Sutures and Needles

22/11/2014 Sutures and Needles
Sutures and Needles
Author: Stephen Y Lai, MD, PhD; Chief Editor: Arlen D Meyers, MD, MBA more...
Updated: Jun 3, 2013
Products
The goal of this article is to review the types of sutures and needles for wound closure and to discuss principles that
influence suture and needle selection.
Suture selection is dependent on the anatomic site, surgeon's preference, and the required suture characteristics.
No standardized sizing system or nomenclature is available for needles or needle holders; the main consideration in
needle selection is to minimize trauma. The length, diameter, and curvature of the needle influence the surgeon's
ability to place a suture.
For patient education information, see Suture Care.
Categories
Sutures, needles
Device details
Sutures
Absorbable natural sutures
Collagen
Plain surgical gut
Fastabsorbing surgical gut
Chromic surgical gut
Absorbable synthetic sutures
Polyglactin 910 (Vicryl)
Polycaprolate (Dexon II)
Poliglecaprone 25 (Monocryl)
Polysorb
Polydioxanone (PDS II)
Maxon
VLoc
Absorbable monofilament sutures
Caprosyn
Absorbable multifilament sutures
Nonabsorbable natural sutures
Surgical silk
Surgical cotton
Surgical steel
Nonabsorbable synthetic sutures
Nylon
Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ticron [coated])
Polybutester Suture (Novafil)
Coated Polybutester Suture (Vascufil)
Polypropylene (Prolene)
Surgipro II
Needles
Point types
Cutting (conventional, reverse, or side [spatula])
Taperpoint (round)
Beveled, conventional cutting edge
Blunt point
See the images below.
Anatomy of a needle.
http://emedicine.medscape.com/article/884838overview 1/11
Commonly used suture needles, with crosssections of the needles shown at the point, body, and swage. A: A taper needle; B: a
conventional cutting needle; C: a reverse cutting needle.
Body types
Straight
Halfcurved ski
Curved
Compound curved
Swage types
Channel
Drill
Nonswaged
Design Features
The goals of wound closure include obliteration of dead space, even distribution of tension along deep suture lines,
maintenance of tensile strength across the wound until tissue tensile strength is adequate, and approximation and
eversion of the epithelial portion of the closure. Methods for mechanical wound closure include staples, tape,
adhesive, and sutures. Each method has specific indications, advantages and disadvantages, and special
considerations.
The subject of this article is the suture closure of wounds. Similar to other methods of wound closure, suture closure
permits primary wound healing. Tissues are held in proximity until enough healing occurs to withstand stress without
mechanical support. An extensive review of wound healing and the factors that influence this process are available
elsewhere. (See Incision Placement; Wound Healing and Repair; and Wound Closure Technique).
Sutures
Suture material is a foreign body implanted into human tissues; it elicits a foreign body tissue reaction. During
wound closure, a sterile field and meticulous aseptic technique are critical to minimize the risk of wound infection.
Other complications of wound healing, such as hypertrophic scars, wide scars, and wound dehiscence, may result
from patient factors (eg, nutritional status), incorrect suture selection, or a technique that results in excessive
tension across the wound.
Skillful wound closure requires not only knowledge of proper surgical techniques but also knowledge of the physical
characteristics and properties of the suture and needle.
Suture qualities
Ideal, essential, and other suture characteristics as well as suture size are discussed in this section.
Ideal suture characteristics
The ideal suture has the following characteristics:
Sterile
All purpose (composed of material that can be used in any surgical procedure)
Causes minimal tissue injury or tissue reaction (ie, nonelectrolytic, noncapillary, nonallergenic,
noncarcinogenic)
Easy to handle
Holds securely when knotted (ie, no fraying or cutting)
High tensile strength
Favorable absorption profile
Resistant to infection
Unfortunately, at present, no single material can provide all of these characteristics. In different situations and with
differences in tissue composition throughout the body, the requirements for adequate wound closure require
different suture characteristics.
Essential suture characteristics
All sutures should be manufactured to assure several fundamental characteristics, as follows:
Sterility
Uniform diameter and size
Pliability for ease of handling and knot security
Uniform tensile strength by suture type and size
Freedom from irritants or impurities that would elicit tissue reaction
Other suture characteristics
The following terms describe various characteristics related to suture material:
Absorbable Progressive loss of mass and/or volume of suture material; does not correlate with initial tensile
strength
Breaking strength Limit of tensile strength at which suture failure occurs
Capillarity Extent to which absorbed fluid is transferred along the suture
Elasticity Measure of the ability of the material to regain its original form and length after deformation
Fluid absorption Ability to take up fluid after immersion
Knotpull tensile strength Breaking strength of knotted suture material (1040% weaker after deformation by
knot placement)
Knot strength Amount of force necessary to cause a knot to slip (related to the coefficient of static friction
and plasticity of a given material)
Memory Inherent capability of suture to return to or maintain its original gross shape (related to elasticity,
plasticity, and diameter)
Nonabsorbable Surgical suture material that is relatively unaffected by the biologic activities of the body
tissues and is therefore permanent unless removed
Plasticity Measure of the ability to deform without breaking and to maintain a new form after relief of the
deforming force
Pliability Ease of handling of suture material; ability to adjust knot tension and to secure knots (related to
suture material, filament type, and diameter)
Straightpull tensile strength Linear breaking strength of suture material
Suture pullout value The application of force to a loop of suture located where tissue failure occurs, which
measures the strength of a particular tissue; variable depending on anatomic site and histologic composition
(fat, 0.2 kg; muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg)
Tensile strength Measure of the ability of a material or tissue to resist deformation and breakage
Wound breaking strength Limit of tensile strength of a healing wound at which separation of the wound
edges occurs
Suture size
The United States Pharmacopeia (USP) classification system was established in 1937 for standardization and
comparison of suture materials, corresponding to metric measures. The 3 classes of sutures are collagen, synthetic
absorbable, and nonabsorbable.
