SUTURES AND SUTURE

TECHNIQUES

Suture:
 used to close a wound
 used to make a ligature
 a stitch or series of stitches
 method of use e.g.interrupted/mattress
 verb---to suture or to stitch

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Factors that influence suture
selection
 Physical properties
 Biological interaction e.g. absorbability

 Contamination and infection

 Size of tissue

 Tissue tension

---suture size = diameter---caliber

---larger suture—excessive f.b. reaction
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Number or amount of sutures
 Too many---ischaemia, excess f.b. reaction
 Too few-poor apposition, poor healing
 Too tight---ischaemia, delayed healing

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Properties of an ideal suture
1. High and uniform tensile strength
2. Usable in any tissue
3. Bio-inert—cause minimal tissue reaction
e.g. pain, swelling, allergy
4. Easy to sterilize. Resterilization without
altering tensile strength
5. Easy availability and cheap

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Properties of ideal suture
cont’d
6. Easy to handle dry or wet
7. Non-capillary
8. Easy to knot and good knot security
9. Predicable absorbability rate
10. Fine in caliber yet strong

11. No friction, grabbing or cutting tissue

NB: choose one with more properties

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Suture classification
 Absorbable / non-absorbable
 Natural / synthetic
 Monofilament / multifilament
 Braided / non-braided

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Fate of sutures in the body
 Enzymatic absorption / phagocytosis
 Encapsulation by fibrous tissue sheath
 Physical removal

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Absorbable sutures
Definition
 loss of appreciable amount of initial
tensile strength within 60 days.

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Types of absorbable sutures
Catgut (surgical gut)
 submucosa of sheep or pig intestine
 serosa of bovine intestine
 gamma sterilized
 at least 85% alcohol
 not resterilizable

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Catgut cont’d
Plain catgut
 untreated
 loss of strength faster
 3-7 days to start losing

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Chromic catgut
 Different degrees of tanning with chromic
acid
 Determines rate of absorption
 Mild, medium, hard
 Longer in tissue than plain catgut
 Reduced tissue reaction

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Advantages of catgut
 Easy to handle
 Tolerated in most tissue
 Degree of elasticity = non-strangulating

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Disadvantages of catgut
 Swells when wet
 Cannot use in septic conditions

 Non-resterilizable

 Degree of capillarity

Indications:
 internal structures, muscles
At least 3 “throws”
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Collagen
 Flexor tendons of steers
 Similar to catgut
 Smoother than catgut
 Ophthalmic surgery
 Wherever absorbable suture is required

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Polyglycolic acid (Dexon®) and
polyglactin 910 (Vicryl®)
 Braided synthetic
 Ethylene oxide
 Polyglycolic acid—polymer of glycolic acid
and hydroacetic acid
 Polyglactin 910—polymer of glycolic acid
and lactic acid in 9:10
 Absorption by hydrolysis

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Advantages of dexon and vicryl
 Easy to knot since braided
 No swelling when wet
 Lubricated for ease of slippage thru tissue
 Stronger than catgut (2x as the same G of
catgut)
 55% original strength remains in 14 days
and more than 20% at 21 days

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Advantages of dexon and vicryl
cont’d
 Absorbed within 90 days by hydrolysis
 Less tissue reaction

Disadvantages:
 Knot slippage

 Drags through tissue

 Cut soft organs

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Indications
 Used like catgut
 Where absorbable suture is needed
 Urinary tract surgeries

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Polydioxanone (PDS)
 Synthetic polyester
 Monofilament
 Slow hydrolysis

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Advantages of polydioxanone
 Low tissue reaction
 Monofilament
 Tolerable in sepsis
 Moderate Knot security
 Strong
 At 28 days it retains 50% strength
 Smooth passage without tissue drag
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Advantages of PDS cont’d
 Can use in friable tissue
 Ethylene oxide

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 Wherever absorbable suture required.

 Fulfils more of ideal suture properties.

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Non-absorbable sutures
 Retain tensile strength more than 60 days.
 Natural fibres
 Metallic sutures
 Synthetic fibres
 Less tissue reaction
 Can cause draining sinuses

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Types of non-absorbable
sutures
Nylon (dermalon, ethilon)
 Polyamide polymer

 Monofilament commonest and better

 Multifilament occasionally

 Braided as nurolon and better knot security

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Advantages of nylon
 Relatively inert
 Tissue encapsulation
 Non-capillary and can use in sepsis
 High tensile strength
 Degree of elasticity

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Disadvantages of nylon
 High “memory” stiffness-resists bending
 Poor knot security
 Need at least 4 “throws”
 Skin suture

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Polymerized caprolactam
(supramid, vetafil)
 Twisted synthetic fibre
 Smooth coating

________________________________
Advantages
 High tensile strength

 Low cellular reaction

 Chemical sterilization in bottles (spools)

