1 november 16, 2009 a-b tech kurt prewitt this promotional educational activity is brought to you by...
TRANSCRIPT
1
November 16, 2009
A-B Tech
Kurt Prewitt
This promotional educational activity is brought to you by Ethicon, Inc. and is not certified for continuing medical education.
2
SUTURES
SUTURE OVERVIEW
ABSORBABLE SUTURES
NON-ABSORBABLE SUTURES
SUTURE SELECTION BY TISSUE
3
SUTURES OVERVIEW
4SUTURES OVERVIEW
OBJECTIVES
1. Trace the evolution of sutures as a method of
ligating and approximating tissue
2. Aspects of wound healing
3. Differentiate among the types of sutures
5
WHAT IS SUTURE?
Suture Definition
• The word “suture” describes any strand of
material used to ligate (tie) blood vessels or
approximate (sew) tissues
6
A Timeline50,000 BC Eyed needles are invented.
20,000 BC Bone needles are standard.
1600 BC One of the earliest known references to suture material. Sutures are
made from flax, hemp, bark fiber, hair, etc.
900 AD Used strings from a kit, a guitar-like musical instrument
1867-9 Joseph Lister proves that the body absorbs catgut sutures. However
he is most famous for demonstrating the need for antiseptic techniques
for sterilization of implanted sutures.
1918 George Merson begins the sale of eyeless needled sutures where one
strand of suture material is attached to the butt of the needle. This
type of swaged needle is still in use and is the standard today.
1947 Introduction of Nylon.
1972 First synthetic absorbable suture introduced.
2000 Distribution of gut material ends in many parts of Europe and Japan
due to Bovine Spongiform Encephalopathy (“Mad Cow Disease”)
SUTURES OVERVIEW
HISTORY OF SUTURES
7
1. Sterile
2. Easy to handle
3. Minimal tissue reaction/trauma
4. High tensile strength retention
5. Knot security
6. Absorbable
7. Useful in all tissues
SUTURES OVERVIEW
IDEAL SUTURE
8
Skin
Mucosa
Subcutaneous
Peritoneum
Fascia
0 5 7 14 21 28 Days
5-7 Days
5-7 Days
7-14 Days
7-14 Days
14-28 Days
Tissue Healing Times
SUTURES OVERVIEW
CRITICAL WOUND HEALING PERIOD
9SUTURES OVERVIEW
SUTURE SIZING
Ethicon Suture Sizing
• Ranging from 7 to 11-0
• Size 7 is largest
• Size 11-0 is smallest
• Size 7-0 approximately
corresponds to the
thickness of human hair
10
1887 20071947 1958 1969 1974 1976 1979 1989 1992 1993 1995 1996 1998 2002 2003 2006
ETHIBOND EXCEL* Polyester
SutureSilk and Cat Gut
Nylon
MERSILENE* Polyester Fiber
Suture
PROLENE* Polypropylene
Suture
VICRYL*(polyglactin 910)
Suture
Coated VICRYL* (polyglactin 910)
Suture
PDS* II (polydioxanone)
Suture
ETHIGUARD*Blunt Point
Needle
MONOCRYL* (poliglecaprone 25)
Suture
VICRYL RAPIDE* (polyglactin 910)
Suture
Dyed MONOCRYL*
(poliglecaprone 25) Suture
DERMABOND®
Topical Skin
Adhesive
DERMABOND®
Topical Skin
Adhesive High
Viscosity
Coated VICRYL* Plus Antibacterial (polyglactin 910)
Suture
PDS* Plus Antibacterial
(polydioxanone) Suture (May
2007 Launch)
MONOCRYL* Plus Antibacterial
(poliglecaprone 25) Suture
HISTORY OF INNOVATION
SUTURES OVERVIEW* Trademark
11SUTURES OVERVIEW
SUTURE CLASSIFICATIONS
• Absorbable / Non-Absorbable
• Natural / Synthetic
• Braided / Monofilament
• Antibacterial Sutures
12SUTURES OVERVIEW
ABSORBABLE / NON-ABSORBABLE SUTURES
Absorbable Sutures• Sutures that undergo degradation in tissues, losing their tensile