Suture size refers to the diameter of the suture strand and is denoted as zeroes. The more zeroes characterizing a
suture size, the smaller the resultant strand diameter (eg, 40 or 0000 is larger than 50 or 00000). The smaller the
suture, the less the tensile strength of the strand.
Suture material and structure
Natural sutures, monofilament versus multifilament sutures, and absorbable versus nonabsorbable sutures are
reviewed in this section.
Natural sutures
Natural sutures can be made of collagen from mammal intestines or from synthetic collagen (polymers). Tissue
reaction and suture antigenicity lead to inflammatory reactions, especially with natural materials. [1, 2]
Monofilament vs multifilament sutures
Monofilament suture is made of a single strand; this structure is relatively more resistant to harboring
microorganisms. The monofilament suture also exhibits less resistance to passage through tissue than the
multifilament suture. However, great care must be taken in handling and tying the monofilament suture, because
crushing or crimping of this suture can nick or weaken the suture and lead to undesirable and premature suture
failure.
Multifilament suture is composed of several filaments twisted or braided together; these materials are less stiff but
have a higher coefficient of friction. Multifilament suture generally has greater tensile strength and better pliability
and flexibility than monofilament suture, and this type of suture handles and ties well. However, because
multifilament materials have increased capillarity (ie, the extent to which absorbed fluid is transferred along the
suture), the increased absorption of fluid may act as a tract for the introduction of pathogens, which increases the
risk for wound infection and dehiscence.
In addition, because the individual filaments of a multifilament suture are braided together, an increased coefficient
of friction is created when the suture is passed through tissue. Multifilament sutures are often treated with special
coatings to allow tissue passage to occur more easily and to reduce subsequent tissue damage.
Absorbable vs nonabsorbable sutures
Absorbable sutures provide temporary wound support, until the wound heals well enough to withstand normal stress.
Absorption occurs by enzymatic degradation in natural materials and by hydrolysis in synthetic materials. Hydrolysis
causes less tissue reaction than enzymatic degradation.
The first stage of absorption has a linear rate, lasting for several days to weeks. The second stage is characterized
by loss of suture mass and overlaps the first stage. Loss of suture mass occurs as a result of leukocytic cellular
responses that remove cellular debris and suture material from the line of tissue approximation. Chemical
treatments, such as chromic salts, lengthen the absorption time.
Importantly, note that loss of tensile strength and the rate of absorption are separate phenomena. The surgeon
must recognize that accelerated absorption may occur in patients with fever, infection, or protein deficiency, and this
may lead to an excessively rapid decline in tensile strength. Accelerated absorption may also occur in a body cavity
that is moist or filled with fluid or if sutures become wet or moist during handling before implantation.
Nonabsorbable sutures elicit a tissue reaction that results in encapsulation of the suture material by fibroblasts. The
USP classification of nonabsorbable sutures is as follows:
Class I Silk or synthetic fibers of monofilament, twisted, or braided construction
Class II Cotton or linen fibers or coated natural or synthetic fibers in which the coating contributes to suture
thickness without adding strength
Class III Metal wire of monofilament or multifilament construction
Suture characteristics
The absorbable and nonabsorbable surgical sutures are made from either "natural" or synthetic polymers and are
discussed separately.
Absorbable sutures
Absorbable natural sutures include the following:
Collagen
Plain surgical gut
Fastabsorbing surgical gut
Chromic surgical gut
The collagen sutures are derived from the submucosal layer of ovine small intestine or the serosal layer of the
bovine small intestine "gut." This collagenous tissue is treated with an aldehyde solution, which crosslinks and
strengthens the suture and makes it more resistant to enzymatic degradation. Suture materials treated in this way
are called plain gut.
The tensile strength of plain surgical gut is maintained for 710 days postimplantation (variable with individual
patient characteristics), and absorption is complete within 70 days. This type of suture is used for: (1) repairing
rapidly healing tissues that require minimal support and (2) ligating superficial blood vessels.
Fastabsorbing surgical gut is indicated for epidermal use (required only for 57 d) and is not recommended for
internal use.
