56392793 suture materials amp suturing techniques dr ayesha
TRANSCRIPT
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GOO
MORNING
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SUTURE MATERIALS
&
SUTURING TECHNIQUES
COMPILED BY: NUZHAT NOOR AYESHA
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CONTENTSIntroduction
History
DefinitionGoals 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, scissorPrinciples of suturing
Suturing Techniques
Knots
Suture Removal
Other methods of wound closure
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• Suture means to ‘sew’ or ‘seam’. In
surgery suture is the act of sewingor bringing tissue together and
holding them in apposition untilhealing has taken place.
• A suture is a strand of material usedto ligate blood vessels and toapproximate tissues together.
INTRODUCTION
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HISTORY
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HISTORY
History of the Surgical Suture “I dress the wound
God heals it.“ Ambroise Pare, surgeon16th century
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•
The act of sewing is probably older thenHomo sapiens, because Neanderthal manwore some sort of clothing.
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HISTORY
Perhaps the world’s oldest suture was placed by anembalmer on the body of a twenty first dynasty mummy
about 1100 B.C.
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• A south American method of woundclosure used large black ants which bite
the wound edges together and the antsbody is then twisted off leaving the headin place.
• East African tribes ligated blood vesselswith tendons and closed wounds withacacia throns
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• The first detaileddescription of a wound
suture and suturematerials used in it is bythe Indian physicianSushruta, written in 500BC.
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Galen, the physician to
Roman gladiators in thesecond century A.D. used
silk for hemostasis.
Andreas Vesalius firstadvocated the suture of allfresh wounds as well assevered tendon and nerves.
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• Joseph Lister (1827-1912)discovered that bacteriapresent in suture strandscause wound infection. Hedisinfected sutures withcarbolic acid. He madesterile sutures possible to
bury it in clean woundswithout infection.
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• Sometime around 30 A.D., a
medical encyclopedia was writtenby a Roman named AureliusCornelius Celsus. His work, De ReMedicina, tells the reader thatsutures should be “soft, and notover twisted, so that they may bemore easy on the part.” He is
also credited with firstsubstantiated mention of ligatingby recommending it as asecondary means of stopping a
hemorrhage.
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• Rhazes of Arabia was credited
in 900 A.D. with first employing„kit gut‟ to suture abdominalwounds. The Arabic word „kit‟means a dancing master‟s fiddle,
the musical strings of which „kitstring‟ were made up of sheepintestines. Over the years „kit‟was confused with kitten or cat,
and the misuse of the term waspropagated.
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DEFINITIONS
• DEFINITION: suture material is an artificialfibre used to keep wound together until theyhold sufficiently well by themselves by naturalfibre (collagen) which is synthesized and woveninto a stronger scar
• Suture is a Stitch/Series of Stiches made tosecure apposition of the edges of a
Surgical/Traumatic wound (Wilkins)
• Any Strand of Material utilised to ligate bloodvessels or approximate Tissues (Silverstein L.H1999)
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GOALS OF SUTURING
Suturing is performed toProvide adequate tension
Maintain hemostasis
Provide support for tissuemargins
Reduce post-op pain
Prevent bone exposurePermit proper flap position
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SUTURE
MATERIALS
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• The basic purpose of a suture is to hold
severed tissues in close approximationuntil the healing process provides thewound with sufficient strength towithstand stress without the need for
mechanical support.
• Since wounds do not gain strength until4-6 days after injury, the tissues are
approximated till then by sutures.
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The amount of tension or pull thesuture can withstand beforebreaking is important.
Tensile St α diameter of suture
If the diameter of suture is
doubled, T.S is quadrupled.
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Suture material should be atleast as
strong as the tissues in which theyare used. By the end of 2nd week,when most skin sutures are removed,the wound would have attained 3%-
7% of final Tensile St.3rd week – 20% of T.S4th week – 50% of T.S
Wounds will never regain more than80% of Tensile St. of intact skin
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REQUISITES OF AN IDEAL SUTURE
• Tensile st: adequate material strengthwill prevent suture breakdown & use ofproper knots for the material used willprevent untying or knot slippage.
• Tissue biocompatibility: sutures madefrom organic material will evoke a higher
tissue response than synthetic sutures.tissue reaction α amount & size of
suture material.
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• Low capillarity: multifilament type soakup tissue fluid by capillary action
providing a rich medium for microbesincreasing chances of inflammation &infection.
•Good handling & knotting properties:ease of tying & a thread type thatpermits minimal knot slippage alsoinfluence thread selection.
