Surgical sutures and ligatures pdf

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surgical sutures and ligatures pdf

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Surgeons must select the optimal suture materials for tissue approximation to maximize wound healing and scar aesthetics.

Sutures are used by your doctor to close wounds to your skin or other tissues. There are a variety of available materials that can be used for suturing. This is because enzymes found in the tissues of your body naturally digest them. Nonabsorbable sutures will need to be removed by your doctor at a later date or in some cases left in permanently. Second, the suture material can be classified according to the actual structure of the material.

Everything You Need to Know About Surgical Sutures

Surgeons must select the optimal suture materials for tissue approximation to maximize wound healing and scar aesthetics. Thus, knowledge regarding their characteristics is crucial to minimize ischaemia, excess wound tension, and tissue injury.

This article describes the selection of various suture materials available today and their intended design. Modern suture material should have predictable tensile strength, good handling, secure knot-tying properties, and could be enhanced with an antibacterial agent to resist infection. Tensile strength is limited by suture size. The smallest suture size that will accomplish the purpose should be chosen to minimize tissue trauma and foreign material within tissues. Monofilament suture has lower resistance when passed through tissues, whereas multifilament sutures possesses higher tensile strength and flexibility but greater tissue friction and pose risks of suture sinus and infection.

Natural absorbable sutures derived from mammalian collagen undergo enzymatic degradation whereas synthetic polymers undergo hydrolysis. Collagen or polymer structures in the suture can be modified to control absorption time.

In contrast, nonabsorbable sutures typically cause an inflammatory reaction that eventually encapsulates by fibrous tissue formation.

Excess reaction leads to chronic inflammation, suboptimal scarring, or suture extrusion. More recently, barbed sutures have transformed the way surgeons approximate wounds by eliminating knots, distributing wound tension, and increasing efficiency of closure. Similarly, modern skin adhesives function both as wound closure devices as well as an occlusive dressing.

They eliminate the need for skin sutures, thus improving scar aesthetics while sealing the wound from the external environment. Many adaptations over time have led to the highly sophisticated products we use in our practice today. Surgeons approximate tissue daily, but often their choice of suture and needle are based on what they learned in training or through negative events during their careers.

The surgeon must be well informed regarding the characteristics of their suture choice and select a suitable material that will minimize dead space and risk of microbial invasion while maximizing precise wound approximation and, ultimately, optimizing scar aesthetics.

What suture or suture combinations to utilize in any particular surgical case varies greatly among surgeons. Thus, knowledge regarding the multiple available options gives direction and enables surgeons to develop their own predilections. The purpose of this article is to familiarize the reader with the general characteristics of sutures, along with the accompanying article on the characteristics of needles, so that operative choices are better understood in the greater scheme of the science of tissue coaptation.

The favorable characteristics of a suture are well documented and include possessing the greatest predictable tensile strength consistent with size limitations, good handling properties, and secure knot tying. Table 1 provides size comparison based on USP denotation, metric gauge, and diameter. An example of an extremely fine suture for ophthalmic and microsurgery such as USP size has a metric gauge size of 0. The purpose of sutures in general is to approximate tissues, without excess tension, while minimizing ischaemia and tissue injury.

As wound healing progresses, the wound strength increases over weeks or months until it approximates the original tensile strength of the tissue. Whether wound closure is single or multilayered, the smallest size or diameter of suture that will accomplish the purpose at hand should be chosen, thus minimizing both tissue trauma with each passage of the needle and the amount of foreign material left behind.

Smaller-diameter sutures are, however, associated with less tensile strength, and a balance must be struck between size of suture and maintainance of tissue reapproximation.

Whether a suture has a single or multiple strand composition is an important consideration, especially when weighing its potential for harboring bacteria against the need for greater tensile strength.

Monofilament sutures pose lower resistance on tissue passage, are less likely to accommodate organisms, and tend to snug down more readily. On the other hand, they must be handled carefully, because when crushed by certain instruments, they can weaken or break. They are favored in vascular and microvascular surgery where ease of tying down sutures is crucial. When several strands are braided together forming the multifilament suture, greater tensile strength, flexibility, and pliability is offered.

In recent years, coating the suture has assisted its passage through tissue and decreased potential for infection, making multifilament suture the choice for many intestinal surgeries. Multifilament sutures, when used on the subcutaneous or intradermal level, tend to be extruded in the form of a suture sinus or small localized abscess, compared with a monofilament, which behaves in a cleaner, less reactive manner.

The manner by which a suture degrades influences the material choice for internal use in deeper layers and for skin approximation. Absorbable sutures are typically made from either mammalian collagen, which is ultimately digested by body enzymes, or synthetic polymers that undergo hydrolysis. Maintaining the balance between rapid absorption and the prolongation of tensile strength has been aided by treatments and chemical structuring, which lengthen absorption time.

