sutures and mesh

SURGICAL SUTURES AND MESH

PRESENTED BY DR ANKUR GOELGUIDE DR T.R.CHIKKANNACHARI

CO-GUIDE DR APARAJITA MOOKHERJEE

Abdominal Incisions

History of Sutures

Animal sinew such as tendons and ligaments were the first recorded sutures.

Egyptian literature mentions the use of linen strips coated with a mixture of honey and flour

Sushruta described sutures and needles for the first time

History of Sutures

Early wound closure devices were made of natural materials such as flax, silk, linen strips, and cotton. These natural materials were lubricated in oil and wine prior to application so as to reduce tissue drag and create a cleaner wound closure procedure

Another early form of a wound closure technique involved the use of the mandibles of soldier ants

History of Sutures

Galen, a Roman surgeon, first commented on using catgut as a suture material

Lister first used sterilized suture material by using carbolic acid and then presenting the suture material in a glass tube

Halsted is still remembered for his rules of surgery advocating gentle handling of tissues, meticulous haemostasis, and interrupted silk sutures

History of Sutures

By 1900 the catgut industry was firmly established in Germany due to the use of sheep intestines in their sausage industry

George Merson developed atraumatic sutures

1940s- uniform preparation and sterilization of sutures

1950s- sutures attached to pre attached needles

1960s- synthetic absorbable sutures introduced

Definition of Suture

The word suture describes any material used to approximate tissue edges together or ligate blood vessels.

A suture attached to a needle is called as a ‘Stick tie’

A single strand of suture handed to the surgeon is called a ‘Free tie’

A free tie placed on the tip of a forceps or an instrument is called a ‘Tie on a passer’

Atraumatic sutures

When a suture is attached to an eyeless needle, it is called an atraumatic suture.

Developed first by George Merson of Edinburgh. Hence these sutures are also called as ‘Mersutures’ in his memory.

Suture size

Defined by US pharmacopoiea The size reflects suture diameter As the suture number increases,

suture diameter decreases Suture size is selected on the basis

of tissue being sutured The smallest size required should

always be chosen to reduce injury to the tissue.

Knot strength

Measured as force in pounds a suture will withstand before it breaks when knotted

The tensile strength of the suture material should not exceed the tensile strength of the tissue.

Characteristic of Ideal suture material Sterile and cost efficient Non electrolytic, not allergenic, non carcinogenic Inert Easy to handle Capable of securely holding the tissue layers

throughout the healing process Minimally reactive to tissue Absorbed completely with minimal tissue reaction once

the wound is healed Should have uniform diameter Should have adequate tensile strength until the

purpose is overUnfortunately an ideal suture material does not exist.

Suture strands

Monofilament Multifilament

Goes through the tissue with less drag or resistance

Less chance of suture line infection- hence suture of choice for vascular surgeries

Greater chance of getting crushed

Several strands braided together

Greater tensile strength, pliability, flexibility

Are coated to reduce the drag

May act as a cove for organisms, hence never used in infected wounds

Suture strands

Monofilament Multifilament

Due to its smoothness, knots more likely to slip

No fraying of the ends on cutting

Less tissue reaction

Eg. Prolene, PDS II

Knots are more secure Fraying on cutting

edges

Eg Vicryl, Silk

Cross section of sutures

Sutures

Absorbable suturesNon absorbable sutures

Are digested by enzymes and phagocytosed eg. Catgut

Or get hydrolysed and removed by phagocytosis eg. Vicryl

Are used to hold the wound edges in approximation temporarily until the wound is healed sufficiently to withstand normal stress

Are used to suture at sites where tensile strength needs to be maintained for at least a year

Made of non biodegradable materials that are ultimately encapsulated or walled off by body’s fibroblasts

Sutures

Absorbable suturesNon absorbable sutures

Are used to suture internal structures in the body where suture removal is not possible/feasible

