DR. SIDHARTH YADAVDEPT. OF ORTHOPAEDICSNKPSIMS

HISTORY 50,000-30,000 B.C eyed needle were invented.

East african tribes ligated blood vessels with tendon & closed wound with strips of vegetation wounds round the protruding ends in figure of 8.

South american used large black ants for wound closure.

Egyptian literature of around 1600 B.C mentions use of linen strips.

Albucasis A.D 936 first described a double suture.

Ambrose Pare described method of dry suturing for wounds

on face.

A Suture is a stitch to approximate tissues or structures till normal process of healing is complete.

A ligature is a suture used to encircle a blood vessel to control bleeding.

CLASSIFICATION

MONOFILAMENT MULTIFILAMENT

SYNTHETIC BIOLOGICAL

ABSORBABLE NONABSORBABLE

ABSORBABLE SUTURES

• NATURAL 1. Surgical Gut

- Plain Gut - Chromic Gut

2. Collagen

3. Living tissue - Fascia lata - Kangaroo tendon

- Cargil tendon.

ABSORBABLE SUTURES

SYNTHETIC - Polyglycocolic acid (PGA)

- Polygalactin 910 (vicryl)

- Polydioxanone (PDS)

- Polyglyconate (MAXONE)

NON ABSORBABLE

NATURAL - Cotton - Linen - Silk - Silk worm gut

SYNTHETIC - Polyamides - Polyesters - Polyoletins

NON ABSORBABLE

METALLIC WIRE

ADHESIVE TAPE CLOSURE

PROPERTIES OF SUTURE TENSILE STRENGTH The tensile strength of a material is determined by

the weight required to break a suture divided by its cross-sectional area.

Implantation and tying of a suture decreases its strength.

Dry, unused absorbable suture loses 4-13% of its initial strength after being soaked in sodium chloride

Knotted sutures have two-thirds the strength of unknotted sutures.

Tensile strength of a suture should not exceed that of the tissue.

KNOTS

The knot is the weakest portion of the suture.

Its strength is defined by the force necessary to cause slippage.

Takes at least three throws when polyglactin 910, polyglycolic acid, surgical gut, or polypropylene suture material is used but at least four throws when polydioxanone or nylon is used.

PLASTICITY & ELASTICITY

Plasticity is the ability of the suture to retain its new form and length after stretching.

Plasticity allows a suture to accommodate wound swelling, thereby decreasing the risk of strangulated tissue and crosshatch marks.

Elasticity is the ability of a suture to regain its original form and length after stretching. After the swelling of a wound recedes, the suture returns to its original length and keeps the wound well approximated.

Memory is the ability of a suture to return to its original shape after deformation by tying

HANDLING Handling characteristics of suture materials are

defined by pliability and coefficient of friction.

Pliability refers to the ease with which a suture can be bent.

The coefficient of friction is a measure of the

slipperiness of the suture.

Sutures with a high coefficient of friction, generally multifilament sutures, are more difficult to pass through tissue, thereby causing a greater degree of tissue injury during placement and removal.

TISSUE REACTION Different suture materials produce varying

degrees of tissue reaction.

Natural materials are absorbed by proteolysis, which causes a prominent inflammatory response, while synthetic materials are absorbed by hydrolysis, which produces a minimal reaction.

Multifilamentous sutures have a high degree of capillarity, which is correlated with a tendency toabsorb and retain both fluid and bacteria

PRINCIPLE OF SUTURE SELECTION

RATE OF TISSUE HEALING When a wound has reached its maximal

strength sutures are no longer needed.

Tissue that heals slowly such as skin , fascia & tendon should be closed with non absorbable sutures e.g. ethilone etc.

Tissue that heals rapidly such as liver , peritoneum may be closed with absorbable sutures e.g. vicryl etc.

TISSUE CONTAMINATION

Avoid multifilament sutures as bacteria can linger with them & can infect wound.

Use monofilament or nonabsorbable sutures in contaminated wound.

Monofilament polypropylene is ideal.

COSMETIC RESULTS

Close & prolonged apposition of wound.

