Transcript
-- Presented by
Dr. Anindya Chakrabarty
CONTENT
Introduction
History
Definition
Goals of suturing
Suture materials
- Introduction
- Requisites of ideal suture
- Classification
- Selection of suture material
- Absorption of suture material
- Biological response of body to suture.
Suture armamentarium- needles, needle holder, scissor
Principles of suturing
Suturing Techniques
Knots
Suture Removal
Other methods of wound closure
Suture means to ‘sew’ or ‘seam’. In surgery suture
is the act of sewing or bringing tissue together and
holding them in apposition until healing has taken
place.
A suture is a strand of material used to ligate blood
vessels and to approximate tissues together.
HISTORY
History of the Surgical Suture “I dress the wound, God heals it”.-- Ambroise Pare, surgeon16th century
The act of sewing is probably older then Homo sapiens, because Neanderthal man wore some sort of clothing.
Perhaps the world’s oldest suture was placed by an embalmer on the body of a twenty first dynasty mummy about 1100 B.C.
A south American method of wound closure used large black ants which bite the wound edges together and the ants body is then twisted off leaving the head in place.
East African tribes ligated blood vessels with tendons and closed wounds with acacia throns
The first detailed description of a wound suture and suture materials used in it is by the Indian, physician Sushruta written in 500 BC.
Galen, the physician to Roman gladiators in the second century A.D. used silk for
haemostasis.
Andreas Vesalius first advocated the suture of all fresh wounds as well as severed tendon and nerves.
Joseph Lister (1827-1912) discovered that bacteria present in suture strands cause wound infection. He disinfected sutures with carbolic acid. He made sterile sutures possible to bury it in clean wounds without infection.
Rhazes of Arabia was credited in 900 A.D. with first employing ‘kit gut’ to suture
abdominal wounds. The Arabic word ‘kit’ means a dancing master’s fiddle, the musical strings of which ‘kit string’ were made up of sheep intestines. Over the years ‘kit’ was confused with kitten or cat, and the misuse of the term was propagated.
DEFINITION
suture material is an artificial fiber used to keep wound together until they hold sufficiently well by themselves by natural fiber (collagen) which is synthesized and woven into a stronger scar
Suture is a Stitch/Series of Stitches made to secure apposition of the edges of a Surgical/Traumatic wound (Wilkins)
Any Strand of Material utilized to ligate blood vessels or approximate Tissues (Silverstein L.H 1999)
GOALS OF SUTURING
Provide adequate tension
Maintain hemostasis
Provide support for tissue margins
Reduce post-op pain
Prevent bone exposure
Permit proper flap position
BASIC REQUISITE OF SUTURE MATERIALS
Tensile strength Tissue biocompatibility Low capillarity Good handling & knotting properties Sterilization without deterioration of properties Non allergic, non electrolytic and non carcinogènic Low cost
It should not fray, should slide through tissues readily & knot should not slip after tying.
It should be readily visualized
On break down ,it should not release toxic agents
It should disappear without excessive reaction once its task is completed
natural
synthetic
metallic
monofilament
multifilament
absorbable
Non-
absorbable
coated
Un-coated
Advantages
Smooth surface
Less tissue trauma
No bacterial harbours
No capillarity
Disadvantages
Handling and knotting
Stretch
Any nick or crimp in the material leads to breakage.
Absorbable
Surgical Gut- Plain, Chromic
Polydiaxanone
Polyglactin 910
Non Absorbable
Polypropylene
Polyester
Nylon/polyamide
Polyvinylidene fluoride / PVDF Sutures
Advantages Strength Soft and
pliable Good handling Good knotting
Disadvantages Bacterial
harbours Capillary action Tissue trauma
Non Absorbable
Silk
Cotton
Linen
Absorbable
Polyglactin 910
Polyglycolic Acid
ABSORBABLE – NATURAL
Plain catgut: light milk, Derived from submucusa of
sheep intestine or serosa of beef
intestine
Used for ligating superficial bld vessels &
subcut fatty tissues
Chromic catgut: yellow,Treated with chromium salt.
