Sutures’ material &Techniques

‫ ليه بنخيط الجرح ؟‬, why sutures?

1. To promote contact between the edges of the wound to
achieve rapid healing.
2. To give the wound resistance to tension.
3. To limit residual dead spaces between the margins of the
wound.
4. To prevent complications, i.e., infection, hemorrhage, and
tissue necrosis.
5. To preserve the normal contour and shape of tissue.

Ideal sutures:
1. Possessing the greatest predictable tensile strength
consistent with size limitations.
2. Good Handling properties.
3. Secure knot tying.

Sutures’ size & Tensile strength

Sutures’ sizes are commonly denoted using the United States
Pharmacopeia (USP) system that is normally centered around
Zero (0).
• The purpose of sutures in general is to approximate tissues,
without excess tension, while minimizing ischaemia and tissue
injury.
• Whether wound closure is single or multilayered, the smallest
size or diameter of suture that will accomplish the purpose at
hand should be chosen, thus minimizing both tissue trauma with
each passage of the needle and the amount of foreign material
left behind.
• However, it should be noted that the smaller the size of the
suture the lower the tensile strength.
 Mono- & Multifilament Sutures
Monofilament
-Harboring bacteria
-Tensile Strength
• Lower tissue resistance for
its passage
• Less likely to accommodate
Pros micro-organisms
• Easier to tie
• Less tissue reaction
Multifilament
+Harboring bacteria
+Tensile Strength
• It can be braided or twisted
• Excellent handling property
(Flexibility)
• Knot security is high
• Greater tensile strength
• Fewer number of knots
• Less memory

Vascular surgery
• Must be handled carefully, • Higher risk of harboring
because if they are crushed micro-organism.
by an instrument, it may • More tissue reaction
Cons break or weaken. • More tissue resistance to
• Knot security is poorer. sutures
• Lower tensile strength
Pseudo mono-filament:
Intestinal • Twisted or braided core material
coated with extruded material
surgery
• Fair flexibility
• Less tissue resistance to sutures
• Lower risk of infection
• Knot security is lower than
multifilament
 Sutures Degradation
Absorbable sutures undergo degradation by losing 50% of their tensile strength
within 60 days in tissues, whereas, nonabsorbable sutures can retain their
tensile strength exceeding 60 days
1.absorbable 2.non-absorbable
Absorbable sutures are typically made from • Non-absorbable sutures may be
1.mammalian collagen: composed of natural or synthetic
• Degradation through digestion by body materials.
enzymes (Proteolytic enzymes).
• More tissue reaction • The tissue response to this type of
Or 2.synthetic polymers: sutures is different as fibroblasts
• Degradation by hydrolysis (a process encapsulate the sutures by fibrous
where water penetrates the suture capsule formation. Adjacent
strands causing breakdown of filament’s macrophages and foreign body giant
polymer structure) cells respond in a process known as
• lesser degrees of tissue reaction frustrated phagocytosis, where they
• Typically, when a wound is closed with attempt to enzymatically degrade it.
absorbable suture, the decrease in tensile
strength over the first weeks is in a • i.e. Silk sutures are commonly used to
gradual, linear fashion. approximate skin; however, they should
be removed early to avoid body
• During this period, leukocyte infiltration reaction,
occurs to remove all cellular debris and while prolene sutures are used for
physical suture material. Mesh fixation as they are surrounded by
fibrous tissue together with the mesh.
• Protein deficiency and infection can
cause rapid loss of tensile strength and
wound dehiscence.
 Surface Texture
1.Smooth Surface
• Knot tying required for anchoring
into tissues
• There are weak spots across the
suture line and knotted portion
• Tightened knots leads to tissue
necrosis, tissue overlap and
reduce fibroblast proliferation
impairing the healing process.
• Knots increase the inflammatory
reactions and the risk of
bacterial growth.
• Difficult for minimally invasive
surgeries.
2.Barbed Surface
• Knotless/ self anchoring to the
tissues.
• Barbs pierce into the tissue and
locks firmly in place.
• Controls tension across the wound
• Self-anchoring resists migration of
sutures and reduce the hightension
points.

Sutures Material

Natural Synthetic
Absorbable non
Absorbable Non
1.catgut 1.silk 1.building blocks 1.nylon
2. plain catgut 2.surgical stainless steel 2.coated 2.prolene
3.chronic 3. vicryl
4. PDSII
5. monocryl
 A.Natural suture material
1.absorbable
1.catgut • They are formed mainly from processed strands of highly purified
collagen (97% - 98% pure strands of collagen) obtained from sheep
or cattle submucosa.
• They can be either plain (treated with aldehyde material) or
coated with chromic acid (Chromic catgut).
• It is characterized by poor tensile strength and knot security, and
moderate tissue reaction

2.plain • Plain catgut is rapidly absorbed, the tensile strength is

catgut maintained for 7-10 days, and absorption is complete by 70 days.
• They are typically used for closing of epidermis, ligating
superficial blood vessels, and suturing subcutaneous tissues
(mucosa of the lip, eye, and
external suture for rhinoplasty) where minimal tensile strength is
required.