Avoidance of irritants.

Close subcuticularly where ever possible.

Use smallest suture material.

NUTRITIONAL STATUS

When a patient is undernourished & hypoproteinemic non absorbable sutures should be used as long period of approximation is required.

Absorbable sutures will lead to wound dehiscence.

SUTURE SELECTION

Sutures hold tissue together until the natural process of wound healing has taken place.

All sutures are foreign bodies and impact on wound healing.

Absorbable sutures elicit more inflammatory reaction than non-absorbable sutures.

SUTURE SELECTION

Natural sutures absorbed by proteolytic enzymes induce more inflammation than synthetic ones absorbed by hydrolysis.

Monofilaments require more knots to prevent slippage.

Braided sutures handle easily and knot easily.

Braided suture may harbor bacteria.

SUTURE SELECTION

Use the smallest size suture that can hold the tissue together during the healing process.

Fascia heals slowly - use bigger, stronger suture.

Mucosa heals quickly, use smaller suture.

MonofilamentMonofilament Multifilament (braided)Multifilament (braided)Single strand of suture

materialMinimal tissue traumaSmooth tying but more

knots neededHarder to handle due

to memoryExamples: nylon,

monocryl, prolene, PDS.

Fibers are braided or twisted together

More tissue resistance Easier to handle Fewer knots needed Examples: vicryl, silk,

chromic gut.

ABSORBABLE SUTUREGUT

Prepared from submucosa of :-(submucosa)(subserosa)Types : - Plain - Chromic cat gut.

Both types consist of processed strands of highly purified collagen.

The percentage of collagen in the suture determines its tensile strength and its ability to be absorbed by the body without adverse reaction.

;

- sheep - Lamb- oxen

PLAIN CATGUT Tensile strength is maintained for only 7 to 10

days.

Absorption is complete within 70 days.

Reaction increases with increasing size of catgut.

Used for :- ligating bleeders -suturing subcutaneous tissue. - suturing skin & mucosa in circumcision - suturing mucosa of genito urinary

tract.

CHROMIC CATGUT

Treated with a chromium salt solution to resist body enzymes, prolonging absorption time over 90 days.

Treatment with chromic acid (20%) increases the durability & tensile strength.

Uses :- suturing muscles - fascia -GIT - Liver etc.

POLYGLYCOLIC ACIDNon protein synthetic material which is

absorbable.

Removed by enzymes – ESTERASES

Has advantage of :- -Minimum tissue reaction -Minimum tissue oedema.

Knot holding property is better than chromic catgut as it is not subjected to :-

-Fraying -Breaking -Swelling -Slipping

VICRYL Fastest-absorbing synthetic suture.

Lower tissue reaction than chromic gut suture.

Retain approximately 50% of the original tensile strength at 5 days post implantation.

All of the original tensile strength is lost by approximately 10 to 14 days.

Absorption by 42 days.

LINEN & COTTON

Prepared from cotton.

Have low tensile strength.

Greater chances of infection because of fluid absorption.

SILK Naturally occuring fibre.

Very slow absorbing suture.

Second only to gut for tissue inflammation.

Weaker when wet.

Silk filaments can be twisted or braided, providing the best handling qualities

ETHILONE

High tensile strength and extremely low tissue reactivity.

Degrade by hydrolysis.

Monofilament nylon sutures have a tendency to return to their original straight extruded state (a property known as "memory").

SURGICAL NEEDLE

NEEDLES

Needle Shapes

•Eye•Microsurgery

•Dura•Eye•Fascia•Nerve

•Muscle•Eye•Skin•Peritoneum

•Cardiovascular•Oral•Pelvis•Urogenital tract

•Nasal cavity•Nerve•Skin•Tendon

•Eye (Anterior segment)

•Laparoscopy

Closure Types

Primary closure (primary intention)-Wound edges are brought together so that they

are adjacent to each other (re-approximated).

Secondary closure (secondary intention) Wound is left open and closes naturally

(granulation)

Tertiary closure (delayed primary closure) Wound is left open for a number of days and

then closed if it is found to be clean.

THANK YOU...