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K N O T T Y I N G M A N U A L

ADVANCE YOUR
EXPERTISE
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PATIENT CARE
Selected Terms
Absorption Rate Measures how quickly a suture is absorbed, or broken
down by the body. Refers only to the presence or absence
of suture material and not to the amount of strength
remaining in the suture.

Breaking Strength Retention (BSR) Measures tensile strength (see below) retained by a suture
in vivo over time. For example, a suture with an initial tensile
strength of 20 lbs. and 50% of its BSR at 1 week has 10 lbs.
of tensile strength in vivo at 1 week.

Extensibility The characteristic of suture stretch during knot tying and


recovery thereafter. Familiarity with a suture’s extensibility
will help the surgeon know when the suture knot is snug.

Memory Refers to a suture’s tendency to retain kinks or bends


(set by the material’s extrusion process or packaging)
instead of lying fiat.

Monofilament Describes a suture made of a single strand or filament.

Multifilament Describes a suture made of several braided or twisted strands


or filaments.

Tensile Strength The measured pounds of tension that a knotted suture strand
can withstand before breaking.

United States Pharmacopeia (U.S.P) An organization that promotes the public health by
establishing and disseminating officially recognized
standards of quality and authoritative information for
the use of medicines and other health care technologies
by health professionals, patients, and consumers.
Practice Board †

The KNOT TYING MANUAL and practice board are


available from ETHICON, for all trainees of suturing and
knot tying techniques.

† Contributing Designer–Bashir Zikria, MD, FACS


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Foreword Table of Contents

Surgery draws upon all the sciences, but its very BASIC KNOTS 4
nature places it in the category of an art. Dexterity Knot Security 4
and speed in tying knots correctly constitute an General Principles of Knot Tying 5
art which only practice can make perfect.
SQUARE KNOT
Of the more than 1,400 different types of knots Two-Hand Technique 6-11
described in THE ENCYCLOPEDIA OF KNOTS, One-Hand Technique 12-15
only a few are used in modern surgery. It is of
paramount importance that each knot placed for SURGEON’S OR FRICTION KNOT 16-21
approximation of tissues or ligation of vessels be
perfect. It must hold with proper tension. DEEP TIE 22-25

In the early days of surgery, materials were heavy LIGATION AROUND HAEMOSTATIC CLAMP
and crude, knots bulky and inefficient. It was not More Common of Two Methods 26-27
unusual for the surgeon to place three or even Alternate Technique 28-29
four knots in the suture strand “just to be sure” it
would hold. INSTRUMENT TIE 30-32

Research and refinements of manufacture and GRANNY KNOT 33


sterilisation have provided the surgeon of today
with a wide choice of natural and synthetic suture SUTURE MATERIALS 34
materials. The successful use of any of these is
dependent upon skillful knot tying and meticulous PRINCIPLES OF SUTURE SELECTION 35
care in the handling of the suture. The adoption of
finer gauge sutures has been accompanied by ABSORBABLE SUTURES 36-37
more refined, simplified, and standardised
suturing techniques. NON ABSORBABLE SUTURES 38-39

It is the hope of ETHICON, that this KNOT TYING SURGICAL NEEDLES 40


MANUAL will help train medical students,
assistants and surgeons in training and others in
the techniques of knot tying and the handling of
sutures.

3
Basic Knots

The knots demonstrated on Multifilament sutures are


the following pages are those generally easier to handle
most frequently used, and and to tie than monofilament
are applicable to all types of sutures, however, all the
operative procedures. The synthetic materials require a
camera was placed behind specific knotting technique.
the demonstrator so that With multifilament sutures,
each step of the knot is the nature of the material and
shown as seen by the 1. Simple knot: incomplete basic unit
the braided or twisted
operator. For clarity, one-half 2. Square knot: completed common knot construction provide a high
of the strand is purple and 3. Surgeon’s or Friction knot: completed coefficient of friction and the
the other white. The purple tension knot knots remain as they are laid
working strand is initially held down. In monofilament
in the right hand. The sutures, on the other hand,
left-handed person may choose to the coefficient of friction is relatively low, resulting in a
study the photographs in a mirror. greater tendency for the knot to loosen after it has
been tied. In addition, monofilament synthetic
Knot Security polymeric materials possess the property of memory.
The construction of ETHICON sutures has been Memory is the tendency not to lie flat, but to return to
carefully designed to produce the optimum a given shape set by the material’s extrusion process
combination of strength, uniformity, and hand for or the suture’s packaging. The RELAY* suture
each material. The term hand is the most subtle of delivery system delivers sutures with minimal
all suture quality aspects. It relates to the feel of the package memory due to its unique package design.
suture in the surgeon’s hands, the smoothness with
which it passes through tissue and ties down, the Suture knots must be properly placed to be secure.
way in which knots can be set and snugged down, Speed in tying knots may result in less than perfect
and most of all, to the firmness or body of the placement of the strands. In addition to variables
suture. Extensibility relates to the way in which the inherent in the suture materials, considerable
suture will stretch slightly during knot tying and then variation can be found between knots tied by different
recover. The stretching characteristics provide the surgeons and even between knots tied by the same
signal that alerts the surgeon to the precise moment individual on different occasions.
when the suture knot is snug.

