56392793 suture materials amp suturing techniques dr ayesha

8/13/2019 56392793 Suture Materials Amp Suturing Techniques Dr Ayesha

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GOO

MORNING



SUTURE MATERIALS

&

SUTURING TECHNIQUES

COMPILED BY: NUZHAT NOOR AYESHA



CONTENTSIntroduction

History

DefinitionGoals of suturing

Suture materials

- Introduction

- Requisites of ideal suture

- Classification

- Selection of suture material

- Absorption of suture material

- Biological response of body to suture.

Suture armamentarium- needles, needle holder, scissorPrinciples of suturing

Suturing Techniques

Knots

Suture Removal

Other methods of wound closure



• Suture means to ‘sew’ or ‘seam’. In

surgery suture is the act of sewingor bringing tissue together and

holding them in apposition untilhealing has taken place.

• A suture is a strand of material usedto ligate blood vessels and toapproximate tissues together.

INTRODUCTION



HISTORY



HISTORY

History of the Surgical Suture “I dress the wound

God heals it.“ Ambroise Pare, surgeon16th century



•

The act of sewing is probably older thenHomo sapiens, because Neanderthal manwore some sort of clothing.



HISTORY

Perhaps the world’s oldest suture was placed by anembalmer on the body of a twenty first dynasty mummy

about 1100 B.C.



• A south American method of woundclosure used large black ants which bite

the wound edges together and the antsbody is then twisted off leaving the headin place.

• East African tribes ligated blood vesselswith tendons and closed wounds withacacia throns



• The first detaileddescription of a wound

suture and suturematerials used in it is bythe Indian physicianSushruta, written in 500BC.



Galen, the physician to

Roman gladiators in thesecond century A.D. used

silk for hemostasis.

Andreas Vesalius firstadvocated the suture of allfresh wounds as well assevered tendon and nerves.



• Joseph Lister (1827-1912)discovered that bacteriapresent in suture strandscause wound infection. Hedisinfected sutures withcarbolic acid. He madesterile sutures possible to

bury it in clean woundswithout infection.



• Sometime around 30 A.D., a

medical encyclopedia was writtenby a Roman named AureliusCornelius Celsus. His work, De ReMedicina, tells the reader thatsutures should be “soft, and notover twisted, so that they may bemore easy on the part.” He is

also credited with firstsubstantiated mention of ligatingby recommending it as asecondary means of stopping a

hemorrhage.



• Rhazes of Arabia was credited

in 900 A.D. with first employing„kit gut‟ to suture abdominalwounds. The Arabic word „kit‟means a dancing master‟s fiddle,

the musical strings of which „kitstring‟ were made up of sheepintestines. Over the years „kit‟was confused with kitten or cat,

and the misuse of the term waspropagated.



DEFINITIONS

• DEFINITION: suture material is an artificialfibre used to keep wound together until theyhold sufficiently well by themselves by naturalfibre (collagen) which is synthesized and woveninto a stronger scar

• Suture is a Stitch/Series of Stiches made tosecure apposition of the edges of a

Surgical/Traumatic wound (Wilkins)

• Any Strand of Material utilised to ligate bloodvessels or approximate Tissues (Silverstein L.H1999)



GOALS OF SUTURING

Suturing is performed toProvide adequate tension

Maintain hemostasis

Provide support for tissuemargins

Reduce post-op pain

Prevent bone exposurePermit proper flap position



SUTURE

MATERIALS



• The basic purpose of a suture is to hold

severed tissues in close approximationuntil the healing process provides thewound with sufficient strength towithstand stress without the need for

mechanical support.

• Since wounds do not gain strength until4-6 days after injury, the tissues are

approximated till then by sutures.



The amount of tension or pull thesuture can withstand beforebreaking is important.

Tensile St α diameter of suture

If the diameter of suture is

doubled, T.S is quadrupled.



Suture material should be atleast as

strong as the tissues in which theyare used. By the end of 2nd week,when most skin sutures are removed,the wound would have attained 3%-

7% of final Tensile St.3rd week – 20% of T.S4th week – 50% of T.S

Wounds will never regain more than80% of Tensile St. of intact skin



REQUISITES OF AN IDEAL SUTURE

• Tensile st: adequate material strengthwill prevent suture breakdown & use ofproper knots for the material used willprevent untying or knot slippage.

• Tissue biocompatibility: sutures madefrom organic material will evoke a higher

tissue response than synthetic sutures.tissue reaction α amount & size of

suture material.



• Low capillarity: multifilament type soakup tissue fluid by capillary action

providing a rich medium for microbesincreasing chances of inflammation &infection.

•Good handling & knotting properties:ease of tying & a thread type thatpermits minimal knot slippage alsoinfluence thread selection.

• Sterilization without deterioration ofproperties: most sutures available inpackages are sterilized by dry heat &ethylene oxide gas.



• Non allergic, non electrolytic and non

carcinogènic

• Its use should be possible in anyoperation.

• Low cost

• It should not fray, should slide throughtissues readily & knot should not slip aftertying.



• It should be readily visualized , should notshrink & should not be extruded from thewound.

• On break down ,it should not release toxicagents.

•

It should disappear without excessivereaction once its task is completed.