3.chronic • The collagen filaments are bathed in buffered chrome tanning

catgut solution salt before formation into strands.
• Chromic acid resists the body’s enzymatic degradation.
• The tensile strength is maintained for 10-14 days and
complete absorption in 90 days.
• The main advantage over plain catgut is less tissue reaction.
 2.Non-absorbable
1.silk • The raw silk (from silkworm) may be processed to become a tightly
braided, dyed suture coated with wax or silicone to reduce tissue
friction.
• Although silk sutures is classified as a non-absorbable suture in the
USP, in the material literature it is considered a degradable material
by enzymatic degradation.
• However, this degradation is extremely slow as tensile
strength is kept for over a year.
• Its main advantage is ease of handling, ability to hold knots, and
relatively low tissue reaction, while its tensile strength is low.
• Silk should not be used in superficial soft tissue which may be
contaminated as small abscesses may develop and fistulate until the
suture material is removed from the body.
• Silk should not be used in infected wounds as it is prone to
infection due to the braided configuration.
• Its main advantage is ease of handling, ability to hold knots, and
relatively low tissue reaction.
• Silk should not be used in superficial soft tissue which may be
contaminated as small abscesses may develop and fistulate until the
suture material is removed from the body.
• Silk should not be used in infected wounds
• Mainly used nowadays for skin closure.
2.Surgical • It’s formed of braided multifilament of 316L low-carbon
Stainless alloy formula.
Steel • Mainly used in plastic surgery including reconstruction of
sternal wound or in hand fracture fixation.
• Indefinite tensile strength
• Allergy to chromium and nickel may occur in susceptible
patients.
 B.Synthetic
1.absorbable
1.Coated • High tensile strength for a predictable period of time (28 days) with
Vicryl lower tissue reaction than surgical gut.
• It is braided, coated to secure knots and facilitate tissue passage
(Polyglactin 360 & Calcium Citrate).
• 25% of the sutures undergoes hydrolysis at 2 weeks, 75% at one month,
and completely absorbed at 56 – 70 days.
• Useful for soft tissue approximation.
2.Vicryl • Treated coated undyed Vicryl with gamma rays to have a lower
Rapide molecular weight and subsequently faster absorption.
• 50% of tensile strength is lost at 5 days with complete absorption at 6
weeks.
• Ideally used for short-term wound support.
3.PDS II • It is a polyster polymer monofilament.
• 25% of tensile strength remaining at 6 weeks and maximum support for
2 weeks (70%).
• Favored in pediatric, cardiovascular, and ophthalmic surgery due to its
low tissue reaction.
4.Monocryl • It was mainly manufactured for skin closure.
• It is a monofilament that retain 60-70% of its tensile strength at 1 week,
with complete loss at 3 weeks.
• Completely absorbed at 90 - 119 days.
• Ideally used for subcuticular skin closure
 2.Non-absorbable
1.nylon • It is composed of long-chain polymers of nylon 6 and is available in both
mono-filament or braided forms.
• Braided forms are rarely used as it is associated with higher infection
rates.
• The mono-filament is most widely used non-absorbable suture material.
• Characterized by high tensile strength, low tissue reactivity, high elasticity,
and low cost.
• However, it has high memory and low pliability rendering it difficult to use.
• Alcohol-soaked forms are available to overcome the high memory and low
pliability.
• It undergoes slow hydrolysis losing 15-20% of its tensile strength yearly.
• They can be used for skin approximation, vessel ligation, and microsurgery.

2.prolene • Polyprolene is a monofilament suture that is made from catalytic

polymerization of propylene
• Has higher tensile strength than nylon, very smooth surface allowing easy
passage through tissues, and induce minimal reaction.
• Ideal for intradermal sutures (subcuticular)
• The smooth surface reduce the knot security, thus requiring higher
number of knots.
• High plasticity allowing it to accommodate to tissue swelling.
 Surgical Needles
Point ----- Body -------- Eye

Curvature is described as a fraction of the arc of a circle.

RECENT ADVANCES IN SUTURES
1.Topical • This glue is being increasingly used for closure of traumatic
Tissue lacerations.
adhesive • As soon as it contact the blood it forms a solid film that bridges
the wounds and hold the apposed edges together.
• It has acceptable tensile strength
• Usually slough off in 5-10 days as epidermis regenerates.
• Advantages (faster, less pain, no need for sutures removal);
however, it should not be used in areas with high tension
(tendons)
2.Adhesive • Can be used in small superficial wounds or after buried sutures
Strips are placed.
• Fast, inexpensive, comfortable, minimal reactivity.
• Not adhesive to moist areas or mobile areas
3.Staplers •Time saving
• There are two types (absorbable and nonabsorbable)
• Higher cost

Suturing Techniques
1.simple
interrupted
sutures
2.simple running
continuous
sutures

3.verical
mattress sutures

4.horizontal
mattress sutures

5.subcuticular
sutures