Discuss Sutures in Surgical Practice

OUTLINE

• INTRODUCTION/DEFINITION

• BRIEF HISTORY

• PROPERTIES OF AN IDEAL SUTURE

• CLASSIFICATION OF SUTURES

• CLASSIFICATION OF NEEDLES

• SUTURE TECHNIQUE AND KNOTTING

• USES IN SURGERY

• PRINCIPLES OF SUTURING

• PRINCIPLES OF SUTURE REMOVAL

• STERILISATION OF SUTURES

• COMPLICATIONS

• CONCLUSION

Introduction/definition

• Suture can be defined as a natural or synthetic material used for tissue approximation &/or securing haemostasis in a wounded tissue

• Its use cuts across all surgical subspecialty

• The postoperative appearance of a beautifully designed closure or flap can be compromised if an incorrect suture and or technique is chosen or if the execution is poor.

• A good knowledge of suture material, suturing techniques and adherence to surgical principles is key in preventing morbidity

Brief History

• The earliest records of surgical sutures dates back to 3500 B.C in Egypt

• Hippocrates first used the term ‘ suture’ in 400 B.C and it literally means to sew

• The first sutures were fashioned from hair, tendon, cotton or silk. they were used on needles made of bone, wood or stone

• Sutures were originally used to close open wounds but later shortly adapted to ligate tissue.

• Infection became a proble

• In 1867, Joseph lister first attempted to sterilize suture. He used silk suture that was ‘ sterilized’ in carbolic acid. The 1st trials were not successful

• In 1869,lister changed to ‘catgut’ suture which was being widely used in Germany due to its absorbability. The trials showed a great reduction in infection rates

• Halstead in the early 1900s, indicated the advantages of non absorbable silk and emphasised the importance of incorporation of part of normal tissue

• The recent trend tends towards use of adhesive and staples for tissue approximation

Properties of an ideal Suture material

• It should evoke no adverse tissue reaction

• It should not predispose to infection

• It should maintain its tensile strength indefinitely

• It should have a good knotting properties

• It is non toxic

• Its non teratogenic

• It is durable

• It should have no capillary action

• It should have poor memory

• It should be inexpensive and easily sterilised

• THERE IS NO IDEAL SUTURE MATERIAL 

• Choice of suture depends on tissue integrity cost availability surgeon factor and suture factor such as

• Thickness of the suture
• Tensile strength
• Physical structure (mono or multifilament)
• Rate of absorption
• Tissue responseClassification of sutures
• Absorbable or Non absorbable
• Natural or synthetic
• Monofilament or multifilament

• Absorbable
• Natural: catgut( plain or chromic), Recon collagen
• Synthetic: polyglycolic acid (Dexon), polyglactic 910 (vicryl) and polydioxanone
• ( PDS)

• Non Absorbable

• Natural: silk, steel, cotton
• Synthetic: Nylon, Prolene, Dacron

• 
  Monofilaments predispose to lesser infection as single strands has less interstices for nidus

• Different tissue require the use of different material

• Skin- nylon, prolene

• Aponeurosis- nylon

• Bile duct, Ureter,bladder- absorbable sutures

• Vascular tree- prolene

• Sternum, orthopaedic- stainless steel wire( Kwires)

• Absorbable suture degraded via two ways

• Proteolysis (enzymatic degradation of protein)

• catgut plain 5-7days; chromic 21 days

• Hydrolysis( effect of water on suture)- vicryl 28-56days, Dexon 60-90day, PDS 180 days

• Thickness of suture

• Suture have different size with numerical number based on diameter

• 0.2-8mm implied 2/0, 1/0…..8

Classification of Needles

• Classified based on

• Traumatic or non traumatic

• Shape

• Point of geometry

• Traumatic needle are needles with hole or eyes which are supplied different from their suture thread

• Non traumatic are eyeless needle attached to a specific length of suture thread. Usually less time consumingBased on Shape

• 3/8 circle

• 1/2 circle

• Straight

• SpecialtyBased on point of Geometry

Points of needle:

1. Cutting points : it used to penetrate when tissue is difficult to be penetrated as skin and tendon
2. Reverse cutting
3. Taper point : these needles are used in soft tissue such as intestine and peritoneum, the sharp point at the tip of needle
4. Blunt point : these are using for suturing friable tissue such as liver and kidneySuture techniques and knotting

• Simple continous- bowel, fascia

• Interrupted- skin, fascia or areas with risk of infection

• Mattress- vertical, horizontal, semi-mattress; approx of skin edges, obliteration of dead space in subcutaneous tissue

• Subcuticular- skin closure with no stitch mark

• Figure of

• A suture knot has three components

1. The loop created by the knot
2. The knot itself, which is composed of a number of tight “throws”, each throw represents a weave of the two strands
3. The ears, which are the cut ends of the suture

Uses in Surgery

• Close defect and approximate tissue

• Haemostasis and ligation

• Other uses include:

• Stay suture
• Retraction
• Seton
• Anchoring drains
• To hold mesh

• As markers-Hartmann colostomyPrinciples of suturing

1. The completed knot must be tight, firm, and tied so that slippage will not occur
2. To avoid wicking of bacteria, knot should not be placed in incision lines
3. Knots should be small and the ends cut short (2-3mm)
4. Avoid excessive tension to finer gauge materials as breakage may occur5- Avoid using a jerking motion, which may break the suture
5. Avoid crushing or crimping of suture materials by not using hemostats or needle holders on
6. them except on the free end for tying
7. Do not tie suture too tightly as tissue necrosis may occur. Knot tension should not produce tissue blanching
8. Maintain adequate traction on one end while tying to avoid loosing the first loopPrinciples of suture removal

1. The area should be swabbed with antiseptic for removal of encrusted necrotic debris, blood, and serum from about the sutures
2. A sharp suture scissors should be used to cut the loops of individual or continuous sutures
3. about the teethPrinciples of suture removal
4. It is often helpful to use a No. 23 explorer to help lift the sutures if they are within the sulcus or in close apposition to the tissue
5. A cotton pliers is used to remove the suture. The location of the knots should be noted so

that they can be removed first. This will prevent unnecessary entrapment under the flapSterilisation of sutures

• Autoclaving

• Ionizing radiation

• Ethylene oxide

• Lugol’s iodine for catgutcomplications

• Allergic reactions

• Stitch sinus

• Stitch abscess

• Stitch granuloma

• Stitch mark

• Suture failureconclusion

• Suture remains an inseparable tool in surgical practice

• Adequate knowledge of suture material with adherence to surgical principles is important in achieving good outcome

Thank you

References

• Principles and practice of surgery-E.A Badoe and co, 4th Edition

• Postgraduate surgery- M.A.R Al-fallouji, 2nd edition

• Medscape- suturing technique, Julian MackayWiggan et al

• Wound closure manual www.uphs.upenn.edu/surgery/education/facilitie s/measey/wound_closure_manual.pdf

• E-med books