CLASSIFICATION OF SUTURE

MATERIALS

According to source:

1. Natural2. Synthetic

3. Metallic



According to structure 1. Monofilament

2. MultifilamentAccording to fate:

1. Absorbable (undergo degradation and

lose T.S. < 60 days)2. Non absorbable ( maintain T.S > 60

days)

According to coating: 1. Coated

2. Uncoated



NATURAL

Absorbable

CatgutChromic catgutCollagenFascia latakangaroo tendonBeef tendonCargile membrane

Non Absorbable

SilkSilk worm gutLinen

Cotton

RamieHorse hair



SYNTHETIC

Absorbable

Polyglycolic Acid Polyglactic Acid

Polyglactin 910(Vicryl)

Polydioxanone(PDS)

Polyglecaprone 25

Non Absorbable

Nylon/ polyamide

PolyPropylene

Polyesters

Polyethelene

Polybutester Polyvinylidene fluoride /

PVDF Sutures



Monofilament

Multifilament



MONOFILAMENT

Advantages

• Smooth surface

• Less tissue trauma• No bacterial

harbours

• No capillarity

Disadvantages

• Handling and

knotting• Stretch

• Any nick or crimp inthe material leadsto breakage.



MONOFILAMENT

Absorbable

Surgical Gut- Plain,Chromic

Polydiaxanone

Polyglactin 910

Non Absorbable

Polypropylene Polyester

Nylon/polyamide

Polyvinylidene fluoride /

PVDF Sutures



MULTI FILAMENT

Advantages

• Strength

• Soft and pliable• Good handling

• Good knotting

Disadvantages

• Bacterial harbours

• Capillary action• Tissue trauma



MULTIFILAMENT

Absorbable

Polyglactin 910

Polyglycolic Acid

Non Absorbable

Silk

Cotton

Linen



MONOFILAMENT

Handling Difficult

Smooth & strong

No Wicking

Thinner

MULTIFILAMENT

Handling easy

Low Strength

Wicking is a Problem

Thicker



Metallic

SS

Tantalum

Gold

SilverAluminium



Non absorbable sutures are categorizedby the United States Pharmacopeia(USP) as

Class I - Silk or synthetic fibers of

monofilaments with twisted or braidedconstructionClass II - Cotton or linen fibers, coated

natural or synthetic fibers in which the

coating does not contribute to T.SClass III - Metal wire of monofilament ormultifilament construction.



SELECTION OF SUTURE

MATERIAL

A variety of suture materials and suture/needlecombinations is available. The choice of suturefor a particular procedure is based on the knownphysical and biologic characteristics of the

suture material and the healing properties of thesutured tissues.



Principles of suture selection

The selection of suture material by asurgeon must be based on a soundknowledge of

• Healing characteristics of the tissueswhich are to be approximated,

• The physical and biological properties ofthe suture materials,

• The condition of the wound to be closedand

• The probable post-operative course ofthe patient.

1 R t f h li f ti :



1. Rate of healing of tissues:

• When a wound has reached maximal strength,sutures are no longer needed.

• Tissues that ordinarily heal slowly such as skin,fascia and tendons should usually closed with non –

absorbable sutures.

• Tissues that heal rapidly such as peritoneum, liver,small intestine, muscles, stomach ,colon andbladder may be closed with absorbable sutures.

• Suture should be stronger than the suturedtissues, and it is unwise to implant more materialthan necessary.



2.Tissue contamination:

• Avoid multifilament sutures asbacteria can linger with them andmay convert a contaminated wound

into an infected one.

• Use monofilament absorbable or

nonabsorbable sutures inpotentially contaminated tissues.Monofilament polypropylene isideal



3. cosmetic results :

• Where cosmetic results are important,

close and prolonged apposition ofwounds and avoidance of irritants will

produce the best results. Therefore usea smallest, inert monofilament suture

materials such as poly amide andpolypropylene.

• Avoid skin sutures and close

subcuticularly whenever possible• Under certain circumstances, to secure

close apposition of skin edges , skinclosure tape may be used



4. cardiovascular surgery:• Monofilament polypropylene, polyester,

coated and un coated and braidedsurgical silk are recommended.

• Monofilament polypropylene being smooth,

possess high TS is the material of choicefor vascular anastomosis. This materialdoes not encourage any thrombusformation.

• Polyester is preferred for suturingartificial heart valves, myocardium andvascular prosthesis.



5. Microsurgical procedure:• Most commonly used suture is 10-0 poly

amide monofilament

6.wound repair in patients followingirradiation

• In this group of patients ,not only thenormal healing process is delayed but thetolerance to the trauma of irradiated tissueis markedly reduced . So

• Extremely careful and gentle

surgical technique Avoid tension sutures and

mattress sutures as they further increasethe degree of ischemia.



Closure in layers

Avoid continuous and constantpressure on irradiated tissues.

Fascial layer –non-absorbable

sutures, polypropylene is ideal



The selection of suture material is basedon

The condition of the wound,The tissues to be repaired,The tensile strength of the suture

materialKnot-holding characteristics of the

suture material and

The reaction of surrounding tissues tothe suture materials.



ABSORPTION OF SUTURE MATERIALS Degraded either by enzymatic process as in gutsutures, or by hydrolysis, as in many of thesynthetic materials like glycolic acid,ployglactin910 or polydioxanone.

Non absorbable sutures are walled off orencapsulated.

In infected tissues or in a patient who is febrile orprotein deficient, suture breakdown may be

accelerated. If the loss of TS outpaces the healing phase,

failure of the wound results.

Absorbable sutures must be placed well into the

dermis.



