SUTURES

What is a suture?
A suture is a piece of thread-like material used to stitch or approximate tissues, and hold the wound together until healing takes place. Any strand of material used for ligating or approximating tissue. Any materials used to sew, sick or hold tissue together until healing process occurs.

Purpose of suture

to hold a wound together in good apposition until such time as the natural healing process is sufficiently well established to make the support from the suture material unnecessary and redundant.

Forms of Suture
LIGATURE- the material that is tied around the blood vessel that occlude a lumen. FREE TIE a single strand of material handed to a surgeon to ligate a vessel. This stand is not threaded on a needle.

Forms of Suture
SUTURE LIGATURE a strand attached to a needle before use. The needle is used to anchor the strand in tissue before occluding a deep or large vessel.

STICK forceps.

TIE a strand attached to a

CLASSIFICATION OF SUTURE MATERIAL

MONOFILAMENT A strand consisting of a single threadlike structure; they are smooth The slide well in tissues but if handles inappropriately they can fracture

MULTIFILAMENT Made of more than one thread like structure together by spinning/braiding/twisting They have a greater surface area They are easier to handle and knot well

KIND OF SUTURES

ABSORBABLE SUTURE

An absorbable suture is made from material that can be absorbed (digested) by body cells and fluids. They are sterile strands prepared from collagen derived from healthy mammals Rate of absorption depends on various factors, including type of bodytissue , nutritional status of the patient, and the presence of infection.

PLAIN GUT
Plain indicates a surgical gut material that has not been treated to lengthen its absorption time in the tissue. This suture is absorbed more rapidly than treated suture.

CHROMIC GUT

Chromic surgical gut has been treated with chromic oxide so that it will delay its rate of digestion or absorption.

SYNTHETIC ABSORBABLE SUTURES

Polyglactin 910 (Vicryl). Polyglycolic Acid (Dexon). Polydioxanone (PDS).

NON ABSORBABLE SUTURES

This suture material is not absorbed during the healing process. They are strands of material that effectively resists enzymatic digestion or absorption of living tissues. Nonabsorbable suture becomes encapsulated (enclosed in a capsule) with tissue and remains in the body until it is removed or cast off. Silk, nylon, cotton, linen, polypropylene, and corrosion-resisting steel wire are examples of nonabsorbable sutures.

SUTURE SIZES

Sutures are sized by the USP (United States Pharmacopoeia) scale The available sizes and diameters are:
6-0 = 0.07 mm 5-0 = 0.10 mm 4-0 = 0.15 mm 3-0 = 0.20 mm 2-0 = 0.30 mm 0 = 0.35 mm 1 = 0.40 mm 2 = 0.5 mm

SUTURE CHARACTERISTICS

Suture materials vary in their physical characteristics Sterile All-purpose (composed of material that can be used in any surgical procedure) Causes minimal tissue injury or tissue reaction (i.e., non-electrolytic, noncapillary, non-allergenic, noncarcinogenic) Easy to handle Holds securely when knotted (ie, no fraying or cutting) High tensile strength Favorable absorption profile Resistant to infection

NEEDLE S

What is a surgical needle?

Are needed to carry the suture material through tissue with the least amount of trauma.

Anatomy of a needle
POINT
This portion of the needle extends from the tip to the maximum cross-section of the body.

BODY
This part of the needle incorporates most of the needle length. The body of the needle is important for interaction with the needle holder and the ability to transmit the penetrating force to the point.

SWAGE
The suture attachment end creates a single, continuous unit of suture and needle.

NEEDLE COATING
The needle may be coated with silicone to permit easier tissue passage.

NEEDLE POINTS

CUTTING

The 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

This type of needle has 3 cutting edges (triangular cross-section that changes to a flattened body). The third cutting edge is on the inner, concave curvature (surfaceseeking). REVERSE CUTTING NEEDLES
The third cutting edge is on the outer convex curvature of the needle (depth-seeking). 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).

SIDE CUTTING NEEDLES

These needles are flat on the top and bottom surfaces to reduce tissue injury. The needles allow maximum ease of penetration and control as they pass between and through tissue layers. Sidecutting needles were designed initially for ophthalmic procedures.

TAPER POINT/ ROUND NEEDLES

This type of needle penetrates and passes through tissues by stretching without cutting. A sharp tip at the point flattens to an oval/rectangular shape. The needle is sharper if it has a higher taper ratio and lower tip angle. The taper-point needle is used for easily penetrated tissues (eg, subcutaneous layers, dura, peritoneum, abdominal viscera) and minimizes potential tearing of fascia.

