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Suture Materials &

Tying knots
International Microsurgical Training Centre
Prof.dr. René Remie
Dr. Klaas Kramer
z Important factors in surgery
z Properties of suture materials
z Absorbable
z Non-absorbable
z Tissue reactions
z Needles
z Suture techniques
z Suture-related infections
z Suture length to wound lenght ratio
z How to tie a knot
z Take home messages
z Practical part
Important factors in surgery
z Basic principles
z Surgical protocol
z Anatomy
z Suture materials
z Peri-operative care
z Temperature
z Body fluids
Basic principles of surgery
z Halstead’s principle of not doing harm to
the tissue
z Set of interrelated principles:
z Tissue handling
z Tissue exposure
z Hemostasis
z Asepsis
Tissue handling
z Remember that every time you pick up
tissue with your instruments, you kill cells
z Try to kill as few cells as possible
z Be goal oriented in your approach
z Sharp dissection is generally less
traumatic than blunt dissection
Tissue exposure
z Make sure your view is unobstructed, with
proper illumination and physical access
z The wound should be sufficient in size and
certainly not too small
z 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
z Absorbable, Non-absorbable
z Always use absorbable sutures unless you have to
fixate something
z Braided
z Tissue drag
z Capillary filling effect
z Good handling properties
z Monofilament
z Memory effect
z Pseudo-monofilament

z Synthetic
z Hydrolysis
z Minor tissue reaction
z Degradation products
z CO2 , H2O

z Examples
z Polyglycolicacid
z Polydioxanon
z Polylactate
z Tensile strength retention
z Variable
z Polyglycolic acid (PGA)
z 14 days 65% remains
z 21 days 40% remains
z Gone between 56 and 70 days
z Polycaprone
z 7 days 50% remains
z 14 days 25% ramains
z Gone between 90 and 119 days
z Natural materials
z Silk, linen and cotton
z Synthetic
z Polyesther (Dacron)
z Polypropyleen
z Polyamide (Nylon)

z Mineral
z Stainless steel wire
Tissue reaction
z Qualitative ranking (Sewell et al.)
z Sizeof the reaction
z Concentration of cells
z Type of cells (phagocytes)
z Edema present
z Necrosis present
z Absorption of the material
Tissue reaction
Method acc. to Sewell et al.

Stainless steel
Vicryl rapide

Ethibond Reeks2
Mersilene Reeks1

Catgut plain
Catgut chroom

0 20 40 60 80
Re action rate
z Conventional
z Swedged-on atraumatic
z Non cutting (rond-bodied)
z Cutting (spatula, triangle)
Suture technique
z Tissue dependant
z Proper instruments
z Proper knotting technique
z Hand
z Instrument
z Equalstrength
z Proper approximation
Suture technique
Suture technique
Suture technique
Information on the outside
Knot definition (Tera)
z 1=1 Square- or reef knot
z 1x1 Granny knot
z 2=1 Surgical knot
z 2=1=1 Surgical knot with
extra loop
How to tie a knot?
How to tie a knot?
Cause of suture-related infection
z Excessively tight sutures
z Allowsbacteria to be protected in tissues made
ischemic by pressure
z Too many sutures making large ischemic
z Use of multi filamented braided suture
z Provide interstices accessible to bacteria but not
to phagocytes (capillary filling)
Cause of suture-related infection
z Most pronounced in moderately
contaminated wounds
z Contamination is very low
z The local defenses may handle the situation despite
the presence of foreign body
z Contamination is massive ==> infection will occur

z The magnitude of the wound contamination is

expressed as class I, II, III or IV
Suture length to wound length ratio

z SLWL ratio
z Hoer et al. 2001
z Median laparotomy (ML) in rats
z Best mechanical quality of healing at 4:1 - 8:1 ratio
z Running technique superior to interrupted
z Bite size approx. 5 mm. (2-3 times thickness of the wall)
z Low suture tension ==> stronger scars
z Cengiz et al. 2001
z Bite size and number of stitches in ML in rats
z Best mechanical quality of healing at 4:1 ratio
z 3-6 mm bite size
Take home messages
z Do not harm to the tissue!!
z Absorbable sutures are preferred
z Approximation, that’s all
z Do not pull sutures too tight
z Do not tie tumbled knots
Thanks for listening
Practical part
z Macro knot tying (30 minutes)
z Two persons, one rope
z Tea / Coffee break
z Tying knots using the anastomosis device
z 3- 0sutures (60 minutes)
z 5-0 sutures (60 minutes)

z Closing remarks