Chromic surgical gut is treated with chromium salt, which slows down the absorption rate (90 d). Tensile strength is
maintained for 1014 days. Tissue reaction is due to the noncollagenous material present in these sutures. Also,
patient factors affect rates of absorption and make tensile strength somewhat unpredictable. Salthouse and
colleagues demonstrated that the mechanism by which chromic surgical gut reabsorbs is the result of sequential
attacks by lysosomal enzymes. [3]
Natural fiber absorbable sutures have several distinct disadvantages. First, these natural fiber absorbable sutures
have a tendency to fray during knot construction. Second, there is considerably more variability in their retention of
tensile strength than is found with the synthetic absorbable sutures. A search for a synthetic substitute for collagen
sutures began in the 1960s. Soon, procedures were perfected for the synthesis of high molecular weight polyglycolic
acid, which led to the development of the polyglycolic acid sutures. [3]
Absorbable synthetic sutures are composed of chemical polymers that are absorbed by hydrolysis and cause a
lesser degree of tissue reaction following placement. Many types of synthetic absorbable suture are available
depending on the anatomic site, surgeon's preference, and the required suture characteristics, including the
following, among others:
Polyglactin 910 (Vicryl)
Polycaprolate (Dexon II)
Poliglecaprone 25 (Monocryl)
Polysorb
Polydioxanone (PDS II)
Maxon
VLoc
Polyglactin 910 (Vicryl) synthetic suture is a braided multifilament suture coated with a copolymer of lactide and
glycolide (polyglactin 370). The waterrepelling quality of lactide slows loss of tensile strength, and the bulkiness of
lactide leads to rapid absorption of suture mass once tensile strength is lost. The suture is also coated with calcium
stearate, which permits easy tissue passage, precise knot placement, and smooth tiedown. Tensile strength is
approximately 65% at 14 days postimplantation. Absorption is minimal for 40 days and complete in 5670 days.
These sutures cause only minimal tissue reaction. Vicryl sutures are used in general softtissue approximation and
vessel ligation. Another similar suture material is made from polyglycolic acid and coated with Polycaprolate (Dexon
II). This material has a similar tensile strength and absorption profile.
Poliglecaprone 25 (Monocryl) synthetic suture is a monofilament suture that is a copolymer of glycolide and e
caprolactone. The suture has superior pliability, leading to ease in handling and tying. Tensile strength is high
initially, 5060% at 7 days, and is lost at 21 days. Absorption is complete at 91119 days. Poliglecaprone 25 sutures
are used for subcuticular closure and softtissue approximations and ligations.
Polysorb is a new, braided absorbable suture produced from the production of a Lactomer copolymer via synthesis
of copolymers of glycolide and lactide. The glycolide and lactide behave differently when exposed to tissue
hydrolysis. Glycolide provides for high initial tensile strength, but hydrolyzes rapidly in tissue. [4] Lactide has a slower
and controlled rate of hydrolysis, or tensile strength loss, and provides for prolonged tensile strength in tissue. [4]
The Lactomer copolymer consists of glycolide and lactide in a 9:1 ratio. The handling characteristics of the Polysorb
sutures were found to be superior to those of the Polyglactin 910 suture. [4] Using comparable knot construction and
suture sizes, the knotbreaking strength of Polysorb sutures was significantly greater than that encountered by
Polyglactin 910 sutures. In addition, the mean maximum knot rundown force encountered with the Polysorb sutures
was significantly lower than that noted with the Polyglactin 910 sutures, facilitating knot construction.
The surfaces of the Polysorb sutures have been coated to decrease their coefficient friction. [5] The Polysorb suture
is coated with an absorbable mixture of caprolactone/glycolide copolymer and calcium stearyl lactylate. At 14 days
postimplantation, nearly 80% of the USP tensile strength of these braided sutures remains. Approximately 30% of
their USP tensile strength is retained at 21 days. Absorption is essentially complete between days 56 and 70.
To study the determinants of suture extrusion following subcuticular closure by synthetic braided absorbable sutures
in dermal skin wounds, Drake et al used miniature swine to develop a model that reproduced the human clinical
experience. [6] Standard, fullthickness skin incisions were made on each leg and abdomen. The wounds were closed
with either sized 40 Polysorb or Vicryl sutures. Each incision was closed with 5 interrupted, subcuticular, vertical,
loops secured with a surgeon’s knot. The loops were secured with 3throw knots in one pig, 4throw knots in the
second pig, and 5throw knots in the third pig. Suture extrusion, wound dehiscence, stitch abscess, and granuloma
formation were all observed. [6]
The cumulative incidence of suture extrusion over 5 weeks ranged from 10% to 33%. Vicryl sutures had a higher
cumulative incidence of suture extrusion than that of the Polysorb sutures (31% vs 19%). With Polysorb sutures, the
5throw surgeon’s knot had a higher cumulative incidence of suture extrusion than the 3throw or 4throw surgeon’s
knot square, 30% versus 17% and 10%, respectively. [6]
Polydioxanone (PDS II) is a polyester monofilament suture made of polydioxanone. This suture provides extended
wound support and elicits only a slight tissue reaction. Tensile strength is 70% at 14 days and 25% at 42 days.
Wound support remains for up to 6 weeks. Absorption is minimal for the first 90 days and essentially complete
within 6 months. This material has a low affinity for microorganisms (like other monofilament sutures). PDS II
suture is used for softtissue approximation, especially in pediatric, cardiovascular, gynecologic, ophthalmic, plastic,
and digestive (colonic) situations. Another similar, new synthetic absorbable suture material is made from
polytrimethylene carbonate (Maxon). This material has a similar tensile strength and absorption profile.