Typically, when a wound is closed with absorbable suture, the decrease in tensile strength over the first weeks is in a gradual, linear fashion. During this period, a leukocyte cellular response is mounted to remove cell debris and physical suture material, and this process overlaps with the second stage where the majority of suture mass is lost.

Either of these phases can be affected by infection and protein deficiency, where tensile strength is lost too quickly, and wound dehiscence is manifested clinically.

Hydrolysis produces a lesser degree of tissue reaction compared with the enzymatic degradation process. In contrast, the in vivo tissue response around nondegradable material involves fibroblasts that encapsulate the suture by fibrous capsule formation. Adjacent macrophages and foreign body giant cells respond in a process known as frustrated phagocytosis, where they attempt to enzymatically degrade the nondegradable suture.

For example, nonabsorbable Nylon sutures are commonly used to approximate skin edges on the face where aesthetic outcome is crucial. These are removed early to avoid tissue inflammation and unwanted tissue response around the suture material, which would leave undesirable track marks. In contrast, nonabsorbable Prolene sutures can be used for optimal mesh fixation in hernia repair.

They are left permanently in situ, where they remain encapsulated by fibrous tissue together with the mesh. When enhanced mechanical strength is required such as in the closure of sternotomy, steel wires are used to achieve bony union. The naturally occurring types of surgical gut are formed from processed strands of highly purified collagen, which dictates not only the tensile strength but also its degradability.

A higher percentage of pure collagen along the strand equates to less foreign material in the wound. This eliminates variations known as high and low spots, which contribute to frays and breakages in the suture knot that is malpositioned or unsecurely tied down.

Plain surgical gut is a rapidly absorbed suture, generally used for closing the epidermis, ligating superficial blood vessels, and suturing subcutaneous tissue. The tensile strength is maintained for 7 to 10 days and absorption is complete by 70 days. When heat treated, the filaments are absorbed at a more rapid pace and they lose tensile strength compared with their nontreated counterparts.

Clinically, it can be placed in the mucosa of the lip and eye and as an external suture for rhinoplasty closure where minimal tensile strength is required. The collagen filaments are bathed in buffered chrome tanning solution salt before formation into its strands. This process turns the suture yellowish tan to brown. Tensile strength remains for 10 to 14 days, with residual measurable strength present for 3 weeks and absorption time prolonged to over 90 days. The main advantage over plain gut is less tissue reaction.

One of the most frequently used sutures amongst plastic surgeons is an absorbable suture that holds its tensile strength for a predictable period of time and shows lower tissue reaction than surgical gut. The original introduction to the market of one such suture in was Vicryl , a braided, naturally absorbing pliable suture, which was later modified in to improve smoother tissue passage and handling and ensure more secure knot tying Coated Vicryl.

The raw material of this braided suture is a copolymer of lactide and glycolide coated with polyglactin and calcium sterate. In , a broad-spectrum antibacterial agent, triclosan, was added.

It is ideally used for short-term wound support of superficial soft tissue mucosa and skin. The actual absorption is insignificant until 3 months and is essentially complete by 6 months.

Because of its minimal tissue reaction, it is also favored in pediatric, cardiovascular, and ophthalmic surgeries. A synthetic suture specifically for skin closure, Monocryl Poliglecaprone 25 , was introduced in and is formed of a copolymer of glycolide and epsilon-caprolactone.

Dyed and antibacterial versions have a similar profile. Nonabsorbable sutures are useful for their superior handling characteristics. Raw silk is produced through a process whereby a continuous filament is spun by the silkworm. The silk filaments were processed to become a tightly braided, dyed suture coated with waxes or silicone. Although silk suture is classified as a nonabsorbable suture in the USP, in the materials literature it is considered a degradable material by material scientists.

Silk biodegradation is mediated by foreign body tissue response. Slow but progressive enzymatic degradation of the fibers will result in gradual loss of tensile strength. Surgical stainless steel is used in its L low-carbon alloy formula and may be braided into multifilaments. It is most typically encountered by the plastic surgeon reconstructing a sternal wound or in hand fracture fixation.

It affords indefinite tensile strength and flexibility and lacks toxic elements, but sensitivity to chromium and nickel may occur in susceptible patients. Wires can be associated with difficult handling, fragmentation, or kinking, which can result in fatigue.

There is a risk of tearing tissue and puncturing skin, thus posing risk of virus transmission and the possibility of unfavorable electrolytic reactions. Nylons were introduced to the market by the DuPont Company in the late s with Nylon 66, the first true synthetic fiber. Sutures are produced from the long-chain aliphatic polymers Nylon 6 and Nylon 6. They lend themselves to a broad range of applications in surgery including skin approximation, vessel ligation, and microsurgery. With the introduction of fine needles and sutures to , the scope for microscopic surgery has greatly expanded in all specialties.