• Sterilization without deterioration ofproperties: most sutures available inpackages are sterilized by dry heat ðylene oxide gas.
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• Non allergic, non electrolytic and non
carcinogènic
• Its use should be possible in anyoperation.
• Low cost
• It should not fray, should slide throughtissues readily & knot should not slip aftertying.
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• It should be readily visualized , should notshrink & should not be extruded from thewound.
• On break down ,it should not release toxicagents.
•
It should disappear without excessivereaction once its task is completed.
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CLASSIFICATION OF SUTURE
MATERIALS
According to source:
1. Natural2. Synthetic
3. Metallic
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According to structure 1. Monofilament
2. MultifilamentAccording to fate:
1. Absorbable (undergo degradation and
lose T.S. < 60 days)2. Non absorbable ( maintain T.S > 60
days)
According to coating: 1. Coated
2. Uncoated
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NATURAL
Absorbable
CatgutChromic catgutCollagenFascia latakangaroo tendonBeef tendonCargile membrane
Non Absorbable
SilkSilk worm gutLinen
Cotton
RamieHorse hair
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SYNTHETIC
Absorbable
Polyglycolic Acid Polyglactic Acid
Polyglactin 910(Vicryl)
Polydioxanone(PDS)
Polyglecaprone 25
Non Absorbable
Nylon/ polyamide
PolyPropylene
Polyesters
Polyethelene
Polybutester Polyvinylidene fluoride /
PVDF Sutures
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Monofilament
Multifilament
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MONOFILAMENT
Advantages
• Smooth surface
• Less tissue trauma• No bacterial
harbours
• No capillarity
Disadvantages
• Handling and
knotting• Stretch
• Any nick or crimp inthe material leadsto breakage.
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MONOFILAMENT
Absorbable
Surgical Gut- Plain,Chromic
Polydiaxanone
Polyglactin 910
Non Absorbable
Polypropylene Polyester
Nylon/polyamide
Polyvinylidene fluoride /
PVDF Sutures
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MULTI FILAMENT
Advantages
• Strength
• Soft and pliable• Good handling
• Good knotting
Disadvantages
• Bacterial harbours
• Capillary action• Tissue trauma
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MULTIFILAMENT
Absorbable
Polyglactin 910
Polyglycolic Acid
Non Absorbable
Silk
Cotton
Linen
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MONOFILAMENT
Handling Difficult
Smooth & strong
No Wicking
Thinner
MULTIFILAMENT
Handling easy
Low Strength
Wicking is a Problem
Thicker
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Metallic
SS
Tantalum
Gold
SilverAluminium
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Non absorbable sutures are categorizedby the United States Pharmacopeia(USP) as
Class I - Silk or synthetic fibers of
monofilaments with twisted or braidedconstructionClass II - Cotton or linen fibers, coated
natural or synthetic fibers in which the
coating does not contribute to T.SClass III - Metal wire of monofilament ormultifilament construction.
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SELECTION OF SUTURE
MATERIAL
A variety of suture materials and suture/needlecombinations is available. The choice of suturefor a particular procedure is based on the knownphysical and biologic characteristics of the
suture material and the healing properties of thesutured tissues.
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Principles of suture selection
The selection of suture material by asurgeon must be based on a soundknowledge of
• Healing characteristics of the tissueswhich are to be approximated,
• The physical and biological properties ofthe suture materials,
• The condition of the wound to be closedand
• The probable post-operative course ofthe patient.
1 R t f h li f ti :
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1. Rate of healing of tissues:
• When a wound has reached maximal strength,sutures are no longer needed.
• Tissues that ordinarily heal slowly such as skin,fascia and tendons should usually closed with non –
absorbable sutures.
• Tissues that heal rapidly such as peritoneum, liver,small intestine, muscles, stomach ,colon andbladder may be closed with absorbable sutures.
• Suture should be stronger than the suturedtissues, and it is unwise to implant more materialthan necessary.
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2.Tissue contamination:
• Avoid multifilament sutures asbacteria can linger with them andmay convert a contaminated wound
into an infected one.
• Use monofilament absorbable or
non- absorbable sutures inpotentially contaminated tissues.Monofilament polypropylene isideal
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3. cosmetic results :
• Where cosmetic results are important,
close and prolonged apposition ofwounds and avoidance of irritants will
produce the best results. Therefore usea smallest, inert monofilament suture
materials such as poly amide andpolypropylene.