Eg. Catgut, Vicryl

Are used at exposed sites in the body from where they can be removed whenever needed eg. Skin

Eg. Nylon, Silk, polypropylene

Classification of suture materials

Monofilament Natural Absorbable

Catgut Synthetic Absorbable

Monocryl Caprosyn Biosyn Maxon PDS II

Non absorbable Synthetic

Polypropylene(prolene) Nylon (ethilon) Stainless steel

Polyfilament Absorbable

Natural Synthetic

Polyglactin (Vicryl) Dexon II Bondek

Non absorbable Natural

Cotton Silk

Synthetic Nurolon Mersilene Tevdek

Catgut

Catgut

Natural absorbable surgical suture It is a brand name- manufactured by

Ethicon division f Johnson and Johnson; other similar sutures include Trugut, Progut, etc.

It is 99% collagen Absorbed by enzymatic digestion by

proteolytic enzymes Easy to handle and knots well

Catgut

Derived from submucosa of sheep’s intestine or serosa of cattle’s intestine. The layers of intestine are scraped off to leave only submucosa. It is then treated by a fat solvent to wash of any fat. It is then dried and cut into various size. This is plain catgut.

Catgut

If this is further treated with 20% chromic acid, it is called chromic catgut. Chromic acid increases the tissue life of the suture and thereby the tensile strength of the suture is maintained for a longer time.

Sterilized with gamma radiation and packed with isopropyl alcohol.

Plain Catgut

Loses 50% tensile strength in 3 days and 100% strength by 15 days

Gets completely absorbed in tissue by 60 daysUses: 1. To tie small subcutaneous vessels2. To approximate subcutaneous tissue during

closure of incision3. In circumcision to suture the cut margins of

the prepuce4. To repair the wound of lip or the oral cavity.

Chromic Catgut

Loses 50% tensile strength in 7 days and 100% strength by 28 days

Gets completely absorbed in tissue in 90-100 days

Uses1. To suture muscles, bowel anastomosis,

peritoneum2. During appendicectomy, to tie the

mesoappendix and the base of appendix3. The inner layer during two layer anastomosis

of the small gut or anastomosis during gastrojejunostomy

Chromic Catgut

4. During cholecystectomy, to stop bleeding from gall bladder bed.

For most of the above said uses however, polygalactin sutures are replacing catgut.

Polyglecaprone 25 (Monocryl)

Monofilament Copolymer of 75%

glycolide and 25% caprolactone

Undyed or dyed violet Double the strength of

chromic catgut Good handling

properties and smooth surface- easy passage through tissue

Monocryl

Tensile strength maintained for 21 days and absorbed in 90-120 days by hydrolysis

Is sterilized by ethylene oxide

Uses1. Can be used instead

of catgut2. Intestinal anastomosis3. For closure of

peritoneum4. Subcutaneous tissue

apposition5. Urological procedures-

pyeloplasty, ureter repair

Polydioxanone Suture (PDS-II)

Polymer of paradioxanone Is dyed violet Is soft pliable and smooth

and allows easy passage through tissues.

Tensile strength maintained for about 8 weeks and complete absorption in 180-210 days

Well suited for paediatric, CVS, orthopaedic, ophthalmic, plastic and gastro-intestinal surgeries

Polypropylene( Prolene)

Synthetic monofilament non absorbable suture

Is inert with extremely low tissue reactivity

Low coefficient of friction, so it passes through the tissue plane easily.


The suture can extend upto 30% before breaking and hence is useful in situations where post operatively some elasticity is required on the part of the suture to accommodate post operative swelling and thereby helps prevent tissue strangulation.