BIOLOGIC RESPONSE OF BODY

TOSUTURE M TERI LS



BIOLOGIC RESPONSE OF BODY TO SUTURE M TERI LS

• The initial body response to sutures is almostidentical in the first 4-7 days, regardless of thesuture material.

• The early response is a generalized acute asepticinflammation, involving primarily polymorphonuclearleukocytes.

• After few days mononuclear cells, fibroblasts &histiocytes become evident.

• Capillary formation occurs at the end of this initial

phase.



• Natural Absorbable – Proteolytic

degradation. Intense tissue response

• Synthetic Absorbable – Hydrolysis. LessIntense

• Non Absorbable – Encapsulation. Acellular

Response



RAILROAD SCAR

Sutures passing through mucous membrane orskin provide a „wick‟ or pathway through whichbacteria track down, and bacteria gain access

to underlying tissues. The longer the suture remains, the deeper the

epithelial invasion of the underlying tissue.When suture removed, epithelial tract remains.

These cells may eventually disappear or remainto form keratin and epithelial inclusion cysts.The epithelial pathway result in typical„railroad scar‟ formation.



ABSORBABLE NATURAL

Gut / cat gut Oldest known absorbable suture.

Galen referred to gut suture as early as 175A.D.

Derived from sheep intestinal sub mucosa orbovine intestinal serosa.

Submucosa of sheep has a rich elastic tissuecontent which accounts for high tensile strength

of the catgut. It is monofilament and is availablein the plain form as well as “tanned” in chromicacid. The tanning process delays the digestion bywhite blood cell lysozymes.



• Catgut should not be boiled or autoclaved as heatdestroys its tensile strength.

• Catgut is sterilized during preparation and kept in apreservative solution (isopropyl alcohol) inside spoolsor foils. Unused and reusable catgut is hygroscopic

so, catgut will swell due to water absorption and itstensile strength will be reduced .

• Absorption :40-60 days

• When placed intra orally sutures are digested in 3-5days.



• It is available pre-sterilized in aluminium-

coated sterile foil overwrap pack withethicon fluid as a preservative.

• Colour : Plain catgut is yellow , while

chromic catgut is tan

• Absorbtion : Catgut is absorbed byproteolytic digestive enzymes releasedfrom inflammatory cells collected aroundthe catgut. So, in the presence ofinfection catgut is rapidly absorbed.



CHROMIC CATGUT

Coated with thin layer of chromium saltsolution to minimize tissue reaction,increase TS, slow the absorption rate,better knot security, and ease of

handling.TS – 10-14 days

Absorbed in 90 days

Uses:Opthalmic surgery (6-0)

Oral surgery

Suture subcutaneous tissues



As it is an organic material andsusceptible to enzymatic degradation,packed in isopropyl alcohol as apreservative. Also condition or soften

it.

Suture absorbs alcohol and swells. It iscombustible and is also irritating totissues. It is removed by a quick risein saline prior to use.



COLLAGEN SUTURE

Natural, absorbable, monofilamentObtained by homogenous dispersion of

pure collagen fibrils from the flexortendons of cattle.

Absorption – 56 days

TS - < 10% after 10 days.

Used in opthalmic surgery

Disadvantage of premature absorption.

SYNTHETIC ABSORBABLE



POLYGLACTIN 910 VICRYL) Polyglactic

acid

Coated and uncoated

Synthetic suture

Monofilament/multifilament

Lactide has hydrophobic qualities→delaying loss of

TS

TS - 14 – 21 days.

Absorption – 56-70 days.



Minimal tissue reactivity and can be used in

infected tissues

Available in purple and undyed. Undyed used on

face.

Coated with polyglactin 370 and calcium stearate

which allows easy passage through tissues as well

as easier knot placement.

On skin wounds, associated with delayed

absorption as well as increased inflammation.



VICRYL – RAPIDE

• It is braided synthetic absorbable suture material.• Colour: White.

• It has a similar initial high tensile strength as that of

the normal vicryl suture.

• It gives wound support upto 12 days. It shows 50% ofthe original tensile strength after 5 days and all of itstensile strength is lost after 14 days.

• Its absorption is associated with minimal tissue reactionfacilitating improved cosmetics and reduction ofpostoperative pain.



• The absorption is essentially complete

within 35-42 days.

• Uses: Low tensile strength and Rapidabsorption rate --Ideal for intra-oral

use (dental surgeries).



VICRYL plus ANTIBACTERIAL SUTURE

• Handles andperforms same asnormal vicryl.

• In vitro studiesshown that triclosanon VICRYL plus

creates a zone ofinhibition aroundthe suture.



GLYCOLIC ACID HOMOPOLYMER

DEXON) POLYGLYCOLIC ACID

Polymer of glycolic acid with greater knot pulland TS than gut.

Synthetic, absorbable, braided Absorption- hydrolysis, which results in

minimal tissue reactivity.

Braided and so catches on itself, and knot

tying and passage through tissues difficult. Does not tolerate wound infection and not

percutaneous suture.



GLYCOLIC ACID MAXON) POLYGLYCONATE

-Synthetic, absorbable, monofilament.

-Polyglycolic acid and trimethylene carbonate-TS – 14-21 days (>Dexon)

Absorption – Hydrolysis in 180 days

In vitro studies by Edlich and co-workers (1973)have suggested that the degradation products ofpolyglycolic acid and nylon sutures - glycolic acid,1,6-hexane diamine and adipic acid areantibacterial agents.