• Avoid skin sutures and close
subcuticularly whenever possible• Under certain circumstances, to secure
close apposition of skin edges , skinclosure tape may be used
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4. cardiovascular surgery:• Monofilament polypropylene, polyester,
coated and un coated and braidedsurgical silk are recommended.
• Monofilament polypropylene being smooth,
possess high TS is the material of choicefor vascular anastomosis. This materialdoes not encourage any thrombusformation.
• Polyester is preferred for suturingartificial heart valves, myocardium andvascular prosthesis.
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5. Microsurgical procedure:• Most commonly used suture is 10-0 poly
amide monofilament
6.wound repair in patients followingirradiation
• In this group of patients ,not only thenormal healing process is delayed but thetolerance to the trauma of irradiated tissueis markedly reduced . So
• Extremely careful and gentle
surgical technique Avoid tension sutures and
mattress sutures as they further increasethe degree of ischemia.
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Closure in layers
Avoid continuous and constantpressure on irradiated tissues.
Fascial layer –non-absorbable
sutures, polypropylene is ideal
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The selection of suture material is basedon
The condition of the wound,The tissues to be repaired,The tensile strength of the suture
materialKnot-holding characteristics of the
suture material and
The reaction of surrounding tissues tothe suture materials.
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ABSORPTION OF SUTURE MATERIALS Degraded either by enzymatic process as in gutsutures, or by hydrolysis, as in many of thesynthetic materials like glycolic acid,ployglactin910 or polydioxanone.
Non absorbable sutures are walled off orencapsulated.
In infected tissues or in a patient who is febrile orprotein 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.
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BIOLOGIC RESPONSE OF BODY
TOSUTURE M TERI LS
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BIOLOGIC RESPONSE OF BODY TO SUTURE M TERI LS
• The initial body response to sutures is almostidentical in the first 4-7 days, regardless of thesuture material.
• The early response is a generalized acute asepticinflammation, involving primarily polymorphonuclearleukocytes.
• After few days mononuclear cells, fibroblasts &histiocytes become evident.
• Capillary formation occurs at the end of this initial
phase.
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• Natural Absorbable – Proteolytic
degradation. Intense tissue response
• Synthetic Absorbable – Hydrolysis. LessIntense
• Non Absorbable – Encapsulation. Acellular
Response
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RAILROAD SCAR
Sutures passing through mucous membrane orskin provide a „wick‟ or pathway through whichbacteria track down, and bacteria gain access
to underlying tissues. The longer the suture remains, the deeper the
epithelial invasion of the underlying tissue.When suture removed, epithelial tract remains.
These cells may eventually disappear or remainto form keratin and epithelial inclusion cysts.The epithelial pathway result in typical„railroad scar‟ formation.
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ABSORBABLE NATURAL
Gut / cat gut Oldest known absorbable suture.
Galen referred to gut suture as early as 175A.D.
Derived from sheep intestinal sub mucosa orbovine intestinal serosa.
Submucosa of sheep has a rich elastic tissuecontent which accounts for high tensile strength
of the catgut. It is monofilament and is availablein the plain form as well as “tanned” in chromicacid. The tanning process delays the digestion bywhite blood cell lysozymes.
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• Catgut should not be boiled or autoclaved as heatdestroys its tensile strength.
• Catgut is sterilized during preparation and kept in apreservative solution (isopropyl alcohol) inside spoolsor foils. Unused and reusable catgut is hygroscopic
so, catgut will swell due to water absorption and itstensile strength will be reduced .
• Absorption :40-60 days
• When placed intra orally sutures are digested in 3-5days.
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• It is available pre-sterilized in aluminium-
coated sterile foil overwrap pack withethicon fluid as a preservative.
• Colour : Plain catgut is yellow , while
chromic catgut is tan
• Absorbtion : Catgut is absorbed byproteolytic digestive enzymes releasedfrom inflammatory cells collected aroundthe catgut. So, in the presence ofinfection catgut is rapidly absorbed.
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CHROMIC CATGUT
Coated with thin layer of chromium saltsolution 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
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As it is an organic material andsusceptible to enzymatic degradation,packed in isopropyl alcohol as apreservative. Also condition or soften
it.
Suture absorbs alcohol and swells. It iscombustible and is also irritating totissues. It is removed by a quick risein saline prior to use.
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COLLAGEN SUTURE
Natural, absorbable, monofilamentObtained by homogenous dispersion of
pure collagen fibrils from the flexortendons of cattle.
