Morning Meeting

26th Sept 2024

 SUTURES

 Surgical sutures are critical tools in wound closure

and tissue approximation
Ideal Suture Material

 Easy to handle Inexpensive

 Predictable behaviour in tissues
Minimal tissue reaction
 Predictable tensile strength
 Sterile Non-capillary
 Glides through tissues easily Non-allergenic
 Secure knotting ability Non-carcinogenic
Physical Structure
Monofilament Multifilament
No capillary action Has capillary action
Less infection risk Increased risk of infection
Smooth tissue passage Less smooth passage
Higher tensile strength Less tensile strength
Tough handling Better handling
More throws required Better knot security
Strength
 The tensile strength of a suture is described as the force required to break it
when pulling two ends apart.
 Absorbable sutures decay of this strength with time
 Catgut – tensile strength of a week
 PDS – tensile strength of multiple weeks
 Polypropylene – maintains strength indefinitely
 Silk – should never be used in vascular anastomoses for fear of late fistula
formation
Tensile behaviour
 Elasticity- memory
 Plasticity – kinking
 Knot integrity
Absorbability
Biological Behaviour
 Depends on constituent materials
 Degradation : Proteolysis vs Hydrolysis
 Transmission of infection
 Local recurrence of gut infections
Needles

Sharp Needle Blunt Needle

Sharpened tip Rounded tip
Punctures tissues Separates and dilated tissues
Lacks safety Improved safety
• Cutting needles
 Sharpened point which cuts a path through tissues.
 Looks like a triangle in cross-section.
 Cutting needles are useful for passing through tough tissues, such as thick
skin, fascia and the sternum
• Reverse cutting needles
 Sharpened point
 Looks like an upside-down triangle in cross-section.
 Reverse cutting needles are useful in tissues with a risk of the suture cutting
out and causing additional damage, such as thinner skin, tendons, ligaments,
oral mucosa and the eye.
• Side cutting (spatula) needles
• Have a trapezoid shape with cutting edges on both sides, which allows them to
safely create a path within thin layers of tissue. These are very useful for eye
surgery.
• Round bodied needles
• Round bodied needles have a smooth, tapering point which dilates tissue.
• This looks like a circle in cross-section
• Blunt round-bodied needles are ideal for suturing friable tissues such as an injured
liver or spleen.
Taper point needles are useful in potentially leaky tissues which require precise
suturing with minimal trauma, such as bowel, bile ducts, blood vessels and
myocardium.
Taper cut needles are useful in harder tissues and especially valuable in vascular
surgery, as the needle point can easily puncture through calcified atherosclerotic
tissue without cutting it any further.
Suturing Protocols
• The instruments also need to be correctly sterilised and handled
carefully.
• The basic suturing kit includes:
• Needle holder
• Fine suture scissors
• Toothed tissue forceps
• Appropriate suture material
 The needle should always penetrate the skin at a 90° angle, which
minimizes the size of the entry wound and promotes eversion of the
skin edges.
 The needle should be inserted 1-3 mm from the wound edge,
depending on skin thickness.
 The depth and angle of the suture depends on the particular suturing
technique.
 In general, the two sides of the suture should become mirror images,
and the needle should also exit the skin perpendicular to the skin
surface.
Suturing Procedure
• 1. Selecting the suture material
• Suture material should be flexible enough for use in any operation,
the only variable being determined by tensile strength.
• There are two types of sutures:
• a) Absorbable (temporary support)
• b) Non-absorbable (permanent support).
• A) Absorbable (catgut)
• This type of suture is capable of being absorbed by living mammalian tissue. It is manufactured
from the submucosal layer of sheep intestine or the serosal layer of beef intestine, and is
available in plain or chromic.
• Plain: looses half its strength in 10-14 days and all its effective strength in 21 days.
• Complete absorption occurs within 30-50 days.
• Chromic: looses half its strength in 11-14 days and all its effective strength in 28 days.
• Complete absorption occurs within 45-90 days.
• B) Non - absorbable
• These sutures can be made from silk, polyester, polypropylene or stainless steel.
• 2. Selecting the Size of Suture Material
• If the suture used for wound closure is too thick wound healing can be
delayed.
• Suture materials are gauged using metric figures.
• In Metric, size 0.1 refers to the finest material, and 9 metric refers to the
thickest.
• The table below shows comparisons between metric & BPC gauges.
As a general rule of thumb - in children reduce gauge size by one.
• Needle Type
• Needle Shape
• Needle Strength
• Use of Needle Holders
• The needle holder should be carefully selected to match the size of needle
used.
• 3. Selecting the type of suture
• The following are the most common:
• • Simple interrupted
• • Vertical mattress
• • Horizontal mattress
• • Sub-cuticular
• Advice to Patients post-Suturing
• Patients must be provided with written information regarding care of their
wound prior to discharge. They should know how to care for their wound,
when to return for suture removal and what action to take and where to seek
help, should something go wrong, e.g.
• • wound opens up
• • experiencing pain
• • wound starts to ooze
• • wound appears red and inflamed
• • stitches fall out before removal time.
• Removal of Sutures
• Generally, sutures can be removed earlier from tissues with a good
blood supply (i.e. face and scalp); however sutures should be left in
situ a little longer over particularly mobile skin.
• The following list gives approximate durations of suture removals:
• Facial wounds: 5 days
• Scalp wounds: 7 days
• Arm/hand: 7-10 days
• Lower limb or joints: 10-14 days
• The timing of removal of the sutures will vary.
• Where there is little tension and good blood supply e.g. the face, the suture can
be moved from 3-7 days.
• Where the wound is subjected to increased tension e.g. over a joint, the suture
should be left for 10-14 days.
Knotting Techniques
• Knot tying is one of the most fundamental techniques in surgery and a poorly
constructed knot may jeopardise another wise successful surgical procedure.
• ● The knot must be tied firmly, but without strangulating the tissues.
• ● The knot must be as small as possible to minimise the amount of foreign
material.
• ● The knot must be tightened without exerting any tension or pressure on the
tissues being ligated, i.e. the knot should be bedded down carefully, only exerting
pressure against counter-pressure from the index finger or thumb.
• ● The suture material must not be ‘sawed’ as this weakens the thread and cuts
through delicate tissue like a cheese wire.
• ● The suture material must be laid square during tying; otherwise, tension
during tightening may cause breakage or fracture of the thread.
• ● When tying an instrument knot, the thread should only be grasped at the
free end, as gripping the thread with the needle holder can damage the
material, resulting in break-age or fracture.
• ● The standard surgical knot is the reef knot with a third throw for security,
although with monofilament sutures six throws are required for security
• ● When the suture is cut after knotting, the ends should be left about 1–2
mm long to prevent unravelling. This is particularly important when using
monofilament material.
Complications
• Infection
• Tissue reaction
• Wound dehiscence
• Abscess and sinus formation
• Scarring