strength within 60 days
– Absorption Rate: Time required for a suture to be fully absorbed into
the tissue
– Tensile Strength In Vivo: Tension which a suture will withstand before it
breaks down inside the tissue
Non-Absorbable Sutures• Sutures which are not digested by body enzymes or hydrolyzed in
body tissue
13SUTURES OVERVIEW
NATURAL / SYNTHETIC SUTURES
Natural Sutures
• Sutures made of material that can be found in nature
– Absorption method (if absorbable): Enzymatic
Synthetic Sutures
• Sutures made of materials created by man
– Absorption Method (if absorbable): Hydrolysis –
breakdown in the presence of water or moisture
14SUTURES OVERVIEW
MONOFILAMENT / BRAIDED SUTURES
Monofilament• A single strand of material
– Less resistance as it passes through tissue
– Resists bacterial harboring compared to braided
Braided • Multifilament sutures that consist of several filaments or strands,
twisted or braided together
– Greater tensile strength
– Pliability and flexibility
15SUTURES OVERVIEW
ANTIBACTERIAL SUTURES
Properties of Antibacterial Sutures
– Biocompatibility
– Effectiveness against S.Aureus and S.Epidermidis
(most common for device infections) among other bacteria1-3
– Ability to withstand manufacturing process
o Heat, humidity, solvent, sterilization, etc
o Mass production
– Will not negatively alter suture properties
– Ability to maintain antibacterial activity on the suture for a
clinically relevant duration1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
16
Class IClean
Uninfected wound in which no inflammation is
encountered and respiratory, alimentary, genital, or
uninfected urinary tract is not entered.
Class IIClean-contaminated
Operative wound in which respiratory, alimentary, genital,
or urinary tracts are entered under controlled conditions
and without unusual contamination.
Class IIIContaminated
Open, fresh, accidental wounds.
Class IVDirty-infected
Old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infection or perforated
viscera.
1. CDC=Centers for Disease Control and Prevention. Mangram AJ et al. Am J Infect Control. 1999;27:97-134.
SUTURES OVERVIEW
CDC SURGICAL WOUND CATEGORIES1
17SUTURES OVERVIEW
COMPLICATIONS IN WOUND HEALING
• Infection (including SSIs)
• Wound Disruption
– Deshiscence – Splitting open of the wound due to
o Too much tension placed on the wound
o Improper suturing technique
o Inappropriate suture materials
o Weakened tissue
– Evisceration – Protrusion of the bowel through the
separated edges of the abdominal wound closure
18
PLUS ANTIBATERIAL SUTURES
• Coated polyglactin 910 sutures with triclosan exhibit
antibacterial activity on the suture in vitro against methicillin-
sensitive and -resistant S aureus and S epidermidis
compared with untreated controls1
• Antibacterial activity endures on the suture despite
extended exposure to aqueous environment1
• Suture diameter, knotting, or passage through tissues
does not diminish antibacterial activity of triclosan-coated
sutures1
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3(suppl):S79-S87.
SUTURES OVERVIEW
19
1. Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial adherence to surgical sutures J Am Coll Surg. 2006;203:481-489.