When Sanz et al randomized 210 rats into 1 of 5 study groups to compare Maxon with 3 absorbable sutures (Vicryl,
chromic catgut, and PDS II) with respect to tissue inflammatory reaction, knot security, suture tensile strength, and
suture absorption, Maxon and PDS II elicited a lower degree of chronic inflammation relative to Vicryl and chromic
catgut. [7] In addition, the tensile strengths of Maxon and Vicryl significantly exceeded those of PDS II and chromic
catgut during the critical period of wound healing. Maxon and PDS II retained a larger percentage of tensile strength
during the long postoperative period, whereas Vicryl and chromic catgut were mostly absorbed. The investigators
concluded that Maxon was an excellent addition to the armamentarium of the surgeon. [7]
A barbed suture (VLoc, Covidien Inc) was developed that is selfanchoring with no knots required for wound
closure. The elimination of knot tying may reduce many of the challenges of knot construction. The barbed suture is
manufactured from a size 0 polydioxanone that reabsorbs within 26 weeks. This suture consists of axially barbed
segments on each side of a mid point at which the barbs change direction. The tensile strength of the barbed suture
decreases over time. Each suture is attached to a premium cutting and taper point needle with NuCoat coating
technology. [8]
The unique performance of the barbed suture was confirmed for gastrointestinal wound closure in a randomized
control study. [9] The VLoc wound closure device appeared to offer comparable gastrointestinal closure as compared
to 30 Maxon, while being significantly faster. However, further studies with VLoc are required to evaluate its use in
laparoscopic surgery. [9]
Caprosyn suture is rapidly absorbing and the latest innovation in the development of monofilament absorbable
suture. Caprosyn monofilament synthetic absorbable sutures are prepared from Polyglytone 621 synthetic polyester,
which is composed of glycolide, caprolactone, trimethylene carbonate, and lactide. Implantation studies in animals
indicate that Caprosyn suture retains a minimum of 5060% USP knot strength at 5 days postimplantation, and a
minimum of 2030% of knot strength at 10 days postimplantation. All of its tensile strength is essentially lost by 21
days postimplantation.
When PinerosFernandez et al compared the biomechanical performance of Caprosyn suture with that of chromic
gut suture, both suture types provided comparable resistance to wound disruption. [10] The biomechanical
performance studies included quantitative measurements of wound security, strength loss, mass loss, potentiation
of infection, tissue drag, knot security, knot rundown, as well as suture stiffness. Before implantation, suture loops
of Caprosyn had significantly greater mean breaking strength than suture loops of chromic gut [10] ; 3 weeks after
implantation of these absorbable suture loops, the sutures had no appreciable strength. The rate loss of suture
mass of these 2 sutures was similar.
As expected, chromic gut sutures potentiated significantly more infection than did the Caprosyn sutures. [10]
However, the handling properties of the Caprosyn sutures were far superior to those of the chromic gut sutures, and
the smooth surface of the Caprosyn sutures encountered lower drag forces than did the chromic gut sutures.
Furthermore, it was much easier to reposition the Caprosyn knotted sutures than the knotted chromic gut sutures.
[10] In the case of chromic gut sutures, it was not possible to reposition a 2throw granny knot. These biomechanical
performance studies demonstrated the superior performance of the synthetic Caprosyn sutures compared with
chromic gut sutures and provide compelling evidence of why Caprosyn sutures are an excellent alternative to
chromic gut sutures.
Nonabsorbable sutures
Natural nonabsorbable sutures include the following:
Surgical silk
Surgical cotton
Surgical steel
Surgical silk suture is made of raw silk spun by silkworms. The suture may be coated with beeswax or silicone.
Many surgeons consider silk suture the standard of performance (superior handling characteristics). Although
classified as a nonabsorbable material, silk suture becomes absorbed by proteolysis and is often undetectable in the
wound site by 2 years. Tensile strength decreases with moisture absorption and is lost by 1 year. The problem with
silk suture is the acute inflammatory reaction triggered by this material. Host reaction leads to encapsulation by
fibrous connective tissue.
Surgical cotton suture is made of twisted, long, staple cotton fibers. Tensile strength is 50% within 6 months and
3040% by 2 years. Surgical cotton is nonabsorbable and becomes encapsulated within body tissues. Surgical steel
suture is made of stainless steel (ironchromiumnickelmolybdenum alloy) as a monofilament and twisted
multifilament. This suture can be made with flexibility, fine size, and the absence of toxic elements. Surgical steel
demonstrates high tensile strength with little loss over time and low tissue reactivity. The material also holds knots
well.
Surgical steel suture is used primarily in orthopedic, neurosurgical, and thoracic applications. This type of suture
may also be used in abdominal wall closure, sternum closure, and retention. However, this material can be difficult
to handle because of kinking, fragmentation, and barbing, which renders the wire useless and may present a risk to
the surgeon's safety. [11]
The cutting, tearing, or pulling of other patient tissues is also a risk. In addition, surgical steel in the presence of
other metals or alloys may cause electrolytic reactions and, therefore, is not a safe choice in these circumstances.
The size of the steel wires is classified by the Brown and Sharpe gauge, that is, 18 (largest diameter) to 40
(smallest diameter). The standard USP classification is also used to denote wire diameter.
Nonabsorbable synthetic sutures include the following:
Nylon
Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ticron [coated])
Polybutester Suture (Novafil)
Coated Polybutester Suture (Vascufil)
Polypropylene (Prolene)
Surgipro II
Nylon suture is a polyamide polymer suture material available in monofilament (Ethilon/Monosof) and braided
(Nurolon/Surgilon) forms. The elasticity of this material makes it useful in retention and skin closure. Nylon is quite
pliable, especially when moist. Of note, a premoistened form is available for cosmetic plastic surgery. The braided
forms are coated with silicone. Nylon suture has good handling characteristics, although its memory tends to return
the material to its original straight form. Nylon has 81% tensile strength at 1 year, 72% at 2 years, and 66% at 11
years. The material is stronger than silk suture and elicits minimal acute inflammatory reaction. Nylon is hydrolyzed
slowly, but remaining suture material is stable at 2 years, due to gradual encapsulation by fibrous connective tissue.
Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ticron [coated]) suture material is formed from
polyester, a polymer of polyethylene terephthalate. The multifilament braided suture also comes coated with
polybutilate (Ethibond) or silicone (Ticron). The coating reduces friction for ease of tissue passage and improved
suture pliability and tiedown. The suture elicits minimal tissue reaction and lasts indefinitely in the body. Polyester
fiber sutures are stronger than natural fibers and do not weaken with moistening. The material provides precise
consistent suture tension and retains tensile strength. This suture is commonly used for vessel anastomosis and the
placement of prosthetic materials.
Polybutester suture (Novafil) is a block copolymer that contains butylene terephthalate and polytetramethylene ether
glycol. This monofilament synthetic nonabsorbable suture has unique performance characteristics that may be
advantageous for wound closure, [12] and it exhibits distinct differences in elongation compared with other sutures.
With the polybutester suture, low forces yield significantly greater elongation than is seen in the other sutures. In
addition, its elasticity is superior to the other sutures, allowing the suture to return to its original length once the load
is removed.
Coated polybutester suture (Vascufil) is a unique absorbable polymer that enhances the clinical performance of
polybutester suture by its coating, a polytribolate polymer composed of 3 compounds: glycolide, εcaprolactone, and
poloxamer 188. [13] Coating the polybutester suture markedly reduces its drag force in musculoaponeurotic, colonic,
and vascular tissue.
Polypropylene (Prolene) is a monofilament suture that is an isostatic crystalline stereoisomer of a linear propylene
polymer, permitting little or no saturation. The material does not adhere to tissues and is useful as a pullout suture
(eg, subcuticular closure). Polypropylene also holds knots better than other monofilament synthetic materials. This
material is biologically inert and elicits minimal tissue reaction. Prolene is not subject to degradation or weakening
and maintains tensile strength for up to 2 years. This material is useful in contaminated and infected wounds,
minimizing later sinus formation and suture extrusion.
Surgipro II is a polypropylene suture that has been developed with increased resistance to fraying during knot
rundown, especially with smaller diameter sutures. This suture is extremely inert in tissue and has been found to
retain tensile strength in tissues for as long as 2 years. Surgipro II is widely used in plastic, cardiovascular, general,
and orthopedic surgery. It exhibits a lower drag coefficient in tissue than nylon sutures, making them ideal for use in
continuous suture closure. [14]
Needles
Surgical needles are produced from stainless steel alloys, which have excellent resistance to corrosion. [14] All true
stainless steels contain a minimum of 12% chromium, which allows a thin, protective surface layer of chromium
oxide to form when the steel is exposed oxygen. Since their development during the early 1960s, high nickel
maraging stainless steels have found extensive use in structural materials in many applications that require a
combination of high strength and toughness.
The basic principle of maraging consists of strengthening tetrataenite (FeNi) martensitic matrices by the
precipitation of fine intermetallic phases, such as nickeltitanium (Ni3 Ti). These precipitates are so small that they
are only evident on transmission electron microscopy. They strengthen the metal by preventing the planes of atoms
in the stainless steel from sliding over each other. A high nickel maraging stainless steel, like S45500, is composed
of 7.59.5% nickel, 0.81.4% titanium, and 1112.5% chromium. In contrast, S42000 stainless steel is composed of
1214% chromium without nickel or titanium. Scientists have successfully used the concept of high nickel maraging
stainless steels (S45500) to develop stainless steel wires with superior strength and ductility for use as surgical
needles. Surgical needles made of a high nickel maraging stainless steel have a greater resistance to bending and
breakage than stainless steels without nickel.
Wound closure and healing is affected by the initial tissue injury caused by needle penetration and subsequent
suture passage. Needle selection, surface characteristics of the suture (eg, coefficient of friction), and suturecoating
materials selected for wound closure are important factors that must be considered by the surgeon.
Needle qualities
Characteristics of the ideal surgical needle and needle performance are reviewed in this section.
Ideal surgical needle characteristics
The ideal surgical needle has the following characteristics:
Highquality stainless steel
Smallest diameter possible
Stable in the grasp of the needle holder (see the following image)
Interaction between the needle holder and suture needle. A: A needle holder of appropriate size for the needle; B: a needle
holder that is too large for the needle—pressure applied by the needle holder leads to inadvertent straightening of the suture
needle; C: a needle holder that is too small for the needle—the needle rotates around the long axis of the needle holder.
Capable of implanting suture material through tissue with minimal trauma
Sharp enough to penetrate tissue with minimal resistance
Sterile and corrosionresistant to prevent introduction of microorganisms or foreign materials into the wound
Needle performance characteristics and definitions
The following terms describe various characteristics related to needle performance:
Strength Resistance to deformation during repeated passes through tissue (ie, increased needle strength
results in decreased tissue trauma); ultimate moment is the measure of maximum strength determined by
bending the needle to 90°, and surgicalyield moment is the amount of angular deformation that can occur
before permanent needle deformation occurs
Ductility Resistance (of a needle) to breakage under a given amount of deformation/bending
Sharpness Measure of the ability of the needle to penetrate tissue; factors affecting sharpness include the
angle of the point and the taper ratio (ie, ratio of taper length to needle diameter)
Clamping moment Stability of a needle in a needle holder, determined by measuring the interaction of the
needle body with the jaws of the needle holder
Anatomy of a needle
The anatomy of a needle includes the point, body, and swage (see the following image).
