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Types of sutures

A. Absorbable Sutures

Are made of materials which are broken down in tissue after a given period of time, which depending on the material can be from ten days to eight weeks. They are used therefore in many of the internal tissues of the body. In most cases, three weeks is sufficient for the wound to close firmly. The suture is not needed any more, and the fact that it disappears is an advantage, as there is no foreign material left inside the body and no need for the patient to have the sutures removed. Absorbable sutures were originally made of the intestines of sheep, the so called catgut. The manufacturing process was similar to that of natural musical strings for violins and guitar, and also of natural strings for tennis racquets. Today, gut sutures are made of specially prepared beef and sheep intestine, and may be untreated (plain gut), tanned with chromium salts to increase their persistence in the body (chromic gut), or heat-treated to give more rapid absorption (fast gut). However, the majority of absorbable sutures are now made of synthetic polymer fibres, which may be braided or monofilament; these offer numerous advantages over gut sutures, notably ease of handling, low cost, low tissue reaction, consistent performance and guaranteed non-toxicity. In Europe and Japan, gut sutures have been banned due to concerns over bovine spongiform encephalopathy (mad-cow disease), although the herds from which gut is harvested are certified BSE-free. Each major suture manufacturer has its own proprietary formulations for its brands of synthetic absorbable sutures; various blends of polyglycolic acid, polylactic acid or caprolactone are common. Natural Absorbable Sutures Surgical Gut: are also known as catgut and are made from the submucous layer of a sheeps intestine. Once cleaned, dried and twisted into threads of various sizes they are prepared for use by special processes, that include innumerable inspections of gauze and tensile strength and scrupulous sterilization. The length of time for complete absorption of surgical gut in a wound varies according to the action of certain hardening agents. Surgical gut, plain: Tensile strength is maintained for 7-10 days postimplantation (variable with individual patient characteristics), and absorption is complete within 70 days. This type of suture is used for (1) repairing rapidly healing tissues that require minimal support and (2) ligating superficial blood vessels. Surgical gut, fast-absorbing: This type of suture is indicated for epidermal use (required only for 5-7 d) and is not recommended for internal use. Surgical gut, chromic (treated with chromium salt): Tensile strength is maintained for 10-14 days. The absorption rate is slowed by chromium salt (90 d). Tissue reaction is due to the noncollagenous material present in these sutures.

Also, patient factors affect rates of absorption and make tensile strength somewhat unpredictable. =Salthouse and colleagues demonstrated that the mechanism by which gut reabsorbs is the result of sequential attacks by lysosomal enzymes. 3 Natural fiber absorbable sutures have several distinct disadvantages. First, these natural fiber absorbable sutures have a tendency to fray during knot construction. Second, there is considerably more variability in their retention of tensile strength than is found with the synthetic absorbable sutures. A search for a synthetic substitute for collagen sutures began in the 1960s. Soon, procedures were perfected for the synthesis of high molecular weight polyglycolic acid, which led to the development of the polyglycolic acid sutures.3 Fascia Lata: This muscle connective tissue of beef has been used in reconstructive orthopedic surgery and for the repair of hernias. It is not a true absorbable suture, but becomes part of the tissue after the wound has healed. Collagen: The collagen sutures are derived from the submucosal layer of ovine small intestine or the serosal layer bovine small intestine "gut." This collagenous tissue is treated with an aldehyde solution, which cross-links and strengthens the suture and makes it more resistant to enzymatic degradation. Suture materials treated in this way are called plain gut. Synthetic Absorbable Sutures Chemical polymers are absorbed by hydrolysis and cause a lesser degree of tissue reaction following placement. Polyglactin 910 (Vicryl): This synthetic suture is a braided multifilament suture coated with a copolymer of lactide and glycolide (polyglactin 370). The water-repelling quality of lactide slows loss of tensile strength and the bulkiness of lactide leads to rapid absorption of suture mass once tensile strength is lost. The suture is also coated with calcium stearate, which permits easy tissue passage, precise knot placement, and smooth tie-down. Tensile strength is approximately 65% at 14 days post implantation. Absorption is minimal for 40 days and complete in 56-70 days. These sutures cause only minimal tissue reaction. Vicryl sutures are used in general soft tissue approximation and vessel ligation. Another similar suture material is made from polyglycolic acid and coated with Polycaprolate (Dexon II). This material has a similar tensile strength and absorption profile. Poliglecaprone 25 (Monocryl): This synthetic suture is a monofilament suture that is a copolymer of glycolide and e-caprolactone. The suture has superior pliability, leading to ease in handling and tying. Tensile strength is high initially, 50-60% at 7 days, and is lost at 21 days. Absorption is complete at 91-119 days. Poliglecaprone 25 sutures are used for subcuticular closure and soft tissue approximations and ligations. Polysorb: Copolymers of glycolide and lactide were synthesized to produce a Lactomer copolymer that is used to produce a new braided absorbable suture, Polysorb. The glycolide and lactide behaved differently when exposed to tissue hydrolysis. Glycolide