Adv may be used in the presence of infection
Gut / cat gut
Oldest known absorbable suture.
Galen referred to gut suture as early as 175 A.D.
Derived from sheep intestinal sub mucosa or bovine intestinal serosa.
Submucosa of sheep has a rich elastic tissue content which accounts for high tensile strength of the catgut. It is monofilament and is available in the plain form as well as “tanned” in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.
ABSORBABLE -NATURAL
Catgut should not be boiled or autoclaved as heat destroys its tensile strength.
Catgut is sterilized during preparation and kept in a preservative solution (isopropyl alcohol) inside spools or foils. Unused and reusable catgut is hygroscopic so, catgut will swell due to water absorption and its tensile strength will be reduced .
Absorption :40-60 days
When placed intra orally sutures are digested in 3-5days.
It is available pre-sterilized in aluminium-coated sterile foil overwrap pack with ethicon fluid as a preservative.
Colour: Plain catgut is yellow, while chromic catgut is tan
Absorbtion: Catgut is absorbed by proteolytic digestive enzymes released from inflammatory cells collected around the catgut. So, in the presence of infection catgut is rapidly absorbed.
CHROMIC CATGUTCoated with thin layer of chromium salt solution to minimize tissue reaction, increase TS, slow the absorption rate, better knot security, and ease of handling.TS – 10-14 days
Absorbed in 90 days
Uses : Opthalmic surgery (6-0)
Oral surgery
Suture subcutaneous tissues
As it is an organic material and susceptibleto enzymatic degradation, packed inisopropyl alcohol as a preservative. Alsocondition or soften it.
Suture absorbs alcohol and swells. It iscombustible and is also irritating totissues. It is removed by a quick rinse insaline prior to use.
COLLAGEN SUTURE
Natural, absorbable, monofilament
Obtained by homogenous dispersion of pure
collagen fibrils from the flexor tendons of cattle.
Absorption – 56 days
TS - < 10% after 10 days.
Used in opthalmic surgery
Disadvantage of premature absorption.
ABSORBABLE - SYNTHETIC Polyglactin (vicryl):cream, copolymer of
lactide & glycolide
Minimal tissue rxn
Used in general soft tissue approx,intestinalanastomosis,vessels ligation in all surgical specialties
Minimal tissue reactivity and can be used in
infected tissues
Available in purple and undyed. Undyed used
on face.
Coated with polyglactin 370 and calcium
stearate which allows easy passage through
tissues as well as easier knot placement.
On skin wounds, associated with delayed
absorption as well as increased inflammation.
Dexon(Polyglyconic acid):purple/cream
Homo polymers of glycolide.
Avoid in adipose tissue
Losses tensile strength more rapidlythan vicryl.
Other e.g Polyglyconate(maxon) polydiaxone(PDS),Polyglecaprone(monocryl)
POLYDIOXANONE (PDS II)
Synthetic,absorbable,monofilament.
Polyester derivative poly P dioxanone.
TS -14-42 days
Absorption – Hydrolysis in 6 months.
Passes through tissues easily.
Significant memory – compromises theease of knot-tying and knot security.
Minimal tissue reaction
For wounds under tension andcontaminated wounds.
May extrude through the wound over time.So used only in tissues deeper thansubcuticular layer. Or if in face 6-0 used.
VICRYL –RAPIDE It is braided synthetic absorbable suture
material. Colour : White.
It has a similar initial high tensile strength as that of the normal vicryl suture.
It gives wound support upto 12 days. It shows 50% of the original tensile strength after 5 days and all of its tensile strength is lost after 14 days.
Its absorption is associated with minimal tissue reaction facilitating improved cosmetics and reduction of postoperative pain.
The absorption is essentially complete within 35-42 days.
Uses: Low tensile strength and Rapid absorption rate --Ideal for intra-oral use (dental surgeries).
VICRYL PLUS ANTIBACTERIAL SUTURE
Handles and performs same as normal vicryl.
In vitro studies shown that triclosan on VICRYL plus creates a zone of inhibition around the suture.
