Principles of use and abuse of suture

Principles of use and abuse of sutureByDr Kabiru SalisuSurgery Department AKTH

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OUTLINEIntroductionQualities of ideal sutureClassifications of suturePre operative suture handlingSelection of sutureUses of sutureSuturing techniquesTypes of wound closureSuture removalAlternatives to sutureConclusionReferences

INTRODUCTIONDefinition Suture is a strand of material used in surgery to approximate living tissues or structures until the normal process of healing is completeSuture are use to ligate vessels, appose anastemotic surfaces or close wounds

Surgery is licensed assault with the aim of achieving cure or palliation of a disease processHowever this assault is repaired by the use of sutureSound knowledge on how to use suture will prevent it abuse, and help surgeon to achieve his goal

Definition of termsTENSILE STRENGTH-measure of a material ability to resist deformation & breakageBREAKING STRENGTH-limit of tensile strength at which suture failure occursELASTICITY-measure of the ability to regain original form & length after deformationKNOT STRENGTH-amount of force necessary to cause a knot to slipMEMORY-inherent capability of suture to return to or maintain its original gross shape PLASTICITY-measure of ability to deform without breaking and to maintain a new form after relief of the deforming forcePLIABILITY-ease of handling of suture material; ability to adjust knot tension and to secure knots

BREAKING STRENGTH-limit of tensile strength at which suture failure occursCAPILLARITY-extent to which absorbed fluid is transferred along the sutureELASTICITY-measure of the ability to regain original form & length after deformationKNOT STRENGTH-amount of force necessary to cause a knot to slipMEMORY-inherent capability of suture to return to or maintain its original gross shape PLASTICITY-measure of ability to deform without breaking and to maintain a new form after relief of the deforming forcePLIABILITY-ease of handling of suture material; ability to adjust knot tension and to secure knotsSTRAIGHT-PULL TENSILE STRENGTH- linear breaking strength of suture materialSUTURE PULLOUT VALUE-applying force to a loop of suture located where tissue failure occurs measures the strength of a particular tissue.(Fat-0.2kg,Muscle-1.27kg,Skin-1.82kg, Fascia-3.77kgTENSILE STRENGTH-measure of a material or tissues ability to resist deformation & breakage5

History The earlier report of surgical suture dated back to 3000BC found on Egyptian mummySushruta an Indian physician 500BC was the 1st to describe wound suture and suture materialHippocrate descrive suturing techniqueAl-zahrani andalusian surgeon was 1st to report how to make absorbable suture from the intestine of sheep

Goals of suturing1- Provide an adequate tension of wound closure without dead space2- Maintain hemostasis.3- Permit primary intention healing4- Reduce postoperative pain 5- Provide support for tissue margins until they have healed 6- Prevent bone exposure resulting in delayed healing and unnecessary resorption7- Permit proper flap position

7but loose enough to obviate tissue ischemia and necrosis.

Qualities of the Ideal Suture Material 1- Pliability, for ease of handling2- Knot security3- Sterilizable4- Appropriate elasticity5- Non-reactivity6- Adequate tensile strength for wound healing7- Chemical biodegradability as opposed to foreign body breakdown8- Resistant to shrinking in tissueThis type of suture does not exist, thus surgeon must select the suture base on what they want to achieve

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Classification of suture

MonofilamentMultifilament (braided)Single strand of suture materialMinimal tissue traumaSmooth tying but more knots neededHarder to handle due to good memoryExamples: nylon, monocryl, prolene, PDSFibers are braided or twisted togetherMore tissue resistanceEasier to handleFewer knots neededExamples: vicryl, silk, chromic

Suture sizeThis denote the diameter of the sutureUSP gauge Various sizes: Os indicate size, the more is the Os the smaller Ex: 4-0 = 0000 which is smaller than 2-0 = 00Metric gauge;- uses numbers 1,2,3

1 - surgical gut (cat-gut)- Obtained from intestine of sheep- either plain or chromic - consist of highly purified collagen - The % of collagen in the suture determines its tensile strength and its ability to be absorbed by the body without adverse reaction.- Non collagenous material can cause a reaction ranging from irritation to rejection of the suture.

A- Plain surgical gutB- Chromic gut

is rapidly absorbed. Tensile strength is maintained for only 7 to 10 daysAbsorption is complete within 70 days.plain gut can be use in tissues which heal rapidly within 7days and require minimal support Plain surgical gut can also be specially heat-treated to accelerate tensile strength loss and absorption

Treated with a chromium salt solution to resist body enzymes, prolonging absorption time over 90 days.Rx change it from yellowish-tan to brown.Chromic gut sutures minimize tissue irritation, causing less reaction than plain surgical gutTensile strength may be retained for 10 to 14 days, with some measurable strength remaining for up to 21 days.