4
General Principles of Knot Tying 7. After the first loop is tied, it is necessary to maintain
Certain general principles govern the tying of all knots and traction on one end of the strand to avoid loosening
apply to all suture materials. of the throw if being tied under any tension.

1. The completed knot must be firm, and so tied that 8. Final tension on final throw should be as nearly
slipping is virtually impossible. The simplest knot for horizontal as possible.
the material is the most desirable.
9. The surgeon should not hesitate to change stance
2. The knot must be as small as possible to prevent an or position in relation to the patient in order to place
excessive amount of tissue reaction when absorbable a knot securely and flat.
sutures are used, or to minimize foreign body reaction
to non absorbable sutures. Ends should be cut as 10. Extra ties do not add to the strength of a properly
short as possible. tied knot. They only contribute to its bulk. With some
synthetic materials, knot security requires the
3. In tying any knot, friction between strands (“sawing”) standard surgical technique of flat and square ties
must be avoided as this can weaken the integrity of with additional throws if indicated by surgical
the suture. circumstance and the experience of the surgeon.

4. Care should be taken to avoid damage to the suture An important part of good suturing technique is correct
material when handling. Avoid the crushing or method in knot tying. A seesaw motion, or the sawing of
crimping application of surgical instruments, such as one strand down over another until the knot is formed,
needleholders and forceps, to the strand except may materially weaken sutures to the point that they
when grasping the free end of the suture during an may break when the second throw is made or, even
instrument tie. worse, in the postoperative period when the suture is
further weakened by increased tension or motion.
5. Excessive tension applied by the surgeon will cause
breaking of the suture and may cut tissue. Practice If the two ends of the suture are pulled in opposite
in avoiding excessive tension leads to successful directions with uniform rate and tension, the knot may
use of finer gauge materials. be tied more securely. This point is well-illustrated in the
knot tying techniques shown in the next section of this
6. Sutures used for approximation should not be tied manual.
too tightly, because this may contribute to tissue
strangulation.

5
Square Knot
TWO-HAND TECHNIQUE
The two-hand square knot is the easiest and the operator should be used to tie MONOCRYL*
most reliable for tying most suture materials. (Poliglecaprone 25) Suture, Coated VICRYL*
It may be used to tie surgical gut, virgin silk, (Polyglactin 910) Suture, Coated VICRYL* rapide
surgical cotton, and surgical stainless steel. (Polyglactin 910) Suture, PDS* II
(Polydioxanone) Suture, ETHILON* Nylon
Standard technique of flat and square ties Suture, ETHIBOND* EXCEL Polyester Suture,
with additional throws if indicated by the PRONOVA* Poly (Hexafluoropropylene-VDF)
surgical circumstance and the experience of Suture, and PROLENE* Polypropylene Suture.

1 White strand placed over


extended index finger of
Purple strand held in right
hand brought between left
2
left hand acting as bridge, thumb and index finger.
and held in palm of left
hand. Purple strand held
in right hand.

6
3 Left hand turned inward
by pronation, and thumb
Purple strand crossed
over white and held
4
swung under white strand between thumb and
to form the first loop. index finger of left hand.

7
Square Knot
TWO-HAND TECHNIQUE

5 Right hand releases purple


strand. Then left hand
Purple strand released
by left hand and grasped
6
supinated, with thumb and by right. Horizontal tension
index finger still grasping is applied with left hand
purple strand, to bring toward and right hand
purple strand through the away from operator. This
white loop. Regrasp purple completes first half hitch.
strand with right hand.

8
7 Left index finger released
from white strand and left
Purple strand brought
toward the operator with
8
hand again supinated to the right hand and placed
loop white strand over left between left thumb and
thumb. Purple strand held index finger. Purple strand
in right hand is angled crosses over white strand.
slightly to the left.

9
Square Knot
TWO-HAND TECHNIQUE

9 By further supinating left


hand, white strand slides
Left hand rotated inward
by pronation with thumb
10
onto left index finger to carrying purple strand
form a loop as purple through loop of white
strand is grasped between strand. Purple strand is
left index finger and thumb. grasped between right
thumb and index finger.

10
11 Horizontal tension applied
with left hand away from
The final tension on the final
throw should be as nearly
12
and right hand toward the horizontal as possible.
operator. This completes
the second half hitch.

11
Square Knot
ONE-HAND TECHNIQUE
Wherever possible, the square knot is tied using surgeon be holding a reel of suture material
the two-hand technique. On some occasions it in the right hand and placing a series of
will be necessary to use one hand, either the left ligatures. In either case, it cannot be too
or the right, to tie a square knot. These strongly emphasised that the directions the
illustrations employ the left-handed technique. hands travel must be reversed proceeding
from one throw to the next to ensure that
The sequence of throws illustrated is most the knot formed lands flat and square. Half
commonly used for tying single suture strands. hitches result if this precaution is not taken.
The sequence may be reversed should the

1 White strand held between


thumb and index finger of left
Purple strand brought over
white strand on left index
2
hand with loop over extended finger by moving right hand
index finger. away from operator.
Purple strand held between
thumb and index finger
of right hand.