POLYDIOXANONE PDS II)

Synthetic,absorbable,monofilament.

Polyester derivative poly P dioxanone.

TS -14-42 days Absorption – Hydrolysis in 6 months.

Passes through tissues easily.



Significant memory – compromises theease of knot-tying and knot security.

Minimal tissue reaction

For wounds under tension andcontaminated wounds.

May extrude through the wound overtime. So used only in tissues deeperthan subcuticular layer. Or if in face 6-0 used.



NON ABSORBABLE SUTURES

• Natural – silk, silk worm gut, cotton ,ramie,linen

• Synthetic-polyester, polyamide, polypropylene, polybutester,polyethelene

• Metals : SS

Tantalum

platinum

silver wiresgold

aluminium

NATURAL NON-ABSORBABLE



SURGICAL SILK

-Braided or twisted

-Made from the filament spun by silkworm larvato form its cocoon. Each filament isprocessed to remove the natural waxes andsericin gum. After braiding, the strands aredyed, stretched and impregnated with amixture of waxes and silicone. Dry silk sutureis stronger than wet silk suture.



Advantage: Ease of handling – more for braided Good knot security made non capillary in order to withstand action

of body fluids & moisture.(wax or silicon coated) Cost effective

Contraindications:Should not be used in presence of infection



Uses:Plastic surgery, ophthalmic and general

surgeries, ligating body tissues.

Although characterized as non-absorbable,studies show that it loses most of theirTS after 1 yr. and cannot be detectedin tissues after 2 yrs.



SURGICAL COTTON

Natural, multifilament, non absorbable

From stable Egyptian cotton fibers

good knot securityNot good in presence of contaminated

wounds or infection

Rarely used nowadaysUses:

Most body tissues for ligating andsuturing



LINEN

Natural, multifilament, non absorbable

Made from stable flax fibers

Poor TS and so not for suturing undertension

Uses:

Ligation of superficial vessels

Mucosal suturing without stress

SYNTHETIC NON-ABSORBABLE



POLYPROPYLENE PROLENE)

-Polymer of propylene.-Inert and TS for 2 yrs-Holds knots better than other synthetic

sutures.

Advantages-Minimal suture reaction and so used in infected

and contaminated wounds.-Do not adhere to tissues and is flexible. So

used for „pull-out‟ type of sutures.Uses:General, plastic, cardiovascular surgery, skinclosure, ophthalmology.



NYLON – BRAIDED SURGILON, NURILON)

Synthetic, non absorbable

Inert polyamide polymer

Braided and sealed with silicon coating

Look, handle and feel like silk, butmore stronger

Multifilament nylon is weaker and lesssecure when knotted, offering little

advantage over monofilament nylon.



NYLON MONOFILAMENT DERMALON,ETHILON)

Uncoated, but inert and non irritating tothe tissues.

High TS and low tissue reactivitySome memory and return to original

linear shape over time. Because of thismore throws (4 throws) indicated.Moistened nylon monofilament are more

easily handled and are packaged wet.

Uses: Skin closure, retention, plastic, ophthalmic

and microsurgery.



POLYESTER – BRAIDED

Tycron, Mersilene -UncoatedDacron, Ethibond - Coated (with polybutilate)

Multifilament fibers of polyester Excellent TS which is maintained indefinitely Uncoated is rougher and stiffer than coated form

Coated provides -low infection rate-secure knotting-smooth removal-low reactivity

-easy passage throughtissues More expensive In deeper layers, may last indefinitely.



GOR-TEX

Nonabsorbable,synthetic,MonofilamentFrom,expanded polytetrafluoroethylene

(ePTFE)

Extremely low tissue reaction, good knottensile strenghtand ease of handling.

Uses

All type of soft tissue approximation andcardiovascular surgeries.



MONOCRYL

Absorbable, synthetic, monofilamentPoliglecaprone 25; copolymer of glycolide

and caprolactone

Hydrolysis 90-120 daysTissue reaction – minimal

Good knot strength

Used for soft tissue closure

Most pliable material ever made

POLYBUTESTER (NOVOFIL)



-New, monofilament, nonabsorbable, synthetic

-Made of polyglycol trephthate and polybutyleneterephthalate and is considered as a modified polyestersuture.

-No significant memory compared to polypropylene andnylon. Easier to manipulate and greater knot security.

-Unique feature is their ability to elongate or stretchwith increasing wound edema. When edema subsides,suture resumes original shape; so it is an ideal suturefor lacerations secondary to blunt trauma.



-TS high and lasts longer-Minimal tissue reactivity.

-Popularity in cutaneous surgery is gradually

increasing.



SURGICAL STEEL

Natural, monofilament/multifilament, nonabsorbable

Alloy of iron, nickel and chromium Good TS even in infection

Difficult to handle and tendency to cutthrough tissues. Very hard to tie, and knotends require special handling.

P t ti l t d b k t i t



Potential to corrode or break at pointsof twisting, bending or knotting.

Not to be used with a prosthesis ofanother alloy.

Used in abdominal wall and skin closure,sternal closure, retention, tendonrepair, orthopedic and neurosurgery.

OMFS- for suspension of splints orarch bars and not as suture material.



Major Disadvantages

1.Linear artifacts caused by substances withhigh atomic number on CT images

2.Possible movement of metal suture duringMRI

3.Patch test for nickel sensitivity should bedone.