Absorption – 56 days
TS - < 10% after 10 days.
Used in opthalmic surgery
Disadvantage of premature absorption.
SYNTHETIC ABSORBABLE
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POLYGLACTIN 910 VICRYL) Polyglactic
acid
Coated and uncoated
Synthetic suture
Monofilament/multifilament
Lactide has hydrophobic qualities→delaying loss of
TS
TS - 14 – 21 days.
Absorption – 56-70 days.
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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.
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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% ofthe original tensile strength after 5 days and all of itstensile strength is lost after 14 days.
• Its absorption is associated with minimal tissue reactionfacilitating improved cosmetics and reduction ofpostoperative pain.
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• The absorption is essentially complete
within 35-42 days.
• Uses: Low tensile strength and Rapidabsorption rate --Ideal for intra-oral
use (dental surgeries).
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VICRYL plus ANTIBACTERIAL SUTURE
• Handles andperforms same asnormal vicryl.
• In vitro studiesshown that triclosanon VICRYL plus
creates a zone ofinhibition aroundthe suture.
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GLYCOLIC ACID HOMOPOLYMER
DEXON) POLYGLYCOLIC ACID
Polymer of glycolic acid with greater knot pulland TS than gut.
Synthetic, absorbable, braided Absorption- hydrolysis, which results in
minimal tissue reactivity.
Braided and so catches on itself, and knot
tying and passage through tissues difficult. Does not tolerate wound infection and not
percutaneous suture.
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GLYCOLIC ACID MAXON) POLYGLYCONATE
-Synthetic, absorbable, monofilament.
-Polyglycolic acid and trimethylene carbonate-TS – 14-21 days (>Dexon)
Absorption – Hydrolysis in 180 days
In vitro studies by Edlich and co-workers (1973)have suggested that the degradation products ofpolyglycolic acid and nylon sutures - glycolic acid,1,6-hexane diamine and adipic acid areantibacterial agents.
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POLYDIOXANONE PDS II)
Synthetic,absorbable,monofilament.
Polyester derivative poly P dioxanone.
TS -14-42 days Absorption – Hydrolysis in 6 months.
Passes through tissues easily.
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Significant memory – compromises theease of knot-tying and knot security.
Minimal tissue reaction
For wounds under tension andcontaminated wounds.
May extrude through the wound overtime. So used only in tissues deeperthan subcuticular layer. Or if in face 6-0 used.
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NON ABSORBABLE SUTURES
• Natural – silk, silk worm gut, cotton ,ramie,linen
• Synthetic-polyester, polyamide, polypropylene, polybutester,polyethelene
• Metals : SS
Tantalum
platinum
silver wiresgold
aluminium
NATURAL NON-ABSORBABLE
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SURGICAL SILK
-Braided or twisted
-Made from the filament spun by silkworm larvato form its cocoon. Each filament isprocessed to remove the natural waxes andsericin gum. After braiding, the strands aredyed, stretched and impregnated with amixture of waxes and silicone. Dry silk sutureis stronger than wet silk suture.
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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
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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 detectedin tissues after 2 yrs.
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SURGICAL COTTON
Natural, multifilament, non absorbable
From stable Egyptian cotton fibers
good knot securityNot good in presence of contaminated
wounds or infection
Rarely used nowadaysUses:
Most body tissues for ligating andsuturing
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LINEN
Natural, multifilament, non absorbable
Made from stable flax fibers
Poor TS and so not for suturing undertension
Uses:
Ligation of superficial vessels
Mucosal suturing without stress
SYNTHETIC NON-ABSORBABLE
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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.
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NYLON – BRAIDED SURGILON, NURILON)
Synthetic, non absorbable
Inert polyamide polymer
Braided and sealed with silicon coating
Look, handle and feel like silk, butmore stronger
Multifilament nylon is weaker and lesssecure when knotted, offering little
advantage over monofilament nylon.
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NYLON MONOFILAMENT DERMALON,ETHILON)
Uncoated, but inert and non irritating tothe tissues.
High TS and low tissue reactivitySome memory and return to original
linear shape over time. Because of thismore throws (4 throws) indicated.Moistened nylon monofilament are more
easily handled and are packaged wet.
Uses: Skin closure, retention, plastic, ophthalmic
and microsurgery.
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POLYESTER – BRAIDED
Tycron, Mersilene -UncoatedDacron, Ethibond - Coated (with polybutilate)
Multifilament fibers of polyester Excellent TS which is maintained indefinitely Uncoated is rougher and stiffer than coated form
Coated provides -low infection rate-secure knotting-smooth removal-low reactivity
-easy passage throughtissues More expensive In deeper layers, may last indefinitely.