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2 - VICRYL(POLYGLACTIN 910) SUTURE

This is smoother synthetic absorbable suture Easy tissue passagePrecise knot placement Smooth tie downDecreased tendency to incarcerate tissue excellent knot security At 2 weeks, approximately 75% of the tensile strength remains.Approximately 50% of tensile strength is retained at 3 weeks Absorption is complete between 56 and 70 days.

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3- MONOCRYLThis monofilament suture features superior pliability for easy handling and tying It is virtually inert in tissue and absorbs predictably. MONOCRYL sutures can be use for procedures which require high initial tensile strength diminishing over 2 weeks postoperatively (e.g subcuticular closure) At 7 days, 50% to 60% of initial strength remains, reduced to 20% to 30% at 14 days strength lost at 21 days. Absorption is essentially complete at 91 to 119 days.

4- PDS (polydioxanone)Suture Comprised of the polyester poly (p-dioxanone)synthetic absorbable sutures It combines the features of soft, pliable, single-strand extended wound support for up to 6 weeks. It elicits only a slight tissue reactionsuited for many types of soft tissue approximation, including pediatric cardiovascular, gynecologic, ophthalmic, plastic, digestive, and colonic surgeries70% of tensile strength remains 14 days post-implantation Absorption complete within 6 months.

5- SURGICAL SILK

NATURALLY OCCURING NON ABSORBABLE SUTURESSuperior handling characteristics. Silk filaments can be twisted or braided, providing the best handling qualities Losses most of it strength in 1yr Thus, it behaves in reality as a very slowly absorbing suture.

5- NYLON SUTURE

monofilament strands characterized by high tensile strength extremely low tissue reactivity. They degrade in vivo at rate 15% to 20% per year by hydrolysis. Have good memoryused in ophthalmology and micro-surgery procedures in very fine sizes. For this reason, sizes 9-0 and 10-0 have an intensified black dye for high visibility.

7- PROLENE (POLYPROPYLENE)SUTURE

Widely used in general, cardiovascular, plastic, and orthopaedic surgery,PROLENE sutures do not adhere to tissue relatively biologically inert, offering proven strength, reliability and versatility.recommended for use where minimal suture reaction is desired, such as in contaminated and infected wounds to minimize later sinus formation and suture extrusion. They are available clear or dyed blue.

Surgical Stainless SteelThe essential qualities include;the absence of toxic elements,Flexibilityfine wire size. high in tensile strength, low in tissue reactivity, hold a knot well..

Disadvantages difficulty in handlingpossible cutting, pullingtearing of the patient's tissue fragmentation kinking.

Provided that the sutures do not fragment, there is little loss of tensile strength in tissues. Stainless steel sutures may also be used in abdominal wall closure, sternum closure, retention, skin closure, a variety of orthopaedic procedures, and neurosurgery20

Pre operative suture handling

Read labels. Heed expiration dates Open only those sutures needed for the procedure at hand Straighten sutures with a gentle pullDon't pull on needles. Avoid crushing or crimping suture strands with surgical instruments. Don't store surgical gut near heat. Moisten -- but never soak -- surgical gut. Do not wet rapidly absorbing sutures. Wet linen and cotton to increase their strength. Don't bend stainless steel wire. Draw nylon between gloved fingers to remove the packaging "memory." Arm a needle holder properly.

Selection of sutureSuture are no longer needed when wound has healed- Close slow-healing tissues (skin, fascia, tendons) with non absorbable sutures or a long-lasting absorbable suture. - Close fast-healing tissues (stomach, colon, bladder) with absorbable sutures.For Contaminated wound- Avoid multifilament - Use monofilament sutures Where cosmetic results are important; - Use the smallest inert monofilament suture materials (nylon, polypropylene). - Avoid using skin sutures alone (Close subcut). - Try and get Close apposition of skin edges

When a wound reaches maximal strength, sutures are no longer needed. Therefore: Close slow-healing tissues (skin, fascia, tendons) with nonabsorbable sutures or a long-lasting absorbable suture. Close fast-healing tissues (stomach, colon, bladder) with absorbable sutures. Foreign bodies in potentially contaminated tissues may convert contamination into infection. Therefore: Avoid multifilament sutures which may convert a contaminated wound into an infected one. Use monofilament sutures or absorbable sutures which resist harboring infection. Where cosmetic results are important, close and prolonged apposition of tissues and avoidance of irritants will produce the best results. Therefore: Use the smallest inert monofilament suture materials (nylon, polypropylene). Avoid using skin sutures alone. Close subcuticularly whenever possible. Use sterile skin closure strips to secure close apposition of skin edges when circumstance permits22

