Suture Materials & Techniques

Tying knots IMTC
International Microsurgical Training Centre Prof.dr. René Remie Dr. Klaas Kramer

Important factors in surgery Properties of suture materials
Absorbable Non-absorbable Tissue reactions Needles

Suture techniques Suture-related infections Suture length to wound lenght ratio How to tie a knot Take home messages Practical part

Important factors in surgery
Basic principles Surgical protocol Anatomy Suture materials Peri-operative care
Temperature Body fluids

Basic principles of surgery
Halstead’s principle of not doing harm to the tissue
Set of interrelated principles:
Tissue handling Tissue exposure Hemostasis Asepsis

Tissue handling
Remember that every time you pick up tissue with your instruments, you kill cells Try to kill as few cells as possible Be goal oriented in your approach Sharp dissection is generally less traumatic than blunt dissection

Tissue exposure
Make sure your view is unobstructed, with proper illumination and physical access The wound should be sufficient in size and certainly not too small Do not worry about the healing of the wound, as it is not primarily affected by its size, but rather by appropriate approximation of the wound edges

Let’s have a closer look at suture materials

Suture size and strength

General properties of sutures
Absorbable, Non-absorbable
Always use absorbable sutures unless you have to fixate something

Tissue drag Capillary filling effect Good handling properties

Memory effect


Hydrolysis Minor tissue reaction Degradation products CO2 , H2O

Polyglycolic acid Polydioxanon Polylactate

Tensile strength retention
Polyglycolic acid (PGA)
14 days 65% remains 21 days 40% remains Gone between 56 and 70 days

7 days 50% remains 14 days 25% ramains Gone between 90 and 119 days

Natural materials
Silk, linen and cotton

Polyesther (Dacron) Polypropyleen Polyamide (Nylon)

Stainless steel wire

Tissue reaction
Qualitative ranking (Sewell et al.)
Size of the reaction Concentration of cells Type of cells (phagocytes) Edema present Necrosis present Absorption of the material

Tissue reaction
Method acc. to Sewell et al.
Stainless steel Prolene PDS Vicryl rapide Materials Vicryl Ethibond Mersilene Polyamide Silk Linen Catgut plain Catgut chroom 0 20 40 Re action rate 60 80

Conventional Swedged-on atraumatic
Non cutting (rond-bodied) Cutting (spatula, triangle)



Suture technique
Tissue dependant Proper instruments Proper knotting technique
Hand Instrument Equal strength Proper approximation

Suture technique

Suture technique

Suture technique

Information on the outside

Knot definition (Tera)
1=1 Square- or reef knot 1x1 Granny knot 2=1 Surgical knot 2=1=1 Surgical knot with extra loop

How to tie a knot?

How to tie a knot?

Cause of suture-related infection
Excessively tight sutures
Allows bacteria to be protected in tissues made ischemic by pressure

Too many sutures making large ischemic portions Use of multi filamented braided suture materials
Provide interstices accessible to bacteria but not to phagocytes (capillary filling)

Cause of suture-related infection
Most pronounced in moderately contaminated wounds
Contamination is very low
The local defenses may handle the situation despite the presence of foreign body Contamination is massive ==> infection will occur

The magnitude of the wound contamination is expressed as class I, II, III or IV

Suture length to wound length ratio
SLWL ratio
Hoer et al. 2001
Median laparotomy (ML) in rats
Best mechanical quality of healing at 4:1 - 8:1 ratio Running technique superior to interrupted Bite size approx. 5 mm. (2-3 times thickness of the wall) Low suture tension ==> stronger scars

Cengiz et al. 2001
Bite size and number of stitches in ML in rats
Best mechanical quality of healing at 4:1 ratio 3-6 mm bite size

Take home messages
Do not harm to the tissue!! Absorbable sutures are preferred Approximation, that’s all Do not pull sutures too tight Do not tie tumbled knots

Thanks for listening

Practical part
Macro knot tying (30 minutes)
Two persons, one rope

Tea / Coffee break Tying knots using the anastomosis device
3-0 sutures (60 minutes) 5-0 sutures (60 minutes)

Closing remarks

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