3. 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
4. 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
5. 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
6. 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
7. 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’
8. 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.
9. 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.
10. 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.
11. 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 over
Unfortunately an ideal suture material does not exist.
12. Suture strands
Monofilament Multifilament
Goes through the tissue Several strands braided
with less drag or together
resistance Greater tensile strength,
Less chance of suture
pliability, flexibility
line infection- hence Are coated to reduce the
suture of choice for drag
vascular surgeries May act as a cove for
organisms, hence never
Greater chance of getting used in infected wounds
crushed
13. Suture strands
Monofilament Multifilament
Due to its smoothness, Knots are more secure
knots more likely to slip Fraying on cutting edges
No fraying of the ends on
cutting
Less tissue reaction
Eg Vicryl, Silk
Eg. Prolene, PDS II
15. Sutures
Absorbable sutures Non absorbable sutures
Are digested by enzymes Are used to suture at
and phagocytosed eg.
Catgut sites where tensile
Or get hydrolysed and strength needs to be
removed by phagocytosis maintained for at least a
eg. Vicryl year
Are used to hold the wound
edges in approximation Made of non
temporarily until the wound biodegradable materials
is healed sufficiently to
withstand normal stress that are ultimately
encapsulated or walled
off by body’s fibroblasts
16. Sutures
Absorbable sutures Non absorbable sutures
Are used to suture Are used at exposed
internal structures in the sites in the body from
body where suture where they can be
removal is not removed whenever
possible/feasible needed eg. Skin
Eg. Catgut, Vicryl Eg. Nylon, Silk,
polypropylene
19. 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
20. 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.
21. 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.
22. Plain Catgut
Loses 50% tensile strength in 3 days and 100%
strength by 15 days
Gets completely absorbed in tissue by 60 days
Uses:
1. To tie small subcutaneous vessels
2. To approximate subcutaneous tissue during
closure of incision
3. In circumcision to suture the cut margins of the
prepuce
4. To repair the wound of lip or the oral cavity.
23. Chromic Catgut
Loses 50% tensile strength in 7 days and 100%
strength by 28 days
Gets completely absorbed in tissue in 90-100
days
Uses
1. To suture muscles, bowel anastomosis,
peritoneum
2. During appendicectomy, to tie the
mesoappendix and the base of appendix
3. The inner layer during two layer anastomosis of
the small gut or anastomosis during
gastrojejunostomy
24. 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.
25. 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
26. Monocryl
Tensile strength Uses
maintained for 21 days 1. Can be used instead of
and absorbed in 90-120 catgut
days by hydrolysis
2. Intestinal anastomosis
Is sterilized by ethylene
oxide 3. For closure of
peritoneum
4. Subcutaneous tissue
apposition
5. Urological procedures-
pyeloplasty, ureter
repair
27. 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
28. 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.
29. Polypropylene( Prolene)
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
30. Polypropylene( Prolene)
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
31. Polyamide (Ethilon)
Synthetic, non High tensile strength
absorbable, Loses 25 % tensile
monofilamentous strength after 1 year
Very low coefficient of Knot security is poor
friction; hence
passes through the
tissues easily
Minimal tissue
reaction
32. Ethilon
Uses
Closure of skin
incision
For hernioraphhy
Vascular surgery
33. Stainless Steel Suture
Is composed of 316L Non needled or
stainless steel affixed to needles
conforming to with permanent
American Society for attachment
Testing and Materials techniques or by
Available in precut ROTOGRIP
lengths Get encapsulated by
Very high tensile fibroblast inside the
strength body
34. Stainless Steel Suture
Indicated for Contraindicated in
abdominal wound people with known
closure, intestinal metal allergies
anastomosis, hernia May interfere with
repair, sternal closure certain
and some orthopedic radiodiagnostics
procedures like
tendon repair
36. 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.
38. 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.
39. Dexon and Vicryl
Uses
1. Indicated in all the situations where
catgut is used
2. Better suited than catgut to suture
infected wounds
Disadvantages
1. Fraying of ends
2. Roughness
40. Vicryl Rapide Suture
Polyglactin 910
irradiated with
gamma rays
This leads to a suture
material with a lower
molecular weight and
hence faster
absorption
41. Vicryl Rapide Suture
Maintains tensile
strength for 10-12 days
and absorbed by 42
days
Is undyed
Use
1. Subcuticular suturing
2. Mucosal sutures
3. In circumcision
4. Episiotomy repair
42. 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.
