SUR 111

Suture and Staplers

Skill Assessments

• 10-3 Load and Pass Needleholders (NH)• 10-3 Load and Pass free needles• 10-4 Ties, reels, free tie on a Passer• 11-2 Load clip appliers and Pass Staplers

10-3 Load and Pass NH

• Choose appropriate size NH based on size of the needle being used by the surgeon

• Heavy NH will bend delicate needles• Delicate NH will be damaged being loaded

onto large needles

Load and Pass the NH• Load needle by grasping it in the center of the body with

the NH in the packaging• Some surgeons prefer NH grasping needle about 1/3

from the swaged end of the needle• Gently pull out of packaging pulling the strand gently if

necessary to release suture memory prn• Pass to surgeon with NH’s loaded needle tip pointing

towards the surgeon’s thumb• STSR’s hand position should be behind the needle point

at lower shank/box lock level• DO NOT allow suture strand to drop below sterile field!• See text page 368-369 Figure 12-45 • Note ligating methods text page 290-291

10-3 Load and Pass Free Needles

• Differs from previous in that the suture strand must be secured unlike the swaged on suture

• You will be shown different methods for doing this

• Tip: Do not load the suture evenly, only load a short end of suture into the NH or it will pull right out of the tissue it is placed in

• Passing technique is the same

10-4 Ties, Reels, Free tie on a Passer

• Ties • Lay near incision so surgeon may grasp with his

forceps or • Pass to surgeon assistant so that person may

grab with their forceps and pass to surgeon who likely will have a right angle in his or her hand to receive the tie and ligate a vessel

• Always have these ready in pairs, if one is used another will follow

Ties, Reels, Free tie on a Passer

• Reels • Release strand of suture from reel about

1 + ½ inches and pass reel to surgeon• Surgeon grasps other end of strand and

ties holding onto the reel and suture• Reels ARE COUNTED ITEMS!

Ties, Reels, Free tie on a Passer

• Tie on a Passer (usually a tonsil can be right angle)

• Ties are loaded as an extension of the clamp it is loaded on

• It will look like it is part of the tip if loaded properly

• Pass clamp in the normal manner taking heed to not allow suture to drop below sterile table level

Suture

• Absorbable• Designed to hold tissue together until it heals• Different types have different absorption rates• Suture type used depends on the type of tissue being

sewn and that tissue’s normal healing time

• Nonabsorbable • Designed to hold tissue together permanently

Suture Characteristics

• Absorbable• Monofilament• Braided (multi-filament)• Dyed• Undyed • Natural• Synthetic

• Nonabsorbable • Monofilament• Braided (multi-filament)• Dyed• Undyed • Natural• Synthetic

Suture CharacterisitcsMonofiliment verses Multi-filament

• Monofilament• Single strand• Inert (little to no tissue reaction)• Do not harbor bacteria• Can use in presence of infection• Minimal tissue damage as they glide easily through

tissue

• Multi-filament• Braided• Capillarity (able to harbor bacteria that can be

communicated up the strand)• NOT used in presence of infection• Can be traumatic to tissue if not coated• Greater tensile strength• Hold knots securely

Suture CharacterisitcsNatural verses Synthetic

• Natural• From naturally occurring substances:• Cellulose• Animal products• Animal tissue

• Synthetic• Man made:• Petroleum based products

Suture Sizes

• Correlate with tissue to be sewn• Heavy tissue needs a heavy strand of

suture to hold it together• Delicate tissue does not require a heavy

strand but a small or delicate strand of suture

• Suture diameter is called the gauge

Suture Gauge

• #5 is largest available• #1 to 4-0 are most commonly used• #1 and #0 are typical orthopedic sutures• 6-0 to 7-0 for vascular anastamoses• 8-0 to 11-0 for eye procedures• 4-0 and 3-0 for skin closure (called

subcuticular closure)

Suture Gauges(See text 286 table 11-4 ST for the ST) • #5 largest, #4, #3, #2, #1, #0, 2-0, 3-0,