IRGACARE® MP
IRGACARE® MP, the antibacterial component of Ethicon
Plus Sutures, is effective on the suture against the
pathogens most commonly associated with SSIs1
• Staphylococcus aureus
• Staphylococcus epidermidis
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Methicillin-resistant Stapylococcus aureus (MRSE)
• Escherichia coli †
• Klebsiella pneumoniae †
SUTURES OVERVIEW
† Only for MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture and PDS* Plus Antibacterial (polydioxanone) Suture* Trademark
20SUTURES OVERVIEW
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
PLUS Antibacterial Sutures kill bacteria on the suture and
inhibit bacterial colonization of the suture1-3
ZONE OF INHIBITION
MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture
Coated VICRYL* Plus Antibacterial (polyglactin
910) Suture
PDS* Plus Antibacterial (polydioxanone) Suture
Zone of Inhibition – Areas of inhibited bacterial growth for Plus Antibaterial Sutures
* Trademark
21SUTURES OVERVIEW
PLUS ANTIBACTERIAL SUTURES
• In vitro testing (petri dish) has shown Plus Antibacterial
Sutures create a zone of inhibition around the suture in which
certain bacteria are unable to grow1-3
• IRGACARE® MP in the Plus Sutures creates a zone of
inhibition which lasts in vitro for:
Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture
Minimum of 7 days for S.Aureus
MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture
31 days for S.Aureus21 days for E.Coli
PDS* Plus Antibacterial (polydioxanone) Suture
23 days for S.Aureus17 days for E.Coli
* Trademark
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
22
ABSORBABLE SUTURES
23
Natural
Short-Medium
Short
FastAbsorbing
Gut
PlainGut
Medium
Chromic Gut
Virtual Monofilament
Natural Absorbable
Synthetic
Synthetic Absorbable
ABSORBABLE SUTURES
ABSORBABLE SUTURE TYPES
* Trademark
Monofilament Braided
Short / Medium
Long Short Medium
MONOCRYL* (poliglecaprone 25) Suture, MONOCRYL* Plus Antibacterial (poliglecaprone
25) Suture
PDS* II (polydioxanone) Suture, PDS* Plus
Antibacterial (polydioxanone) Suture
VICRYL RAPIDE* (polyglactin 910)
Suture
Coated VICRYL* (polyglactin 910) Suture, Coated VICRYL*
Plus Antibacterial (polyglactin 910) Suture
24
NATURAL ABSORBABLE SUTURES
Ethicon Gut Sutures1
• Submucosal or serosal layer of animal intestine
• 97-98% pure collagen
• Clean and purified
• Strands twisted for controlled diameter
• Packaged wet to maintain pliability
• Spun and polished into virtual monofilament
strands
ABSORBABLE SUTURES1. Wound Closure Manual, page 13
25ABSORBABLE SUTURES
NATURAL ABSORBABLE SUTURES
Plain gut
• TRU-GAUGING process1
– Eliminates high and low spots
– Greater surface smoothness
– No fraying of the suture
– Better knot security
– Uniform diameter across entire length
– Uniform high tensile strength
– Wound support for approximately 2 weeks1. Wound Closure Manual, page 13,14
26ABSORBABLE SUTURES
NATURAL ABSORBABLE SUTURES
Chromic gut
– TRU-GAUGING process1
– TRU-CHROMICIZING process1
o Entire cross-section of strand is
evenly chromicized
o Minimizes tissue irritation
o Less reaction
– Wound support for approximately 4 weeks2
Fast-absorbing gut
– Plain surgical gut is heat treated to accelerate tensile strength
loss and absorption1
– Wound support for approximately 1 week
Chromic Gut
1. Wound Closure Manual, page 13,142. Chromic Gut Product Insert
27ABSORBABLE SUTURES
SYNTHETIC ABSORBABLE SUTURES
VICRYL RAPIDE*(polyglactin 910) Suture
• Short-term wound support1
– 7-10 days
– Rapid strength loss
– Absorption complete in just 42 days
• For mucosa and superficial closure of skin
• Convenient for the patients
– No return visit necessary for suture removal
* Trademark
1. Wound Closure Manual, page 14
28ABSORBABLE SUTURES