12
3 With purple strand supported
in right hand, the distal
The first half hitch is
completed by advancing
4
phalanx of left index finger tension in the horizontal
passes under the white plane with the left hand
strand to place it over tip drawn toward and right
of left index finger. Then hand away from the
the white strand is pulled operator
through loop in preparation
for applying tension.

13
Square Knot
ONE-HAND TECHNIQUE

5 White strand looped


around three fingers
Purple strand held in
right hand brought toward
6
of left hand with distal the operator to cross over
end held between thumb the white strand. Continue
and index finger hand motion by flexing
distal phalanx of left middle
finger to bring it beneath
white strand.

14
7 As the middle finger
is extended and the left
Horizontal tension
applied with the left
8
hand pronated, the white hand away and the
strand is brought beneath right hand toward the
the purple strand. operator. This completes
the second half hitch
of the square knot. Final
tension should be as nearly
horizontal as possible.

15
Surgeon’s or Friction Knot
The surgeon’s or friction knot is recommended (hexafluoropropylene-VDF) Suture, and
for tying Coated VICRYL* (Polyglactin 910) PROLENE* Polypropylene Suture.
Suture, Coated VICRYL Plus Antibacterial The surgeon’s knot also may be performed
(Polyglactin 910) Suture, ETHIBOND* EXCEL using a one-hand technique in a manner
Polyester Suture, ETHILON* Nylon Suture, analogous to that illustrated for the square
MERSILENE* Polyester Fibre Suture, knot one-hand technique.
NUROLON* Nylon Suture, PRONOVA* Poly

1 White strand placed


over extended index
Purple strand crossed
over white strand by
2
finger of left hand and moving right hand away
held in palm of left hand. from operator at an angle
Purple strand held between to the left. Thumb and index
thumb and index finger finger of left hand pinched
of right hand. to form loop in the white
strand over index finger.

16
3 Left hand turned inward
by pronation, and loop of
Left hand rotated by
supination extending
4
white strand slipped onto left index finger to pass
left thumb. Purple strand purple strand through
grasped between thumb loop. Regrasp purple
and index finger of left strand with right hand.
hand. Release right hand.

17
Surgeon’s or Friction Knot

5 The loop is slid onto the


thumb of the left hand
Purple strand drawn
left with right hand and
6
by pronating the pinched again grasped between
thumb and index finger of thumb and index finger
left hand beneath the loop. of left hand.

18
7 Left hand rotated by
supination extending
Horizontal tension is applied
with left hand toward and
8
left index finger to again right hand away from the
pass purple strand through operator. This double loop
forming a double loop. must be placed in precise
position for the final knot.

19
Surgeon’s or Friction Knot

9 With thumb swung


under white strand,
Purple strand released.
Left hand supinates to
10
purple strand is grasped regrasp purple strand with
between thumb and index finger beneath the
index finger of left hand loop of the white strand.
and held over white
strand with right hand.

20
11 Purple strand rotated
beneath the white strand
Hands continue to apply
horizontal tension with
12
by supinating pinched left hand away from and
thumb and index finger of right hand toward the
left hand to draw purple operator. Final tension on
strand through the loop. final throw should be as
Right hand regrasps purple nearly horizontal as possible.
strand to complete the
second throw square.

21
Deep Tie
Tying deep in a body cavity can be difficult. The However the operator must avoid upward
square knot must be firmly snugged down as in tension which may tear or avulse the tissue.
all situations.

1 Strand looped around


hook in plastic cup on
Purple strand held in right
hand brought bertween
2
Practice Board with index left thumb and index finger.
finger of right hand which Left hand turned inward
holds purple strand in by pronation, and thumb
palm of hand. White swung under white strand
strand held in left hand. to form the first loop.

22
3 By placing index finger
of left hand on white
Horizontal tension applied
by pushing down on white
4
strand, advance the strand with left index finger
loop into the cavity. while maintaining counter-
tension with index finger of
right hand on purple strand.

23
Deep Tie

5 Purple strand looped over


and under white strand
Purple strand looped
around white strand to
6
with right hand. form second loop. This
throw is advanced into
the depths of the cavity.

24
7 Horizontal tension applied
by pushing down on purple
strand with right index finger
while maintaining counter-
tension on white strand
with left index finger. Final
tension should be as nearly
horizontal as possible.

25
Ligation Around Haemostatic Clamp
MORE COMMON OF TWO METHODS
Frequently it is necessary to ligate a blood
vessel or tissue grasped in a haemostatic clamp
to achieve haemostasis in the operative field.

1 When sufficient tissue has


been cleared away to permit
Left hand grasps free
end of the strand and
2
easy passage of the suture gently advances it behind
ligature, the white strand clamp until both ends are
held in the right hand is of equal length.
passed behind the clamp.