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GOR-TEX
Nonabsorbable,synthetic,MonofilamentFrom,expanded polytetrafluoroethylene
(ePTFE)
Extremely low tissue reaction, good knottensile strenghtand ease of handling.
Uses
All type of soft tissue approximation andcardiovascular surgeries.
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MONOCRYL
Absorbable, synthetic, monofilamentPoliglecaprone 25; copolymer of glycolide
and caprolactone
Hydrolysis 90-120 daysTissue reaction – minimal
Good knot strength
Used for soft tissue closure
Most pliable material ever made
POLYBUTESTER (NOVOFIL)
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-New, monofilament, nonabsorbable, synthetic
-Made of polyglycol trephthate and polybutyleneterephthalate and is considered as a modified polyestersuture.
-No significant memory compared to polypropylene andnylon. Easier to manipulate and greater knot security.
-Unique feature is their ability to elongate or stretchwith increasing wound edema. When edema subsides,suture resumes original shape; so it is an ideal suturefor lacerations secondary to blunt trauma.
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-TS high and lasts longer-Minimal tissue reactivity.
-Popularity in cutaneous surgery is gradually
increasing.
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SURGICAL STEEL
Natural, monofilament/multifilament, nonabsorbable
Alloy of iron, nickel and chromium Good TS even in infection
Difficult to handle and tendency to cutthrough tissues. Very hard to tie, and knotends require special handling.
P t ti l t d b k t i t
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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.
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Major Disadvantages
1.Linear artifacts caused by substances withhigh atomic number on CT images
2.Possible movement of metal suture duringMRI
3.Patch test for nickel sensitivity should bedone.
Packaging………
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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
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SUTURE SIZES
• Largest size 1 to extremely fine 11-0.Increasing number of zeroes correlates withdecreasing suture diameter and strength.
• Thicker sutures are used for approximation ofdeeper layers, wounds in tension prone areasand for ligation of blood vessels.
• Thin sutures are used for closing delicatetissues like conjunctiva and skin incisions of theface. Size is chosen to correlate with thetensile strength of the tissue being sutured.
3-0 or 4-0 OMFS, muscle, deep skin
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5-0 or 6-0 facial skin closure9-0 or 10-0 microsurgery
SUTURE NEEDLES
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Surgical needles are designed to leadsuture material through tissue withminimal injury. Needles can be
- straight (GIT) or curved
- swaged or eyedMade 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.
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Made up of either SS or carbon steel.
CLASSIFICATION OF SURGICAL NEEDLES 1.According to eye -eye less needles
-needles with eye2.According to shape -straight needles. -curved needles
3.According to cutting edgea) round body
b) cutting -conventional-reverse cutting
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• 4.According to its tip -triangular tip
-round tip
-blunt tip
• 5.Others -spatula needles
-micro point needles
-cuticular needles-plastic needles
Ideal Properties Of Needles
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Ideal Properties Of Needles
• High quality stainless steel
• Smallest diameter possible
• Capable of implanting sutures with minimal trauma
to tissues.
• Stable in the needle holder
• Should be sharp.
• Sterile and corrosion resistant.
natomy of a Needle
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Term Definition
Chord
Length of needle
Radius
Diameter
The linear distance between eye andtip.
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.
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COMPONENTS OF SURGIC L NEEDLE
1 ThCLOSED
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1. The eye
2. The body; and
3.The pointThe eye can be - closed
- swaged
- chanelled/drilled
Shape of the eye may be - round
- oblong; or
- square
Open French-eye needle is easy to load withvarying caliber, but has additional bulk.
SWAGED
CHANELLED
Eyed require threading prior tolt i lli d bl
Suture loop inserted through eye
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use, results in pulling a doublestrand through tissue. Tying the
suture to the eye increases bulkof suture material drawn throughtissues. So they are also called„traumatic needles‟.
Most suture materials andneedles are difficult to sterilize.Needles are also difficult toclean after use and become blunt
and workhardened so that theysnap.
Loop placed over tip
Loop drawn back
Suture tied on eyed needle
SWAGED NEEDLE
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• Swaged needles do not require threading andpermit a single strand of suture material to bedrawn.
• Suture attached to needle via a hole drilledthrough the end of the needle, and the end isswaged during manufacturing.
• It is atraumatic and
act as a single unit.