SYNTHETIC ABSORBABLE SUTURES
VICRYL RAPIDE*(polyglactin 910) Suture
• Initial strength comparable to that
of Nylon and Gut
• Fastest-absorbing synthetic suture
• Elicits lower tissue reaction than chromic gut suture
* Trademark
1. Wound Closure Manual, page 14; Product Inserts of VICRYL RAPIDE* (polyglactin 910) Suture, ETHILON* Nylon Suture and Chromic Gut
29
ANTIBACTERIAL SUTURES
• Wound support for approximately 14 days
• Consistent handling and performance
– Significantly less tissue drag than chromic gut
sutures and braided synthetic absorbable sutures
– Excellent knot security
ABSORBABLE SUTURES* Trademark
1. Wound Closure Manual, page 14; MONOCRYL Plus Suture Product Insert
30
ANTIBACTERIAL SUTURES
Reliable Strength
• Consistent absorption rate with a predictable decrease in
tensile strength over time
• Stronger than gut suture initially and through the critical
wound-healing period
• Offers protection for subcuticular closure and soft tissue
approximation
ABSORBABLE SUTURES* Trademark
1. Wound Closure Manual, page 13,14; MONOCRYL Plus Suture Product Insert, Chromic Gut Product Insert
31ABSORBABLE SUTURES
ANTIBACTERIAL SUTURES
Excellent handling and performance
– Knot security and knot snug-down
– First-throw holding security
– Smooth passage with minimal tissue drag
– Virtually no package memory
* Trademark
32ABSORBABLE SUTURES
ANTIBACTERIAL SUTURES
Exceptional strength
– Wound support for approximately 4 weeks
– Offers protection and strength for general tissue
approximation
* Trademark
1. Product Inserts for Coated VICRYL Plus Suture, MONOCRYL Plus Suture, Chromic Gut and Plain Gut
33ABSORBABLE SUTURES
ANTIBACTERIAL SUTURES
• Extended monofilament wound support for
approximately 42 days
• Offers protection and strength for slow-healing tissue
– Fascia closure, Orthopedic surgery
– Blood vessel anastomoses
– Diabetic, cancer and obese patients
* Trademark
1. Wound Closure Manual page 20,21; PDS Plus Suture Product Insert
34ABSORBABLE SUTURES
ANTIBACTERIAL SUTURES
PDS Plus Sutures offer surgeons:
– Low out-of-package memory
– Smooth passage through tissue
– Low bending stiffness for more pliability and easier
handling
PDS Plus Suture stays stronger, longer†
† Compared to Maxon™ or Biosyn™: Data from Maxon™, Biosyn™ and PDS* Plus Suture product inserts* Trademark
35
NON-ABSORBABLE SUTURES
36
Natural
BraidedMonofilament
SurgicalStainless
Steel
PERMA-HAND* Silk Suture
Synthetic
ETHIBOND EXCEL* Polyester Suture
MERSILENE* Polyester
Fiber Suture
BraidedMonofilament
NUROLON* Nylon Suture
PRONOVA* Poly (Hexafluoropropylene
- VDF) Suture
PROLENE* Polypropylene Suture
ETHILON* Nylon Suture
NON-ABSORBABLE SUTURE TYPES
NON-ABSORBABLE SUTURES* Trademark
37NON-ABSORBABLE SUTURES
SILK - BRAIDED
PERMA-HAND*Silk Suture1
• Wax proofed
– Improves surface quality
– Reduces bacterial harboring
– Reduces capillarity
• Braided
– Excellent handling and knotting characteristics
• Used in a wide variety of surgical procedures
* Trademark
1. Wound Closure Manual, page 16
38NON-ABSORBABLE SUTURES
STEEL - MONOFILAMENT
Surgical Stainless Steel Suture1
• High tensile strength
• Reliable and ductile alloy
− Made of 316L stainless steel
− Optimal compatibility with stainless steel implants
• Low tissue reactivity
• Multistrand packaging
− Eliminates kinking and bending of strands
− 2 or 4 strands per pack1. Wound Closure Manual, page 16
39NON-ABSORBABLE SUTURES
ETHILON*Nylon Suture1
• Well suited for skin and retention
closure
• Finer sizes used in ophthalmic and
microsurgery procedures
• May be clear, or dyed green or black for better visibility
• Specific codes (sizes 3-0 to 6-0) are “pliabilized.” Pliabilization
– Includes pre-moistening the suture to make it more pliable