26
3 To prepare for placing
the knot square, the
As the first throw of the knot
is completed, the assistant
4
white strand is transferred removes the clamp. This
to the right hand and manoeuvre permits any tissue
the purple strand to the that mayhave been bunched
left hand, thus crossing in the clamp to be securely
the white strand over crushed by the first throw.
the purple. The second throw of the
square knot is then completed
with either a two-hand or
one-hand technique as
previously illustrated.
27
Ligation Around Haemostatic Clamp
ALTERNATE TECHNIQUE
Some surgeons prefer this technique because
the operator never loses contact with the suture
ligature as in the preceding technique.

1 Centre of the strand


placed in front of the tip
Purple strand swung
behind clamp and grasped
2
of haemostatic clamp with index finger of left
with purple strand held in hand. Purple strand will
right hand and white be transferred to left hand
strand in left hand. and released by right.

28
3 Purple strand crossed
under white strand with
First throw is completed
in usual manner. Tension
4
left index finger and is placed on both strands
regrasped with right hand. below the tip of the clamp
as the first throw of the
knot is tied. The assistant
then removes the clamp.
The square knot is completed
with either a two-hand or
one-hand technique as
previously illustrated.

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Instrument Tie
The instrument tie is useful when one of both holder with any monofilament suture, as
ends of the suture material are short. For best repeated bending may cause these sutures to
results, exercise caution when using a needle- break.

1 Short purple strand lies


freely. Long white end
Needleholder in right
hand grasps short purple
2
of strand held between end of strand.
thumb and index finger
of left hand. Loop formed
by placing needleholder
on side of strand away
from the operator.

30
3 First half hitch completed
by pulling needleholder
White strand is drawn
toward operator with left
4
toward operator with right hand and looped around
hand and drawing white needleholder held in right
strand away from operator. hand. Loop is formed
Needleholder is released by placing needleholder
from purple strand. on side of strand toward
the operator.

31
Instrument Tie

5 With end of the strand


grasped by the needleholder,
Square knot completed
by horizontal tension
6
purple strand is drawn applied with left hand
through loop in the white holding white strand
strand away from the toward operator and
operator. purple strand in needle-
holder away from operator.
Final tension should be
as nearly horizontal as
possible.

32
Granny Knot
A granny knot is not recommended. However, only to warn against its use. It has the
it may be inadvertently tied by incorrectly cross- tendency to slip when subjected to increasing
ing the strands of a square knot. It is shown pressure.

33
Suture Materials
The requirement for wound support varies in different human tissues in which it is implanted and to a greater or
tissues from a few days for muscle, subcutaneous tissue, lesser degree will elicit a foreign body reaction.
and skin; weeks or months for fascia and tendon; to Two major mechanisms of absorption result in the
long-term stability, as for a vascular prosthesis. The degradation of absorbable sutures. Sutures of biological
surgeon must be aware of these differences in the origin such as surgical gut are gradually digested by
healing rates of various tissues and organs. In addition, tissue enzymes. Sutures manufactured from synthetic
factors present in the individual patient, such as infection, polymers are principally broken down by hydrolysis in
debility, respiratory problems, obesity, etc., can influence tissue fluids.
the postoperative course and the rate of healing.
Non-absorbable sutures made from a variety of nonbio-
Suture selection should be based on the knowledge of degradable materials are ultimately encapsulated or
the physical and biologic characteristics of the material in walled off by the body’s fibroblasts. Non absorbable
relationship to the healing process. The surgeon wants to sutures ordinarily remain where they are buried within
ensure that a suture will retain its strength until the tissue the tissues. When used for skin closure, they must be
regains enough strength to keep the wound edges removed postoperatively.
together on its own. In some tissue that might never A further subdivision of suture materials is useful:
regain preoperative strength, the surgeon will want suture monofilament and multifilament. A monofilament suture is
material that retains strength for a long time. If a suture is made of a single strand, It resists harbouring micro-
going to be placed in tissue that heals rapidly, the organisms, and it ties down smoothly. A multifilament
surgeon may prefer to select a suture that will lose its suture consists of several filaments twisted or braided
tensile strength at about the same rate as the tissue together. This gives good handling and tying qualities.
gains strength and that will be absorbed by the tissue so However, variability in knot strength among multifilament
that no foreign material remains in the wound once the sutures might arise from the technical aspects of the
tissue has healed. With all sutures, acceptable surgical braiding or twisting process.
practice must be followed with respect to drainage and
The sizes and tensile strengths for all suture materials
closure of infected wounds. The amount of tissue reaction
are standardised by U.S.P. regulations. Size denotes the
caused by the suture encourages or retards the healing
diameter of the material. Stated numerically, the more
process.
zeros (0’s) in the number, the smaller the size of the
When all these factors are taken into account, the strand. As the number of 0’s decreases, the size of the
surgeon has several choices of suture materials strand increases. The 0’s are designated as 5-0, for
available. Selection can then be made on the basis of example, meaning 00000 which is smaller than a size 4-
familiarity with the material, its ease of handling, and 0. The smaller the size, the less tensile strength the
other subjective preferences. strand will have. Tensile strength of a suture is the
Sutures can conveniently be divided into two broad measured pounds of tension that the strand will
groups; absorbable and non absorbable. Regardless of withstand before it breaks when knotted. (Refer to pages
its composition, suture material is a foreign body to the 36 through 39.)

