SUTURE MATERIALS

AND TECHNIQUES
The Ideal Suture Material

• Can be used in any tissue

• Easy to handle
• Good knot security
• Minimal tissue reaction
The Ideal Suture Material

• Unfriendly to bacteria

• Strong yet small

• Won’t tear through tissues

• Cheap
What’s It Used for?

• To bring tissue edges together and speed wound healing (=tissue

apposition)

• Orthopedic surgery to help stabilize joints

– Repair ligaments

• Ligate vessels or tissues

Types of Needles

• Eyed needles
–More Traumatic
–Only thread
through once
–Suture on a reel
–Tends to unthread
itself easily
Types of Needles

•Swaged-on needles
– Much less traumatic
– More expensive suture material
– Sterile
Points of Needles

•Taper
– Atraumatic
– Internal organs
Points of Needles

•Cutting
• Cutting edge on inside
of circle
• Skin
• Traumatic
Points of Needles

•Reverse Cutting
• Cutting edge on outside
of circle
• Skin
• Less traumatic than cutting
 Cutting vs Reverse Cutting

• Cutting

• Reverse cutting
Shapes of Needles

• 3/8 circle
• 1/2 circle
• Straight
• Specialty
Characteristics of Suture Material

• Absorbable Vs. Nonabsorbable

• Monofilament Vs. Multifilament

• Natural or Synthetic
Absorbable Sutures

• Internal
• Intradermal/ subcuticular
• Rarely on skin
Non-absorbable Suture

• Primarily Skin
– Needs to be removed later

• Stainless steel = exception

– Can be used internally
• Ligature
• Orthopedics
– Can be left in place for long periods
 Reading the Suture Label
Order Code
Size

Also:
Name
LENGTH
NEEDLE
SYMBOL
Needle COLOR
Absorbable
or Non

• Company
Choosing
Absorbable Vs. Nonabsorbable

• How long you need it to

work

• Do you want to see the

“animal” again for suture
removal
 Monofilament Vs. Multifilament

• memory easy to handle

• less tissue drag more tissue drag
• doesn’t wick wicks/ bacteria
• poor knot security good knot security
• - tissue reaction + tissue reaction
Natural Vs. Synthetic

•Natural:
– Gut
– Chromic Gut
– Silk
– Collagen
• All are absorbable
Gut/ Chromic Gut

• Made of submucosa of
small intestines

• Multifilament

• Breaks down by
phagocytosis:
inflammatory reaction
common
Gut/ Chromic Gut

• Chromic: tanned, lasts longer,

less reactive

• Easy handling

• Plain: 3-5 days

• Chromic: 10-15 days

• Bacteria love this stuff!

Collagen and Silk

• Natural sutures

• VERY reactive,
absorbable

• Ophthalmic surgery only

Vicryl (Polyglactin 910)

• Braided, synthetic, absorbable

• Stronger than gut: retains strength 3 weeks
• Broken down by enzymes, not phagocytosis
• Break-down products inhibit bacterial growth
– Can use in contaminated wounds, unlike other multifilaments
Dexon and PGA

• Polymer of glycolic acids

• Braided, synthetic, absorbable
• Broken down by enzymes
• Both PGA and dexon have increased tissue drag, good knot security
• Both are stronger than gut
PDS (polydioxine)

• Monofilament (less drag, worse knot security – lots of “memory”)

• Synthetic, absorbable
• Very good tensile strength (better than gut, vicryl, dexon) which lasts
months
• Absorbed completely by 182 days
Maxon (polyglyconate)

• Monofilament- memory
• Synthetic Absorbable
• Very little tissue drag
• Poor knot security
• Very strong
NONABSORBABLE SUTURES

• Natural or Synthetic
• Monofilament or multifilament
NYLON

• Synthetic
• Mono or Multifilament
• Memory
• Very little tissue reaction
• Poor knot security
Polymerized Caprolactum

• Vetafil, Braunamid, Supramid

• Multifilament suture with protein coating
• Synthetic
• Good knot security, easy handling
• Not very reactive
• Don’t use in contaminated wound
• Usually comes on a reel
Polypropylene

• Prolene, Surgilene
• Monofilament, Synthetic
• Won’t lose tensile strength over time
• Good knot security
• Very little tissue reaction
Stainless Steel

