BASICS OF SUTURING

DR DILIP KUMAR M
21st NOV, 2012
Steps in wound closure
SUTURE MATERIALS
HISTORICAL BACKGROUND

The word "suture" describes any strand of material used to ligate (tie) blood vessels
or approximate tissues. As far back as 3,000 B.C., written references have been
found describing the use of strings and animal sinews for suturing. Through the
centuries, a wide variety of materials--silk, linen, cotton, horsehair, animal
tendons and intestines, and wire made of precious metals
• 1100 BC – Oldest known suture identified in an Egyptian mummy
• 500 BC – Shushrutha : First ever detailed description of suture materials and their
uses in “Shushrutha Samhitha”
• 400 BC – Hippocrates : described rudimentray surgical techniques
• 150 AD – Galen described gut sutures
• 10th Century - Abu al-Qasim al-Zahrawi : found dissolving nature of catgut
HISTROY
• 1860 – Joseph Lister : sterilisation of suture materials

• 1930s : Production of synthetic threads ;

• 1931 : First Synthetic absorbable suture ( Polyvinyl alcohol)

• 1960 : Polyesters

• 1970s : Polyglycolic acid

Ideal Suture material

If an ideal suture material could be created, it would be:

• Sterile.

• Nonelectrolytic, nonallergenic, and noncarcinogenic.

• Nonferromagnetic, as is the case with stainless steel sutures.

• Easy to handle.

• Minimally reactive in tissue and not predisposed to bacterial growth.

• Capable of holding tissue layers throughout the critical wound healing period securely

when knotted without fraying or cutting.

• Resistant to shrinking in tissues.

• Absorbed completely with minimal tissue reaction after serving its purpose.
Classification of Sutures
Natural suture materials
• Absorbable
– Catgut - Plain or chromic
• Non-Absorbable
– Silk
– Linen
– Stainless Steel Wire
Synthetic suture materials
• Absorbable
– Polyglycolic Acid (Dexon)
– Polyglactin (Vicryl)
– Polydioxone (PDS)
– Polyglyconate (Maxon)
• Non-Absorbable
– Polyamide (Nylon)
– Polyester (Dacron)
– Polypropylene (Prolene)
 Monofilament
made of a single strand of material
e.g: nylon, monocryl, prolene, PDS

Advantages Disadvantages
• Smooth surface
• Handling & knotting
• Less tissue trauma
• Ends/knot burial
• No bacterial harbours
• Stretch , breakage
• No capillarity
 Multifilament
• consist of several filaments, or strands, twisted or braided together

e.g.: vicryl, silk, chromic

Advantages
Disadvantages
• Strength
• Bacterial harbours

• Soft & pliable

• Capillary action
• Good handling

• Tissue trauma
• Good knotting
 Biological / Natural
From natural occuring sources . e.g : Catgut , Silk , linen

Advantages Disadvantages

• Handling & • Tissue reactions –

knotting inflammation, pain,

discomfort
• Economy
 Synthetic
Advantages
Disadvantages
• Non-Absorbables are inert
• Monofilament handling
• Absorbables resemble natural
substances

• Absorption by hydrolysis

• Predictable absorption

• Strength
 Absorbable
eg: catgut, monocryl, vicryl, PDS

Disadvantages
Advantages
• Consideration of
• Broken down by body wound support time
• No foreign body left

Absorbable suture are broken down by either:

•Proteolysis (e.g. Catgut)
•Hydrolysis (e.g. Vicryl, Dexon)
 Non - Absorbable
Disadvantages
Advantages
• Foreign body left

• Permanent wound
• Suture removal can be
Support costly and inconvenient

• Sinus & Extrusion if left in

place
 Catgut
• Collagen derived from serosa of beef intestine or submucosa of sheep intestine.
• Moderate inflammatory reaction
• Chromic: treated with chromic acid salts, lasts longer, less reactive
• Tensile strength – Plain gut 5 – 7 days ; Chromic gut 10 – 14 days
• Mucosal closure, perineum
• General soft tissue approximation, including use in ophthalmic procedures. Not for
use in cardiovascular and neurological tissues.
• Being absorbable, should not be used where extended approximation of tissues
under stress is required.
• Should not be used in patients with known sensitivities or allergies to collagen or
chromium
 Silk

