أسماء الصفدي أسماء الصفدي 220074586220074586

اسراء شحادة اسراء شحادة 220080809220080809

زهور ناجي زهور ناجي 220081698220081698

أسماء ابو عبيد أسماء ابو عبيد 2008382820083828

What is suture???What is suture???

• Suture: as a verb is the act of sewing Suture: as a verb is the act of sewing by bringing tissue together by bringing tissue together

• Suture as a noun is a material used Suture as a noun is a material used to bring tissue togetherto bring tissue together

The Ideal Suture MaterialThe Ideal Suture Material

• Can be used in any Can be used in any tissuetissue

• Easy to handleEasy to handle

• Good knot securityGood knot security

• Minimal tissue Minimal tissue reactionreaction

The Ideal Suture MaterialThe Ideal Suture Material

• Unfriendly to bacteriaUnfriendly to bacteria

• Strong yet smallStrong yet small

• Won’t tear through tissuesWon’t tear through tissues

• CheapCheap

What’s It Used for?What’s It Used for?

• To bring tissue edges together and speed To bring tissue edges together and speed wound healing (=tissue apposition)wound healing (=tissue apposition)

• Orthopedic surgery to help stabilize jointsOrthopedic surgery to help stabilize joints– Repair ligamentsRepair ligaments

• Ligate vessels or tissuesLigate vessels or tissues

Characteristic of surgical Characteristic of surgical needleneedle

• It is rigid enough to prevent excessive It is rigid enough to prevent excessive bending bending

• Not flexible to prevent breaking after bendingNot flexible to prevent breaking after bending

• It strong enough so it dose not break easily It strong enough so it dose not break easily

• It is sharp enough to penetrate tissueIt is sharp enough to penetrate tissue

• It is approximately the same diameter as the It is approximately the same diameter as the suture material ; it carries to minimize truma in suture material ; it carries to minimize truma in passage though tissuepassage though tissue

• It is free of corrosion and rust to prevent infection It is free of corrosion and rust to prevent infection and tissue truamaand tissue truama

Basic components for Basic components for the needlethe needle

A.A.Points of needle:Points of needle: 1.1. Cutting points : it used to penetrate when tissue Cutting points : it used to penetrate when tissue

is difficult to be penetrated as skin and tendonis difficult to be penetrated as skin and tendon2.2. Reverse cuttingReverse cutting3.3. Taper point : these needles are used in soft tissue Taper point : these needles are used in soft tissue

such as intestine and peritoneum, the sharp point such as intestine and peritoneum, the sharp point at the tip of needieat the tip of needie

4.4. Blunt point : thses are using for suturing friable Blunt point : thses are using for suturing friable tissue such as liver and kidneytissue such as liver and kidney

Basic components for Basic components for the needlethe needle

B. Body of needle :B. Body of needle :1.1.StraightStraight 2. 2.curvedcurved

C. Eyed of needle:C. Eyed of needle:thethe eye is the segment of eye is the segment of needle where the suture strand is attached needle where the suture strand is attached

1.Eyed needle 1.Eyed needle : like of any household sewing needle : like of any household sewing needle

2. 2. Frensh eye needleFrensh eye needle: it has a slit from the inside if : it has a slit from the inside if the eye to the end of the needle through which the the eye to the end of the needle through which the suture is drawnsuture is drawn

3.3.Eyeless needle Eyeless needle : the suture strand the needle are : the suture strand the needle are one unitone unit

Points of NeedlesPoints of Needles

•CuttingCuttingCutting edge on Cutting edge on

inside of circleinside of circle

SkinSkinTraumaticTraumatic

Points of NeedlesPoints of Needles

•Reverse Reverse CuttingCutting

Cutting edge on Cutting edge on outside of circleoutside of circle

SkinSkinLess traumatic Less traumatic

than cuttingthan cutting

Points of NeedlePoints of Needle

• Taper pointTaper point

Cutting vs Reverse CuttingCutting vs Reverse Cutting

• CuttingCutting

• Reverse Reverse cuttingcutting

Shapes of NeedlesShapes of Needles

• 3/8 circle3/8 circle

• 1/2 circle1/2 circle

• StraightStraight

• SpecialtySpecialty

Needle Holder Needle Holder SelectionSelection1- Use an approximate size for the 1- Use an approximate size for the

given needle. The smaller the needle, given needle. The smaller the needle, the smaller the needle holder the smaller the needle holder requiredrequired

