Basic Surgical Skills

Sutures & Needles

- Dr. Utham Murali. M.S ; M.B.A. Prof. of Surgery

Definition

The term “Suture” describes any strand of material utilized to

approximate tissues.

Suturing refers to sewing together two structure using suture threaded

on a needle.

Ligating or ligaturing refers to tying a ductal structure such as blood

vessel simply by means of a suture thread.

History

The origins of surgery can be traced back many centuries. Through the ages,

practitioners have used a wide range of materials and techniques for closing

tissue……..

They also used adhesive linen strips, similar to modern-day Steristrips.

By 1000 BC, Indian surgeons were using horsehair, cotton and leather sutures.

In Roman times, linen and silk and metal clips called “fibulae” were commonly

used to close gladiatorial wounds.

By the end of the nineteenth century, developments in the textile industry led to

major advances, and both silk and catgut became popular as suture materials.

Suturing – Goals

Provide adequate tension for wound closure but loose enough to prevent tissue

ischaemia & necrosis.

Protecting underlying tissues from infection or other irritating factors.

Preventing post-operative haemorrhage.

Permitting healing by primary intention.

Preventing bone exposure resulting in delayed healing & bone resorbption.

Permit proper flap position.

Ideal Suture – Qualities

Minimal tissue reaction

Smoothness - minimum tissue drag

Easily Sterilisable

Adequate tensile strength

Ease of handling - Minimum memory

Knot security

Cost effectiveness

Favourable absorption profile

Resistance to infection

Basic Definitions

Suture is a material used to approximate living tissues or sutures together.

Ligature is a suture used to encircle a blood vessel to arrest or control bleeding.

Tensile strength is the ability of the material or tissues to resist deformation or breakage.

Elasticity is the ability of the material to regain its original form or length after deformation.

Pliability is the ability to adjust knot tension & to secure knot.

Memory is the inherent capability of suture to return or maintain its original gross shape.

Suture material – Types

Behavior – Tissue : Absorbable / Non-absorbable

Structure : Monofilament / Multifilament

Origin : Natural / Synthetic

Suture material

Absorbable

Catgut

Chromic Catgut

Dexon (Polyglycolic acid)

Vicryl (Polyglacitin)

PDS (Polydioxanone)

Collagen

Maxon (Polyglyconate)

Monocryl (Polyglycaprone)

Non - Absorbable

Silk, Linen. Cotton

Horse / Human hair

Nylon or Ethilon

Polyester (Mersilene / Ethibond)

Polypropylene (Prolene)

Stainless steel, Aluminium Wire

Clips

Staples, Skin tapes, adhesives

Absorbable – Natural

Plain catgut : Light. Derived from submucosa of sheep intestine or

serosa of beef intestine.

* Used for ligating superficial blood vessels & subcutaneous fatty

tissues.

Chromic catgut : Yellow. Treated with chromium salt.

* It may be used in the presence of infection & in cancer cases.

Absorbable – Synthetic

Polyglactin (Vicryl) : purple, copolymer of Lactide & Glycolide.

* Minimal tissue reaction. Used in general soft tissue approx ; Intestinal

anastomosis, Vessels ligation in all surgical specialties.

Dexon (Polyglyconic acid) : purple/cream, homo polymers of glycolide.

* Avoid in adipose tissue & losses tensile strength more rapidly than vicryl.

Others:e.g; Polyglyconate(maxon), Polydiaxone(PDS), Polyglecaprone(monocryl)

Non – Absorbable – Natural

Surgical silk: Black. Derived from the cocoon of the silk worm larvae, trigger

inflammatory reactions, undergo proteolysis & undetected by 2yrs.

* Used in ligating major blood vessels, tendon repair etc.

Surgical steel & wires : High tensile strength & Hold knots very well

* Used in orthopaedic, Neurosurg & Thoracic surgery

Others: e.g; Virgin silk, cotton, linen

Non – Absorbable – Synthetic

Nylon : Is a polyamide polymer, Blue / White

* 81% tensile strength at 1yr & 66% at 11yrs

* Elicits minimal tissue reaction

* Has good memory

* Pliable when moist

* Premoistened form is used in cosmetic plastic surgery

* Its elasticity makes it useful for skin closure & Herniorrhapy

Others : e.g; Polypropylene (Prolene), Polyester fiber (Mersilene/Dacron/Ethibond)

Monofilament

Grossly appears as single strand of suture material; all fibers run parallel

Minimal tissue trauma. Resists harboring microorganisms

Ties smoothly

Requires more knots than multifilament suture

Possesses memory

Examples:

* Monocryl

* PDS, Prolene

* Nylon

Multifilament

Fibers are twisted or braided together

Greater resistance in tissue

Provides good handling and ease off tying

Fewer knots required

Examples:

* Vicryl (braided)

* Chromic (twisted)

* Silk (braided)

Suture Degradation

Suture Material Method of Absorption Time to Absorb

Catgut Proteolytic enzymaticdigestive process.