NON-ABSORBABLE-NATURAL
Surgical silk: Black, Derived from the cocoon of the silk
worm larvae, superior handling xtics,Triggerinflam rxns,Undergo proteolysis & undetected by 2yrs,Used in ligating maj bld
ves,tendon repair etc
Other e.g Virgin silk, cotton, linen
Surgical steel & wires High tensile strength
Hold knots very well
Used in orthopaedic,Neurosurg,& Thoracic surg
OMFS- for suspension of splints or arch bars and not as suture material
SURGICAL SILK-Braided or twisted
-Made from the filament spun by silkworm larva toform its cocoon. Each filament is processed toremove the natural waxes and sericin gum. Afterbraiding, the strands are dyed, stretched andimpregnated with a mixture of waxes andsilicone. Dry silk suture is stronger than wet silksuture.
NATURAL NON-ABSORBABLE
Advantage: Ease of handling – more for braided Good knot security made non capillary in order to withstand action of
body fluids & moisture.(wax or silicon coated) Cost effective
Contraindications:Should not be used in presence of infection
Uses:Plastic surgery, ophthalmic and general
surgeries, ligating body tissues.
Although characterized as non-absorbable,studies show that it loses most of theirTS after 1 yr. and cannot be detected intissues after 2 yrs.
SURGICAL COTTON
Natural, multifilament, non absorbable
From stable Egyptian cotton fibers
good knot security
Not good in presence of contaminated wounds or infection
Rarely used nowadays
Uses:
Most body tissues for ligating and suturing
SURGICAL STEEL
Natural, monofilament/multifilament, nonabsorbable
Alloy of iron, nickel and chromium Good TS even in infection Difficult to handle and tendency to cut through
tissues. Very hard to tie, and knot ends requirespecial handling.
Potential to corrode or break at pointsof twisting, bending or knotting.
Not to be used with a prosthesis ofanother alloy.
Used in abdominal wall and skin closure,sternal closure, retention, tendonrepair, orthopedic and neurosurgery.
OMFS- for suspension of splints orarch bars and not as suture material.
Major Disadvantages
1.Linear artifacts caused by substances with high atomic number on CT images
2.Possible movement of metal suture during MRI
3.Patch test for nickel sensitivity should be done.
NON-ABSORBABLE - SYNTHETIC
Nylon: Is a polyamide polymer,blue
81% tensile strength at 1yr & 66% at 11yrs
Elicits minimal tissue rxn
Has good memory
Pliable when moist
Premoistened form is used cosmetic plastic surgery
Its elasticity makes it useful for skin closure & Herniorhapy
Other e.g;Polypropylene(prolene),Polyester fiber(Mersilene/Dacron,Ethibond)
POLYPROPYLENE (PROLENE)-Polymer of propylene.-Inert and TS for 2 yrs-Holds knots better than other synthetic sutures.
Advantages-Minimal suture reaction and so used in infected
and contaminated wounds.-Do not adhere to tissues and is flexible. So used
for ‘pull-out’ type of sutures.Uses:
General, plastic, cardiovascular surgery, skinclosure, ophthalmology.
GORE-TEX
Nonabsorbable,synthetic,Monofilament
From,expanded polytetrafluoroethylene (ePTFE)
Extremely low tissue reaction, good knot tensile strenghtand ease ofhandling.
Uses
All type of soft tissue approximation and cardiovascular surgeries.
-New, monofilament, nonabsorbable, synthetic
-Made of polyglycol trephthate and polybutylene terephthalate and isconsidered as a modified polyester suture.
-No significant memory compared to polypropylene and nylon. Easier tomanipulate and greater knot security.
-Unique feature is their ability to elongate or stretch with increasingwound edema. When edema subsides, suture resumes original shape;so it is an ideal suture for lacerations secondary to blunt trauma.
POLYBUTESTER (NOVOFIL)
SUTURE SELECTION
The condition of the
wound,
The tissues to be repaired,
The tensile strength of the
suture material
Knot-holding
characteristics of the
suture material
The reaction of
surrounding tissues to the
suture materials.