• Monofilament
• Strongest !
• Great knot security
• Difficult handling
• Can cut through tissues
• Very little tissue reaction, won’t harbor bacteria
 Suture Materials
Suture filament Absorbing Tissue Tensile Tensile cost Uses
material properties reaction strength strength
retention
plain gut collegen absorbable moderate poor 2-4 days low Inside the wound where it
absorbs and wound healing is
quick
chromic gut collegen absorbable moderate poor 7-10 days low Inside the wound where it
absorbs and wound healing time
is average length
polyglactin braided absorbable mild poor 2-3 weeks moderate Inside the wound where it
(Vicryl) absorbs and longer wound healing
time is required, such as tendons.
silk braided Non- high poor 1year low Skin closure or fascia
absorbable
nylon monofiliment Non- Very low good Loses low Skin closure or fascia or where
absorbable 20%/yr long term strength is needed
Poly monofiliment Non- minimal excellent indefinite high Sub-cuticular skin closure or
propylene absorbable fascia or where permanent
(Prolene) strength is needed.
Polyester braided Non- minimal good indefinite high Internally where low reaction
(Mersilene) absorbable braided suture is required to allow
tissue to adhere to it.
stainless monofiliment Non- low excellent indefinite moderate Bone , tendons, strong connective
steel absorbable tissue where permanent strength is
required
Suture Sizes

• Sized #5-4-3-2-1-0-00-000-0000…30-0
– BIGGER >>>>>>>>>>>>>>>>SMALLER

• 00 = 2-0, “two ought”

• SA : 0 through 3-0 (Optho 5-0 >>7-0)

• LA : 0 through 3
Suture Sizes (cont)

• Stainless Steel
– In gauges (like needles)
• Smaller gauge = bigger, stronger
• Larger gauge= smaller, finer

– 26 gauge = “ought”
– 28 gauge = 2-0
Problems Associated with Surgical
Sutures
• Time-consuming nature of secure knot tying
• Need for knot security under all conditions with all sutures
• Risk of suture breakage during surgery
• Loss of control due to needle slippage or rotation within the needle
holder
• Postsurgical slippage of the knotted suture
• Early or pathologically induced degradation of absorbable suture
 Skin Staples

• Very common in human medicine

• Expensive
• Very easy
• Very secure
• Very little tissue reaction
• Removal =
– Special tool required
Ligating Clips
• Essentially “clips” to replace
sutures when occluding (closing)
the lumen (central canal) of a
vessel or tubular organ
• Blood vessels
• Gynecological & urological (GU)
procedures
• Metallic or polymeric
• Requirements
• Nontoxic and biocompatible
• Absence of allergic and
immunogenic effects
• Tolerated by wide range of tissue
types
• High strength and low solubility
• Finite longevity
• Secure
Metallic Clips

• First – Cushing neurosurgery clip, • Desirable properties in metallic clips

1910 • High strength
• Ag wire formed in the shape of a • Malleability & ductility – can
“U” and closed around blood make fine wire
vessel • Capacity for work-hardening
• Tantulum (1940) • Corrosion resistance
• Tubule ligation
• Some problems
• Others
• Allergic reaction
• Co-Cr
• Radio-opaque – can cause
• Titanium problems with CT, X-ray, and MRI
• Stainless Steel examinations
• “Memory metal” – Ni-Ti alloy
Polymeric Clips

• Absorbable and non-

absorbable
• Viscoelastic
• Creep
• Stress-relaxation
Surgical Stapling

• Introduced in the late 1970s • Staples originally stainless but

• Used widely in human and now Ti and polymeric used
veterinary medicine • Polymeric – 2 parts
• “U”-shaped fastener
• Gynecological
• Figure “8” retainer
• Cardiovascular
• Gastrointestinal
• Esophageal
• Pulmonary
Surgical Staples

Staple Staple Gun

Staple Remover
Staples & Clips vs. Sutures

• Speed
• Convenience
• Reduced infection rate
• Lower cost
• If done properly, no cosmetic difference
Tissue Adhesives
Before Curing
• Sterilizable
• Easy in preparation
• Viscous liquid or liquid
possible for spray
• Nontoxic
• Rapidly curable under wet
physiological conditions (pH
7.3, 37°C, 1 atm)
• Reasonable cost
After Curing
• Strongly bondable to tissues
• Biostable union until wound
healing
• Tough and pliable
• Resorbable after wound
healing
• Nontoxic
• Nonobstructive to wound
healing or promoting wound
healing
Natural Tissue – Fibrin Glue