– Enhances handling and knot tying characteristics to approximate
that of braided sutures
NYLON - MONOFILAMENT
* Trademark
1. Wound Closure Manual, page 17
40NON-ABSORBABLE SUTURES
NYLON - BRAIDED
NUROLON*NYLON SUTURE1
• Handles like silk
• Stronger than silk
• Better knot tie-down than silk
• Lower tissue reactivity
• Less fragmentation
• Ideal silk replacement in neurosurgery
* Trademark
1. Wound Closure Manual, page 17
41NON-ABSORBABLE SUTURES
POLYESTER - BRAIDED
MERSILENE* Polyester Fiber Suture1
Polyester
– Permanent wound support
Braided
– Good handling characteristics
– Provide precise and consistent suture tension
Synthetic
– Less tissue reaction
* Trademark
1. Wound Closure Manual, page 18
42
POLYESTER - BRAIDED
NON-ABSORBABLE SUTURES
• Polyester: permanent wound support
• Minimal tissue reaction; suture material and
coating are pharmacologically inactive1
• A central core and 16 outer carriers
– Tighter, compact and stronger braid
• Excellent handling properties (suppleness
and pliability)
• Polybutylate coating
– Smooth knot tie-down
– High knot and tensile strength
* Trademark
1. Wound Closure Manual page 18
43
POLYESTER - BRAIDED
Many options available1:
• Specialized CV Needles
• Single or Multi-strand
• D-Specials
• Pledgets – Soft and hard, 2 sizes
• In green & white for ease of use
• Available in many suture sizes & lengths used in CV
and Ortho procedures
NON-ABSORBABLE SUTURES* Trademark
1. ETHIBOND EXCEL Suture Product Insert
44
POLYESTER - BRAIDED
Improvements in ETHIBOND
EXCEL Suture
•Tight, compact braid– Results in stronger suture
– Avoids suture bunching
•Effective coating levels– Less “slippery” suture
– Excellent knot security
•Packaging– Fast, reliable suture delivery
– Clear package and box graphics
NON-ABSORBABLE SUTURES* Trademark
1. CPC-2007-0160 and AST-2008-0046 ETHIBOND EXCEL Suture reports
45NON-ABSORBABLE SUTURES
POLYPROPYLENE - MONOFILAMENT
• Minimal tissue reaction
• Polypropylene: Inert, reliable, strong, smooth, secure− Will not fatigue with normal flexing
− Exceptionally smooth surface avoids snagging vessel adventitia
• Plastic knot deformity - When knotted, deforms and flattens to
provide excellent knot security2
• Controlled linear elongation - Excellent pliability2
* Trademark
1. Wound Closure Manual page 182. CPC-2006-0445 and CPC-2008-0046 PROLENE Suture Reports
46NON-ABSORBABLE SUTURES
POLYPROPYLENE - MONOFILAMENT
• Laser scanning process for sizes
5-0, 6-0 and 7-0
– More consistent diameter and improved
tensile strength
• Sizes 8/0 and smaller are hand inspected
* Trademark
47NON-ABSORBABLE SUTURES
POLYPROPYLENE - MONOFILAMENT
Packaging
• Unique RELAY* Suture Delivery System
• Straight pack delivers the suture virtually memory-free
Many options available1
• Available in a variety of sizes and lengths used in different specialties
• Specialized Cardiovascular needles
• Single or multi-strand
• E-Packs and D-Specials
* Trademark
1. Prolene Package Insert
48NON-ABSORBABLE SUTURES
PRONOVA - MONOFILAMENT
PRONOVA* Poly (hexafluoropropylene-VDF) Suture1
• Offers excellent strength
• Less memory than polypropylene
• Exceptional strength for delicate tissues
• Monofilament, more resistant to bacterial colonization
• Strong resistance to handling damage and fraying
• Excellent handling and tying characteristics
• Excellent resistance to repetitive stress fatigue such as to those
imposed by heart and vessels
* Trademark
1. Wound Closure Manual page 18
49
SUTURE SELECTION BY TISSUE TYPE
50
Joint Capsule (knee, hip, shoulder)
Recommended Suture†
Needle Options††
OS-4, OS-6, OS-8, CT-1, CTX, MO-4
Tissue CharacteristicsLigamentous sac surrounding the articular cavity of the joint; consists of
vascular, very dense, fibrous tissue. Heals in approximately 3 weeks.