Suture selection cont.Foreign bodies may cause precipitation and stone formation- Use absorbable sutures in the urinary and biliary tracts. Regarding suture size: - Use the finest size suture commensurate with the natural strength of the tissue to be sutured. - Use retention sutures to reinforce appropriately sized primary sutures

Foreign bodies in the presence of fluids containing high crystalloid concentrations may cause precipitation and stone formation. Therefore: Use absorbable sutures in the urinary and biliary tracts. Regarding suture size: Use the finest size suture commensurate with the natural strength of the tissue to be sutured. Use retention sutures to reinforce appropriately sized primary sutures if the patient is at risk of producing sudden strains on the suture line postoperatively. Remove the retention sutures as soon as that risk is reduced.23

Uses of sutureHaemostesisWound closureTagging structuresTissue repairDevascularisation Closing defectObliteration of cavityAnastomosisAnchorage Application of circular stapler

Suturing technique

Suturing materialSurgical NeedleTissue forcepsNeedle holderStitch scissorsDrapesAntisepticsAneasthetics- Artery forceps

Surgical NeedlesMost of surgical needles are fabricated from heat treated steel Composed of three parts1- The eye or swaged end2- The body ; round, oval, rectangular, trapezoid, or side flattened3- The point which runs from the tip to the maximum cross-sectional area of the body. it could be cutting, taper, blunt

271- The eye which is swaged and permits the suture and needle to act as a single unit to decrease trauma2- The body which is the widest point of the needle and is also referred to as the grasping area. The body comes in number of shapes (round, oval, rectangular, trapezoid, or side flattened)3- The point which runs from the tip to the maximum cross-sectional area of the body. The point also comes in a number of different shapes (conventional cutting, reverse cutting, side cutting, taper cut,taper, blunt

Types of needlesNeedle eyeNeedle point

Needle Holder Selection1- Use an approximate size for the given needle. 2- Needle grasped3- The needle should be placed securely in the tips of the jaws and should not rock, twist, or turn

291-Use an approximate size for the given needle. The smaller the needle, the smaller the needle holder required2- Needle should be grasped one-quarter to one half the distance from the swaged area 3- The tip of the jaws of the needle holder should meet before remaining portion of the jaws

Needle Holder Selection

4- Do not over close the needle holder6- Pass the needle holder so it is always directed by the operator thumb

304- Do not over close the needle holder. It should close only to the first or second ratchet. This will avoid damaging the needle6- Pass the needle holder so it is always directed by the operator thumb

Placement of Needle in Tissue1-place needle at 90 to the skin when applying simple suture2- Force should always be applied in the direction that follows the curvature of the needle3- Suturing should always be from movable to a nonmovable tissue4- Avoid excessive tissue bites with small needle as it will be difficult to retrieve them

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Placement of Needle in Tissue6- Use only sharp needles with minimal force. Replace dull needles7- Never force the needle through the tissue8- Grasp the needle in the body 1/4 to 1/2 from the swaged area. Do not hold the swaged or the point area

32Use only sharp needles with minimal force. Replace dull needles7- Never force the needle through the tissue8- Grasp the needle in the body one-quarter to one-half of the length from the swaged area. Do not hold the swaged area; this may bend or break the needle. Do not grasp the point area as damage or notching may result

Placement of Needle in Tissue9- Avoid retrieving the needle from the tissue by the tip. This will damage or dull the needle10- Suture should be placed in keratinized tissue whenever possible11- An adequate tissue bite is required to prevent the flap from tearing

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Knot application1- The completed knot must be tight, firm, and tied so that slippage will not occur2- To ovoid wicking of bacteria, knot should not be placed in incision lines3- Knots should be small and the ends cut short (2-4mm)4- Avoid excessive tension to finer gauge materials as breakage may occur

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types of knots

The Aberdeen knot

(a) After the last suture has beeninserted, it is drawn through until there is only a small loop. Thesurgeon passes his or her index finger and thumb through the loop tograsp the suture and pull it through to form the next loop. (b) As eachnew loop is formed, the previous loop is allowed to close to form thenext layer of the knot. (c) Finally, the end of the suture rather thana loop of it is passed through the loop and the knot tightened.36