• Prepacked and presterilized
by gamma radiation.
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Needle attached to suture
Favourable for I/O use but expensiveLess tissue damageNew needle each time
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THE BODY
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• Body is the widest portion of the needle
• It is known as grasping area.
-Most commonly used are 3/8 circle. They can beeasily manipulated in large and superficial woundsand require only less wrist movement.
-1/2 circle used for suturing tissues in small wounds,and body cavities and orifices. Require less space,but more supination and pronation of wristrequired.
-5/8 used in oral cavity.
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Tapered
utting
Reverse cutting
RADIUS OF CURVATURE OF THEBODY(NEEDLE)
CLINICAL USE
Straight Needle Needle of choice for the skin
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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, woundclosure after placement of
osseointegrated implants and GTR
procedures
May be used in all surgical wounds
Needle of choice in oral surgeryWide range of uses in many
surgical wounds
Wounds of the urogenital tract
THE POINT
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Point runs from tip to the max. cross sectionalarea of the body.
• Can be -triangular tip/cutting
-round tip-blunt tip
• Cutting needles are Ideal for suturing keratinizedtissues like skin, palatal mucosa, subcuticularlayers and for securing drains.
• Round/tapered needles used for closingmesenchymal layers such as muscle or fascia thatare soft and easily penetrable
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• The conventionalcutting point has two
• The reverse cuttingpoint has two opposing
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g popposing cutting edgesand third edge on the
inside curvature of theneedle.
p pp gcutting edges and thirdcutting edge on the
outer curvature of theneedle.
• The tapered point is used primarily on soft,easily penetrated tissues . it leaves small hole
d b d i l ll
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and can be used in vascular surgery as well asfascial soft tissue surgery.
• The blunt point has a rounded end which doesnt cut through the tissue .it is used in friabletissue suturing or to the parotid duct or
lacrimal canaliculi.
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Cuticular needles
• Sharpened 12 times
• Designated as C or FS(CUTICULAR or FOR SKIN)
Plastic needles
• Sharpened an additional24 times
• Designated as P or PS orPC(PREMIUM or PLASTIC
SURGERY or PRECISIONCOSMETIC ).
• Needles in the PC series
are made up of strongerSS alloy and haveflattened andconventional cuttingedge.
• Curvature of the needle is selected according tothe accessibility The needle must exit in a
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the accessibility. The needle must exit in avisible spot so that the surgeon is aware of theposition of the point of the needle at all thetimes.
• Try to match the needle thickness with suturediameter .it is not appropriate to use wide thickneedle with small suture material . This willcause laxity of immediate suture line and allowsbacterial contamination & ingrowth of epithelium& in vascular surgery it may allow oozing of blood
throught/suture hole.
Placement of a Needle into the Tissue
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Force should always be applied in the
direction that follows the curvature ofthe needle.
Movable to a non-movable tissue.
Only sharp needles with minimal force.
Never force the needle through the
tissue.
Avoid retrieving the needle from the
tissue by the tip.
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Grasp the needle in the body 1/4th to
half of the length from the swagedarea.
Do not hold the needle by the swaged
area or the eye.
Avoid excessive tissue bites with smallneedles, as it will be difficult to
retrieve them
NEEDLE HOLDER
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• The needle holder is used to handlethe suture needle and thread whilesuturing the surgical wound.
• If used properly it enables thesurgeon to perform procedurescorrectly and with great precision.
PARTS OF NEEDLE HOLDER
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• Working tip/ jaws• Hinge device
• Shank/body
• Catch mechanism/ ratchet• Grip area
NEEDLE HOLDER
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There are different types of needle holders.
The beaks may be short or long, broad or
narrow, slotted or flat, concave or convex,
smooth or serrated. Commonly used have a
locking hand and short beaks and 6’ long
Gilles needle holder (scissors incorporated into
blades)
Kilner needle holder
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• Atraumatic needle holder ensures
needle movement and compatibility ofclamping movement. It has texturedtungsten carbide jaw inserts, and itsrounded needle holder jaw edges do not
cause structural damage tomonofilament suture or needle
GILLES NEEDLE HOLDER
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Scissors are incorporated into the blades
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OLSEN HEGAR NEEDLE HOLDER KILNER NEEDLE HOLDER
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MAYO HAGER NEEDLEYASARGIL MICRO NEEDLE HOLDER
Gripping needle holder
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The scissor grip
Used in the anterior part of the mouth and in
areas of easy access
The instrument is stabilized with the index finger
Palm grip
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g p
• Used in the deeper parts of oral
cavity
Use appropriate size forneedle
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needle
Grasped 1/4 to ½ distance
from swaged area Tips of the jaws should
meet before remainingportion of jaw
Needle placed securely Do not overclose
Always directed bysurgeon‟s thumb
Do not use digital pressureon tissues
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PRINCIPLES
OF
SUTURING
PRINCIPLES OF SUTURING
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1.Needle grasped at 1/4th to half the
distance from eye.