SUTURE SELECTION* Trademark
† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
SUTURE SELECTION
51
Epidermis, Oral (facial)/Vaginal Mucosa, Perineal Skin
Recommended Suture
Needle Options†
PC-1, PC-3, P-1, P-3, PS-2
Tissue CharacteristicsSuperficial layer of skin; dense and tough, but thin. It is usually supported by
dermal closure.
SUTURE SELECTION
SUTURE SELECTION
VICRYL RAPIDE*(polyglactin 910) Suture
* Trademark
† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
52
Peritoneum
Recommended Suture†
Needle Options††
SH, CT-1
Tissue CharacteristicsThin, membranous lining of the abdominal cavity. Very little fibrosis. Heals
quickly. Closure is optional, based on surgeon preference.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
53
Dermis / Subcuticular
Recommended Suture†
Needle Options††
PC-5, PS-2, PS-1, PS#, PSL, PSLX#
Tissue CharacteristicsDeep, vascular, subcuticular layer; 3 times thicker than epidermis; consists of
dense connective tissue. Regains tensile strength slowly. Most of the stress
placed upon the healing wound is absorbed by fascia. Sutures need only be strong
enough to withstand natural skin tension and hold wound edges in apposition.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture# Available on ETHILON* Nylon Suture which may also used for subcuticular closure
54
Abdominal Fascia
Recommended Suture†
Needle Options††
CT-1, CT, CTX, TP-1, XLH
Tissue CharacteristicsFibrous, sheath-like, connective tissue covering muscle.
Strongest tissue in abdominal wall; regains 25% - 40% of original strength
in 1 month; 55% - 65% in 3 months; 70% -80% in 9 months.
Never regains full original strength.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
55
Urinary Bladder
Recommended Suture†
Needle Options††
RB-1, SH-1, SH
Tissue CharacteristicsVery vascular, dense, tough, muscular membranous sac.
Composed of multiple layers.
Heals quickly, achieving 75% to 90% of original strength in 2 weeks.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
56
Colon
Recommended Suture†
Needle Options††
SH, SHB
Tissue CharacteristicsWall varies in consistency and density; relatively soft and rubbery, with little
dense, fibrous support.
Heals rapidly, achieving 50% to 60% of original strength in 1 month.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
57
Ureter
Recommended Suture†
Needle Options††
TF, RB-1, SH-1
Tissue CharacteristicsNarrow tube with vulnerable blood supply.
Easy to manipulate and penetrate, unless fibrous or hardened.
Achieves normal healing in 7 days.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
58
Ligament
Recommended Suture†
Needle Options††
PS-4, PS-2, OS-4, MO-6, CT-2, CT-1
Tissue CharacteristicsVery dense, longitudinally arrayed, collagenous tissue.
Achieves 50% to 70% of original strength in 12 months.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† PDS II Suture may also be used in place of PDS Plus Suture†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
59
Subcutaneous (fat) / Superficial Fascia
Recommended Suture†
Needle Options††
SH, CT-1
Tissue CharacteristicsSoft, friable, poorly vascularized tissue; fat does not hold sutures well.
