING

NA

NA

NA

Polycaprolac tone

SIGNIFICATE TENSILE STRENGTH ABSORPTION Page  25 PROFILE

10 Days

21 days

42 Days 180-210 Days

21 Days

56 Days

90-110 Days

56-70 Days

60-90 Days

Suture Materials : Structure

Monofilament

Multifilament (braided)

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Comparison 

No

capillary action Increased infection risk Less smooth passage Less tensile strength Better handling Better knot security
. 

Has

capillary action Less infection risk Smooth tissue passage Higher tensile strength Has memory More throws required
.

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Suture Materials : Suture Size

USP (United States Pharmacopoeia) Oral
5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0

General

Thick

Thin

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Suture Materials

The most commonly used suture sizes are ‡4±0 and 3±0 for resorbable sutures, ‡3±0 and 2±0 for nonresorbable sutures. These kinds of sutures are sold in sterilized packages with pre attached atraumatic needles or in bundles without needles.

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The Suture Packaging

PRODUCT CODE

STRAND SIZE

MATERIAL

STRAND LENGTH

NEEDLE CODE WITH LIFE SIZE PICTURE OF NEEDLE

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COLOUR

NEEDLE CIRCLE

POINT TYPE

NEEDLE LENGTH

The Suture Packaging

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Suturing Techniques : Tools Manipulation

Beak of the needle holder grasps a suture needle. The needle holder¶s beak face is crosshatched, ensuring stability of the needle during tissue penetration
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Suturing Techniques : Tools Manipulation

Correct position of the fingers for holding the needle holder

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Suturing Techniques : Tools Manipulation

Scissors are held the same way as needle holders

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Suturing Techniques : Tools Manipulation

‡The needle enters 2±3 mm away from the margin of the flap (mobile tissue) and exits at the same distance on the opposite side. ‡The two ends of the suture are then tied in a knot and are cut 0.8 cm above the knot. ‡To avoid tearing the flap, the needle must pass through the wound margins one at a time, and be at least 0.5 cm away from the edges. ‡Over-tightening of the suture must also be avoided (risk of tissue necrosis), as well as overlapping of wound edges when positioning the knot.

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Suturing Techniques : Knots

Suture is initially wrapped twice around the needle holder

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Suturing Techniques : Knots

The two ends of the suture are tightened to create a surgeon¶s knot over thewound (double knot)

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Suturing Techniques : Knots

Safety knot, created by the single wrap of the suture in the counterclockwise direction as opposed to the first one

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Suturing Techniques : Knots

Tightening of the safety knot over the initial surgeon¶s knot

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Suturing Techniques

‡The main sutures used in oral surgery are the ‡interrupted, ‡continuous, ‡and mattress sutures.

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Suturing Techniques: Interrupted Suture.

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Suturing Techniques: Continuous Simple Suture.

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Suturing Techniques: Continuous Locking Suture.

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Mattress Suture

‡This is a special type of suture and is described as ‡horizontal (interrupted and continuous) ‡and vertical It is indicated in cases where strong and secure reapproximation of wound margins is required.

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Mattress Suture : Horizontal interrupted mattress

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Mattress Suture : Horizontal continuous mattress

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Mattress Suture : Vertical mattress

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Thank you for your attention! Any Questions?

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Contact Details
Dr. Iyad Abou Rabii
www.facebook.com/iarabii www.Twitter.com/iarabii www.Scribd.com/iyad abou rabii

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Copyright notice

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