provides for high initial tensile strength, but hydrolyzes rapidly in tissue. Lactide has a slower and controlled rate of hydrolysis, or tensile strength loss, and provides for prolonged tensile strength in tissue. Polydioxanone (PDS II): This is a polyester monofilament suture made of polydioxanone. This suture provides extended wound support and elicits only a slight tissue reaction. Tensile strength is 70% at 14 days and 25% at 42 days. Wound support remains for up to 6 weeks. Absorption is minimal for the first 90 days and essentially complete within 6 months. This material has a low affinity for microorganisms (like other monofilament). PDS II suture is used for soft tissue approximation, especially in pediatric, cardiovascular, gynecologic, ophthalmic, plastic, and digestive (colonic) situations. Another similar suture material is made from polytrimethylene carbonate (Maxon). This material has a similar tensile strength and absorption profile. A barbed suture (V-Loc, Covidien Inc): Was developed that is self-anchoring with no knots required for wound closure. The elimination of knot tying may reduce many of the challenges of knot construction.

The barbed suture is manufactured from a size O polydioxanone that reabsorbs within 26 weeks. This suture consists of axially barbed segments on each side of a mid point at which the barbs change direction. The tensile strength of the barbed suture decreases over time. Each suture is attached to a Premium Cutting and Taper Point needle with NuCoating technology. The unique performance of the barbed suture was confirmed for gastrointestinal wound closure in a randomized control study. The V-Loc wound closure device appeared to offer comparable gastrointestinal closure as compared to 3-O Maxon, while being significantly faster. However, further studies with V-Loc are required to evaluate its use in laparoscopic surgery.

Caprosyn

The latest innovation in the development of monofilament absorbable sutures has been the rapidly absorbing Caprosyn suture. Caprosynmonofilament synthetic absorbable sutures are prepared from Polyglytone 621 synthetic polyester, which is composed of glycolide, caprolactone, trimethylene carbonate, and lactide. Implantation studies in animals indicate that Caprosyn suture retains a minimum of 50-60% USP knot strength at 5 days postimplantation, and a minimum of 2030% of knot strength at 10 days postimplantation. All of its tensile strength is essentially lost by 21 days postimplantation. As expected, chromic gut sutures potentiated significantly more infection than did the Caprosyn sutures. The handling properties of the Caprosyn sutures were far superior to those of the chromic gut sutures. The smooth surface of the Caprosyn sutures encountered lower drag forces than did the chromic gut sutures. Furthermore, it was much easier to reposition the Caprosyn knotted sutures than the knotted chromic gut sutures. In the case of chromic gut sutures, it was not possible to reposition a two-throw granny knot. These biomechanical performance studies demonstrated the superior performance of the synthetic Caprosyn sutures

compared with chromic gut sutures and provide compelling evidence of why Caprosyn sutures are an excellent alternative to chromic gut sutures.