The point portion of the needle extends from the tip to the maximum crosssection of the body. Point types include
the following (see the image below):
Cutting needles (conventional, reverse, or side [spatula])
Taperpoint (round) needles
Beveled, conventional cutting edge needles
Bluntpoint needles
See the image below.
Commonly used suture needles, with crosssections of the needles shown at the point, body, and swage. A: A taper needle; B: a
conventional cutting needle; C: a reverse cutting needle.
Cutting needles
The cutting needle has at least 2 opposing cutting edges (the point is usually triangular). This type is designed for
penetration through dense, irregular, and relatively thick tissues. The point cuts a pathway through tissue and is
ideal for skin sutures. Sharpness is due to the cutting edges.
Conventional cutting needles have 3 cutting edges (triangular crosssection that changes to a flattened body). The
third cutting edge is on the inner, concave curvature (surfaceseeking).
In reversecutting needles, the third cutting edge is on the outer convex curvature of the needle (depthseeking).
These needles are stronger than conventional cutting needles and have a reduced risk of cutting out tissue. The
needles are designed for tissue that is tough to penetrate (eg, skin, tendon sheaths, oral mucosa). Reversecutting
needles are also beneficial in cosmetic and ophthalmic surgery, causing minimal trauma.
Sidecutting (spatula) needles are flat on the top and bottom surfaces to reduce tissue injury. These needles allow
maximum ease of penetration and control as they pass between and through tissue layers. Sidecutting needles
were designed initially for ophthalmic procedures.
Taperpoint needles
Taperpoint (round) needles penetrate and pass through tissues by stretching without cutting. A sharp tip at the
point flattens to an oval/rectangular shape. The sharpness is determined by taper ratio (812:1) and tip angle (20
35°). The needle is sharper if it has a higher taper ratio and lower tip angle. The taperpoint needle is used for easily
penetrated tissues (eg, subcutaneous layers, dura, peritoneum, abdominal viscera) and minimizes the potential
tearing of fascia.
Beveled, conventional cutting edge needles
A beveled, conventional cutting edge needle was developed with superior performance characteristics over those of
other conventional cutting edge needles. It is composed of a unique stainless steel, ASTM 45500, that has been
heattreated after the curving process to enhance the resistance to bending. The angle of presentation of its cutting
edge has been decreased to enhance needle sharpness. On the basis of the results of experimental and clinical
studies done by Kaulbach et al, this needle is recommended for closure of lacerations. [15]
Bluntpoint needles
Blunt point needles dissect friable tissue rather than cut it. The points are rounded and blunt, ideal for suturing the
liver and kidneys. Additionally, blunt needles are being developed for more conventional uses in an effort to reduce
needlestick injuries.
Needle body types include the following:
Straight body
Halfcurved ski body
Curved body
Compound curved body
The body part of the needle incorporates most of the needle length and is important for interaction with the needle
holder and the ability to transmit the penetrating force to the point. The needle factors that affect this interaction
include needle diameter and radius, body geometry, and stainless steel alloy. These components determine the
needlebending moment, ultimate moment, surgicalyield moment, and needle ductility.
The straight body needle is used to suture easily accessible tissue that can be manipulated directly by hand. This
needle is also useful in microsurgery for nerve and vessel repair. Examples of straightbody needles include the
Keith needle, which is a straight cutting needle used for skin closure of abdominal wounds, and the Bunnell needle,
which is used for tendon/gastrointestinal tract repair.
The halfcurved ski needle is rarely used in skin closure, because it is difficult to handle. The straight portion of the
body does not follow the curved point, resulting in an enlarged curved point, which makes the needle difficult to
handle.
The curved needle has a predictable path through tissue and requires less space for maneuvering than a straight
needle does. The semicircular path is the optimal course for sutures through tissue and provides an even distribution
of tension. Body curvature is commonly a onequarter–inch, threeeighths–inch, halfinch, or fiveeighths–inch circle.
The threeeighths–inch circle is used most commonly for skin closure. The halfinch circle was designed for confined
spaces, and more manipulation by the surgeon is required (ie, increased wrist motion is required).
The compound curved needle curvature was originally designed for anterior segment ophthalmic surgery. The body
has a tight 80° curvature at the tip, which becomes a 45° curvature throughout the remainder of the body. A
microvascular compound curved needle may also facilitate vessel approximation in microvascular surgery.
Swage
The suture attachment end creates a single, continuous unit of suture and needle; this is known as the swage. The
swage may be designed to permit easy release of the needle and suture material (popoff), and includes the
following types:
Channel
Drill
Nonswaged
In a channel swage, a needle is created with a channel into which the suture is introduced, and the channel is
crimped over the suture to secure it into place. The diameter of the channel swage is greater than the diameter of
the needle body.
In a drill swage, material is removed from the needle end (sometimes with a laser), and the needle is crimped over
the suture. The diameter of the drill swage is less than the diameter of the needle body.