High tensile strength for an indefinite period of time


Uses In repair of posterior inguinal wall in

hernia operations Closure of skin incisions Repair tendon injuries Single layer closure of abdomen in case

of intra abdominal infections/ obese patients

To secure prolene meshes

Polyamide (Ethilon)

Synthetic, non absorbable, monofilamentous

Very low coefficient of friction; hence passes through the tissues easily

Minimal tissue reaction

High tensile strength

Loses 25 % tensile strength after 1 year

Knot security is poor

Ethilon

Uses Closure of skin

incision For hernioraphhy Vascular surgery

Stainless Steel Suture

Is composed of 316L stainless steel conforming to American Society for Testing and Materials

Available in precut lengths

Very high tensile strength

Non needled or affixed to needles with permanent attachment techniques or by ROTOGRIP

Get encapsulated by fibroblast inside the body


Indicated for abdominal wound closure, intestinal anastomosis, hernia repair, sternal closure and some orthopedic procedures like tendon repair

Contraindicated in people with known metal allergies

May interfere with certain radiodiagnostics


Requires expert technique for suturing

Sterilized by autoclaving

Polyglycolic acid suture (dexon)

Delayed absorbable polyfilament

Green in colour Maintains tensile

strength for about 30 days and gets absorbed in 80-90 days

Dexon is a brand name for the suture synthesized by US surgical. Other brand names are Petcryl and Maxon.

Polyglactin 910 Sutures (Vicryl)

Polygalactin Sutures (Vicryl)

Is a copolymer of glycolide (90%) and lactide (10%)

Is digested by hydrolysis and not enzymatic reaction, hence there is less tissue reaction

Tensile strength lasts for 28-30 days and gets completely absorbed by 80-90 days.

Vicyl is a brand name for the polyglactin suture made by Ethicon. Other analogues are Truglyde, Centricryl and Safil.

Dexon and Vicryl

Uses1. Indicated in all the situations where

catgut is used2. Better suited than catgut to suture

infected wounds

Disadvantages3. Fraying of ends4. Roughness

Vicryl Rapide Suture

Polyglactin 910 irradiated with gamma rays

This leads to a suture material with a lower molecular weight and hence faster absorption

Vicryl Rapide Suture

Maintains tensile strength for 10-12 days and absorbed by 42 days

Is undyed Use1. Subcuticular

suturing2. Mucosal sutures3. In circumcision4. Episiotomy repair

Silk

Natural non absorbable braided suture

Dyed black Derived from cocoon

of silk worm larva. Is covered with a an albuminous layer which is removed during processing by a process called degummation.

Silk

Handling property is very good and knots securely

Maintains tensile strength for a long time (2 years)

Is supplied as a reel or over atraumatic needles (as Mersilk)

Sterilized by gamma radiation/ autoclaving

Loses tensile strength when wet

Causes tissue reaction leading to PMN infiltration and fibrous capsule formation around the silk

Although classified as non absorbable, it loses its tensile strength in 1 year and cannot be detected after 2 years, hence may be re-classified as delayed absorbable suture

Silk

Uses In cholecystectomy to ligate cystic duct and cystic

artery Ligating mesenteric vessels during bowel resection To ligate pedicles in nephrectomy and splenectomy Ligation of Vagus nerve trunks during trunkal

vagotomy May be used for skin closure To repair posterior wall of inguinal canal during

hernioraphy To secure drains/ tubes

Cotton

Weakest non absorbable suture Gains tensile strength when wet Indicated for retracting vessels in

CVS or pediatric surgeries For tying off umbilicus in newborns

SOFSILK

Multifilament, non absorbable, natural Composed of natural, proteinaceous silk

fibres called fibroin obtained from silk worm (Bombyx mori)

Black colour Lubricated with wax or silicon Used in CVS, ophthalmic or neuro-

surgery CI- Kidney, Urinary bladder surgeries as

it is a nucleus for stone formation

Misc multifilament non absorbable sutures Ethibond excel suture- ethylene

terephthalate Mersilene- ethylene terephthtalate Surgilon- Nylon 6 coated with silicon Nurolon- Nylon 6 Ti-Cron- Braided polyester suture