2- Needle should be grasped one-2- Needle should be grasped one-quarter to one half the distance from quarter to one half the distance from the swaged area the swaged area

3- The tip of the jaws of the needle 3- The tip of the jaws of the needle holder should meet before remaining holder should meet before remaining portion of the jaws portion of the jaws

Needle Holder Needle Holder SelectionSelection4- The needle should be placed 4- The needle should be placed

securely in the tips of the jaws securely in the tips of the jaws and should not rock, twist, or turnand should not rock, twist, or turn

5- Do not over close the needle 5- Do not over close the needle holder. It should close only to the holder. It should close only to the first or second ratchet. This will first or second ratchet. This will avoid damaging the needleavoid damaging the needle

6- Pass the needle holder so it is 6- Pass the needle holder so it is always directed by the operator always directed by the operator thumb thumb

Placement of Needle in Placement of Needle in TissueTissue

1- Force should always be applied 1- Force should always be applied in the direction that follows the in the direction that follows the curvature of the needlecurvature of the needle

2- Suturing should always be from 2- Suturing should always be from movable to a nonmovable tissuemovable to a nonmovable tissue

3- Avoid excessive tissue bites 3- Avoid excessive tissue bites with small needle as it will be with small needle as it will be difficult to retrieve themdifficult to retrieve them

Placement of Needle in Placement of Needle in TissueTissue4- Use only sharp needles with minimal 4- Use only sharp needles with minimal

force. Replace dull needlesforce. Replace dull needles

5- Never force the needle through the 5- Never force the needle through the tissuetissue

6- Grasp the needle in the body one-6- Grasp the needle in the body one-quarter to one-half of the length from the quarter to one-half of the length from the swaged area. Do not hold the swaged swaged area. Do not hold the swaged area; this may bend or break the needle. area; this may bend or break the needle. Do not grasp the point area as damage or Do not grasp the point area as damage or notching may resultnotching may result

Placement of Needle in Placement of Needle in TissueTissue7- Avoid retrieving the needle from 7- Avoid retrieving the needle from

the tissue by the tip. This will the tissue by the tip. This will damage or dull the needledamage or dull the needle

8- Suture should be placed in 8- Suture should be placed in keratinized tissue whenever keratinized tissue whenever possiblepossible

9- An adequate tissue bite is required 9- An adequate tissue bite is required to prevent the flap from tearing to prevent the flap from tearing

Characteristics of Suture Characteristics of Suture MaterialMaterial

• Absorbable Vs. NonabsorbableAbsorbable Vs. Nonabsorbable

• Monofilament Vs. MultifilamentMonofilament Vs. Multifilament

• Natural or SyntheticNatural or Synthetic

Absorbable SuturesAbsorbable Sutures

• InternalInternal

• Intradermal/ subcuticularIntradermal/ subcuticular

• Rarely on skinRarely on skin

Non-absorbable SutureNon-absorbable Suture

• Primarily SkinPrimarily Skin– Needs to be removed laterNeeds to be removed later

• Stainless steel = exceptionStainless steel = exception– Can be used internally Can be used internally

•LigatureLigature

•OrthopedicsOrthopedics

– Can be left in place for long periodsCan be left in place for long periods

Reading the Suture LabelReading the Suture Label

• CompanyCompany

Needle

SizeOrder Code

NameAlso:

LENGTH

NEEDLE SYMBOL

COLOR

Absorbable or Non

ChoosingChoosingAbsorbable Vs. NonabsorbableAbsorbable Vs. Nonabsorbable

• How long you need How long you need it to workit to work

• Do you want to see Do you want to see the animal again the animal again for suture removalfor suture removal

Monofilament Vs. MultifilamentMonofilament Vs. Multifilament

• memorymemory easy to handle easy to handle

• less tissue dragless tissue drag more tissue drag more tissue drag

• doesn’t wickdoesn’t wick wicks/ bacteria wicks/ bacteria

• poor knot securitypoor knot security good knot good knot securitysecurity

• - - tissue reactiontissue reaction ++tissue reactiontissue reaction

Natural Vs. SyntheticNatural Vs. Synthetic

•Natural:Natural:– GutGut– Chromic GutChromic Gut– SilkSilk– CollagenCollagen

• All are absorbableAll are absorbable

Gut/ Chromic GutGut/ Chromic Gut

• Made of submucosa Made of submucosa of small intestinesof small intestines

• MultifilamentMultifilament

• Breaks down by Breaks down by phagocytosis: phagocytosis: inflammatory inflammatory reaction commonreaction common

Gut/ Chromic GutGut/ Chromic Gut

• Chromic: tanned, lasts Chromic: tanned, lasts longer, less reactivelonger, less reactive

• Easy handlingEasy handling

• Plain: 3-5 days Plain: 3-5 days • Chromic: 10-15 daysChromic: 10-15 days

• Bacteria love this stuff!Bacteria love this stuff!