SUTURE SIZES
Largest size 1 to extremely fine 11-0. Increasing number of zeroes correlates with decreasing suture diameter and strength.
Thicker sutures are used for approximation of deeper layers, wounds in tension prone areas and for ligation of blood vessels.
Thin sutures are used for closing delicate tissues like conjunctiva and skin incisions of the face. Size is chosen to correlate with the tensile strength of the tissue being sutured.
SUTURE SIZE
UNITED STATES PHARMACOPEIA
Sized according to diameter with “0” as reference size
Numbers alone indicate progressively larger sutures
(“1”,“2”, etc)
Numbers followed by a “0” indicate progressively
smaller sutures (“2-0”, “4-0”, etc)
Smaller<------------------------------------->Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....
SIZE OF SUTURES
OLD GAUGE(USPD) DIAMETER IN MM
8/0 0.05
7/0 0.O7
6/0 0.1
5/0 0.15
4/0 0.2
3/0 0.3
2/0 0.35
0 0.4
1 0.5
2 0.6
3 0.7
4 0.8
PACKAGING………
METRIC GUAGE IMPERIAL GUAGE PRODUCT CODE
NEEDLE SIZE &
CURVATURE
NEEDLE TYPE
NEEDLE TIP
NEEDLE PROFILE
STERILIZED
ETHELENE OXIDE
DO NOT REUSE
SEE INSTRUCTIONS FOR USE
EXPIRY DATE BATCH NO
STERILIZATION OF SUTURES
May affect suture properties to some extent
Gamma Radiation
Ethylene oxide; poisonous gas is less
attractive
Autoclave
Sutures are usually stored in sterile pack by
the manufacturers , their integrity must be
checked before use
ARMAMENTARIUM FOR SUTURING
Suture needle
Needle holder
addson’s tissue forcep
SUTURE NEEDLE
Surgical needles are designed to lead suture material through tissue with minimal injury. Needles can be
- straight (GIT) or curved
- swaged or eyed
Made up of either SS or carbon steel.
Needle is selected according to:
-type of tissue to be sutured
-tissue’s accessibility
-diameter of suture material.
CLASSIFICATION OF SURGICAL NEEDLES
1.According to eye -eye less needles
-needles with eye
2.According to shape -straight needles
. -curved needles
3.According to cutting edge
a) round body
b) cutting -conventional
-reverse cutting
4.According to its tip -triangular tip
-round tip
-blunt tip
5.Others -spatula needles
-micro point needles
-cuticular needles
-plastic needles
Eyed require threading prior to use,results in pulling a double strandthrough tissue. Tying the suture tothe eye increases bulk of suturematerial drawn through tissues. Sothey are also called ‘traumaticneedles’.
Most suture materials and needlesare difficult to sterilize. Needlesare also difficult to clean afteruse and become blunt andworkhardened so that they snap.
Suture loop inserted through eye
Loop placed over tip
Loop drawn back
Suture tied on eyed needle
SWAGED NEEDLE
Swaged needles do not require threading and permit asingle strand of suture material to be drawn.
Suture attached to needle via a hole drilled throughthe end of the needle, and the end is swaged duringmanufacturing.
It is atraumatic and
act as a single unit.
Prepacked and presterilized
by gamma radiation.
NEEDLE ANATOMY
Term Definition
Chord
Length of needle
Radius
Diameter
The linear distance
between eye and tip.
The distance between
eye and tip following
the curvature
The distance of the
body of the needle from
the centre of the circle
Gauge or thickness of
the metal wire out of
which the needle is
made.
RADIUS OF CURVATURE OF THE
BODY(NEEDLE)
CLINICAL USE
Straight Needle
¼ circle
3/8 circle
½ circle
5/8 circle
Needle of choice for the skin
Limited use in oral surgery
May be used in surgery of the nose,
pharynx, tendons
Needle of choice for microsurgery
associated with very fine sutures;
ophthalmology
Oral surgery, flap surgery, wound closure
after placement of osseointegrated
implants and GTR procedures
May be used in all surgical wounds
Needle of choice in oral surgery
Wide range of uses in many surgical
wounds
Wounds of the urogenital tract
THE POINT
Point runs from tip to the max. cross sectional area of the body.
