INTRODUCTION

Suture
 known as stitches
 A piece of thread like material used to secure wound
edges or body part together after an injury or surgery.
 A variety of suture exists in size, strength and durability.
Stitches placed deep inside the wound always requires the
use of dissolvable (absorbable) sutures.
stitches visible on the skin (placed superficially) may use
dissolvable or non-dissolving (non-absorbable) sutures.
 Terminologies of sutures
A. Monofilament suture
- a single strand
- non capillary (Resistant to fluids soaking into the suture).

B. Multifilament suture
- multiple strands of suture held together by a process of
twisting, braiding of spinning the material.
- All have certain capacity to absorb body fluid(capillarity),which
elicits a higher degree of tissue reaction.
- Also classified as Type A.
 Features of ideal suture material

• Adequate tensile strength

• Good knot holding property
• Should be least reactive
• Easy handling property
• Should have less memory
• Should be easily available and cost effective
 Suture Classification
1. Absorbable sutures
 capable of being absorbed by living mammalian
tissue.
 Can be treated to modify resistance to
absorption, source is both natural and synthetic.
 Tissue interaction: are digested by body
enzymes by first losing their strength then
gradually disappearing form the tissue.
 Uses of absorbable suture materials
• In bowel anastomosis like gastrojejunostomy,
resection and anastomosis.

• In cholecystojejunostomy (CCJ), choledocho-jejunostomy

(CDJ), pancreaticojejunostomy. -Vicryl is used.

• In suturing muscle, fascia, peritoneum, subcutaneous

tissue, mucosa.

• In ligating pedicles. 1-zero chromic catgut or vicryl are used, e.g.

ligation of pedicles during hysterectomy
• In circumcision, usually 3-zero plain or chromic catgut are used
 EXAMPLES OF ABSORBABLE SUTURE
MATERIALS
1. Plain catgut
- derived from submucosa of jejunum of sheep.
- yellowish white in colour.
- absorbed by inflammatory reaction and
phagocytosis- (absorption time is 7 days.)
- used for subcutaneous tissue, muscle,
circumcision in children.
 2. Chromic catgut
- is catgut with chromic acid salt.
- brown in colour.
- absorption time is 21 days.
- used for suturing muscle, fascia, external
oblique aponeurosis, ligating pedicles, etc.
 3. Vicryl (Polyglactic acid):

- synthetic absorbable suture material.

- absorbed in 90 days.
- Absorption is by hydrolysis.
- violet in colour (braided).
- multifilament and braided.
- for bowel anastomosis, suturing muscles,
closure of peritoneum.
 4.Dexon (Polyglycolic acid)
• is synthetic absorbable
• suture material like vicryl.
• creamy yellow in colour (braided).
5. Maxon (Polyglyconate) monofilament.
6. PDS (Poly Dioxanone Suture material)
 absorbable suture material.
 creamy in colour
 Have properties like vicryl.
 costly but better suture material than vicryl.
7. Monocryl (Polyglecaprone)
monofilament
8. Biosyn (Glycomer) monofilament.
 2.Non Absorbable sutures
 material not affected by enzyme activity or absorption
in living tissues and are natural and synthetic sources.
 Tissue interaction: become encapsulated in fibrous
tissue during the healing process and remains
embedded in body tissues unless they are surgically
removed.
A.Class 1-silk or synthetic fibers of monofilament,
twisted of branded construction.
B.Class 2 -cotton or linen fibers or coated natural or
synthetic fibers. The coating forms a thickness, yet
does not contribute to its strength.
Uses of non-absorbable suture materials:

• In herniorrhaphy for repair

• For closure of abdomen after laparotomy
• For vascular anastomosis (6-zero), nerve
suturing, tendon suturing
• For tension suturing in the abdomen
• For suturing the skin
Examples of nonabsorbable suture
materials:
1. Silk
- natural, multifilament, braided, non-
absorbable
- derived from cocoon of silkworm larva.
- black in colour.
- coated suture material to reduce capillary
action.
 2. Polypropylene (Prolene)
- synthetic, monofilament suture material.
- blue in colour.
- has high memory. (Memory of suture material
is recoiling tendency after removal from the
packet. Ideally suture material should have
low memory.)
- (Prolene mesh used for hernioplasty is white
in colour).
 3.Polyethylene (Ethylene)
• synthetic monofilament
• nonabsorbable suture material.
• black in colour.
4. Cotton
- twisted multifilament natural
- Nonabsorbable suture material.
- white in colour.
5. Linen
- derived from bark of cotton tree.
6. other nonabsorbable suture materials.
- Steel, Polyester, Polyamide, Nylon are
 CLASSIFICATION II
A. Natural
• Catgut.
• Silk.
• Cotton.
• Linen.
B. SYTHETIC
• Vicryl, dexon, PDS, maxon.
• Polypropylene, polyethylene, polyester,
polyamide.
CLASSIFICATION Ill
• Braided:
- Polyester, polyamide, vicryl, dexon, silk.
• Twisted:
- Cotton, linen.
CLASSIFICATION IV
• Monofilament: Polypropylene, polyethylene, PDS,
catgut, steel.
• Multifilament: Polyester, polyamide, vicryl, dexon,
silk, cotton.
 CLASSIFICATION V

• Coated.
• Uncoated.
NUMBERING OF SUTURE MATERIAL

• 3-Thickest-For pedicles
• 2-Thick. For pedicle ligation.
• 1-
• 0-zero.
• 1-zero(1/0)
• 2-zero. For bowel suturing.
• 3-zero.
• 4-zero.
• 5-zero. For vascular anastomosis.
• 6-zero.
• 7-zero.
• 8-zero.
• 9-zero. For ophthalmic surgery. Requires operating microscope.
Different sizes on sutures
TYPES OF SUTURING/TECHNIQUE

• Continuous suturing
• Interrupted simple suturing
• Interrupted mattress suturing
• Sub-cuticular suturing
• Horizontal tension suturing
• Vertical tension suturing
 TYPES OF KNOTS

 Reef knot
 Granny knot
 Surgeon's knot

REQUIREMENTS FOR SUTURING

RERE
 Types of Needles
May be classified as:
• Round body
• Cutting needle
OR
• Curved
• Staright-rare
Round body
Round body
Cutting
 Some Guidelines for suturing and removal
•  Scalps :- Ethilon suture size 3.0
• Removal time :- 7 days
•  Upper Limbs :- Ethilon suture size 4.0
• Removal time :- 8-10 days
•  Lower Limbs/ Trunk :- Ethilon suture size 4.0
• Removal time :- 10/14 days
•  Faces :- Ethilon suture size 6.0
• Removal time :- 5 days
• etc
DRAINS & TUBES
A drain
- is a created channel which allows any fluid
collected, to come out after closure of the
main wound.
TYPES OF DRAINS

1. Corrugated rubber drain:

 drains by capillary action and gravity.
 cheaper and technically easier.
 allows soakage of dressings
 causes discomfort to the patient.
2. Tube drains:
- Malecot catheter can be used as a tube drain.
- Penrose soft latex rubber tube.
- Multiple perforated tubes.
3. Closed suction tube drain system.
4. Glove drain.
5. Wick drain
- a gauze drain to drain pus, discharge,etc.
6. Sump drain:
-here parallel air vent prevents the
adjacent soft tissues from being sucked into
the drain when negative pressure is applied.
Closed suction tube drain system.

• There is a sharp metallic introducer to pass

the tube into the required area after
puncturing the skin.
• used for thyroidectomy, mastectomy, radical
dissection, wide excisions, flap surgeries, etc.
 ADVANTAGES OF TUBE DRAINS

• Quantity of fluid like bile, pus can be measured

• It can be kept for longer time
• Skin excoriation will not occur
• Patient remains more comfortable
• Infection rate is less
• Removal is easier
• Dye can be injected and cavity or
communication can be assessed using 'C-ARM'
ADVANTAGES OF SUMP DRAIN
• No drain blockade
• Resists collapse of the structure when suction is
applied.
USES OF SUMP DRAIN
• Collection of irritant discharges
( enterocutaneous fistula)
• Collection of secretions having activated
enzymes (high small bowel, pancreatic fistula)
• Draining proximal stump in TEF with esophageal
atresia to prevent aspiration
 Classification of Drain Systems