• First reported in 1940

• Mimics blood clot – major component fibrin network
• Excellent tissue adhesive but insufficient in amount for larger wounds
• Nontoxic if human protein sources are used to obtain fibrin
Synthetic Systems:
Poly-Alkyl-2-Cyanoacrylates
• Discovered in 1951
• “Crazy Glue”
• H2C=C―CO2―R
CN
• R = alkyl group
• CH3 (methyl)
• H3CCH2 (ethyl)
• Release small amount of
formaldehyde when curing
• amount lessens with length
of alkyl chain
Characteristics of Currently Available Adhesive
Systems

Fibrin Glue Cyanoacrylate

Handling Excellent Poor
Set time Medium Short
Tissue bonding Poor Good
Pliability Excellent Poor
Toxicity Low Medium
Resorbability Good Poor
Cell infiltration Excellent Poor
Tissue Adhesive

• Nexaband, Vetbond, and

others

• Little strength

• Should not be placed

between skin layers or
inside body
Other Experimental Systems

• Gelatin-based adhesives
• Mimic coagulation but without fibrin
• Polyurethane (-HNOCO-) based adhesives
• Capped with isocyanate to rapidly gel upon exposure to water
• More flexible than current cyanoacrylate adhesives
• Collagen-based adhesives
Knots
• A suture knot has three components
1- The loop created by the knot
2- The knot itself, which is composed of a number of tight “throws”,
each throw represents a weave of the two stands
3- The ears, which are the cut ends of the suture
Principles of Suturing

• The completed knot must be tight, firm, and tied so that slippage will
not occur
• To ovoid wicking of bacteria, knot should not be placed in incision
lines
• Knots should be small and the ends cut short (2-3mm)
• Avoid excessive tension to finer gauge materials as breakage may
occur
Principles of Suturing
• Avoid using a jerking motion, which may break the suture
• Avoid crushing or crimping of suture materials by not using
hemostats or needle holders on them except on the free end for
tying
• Do not tie suture too tightly as tissue necrosis may occur. Knot
tension should not produce tissue blanching
• Maintain adequate traction on one end while tying to avoid
loosening of the first knot
Principles for Suture Removal

• The area should be swabbed with hydrogen peroxide for removal of

encrusted necrotic debris, blood, and serum from about the sutures
• A sharp suture scissors should be used to cut the loops of individual
or continuous sutures

Sutures should be removed in 5 to 7 days to prevent epithelialization

or infection.
Suturing Technique
Discussion points

• Aseptic vs. Sterile technique

• Surgical conscience
• Common surgical instruments
• Choice of anaesthetic
• Preparing the wound
• Correct knot tying methods
• Wound closure with a variety of suturing techniques
• Common pitfalls
• Practical tips on improving your technique
• Guidelines for choosing the correct suture and needle
 Wound healing and scars
The goal of optimal wound closure is to obtain a
fine line scar that maintains both the form and
appearance of the tissue. It is important to let
your patient know that any time there is an an
incision there is going to be a scar. However
with careful technique and close attention to
tissue integrity this scar can be minimized.
Know when it is a closure that you should not
attempt e.g. lip, eyelid, across a joint, tendon
involved, or the web space of a hand.
• Plan the incision or type of closure
• Gather equipment – irrigation, syringes, anesthetic, instruments, suture,
drapes, dressing.
• Time out:
• Check patient name and sign a consent
• Check what procedure is to be done
• Scrub glove and drape
• Prepare the skin – betadine on the outside
• Local anesthetic – lidocaine or bupivacaine
• Debridement or incision
• Undermining where necessary
Preparation
• Plan the incision or type of closure
• Gather equipment – irrigation, syringes, anesthetic, instruments, suture,
drapes, dressing.
• Time out:
• Check patient name and sign a consent
• Check what procedure is to be done
• Scrub glove and drape
• Prepare the skin – betadine on the outside
• Local anesthetic – lidocaine or bupivacaine
• Debridement or incision
• Undermining where necessary
Start in the center and swab in circles going outward
 Instruments

adison forceps hemostat metzenbaum scissors suture scissors

 Instruments

Needle holders blade handle suture removal scissors bandage scissors

 Sterile instruments

• Have the instruments been sterilized and packed in sterile packages?