Can be -triangular tip/cutting
-round tip-blunt tip
Cutting needles are Ideal for suturing keratinizedtissues like skin, palatal mucosa, subcuticular layersand for securing drains.
Round/tapered needles used for closing mesenchymallayers such as muscle or fascia that are soft andeasily penetrable
The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle.
The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle.
The tapered point is used primarily on soft, easily penetrated tissues . it leaves small hole and can be used in vascular surgery as well as fascial soft tissue surgery.
The blunt point has a rounded end which does ntcut through the tissue .it is used in friable tissue suturing or to the parotid duct or lacrimalcanaliculi.
Sharpened 12 times Designated as C or FS(CUTICULAR or FOR SKIN)
Sharpened an additional 24 times
Designated as P or PS or PC(PREMIUM or PLASTIC
SURGERY or PRECISION COSMETIC ).
Needles in the PC series are made up of stronger SS alloy and have flattened and conventional cutting edge.
Cuticular needles Plastic needles
NEEDLE HOLDER
The needle holder is used to
handle the suture needle and
thread while suturing the
surgical wound.
If used properly it enables the
surgeon to perform
procedures correctly and with
great precision.
Working tip/ jaws
Hinge device
Shank/body
Catch mechanism/ ratchet
Grip area
GRIPPING OF NEEDLE HOLDER
The scissor gripPalm Grip
PRINCIPLES OF SUTURING
1.Needle grasped at 1/4th to half the distance from eye.2.Needle should enter perpendicular to tissue surface3.Needle passed along its curve
4.The bite should be equal on both sides of the wound margin and the point of the entry of the needle should be closer to the wound edge than its point of exit on the deep surface
5.The bite should be about 2-3 mm from the wound margin of the flap because after wound closure the edge of the wound softens due to collagenolysisand the holding power is impaired.
6. Usually the needle to be passed from mobile side to the fixed side but not
always(exception in lingual mucoperiosteum flap) and from thinner to thicker
& from deeper to superficial flap.
7.The tissues should not be closed under tension , since they will either tear or
necrose around the the suture
8.Tie to approximate; not to blanch
9.Knot must not lie on incision line
10.The distance b/w one suture to another should be about 3-4 mm apart to prevent strangulation of the tissue & to allow escape of the serum or inflammatory exudate & to get more strength of the wound.
11.Sutures placed at a greater depth than distance from the incision to evert wound margins
12.Close deep wounds in layers
13.Avoid retrieving needle by tip
14.Adequate tissue bite to prevent tearing
15.sutures should have correct tension while tying knot for provision of the slight edema post operatively, more tensioned sutures cause ischemia of the edges of the incision
causes tearing of the tissues
may leave suture mark
edges may get overlapped
16.Occasionally extra tissue may be present on one side of incision and cause ”DOG EAR” to be formed in the final phase of wound closure.
Simply extending the length of the incision to hide the exists will produce an unsatisfactory result.
Thus after undermining excess tissue incision is made at approx. 300 to parent incision directed towards undermined side. Extra tissue is pulled over incision and appropriate amount is excised. Incision is closed in normal manner.
SUTURING TECHNIQUES
INTERRUPTED SIMPLE SUTURE
Most commonly used. Inserted singly through side
of the wound and tied with a surgeon’s knot.
Advantages
Strong and can be used in areas of stress
Placed 4-8 mm apart to close large wounds, so that
tension is shared
Each is independent and loosening one will not
produce loosening of the other
Degree of eversion produced
In infection or hematoma, removal of few sutures
Free of interferences b/w each stitch and easy to clean
SIMPLE CONTINUOUS / RUNNING
A simple interrupted suture
placed and needle reinserted
in a continuous fashion such
that the suture passes
perpendicular to the incision
line below and obliquely
above. Ended by passing a
knot over the untightened
end of the suture.