34
Principles of Suture Selection
The surgeon has a choice of suture materials from 3. Where cosmetic results are important, close
which to select for use in body tissues. Adequate and prolonged apposition of wounds and
strength of the suture material will prevent suture avoidance of irritants will produce the best
breakage. Secure knots will prevent knot slippage. result. Therefore:
But the surgeon must understand the nature of the a.Use the smallest inert monofilament suture
suture material, the biologic forces in the healing materials such as nylon or polypropylene.
wound, and the interaction of the suture and the
b.Avoid skin sutures and close subcuticularly,
tissues. The following principles should guide the
whenever possible.
surgeon in suture selection.
c. Under certain circumstances, to secure close
1. When a wound has reached maximal strength,
apposition of skin edges, a topical skin adhesive
sutures are no longer needed. Therefore:
or skin closure tape may be used.
a.Tissues that ordinarily heal slowly such as skin,
4. Foreign bodies in the presence of fluids
fascia, and tendons should usually be closed
containing high concentrations of crystalloids
with non absorbable sutures. An absorbable
may act as a nidus for precipitation and stone
suture with extended (up to 6 months) wound
formation. Therefore:
support may also be used.
a.In the urinary and biliary tract, use rapidly
b.Tissues that heal rapidly such as stomach,
absorbed sutures.
colon, and bladder may be closed with
absorbable sutures. 5. Regarding suture size:
2. Foreign bodies in potentially contaminated a.Use the finest size, commensurate with the
tissues may convert contamination to natural strength of the tissue.
infection. Therefore: b.If the postoperative course of the patient may
a.Avoid multifilament sutures which may convert produce sudden strains on the suture line,
a contaminated wound into an infected one. reinforce it with retention sutures. Remove them
as soon as the patient’s condition is stabilised.
b.Use monofilament or absorbable sutures in
potentially contaminated tissues.

Metric Measures and U.S.P. Suture Diameter Equivalents


U.S.P. 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

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 –

Non-absorbable 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

35
Absorbable Sutures
The United States Pharmacopeia (U.S.P.) defines an absorbable surgical suture as a “sterile strand prepared from collagen
derived from healthy mammals or a synthetic polymer. It is capable of being absorbed by living mammalian tissue.
but may be treated to modify its resistence to absorption. It may be impregnated or coated with a suitable antimicrobial
agent. It may be coloured by a colour additive approved by the Federal Food and Drug Administration (F.D.A.).”
The United States Pharmacopeia, Twentieth Revision, Official from July 1, 1980.

Absorbable Suture Materials Most Commonly Used


SUTURE TYPES COLOUR OF RAW MATERIAL TENSILE STRENGTH ABSORPTION RATE
MATERIAL RETENTION in vivo
Coated VICRYL Braided Violet Copolymer of lactide Approximately 75% remains at Essentially complete
(Polyglactin 910) and glycolide coated two weeks. Approximately 50% between 56-70 days.
Suture Monofilament Undyed with polyglactin 370 remains at three weeks. Absorbed by hydrolysis.
(Natural) and calcium stearate.

Coated VICRYL Plus Braided Violet Copolymer of lactide Approximately 75% remains at Essentially complete
(Polyglactin 910) and glycolide coated two weeks. Approximately 50% between 56-70 days.
Suture Undyed with polyglactin 370 remains at three weeks. Absorbed by hydrolysis.
and calcium stearate +
Triclosan - IRGACARE MP

Coated Braided Undyed Copolymer of lactide Approximately 50% remains Essentially complete by 42
VICRYL rapide (Natural) and glycolide coated at 5 days. days. Absorbed by hydrolysis.
(Polyglactin 910) with polyglactin 370
Suture and calcium stearate

MONOCRYL Monofilament Undyed Copolymer of glycolide and Approximately 50-60% (violet: Complete at 90-120 days.
(Poliglecaprone 25) (Natural) epsilon-caprolactone. 60-70%) remains at one week. Absorbed by hydrolysis.
Suture Approximately 20-30% (violet:
30-40%) remains at two weeks.
Violet Lost within three weeks (violet:
four weeks).

PDS II Monofilament Violet Polyester polymer Approximately 70% remains at Absorbed in 180 - 210 days.
(Polydioxanone) two weeks. Approximately Absorbed by slow hydrolysis.
Suture 50%) remains at four weeks.
Approximately 25% remains
Blue at six weeks).
Clear

36
COLOUR CODE
TISSUE REACTION CONTRAINDICATIONS FREQUENT USES HOW SUPPLIED OF PACKETS
Minimal acute Being absorbable, should General soft tissue approximation 8-0 through 3 with and without needles, Violet
inflammatory reaction not be used where extended and/or ligation, including use and on LIGAPAK dispensing reels
approximation of tissues is required. in ophthalmic procedures. Not 4-0 through 1 with CONTROL RELEASE
for use in cardiovascular and needles.
neurological tissues.