Alternatively, in a nonswaged needle, the suture may be passed through an eye, similar to that found in a sewing
needle. In a closedeye configuration, the shape may be round, oblong, or square. In a French (split or spring) eye,
a slit is in the end of the needle with ridges that catch and hold the suture in place.
Several disadvantages are associated with the use of a nonswaged needle. Tissue passage of a double strand of
suture leads to more tissue trauma. In a swaged needle, the suture is less likely to become unthreaded prematurely.
Also, decreased handling helps maintain suture integrity. Swaged sutures are not subject to suture fraying or
damage due to sharp corners in the eye of eyed needles.
Needle coating and needle measurements
The needle may be coated with silicone to permit easier tissue passage. The coating helps reduce the force needed
to make initial tissue penetration and the frictional forces as the body of the needle passes through the tissue.
The chord length, or bite width, is the linear distance from the point of the curved needle to the swage (bite width).
The needle length is the distance measured along the needle from the point to the swage. Needle length, not chord
length, is the measurement supplied on suture packages. The radius is the distance from the body of the needle to
the center of the circle along which the needle curves (bite depth), and the diameter is considered the gauge or
thickness of the needle wire. See the image below.
Needle–needle holder interaction
The stability of the needle within the needle holder affects needle control and performance. The jaws of the needle
holder must be appropriate to the needle size to hold it securely and prevent rocking, turning, and twisting (see the
following image). An ovoid crosssection of the needle body often maximizes both the surface contact with the
needleholder jaws and the bending moment of the needle.
Interaction between the needle holder and suture needle. A: A needle holder of appropriate size for the needle; B: a needle holder that
is too large for the needle—pressure applied by the needle holder leads to inadvertent straightening of the suture needle; C: a needle
holder that is too small for the needle—the needle rotates around the long axis of the needle holder.
The needleholder handle must be appropriate for the depth needed for placement of the suture. The difference
between the length of the handle and the jaw creates a mechanical advantage for exerting force through the needle
point.
The needleholder clamping moment is the force applied to a suture needle by a needle holder. The jaws of the
needle holder contact a curved needle at 1 point on the outer curvature and 2 points along the inner curvature. The
force against the needle creates a moment arm, which acts to flatten the curvature of the needle.
Technically speaking, the needleholder clamping moment must be less than the surgical yield of the needle, or the
needle will bend and ultimately may break. A bent needle takes a relatively traumatic path through soft tissue and
may cause increased softtissue injury. Repetitive injury by the needle holder also may cause the needle to break. If
the broken portion of the needle is not identified and retrieved immediately, surgery may be delayed in efforts to
find it. The need for intraoperative radiology and other potential difficulties may ensue.
Studies by Abidin et al demonstrated that the sharp edges of smooth needleholder jaws cut the smooth surface of
monofilament sutures, weakening their strength. [16] When the smooth tungsten carbide inserts of needle holders
clamped 60 monofilament nylon suture with the first opposing teeth of the needle holder ratchet mechanism
interlock, there was a significant reduction in suture breaking strength. [16]
This sutural damage can be prevented by mechanical grinding the outer edges of the smooth tungsten carbide
inserts, resulting in a rounded edge. Clamping the suture with the smooth jaws of the needle holder was atraumatic
with no demonstrable damage to the suture's breaking strength. [16]
Clinical Implementation
It is important to emphasize that the performance of needles and sutures should be evaluated in a selection
program by a healthcare resource management group purchasing organization. [14] Unfortunately, only Consorta, Inc.
(Rolling Meadows, Ill) has had the leadership to do such a surgical suture and needle product evaluation. In this
expanded evaluation program, when 42 Consorta shareholder hospitals enrolled 1913 surgeons to participate in an
observational study of the clinical performance of surgical sutures and needles produced by Covidien, in the 30day
studies, surgeons found that the needles and sutures were clinically acceptable in 98.1% of the evaluations. [14]
Selection of sutures, surgical gloves, needles, and needle holders in clinical practice are briefly discussed in this
section.
Suture selection
Much of the process regarding suture selection depends on surgeon training and preference. A wide variety of
suture materials are available for each surgical location and surgical requirement. Generally, the surgeon selects the
smallest suture that adequately holds the healing wound edges. The tensile strength of the suture should never
exceed the tensile strength of the tissue. As the wound heals, the relative loss of suture strength over time should
be slower than the gain of tissue tensile strength.
Certain general principles can be applied to suture selection. Sutures are no longer needed when a wound has
reached maximum strength. Therefore, consider nonabsorbable suture in skin, fascia, and tendons (slowly healing
tissues), whereas mucosal wounds (rapidly healing tissues) may be closed with absorbable sutures.
Aesthetic concerns
Aesthetic concerns are at a premium in the anatomic regions of the head and neck, such as the eyelid, periorbital
area, nose, pinna, lip, and vermillion. In these areas, tensile strength requirements tend to be less, and smaller
suture sizes are preferred. However, the mobility of the lip and vermillion requires a relatively higher suture tensile
strength. The activity and mobility of the face, anterior and posterior neck, scalp, superior trunk, and nasal and oral
mucosa demand higher tensile strength requirements in suture selection. Additionally, major musculocutaneous
flaps tend to be closed under significant tension, requiring maximal longterm tensile strength.
