Wound Closure Presentation
Jessica Carter
Aimee 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:
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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 Structure
Monofilament /Multifilament
Suture Sizing - USP
(United States Pharmacopoeia: - Diameters and strengths)
Human hair
Chest
7 6 5 4 3 2 1
Skin
0
Micro / Ophthalmic
2-0 3-0 4-0 5-0 6-0 7-0 8-0
Abdominal
closure
9-0 10-0 11-0
CABG
More 0’s = smaller size
Suture Products
 Absorbable Products:
– Braided Synthetic
– Monofilament Synthetic
– Organic Absorbables
 Non-absorbable Products
– Braided Synthetic
– Monofilament Synthetic
– Organic Nonabsorbables
Suture Products
Absorbable 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 Products
Absorbable Sutures
 Braided Synthetic Absorbable (BSA) Advantages:
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Tremendous strength
Resistance to breakage due to multifilament construction
Relatively little memory
Easy to handle and tie
Tremendous variety of needle/suture combinations.
Suture Products
Absorbable 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 Products
Absorbable Sutures
 BSA General Applications:
– General Surgery
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Mid line fascia closure
Subcutaneous layer closure
Subcuticular skin closure
Bowel anastomosis
Other general tissue closures
Suture Products
Absorbable Sutures
 BSA Applications (Cont).
 Ortho/Neuro
– General tissue layer closure
 GYN
– Ligation (TAH/TVH)
– Vaginal Cuff Closure
– Hysterotomy Closure
Suture Products
Absorbable 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 Products
Absorbable Sutures
 Short Absorption MSA Applications:
 General Surgery
– Skin Closure
– Colo-Rectal Applications
 GYN
– Adnexa ligation
– Vaginal Cuff Closure
– Hysterotomy Closure
Suture Products
Absorbable 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 Products
Absorbable 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 Products
Absorbable 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 Products
Absorbable Sutures
 MSA Disadvantages:
– Out of package memory
– Stiff and slightly more difficult to work with
– Knots require additional throws
Suture Products
Absorbable Sutures
 Organic Absorbable Sutures
Suture Products
Absorbable Sutures
 Gut Products - Ribbons of beef serosa (inner most layer of intestines)
twisted to form suture strands
– Fast Absorbing Gut
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Proprietary to Ethicon
Extremely short absorption profile
– Plain Gut
– Mild Chromic Gut
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Proprietary to Syneture
– Chromic Gut
CAPROSYN is an excellent alternative to using Gut suture.
Suture Products
Absorbable Sutures
 Gut Products
 Generally fast, unpredictable
absorption rates
 Decreasing in popularity
 Banned in Europe and Japan
Suture Products
Absorbable 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 Products
Absorbable Sutures
Any
Questions?
Suture Products
Non Absorbable Sutures
Suture Products
Non 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 Products
Non Absorbable Sutures
 Polyester Suture Applications
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Heart valve replacement
Tendon Repair
ACL Graft
Direct repair of hernia
Uterine suspension
Suture Products
Non Absorbable Sutures
 Braided Synthetic Non Absorbables (Cont)
– Braided Nylon
• Surgilon - Syneture
• Nurolon - Ethicon
Suture Products
Non Absorbable Sutures
 Braided Nylon Applications:
– Neuro surgery - Dura closure
– Direct repair of Hernia
– Cannulation during heart bypass surgery
Suture Products
Non Absorbable Sutures
 Synthetic Monofilament Non Absorbables
– Polypropylene
• Surgipro II – Syneture
• Prolene - Ethicon
Suture Products
Non Absorbable Sutures
 Polypropylene applications:
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Blood vessel anastomosis
Hernia repairs using mesh
Uterine and bladder suspension
Percutaneous skin closure
Abdominal wall closure
• (where permanent suture is required)
Suture Products
Non Absorbable Sutures
 Monofilament Nylon Sutures
– Monosof (black) – Syneture
– Dermalon (blue) - Syneture
– Ethilon - Ethicon
Suture Products
Non Absorbable Sutures
 Monofilament Nylon Applications:
– Percutaneous skin closure
– Secure Drains
– Abdominal wall closure
Suture Products
Non 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 Products
Non 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 Products
Non 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:
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Laparoscopic Procedures
Biopsies
Cosmetic Surgery
ER/ Lacerations
Dressing/ Microbial Barrier
Non Absorbable Sutures
and 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.
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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!