• Natural , Non absorbable , Braided

• Progressive degradation leads to weakening

• High reactivity

• Don’t use in pts allergic to silk

• General tissue approximation / ligation

• Can not be found after 2 yrs

 Vicryl
• Absorbable, synthetic, Braided
• Polyglyactin (Copolymer of glycolide and lactide coated with
polyglactin 370 and calcium stearate. )
• Minimal reaction
• Tensile Strength : 3 – 4 wks
• Complete absorption by hydrolysis in 60 - 90days
• Subcutaneous, intra cutaneous closures, thoracic surgeries
• Vicryl Plus : Impregnated with antimicrobial : Triclosan
 Monocryl

• Synthetic, absorbable, monofilament

• poliglecaprone 25

• Dyed (violet), undyed (clear)

• Subcuticular

• Not used in araes of high tension

• Half life : 7-14 days , complete absorption 90- 120 days

 Prolene

• Polypropylene
• Synthetic, Monofilament , Non absorbable
• Skin, Soft tissues , Cardiac , vascular, neurosurgical, Ophthalmic
• High durabiliy, less reactivity
• Not subgected to degradation or weakening
• Expensive
• Prolene mesh – hernias , fascia repair
 Nylon

• Polyamide

• Synthetic, Non absorbable , Monofilament

• Extremely low reaction

• For skin closure , rectus sheath

 Mersilene
• BraidedMonofilament , synthetic , non absorable

• Polyester

• Minimal inflammation

• Preparing mesh

• General soft tissue approximation and/or ligation, including

use in cardiovascular, ophthalmic, and neurological
procedures
 PDS (polydioxanone)

• Synthetic, Monofilament, absorbable

• Tensile strength : 80 % at 2 wks , 44 % at 8 wks

• Complete absorption in 200 days

• High initial holding power

• Used where combination of absorbable suture with

extended wound support is desirable

e.g :cardiovascular, ophthalmic

 Surgical Stainless Steel
• Synthetic, non absorbable , Mono / multifilament
• Indefinite tensile strength
• Minimal inflammatory reaction
• Sternal closure, Abdominal wounds (secondary closures), hernia repair,
and orthopedic procedures including cerclage and tendon repair.
• C/I: know allergy to stainless steel or its constituents Chromium, Nickel)
• Great Knot security, Does not harbor bacteria
• Difficult to handle
• Size measured in Gauge : 26 Gz= “ O “, 28 Gz= 2-0
 Size of suture material

• Size denotes the diameter of the suture material.

• The accepted surgical practice is to use the smallest

diameter suture that will adequately hold the mending
wounded tissue
• Human Hair is 6-0
• Size originally scaled from 0-3
• As technology advanced and sutures became smaller,
extra 0s were added
• Scale now ranges from 3 (largest) to 12/0 (smallest)

Size Uses
7/0 and smaller Ophthalmology, microsurgery
6/0 Face, blood vessels
5/0 Face, neck, blood vessels, Penis
Mucosa, neck, hands, limbs, tendons,
4/0
blood vessels
3/0 Limbs, trunk, gut blood vessels
2/0 Trunk, fascia, viscera, blood vessels
Abdominal wall, fascia, drain sites,
0 and larger
arterial lines, orthopaedics
 Selection of Suture material

• Location and layer,

• patient factors, strength, healing, availability
• Absorbable for GI, urinary or biliary
• Non-absorbable or extended for up to 6 mos for
skin, tendons, fascia
• Cosmetics = monofilament or subcuticular
• Handling of a suture
– Memory
• Tendency to stay in one position
• Leads to difficulty in tying sutures and knot unravelling

– Elasticity
• Ability to return to its original length after stretching
• High elasticity sutures should be used in oedematous tissue

– Knot strength
• Force required for a knot to slip
• Important to consider when ligating arteries

• Tensile strength
– Force necessary to break a suture
– Important to consider in areas of tension (linea alba)

• Tissue reaction
– Undesirable since inflammation worsens the scar
– Maximal between Day 3&7

• Non-absorbable or absorbable
• Monofilament or multifilament
 Tissue Adhesives

• Butyl or 2-octyl Cyanoacrylate

which provides waterproof,
microbial barrier
• Low tension dry &
haemostatic wounds
• Should not be placed between
skin layers or inside body
• Brands: Dermabond,
Nexaband, Vetbond,
 Skin Staples

• Very easy

• Expensive

• Very secure

• Very little tissue reaction

• Removal = Special tool required

• Steri strips / Micropore
surgical tape can be applied
for superficial wounds
• Lesser infection, Scarring

• Less durability
Surgical Needles
• The main types of needle include:

– Tapered
• Gradually taper to the point and cross-section reveals
a round, smooth shaft
• Used for tissue that is easy to penetrate, such as
bowel or blood vessels