Collagen and SilkCollagen and Silk

• Natural suturesNatural sutures

• VERY reactive, VERY reactive, absorbableabsorbable

• Ophthalmic Ophthalmic surgery onlysurgery only

Vicryl (Polyglactin 910)Vicryl (Polyglactin 910)

• Braided, synthetic, absorbableBraided, synthetic, absorbable

• Stronger than gut: retains strength Stronger than gut: retains strength 3 3 weeksweeks

• Broken down by enzymes, not Broken down by enzymes, not phagocytosisphagocytosis

• Break-down products inhibit bacterial Break-down products inhibit bacterial growthgrowth– Can use in contaminated wounds, unlike Can use in contaminated wounds, unlike

other multifilamentsother multifilaments

Dexon and PGADexon and PGA

• Polymer of glycolic acidsPolymer of glycolic acids

• Braided, synthetic, absorbableBraided, synthetic, absorbable

• Broken down by enzymesBroken down by enzymes

• Both PGA and dexon have increased Both PGA and dexon have increased tissue drag, good knot securitytissue drag, good knot security

• Both are stronger than gutBoth are stronger than gut

PDS (polydioxine)PDS (polydioxine)

• Monofilament (less drag, worse knot Monofilament (less drag, worse knot security – lots of “memory”)security – lots of “memory”)

• Synthetic, absorbableSynthetic, absorbable

• Very good tensile strength (better Very good tensile strength (better than gut, vicryl, dexon) which than gut, vicryl, dexon) which lasts lasts monthsmonths

• Absorbed completely by Absorbed completely by 182 days182 days

MMaxon (polyglyconate)axon (polyglyconate)

• MMonofilament- onofilament- mmemoryemory

• Synthetic AbsorbableSynthetic Absorbable

• Very little tissue dragVery little tissue drag

• Poor knot securityPoor knot security

• Very strongVery strong

NONABSORBABLE SUTURESNONABSORBABLE SUTURES

• Natural or SyntheticNatural or Synthetic

• Monofilament or multifilamentMonofilament or multifilament

                           

NYLONNYLON

• SyntheticSynthetic

• Mono or MultifilamentMono or Multifilament

• MemoryMemory

• Very little tissue reactionVery little tissue reaction

• Poor knot securityPoor knot security

Polymerized CaprolactumPolymerized Caprolactum

• Vetafil, Braunamid, SupramidVetafil, Braunamid, Supramid

• Multifilament suture with protein coatingMultifilament suture with protein coating

• SyntheticSynthetic

• Good knot security, easy handlingGood knot security, easy handling

• Not very reactiveNot very reactive

• Don’t use in contaminated woundDon’t use in contaminated wound

• Usually comes on a reelUsually comes on a reel

PolypropylenePolypropylene

• Prolene, SurgileneProlene, Surgilene

• Monofilament, SyntheticMonofilament, Synthetic

• Won’t lose tensile strength over timeWon’t lose tensile strength over time

• Good knot securityGood knot security

• Very little tissue reactionVery little tissue reaction

Stainless SteelStainless Steel

• Monofilament Monofilament

• Strongest !Strongest !

• Great knot securityGreat knot security

• Difficult handlingDifficult handling

• Can cut through tissuesCan cut through tissues

• Very little tissue reaction, won’t Very little tissue reaction, won’t harbor bacteriaharbor bacteria

Suture SizesSuture Sizes

• Sized #5-4-3-2-1-0-00-000-0000…30-0Sized #5-4-3-2-1-0-00-000-0000…30-0– BIGGER >>>>>>>>>>>>>>>>SMALLERBIGGER >>>>>>>>>>>>>>>>SMALLER

• 00 = 2-0, “two ought”00 = 2-0, “two ought”

• SA : 0 through 3-0 (Optho 5-0 >>7-0)SA : 0 through 3-0 (Optho 5-0 >>7-0)

• LA : 0 through 3LA : 0 through 3

Suture Sizes (cont)Suture Sizes (cont)

• Stainless Steel Stainless Steel – In gauges (like needles)In gauges (like needles)