B. Non-absorbable Sutures

are made of materials which are not metabolized by the body, and are used therefore either on skin wound closure, where the sutures can be removed after a few weeks, or in some inner tissues in which absorbable sutures are not adequate. This is the case, for example, in the heart and in blood vessels, whose rhythmic movement requires a suture which stays longer than three weeks, to give the wound enough time to close. Other organs, like the bladder, contain fluids which make absorbable sutures disappear in only a few days, too early for the wound to heal. Inflammation caused by the foreign protein in some absorbable sutures can amplify scarring, so if other types of suture are less antigenic (i.e., do not provoke as much of an immune response) it would represent a way to reduce scarring. There are several materials used for non absorbable sutures. The most common is a natural fibre, silk, which undergoes a special manufacturing process to make it adequate for its use in surgery. Other non-absorbable sutures are made of artificial fibres, like polypropylene, polyester or nylon; these may or may not have coatings to enhance their performance characteristics. Finally, stainless steel wires are commonly used in orthopaedic surgery and for sternal closure in cardiac surgery. Natural Surgical silk: This suture is made of raw silk spun by silkworms. The suture may be coated with beeswax or silicone. Many surgeons consider silk suture the standard of performance (superior handling characteristics). Although classified as a nonabsorbable material, silk suture becomes absorbed by proteolysis and is often undetectable in the wound site by 2 years. Tensile strength decreases with moisture absorption and is lost by 1 year. The problem with silk suture is the acute inflammatory reaction triggered by this material. Host reaction leads to encapsulation by fibrous connective tissue. Surgical cotton: This is made of twisted, long, staple cotton fibers. Tensile strength is 50% in 6 months and 30-40% by 2 years. Surgical cotton is nonabsorbable and becomes encapsulated within body tissues. Surgical steel: This is made of stainless steel (iron-chromium-nickel-molybdenum alloy) as a monofilament and twisted multifilament. It can be made with flexibility, fine size, and the absence of toxic elements. Surgical steel demonstrates high tensile strength with little loss over time and low tissue reactivity. The material also holds knots well. Surgical steel suture is used primarily in orthopedic, neurosurgical, and thoracic applications. This type of suture also may be used in abdominal wall closure, sternum closure, and retention. This material can be difficult to handle because of kinking, fragmentation, and barbing, which renders the wire useless and may present a risk to the surgeon's safety.11

Synthetic

Nylon: This is a polyamide polymer suture material available in monofilament (Ethilon/Monosof) and braided (Nurolon/Surgilon) forms. The elasticity of this material makes it useful in retention and skin closure. Nylon is quite pliable, especially when moist. Of note, a premoistened form is available for cosmetic plastic surgery. The braided forms are coated with silicone. Nylon suture has good handling characteristics, although its memory tends to return the material to its original straight form. Nylon has 81% tensile strength at 1 year, 72% at 2 years, and 66% at 11 years. The material is stronger than silk suture and elicits minimal acute inflammatory reaction. Nylon is hydrolyzed slowly, but remaining suture material is stable at 2 years, due to gradual encapsulation by fibrous connective tissue. Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]): This suture material is formed from polyester, a polymer of polyethylene terephthalate. The multifilament braided suture also comes coated with polybutilate (Ethibond) or silicone (Ti-cron). The coating reduces friction for ease of tissue passage and improved suture pliability and tie-down. The suture elicits minimal tissue reaction and lasts indefinitely in the body. Polyester fiber sutures are stronger than natural fibers and do not weaken with moistening. The material provides precise consistent suture tension and retains tensile strength. This suture is commonly used for vessel anastomosis and the placement of prosthetic materials. Polybutester Suture (Novafil): The polybutester is a block copolymer that contains butylene terephthalate and polytetramethylene ether glycol. The polybutester suture has unique performance characteristics that may be advantageous for wound closure.12 This monofilament synthetic nonabsorbable suture exhibits distinct differences in elongation compared with other sutures. With the polybutester suture, low forces yield significantly greater elongation than is seen in the other sutures. In addition, its elasticity is superior to the other sutures, allowing the suture to return to its original length once the load is removed. Coated Polybutester Suture (Vascufil): The clinical performance of polybutester suture has been enhanced by coating its surface with a unique absorbable polymer (Vascufil). 13 The coating is a polytribolate polymer that is composed of 3 compounds: gylcolide, caprolactone, and poloxamer 188. Coating the polybutester suture markedly reduces its drag force in musculoaponeurotic, colonic, and vascular tissue. Polypropylene (Prolene): This monofilament suture is an isostatic crystalline stereoisomer of a linear propylene polymer, permitting little or no saturation. The material does not adhere to tissues and is useful as a pull-out suture (eg, subcuticular closure). Polypropylene also holds knots better than other monofilament synthetic materials. This material is biologically inert and elicits minimal tissue reaction. Prolene is not subject to degradation or weakening and maintains tensile strength for up to 2 years. This material is useful in contaminated and infected wounds, minimizing later sinus formation and suture extrusion. Surgipro II: A polypropylene suture has been developed that has increased resistance to fraying during knot rundown, especially with smaller diameter sutures. These sutures are extremely inert in tissue and have been found to retain tensile strength in tissues for as long as 2 years. These sutures are widely used in plastic, cardiovascular, general, and orthopedic surgery. They exhibit a lower drag coefficient in tissue than nylon sutures, making them ideal for use in continuous suture closure.