Packaging………



METRIC GUAGE IMPERIAL GUAGE

PRODUCT CODE

NEEDLE SIZE &

CURVATURE

NEEDLE TYPE

NEEDLE TIP

NEEDLE PROFILE

STERILIZED

ETHELENE OXIDE

DO NOT REUSE

SEE INSTRUCTIONS FOR USE

EXPIRY DATE BATCH NO



SUTURE SIZES

• Largest size 1 to extremely fine 11-0.Increasing number of zeroes correlates withdecreasing suture diameter and strength.

• Thicker sutures are used for approximation ofdeeper layers, wounds in tension prone areasand for ligation of blood vessels.

• Thin sutures are used for closing delicatetissues like conjunctiva and skin incisions of theface. Size is chosen to correlate with thetensile strength of the tissue being sutured.

3-0 or 4-0 OMFS, muscle, deep skin



5-0 or 6-0 facial skin closure9-0 or 10-0 microsurgery

SUTURE NEEDLES



Surgical needles are designed to leadsuture material through tissue withminimal injury. Needles can be

- straight (GIT) or curved

- swaged or eyedMade up of either SS or carbon steel.

Needle is selected according to:-type of tissue to be sutured-tissue‟s accessibility-diameter of suture material.



Made up of either SS or carbon steel.

CLASSIFICATION OF SURGICAL NEEDLES 1.According to eye -eye less needles

-needles with eye2.According to shape -straight needles. -curved needles

3.According to cutting edgea) round body

b) cutting -conventional-reverse cutting



• 4.According to its tip -triangular tip

-round tip

-blunt tip

• 5.Others -spatula needles

-micro point needles

-cuticular needles-plastic needles

Ideal Properties Of Needles



Ideal Properties Of Needles

• High quality stainless steel

• Smallest diameter possible

• Capable of implanting sutures with minimal trauma

to tissues.

• Stable in the needle holder

• Should be sharp.

• Sterile and corrosion resistant.

natomy of a Needle



Term Definition

Chord

Length of needle

Radius

Diameter

The linear distance between eye andtip.

The distance between eye and tip

following the curvature

The distance of the body of the

needle from the centre of the circle

Gauge or thickness of the metal wire

out of which the needle is made.



COMPONENTS OF SURGIC L NEEDLE

1 ThCLOSED



1. The eye

2. The body; and

3.The pointThe eye can be - closed

- swaged

- chanelled/drilled

Shape of the eye may be - round

- oblong; or

- square

Open French-eye needle is easy to load withvarying caliber, but has additional bulk.

SWAGED

CHANELLED

Eyed require threading prior tolt i lli d bl

Suture loop inserted through eye



use, results in pulling a doublestrand through tissue. Tying the

suture to the eye increases bulkof suture material drawn throughtissues. So they are also called„traumatic needles‟.

Most suture materials andneedles are difficult to sterilize.Needles are also difficult toclean after use and become blunt

and workhardened so that theysnap.

Loop placed over tip

Loop drawn back

Suture tied on eyed needle

SWAGED NEEDLE



• Swaged needles do not require threading andpermit a single strand of suture material to bedrawn.

• Suture attached to needle via a hole drilledthrough the end of the needle, and the end isswaged during manufacturing.

• It is atraumatic and

act as a single unit.

• Prepacked and presterilized

by gamma radiation.



Needle attached to suture

Favourable for I/O use but expensiveLess tissue damageNew needle each time



THE BODY



• Body is the widest portion of the needle

• It is known as grasping area.

-Most commonly used are 3/8 circle. They can beeasily manipulated in large and superficial woundsand require only less wrist movement.

-1/2 circle used for suturing tissues in small wounds,and body cavities and orifices. Require less space,but more supination and pronation of wristrequired.

-5/8 used in oral cavity.



Tapered

utting

Reverse cutting

RADIUS OF CURVATURE OF THEBODY(NEEDLE)

CLINICAL USE

Straight Needle Needle of choice for the skin



Straight Needle

¼ circle

3/8 circle

½ circle

5/8 circle

Needle of choice for the skin

Limited use in oral surgery

May be used in surgery of the

nose, pharynx, tendons

Needle of choice for microsurgery

associated with very fine sutures;

ophthalmology

Oral surgery, flap surgery, woundclosure after placement of

osseointegrated implants and GTR

procedures

May be used in all surgical wounds

Needle of choice in oral surgeryWide range of uses in many

surgical wounds

Wounds of the urogenital tract

THE POINT



Point runs from tip to the max. cross sectionalarea of the body.

• Can be -triangular tip/cutting

-round tip-blunt tip

• Cutting needles are Ideal for suturing keratinizedtissues like skin, palatal mucosa, subcuticularlayers and for securing drains.

• Round/tapered needles used for closingmesenchymal layers such as muscle or fascia thatare soft and easily penetrable



• The conventionalcutting point has two

• The reverse cuttingpoint has two opposing



g popposing cutting edgesand third edge on the

inside curvature of theneedle.

p pp gcutting edges and thirdcutting edge on the

outer curvature of theneedle.

• The tapered point is used primarily on soft,easily penetrated tissues . it leaves small hole

d b d i l ll



and can be used in vascular surgery as well asfascial soft tissue surgery.

• The blunt point has a rounded end which doesnt cut through the tissue .it is used in friabletissue suturing or to the parotid duct or

lacrimal canaliculi.