BLUNT POINT NEEDLES

This type of needle dissects friable tissue rather than cuts it. The point is 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.

Characteristics of Surgical Needle

High-quality stainless steel Smallest diameter possible Stable in the grasp of the needle holder Capable of implanting suture material through tissue with minimal trauma Sharp enough to penetrate tissue with minimal resistance Sterile and corrosion-resistant to prevent introduction of microorganisms or foreign materials into the wound

SUTURING TECHNIQUES

SIMPLE INTERRUPTED SUTURE

suture is placed by inserting the needle perpendicular to the epidermis, traversing the epidermis and the full thickness of the dermis, and exiting perpendicular to the epidermis on the opposite side of the wound.

LINE OF INTERRUPTED SUTURE

Compared with running sutures, interrupted sutures are easy to place, have greater tensile strength, and have less potential for causing wound edema and impaired cutaneous circulation.

SIMPLE RUNNING SUTURE

is an uninterrupted series of simple interrupted sutures. The suture is started by placing a simple interrupted stitch, which is tied but not cut.

RUNNING LOCKED SUTURE

The first knot of a running locked suture is tied as in a traditional running suture and may be locked by passing the needle through the loop preceding it as each stitch is placed. This suture is also known as the baseball stitch because of the final appearance of the running locked suture line.

VERTICAL MATTRESS SUTURE

is a variation of the simple interrupted suture. It consists of a simple interrupted stitch placed wide and deep into the wound edge and a second more superficial interrupted stitch placed closer to the wound edge and in the opposite direction.

HALF BURIED VERTICAL MATTRESS SUTURE

is a modification of the vertical mattress suture and eliminates 2 of the 4 entry points, thereby reducing scarring.

PULLEY SUTURE

When pulley sutures are used, a vertical mattress suture is placed, the knot is left untied, and the suture is looped through the external loop on the other side of the incision and pulled across. At this point, the knot is tied. This new loop functions as a pulley, directing tension away from the other strands

FAR-NEAR NEAR-FAR MODIFIED VERTICAL MATTRESS SUTURE

The first loop is placed approximately 4-6 mm from the wound edge on the far side and approximately 2 mm from the wound edge on the near side. The suture crosses the suture line and reenters the skin on the original side at 2 mm from the wound edge on the near side. This placement creates a pulley effect.

HORIZONTAL MATTRESS SUTURE

suture is placed by entering the skin 5 mm to 1 cm from the wound edge. The suture is passed deep in the dermis to the opposite side of the suture line and exits the skin equidistant from the wound edge.

HALF BURIED HORIZONTAL SUTURE OR TIP STITCHES

begins on the side of the wound on which the flap is to be attached. The suture is passed through the dermis of the wound edge to the dermis of the flap tip. The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, and reenters the skin to which the flap is to be attached.

ABSORBABLE BURIED SUTURE

are used as part of a layered closure in wounds under moderate-to-high tension. Buried sutures provide support to the wound and reduce tension on the wound edges, allowing better epidermal approximation of the wound.

DERMAL-SUBDERMAL SUTURE

The suture is placed by inserting the needle parallel to the epidermis at the junction of the dermis and the subcutis. The needle curves upward and exits in the papillary dermis, again parallel to the epidermis. The needle is inserted parallel to the epidermis in the papillary dermis on the opposing edge of the wound, curves down through the reticular dermis, and exits at the base of the wound at the interface between the dermis and the subcutis and parallel to the epidermis.

BURIED HORIZONTAL MATTRESS SUTURE

The buried horizontal mattress suture is a purse-string suture. The suture must be placed in the mid-to-deep part of the dermis to prevent the skin from tearing. If tied too tightly, the suture may strangulate the approximated tissue.

RUNNING HORIZONTAL MATTRESS SUTURE

A simple suture is placed, and the knot is tied but not cut. A continuous series of horizontal mattress sutures is placed, with the final loop tied to the free end of the suture material

RUNNING SUBCUTICULAR SUTURE

is a buried form of the running horizontal mattress suture. It is placed by taking horizontal bites through the papillary dermis on alternating sides of the wound. No suture marks are visible, and the suture may be left in place for several weeks

RUNNING SUBCUTANEOUS SUTURE

The running subcutaneous suture begins with a simple interrupted subcutaneous suture, which is tied but not cut. The suture is looped through the subcutaneous tissue by successively passing through the opposite sides of the wound. The knot is tied at the opposite end of the wound by knotting the long end of the suture material to the loop of the last pass that was placed.