Days

Vicryl Hydrolysis. Weeks

PDS Slow Hydrolysis. Months

Silk / Nylon Gradual encapsulationby fibrous connectivetissue.

Years

Suture Size

Sized according to diameter with “0” as reference size

Numbers alone indicate

progressively larger sutures (“1”,“2”, etc.)

Numbers followed by a “0” indicate progressively

smaller sutures (“2-0”, “4-0”, etc.)

Smaller < --------------------------> Larger

.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

[Thick] [Thin]

Needle – Anatomy

Needle point - Geometry

Taper-Point (Round)

•Suited to soft tissue•Dilates rather than cuts

Reverse cutting•Very sharp•Ideal for skin•Cuts rather than dilates

Conventional Cutting

•Very sharp•Cuts rather than dilates•Creates weakness allowing suture tearout

Taper-cutting•Ideal in tough or calcified tissues•Mainly used in Cardiac & Vascular procedures.

Needle Shapes

EyeMicrosurgery

DuraEyeFasciaNerve

MuscleEyeSkinPeritoneum

CardiovascularOralPelvisUrogenital tract

Nasal cavityNerveSkinTendon

Eye (Anterior segment)

Laparoscopy

Ideal Suture – Needle

High quality stainless steel

Smallest diameter possible

Stable in the grasp of needle holder

Sharp enough to penetrate tissues with minimal resistance & trauma

Sterile & corrosive resistant

Use of Needle Holders

Loading Needle

Needle passing

through skin

Technique

Needle should be grasped with the needle holder approx. 1/3 distance from the

eye & 2/3 from the point.

Needle should be placed perpendicular to surface being entered & pushed

through tissues following curvature of the needle & rotating the wrist.

Needle enters 2-3mm away from the margin of the flap & exists at the same

distance on the opposite side.

The two ends of the suture are then tied in a knot & cut 0.8cm above the knot.

Knot should never lie on incision line.

Never close under tension.

The Suture Packaging

STRAND SIZE

MATERIAL

STRAND LENGTH

PRODUCT CODE

NEEDLE CODE WITH LIFE

SIZE PICTURE OF NEEDLE

NEEDLE LENGTHCOLOUR

POINT TYPENEEDLE CIRCLE

Suture Techniques

Simple sutures

Mattress sutures

Subcuticular sutures

Simple – Interrupted

Suturing is passed through both edges

at an equal depth & distance from the

incision & knot is tied.

Common & Stronger.

Each suture is independent & loosening

of one suture will not produce loosening

of other.

Simple – Continuous

Useful in pediatrics

Rapid

Easy removal

Provides effective hemostasis

Distributed tension evenly along length

Can also be locked with each stitch

Mattress – Vertical

It has a far – far- near – near order of

bites.

The knot is perpendicular to the wound

edge.

Useful in maximising wound eversion ,

reducing dead space and minimising the

tension across the wound.

Mattress – Horizontal

Used for high – tension wounds or

wounds with fragile skin.

The knot is parallel adjacent to the

wound edge.

Useful in maximising wound eversion ,

reducing dead space and minimising the

tension across the wound.

Suture removal

Face: 2- 3 days

Scalp: 5 days

Trunk: 7 days

Arm or leg: 7-10 days

Foot: 10-14 days

Recent Advances

Staples Adhesives Tapes - Steristrips Formed from high quality A sterile, liquid topical skin adhesive Use of tissue

adhesive adjunct

stainless steel Reacts with moisture on skin surface (benzoin)

to form a strong, flexible bond

Suitable for skin closure Only for approx. skin edges of wounds Rarely used for primary closure

Surgical Knots

Square or Reef knot

Square knot formed by wrapping the suture

around the needle holder once in opposite

directions b/w ties.

3 ties are recommended.

The two-hand square knot is the easiest and

most reliable for tying most suture materials.

It may be used to tie surgical gut, virgin silk,

surgical cotton and surgical stainless steel.

Surgeon’s or Friction knot

It is formed by 2 throws of suture around the

needle holder on the first tie & one throw in

the opposite direction on the 2nd tie.

The surgeon's or friction knot is

recommended for tying braided synthetic

absorbable suture, VICRYL*/ ETHIBOND*

polyester suture, ETHILON* nylon suture,

MERSILENE* polyester fiber suture,

NUROLON* nylon.

Granny’s or Slip knot

Granny’s knot involve a tie in one direction

followed by a tie in the same direction & third

tie in the opposite direction to square the knot

& hold it permanently.

It has the tendency to slip when subjected to

increasing pressure.

It is not recommended.

References

Bailey & Love’s - Short Practice of Surgery, 26th edition.

Internet websites .

Thanks…