Advantages
Rapid technique and distributes tensionuniformly
More water tight closure (Shoen, 1975)
Only 2 knots with associated tags
Disadvantages
If cut at one point, suture slackens along thewhole length of the wound which will thengape open.
CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by
withdrawing the suture through its own loop.
Indicated in long edentulous areas, tuberosities or
retromolar area.
Advantages
Will avoid multiple knots
Distributes tension uniformly
Water tight closure
Prevents excessive tightening.
Disadvantage :prevents
adjustment of tension over
suture line as tissue swelling
occurs.
VERTICAL MATTRESS
Specially designed for use in skin.
It passes at 2 levels, one deep to
provide support and adduction of
wound surfaces at a depth and
one superficial to draw the edges
together and evert them.
Used for closing deep wounds
This approximates subcutaneous
and skin edges
Needle passed from one edge to the other and again from
latter edge to the fist and knot tied.
When needle is brought back from second flap to the first,
depth of penetration is more superficial.
Advantages :
for better adaptation and maximum tissue approximation
To get eversion of wound margins slightly
Where healing is expected to be delayed for any reason, it is better to give
wound added support by vertical mattress. Used to control soft tissue
hemorrhage.
Runs parallel to the blood supply of the edge of the flap and therefore not
interfering with healing.
Uses: abdominal surgeries & closure of skin wounds.
HORIZONTAL MATTRESS
It everts mucosal or skin margins, bringing greater
areas of raw tissue into contact. So used for closing
bony deficiencies such as oro-antral fistula or cystic
cavities.
Disadvantage: constricts the blood supply to edges
of incision.
Needle passed from one
edge to the other and
again from the latter to the
first and a knot is tied.
Distance of needle
penetration and depth of
penetration is same for
each entry point, but
horizontal distance of the
points of penetration on
the same side of the flap
differs.
Advantages:
Will evert mucosal or skin margins, bringing greater
areas of raw tissue into contact.
-So used for closing bony deficiencies such as oro-
antral fistula or cystic cavities, extraction socket
wounds.
Prevents the flap from being inverted into the cavity.
To control post-operative hemorrhage from gingiva
around the tooth socket to tense the mucoperiosteum
over the underlying bone.
It does not cut through the tissue ,so used in
case of tissue under tension (inadequate
tissue)
Disadvantages:
More trouble to insert
Constricts the blood supply to the incision if
improperly used, cause wound necrosis and
dehiscence
FIGURE OF “8” SUTURE
Used for extraction socket closure and for adaption
of gingival papilla around the tooth Suturing begun
on buccal surface 3-4mm from the tip of the papilla
so as to prevent tearing of papilla.
Needle first inserted into theouter surface of the buccal flapand then the lingual flap. Needleagain inserted in same fashionat a horizontal distance andthen both ends tied.
SUBCUTICULAR SUTURE
Used to close deep wounds in layers. Knots will beinverted or buried, so that the knot does not lie betweenthe skin margin and cause inflammation or infection.
To bury the knot, first pass of the needle should be fromwithin the wound and through the lower portion of thedermal layer. Needle then passed through the dermallayer and emerge through subcutaneous tissue and knottied
CONTINUOUS SUBCUTICULAR SUTURE
Continuous short lateral
stitches are taken
beneath the epithelial
layer of the skin. The
ends of the suture come
out at each end of the
incision and are knotted.
Advantages
Excellent cosmetic result
Useful in wounds with strong skin tension,
especially for patients prone to keloid formation.
Anchor suture in wound and, from apex, take
bites below the dermal-epidermal layer
Start next stitch directly opposite the one that
precedes it.
PURSE STRING SUTURE
A circular pattern that draws together thetissue in the path of the suture when theends are brought together and tied.
KNOTS
Sutured knot has 3 components
1.Loop created by knot
2.Knot itself which is composed of a number of tight throws
3.Ears which are the cut ends of the suture
PRINCIPLE OF KNOT TYING
Use the simplest knot that will prevent slippage.