The goal of “suturing the fat” is to approximate the superficial fascia
(Scarpa’s fascia) which is located in the upper 1/3 of the fatty layer.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
60
Small Intestine
Recommended Suture†
Needle Options††
RB-1, SH-1, SH
Tissue CharacteristicsWall varies in consistency and density; relatively soft and rubbery, with little
dense, fibrous support.
Heals very rapidly, reaching maximum strength in approximately 14 days.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
61
Uterus
Recommended Suture†
Needle Options††
MO-4, MO-2, CT-1, CT, CTX
Tissue CharacteristicsVery vascular, tough and muscular.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
62
Vagina
Recommended Suture†
Needle Options††
V-34, CP-1, CT-1, SH
Tissue CharacteristicsExtremely thick, tough and vascular.
Heals completely in 10 days.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
VICRYL RAPIDE*(polyglactin 910) Suture
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
63
Tendon
Recommended Suture†
Needle Options††
OS-4, MO-6, CT-2, CT-1
Tissue CharacteristicsVery dense, longitudinally arrayed, collagenous tissue.
SUTURE SELECTION
SUTURE SELECTION
† PRONOVA* Poly (hexafluoropropylene-VDF) Suture and NUROLON* Nylon Suture may also be used to suture tendon to bone. PDS II Suture may also be used in place of PDS Plus Suture†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture* Trademark
64
Stomach
Recommended Suture†
Needle Options††
SH, SHB
Tissue CharacteristicsRelatively soft and rubbery, with little dense, fibrous support. Submucosa /
mucosa is especially thick and vascular.
Heals quickly, achieving maximum strength within 21 days.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
65
Nerves, Dura Mater
Recommended Suture
Needle Options††
TF, RB-1
Tissue CharacteristicsDura mater tears easily and cannot withstand excessive tension.
In nerve repair, the strength of sutures is less of a consideration than the
degree of inflammatory and fibroplastic tissue reaction.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
NUROLON*NYLON SUTURE
66
Eye, Ocular Muscles
Recommended Suture
Needle Options††
CS140-6, CS160-6, CS90-6, CSB-6, TG140-8
Tissue CharacteristicsCornea is avascular, therefore heals slowly and requires sutures to remain in
place for at least 21 days. Ocular muscles, conjunctiva and the sclera have
good blood supply and require suture support only for about 7 days.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† PDS II Suture may also be used in place of PDS Plus Suture†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
Coated VICRYL* (polyglactin 910) Suture
67
Vessels and Anastomosis
Recommended Suture†
Needle Options††
BV-1, BV130-5, BV175-6, BV175-7, BV175-8, CC, CC-1
Tissue CharacteristicsThe outermost tunica adventitia is fibrous connective tissue. The innermost tunica
intima is the thinnest. Excessive tissue reaction may lead to decreased luminal
diameter or thrombus formation. Hence inert synthetics are material of choice.
SUTURE SELECTION
SUTURE SELECTION
* Trademark
† PDS Plus Suture and PERMA-HAND Silk Suture may be used to permit future growth in patients such as pediatric patients†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
PRONOVA* Poly (hexafluoropropylene-VDF) Suture
68
Vascular Prostheses and Heart Valves
Recommended Suture
Needle Options††
V-5, V-7
Tissue CharacteristicsStrong, dense and fibrous. Adapted to be highly resistant to fatigue. Since there
is constant movement of the suture line, the sutures must retain their original
physical characteristics and strength throughout the life of patient
SUTURE SELECTION
SUTURE SELECTION
* Trademark
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
69
BEST PRACTICE IN WOUND CLOSURE
* Trademark
Surface: DERMABOND® Topical Skin Adhesive
Dermis: MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture
SubQ-Fat: Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture
Fascia/Muscle: ETHIGUARD* Blunt Point Needle with Coated VICRYL Plus or PDS* Plus
Antibacterial (polydioxanone) Suture
SUTURE SELECTION
70
Thank you
EP-0063-09-10/11