Wound Closure Presentation

Jessica CarterAimee Stohler

Syneture: A Division of Covidien

Agenda

· Basic Terms Defined· Names And Types Of Sutures

– Absorbable– Non-Absorbable

· General Applications· Topical Adhesives· Needles

Basic Terms Associated With Sutures

· Primary Suture Manufacturers:– Syneture (Covidien)– Ethicon

Specialty Suture Manufactures:– Gore– Tevdek

Types of Suture Material

Types of Suture Material:– Absorbable - Suture material is absorbed over time by the body.– Non-Absorbable - Suture material is permanent - not absorbed by the body.

Basic Terms Associated With Sutures

· Absorption Profile - The number of weeks or days it takes the body to absorb suture.

· Tensile Strength - The amount of force necessary to break a suture. It is measured in days with absorbable sutures.

· Hydrolysis - Absorption process that uses the body’s water - Synthetic sutures are absorbed by hydrolysis.

Basic Terms Associated With Sutures

· Enzymatic Process - Suture that is absorbed by the body’s enzymes - Gut suture products are absorbed in this manner

· Degrade - A non-absorbable suture’s tendency to crumble and fall apart over time. The material is not absorbed, but it does not stay intact - Silk, Nylon

· Mechanical Trauma– Trauma to the suture by mechanical instruments can result in suture failure.– Compression of sutures between a needle holder with teeth can produce

morphologic changes in sutures that can result in a marked reduction in suture breaking strength

Basic Terms Associated With Sutures

· Braided - A suture strand that is woven or braided with numerous filaments.

· Monofilament - Suture strand is composed of a single strand or filament.

· D-Tach/ Pop-Off - Suture/needle combination that is designed so that the needle detaches from the suture strand when appropriate force is exerted.

Basic Terms Associated With Sutures

· Running Closure - AKA “Continuous Closure” - Incision closed with repeated passes of one single suture.

· Interrupted Closure - Incision is closed with numerous sutures each tied separately.

· Double Armed - Needle on both ends of suture· Taper – Refers to a taper point needle generally used inside the body· Cutter - Refers to a cutting needle used generally to close skin

Review of Primary Tissue Layers

The primary layers which will determine the type of suture, needle and suturing technique used are:

– Skin– Subcutaneous fat– Anterior Fascia– Muscle– Posterior Fascia– Peritoneum

Suture and Tissue Reactivity

Although sutures are necessary to provide wound support so healing will occur, they may also cause a tissue reaction at the wound site.

Tissue reactivity is the patients response to the physiological properties of the suture (what the suture is made from ). It can also be referred to as a foreign body response.

Suture Function and Wound Healing

· Sutures function to hold wounds together until wound healing takes place.

· Fourteen to twenty-one days is often regarded as the critical wound healing period.

· It is during this time that the sutures provide strength to the closed wound, allowing the tissue to heal with minimal scarring.

Suture StructureMonofilament /Multifilament

Suture Sizing - USP (United States Pharmacopoeia: - Diameters and

strengths)

Suture Sizing - USP (United States Pharmacopoeia: - Diameters and

strengths)

7 6 5 4 3 2 1 0 2-0 3-0 4-0 5-0 6-0 7-0 8-0 9-0 10-0 11-0

Human hair

More 0’s = smaller size

Abdominalclosure

Skin

CABG

Chest Micro / Ophthalmic

Suture Products

· Absorbable Products:– Braided Synthetic– Monofilament Synthetic– Organic Absorbables

· Non-absorbable Products– Braided Synthetic– Monofilament Synthetic– Organic Nonabsorbables

Suture ProductsAbsorbable Sutures

· Braided Synthetic Absorbables (BSA)

– Polysorb - Syneture• 92.5% Polyglycolic 7.5% Polylactic Acid• Tensile Strength for 3 weeks• Absorbed in 56 to 70 days

– Vicryl - Ethicon• 90% Polyglycolic 10% Polylactic Acid• Tensile strength for 3 weeks• Absorbed in 56 to 70 days

Suture ProductsAbsorbable Sutures

· Braided Synthetic Absorbable (BSA) Advantages:– Tremendous strength– Resistance to breakage due to multifilament construction– Relatively little memory– Easy to handle and tie– Tremendous variety of needle/suture combinations.

Suture ProductsAbsorbable Sutures

· BSA Disadvantages:

– Tends to be rougher on tissue as suture pulled through.– Braids have potential to harbor infection due to numerous interstices.– Can be a medium for stone formation in GYN and GU procedures

involving the bladder and surrounding structures.