For plastic surgeons, it is frequently utilized for anastomosis, neurorhaphy, and oculoplastic surgeries. Nylon monofilament suture eg, Ethilon possesses the characteristics of high tensile strength and extremely low reactivity.

In the s, Mersons Manufacturing Company produced the first synthetic braided suture preattached to the butt of the needle, which was shown to remain indefinitely in the body. Mersilene polyethylene terephthalate is uncoated and thus has a higher coefficient of friction with passage through tissue, but provides consistent suture tension, and minimal breakage.

Many orthopedic surgeons prefer to use coated polyethylene terephthalate suture Ethibond Excel , a nonabsorbable braided suture for ligament or tendon repair. It is coated with polybutylate, thus enabling easy passage of the fibers through tissue and smooth knot tying. Being inert, it elicits minimal reaction and its tensile strength is not known to significantly change with time. This can lead to problems arising years after surgery.

Prolene, a widely utilized nonabsorbable synthetic monofilament, is an isostatic crystalline stereoisomer of polypropylene. It tends not to lose tensile strength through degradation and can be used on skin to diminish reactivity or, in a contaminated field, to minimize delayed sinus formation and extrusion. Prolene is commonly utilized as a pull-through suture in facial lacerations and trauma, where aesthetics are paramount and track marks must be avoided. A less familiar monofilament suture, which is relatively resistant to infection and contamination, is Pronova Poly hexafluoropropylene-VDF.

It is a polymer blend of poly vinylidene fluoride and poly vinylidene fluoride-co-hexafluoropropylene and is employed in ligation and wound closure, where it resists adherence to adjacent tissues in cardiovascular, ophthalmic, and neurosurgical procedures. Barbed sutures, first designed by John Alcamo in , were granted a US patent in The first FDA-approved barbed suture was not available until Subsequently, barbed absorbable polydioxanone suture was produced for wound closure Quill Medical.

Needles, Sutures, and Instruments

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Copy embed code:. Automatically changes to Flash or non-Flash embed. WordPress Embed Customize Embed. URL: Copy. Presentation Description aimst. Through the ages, practitioners have used a wide range of materials and techniques for closing tissue…….. It was then decapitated and the ant's death grip kept the wound closed PowerPoint Presentation: Thorns The thorn, used by African tribes to close tissue, was passed through the skin on either side of the wound.

A surgical suture is a strand Thread used to constrict and or fiber used to hold the seal off the blood vessel, vein edges of various tissues e. Sutures were made of plant materials flax, hemp and cotton or animal material hair, tendons, arteries, muscle strips and nerves, silk, catgut. African cultures used thorns, and others used ant sutures by coaxing insects to bite wound edges with their jaws and subsequently twisting off the insects' heads 3. Earliest reports of surgical suture from ancient Egypt The oldest known suture is found in a mummy A detailed description of a wound suture and the suture materials used by Sushruta. The manufacturing process involved harvesting 10th century sheep intestines developed AD.


For a number of years I have had it in mind to call attention to the particular method of employing silk ligatures and sutures which has been practiced in the surgical clinic of the Johns Hopkins University since the opening of the Johns Hopkins Hospital in , but have hesitated and also been eager to do so for the same reason, namely, that our school seems to be almost alone in its advocacy of the use of this material. Theodor Kocher, however, has for many years employed silk quite to the exclusion of catgut and our position is greatly strengthened by the support of such eminent authority. Surgeons, old and young, those who have been active and masterful in the marvelous period of development of antiseptic surgery, and the medical student who takes for granted the healing of wounds per primam and the achievements of modern surgery as he does. Halsted WS. Arch Surg.

Application November 9, Serial No. The term sutures as used hereinafter in the description of the invention is meant to include both sutures and ligatures. Surgical catgut sutures are composed mainly of collagen which has the property of shrinking or contracting when heated in the presence of water. A catgut suture which has undergone substantial shrinkage or contraction has markedly diminished tensile strength, is irregular in diameter, and consequently has little or no value for use in suturing or ligating. It is because of the property of collagen, of shrinking or contracting when heated in the presence of water, that heat sterilization of surgical catgut strands to be tubed with an aqueous alcohol tubing fluid, as heretofore and currently practiced, entails a complicated procedure involving the dehydration under stringently controlled conditions before the application of heat of sufficient intensity to kill all microorganisms in vegetative or spore form.

US2832664A - Sterilization of surgical catgut sutures and ligatures - Google Patents

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