Used in CVS, ophthalmic and neuro-surgeries

Tevdek/ Polydek

Made of PTFE Makes the suture

inert and reduces tissue reactivity

Originally designed for heart valves implantation

Dyed green and white

Tevdek/ Polydek

Surgidac

Braided, polyester, non absorbable made of ethelyne terephthalate

Used for general tissue approximation, cardiovascular, ophthtalmic and neuro surgeries

Undyed or dyed green

SUTURE NEEDLES

Things to consider…

… while chosing a needle type for suturing

Type of needle- Type of tissue being closed

Curvature of the needle- based on working space in operative field

Needle material

Initially stainless steel needles were being used

Now we use Surgalloy- a high nickel stainless steel Gives it better resistance to bending and

breakage

Anatomy of the needle

Chord length- straight line distance from point of curve to swage

Needle length- the entire length of the needle

Radius- distance between the centre of the circle to the body of the needle if the curved needle were to make a full circle

Diameter- thickness of the needle

Anatomy of the needle

Swage: This is the suture attachment end creates a single, continuous unit of suture and needle. This may be designed to allow easy release of the needle and suture material (pop-off)

The surgical needle may be coated with silicone to allow easier tissue passage.

Structure of suturing needle

Types of suture needles


Round bodied minimises the tissue trauma because the

needle pierces the tissue without cutting it used for suturing peritoneum, abdominal

viscera, myocardium, dura Cutting needle

Have two opposing cutting edges Designed to cut through tough difficult to

penetrate structures Used in plastic surgery, especially of the

face


Reverse cutting needle Designed with cutting

edge on the outer convex side

For skin, oral mucosa, tendon sheaths

Blunt needles To dissect to friable

tissue rather than cutting through it

For suturing liver and kidney


DermaX needle By Syneture Contains four cutting

edges with a double point tip

Moves smoothly with precision

Better control through subcuticular/ cuticular tissues like forehead, eyelid, nose, chin breast

Shapes of sututre needles

Packaging of sutures

Two layer cover to allow sterile field Outer cover is made of laminate

packing and is heat sealed Inner cover is different for

absorbable and non absorbable sutures

Because absorbable sutures need to be protected from atmospheric moisture, they are heat sealed in aluminium foils.

SUTURING TECHNIQUES

Simple suture

Interrupted suturing

Vertical Mattress suture


Horizontal Mattress Suture


Continuous suturing

Subcuticular suturing

Particularly useful in patients where keloid formation may be suspected.

Running closure (Baseball stitch)

Where wound edges approximate easily and where a straight incision is being approximated

Not done where collection is suspected

Running lock closure

Similar to Running closure except that the stitch is locked before giving the next stitch

Purse string suture

Placed in a circular motion around a lumen and then tightened to invert the opening

Given around the stump of appendix once appendicectomy has been done

In bowel end to end anastomosis

Traction sutures

Used to retract tissues that is not easily held back with a conventional retractor

Eg. In myocardium, sclera of the eye, tongue

Retention suture/ Stay suture

Placed at a distance from primary suture to relieve tension on the primary line

Placed on skin, subcutaneous tissue or fascia

Used for those patients where slow healing is expected

Used as preventive to avoid primary wound disruption

Removed after the tension in the affected area is decreased

Secondary line suture

Used to support the primary line suture, eliminate dead space or prevent fluid accumulation in an abdominal wound

Figure of eight stick tie

Indicated for larger vessels or tissue pedicels

To prevent knot slippage To stop haemorrhage

Timing of Suture Removal

Wound location Timing of removal (days)

Face

Scalp

Arms

Trunk

Legs

Hands or feet

Palms or soles

Three to five

Seven to 10

Seven to 10

10 to 14

10 to 14

10 to 14

14 to 21

TYPES OF KNOTS

Reef Knot

Surgeon’s knot

Granny knot

Principles of knot tying

Ensure that the knot is firm enough to eliminate slippage

Make sure that the knot is as small as possible and the free ends are as short as feasible