1. Open (static) drain: E.g corrugated drain, penrose drain.

Infection rate is higher.
2. Closed siphon drain: drain is connected to a sterile bag
with or without one-way valve. It reduces the infection.
3. Closed suction drain: negative pressure of -100 to -500
mmHg is used to create vacuum to drain the secretions.
4. Sump suction drain: negative suction with a parallel
air-vent is used to prevent the adjacent soft tissues
being sucked into the lumen of the drain.
5. Under water seal drain to drain pleural space.
 Indications for drains

 In drainage of an abscess
 In bleeding surgical conditions like trauma,
peroperative bleedIn haemo, pyo or pneumothorax
 In acute abdominal conditions like peritonitis,
haemoperitoneum
 In major abdominal surgeries like of pancreas,
biliary tree, stomach, etc.
 In thyroid surgery
 In hydrocele surgery
 Problems in Drains

• Infection can occur through the drain.

• Displacement.
• Failure to drain adequately and can give a false
information.
• may interfere with healing process inside.
COMMON DRAIN TUBES
1. Romovac suction drain.
-used in thyroid surgery
2. Foley's catheter
-the normal two way catheter with a ballooning area in
the tip.
3. Malecot's catheter:
-a single way catheter with a balloon in the tip
4. A Three way Catheter.
- for bladder irrigation.-
5. Simple red rubber catheter:
FEEDING TUBES
1. Ryle'stube ( NG Tube)
 one meter long
 made of red rubber or plastic.
 has got three lead shots in the tip which makes it radiopaque.
 facilitates easy passage of the tube through the oesophagus.
 has got markings at different levels:
• At 40 cm distance, at the level of gastro-oesophageal
junction.
• At 50 cm distance, at the level of body of the stomach.

• At 60 cm distance, at the level of the pylorus.

• At 65 cm distance, at the level of the duodenum.
 Indications of NG-Tube

a) . Diagnostic:
• For gastric function tests- To assess free acid
and total acid
• Hollander's test for completion of vagotomy
• To diagnose trachea-oesophageal fistula
• Baid test for pseudocyst of the pancreas
b). Therapeutic:
• In acute abdominal conditions like peritonitis/
obstruction
• In abdominal trauma
• After abdominal surgeries
• In pyloric stenosis
• In upper GIT bleeding
• In paralytic ileus
• For feeding purpose in conditions like comatose
patients, faciomaxillary injuries, major head
and neck surgeries
 2. INFANT FEEDING TUBE

- no lead shots and markings on the tube.

- used for feeding purpose in infants who is
under coma, with facio-maxillary injuries and
anorexia.
Other Tubes

1.KEHR'S 'T' TUBE

• used after opening CBD ( choledochotomy). CBD is
closed with 'T" tube placed in the CBD.
• made up of latex or red rubber.
• has got horizontal part which is placed in the CBD and
vertical part which is allowed to come out, to drain
bile.
NOTE: - Amount of bile draining daily is measured.
-Before removal of the "T" tube, patency of CBD
should be confirmed.
2. Flatus tube
• made up of India rubbe r45 Cm in length.
• one opening in the tip and another on the side
proximal to the tip.
• used in sigmoid volvulus to decompress and derotate in
paralytic ileus; in subacute intestinal obstruction.
• passed per anal into the recto-sigmoid area.
• Proximal end is connected to water container to
observe the quantity of air bubble which signifies the
amount of gas getting deflated.
• NOTE: (Urinary catheter like red rubber catheter has
no opening in the tip, only side opening is present). i.e
different from the Flatus tube.
 URETHRAL DILATORS
• lister's urethral dilator
- got olive tip
- used to dilate stricture urethra.
• Clutton's dilator
• filiform bougies.
 -

GOD BLESS YOU