Minimal acute These sutures, being absorbable General soft tissue approximation 5-0 through 2 with needles. Violet
inflammatory reaction should not be used where extended and/or ligation, including use
approximation of tissues under stress in ophthalmic procedures. Not
is required. VICRYL* PLUS suture for use in cardiovascular and
should not be used in patients with neurological tissues.
known allergic reactions to
IRGACARE MP (Tricloscan)
Minimum to moderate Should not be used where extended Superficial soft tissue approximation 5-0 through 1 with needles. White and Red
acute inflammatory approximation of tissue under stress of skin and mucosa only. Not for
reaction is required or where wound support use in cardiovascular and
beyond 7 days is required. neurological tissues.

Minimal acute Being absorbable, should General soft tissue approximation 6-0 through 2 with and without needles Coral
inflammatory reaction not be used where extended and/or ligation. Not for use in 3-0 through 1 with CONTROL
approximation of tissues under cardiovascular or neurological RELEASE needles
stress is required. Undyed tissues, microsurgery, or
not indicated for use in fascia. ophthalmic surgery.

Slight reaction Being absorbable, should All types of soft tissue approximation 9-0 through 2 with needles Silver
not be used where prolonged including pediatric cardiovascular 3-0 through 1 with CONTROL
approximation of tissues under and ophthalmic procedures. Not for RELEASE needles
stress is required. Should not be use in adult cardiovascular tissue, 9-0 through 7-0 with needles
used with prosthetic devices, such microsurgery, and neural tissue.
as heart valves or synthetic grafts. 7-0 through 1 with needles

37
Non-absorbable Sutures
By U.S.P. definition, “nonabsorbable sutures are strands of material that are suitably resistant to the action of living
mammalian tissue. A suture may be composed of a single or multiple filaments of metal or organic fibres rendered into a
strand by spinning, twisting, or braiding. Each strand is substantially uniform in diameter. throughout its length within U.S.P.
limitations for each size. The material may be uncoloured, naturally coloured, or dyed with an F.D.A. approved dyestuff. It
may be coated or uncoated; treated or untreated for capillarity.”
Non-absorbable Suture Materials Most Commonly Used
SUTURE TYPES COLOUR OF RAW MATERIAL TENSILE STRENGTH ABSORPTION RATE
MATERIAL RETENTION in vivo
Silk Suture Braided Violet Organic protein called fibroin. Progressive degradation of fibre Gradual encapsulation by
may result in gradual loss of fibrous connective tissue.
White tensile strength over time.

Surgical Stainless Monofilament Silver metallic 316L stainless steel. Indefinite. Non-absorbable.
Steel Suture

Multifilament

ETHILON Nylon Monofilament Violet Long-chain aliphatic polymers Progressive hydrolysis may Gradual encapsulation by
Suture Nylon 6 or Nylon 6/6. result in gradual loss of tensile fibrous connective tissue.
Green strength over time.

Undyed (Clear)
NUROLON Nylon Braided Violet Long-chain aliphatic polymers Progressive hydrolysis may Gradual encapsulation by
Suture Nylon 6 or Nylon 6/6. result in gradual loss of tensile fibrous connective tissue.
Green strength over time.

Undyed (Clear)
MERSILENE Braided Green Poly (ethylene terephthalate). No significant change known Gradual encapsulation by
Polyester Fibre to occur in vivo. fibrous connective tissue.
Suture
Monofilament Undyed (White)

ETHIBOND EXCEL Braided Green Poly (ethylene terephthalate) No significant change known Gradual encapsulation by
Polyester Fibre coated with polybutilate. to occur in vivo. fibrous connective tissue.
Suture
Undyed (White)

PROLENE Monofilament Clear Isotactic crystalline stereoiso- Not subject to degradation Non-absorbable
Polypropylene mer of polypropylene. or weakening by action of
Suture Blue tissue enzymes.

PRONOVA Poly Monofilament Blue Polymer blend of poly Not subject to degradation Non-absorbable
(Hexafluoropropylene- (vinylidene fluoride) and poly or weakening by action of
VDF) Suture (vinylidene fluoride-co- tissue enzymes.
hexafluoropropylene).

38
TISSUE REACTION CONTRAINDICATIONS FREQUENT USES HOW SUPPLIED COLOUR CODE
OF PACKETS
Accute inflammatory Should not be used in patients General soft tissue approximation 9-0 through 5with and without Light Blue
reaction with known sensitivities or and/or ligation, including needles, and on LIGAPAK
allergies to silk. cardiovascular ophthalmic and dispensing reels
neurological procedures. 4-0 through 1 with CONTROL
RELEASE needles.
Minimal acute Should not be used in patients Abdominal wound closure, hernia 10-0 through 7 with and without Yellow-Ochre
inflammatory reaction with known sensitivities or allergies repair, sternal closure and needles.
to 316L stainless steel, or orthopaedic procedures including
constituent metals such as cerclage and tendon repair.
chromium and nickel.
Minimal acute Should not be used where General soft tissue approximation 11-0 through 2 with and without Mint Green
inflammatory reaction permanent retention of tensile and/or ligation, including use in needles.
strength is required. cardiovascular ophthalmic and
neurological procedures.