Suture ProductsAbsorbable Sutures

· BSA General Applications:– General Surgery

• Mid line fascia closure• Subcutaneous layer closure• Subcuticular skin closure• Bowel anastomosis• Other general tissue closures

Suture ProductsAbsorbable Sutures

· BSA Applications (Cont).· Ortho/Neuro

– General tissue layer closure· GYN

– Ligation (TAH/TVH)– Vaginal Cuff Closure– Hysterotomy Closure

Suture ProductsAbsorbable Sutures

· Monofilament Absorbable Sutures (MSA’s)– Short Absorption Profile MSA’s

• Biosyn - Syneture– Tensile strength: 3 weeks– Is absorbed in 90 to 110 days

• Caprosyn - Syneture– Tensile strength: 10 days– Is absorbed in 56 days or less

• Monocryl - Ethicon– Tensile strength: 10 to 14 days– Is absorbed in 91 to 119 days

Suture ProductsAbsorbable Sutures

· Short Absorption MSA Applications:· General Surgery

– Skin Closure– Colo-Rectal Applications

· GYN– Adnexa ligation– Vaginal Cuff Closure– Hysterotomy Closure

Suture ProductsAbsorbable Sutures

Long absorption profile Monofilament Synthetic Absorbable• Maxon - Syneture• PDS - Ethicon• Both sutures provide tensile strength for 6 weeks and are absorbed by the body

in 180 days.– Maxon maintains slightly higher tensile strength during the first two weeks

in vivo– Some surgeons might notice slight handling differences between the two

sutures

Suture ProductsAbsorbable Sutures

· Long absorption MSA applications:– Midline incision closures

• Looped products are increasing in popularity– Bowel anastomosis– Any application where extended approximation (three to six weeks) of

tissue is needed.

Suture ProductsAbsorbable Sutures

· MSA Advantages:– Smooth flow through tissue– Resistance to bacteria, infection and stone formation due to

monofilament construction– Latest technology from suture manufacturers– Variety of absorption rates– Best replacement for gut products

Suture ProductsAbsorbable Sutures

· MSA Disadvantages:

– Out of package memory– Stiff and slightly more difficult to work with– Knots require additional throws

Suture ProductsAbsorbable Sutures

· Organic Absorbable Sutures

Suture ProductsAbsorbable Sutures

· Gut Products - Ribbons of beef serosa (inner most layer of intestines) twisted to form suture strands

– Fast Absorbing Gut• Proprietary to Ethicon• Extremely short absorption profile

– Plain Gut– Mild Chromic Gut

• Proprietary to Syneture

– Chromic Gut CAPROSYN is an excellent alternative to using Gut suture.

Suture ProductsAbsorbable Sutures

· Gut Products· Generally fast, unpredictable

absorption rates· Decreasing in popularity · Banned in Europe and Japan

Suture ProductsAbsorbable Sutures

· Things to remember about Absorbable Suture Products - Means of absorption

– Synthetic absorbable sutures are absorbed by hydrolysis (the body’s water) and are generally deemed to have predictable strength and absorption profiles

– Organic absorbable sutures (gut products) are absorbed by the body’s enzymes and are generally thought to be more unpredictable in strength and absorption profile than synthetic absorbables.

Suture ProductsAbsorbable Sutures

Any Questions?

Suture Products

Non Absorbable Sutures

Suture ProductsNon Absorbable Sutures

· Braided Synthetic Non Absorbable Sutures:– Braided Polyester

• Ticron - Syneture– Coated with silicone– Dyed Blue

• Ethibond - Ethicon– Polyester suture coated with PBA (polybutylane adipate)– Dyed Green

Suture ProductsNon Absorbable Sutures

· Polyester Suture Applications

– Heart valve replacement– Tendon Repair– ACL Graft– Direct repair of hernia– Uterine suspension

Suture ProductsNon Absorbable Sutures

· Braided Synthetic Non Absorbables (Cont)

– Braided Nylon

• Surgilon - Syneture • Nurolon - Ethicon

Suture ProductsNon Absorbable Sutures

· Braided Nylon Applications:

– Neuro surgery - Dura closure

– Direct repair of Hernia

– Cannulation during heart bypass surgery

Suture ProductsNon Absorbable Sutures

· Synthetic Monofilament Non Absorbables– Polypropylene

• Surgipro II – Syneture

• Prolene - Ethicon

Suture ProductsNon Absorbable Sutures

· Polypropylene applications:– Blood vessel anastomosis– Hernia repairs using mesh– Uterine and bladder suspension– Percutaneous skin closure– Abdominal wall closure