• Has the indicator tape changed color
• Is the package still sealed and double wrapped

Sterilize with:
• Autoclave 15- 20 psi 220 to 250 degrees F
• Gas
• liquid
 Anesthetic
Lidocaine 1% or 2% - inject locally or a regional block
• gives anesthesia and reduces muscle movement

May be buffered - 9:1 with sodium bicarbonate, to reduce pain on

injection (e.g. remove 2 mL of 1% lidocaine from 20 mL vial, and add 2
mL of sodium bicarbonate solution to vial)

Bupivacaine (Marcaine) 0.25% or 0.5%

• gives anesthesia only
(lidocaine and bupivacaine can be mixed half and half)

Epinephrine can be added to increase anesthetic time and decrease

bleeding – don’t not use on fingers, nose, penis or toes
 Anesthetic
Local Lidocaine (Xylocaine)1% or 2%
• Onset: 2 minutes
• Duration: 1.5 to 2 hours
• Action : anesthesia and reduced muscle movement
• Max dose: 4 mg/kg to 280 mg (14 ml 2%, 28 ml 1%)

Lidocaine with Epinephrine 1:100,000 or 1:200,000

• Onset: 2 minutes
• Duration: 1 – 3 hours
• Action : anesthesia and reduced muscle movement
• Max dose: 7 mg/kg to 500 mg (25 ml 2%, 50 ml 1%)

Bupivacaine (Marcaine) 0.25%

• Onset: 5 minutes
• Duration: 2 to 4 hours
• Action : anesthesia only
• Max dose: 2.5 mg/kg up to 175 mg (50 ml 0.25%, 25 ml 0.5%)
 Basic knot tying

1 2 3 4
1 – square knot
2 – granny knot
3 - slip knot
4 – surgeon’s knot
Instrument tying
Surgical wound closure guidelines

• Adequate debridement and hemostasis

• Atraumatic technique
• Alignment with the relaxed skin tension lines
• Angle of incision
• Perpendicular to skin surface or slightly undermined
• Angle incisions parallel to hair shafts
• Consider area of the body for vascularity and
tension on the wound
 Key techniques

• Close dead space under the incision

• Close that issue in layers
• Carefully align the wound edges
• Careful choice of the axis of incision or axis of closure of the donor skin
flaps
• Correct choice of deep and cutaneous sutures
Undermining
 Bleeding

• Control with pressure directly over the wound immediately

• Locate the nearest artery and put pressure there to give yourself
room to work.

• If necessary tie off the bleeding vessel.

• Use a pressure bandage

Simple Interrupted sutures

• This suture is used for simple laceration closures or closure of office

procedures like biopsies or lesion removals.
• It is also the basic suture used inside the wound to close deep
sutures.
• It is useful in that a few sutures can be removed at a time instead of
all at once to allow for slower sound healing
Continuous Sutures

• The continuous suture as its name suggests, only has a knot at the
beginning and the end.
• There are several methods of continuous suture – locking and non-
locking.
• The knots must be very secure and minimal tesion on the wound or
the wound will come apart if one loop or knot gives way.
• The advantage is that it is very quick and the wound tension is even
across the wound.
Horizontal Mattress Suture

• Used with wounds with poor circulation

• Helps eliminate tension on wound edges
• Requires fewer sutures to close a wound
• Can be placed quite quickly
• Can be done as a continuous suture
Vertical Mattress Sutures

• Deep and shallow approximation of the tissue

• Can be used for wounds under tension.
• Can be useful with lax tissue e.g. elbow and knee.
• Should not be used on volar surface of hands or feet or on the face
because of blind placement of the deep part of the suture.
Sub-cuticular closure

• Used for cosmetic closures

• Use an absorbable suture if you plan to leave the sutures in and bury
the knots
• Use either nylon or prolene (best) and keep the suture sliding while
you are closing. The suture then can be easily removed with no
exterior marks. The ends can be taped or a knot on the skin.
• At each entry point, enter across form the last exit with slight
overlap.
 Eliptical incision
The ellipse should be three times as long as it is wide. This will
make closure of the wound much easier. If the lesion you are
removing is likely to be cancerous, make sure that you leave
wide margins of clear skin around the lesion.
 3 Cornered Suture
• Used to close a skin flap which comes to a point.
• Helps close the wound, but maintain circulation to the tissue.
• Places minimal tension on the wound edges
• #1 Care of the patient
ASANZA
 Surgical Drains:
Indications, Types, & Principals
of Use
Learning Objectives