4-0, 5-0, 6-0, 7-0, 8-0, 9-0, 10-0, 11-0, 11-0 smallest

Suture Length

• 13cm to 150cm

Suture Packaging

• Suture can have a needle incorporated into the suture stand called swaged

• Suture can be without a needle also just called a tie or ligature ( below tie packaged individually)

• These ties can be loaded onto individually packaged “free needles” and these suture ligatures are called “stick ties”

• Ties can be packaged individually• Ties can be on reels similar to a spool of thread

Suture Presentation

• Ties can be presented to a surgeon as a “free tie” laying it by his or her forcep near the incision site

• Ties can be presented “on a passer” typically a tonsil clamp (tie will become an extension of the tonsil’s tip when loaded) Your book calls it “instrument tie”

• Ties can be presented on reels (present by making sure the suture has been pulled out enough for the surgeon to use it and not have to pick and dig into the reel himself)

Suture Reels or Ligapak Dispensing Reel

• Look at a reel like a bike tire: have the tire on the outside and the spokes on the inside

• Limited sutures come in reel style• Examples include: vicryl, plain gut, chromic gut, silk,

nylon• Gauge can be determined by packaging label and

flipping the reel over to where you can visualize the dots in the reel’s spokes – º = 0– º º = 2-0– º º º =3-0– º º º º = 4-0

• Larger gauges come packaged in pre-cut strands as well as these described above that come on reels

Needles

• Necessary to insert suture into tissue• Variety of shapes and sizes to accommodate

specific tissues• Certain designs necessary for certain tissues to

prevent tissue trauma when being used• Anatomy includes: eye, body (shaft), point (see

page 314 textbook)• Also describe by shape (curved (1/4, 3/8, ½, 5/8

circle, ½ curved, or straight)

Needles

• Can be swaged on• Single arm or double arm• Pop-offs or control-release• Individual

~ Individual that must be threaded like you would a needle at thread at home

~ Eyes types vary with individual needles~ Closed eye - thread through eye~ French eye – snap through the eye

~ Unique loading of suture strand to secure it from pulling out of the eye during usage

Needles

1. Cutting• used for tough tissue that can withstand this design of

needle• Sclera, skin, tendons• Curved or straight (straight called “Keith needle”)2. Tapered• Round shaft without a cutting edge • Can pierce or penetrate tissue but do not cut it• Vessels, gastrointestinal tissue, delicate tissue3. Blunt • Round shaft with a blunt tip• Kidney or liver

Cutting Needles

1. Conventional• Three cutting edges2. Reverse cutting • Opposing cutting edges in a triangular shape3. Side cutting• Primarily ophthalmic use as will not penetrate into

deep tissue4. Trocar points• Three sharp edges ending in a sharp point• Your trocars used for endoscopic delivery as well as

surgical wound drain insertion

•

Suture Book

• Textbook read pages 285-289• Your Suture and Surgical Hemostasis

Pocket Guide is most helpful• Please review this material given in this

slide show in this book as well

Most Commonly Used SuturesTo Follow

• Are primarily two manufacturers of suture in this area:

• Ethicon (Johnson & Johnson)• Davis & Geck (US Surgical)• Suture materials are primarily the same with

maybe one chemical difference• Trade names of suture are similar but not the

same • This makes for confusion when learning suture• Most institutions carry only one primary brand• Most places here use Ethicon brand suture

Absorbable Suture

PLAIN GUT

Plain Gut(bright yellow package)

• Monofilament• Natural• Submucosa of sheep intestine or beef intestine serosa• Comes in stick tie, pre-cut lengths, and reel• 5-10 day wound support• Absorbs in 30-60 days• Inflammatory reaction• Used for superficial hemostasis and tissue that heals

quickly• Stored in alcohol solution to maintain pliability and keep

from drying out

CHROMIC GUT

Chromic Gut(beige package)

• Monofilament• Natural• Submucosa of sheep intestine or beef intestine serosa• Difference from plain gut is that it is treated with chromium salts to

delay absorption rate• Comes in stick tie, pre-cut lengths, and reel• 10-14 day wound support• Absorbs in 60-90 days• Inflammatory reaction• Used for superficial hemostasis and tissue that heals quickly• Stored in alcohol solution to maintain pliability and keep from drying

out

PDS

PDS (polydioxanone)(silver package)

