SUTURE MATERIALS

Dr. Hiwa Omer Ahmed Assistant Professor in general surgery

WOUND DRESSINGS

During the past decade, dressings for acute and chronic wounds have changed dramatically. As new material technologies have evolved, new products have inundated the market. Dressing products should be selected on the basis of the type and characteristics of the wound. The acute wound that is closed primarily requires coverage with a dry sterile dressing for a few days. This helps to protect the wound from bacterial invasion and absorbs any wound fluid. The dressing also may provide some psychological benefit to the patient in keeping the surgical wound out of sight. When epithelialization is complete, the dressing can be removed.

Partial-thickness wounds—e.g., donor sites, abrasions, firstand seconddegree burns—require semiocclusive dressings. These products provide a moist environment that enhances the reepithelialization of partial-thickness wounds. If a semiocclusive dressing is applied early to a partial-thickness wound, dry scab formation can be avoided. Scab formation can damage the underlying dermis, and removal of the scab may be painful, cause bleeding, damage new epithelium, and increase the deformity in the final scar. Semiocclusive dressings may not have enough absorption capacity to handle the amount of wound exudate produced in the early phase of healing. Wound fluid can become trapped and cause the area around the wound to macerate or leak, necessitating frequent dressing changes. Combining an absorbent dressing material, such as an alginate, with the polyurethane film or hydrocolloid alleviates this problem

. Occlusive/semiocclusive dressings may exacerbate infection when covering areas in which the bacterial count is higher than 100,000/g of tissue. This risk may be reduced by first controlling the wound bacterial count with topical antimicrobial or systemic antibodies. In addition, several of the hydrogels can be used effectively with antibiotic creams. Hydrogels are thought to accelerate the rate of penetration of the antibiotic into the granulation tissue. Dressings are used to debride. If the wound is dry, it is important that a slower and more gentle process be used, especially when tendons are exposed. This can be accomplished with hydrogels that have little permeability and therefore tend to keep the wound moist. When eschar is present, a hydrocolloid may be more appropriate than a hydrogel dressing. This type of debridement occurs through autolysis. The hydrocolloid traps the wound exudate and creates a moist environment that softens and lifts or causes proteolytic digestion of the eschar. However, in most cases, sharp surgical debridement of eschar is the most efficacious treatment.

Wounds with a large volume of exudate require dressing with a greater capacity to absorb. When dressings do not adequately absorb, the healthy tissue around the wound may become macerated. The use of a skin protectant around the wound may alleviate this problem. There has been concern that hydrocolloids leave pectin base in wounds, which forms granulomas. There are, however, several non-pectin-based hydrocolloids that address this problem and also absorb wound secretions. There are no data to support the contention that one dressing promotes healing better than another. However, selection of dressings may be made on the basis of overall costs, efficacy, and ease of use. It is likely that over the next decade dressings will be designed to have “selective absorption” properties to remove only factors that impede the healing of chronic wounds or prevent scar hypertrophy in primarily closed wounds. Most of the “new” concepts in dressings are marketing gimmicks rather than improvements based on solid and objective scientific data.

MECHANICAL WOUND CLOSURE

The materials used for wound closure are much less important than the techniques of closure. Sutures may be generally classified as absorbable or nonabsorbable. The absorbable sutures may be synthetic, such as polyglycolic acid sutures, or biologic, such as “catgut” sutures, which may be plain or chromium-treated. Traditional teaching is that absorbable sutures are buried and, as they absorb, will not be a nidus for late infection. Nonabsorbable sutures are used on the skin because they are less reactive and allegedly provide a better-appearing scar. These dogma make little sense in the schema of healing. Although it is true that gut sutures are more reactive than polyglycolic acid, which is more reactive than nylon, the argument that tissue reactivity to particular sutures is of significance in the healing process has never been validated. Nonabsorbable sutures may be used in subcutaneous tissue as well as in fascia or for organ repair. By contrast, absorbable sutures often are used on the skin in infants and children; 6-0 plain gut sutures placed in the skin do not require removal in a child, thus avoiding the additional trauma of suture removal. Similarly, absorbable sutures are used commonly for closure of hand wounds— even in adults.

The notion that nonabsorbable sutures in fascia are better than longlasting absorbable sutures is partially myth, because tension will gradually cause remodeling of the connective tissue around the suture. If fascia wound strength has not developed adequately in the repair process, the suture material will not have an influence on outcome. The most important fact about sutures is that any woven suture is more likely to facilitate infection than a smooth suture because bacteria can become entrapped in the interstices of a woven suture and not be destroyed by the normal host responses, thus leading to bacterial propagation and infection. Therefore, woven suture material should not be used in the closure of contaminated wounds

A few suture materials deserve special comment. The nonabsorbable polypropylene suture is extremely smooth and is therefore the best material to use when creating a subcuticular pullout suture. The absorbable polyglycolic dermal suture (PDS) is best for areas in which long-term tensile strength is required. Although stainless steel sutures are still used, they should be banned in the operating room because they often cut through gloves and create an environment where the surgical team may be more susceptible to pathogens such as hepatitis or HIV.

SUTURE MATERIALS

CATGUT

PLAIN CATGUT

POLYESTER BRAIDED

SUTURE MATERIALS

NEEDLES

CURVED NEEDLE

DIFFERENT SIZES NEEDLES

NEEDLE HOLDERS

SUTURE HOLDING

SUTURING

DRUM

►DRESSING

COTTON

CREPE BANDAGE

CREPE BANDAGE

GUAZE

PLASTER

PLASTER DRESSING

PLASTER OF PARIS ( POP)

►Suture

material

Silk
► SILK ► Natural

protien ► 80-100 tensil strength lost by 6 month ► Absorbed slowly over 1-2 years ► Moderate to high tissue reaction ► Not adviced for vascular & longlasting neddy areas, and in infected area

Linen
► Linen ► Long

staple flax fibres ► 50 tensil strength lost by 6 month,30 remains at 2 years ► Nonabsorbed ► Moderate tissue reaction ► Not adviced for vascular suturing

Surgical steel
► An

alloy of iron, nickel and chromium ► Infinit more than one year ► Nonabsorbed ► minimal tissue reaction ► No contraindications

Nylon
► Polyamid

polymer ► 15-20% tensil strength lost / year ► Nonabsorbed ► low tissue reaction ► No contraindications

Chromic catgut
► Collagen

derived from healthy sheep or cattle tanned with chromium ► tensil strength lost by 21-28 days ► Absorbed ► Moderate tissue reaction ► Not adviced for trissues with slow healing which needs prolonged support

Vicryl
► Polymer

of polyglycolic acid ► 80% tensil strength lost by 3 weeks ► Absorbed completely by 60-90 days ► minimal tissue reaction ► Not adviced for trissues with slow healing which needs prolonged support

PDS
► Polyester

polymer ► 85% tensil strength lost by 8 weeks ► Absorbed completely by 180 days ► Mild tissue reaction ► Not adviced for trissues with slow healing which needs prolonged support, for heart valve and synthetic graft suturing

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