• Goals / Indications for Use

• Why use a drain ?
• Types
• What are the major types of drains and how do they work ?
• Principals of Use
• Which drain to use ?
• What are the complications ?
Goals

• Decrease Infection Rate

• Decrease Healing Time
Indications

1. To help eliminate dead space

2. To evacuate existing accumulation of fluid or gas

3. To prevent the potential accumulation of fluid or gas

Drain Types

➢Flat
• Dependent on gravity and capillary
action
• Drainage related to surface area
• Penrose - latex
Drain Types

• Flat drains - Penrose

• Advantages
• Allow drainage
• Help obliterate dead space
• Soft / malleable – less painful
• Disadvantages
• Very irritating
• Allow bacterial ingress
• Cannot be connected to suction
• Gravity dependent
Drain Types

➢Tube
 Single lumen
 +/- side holes
 Silicone, polyvinyl
chloride, red rubber
Drain Types

• Tube drains
• Advantages
• Drain from both within and outside of lumen
• Can be connected to suction
• Can be used with closed collection system
• Disadvantage
• Discomfort due to stiffness
Drain Types

• Double lumen
• Sump drains –
open/open suction
• Drainage of fluid via large
lumen
• Sump lumen – smaller AIR
and allows ingress of air FLUID

AIR
Drain Types
• Double lumen
• Advantages
• More efficient than single lumen
• Maintain patency longer than single lumen
• Disadvantages
• Risk of contamination of wound as environmental air drawn in – reduced
with filter
Drain Types

• Passive
• Active
• Continuous suction
• Intermittent suction
Passive Drains
➢Passive
 Drain by means of pressure differentials, overflow, and
gravity
 Provides a stent that keeps a draining tract / cloaca open
 Allow egress via a path of least resistance
 Flat or with a lumen
 Open or Closed – Closed preferred
Passive Drains

• Passive closed
• Advantages
• Allow evaluation of volume and nature of
fluid
• Prevent bacterial ascension
• Eliminate dead space
• Help appose skin to wound bed – quicker
wound healing
• Disadvantages
• Gravity dependent – affects location of
drain
• Drain easily clogged
 Active Drains
• Vacuum pulls fluid / gas from the wound
• Closed to atmosphere = Closed suction
• Vacuum applied to a single lumen tube
• Not gravity dependent
Active Drains
Active Drains

• Advantages
• Keep wound dry – efficient fluid removal
• Can be placed anywhere
• Prevent bacterial ascension
• Help appose skin to wound bed – quicker wound healing
• Allows evaluation of volume and nature of fluid
• Disadvantages
• High negative pressure may injure tissue
• Drain clogged by tissue
Principals of Ideal Use

• Aseptic site preparation (clip, scrub, debride, lavage)

• Place to avoid anastomosis sites and major vessels
• Exit through separate stab incision, away from surgical incision
• Aseptic postoperative management (cover with sterile
bandage, change before strike through, clean & dry cage)
Principals of Ideal Use

• Protect from premature removal or loss – E-collar

• Remove as soon as possible - drainage decreases or fluid
changes character (2 – 5 days)
• Bacterial culture on removal
Complications and Failure of Drains
• Poor Drain Selection

• Poor Drain Placement

• Poor Post-operative Management

Complications and Failure of Drains
 Infection
 Ascending bacterial invasion
 Foreign body reaction
 Decreased local tissue resistance
 Bacterial hiding places
 Poor placement – fluid accumulation, drain kinked
 Poor postoperative management
Complications and Failure of Drains
• Discomfort / Pain
• Thoracic Tubes – diameter too large
• Stiff tubing
• Inefficient Drainage
• Exiting in non-dependent locale (passive drains)
• Kinked tube
• Obstructed
• Poor drain selection – diameter too small to remove viscous fluid
Complications and Failure of Drains
 Breakdown of anastomotic sites
 Erosion into hollow organs (firm drains)
 Incisional dehiscence / hernia
 Poor placement
 Premature Removal
 Accumulation of fluid