Cuticular needles

• Sharpened 12 times

• Designated as C or FS(CUTICULAR or FOR SKIN)

Plastic needles

• Sharpened an additional24 times

• Designated as P or PS orPC(PREMIUM or PLASTIC

SURGERY or PRECISIONCOSMETIC ).

• Needles in the PC series

are made up of strongerSS alloy and haveflattened andconventional cuttingedge.

• Curvature of the needle is selected according tothe accessibility The needle must exit in a



the accessibility. The needle must exit in avisible spot so that the surgeon is aware of theposition of the point of the needle at all thetimes.

• Try to match the needle thickness with suturediameter .it is not appropriate to use wide thickneedle with small suture material . This willcause laxity of immediate suture line and allowsbacterial contamination & ingrowth of epithelium& in vascular surgery it may allow oozing of blood

throught/suture hole.

Placement of a Needle into the Tissue



Force should always be applied in the

direction that follows the curvature ofthe needle.

Movable to a non-movable tissue.

Only sharp needles with minimal force.

Never force the needle through the

tissue.

Avoid retrieving the needle from the

tissue by the tip.



Grasp the needle in the body 1/4th to

half of the length from the swagedarea.

Do not hold the needle by the swaged

area or the eye.

Avoid excessive tissue bites with smallneedles, as it will be difficult to

retrieve them

NEEDLE HOLDER



• The needle holder is used to handlethe suture needle and thread whilesuturing the surgical wound.

• If used properly it enables thesurgeon to perform procedurescorrectly and with great precision.

PARTS OF NEEDLE HOLDER



• Working tip/ jaws• Hinge device

• Shank/body

• Catch mechanism/ ratchet• Grip area

NEEDLE HOLDER



There are different types of needle holders.

The beaks may be short or long, broad or

narrow, slotted or flat, concave or convex,

smooth or serrated. Commonly used have a

locking hand and short beaks and 6’ long

Gilles needle holder (scissors incorporated into

blades)

Kilner needle holder



• Atraumatic needle holder ensures

needle movement and compatibility ofclamping movement. It has texturedtungsten carbide jaw inserts, and itsrounded needle holder jaw edges do not

cause structural damage tomonofilament suture or needle

GILLES NEEDLE HOLDER



Scissors are incorporated into the blades



OLSEN HEGAR NEEDLE HOLDER KILNER NEEDLE HOLDER



MAYO HAGER NEEDLEYASARGIL MICRO NEEDLE HOLDER

Gripping needle holder



The scissor grip

Used in the anterior part of the mouth and in

areas of easy access

The instrument is stabilized with the index finger

Palm grip



g p

• Used in the deeper parts of oral

cavity

Use appropriate size forneedle



needle

Grasped 1/4 to ½ distance

from swaged area Tips of the jaws should

meet before remainingportion of jaw

Needle placed securely Do not overclose

Always directed bysurgeon‟s thumb

Do not use digital pressureon tissues



PRINCIPLES

OF

SUTURING

PRINCIPLES OF SUTURING



1.Needle grasped at 1/4th to half the

distance from eye.

2.Needle should enter perpendicular totissue surface

3.Needle passed along its curve



4.The bite should be equal on both sides of thewound margin and the point of the entry of theneedle should be closer to the wound edge thanits point of exit on the deep surface

5.The bite should be about 2-3 mm from the woundmargin of the flap because after wound closurethe edge of the wound softens due tocollagenolysis and the holding power is impaired.

6. Usually the needle to be passed from mobile side to the

fixed side but not always(exception in lingual



fixed side but not always(exception in lingual

mucoperiosteum flap) and from thinner to thicker & from

deeper to superficial flap.

7.The tissues should not be closed under tension , since they

will either tear or necrose around the the suture

8 Tie to approximate; not to blanch



8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture toanother should be about 3-4 mm apart

to prevent strangulation of the tissue &

to allow escape of the serum orinflammatory exudate & to get more

strength of the wound.

11.Sutures placed at a greater depth than distancefrom the incision to e ert o nd margins



from the incision to evert wound margins

12.Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.sutures should have correct tension while tyingknot for provision of the slight edema postoperatively, more tensioned sutures cause

ischemia of the edges of the incision

causes tearing of the tissues

may leave suture mark

edges may get overlapped

16.Occasionally extra tissue may be present onid f i i i d DOG EAR t b



one side of incision and cause DOG EAR to beformed in the final phase of wound closure.

• Simply extending the length of the incision tohide the exists will produce an unsatisfactoryresult.

• Thus after undermining excess tissue incisionis made at approx. 300 to parent incisiondirected towards undermined side. Extratissue is pulled over incision and appropriateamount is excised. Incision is closed in normalmanner.



IMPROPER SUTURING TECHNIQUE



SUTURING

TECHNIQUES

1.INTERRUPTED SIMPLE SUTURE



Most commonly used. Inserted singly through side

of the wound and tied with a surgeon’s knot.



Advantages

Strong and can be used in areas of stress

Placed 4-8 mm apart to close large wounds, so that

tension is shared

Each is independent and loosening one will not

produce loosening of the other

Degree of eversion produced

In infection or hematoma, removal of few sutures

Free of interferences b/w each stitch and easy to

clean

2. SIMPLE CONTINUOUS / RUNNING

A i l i t t d



A simple interrupted

suture placed and needlereinserted in a continuous

fashion such that the

suturepasses perpendicular

to the incision line below

and obliquely above.