Contaminated tissues
Because the presence of foreign bodies in contaminated tissues may facilitate infection, special consideration of
suture selection in these locations, such as a contaminated posttraumatic wound, is imperative. Multifilament
sutures are more likely to harbor contaminants than monofilament sutures; thus, monofilament sutures are generally
preferable in potentially contaminated tissues. Use the smallest inert monofilament suture materials, such as nylon
or polypropylene, in this setting.
Suture size
Optimal suture size is generally the smallest size necessary to achieve the desired tensionfree closure. If wound
tension is high, smallerdiameter sutures may actually injure tissues by cutting through them. Therefore, closely
match the tensile strength of the suture and tissue.
Surgical glove selection
Surgeons who use sutures and needles should wear sterile surgical gloves without cornstarch, as cornstarch has
been documented to promote wound infection, to cause serious peritoneal adhesions and granulomatous peritonitis,
and to be a welldocumented vector of the latex allergy epidemic. In 2008, 13 health professionals filed a citizen’s
petition to the US Food and Drug Administration (FDA) to ban cornstarch powder on medical gloves. [17]
Because the FDA allows 1.5% of the surgical gloves to have holes, these holes allow the transmission of blood with
deadly borne viral infections to be transmitted between the patient and the surgeon. After surgery has begun, one of
the major causes of glove holes is surgical needle penetration through the glove. Consequently, the use of the
doubleglove Biogel Puncture Indication System should be used to detect the location and presence of holes in the
gloves, allowing the surgeon to change the gloves when a hole is detected, (as seen in the image below). [18]
A poster for the Biogel Puncture Indication System.
Needle selection
No standardized sizing system or nomenclature is available for needles or needle holders. The main consideration in
needle selection is to minimize trauma. A taper needle is sufficient for tissues that are easy to penetrate. Cutting
needles are typically reserved for tough tissues. As a general guide, select tapered sutures for all closures except
skin sutures. The length, diameter, and curvature of the needle influence the surgeon's ability to place a suture. The
needlebody diameter ideally matches the suture size.
Needleholder selection
As discussed earlier, needle control and performance is affected by the stability of the needle within the needle
holder; thus, for a secure needle hold and prevention of rocking, turning, and twisting, the jaws of the needle holder
must be appropriate to the needle size. Often, the surface contact with the needleholder jaws and the bending
moment of the needle is maximized with an ovoid crosssection of the needle body.
In addition, the handle of the needle handle must be appropriate for the depth needed for the suture placement. A
mechanical advantage for exerting force through the needle point is created by the difference between the length of
the handle and the jaw.
The needleholder clamping moment is a measure of the force applied to a suture needle by the needle holder, and
the needleyield moment is the amount of deformation that can occur before a needle is permanently deformed.
Thus, when the needleholder clamping moment is greater than the needleyield moment, the needle is likely to be
permanently deformed, which may lead to complications.
Contributor Information and Disclosures
Author
Stephen Y Lai, MD, PhD Associate Professor, Department of Head and Neck Surgery, University of Texas MD
Anderson Cancer Center
Stephen Y Lai, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology
Head and Neck Surgery, American Association for Cancer Research, American Head and Neck Society, and
Society of University OtolaryngologistsHead and Neck Surgeons
Disclosure: GlaxoSmithKline Grant/research funds None; Neoprobe Grant/research funds clinical trial
Coauthor(s)
Daniel G Becker, MD Assistant Professor, Department of OtorhinolaryngologyHead and Neck Surgery, Division
of Facial Plastic and Reconstructive Surgery, University of Pennsylvania School of Medicine
Daniel G Becker, MD is a member of the following medical societies: American Academy of Facial Plastic and
Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, and American College of
Surgeons
Disclosure: Nothing to disclose.
Richard F Edlich, MD, PhD, FACS, FASPS, FACEP Distinguished Professor Emeritus of Plastic Surgery,
Biomedical Engineering and Emergency Medicine, University of Virginia Health Care System
Richard F Edlich, MD, PhD, FACS, FASPS, FACEP is a member of the following medical societies: Alpha
Omega Alpha, American Association of Plastic Surgeons, American Burn Association, American College of
Emergency Physicians, American College of Surgeons, American Society of Plastic and Reconstructive Surgery,
American Spinal Injury Association, American Surgical Association, American Trauma Society, Plastic Surgery
Research Council, Society of University Surgeons, and Surgical Infection Society
Specialty Editor Board
Anthony P Sclafani, MD Director of Facial Plastic Surgery and Surgeon Director, New York Eye and Ear
Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and
Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, and American College of
Surgeons
Disclosure: Contura None Board membership; Aesthetic Factors, Inc. Salary Consulting; Meditech Medical
Enterprises Consulting fee Independent contractor
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; EditorinChief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of
Surgery, Division of OtolaryngologyHead and Neck Surgery, Faculty of Medicine, Université de Sherbrooke,
Canada
Christopher L Slack, MD Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal
ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Facial Plastic and Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck
Surgery, and American Medical Association
Chief Editor
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado
School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic
and Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, and American Head
and Neck Society
Disclosure: Axis Three Corporation Ownership interest Consulting; Medvoy Ownership interest Management
position; Cerescan Imaging Honoraria Consulting
Additional Contributors
Acknowledgments
The authors would like to acknowledge Catherine L. Cross, research assistant at Legacy Emanuel Hospital, for
her guidance and advice in the completion of this article.
References
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Medscape Reference © 2011 WebMD, LLC

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