2.Needle should enter perpendicular totissue surface
3.Needle passed along its curve
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4.The bite should be equal on both sides of thewound margin and the point of the entry of theneedle should be closer to the wound edge thanits point of exit on the deep surface
5.The bite should be about 2-3 mm from the woundmargin of the flap because after wound closurethe edge of the wound softens due tocollagenolysis and 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
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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
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8.Tie to approximate; not to blanch
9.Knot must not lie on incision line
10.The distance b/w one suture toanother should be about 3-4 mm apart
to prevent strangulation of the tissue &
to allow escape of the serum orinflammatory exudate & to get more
strength of the wound.
11.Sutures placed at a greater depth than distancefrom the incision to e ert o nd margins
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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 tyingknot for provision of the slight edema postoperatively, 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 onid f i i i d DOG EAR t b
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one side of incision and cause DOG EAR to beformed in the final phase of wound closure.
• Simply extending the length of the incision tohide the exists will produce an unsatisfactoryresult.
• Thus after undermining excess tissue incisionis made at approx. 300 to parent incisiondirected towards undermined side. Extratissue is pulled over incision and appropriateamount is excised. Incision is closed in normalmanner.
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IMPROPER SUTURING TECHNIQUE
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SUTURING
TECHNIQUES
1.INTERRUPTED SIMPLE SUTURE
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Most commonly used. Inserted singly through side
of the wound and tied with a surgeon’s knot.
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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
2. SIMPLE CONTINUOUS / RUNNING
A i l i t t d
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A simple interrupted
suture placed and needlereinserted in a continuous
fashion such that the
suturepasses perpendicular
to the incision line below
and obliquely above.
Ended by passing a knot
over the untightened end
of the suture.
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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
the whole length of the wound which willthen gape open.
3.CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by
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Similar to continuous but locking provided bywithdrawing the suture through its own loop.
Indicated in long edentulous areas, tuberositiesor 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.
4.VERTICAL MATTRESS
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Specially designed for use in
skin. It passes at 2 levels, onedeep to provide support andadduction of wound surfaces at adepth and one superficial to
draw the edges together andevert them.
Used for closing deep wounds
This approximates subcutaneousand skin edges
Needle passed from one edge to the other and again from
latter edge to the fist and knot tied
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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
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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 byvertical mattress. Used to control soft tissuehemorrhage.
• Runs parallel to the blood supply of the edge of theflap and therefore not interfering with healing.
• Uses: abdominal surgeries & closure of skin wounds.
5.HORIZONTAL MATTRESS
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It everts mucosal or skin margins, bringing
greater areas of raw tissue into contact. So usedfor closing bony deficiencies such as oro-antralfistula or cystic cavities.
Disadvantage: constricts the blood supply toedges of incision.
Needle passed from one
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p
edge to the other and
again from the latter tothe first and a knot is tied.
Distance of needle
penetration and depth of
penetration is same for
each entry point, but
horizontal distance of thepoints of penetration on
the same side of the flap
differs.
Advantages:
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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
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• It does not cut through the tissue ,so usedin case of tissue under tension(inadequate tissue)
Disadvantages:
• More trouble to insert
• Constricts the blood supply to the incisionif improperly used, cause wound necrosisand dehiscence
6. FIGURE OF 8 SUTURE
Used for extraction socket closure and for
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adaption of gingival papilla around the tooth
Suturing begun on buccal surface 3-4mm fromthe tip of the papilla so as to prevent tearing ofpapilla.
Needle first inserted into theouter surface of the buccal flapand then the lingual flap.Needle again inserted in same
fashion at a horizontal distanceand then both ends tied.
7. SUBCUTICULAR SUTURE
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Used to close deep wounds in layers. Knots
will be inverted or buried, so that the knotdoes not lie between the skin margin andcause inflammation or infection.