– Cutting
• Triangular tip with the apex forming a cutting surface
• Used for tough tissue, such as skin (use of a tapered
needle with skin causes excess trauma because of
difficulty in penetration)

– Reverse cutting needle

• Similar to a conventional cutting needle except the
cutting edge faces down instead of up
• This may decrease the likelihood of sutures pulling
through soft tissue
 Needle Shapes
•Nasal cavity
•Eye •Nerve
•Microsurgery
•Skin
•Tendon

•Dura
•Eye (Anterior
•Eye
•Fascia segment)
•Nerve

•Muscle
•Eye
•Laparoscopy
•Skin
•Peritoneum

•Cardiovascular
•Oral
•Pelvis
•Urogenital tract
 Packaging…
Imperial Gauge Product (re-order) Code
Metric Gauge

Needle size
& curvature

Needle type

Needle point

Needle profile

Do Not Re-use Batch Number

Sterilised Expiry date
Ethylene Oxide See Instructions
for use
 Wound Evaluation
• Time of incident
• Size of wound
• Depth of wound
• Tendon / nerve involvement
• Bleeding at site
 When to Refer ?
• Deep wounds of hands or feet, or unknown depth of penetration
• Full thickness lacerations of eyelids, lips or ears
• Injuries involving nerves, larger arteries, bones, joints or tendons
• Crush injuries
• Markedly contaminated wounds requiring drainage
• Concern about cosmesis
 Contraindications to Suturing
• Edema of the wound margins

• Infected wounds

• Punctured wounds

• Animal bites

• Tendon, nerve, or vessel involvement

• Wound more than 12 hours old (body) and 24 hrs

(face)
 Closure Types
• Primary closure (primary intention)

– Wound edges are brought together so that they are adjacent to each other (re-

approximated)

– Examples: well-repaired lacerations, well reduced bone fractures, healing after flap

surgery

• Secondary closure (secondary intention)

– Wound is left open and closes naturally (granulation)

– Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced

fractures

• Tertiary closure (delayed primary closure)

– Wound is left open for a number of days and then closed if it is found to be clean

– Examples: healing of wounds by use of tissue grafts.

 Wound Preparation
• Most important step for reducing the risk of wound infection.
• Remove all contaminants and devitalized tissue before wound
closure.
– IRRIGATE w/ NS or TAP WATER (AVOID H2O2, POVIDONE-
IODINE)
– CUT OUT DEAD, FRAGMENTED TISSUE
• If not, the risk of infection and of a cosmetically poor scar are
greatly increased
• Debride crushed tissue
• Personal Precautions
Types of Closures
● Simple interrupted closure – most commonly used, good for shallow
wounds without edge tension
● Continuous closure (running sutures) – good for hemostasis (scalp
wounds) and long wounds with minimal tension
● Locking continuous - useful in wounds under moderate tension or in
those requiring additional hemostasis because of oozing from the skin
edges
● Subcuticular – good for cosmetic results
● Vertical mattress – useful in maximizing wound eversion, reducing
dead space, and minimizing tension across the wound
● Horizontal mattress – good for fragile skin and high tension wounds
● Percutaneous (deep) closure – good to close dead space and decrease
wound tension
Simple inturrupted suturing
Simple, Interrupted
Simple Interrupted
Simple Continuous
Ford Interlocking
Subcuticular
 Vertical Mattress

Good for everting wound edges

(neck, forehead creases, concave surfaces)
 Horizontal Mattress

Good for closing wound edges

under high tension,and for
hemostasis.
Horizontal Mattress
 Before sending the patient
• Need for tetanus globulin and/or vaccine?
– Dirty (playground nail) vs clean (kitchen knife)
– Immunization history (>10 yrs need booster or >5 yrs if contaminated)

• Tell pt to return in one day for recheck, for signs of infection (redness,
heat, pain, puss, etc), inadequate analgesia, or suture complications
(suture strangulation or knot failure with possible wound dehiscence)

• It should be emphasized to patients that they return at the appropriate

time for suture removal or complications may arise leading to further
scarring or subsequent surgical removal of buried sutures.
• Instruct about wound care
 Suture Removal
• Average time frame is 7 – 10 days
– FACE: 3 – 5 d
– NECK: 5 – 7 d
– SCALP: 7 – 12 days
– UPPER EXTREMITY, TRUNK: 10 – 14 days
– LOWER EXTREMITY: 14 – 28 days
– SOLES, PALMS, BACK OR OVER JOINTS: 10 days

• Any suture with pus or signs of infections should be

removed immediately.