Suturing concepts made

easy!
Dr. Guyton and Dr. De Andrade
Objectives

 Be able to handle the needle, load it properly,

and effectively use the needle holder and
forceps

 Be able to select appropriate suture material

for a given suturing task

 Perform common level-appropriate suturing

tasks
Suture Label

Suture labels
Needle anatomy
Needle curvature

Straight
Specialty
 Shape Indications

Needles Cutting

Cutting
Cutting edge on inside of circle Reverse
Traumatic Cutting

Reverse Cutting Side

Cutting edge on outside of circle cutting
Less traumatic than cutting

Taper
Taper
Atraumatic
Cuts through its tip

Blunt
Suture Material

Monofilament vs Polyfilament
Monofilament Vs. Polyfilament

Memory Easy to handle

Less tissue drag More tissue drag
Doesn’t wick Wicks/bacteria
Poor knot security Good knot security
Easier to slide knots Harder to slide knots
(-) Tissue reaction (+) Tissue reaction
Suture Material

Natural vs Synthetic
Natural sutures
 Natural Absorbable:
 Fast Absorbing Plain Gut (3-5 days)
 Plain Gut (5-7)
 Chromic (10-15 days)

 Natural non-absorbable:
 Silk
 Collagen

 High reactivity

 Multifilament
Suture Material

Absorbable vs Nonabsorbable
Absorbable Sutures
 Temporary wound support (minimal tension)

 For short term tension (4-6 weeks)

 Absorption:
 Cell mediated enzymatic degradation for natural
materials
 Hydrolysis in synthetic materials (less tissue reaction)
Absorbable Sutures

Stages of absorption
 1st: Linear, lasting for several days to weeks
 2nd: Loss of suture mass (overlaps 1st stage)

Accelerated absorption may occur in patients with:

 Fever
 Infection
 Protein deficiency
 Moisture
 Suture strength
Loss of tensile strength and the rate of absorption are separate phenomena
Nonabsorbable Sutures

 Primarily Skin
 Needs to be removed

 To provide long-term strength

▪ Blood vessels (Vascular0
▪ Fascia (Hernia, Plastics)
▪ Bones or tendons (Cardiac, Ortho)
▪ Can be left in place for long periods
Suture Sizes
Sizes
5 > 4 > 3 > 2 > 1 > 0 > 2-0 > 3-0 >… > 12-0
BIGGER  SMALLER

General ideas for use:

1, 0 , 2-0 : Closure of Deep and Superficial Fascia, Muscles
3-0 : Deep Dermal, Bowel
4-0 - 6-0 : Skin, Biliary/Pancreatic Ducts
5-0 - 8-0 : Vascular
9-0 - 10-0 : Micro + Hand
Using the Needle Holders
 Choosing the appropriate
needle holder

Length

Holder tip
size
Favorable suturing position
Knot Strength

 Generally 4“throws”
 >90% knot security
 Monofilaments: Nylon needs 5-6, Prolene 8-9
 Fewer“throws” = more likely to untie itself
How much “Tail”?

 Skin Monocryl – next to knot

 Bowel Vicryl – 3-4mm
 Fascia PDS – 1cm
 Skin Nylon – 1cm
Take home message!

• Know your sutures

• Use good technique
• Be cognizant of closing tension
Suturing Tasks

• Skin Closure
• Running subcuticular
• Deep dermal
• Port closure
• Mattress
• Fascial Closure
• Securing chest tubes and drains
• Tying in a hole
• Tying under tension
Suture patterns
Qualities of absorbable sutures
Qualities of nonabsorbable sutures
Composition
Cotton

Silk
Nilon
Mono (Ethilon)
Braided (Surgilon)

Polypropylene
(Prolene)
Polybutester
(Novatil)
Plolyester
Uncoted (Mersilene)
Coated (Ethibond)
Skin Staples

 Expensive
 Easy
 Secure
 Little tissue reaction
 Least ischemic
 Removal?
 Cosmesis is irrelevant
to the use of staples
Adhesives & Steri strips
 Steri strips, Dermabond,
Nexaband, Vetbond, and others

 Little strength

 Substitute subcuticular

 Occlusive dressing

 Should not be placed between

skin layers or inside body