Tying the knot as small as possible and cutting the ends of the
suture as short as reasonable to minimize foreign body reaction.
Avoid friction or sawing
Avoid damage to suture material
Avoid excessive tension
Tying sutures too tightly strangulates the tissue
Placing the final throw as horizontally as possible to keep knot flat
Limiting extra throws to the knot, as they do not add strength to a
properly tied knot.
Square knot Formed by wrapping the
suture around the needle
holder once in opposite
directions between the ties.
Atleast 3 ties are
recommended.
Best for gut, silk, cotton
and SS
Surgeons knot Formed by 2 throws on the
first tie and one throw in the
opposite direction in the
second tie. Recommended
for tying polyester suture
materials such as Vicryl and
Mersiline
Granny’s knot A tie in one direction
followed by a tie in the
same direction and a third
tie in the opposite direction
to square the knot and hold
it permanently.
SUTURE REMOVAL Skin wounds regain TS slowly. It can
be removed in 3-10 days when the wound gained 5%-10% of final TS. Skin sutures on face removed between 3-5 days. Alternate sutures removed on 3rd day and remaining sutures after 2 days.
Intra oral Mucoperiosteal closure (without
tension) -- 5-7 days Where there is tension on the suture
eg : Oro-antral fistula- 7-10 days
Back and legs where cosmesis is less important – 10-14 days.
Continuous subcuticular can be left for 3-4 weeks without formation of suture tracks
A good guide is that as soon as they begin to get loose they should be taken out.
HOW TO REMOVE SUTURE
Suture area is first cleaned with normal saline.
The suture is grasped with non-tooth dissecting forceps and
lifted above the epithelial surface.
Scissors are then passed through one loop and then
transected close to the surface to avoid dragging
contaminated suture material through tissues.
The suture is then pulled out towards incision line to prevent
dehiscence. If suture entrapped in a scab, application of
hydrogen peroxide or saline solution is necessary.
If pieces of suture left, infection or granuloma formation can
ensue.
POSSIBLE COMPLICATION OF LEAVING SUTURE FOR MANY DAYS
1.Sutural abscess.
2.Suture scarring or stitch mark
3.Implanted dermoid cyst
SUTURE MARKS
Suture marks are caused by 3 factors
1.Skin sutures left in place longer than 7 days, resulting in epithelialisation of suture track
2.Tissue necrosis from sutures that were tied too tightly or became tight due to tissue edema
3.Use of reactive sutures in the skin.
Sutures passing through mucous membrane orskin provide a ‘wick’ or pathway through whichbacteria track down, and bacteria gain access tounderlying tissues.
The longer the suture remains, the deeper theepithelial invasion of the underlying tissue. Whensuture removed, epithelial tract remains.
These cells may eventually disappear or remain toform keratin and epithelial inclusion cysts. Theepithelial pathway result in typical ‘railroad scar’formation.
RAILROAD SCAR
NEW ADVANCEMENT IN SUTURING
Ligating clips
Skin staples
Surgical tape
Surgical adhesives
MECHANICAL WOUND CLOSURE DEVICES
Ligating clips :
can be resorbable or non resorbable.
Made up of SS,tantalum or titanium or
pidioxanone.
Designed for the ligation of tubular
structures.
Surgical staples:
Used for skin closure .
Made up of SS.
They are placed uniformly to span the
incision line.
They have minimal tissue reaction .
Can be used for routine skin closure
any where in the body.
Advantages
As the clips do not penetrate skin, yet give
apposition, the cosmetic result is excellent.
Speed and efficacy of stapling is more compared
to sutures.
Suturing causes more necrosis than stapling in
myocutaneous flaps.
Most significant advance is the introduction of
absorbable staples (Lactomer).
Contra indicated when it is not possible
to maintain atleast 5mm distance from
the stapled skin to the underlying bone
and blood vessels.
SURGICAL TAPE
Microporous tape is used alone or in conjugation withskin sutures to decrease tension at the wound margins.