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Advantages of polymerized
caprolactam cont’d
 Cheap
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Disadvantages
 Slight capillarity

 Not in septic wounds

 Sterility not guaranteed

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Disadvantages of polymerized
caprolactam cont’d
 Smooth and knot slippage
 Multifilamented and can harbour microbes

________________________________
 Skin suture unless autoclaved

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Polypropylene (Prolene) and
polyethylene
 Synthetic polymerized sutures
 Polyolefins
 Monofilament
 Ethylene oxide

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Advantages of polypropylene and
polyethylene
 Strong
 Inert and maintain strength long. Little
tissue reaction
 Non-capillary
 Elastic
 Easier to Knot and handle than nylon
 Use in sepsis
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Disadvantages of polypropylene
and polyethylene
 High memory, stiff, poor knot security.
 It requires several throws

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 Sites with tension

 Areas with sepsis

 Plastic and cardiovascular surgeries, urogenital,

skin and intestinal surgeries
 Multifilament sometimes braided but uncommon

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Polyesters
 Braided from synthetic polymers
 Less tissue reaction
 Greater strength
 Ethylene oxide
 Teflon coated = tevdek, polydek
 Silicone coated = ticron
 Polybutylate = ethibond
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Polyesters cont’d
 Uncoated form
 drags in tissue
 cuts tissue
 knots poorly

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Polyesters cont’d
Coating or impregnating:
 decreasing capillarity
 decreasing tissue drag
 reduce knot security
 quite unreactive in tissue
 strong
 multifilament-harbour infection
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Polyesters cont’d
 Used in aseptic conditions
 e.g. mersilene, dacron
 Skin suture and cardiovascular surgeries

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Polybutylate
 Coated braided polyester
 Fine filaments
 Braiding gives strength
 Soft
 Coated with minimal polybutylate to give
smooth lubrication-easy tissue passage

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Polybutylate cont’d
 Coating makes it non-reactive and strong
 Poor knot security
 Opthalmic and cardiac surgeries

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Mersilene
 Braided polyester
 Fine filaments of polyester
 Uncoated
 Smooth
 High tensile strength
 Not affected by wetness
 Tolerable in most tissues
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Mersilene cont’d
 Non-capillary
 Poor knot security
 Gamma irradiation

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Silk (Mersilk)
 Silk worm larvae
 Silicone/wax coated –reduce capillarity
 Twisted and braided
 Packaged dry
 Loses strength when wet
 Dyed –visibility.

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Advantages of silk
 Easy to handle
 Braiding increases strength
 Retains strength long
 30% strength lost in 14 days and 60% in 30
days.
 Good knot security
 Tolerated in most tissue
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Advantages of silk cont’d
 Cheap
 Easily sterilized

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Disadvantages of silk
 high capillarity
 transports infection
Ophthalmic, plastic and cardiovascular
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Cotton suture
 Umbilical tape
 Cotton plant fibresd

 Twisted/braided

Advantages
 cheap
 Tolerated in tissue

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Cotton suture
 Disadvantages of cotton suture
 Poor handling than silk
 Higher capillarity than silk
 Harbours bacteria and cause fistulation
 Clinging onto gloves
 Perineal region-anus, vulva

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Stainless steel suture (surgical
steel)
 Alloy of iron i.e. iron-nickel-chromium
 Monofilament
 Very strong
 Good knot security
 Irradiation
 Inert and non-corrosive
 Re-sterilizable, septic wound use
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Disadvantages of steel suture
 Tissue and glove cutting
 Poor handling
 Kinking
 Lack of elasticity
 Difficult to knot
 Bulky knot

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Surgical steel cont’d
 Skin suture
 Tendon repair
 Neural surgery
 Orthopaedic surgery

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Metal clips
 Michel clips
 Stainless steel
 Non-corrosive
 Pointed at the ends
 Special pair of forceps to bend them
 Pucker the skin
 Increase skin scarring
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Metal clips cont’d
 Common in Caslick’s operation in mares
 Easy to sterilize
 Quick application
 Easy application

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staples
 Proximate staples
 Stainless steel
 Skin stapling
 Used as staplers
 Fast closure
 Well tolerated in tissue
 Easily sterilized
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staplers
 Costly
 Special pair of forceps as applicators and
extractors

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Surgical linen
 Flax fibres twisted or braided
 Specially treated to minimize inherent
irregularities of the material
 Packaged dry
 Strengthened when wet
 Lower strength than other non-absorbable
sutures
 Ethylene oxide, rare use.
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Special skin closure products
Closure strips
 adhesive tapes with special medication
 excellent initial adhesion
 good long-term wound support
 not affected by wetness
 more use in humans

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Skin sealants
 Applied on the suture line
 Special medicated aerosol sprays

 Dry on the suture line

 Form thin adhesive film

Medicated bandages
 Impregnated with wound antimicrobial

 Used with normal wound bandages

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