Ended by passing a knot

over the untightened end

of the suture.



Advantages

Rapid technique and distributes tensionuniformly

More water tight closure (Shoen, 1975)

Only 2 knots with associated tags

Disadvantages

If cut at one point, suture slackens along

the whole length of the wound which willthen gape open.

3.CONTINUOUS LOCKING/BLANKET

Similar to continuous but locking provided by



Similar to continuous but locking provided bywithdrawing the suture through its own loop.

Indicated in long edentulous areas, tuberositiesor retromolar area.

Advantages

Will avoid multiple knots

Distributes tension uniformly

Water tight closure

Prevents excessive tightening.

Disadvantage :prevents

adjustment of tension over

suture line as tissue swelling

occurs.

4.VERTICAL MATTRESS



Specially designed for use in

skin. It passes at 2 levels, onedeep to provide support andadduction of wound surfaces at adepth and one superficial to

draw the edges together andevert them.

Used for closing deep wounds

This approximates subcutaneousand skin edges

Needle passed from one edge to the other and again from

latter edge to the fist and knot tied



latter edge to the fist and knot tied.

When needle is brought back from second flap to the first,

depth of penetration is more superficial.

Advantages :

• for better adaptation and maximum tissue



approximation

• To get eversion of wound margins slightly

• Where healing is expected to be delayed for any

reason, it is better to give wound added support byvertical mattress. Used to control soft tissuehemorrhage.

• Runs parallel to the blood supply of the edge of theflap and therefore not interfering with healing.

• Uses: abdominal surgeries & closure of skin wounds.

5.HORIZONTAL MATTRESS



It everts mucosal or skin margins, bringing

greater areas of raw tissue into contact. So usedfor closing bony deficiencies such as oro-antralfistula or cystic cavities.

Disadvantage: constricts the blood supply toedges of incision.

Needle passed from one



p

edge to the other and

again from the latter tothe first and a knot is tied.

Distance of needle

penetration and depth of

penetration is same for

each entry point, but

horizontal distance of thepoints of penetration on

the same side of the flap

differs.

Advantages:



Will evert mucosal or skin margins, bringing greater

areas of raw tissue into contact.

-So used for closing bony deficiencies such as oro-

antral fistula or cystic cavities, extraction socket

wounds.

• Prevents the flap from being inverted into the cavity.

• To control post-operative hemorrhage from gingiva

around the tooth socket to tense the mucoperiosteum

over the underlying bone.

• It does not cut through the tissue so used



• It does not cut through the tissue ,so usedin case of tissue under tension(inadequate tissue)

Disadvantages:

• More trouble to insert

• Constricts the blood supply to the incisionif improperly used, cause wound necrosisand dehiscence

6. FIGURE OF 8 SUTURE

Used for extraction socket closure and for



adaption of gingival papilla around the tooth

Suturing begun on buccal surface 3-4mm fromthe tip of the papilla so as to prevent tearing ofpapilla.

Needle first inserted into theouter surface of the buccal flapand then the lingual flap.Needle again inserted in same

fashion at a horizontal distanceand then both ends tied.

7. SUBCUTICULAR SUTURE



Used to close deep wounds in layers. Knots

will be inverted or buried, so that the knotdoes not lie between the skin margin andcause inflammation or infection.

To bury the knot, first pass of the needleshould be from within the wound andthrough the lower portion of the dermallayer. Needle then passed through thedermal layer and emerge through

subcutaneous tissue and knot tied



8.CONTINUOUS SUBCUTICULAR SUTURE



Continuous short

lateral stitches are

taken beneath the

epithelial layer of theskin. The ends of the

suture come out at each

end of the incision and

are knotted.



Advantages

Excellent cosmetic result

Useful in wounds with strong skin tension,

especially for patients prone to keloid formation.

Anchor suture in wound and, from apex, take

bites below the dermal-epidermal layer

Start next stitch directly opposite the one that

precedes it.

9.PURSE STRING SUTURE



A circular pattern that draws together

the tissue in the path of the suture whenthe ends are brought together and tied.

KNOT TYING



KNOT TYING



Sutured knot has 3 components

1.Loop created by knot

2.Knot itself which is composed

of a number of tight throws3.Ears which are the cut ends of

the suture

KNOT TYING

Principles of knot tying



Use the simplest knot that will prevent slippage.

Tying the knot as small as possible and cutting the

ends of the suture as short as reasonable to

minimize foreign body reaction.

Avoid friction or sawing

Avoid damage to suture material

Avoid excessive tension

Tying sutures too tightly strangulates the tissue

Maintenance of traction at one end of the



Maintenance of traction at one end of thesuture after the first loop is thrown, to avoid

loosening of the knot.

Placing the final throw as horizontally aspossible to keep knot flat

Limiting extra throws to the knot, as they donot add strength to a properly tied knot.

KNOTS

SQUARE KNOT



SQUARE KNOT

Formed by wrapping thesuture around the needleholder once in oppositedirections between the

ties. Atleast 3 ties arerecommended.

Best for gut, silk, cotton

and SS

SURGEON’S KNOT

Formed by 2 throws on the first tie and one



Formed by 2 throws on the first tie and onethrow in the opposite direction in the secondtie. Recommended for tying polyester suturematerials such as Vicryl and Mersiline

GR NNY’S KNOT

A tie in one direction followed by a tie in



A tie in one direction followed by a tie in

the same direction and a third tie in theopposite direction to square the knot andhold it permanently.