Minimal acute None known. General soft tissue approximation 6-0 through 1 with and without Mint Green
inflammatory reaction and/or ligation, including use in needles
cardiovascular ophthalmic and 4-0 through 1 with CONTROL
neurological procedures.. RELEASE needles

Minimal acute None known. General soft tissue approximation 6-0 through 5 with and without needles Turquoise
inflammatory reaction and/or ligation, including use in 10-0 and 11-0 for ophthalmic (green
cardiovascular ophthalmic and monofilament)
neurological procedures. 0 with CONTROL RELEASE
needles
Minimal acute None known. General soft tissue approximation 7-0 through 2 with needles Orange
inflammatory reaction and/or ligation, including use in 3-0 through 1 with CONTROL
cardiovascular ophthalmic and RELEASE needles
neurological procedures. 9-0 through 7-0 with needles
7-0 through 1 with needles

Minimal acute None known. General soft tissue approximation 6-0 through 2 (clear) with and Deep Blue
inflammatory reaction and/or ligation, including use in without needles
cardiovascular ophthalmic and 10-0 throough 8-0 and 6-0 through 2
neurological procedures. (blue) with and without needles
0 through 2 with CONTROL RELEASE
needles various sizes attached to TFE
polymer pledges

Minimal acute None known. General soft tissue approximation 6-0 through 5-0 with TAPERCUT Royal Blue
inflammatory reaction and/or ligation, including use in surgical needle
cardiovascular ophthalmic and 8-0 through 5-0
neurological procedures. with taper point needle.

39
Surgical Needles
Necessary for the placement of sutures in tissue, surgical suture strand, are supplied in a variety of sizes, shapes,
needles must be designed to carry suture material through and strengths. Some incorporate the CONTROL
tissue with minimal trauma. They must be sharp enough to RELEASE* needle suture principle which facilitates fast
penetrate tissue with minimal resistance. They should be separation of the needle from the suture when desired by
rigid enough to resist bending, yet flexible enough to bend the surgeon. Even though the suture is securely fastened
before breaking. They must be sterile and corrosion- to the needle, a slight, straight tug on the needleholder will
resistant to prevent introduction of micro-organisms or release it. This feature allows rapid placement of many
foreign bodies into the wound. sutures, as in interrupted suture techniques.
To meet these requirements, the best surgical needles are The body, or shaft, of a needle is the portion which is
made of high quality stainless steel, a non-corrosive grasped by the needleholder during the surgical
material. Surgical needles made of carbon steel may procedure. The body should be as close as possible to the
corrode, leaving pits that can harbour micro-organisms. All diameter of the suture material. The curvature of the body
ETHICON* stainless steel needles are heat-treated to give may be straight, half-curved, curved, or compound curved.
them the maximum possible strength and ductility to The cross-sectional configuration of the body may be
perform satisfactorily in the body tissues for which they are round, oval, side-flattened rectangular, triangular, or
designed. ETHALLOY* needle alloy, a non-corrosive trapezoidal. The oval, side-flattened rectangular, and
material, was developed for unsurpassed strength and triangular shapes may be fabricated with longitudinal ribs
ductility in precision needles used in cardiovascular,
on the inside or outside surfaces. This feature provides
ophthalmic, plastic, and microsurgical procedures.
greater stability of the needle in the needleholder.
Ductility is the ability of the needle to bend to a given
The point extends from the extreme tip of the needle to
angle under a given amount of pressure, called load,
the maximum cross-section of the body. The basic needle
without breaking. If too great a force is applied to a needle
points are cutting, tapered, or blunt. Each needle point is
it may break, but a ductile needle will bend before
designed and produced to the required degree of
breaking. If a surgeon feels a needle bending, this is a
sharpness to smoothly penetrate the types of tissue to be
signal that excessive force is being applied. The strength
sutured.
of a needle is determined in the laboratory by bending the
needle 90°; the required force is a measurement of the Surgical needles vary in size and wire gauge. The
strength of the needle. If a needle is weak, it will bend too diameter is the gauge or thickness of the needle wire. This
easily and can compromise the surgeon’s control and varies from 30 microns 1.4 mm). Very small needles of
damage surrounding tissue during the procedure. fine gauge wire are needed for microsurgery. Large, heavy
Regardless of ultimate intended use, all surgical needles gauge needles are used to penetrate the sternum and to
have three basic components: the attachment end, the place retention sutures in the abdominal wall. A broad
body, and the point. spectrum of sizes are available between these two
extremes.
The majority of sutures used today have appropriate
needles attached by the manufacturer. Swaged sutures Of the many types available, the specific needle selected
join the needle and suture together as a continuous unit for use is determined by the type of tissue to be sutured,
that is convenient to use and minimises tissue trauma. the location and accessibility, size of the suture material,
Surgical needles, which are permanently swaged to the and the surgeon’s preference.
40
Types of ETHICON Stainless Steel Needles
ROUND BODIED NEEDLES
Round bodied needles are designed to separate tissue fibres rather than cut them. They are used either for soft
tissue or in situations where easy splitting of tissue fibres is possible. After the passage of the needle, the tissue
closes tightly round the suture material, thereby forming a leak-proof suture line which is particularly vital in
Intestinal and Cardio-vascular surgery.