Avoid damaging suture material while handling

Avoid excessive tension Do not tie the knots too tightly- prevent

strangulation of tissue

NEWER TECHNIQUES

Surgical Staples

Surgical Staples

Basic principles Preservation of adequate tissue

vascularization Creation of adequate lumen Prevention of leaks and fistulas Evading of tissue tension Haemostasis

Surgical Staples

Advantages Less tissue reaction Accelerated wound healing Efficiency Less anesthesia and intra operative time

Surgical Staples

Types of staplers Linear stapler- used for closure of a linear

wound Circular or intraluminal staplers- used in GI

surgeries for end-to-end, end-to-side, side-to-end or side-to-side anastomosis. They offer a circular, double staggered row of staples.

Ligating and dividing stapler- issues a double row of two staples and ligates the tissue. The tissue can then be divided between the staple lines.

Surgical Staples

Purse string suture clamps- for placement of purse string sutures.

Skin staplers- to approximate skin edges.

Endoscopic staplers

Skin stapler

Purse string stapler

Fibrin Glue

Synthesized from bovine blood• Uses• Used to control bleeding and approximating

tissues that are difficult to approximate by suturing, eg. Liver, spleen and lung.

• Microsurgical anastomosis of blood vessels• Used in Cardiopulmonary bypass surgery• Repair ocular implants• Close superficial lacerations and fistula• Repair dural tears

Surgical Glue

Made of cyanoacrylate

For adhesion of superficial lacerations

III COSEAL Surgical sealant

Completely surgical vascular sealant Used in vascular surgeries as an

adjunctive haemostat Seals immediately It is not a substitute for sutures,

staples but an adjunct No contraindication Should not be injected into vessels

IV Vessel Sealing technology (LigaSure)

Vessel Sealing technology (LigaSure) For ligating vessels and tissue bundles Works by fusing the collagen and elastin

fibres in vessels to seal the blood flow It uses ‘Instant Response Technology’- It is a

feedback controlled response system that diagnoses the tissue type in the jaws of the instrument and delivers the appropriate amount of energy to effectively seal the vessel or tissue bundle.

Thermal spread upto 1mm No sticking or charring of tissue.

Ligasure

LigaSure

Adhesive skin closure tapes/strips

Adhesive skin closure tapes/strips Made of nylon or polypropelene Used to reinforce subcuticular skin

closure or to approximate wound edges of small incisions or lacerations

Minimal tissue reactivity Low rate of infection No ischemia or necrosis Is gentler to the skin than needle May have an additional microbiocidal

Adhesive skin closure tapes/strips Disadvantage-

cannot be used in presence of moisture/ infection/ oily surface/ hairy surface/ skin under tension

Eg Dermabond/ Indermil

SURGICAL MESH

Surgical Mesh

Surgical mesh is a woven fabric used for chest wall reconstruction, strengthening tissues, provide support for internal organs, and to treat surgical or traumatic wounds.

The most common types of surgical mesh are hernia mesh, stress urinary incontinence slings and mesh for treating prolapse.

Surgical Mesh

Titanium mesh has been used in some back surgeries

As with any surgical implant, some complications can occur, including infection, inflammation, tissue damage, and septic shock.

Surgical Mesh

Hernioplasty with living FasciaMacArthur’s operation A strip of fascia 1.25 cm wide was cut

from external oblique aponeurosis The strip was left attached to at the

pubic end and cut from where the aponeurosis becomes muscular

The free end was attached to a needle with a wide eye ( Gallie’s needle)

The living mesh was darned into the posterior wall of the inguinal canal

Surgical Mesh

Gallie’s GraftIf external oblique

aponeurosis is thin/friable, tensor fascia lata cut from the outer side of the thigh and grafted over the posterior wall of the inguinal canal

Tantalum Gauze- made of wire darn (filigree)

Surgical Mesh

Hernioplasty with a skin graft (Mair’s procedure)- A full or a partial thickness graft was harvested and sutured to the posterior wall of inguinal canal.