•Smaller gauge = bigger, strongerSmaller gauge = bigger, stronger

•Larger gauge= smaller, finerLarger gauge= smaller, finer

– 26 gauge = “ought”26 gauge = “ought”– 28 gauge = 2-028 gauge = 2-0

Skin StaplesSkin Staples

• Very common in human medicineVery common in human medicine

• ExpensiveExpensive

• Very easyVery easy

• Very secureVery secure

• Very little tissue reactionVery little tissue reaction

• Removal = Removal = – Special tool requiredSpecial tool required

Tissue AdhesiveTissue Adhesive

• Nexaband, Vetbond, Nexaband, Vetbond, and othersand others

• Little strengthLittle strength

• Should not be Should not be placed between placed between skin layers or inside skin layers or inside bodybody

Suture PatternsSuture Patterns

Knot StrengthKnot Strength

• Generally 4 “throws” for >90% knot Generally 4 “throws” for >90% knot security (nylon may need 5)security (nylon may need 5)– Less “throws” = more likely to untie Less “throws” = more likely to untie

itselfitself

• Stainless steel = exception againStainless steel = exception again– 2 “throws” = 99% knot security2 “throws” = 99% knot security

Common suturing techniquesCommon suturing techniques Simple InterruptedSimple Interrupted

Simple Interrupted Suture

Simple ContinuousSimple Continuous

Ford InterlockingFord Interlocking

SubcuticularSubcuticular

KnotsKnots

• A suture knot has three components A suture knot has three components

1- The 1- The loop loop created by the knotcreated by the knot

2- The 2- The knotknot itself, which is composed itself, which is composed of a number of tight “throws”, each of a number of tight “throws”, each throw represents a weave of the two throw represents a weave of the two standsstands

3- The 3- The earsears, which are the cut ends , which are the cut ends of the suture of the suture

Principles of SuturingPrinciples of Suturing

1- The completed knot must be tight, 1- The completed knot must be tight, firm, and tied so that slippage will not firm, and tied so that slippage will not occuroccur

2- To ovoid wicking of bacteria, knot 2- To ovoid wicking of bacteria, knot should not be placed in incision linesshould not be placed in incision lines

3- Knots should be small and the ends 3- Knots should be small and the ends cut short (2-3mm)cut short (2-3mm)

4- Avoid excessive tension to finer gauge 4- Avoid excessive tension to finer gauge materials as breakage may occurmaterials as breakage may occur

Principles of SuturingPrinciples of Suturing

5- Avoid using a jerking motion, which 5- Avoid using a jerking motion, which may break the suturemay break the suture

6- Avoid crushing or crimping of 6- Avoid crushing or crimping of suture materials by not using suture materials by not using hemostats or needle holders on hemostats or needle holders on them except on the free end for them except on the free end for tyingtying

7- Do not tie suture too tightly as 7- Do not tie suture too tightly as tissue necrosis may occur. Knot tissue necrosis may occur. Knot tension should not produce tissue tension should not produce tissue blanching blanching

Principles of SuturingPrinciples of Suturing

8- Maintain adequate traction on 8- Maintain adequate traction on one end while tying to ovoid one end while tying to ovoid loosing the first looploosing the first loop

Principles for Suture Principles for Suture RemovalRemoval

1- The area should be swabbed with 1- The area should be swabbed with hydrogen peroxide for removal of hydrogen peroxide for removal of encrusted necrotic debris, blood, encrusted necrotic debris, blood, and serum from about the suturesand serum from about the sutures

2- A sharp suture scissors should 2- A sharp suture scissors should be used to cut the loops of be used to cut the loops of individual or continuous sutures individual or continuous sutures about the teethabout the teeth

Principles for Suture Principles for Suture RemovalRemoval3- It is often helpful to use a No. 23 3- It is often helpful to use a No. 23

explorer to help lift the sutures if explorer to help lift the sutures if they are within the sulcus or in they are within the sulcus or in close opposition to the tissue close opposition to the tissue

4- A cotton pliers is used to remove 4- A cotton pliers is used to remove the suture. The location of the the suture. The location of the knots should be noted so that knots should be noted so that they can be removed first. This they can be removed first. This will prevent unnecessary will prevent unnecessary entrapment under the flap entrapment under the flap

Suture should be removed in 7 to Suture should be removed in 7 to 10 days to prevent 10 days to prevent epithelialization or wicking epithelialization or wicking about the suture about the suture