Taperpoint Needle
The point profile of a Taperpoint needle is engineered to
provide easy penetration of intended tissues.
Forceps flats are formed in an area half way between the point
and the attachment. Positioning the needle holder in this area
confers extra stability on the needle being held, aiding precise
placement of the sutures.

PLUS Taperpoint Needle

A modified point profile for some of our smaller round bodied


intestinal type needles, typically for needles in the size range
20-30mm. In the modified profile, the tapered cross section
immediately behind the tip has been flattened to an oval shape
rather than the conventional round shape. This continues for
several millimetres before merging into the conventional round
bodied cross section. This design was developed to help
facilitate improved separation of tissue layers.

ETHIGUARD BLUNT TAPERPOINT Needle

This needle has been designed to minimise the risk of needle-


stick injury. The ETHIGUARD Needle point is sharp enough to
penetrate fascia and muscle but not skin. Virtually eliminating
accidental glove puncture, the ETHIGUARD Needle can also
be used for suturing friable tissue such as the liver.

41
ROUND BODIED NEEDLES

BLUNT POINT Needle

This needle has been designed for suturing extremely friable


tissue such as the liver.

TAPERCUT Needle
This needle combines the initial penetration of a cutting needle
with the minimised trauma of a round bodied needle. The
cutting tip is limited to the point of the needle, which then
tapers out to merge smoothly into a round cross section.

CC Needle
The unique point design of the CC Needle provides
significantly improved penetration properties for the Cardiac/
Vascular surgeon when suturing tough, calcified vessels. This
is achieved with no increase in tissue trauma compared to the
conventional round bodied needle. Squared body geometry, in
addition to providing a stronger fine vascular needle, also
means this needle is particularly secure in the needle holder.
CC Needles are made from ETHALLOY (a patented alloy from
ETHICON) which makes them more resistant to bending.

42
ROUND BODIED NEEDLES

VISI BLACK Needle


These black needles have been designed to give outstanding
visibility against tissue and where blood is present in the
operating field. The slim taperpoint design of the VISI-BLACK
Needle brings improved penetration properties and minimises
tissue trauma

CUTTING NEEDLES – CUTICULAR NEEDLES


Cutting needles are required wherever tough or dense tissue needs to be sutured.

Conventional Cutting Needle

This needle has a triangular cross section with the apex of the
triangle on the inside of the needle curvature. The effective
cutting edges are restricted to the front section of the needle
and merge into a triangulated body which continues for half the
length of the needle.

Reverse Cutting Needle

The body of this needle is triangular in cross section, having


the apex cutting edge on the outside of the needle curvature.
This improves the strength of the needle and particularly
increases its resistance to bending.

43
CUTTING NEEDLES – CUTICULAR NEEDLES

PRIME Needle

Specifically designed for surgeons seeking excellence in skin


closure, the PRIME needle incorporates a hollowform point
design which reduces the angles of the cutting edges,
producing the sharpest needles in the ETHICON range. Made
from ETHALLOY (a patented alloy from ETHICON), these
needles can be made slimmer, yet still maintain their resistance
to bending.

TROCAR POINT Needle

Based on the traditional TROCAR POINT, this needle has a


strong cutting head which then merges into a robust round
body. The design of the cutting head ensures powerful
penetration, even when deep in dense tissue.

44
OPHTHALMIC NEEDLES
These fine needles are manufactured using a unique process which ensures extremely sharp cutting edges. The range
includes spatulated designs for suturing specific layers of the eye in Anterior Segment surgery in addition to round
bodied, cutting and TAPERCUT designs for specific ophthalmic and oculoplastic procedures.

CS-ULTIMA Needle

This needle represents a dramatic change in ophthalmic needle


design. Its concave spatula geometry requires considerably
less force to penetrate corneal scleral tissue than existing
needles. This results in much less disruption of the cornea and
the real possibility of reduced post-operative suture related
astigmatism.

ADVANCED MICRO-POINT Spatula Needle

Due to the ultra fine diameter of this needle, a new concept of


design has been necessary. An extremely sharp cutting point
has been merged into a square body to produce superb
penetration characteristics. In addition, the square body greatly
increases resistance to bending and gives much improved
needle holder security, locking the needle at the correct angle
for secure accurate suture placement.

45
OPHTHALMIC NEEDLES

MICRO-POINT Spatula Needle

This needle has a thin, flat profile which allows the


needle to penetrate between the layers of scleral or corneal
tissue.

MICRO-POINT Reverse Cutting Needle

The third cutting edge of this needle lies on the outside of its
curvature, thereby eliminating the possibility of needle cut out
during suture placement.

SPATULATED Needle

Similar in cross section to MICRO-POINT Spatula


needles, this is designed for scleral suturing which requires
stronger needles and where the elimination of cut out or cut
down by a third edge is essential.

46
47
Notes
48
N o te s
ETHICON
A division of JOHNSON & JOHNSON MEDICAL LIMITED
PO Box 1988, Simpson Parkway, Kirkton Campus,
Livingston EH54 0AB
www.ethiconproducts.co.uk Cap No. 20 11 2005
Call our Customer Services on 0800 864 060