Side effects: formation of cysts/ dermoid cyst.

Synthetic meshes- Non absorbable Polypropylene mesh

Monofilament Inert; can be used in presence of infection Good elasticity and high tensile strength Non absorbable Used for

Hernia repair Abdominal wall construction

Sterilized by gamma radiations Fixed with prolene sutures

Synthetic meshes- Non absorbable Polyglactin 910(vicryl) mesh

absorbable mesh that offers temporary support during wound healing

PTFE or Gore-Tex Soft, flexible non absorbable Impervious to fluids Should not be used in presence of

infection

Synthetic meshes- Non absorbable Expanded PTFE (ePTFE)

Greatest expansion of all the meshes Useful in abdominal and vascular

surgeries Stainless steel mesh

Rigid and difficult to work with Causes discomfort to patient

Synthetic meshes- non absorbable

Polyester mesh (Mersilene) Least inert synthetic mesh Never be used in presence of infection Fibres may harbor bacteria

Polyethylene mesh multifilament,; made of polyester fibre Used for abdominal wall repair and

hernia repair

Synthetic meshes- absorbable

Polyglycolic acid; Polyglactin 910 Used for wound closure and organ

support

Mesh for inguinal hernia

Stents

A stent is a small mesh tube that's used to treat narrowed or weakened arteries in the body.

Stents help prevent the arteries from becoming narrowed or blocked again in the months or years after angioplasty

Stents usually are made of metal mesh, but sometimes they're made of fabric. Fabric stents, also called stent grafts, are used in larger arteries.

Some stents are coated with medicines that are slowly and continuously released into the artery. These stents are called drug-eluting stents.

Stents according to location

The most widely known stent use is in the coronary arteries with a bare-metal stent, a drug-eluting stent or occasionally a covered stent.Coronary stents are placed during angioplasty.

http://en.wikipedia.org/wiki/Angioplasty


Ureteral stents are used to ensure the patency of a ureter, which may be compromised, for example, by a kidney stone. This method is sometimes used as a temporary measure, to prevent damage to a blocked kidney, until a procedure to remove the stone can be performed. Indwelling times of 12 months or longer are indicated to hold ureters open, which are compressed by tumors in the neighbourhood of the ureter or by tumors of the ureter itself.

http://en.wikipedia.org/wiki/Ureter

http://en.wikipedia.org/wiki/Kidney_stone


In many cases these tumors are inoperable and the stents are used to ensure drainage of urine through the ureter. If drainage is compromised for longer periods, the kidney can be damaged. The main complications with ureteral stents are dislocation, infection and blockage by encrustation. Recently stents with coatings (e.g. heparin) were approved to reduce infection, encrustation and therefore stent exchanges.


A urethral or Prostatic stent might be needed if a man is unable to urinate. Often this situation occurs when an enlarged prostate pushes against the urethra, blocking the flow of urine. The placement of a stent can open the obstruction.


Stents are used in a variety of vessels aside from the coronary arteries. Stents may be used as a component of peripheral artery angioplasty.


Esophageal stent


Biliary stent


A stent graft is a tubular device, which is composed of special fabric supported by a rigid structure, usually metal. The rigid structure is called a stent. An average stent on its own has no covering, and therefore is usually just a metal mesh. Although there are many types of stent, these stents are used mainly for vascular intervention.The device is used primarily in endovascular surgery

Stent grafts are most commonly used in the repair of an abdominal aortic aneurysm

Bibliography

Bailey and Love’s Short practice of Surgery edition 13, edition 25

Suture and Surgical Haemostasis by Rebecca Pieknik

Farquharson’s textbook of operative general surgery edition 9

Bedside clinics in Surgery Makhan lal Saha

www.wikisurgery.com

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