To bury the knot, first pass of the needleshould be from within the wound andthrough the lower portion of the dermallayer. Needle then passed through thedermal layer and emerge through
subcutaneous tissue and knot tied
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8.CONTINUOUS SUBCUTICULAR SUTURE
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Continuous short
lateral stitches are
taken beneath the
epithelial layer of theskin. The ends of the
suture come out at each
end of the incision and
are knotted.
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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.
9.PURSE STRING SUTURE
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A circular pattern that draws together
the tissue in the path of the suture whenthe ends are brought together and tied.
KNOT TYING
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KNOT TYING
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Sutured knot has 3 components
1.Loop created by knot
2.Knot itself which is composed
of a number of tight throws3.Ears which are the cut ends of
the suture
KNOT TYING
Principles of knot tying
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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
Maintenance of traction at one end of the
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Maintenance of traction at one end of thesuture after the first loop is thrown, to avoid
loosening of the knot.
Placing the final throw as horizontally aspossible to keep knot flat
Limiting extra throws to the knot, as they donot add strength to a properly tied knot.
KNOTS
SQUARE KNOT
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SQUARE KNOT
Formed by wrapping thesuture around the needleholder once in oppositedirections between the
ties. Atleast 3 ties arerecommended.
Best for gut, silk, cotton
and SS
SURGEON’S KNOT
Formed by 2 throws on the first tie and one
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Formed by 2 throws on the first tie and onethrow in the opposite direction in the secondtie. Recommended for tying polyester suturematerials such as Vicryl and Mersiline
GR NNY’S KNOT
A tie in one direction followed by a tie in
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A tie in one direction followed by a tie in
the same direction and a third tie in theopposite direction to square the knot andhold it permanently.
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SUTURE
REMOVAL
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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 d
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5-7 days
- Where there is tension on the sutureeg : 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.
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Suture area is first cleaned with normal saline.
The suture is grasped with non-tooth dissecting forceps
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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.
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• INCORRECT
• CORRECT
• Possible Complication Of Leaving Suture For Many
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Days
1.Sutural abscess.
2.Suture scarring or stitch mark
3.Implanted dermoid cyst
SCISSORS
Dean’s Scissors
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-General purpose scissors-Used for cutting sutures
-Can also be used to trim mucosal margins.
SUTURE MARKS
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Suture marks are caused by 3 factors
1.Skin sutures left in place longer than 7days, resulting in epithelialisation of
suture track
2.Tissue necrosis from sutures that weretied too tightly or became tight due to
tissue edema
3.Use of reactive sutures in the skin.
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Other Methods of Wound Closure
• Ligating clips
•
Skin staples• Surgical tape
• Surgical adhesives
Mechanical wound closure
devices
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devices
Ligating clips :
• can be resorbable or non resorbable.
• Made up of SS,tantalum or titanium or
pidioxanone.
• Designed for the ligation of tubularstructures.
Surgical staples:
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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.
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Advantages
• As the clips do not penetrate skin, yet give
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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
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possible to maintain atleast 5mmdistance from the stapled skin to theunderlying bone and blood vessels.
SURGICAL TAPE
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Microporous tape is used alone or in conjugationwith skin sutures to decrease tension at the woundmargins.
The surgical tapes have a backing of viscous rayonfibers coated with an adhesive copolymer and theyare pervious to sweat but not to blood or purulentmaterial.
Comes in 1/8, 1/4, and 1/2 inch wide strips. Skin
margin is prepared with tincture of benzoin toprovide better adhesiveness for tape.
Used to decrease skin tension oncheek,forehead,chin.
Advantages
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Minimizes wound dehiscence and allows earlier
suture removal
Provides continuous support for the wound andminimizes scar expansion
Avoids the ordeal of suture replacement and
removal in children
Less inflammatory reaction, lower rate of woundinfection, 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 loosen
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Do not evert edges of the wound, and readily loosenwhen wet by blood or serum.
Prior to placement, a thin coat of antibiotic ointmentis placed on wound margin to protect wound fromskin oils and bacteria.
While removing, to avoid epithelial marginseparation, the ends should be lifted equally towardsthe wound margin and then lifted evenly from the
wound.
Cyanoacrylates
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- 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
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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.
REFERENCE
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• Suturing techniques in oral surgery –SandroSiervo
• Atlas of Minor Oral Surgery- Harry Dym
• Laskin vol-1
• Oral & Maxillofacial Surgery Vol 1- W. HarryArcher
• Textbook of oral & maxillofacial surgery-Neelima Anil Malik
• Minor Oral Surgery- Goeffrey L.Howe• Text book of surgery: Sabiston
• Periodontology-Caranza.