SUTURE

REMOVAL



SUTURE REMOVAL

Skin wounds regain TS slowly. It can be

removed in 3-10 days when the wound

gained 5%-10% of final TS. Skin sutures on

face removed between 3-5 days. Alternate

sutures removed on 3rd day and remaining

sutures after 2 days.

Intra oral

- Mucoperiosteal closure (without tension)

5 7 d



5-7 days

- Where there is tension on the sutureeg : Oro-antral fistula- 7-10 days

Back and legs where cosmesis is less important –

10-14 days.

Continuous subcuticular can be left for 3-4

weeks without formation of suture tracks

A good guide is that as soon as they begin to get

loose they should be taken out.



Suture area is first cleaned with normal saline.

The suture is grasped with non-tooth dissecting forceps



and lifted above the epithelial surface.

Scissors are then passed through one loop and then

transected close to the surface to avoid dragging

contaminated suture material through tissues.

The suture is then pulled out towards incision line to

prevent dehiscence.If suture entrapped in a scab,

application of hydrogen peroxide or saline solution is

necessary.

If pieces of suture left, infection or granuloma

formation can ensue.



• INCORRECT

• CORRECT

• Possible Complication Of Leaving Suture For Many



Days

1.Sutural abscess.

2.Suture scarring or stitch mark

3.Implanted dermoid cyst

SCISSORS

Dean’s Scissors



-General purpose scissors-Used for cutting sutures

-Can also be used to trim mucosal margins.

SUTURE MARKS



Suture marks are caused by 3 factors

1.Skin sutures left in place longer than 7days, resulting in epithelialisation of

suture track

2.Tissue necrosis from sutures that weretied too tightly or became tight due to

tissue edema

3.Use of reactive sutures in the skin.



Other Methods of Wound Closure

• Ligating clips

•

Skin staples• Surgical tape

• Surgical adhesives

Mechanical wound closure

devices



devices

Ligating clips :

• can be resorbable or non resorbable.

• Made up of SS,tantalum or titanium or

pidioxanone.

• Designed for the ligation of tubularstructures.

Surgical staples:



Surgical staples:

• Used for skin closure .• Made up of SS.

• They are placed uniformly to span

the incision line.

• They have minimal tissue reaction .

• Can be used for routine skin closure

any where in the body.



Advantages

• As the clips do not penetrate skin, yet give



As the clips do not penetrate skin, yet give

apposition, the cosmetic result is excellent.• Speed and efficacy of stapling is more

compared to sutures.

• Suturing causes more necrosis than stapling in

myocutaneous flaps.

• Most significant advance is the introduction of

absorbable staples (Lactomer).

• Contra indicated when it is not



possible to maintain atleast 5mmdistance from the stapled skin to theunderlying bone and blood vessels.

SURGICAL TAPE



Microporous tape is used alone or in conjugationwith skin sutures to decrease tension at the woundmargins.

The surgical tapes have a backing of viscous rayonfibers coated with an adhesive copolymer and theyare pervious to sweat but not to blood or purulentmaterial.

Comes in 1/8, 1/4, and 1/2 inch wide strips. Skin

margin is prepared with tincture of benzoin toprovide better adhesiveness for tape.

Used to decrease skin tension oncheek,forehead,chin.

Advantages



Minimizes wound dehiscence and allows earlier

suture removal

Provides continuous support for the wound andminimizes scar expansion

Avoids the ordeal of suture replacement and

removal in children

Less inflammatory reaction, lower rate of woundinfection, greater TS and better cosmetic results.

No needle puncture marks and suture canals

Strangulation and necrosis of tissue are eliminated

Sterile paper tape is non expensive

Disadvantage

Do not evert edges of the wound, and readily loosen



Do not evert edges of the wound, and readily loosenwhen wet by blood or serum.

Prior to placement, a thin coat of antibiotic ointmentis placed on wound margin to protect wound fromskin oils and bacteria.

While removing, to avoid epithelial marginseparation, the ends should be lifted equally towardsthe wound margin and then lifted evenly from the

wound.

Cyanoacrylates



- n-butyl cyanoacrylate is the active ingredient.Advantages :

Strong bonding to tissues in presence of moisture

Biodegradable, bacteriostatic & hemostatic.

Reduced post operative pain & facilitates healing.

Good shelf life.

Produces little or no heat during polymerisation.

Bonding is by secondary intermolecular forces aided

by mechanical interlocking of irregular forces.

Quick, atraumatic and cost effective with good



Quick, atraumatic and cost effective with good

cosmesis

No injection, suturing and post-op suture removal.

Disadvantages

1.When applied for skin closure, the polymer acts as

barrier, prevents wound apposition, delays healing,

and increases the infection rate.

2.Should not be allowed to come in contact with tissue

under skin as it causes necrosis.

REFERENCE



• Suturing techniques in oral surgery –SandroSiervo

• Atlas of Minor Oral Surgery- Harry Dym

• Laskin vol-1

• Oral & Maxillofacial Surgery Vol 1- W. HarryArcher

• Textbook of oral & maxillofacial surgery-Neelima Anil Malik

• Minor Oral Surgery- Goeffrey L.Howe• Text book of surgery: Sabiston

• Periodontology-Caranza.



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56392793 suture materials amp suturing techniques dr ayesha

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