43. Silk
Handling property is very Causes tissue reaction
good and knots securely leading to PMN
Maintains tensile infiltration and fibrous
strength for a long time capsule formation
(2 years) around the silk
Is supplied as a reel or Although classified as
over atraumatic needles non absorbable, it loses
(as Mersilk) its tensile strength in 1
year and cannot be
Sterilized by gamma detected after 2 years,
radiation/ autoclaving hence may be re-
Loses tensile strength classified as delayed
when wet absorbable suture
44. 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
45. 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
46. 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
47. 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
48. Tevdek/ Polydek
Made of PTFE
Makes the suture
inert and reduces
tissue reactivity
Originally designed
for heart valves
implantation
Dyed green and
white
50. Surgidac
Braided, polyester, non absorbable made
of ethelyne terephthalate
Used for general tissue approximation,
cardiovascular, ophthtalmic and neuro
surgeries
Undyed or dyed green
52. 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
53. 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
54. 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
55. 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.
58. 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
59. Types of suture needles
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
60. Types of suture needles
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
62. 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.
68. Subcuticular suturing
Particularly useful in
patients where keloid
formation may be
suspected.
69. Running closure (Baseball stitch)
Where wound edges
approximate easily
and where a straight
incision is being
approximated
Not done where
collection is
suspected
70. Running lock closure
Similar to Running
closure except that
the stitch is locked
before giving the next
stitch
71. 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
72. Traction sutures
Used to retract
tissues that is not
easily held back with
a conventional
retractor
Eg. In myocardium,
sclera of the eye,
tongue
73. Retention suture/ Stay suture
Placed at a distance Used as preventive
from primary suture to avoid primary
to relieve tension on wound disruption
the primary line Removed after the
Placed on skin, tension in the
subcutaneous tissue affected area is
or fascia decreased
Used for those
patients where slow
healing is expected
74. Secondary line suture
Used to support the primary line suture,
eliminate dead space or prevent fluid
accumulation in an abdominal wound
75. Figure of eight stick tie
Indicated for larger vessels or tissue
pedicels
To prevent knot slippage
To stop haemorrhage
76. Timing of Suture Removal
Wound location Timing of removal (days)
Face Three to five
Scalp Seven to 10
Arms Seven to 10
Trunk 10 to 14
Legs 10 to 14
Hands or feet 10 to 14
Palms or soles 14 to 21
81. 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
84. Surgical Staples
Basic principles
Preservation of adequate tissue vascularization
Creation of adequate lumen
Prevention of leaks and fistulas
Evading of tissue tension
Haemostasis
85. Surgical Staples
Advantages
Less tissue reaction
Accelerated wound healing
Efficiency
Less anesthesia and intra operative time
86. 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.
87. Surgical Staples
Purse string suture clamps- for
placement of purse string sutures.
Skin staplers- to approximate skin edges.
Endoscopic staplers
90. 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
91. Surgical Glue
Made of
cyanoacrylate
For adhesion of
superficial lacerations
92. 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
94. 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.
98. 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
99. Adhesive skin closure tapes/strips
Disadvantage-
cannot be used in
presence of moisture/
infection/ oily surface/
hairy surface/ skin
under tension
Eg Dermabond/
Indermil
101. 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.
102. 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.
103. Surgical Mesh
Hernioplasty with living Fascia
MacArthur’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
104. Surgical Mesh
Gallie’s Graft
If 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)
105. 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.
106. 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
107. 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
108. 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
109. 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
112. Stents
A stent is a small mesh Stents usually are made
tube that's used to treat of metal mesh, but
narrowed or weakened sometimes they're made
arteries in the body. of fabric. Fabric stents,
Stents help prevent the also called stent grafts,
arteries from becoming are used in larger
narrowed or blocked arteries.
again in the months or Some stents are coated
years after angioplasty with medicines that are
slowly and continuously
released into the artery.
These stents are called
drug-eluting stents.
113. 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.
114.
115. Stents according to location
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.
116. Stents according to location
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.
117. Stents according to location
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.
118. Stents according to location
Stents are used in a
variety of vessels
aside from the
coronary arteries.
Stents may be used
as a component
of peripheral artery
angioplasty.
121. Stents according to location
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
122. 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