• Monofilament • Synthetic• Comes in stick tie, pre-cut, and reels• 6 week wound support• Absorbed in 6 months• Minimal tissue reaction• Dyed or clear

Monocryl (not shown)(pink package)

• Monofilament• Synthetic• 14 day wound support• Absorbs in 91-119 days• Slight tissue reaction• Dyed or undyed• 3-0 through #1 gauge swaged• 6-0 through #2 pre-cut ties• Close skin or soft tissue such as subcutaneous

Vicryl

Vicryl (polyglactin 910)(purple package)

• Multi-filament (braided)• Synthetic• Dyed or undyed• 21 day wound support• 56-70 day absorption• Swaged, control release, free ties, reels• Close fascia, subcutaneous (adipose), skin

(subcuticular), GYN procedures, peritoneum

Nonabsorbable Suture

Prolene

Prolene (polypropylene)(Royal blue packaging)

• Monofilament• Synthetic• Least reactive of all synthetic suture• One of most inert sutures • CAN USE in presence of infection• Used for long term support of suture lines

such as vascular surgery or mesh support in hernia repairs

ETHILONorNYLON

Ethilon or Nylon(mint green package)

• Monofilament• Synthetic • Minimal tissue reaction• One of most inert sutures• Used in ophthalmic, tendon repair, drain sew in,

skin closure (interupted/what you know as “getting stitches”)

• Dyed or undyed• Difficult to handle• Knots poorly

Stainless Steel(not shown)

• Monofilament• Synthetic – chromium and nickel alloy)• Gauge #7 to 6-0• Minimal tissue reaction• Uses tendon repair, bone repair, (sternal closure

(#7 wire)), cerclage (tying the cervix shut to prevent premature abortion)

• Considered most inert of all suture materials• Can use in presence of infection• Not used in presence of other metal alloys!

SILK

Silk (baby blue package)

• Multi-filament• Natural – from cocoon of silk worm• Usage GI tract in absence of infection and

vessel ligature• Excellent knot holding and handling

Nurolon (Nylon Braided) NOT SHOWN

(mint green packaging)• Multi-filament• Synthetic • Dyed or undyed• Minimal tissue reaction• Soft tissue approximation, see in

neurosurgical closure• Coated with silicone to reduce drag and

tissue trauma as pulled through tissue

ETHIBOND (Ethicon)orTICRON (Davis & Geck)

Ethibond (polyethylene terephthalate)(orange packaging)

• Multi-filament (braided)• Synthetic – polyester• Available in pre-cut ties and swaged

suture• Most commonly used for soft tissue and

heart surgery for valvular procedures

11-2 Load and Pass Staplers

• Read text p. 300-303 on stapling devices• There are great pictures there as well• Staplers can come with cutting blades

incorporated into the stapling device• Care must be taken with these to avoid

personal injury especially when re-loading• Staple and clips are made of stainless

steel or titanium• Come disposable and non-disposable

Load and Pass Staplers

• Different stapling devices load differently• Staplers are passed with the STSR holding the

stapling device by the business end and placing the handles into the surgeon’s hand

• Always keep reloads available• Will be shown different staplers in lab• Used for skin closure like a staple gun• Also come in linear, ligating and intra-luminal

designs for open and laparoscopic procedures

Load and Pass Staplers

• Clip appliers – a type of stapling device• Passed with tips pointing down for general

surgeons and up for vascular surgeons• Surgeon will tell you how he or she wants

them passed• Take care NOT to squeeze shank/finger

rings together or the clip will fall out• Passed by placing the shank into the palm

of the surgeon’s hand

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Clip Appliers Long Length

MEDIUM LONG LARGE LONG

MEDIUM REGULARLONG REGULAR

DISPOSABLE CLIP APPLIERSAre pre-loaded with multiple clips

Each tells you how many clips it holds

Davis & Geck AutoSuture Clip Applier

Ethicon laparoscopic clip applier

Skill Assessment Review

• 10-3 Load and Pass Needleholders (NH)• 10-3 Load and Pass free needles• 10-4 Ties, reels, free tie on a Passer• 11-2 Load clip appliers and Pass Staplers