• (where permanent suture is required)

Suture ProductsNon Absorbable Sutures

· Monofilament Nylon Sutures

– Monosof (black) – Syneture– Dermalon (blue) - Syneture– Ethilon - Ethicon

Suture ProductsNon Absorbable Sutures

· Monofilament Nylon Applications:

– Percutaneous skin closure

– Secure Drains

– Abdominal wall closure

Suture ProductsNon Absorbable Sutures

· Monofilament non absorbable sutures that are proprietary to SYNETURE

– Novafil • Monofilament polybutester suture• Unique handling characteristics; Dramatically reduced memory• Can be used in all applications where polypropylene sutures are used

– Vascufil• Vascular version of Novafil• Coated to minimize tissue drag and to improve knot run down

Suture ProductsNon Absorbable Sutures

· Organic Non Absorbable Sutures:– Silk

• Considered the “gold standard” of suture handling• Braided and coated with wax or silicone

– Steel– Sternal Wires - CV– Pacing Wires - CV

Suture ProductsNon Absorbable Sutures

· Things to remember about non-absorbable sutures:– Some non-absorbable sutures will degrade over time. They won’t

absorb, but will degrade• Degrading permanent sutures

– Silk– Nylon

• Non-degrading permanent sutures– Polypropylene– Polybutester– Polyester

Topical Adhesives

· Cyanoacrylate based products used for the closure of topical skin incisions and trauma-induced lacerations in areas of low skin tension with easily approximated wound edges.

· Indermil (Syneture)– n-Butyl 2-Cyanoacrylate

· Dermabond (Ethicon)– 2-Octyl Cyanoacrylate

Topical Adhesives

· Clinical Applications:– Laparoscopic Procedures– Biopsies– Cosmetic Surgery– ER/ Lacerations– Dressing/ Microbial Barrier

Non Absorbable Suturesand Topical Adhesives

· Any Questions?

Surgical Needles

Needles must possess the following characteristics:

· The needle must be sharp enough to penetrate tissue with minimal resistance.

· The needle must carry the suture material through tissue with minimal trauma.

· The needle must be rigid enough to resist bending, yet flexible enough to bend before breaking.

Every surgical needle has three basic parts

The swage is the site of attachment of the suture to the needle.

The body of the needle is the portion that is grasped by a needle holder.

The point of the needle extends from the tip of the needle to the maximum cross section of the body.

Needle Shapes

Needle Points

· Specific points are designed and produced to the required degree of sharpness to smoothly penetrate the types of tissue to be sutured.

· The point is from the extreme tip of the needle to the maximum cross section of the body.

Surgical Needles

· Types of Surgical Needles:

– Taper Needles - Vast majority of needles are this type• General Tissue Closure

– Midline, Sub Q, Peritoneum• Vascular closures and anastomosis• Bowel closure and anastomosis

Surgical Needles

· Types of Surgical Needles (Cont.)– Cutting Needles - Needles with a triangular cutting configuration.

• Used for penetrating tough, fiberous tissue.• Sub Cuticular skin closure• Percutaneous skin closure• Skin sutures for securing drains• Various orthopedic tissue applications

– Ligaments etc.

Surgical Needles

· Types of Surgical Needles (Cont.)– Taper cutting needles - Point of needle has a cutting tip. Body of needle

quickly tapers.• Used in places where taper needles are desired, but may not be quite sharp

enough.• Vascular procedures where vessels are heavily plaqued.

Surgical Needles

· Types of Surgical Needles (Cont.)– Spatula Needles -

• Used primarily in ophthalmic surgery• Deflects or pushes aside tissue as the needle passes• Come in a variety of configurations.

– Blunt Needles - • Needles have a blunt tip• Used primarily on delicate or friable tissue (Liver) or on patients with high

risk blood diseases.

Surgical Needles

· Types of Surgical Needles (cont’d)– X-Cutting Dermax needles (proprietary to Syneture)

• Features a fourth cutting edge that allows four dimensional control: horizontal (left/ right), and vertical (up/ down)

• Unique double-point profile geometry for easier puncturing and needle embodying into the tissue.

• Used primarily in cosmetic procedures, & percutaneous skin closures.

Surgical Needles

· Any Questions?

THANK YOU!