The surgical tapes have a backing of viscous rayonfibers coated with an adhesive copolymer and they arepervious to sweat but not to blood or purulent material.
Comes in 1/8, 1/4, and 1/2 inch wide strips. Skinmargin is prepared with tincture of benzoin to providebetter adhesiveness for tape.
Used to decrease skin tension on cheek,forehead,chin.
ADVANTAGES
Minimizes wound dehiscence and allows earlier suture
removal
Provides continuous support for the wound and
minimizes scar expansion
Avoids the ordeal of suture replacement and removal
in children
Less inflammatory reaction, lower rate of wound
infection, greater TS and better cosmetic results.
No needle puncture marks and suture canals
Strangulation and necrosis of tissue are eliminated
Sterile paper tape is non expensive
Disadvantage
Do not evert edges of the wound, and readily loosenwhen wet by blood or serum.
Prior to placement, a thin coat of antibiotic ointment isplaced on wound margin to protect wound from skin oilsand bacteria.
While removing, to avoid epithelial margin separation,the ends should be lifted equally towards the woundmargin and then lifted evenly from the wound.
Cyanoacrylates
- n-butyl cyanoacrylate is the active ingredient.
Advantages :
Strong bonding to tissues in presence of moisture
Biodegradable, bacteriostatic & hemostatic.
Reduced post operative pain & facilitates healing.
Good shelf life.
Produces little or no heat during polymerisation.
Bonding is by secondary intermolecular forces aided by
mechanical interlocking of irregular forces.
Quick, atraumatic and cost effective with good cosmesis
No injection, suturing and post-op suture removal.
Disadvantages
1.When applied for skin closure, the polymer acts as
barrier, prevents wound apposition, delays healing, and
increases the infection rate.
2.Should not be allowed to come in contact with tissue
under skin as it causes necrosis.
DERMABOND®
A sterile, liquid topical skin adhesive
Reacts with moisture on skin surface to form a strong, flexible bond
Only for easily approximated skin edges of wounds
punctures from minimally invasive surgery
simple, thoroughly cleansed, lacerations
DERMABOND®
Standard surgical wound prep and dry
Crack ampule or applicator tip up; invert
Hold skin edges approximated horizontally
Gently and evenly apply at least two thin
layers on the surface of the edges with a
brushing motion with at least 30 s between
each layer, hold for 60 s after last layer until
not tacky
Apply dressing
Degraded either by enzymatic process as in gut
sutures, or by hydrolysis, as in many of the synthetic
materials like glycolic acid, ployglactin910 or
polydioxanone.
Non absorbable sutures are walled off or
encapsulated.
In infected tissues or in a patient who is febrile or
protein deficient, suture breakdown may be
accelerated.
If the loss of TS outpaces the healing phase, failure
of the wound results.
Absorbable sutures must be placed well into the
dermis.
ABSORPTION OF SUTURE MATERIALS
BIOLOGIC RESPONSE OF BODY
TO
SUTURE MATERIALS
The initial body response to sutures is almost identical in the first 4-7 days, regardless of the suture material.
The early response is a generalized acute aseptic inflammation, involving primarily polymorphonuclearleukocytes.
After few days mononuclear cells, fibroblasts & histiocytes become evident.
Capillary formation occurs at the end of this initial phase.
BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS
Natural Absorbable – Proteolytic
degradation. Intense tissue response
Synthetic Absorbable – Hydrolysis. Less Intense
Non Absorbable – Encapsulation. AcellularResponse
CONCLUSION
Human body is very delicate & important.
When surgeries are needed to improve our
health is very important to select a suitable
suture. Today we know allots of biomaterials
to select, but is important to always think of
biocompatibility.
REFERENCES
Suturing techniques in oral surgery –Sandro Siervo
Laskin vol-1
Oral & Maxillofacial Surgery Vol 1- W. Harry Archer
Textbook of oral & maxillofacial surgery- Neelima Anil Malik
Minor Oral Surgery- Goeffrey L.Howe
Text book of surgery: Sabiston
Periodontology-Caranza.
THANK YOUTHANK YOU
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