Other Principles to note No touch technique should be employed to avoid needle stick injuryAvoid using a jerking motion, which may break the suture Avoid crushing or crimping of suture materials by not using hemostats or needle holders on them except on the free end for tying Do not tie suture too tightly as tissue necrosis may occur Knot tension should not produce tissue blanching Maintain adequate traction on one end while tying to ovoid loosing the first loop

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ligatureA suture tied around a hollow organ to occlude the lumen is called a ligature or tie. used to effecthemostasis (close vessel) or prevent leakage eg intestine. Types;1- free tie ( free hand)2- tranfixation (stick tie)

Types of wound closure

The Primary Suture LineThe primary suture line is the line of sutures that holds the wound edges in approximation during healing by first intention- continuous suture (running suture)- Interrupted suture- Buried suture

Continuous Sutures Also referred to as running stitches, continuous sutures are a series of stitches taken with one strand of material. The strand may be tied to itself at each end, or looped, with both cut ends of the strand tied together

Interrupted sutureInterrupted Sutures -- Interrupted sutures use a number of strands to close the wound. Each strand is tied and cut after insertion. This provides a more secure closure AdvantageSome sutures can be remove without disruption of the whole suture line.Disadvantagedslower to insert

This provides a more secure closure, because if one suture breaks, the remaining sutures will hold the wound edges in approximation43

Simple interrupted sutureEasy to applyMost common suture techniqueEmployed were laceration is not deep or after application of subcutaneous suture

Mattress suturesApposes skin edges tidilyEnsure eversion help to close the dead space in the subcutaneous fat layer They are slower to insert than simpleNo need of subcutenous sutures before closing skinHorizontal mattress useful were closure is require under tension

Vertical mattressHorizontal mattress

Buried SuturesBuried sutures are placed completely under the epidermal skin layer. They may be placed as continuous or interrupted sutures and are not removed postoperatively-Purse string suture-Sub cuticular suture

The Secondary Suture Line

A secondary line of sutures may be usedTo reinforce and support the primary suture lineeliminate dead space and prevent fluid accumulationTo support wounds for healing by second intention. For secondary closure following wound disruption when healing by third intention.Examples; retention, stay, or tension sutures

Principles for Suture Removal1- The area should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood, and serum from about the sutures2- A sharp suture scissors should be used to cut the loops of individual or continuous sutures3- Instrument can be use to lift the knot

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Suture removal time tableFace 3-5daysScalp 5daysTrunk 7-10daysArm and legs 7-10daysFoot 10-14days

Alternatives to suture materialsother wound closure materials include;Adhesive tape Surgical staplesTissue glues

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ADHESIVE TAPESAre used to approximate;Lacerationsskin incisions complement suture or staple closures support in selected operative proceduresAre effective when tensile strength & resistance to infection are not critical factors

Adhesive tape cont.Advantages: Excites minimal tissue reaction rapid application little or no discomfort low costno risk of needle injurydo not cause tissue ischaemia or necrosisDisadvantages: Relatively poor adherenceeasily removed cannot be used over oily or wet areasAFTER CAREIt should be left in place as long as sutures would be left keep it as dry as possible Non adherent dressing covering during the 1st week

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STAPLING DEVICESSaves timeSimultaneous closure of suture lineUniform tensionNo trauma of suture pointsGood HaemostasisNo tissue reaction Disadvantagescost

Circular stapplerLinear stappler

Tissue glue Glues can be used to close the skin edges of low tension woundsButylcyanoacrylate it forms a transparent & flexible bond reducing the risk

Indications:Surgical incisionspunctures from minimally invasive surgicalSimple thoroughly cleansed trauma-induced lacerationfistulasAdvantagesRapid strength & security to woundseals out bacteriapromotes a moist healing environmentprovides cosmetic resultsContraindication wounds subject to significant static or dynamic tensions.

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Placement of glue

Conclusion Most achievement in surgery relied on proper use of suture base on accepted principles.Any use of sutures without following principle is an abuse of suturesSound knowledge of principle of use of sutures and adherence to them will prevent abuse of suture

References Normanns S. williams: Baily and loves short practice of Surgery, edward & arnold ltd, 2008 farquharsons M. and Moran B. : farquharsons text book of operative surgery, edward & arnold ltd, 2005Davis JH: Clinical Surgery, CV Mosby Co., 1987Philips Mshalbwala: suture and staples, WACS basic skill course pptSean wilson MD: basic suturing lecture pptAmerican College of Surgeons, Altemeier WA, et al (eds): Manual on Control of Infection in Surgical Patients, Philadelphia: Lippincott, 1976Sameer mokeen MD: suture and suturing, King saud University, Riyard