SUR 111
Suture and Staplers
Skill Assessments
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10-3 Load and Pass Needleholders (NH)
10-3 Load and Pass free needles
10-4 Ties, reels, free tie on a Passer
11-2 Load clip appliers and Pass Staplers
10-3 Load and Pass NH
• Choose appropriate size NH based on
size of the needle being used by the
surgeon
• Heavy NH will bend delicate needles
• Delicate NH will be damaged being loaded
onto large needles
Load and Pass the NH
• Load needle by grasping it in the center of the body with
the NH in the packaging
• Some surgeons prefer NH grasping needle about 1/3
from the swaged end of the needle
• Gently pull out of packaging pulling the strand gently if
necessary to release suture memory prn
• Pass to surgeon with NH’s loaded needle tip pointing
towards the surgeon’s thumb
• STSR’s hand position should be behind the needle point
at lower shank/box lock level
• DO NOT allow suture strand to drop below sterile field!
• See text page 368-369 Figure 12-45
• Note ligating methods text page 290-291
10-3 Load and Pass Free Needles
• Differs from previous in that the suture
strand must be secured unlike the swaged
on suture
• You will be shown different methods for
doing this
• Tip: Do not load the suture evenly, only
load a short end of suture into the NH or it
will pull right out of the tissue it is placed in
• Passing technique is the same
10-4 Ties, Reels, Free tie on a
Passer
• Ties
• Lay near incision so surgeon may grasp with his
forceps
or
• Pass to surgeon assistant so that person may
grab with their forceps and pass to surgeon who
likely will have a right angle in his or her hand to
receive the tie and ligate a vessel
• Always have these ready in pairs, if one is used
another will follow
Ties, Reels, Free tie on a Passer
• Reels
• Release strand of suture from reel about
1 + ½ inches and pass reel to surgeon
• Surgeon grasps other end of strand and
ties holding onto the reel and suture
• Reels ARE COUNTED ITEMS!
Ties, Reels, Free tie on a Passer
• Tie on a Passer (usually a tonsil can be right
angle)
• Ties are loaded as an extension of the
clamp it is loaded on
• It will look like it is part of the tip if loaded
properly
• Pass clamp in the normal manner taking
heed to not allow suture to drop below
sterile table level
Suture
• Absorbable
• Designed to hold tissue
together until it heals
• Different types have
different absorption rates
• Suture type used
depends on the type of
tissue being sewn and
that tissue’s normal
healing time
• Nonabsorbable
• Designed to hold tissue
together permanently
Suture Characteristics
• Absorbable
• Monofilament
• Braided (multifilament)
• Dyed
• Undyed
• Natural
• Synthetic
• Nonabsorbable
• Monofilament
• Braided (multifilament)
• Dyed
• Undyed
• Natural
• Synthetic
Suture Characterisitcs
Monofiliment verses Multi-filament
• Monofilament
• Single strand
• Inert (little to no tissue
reaction)
• Do not harbor bacteria
• Can use in presence of
infection
• Minimal tissue damage
as they glide easily
through tissue
• Multi-filament
• Braided
• Capillarity (able to
harbor bacteria that can
be communicated up the
strand)
• NOT used in presence of
infection
• Can be traumatic to
tissue if not coated
• Greater tensile strength
• Hold knots securely
Suture Characterisitcs
Natural verses Synthetic
• Natural
• From naturally
occurring substances:
• Cellulose
• Animal products
• Animal tissue
• Synthetic
• Man made:
• Petroleum based
products
Suture Sizes
• Correlate with tissue to be sewn
• Heavy tissue needs a heavy strand of
suture to hold it together
• Delicate tissue does not require a heavy
strand but a small or delicate strand of
suture
• Suture diameter is called the gauge
Suture Gauge
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#5 is largest available
#1 to 4-0 are most commonly used
#1 and #0 are typical orthopedic sutures
6-0 to 7-0 for vascular anastamoses
8-0 to 11-0 for eye procedures
4-0 and 3-0 for skin closure (called
subcuticular closure)
Suture Gauges
(See text 286 table 11-4 ST for the ST)
• #5 largest, #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,
11-0 smallest
Suture Length
• 13cm to 150cm
Suture Packaging
• Suture can have a needle incorporated into the
suture stand called swaged
• Suture can be without a needle also just called a
tie or ligature ( below tie packaged individually)
• These ties can be loaded onto individually
packaged “free needles” and these suture
ligatures are called “stick ties”
• Ties can be packaged individually
• Ties can be on reels similar to a spool of thread
Suture Presentation
• Ties can be presented to a surgeon as a “free
tie” laying it by his or her forcep near the
incision site
• Ties can be presented “on a passer” typically a
tonsil clamp (tie will become an extension of the
tonsil’s tip when loaded) Your book calls it
“instrument tie”
• Ties can be presented on reels (present by
making sure the suture has been pulled out
enough for the surgeon to use it and not have to
pick and dig into the reel himself)
Suture Reels or Ligapak
Dispensing Reel
• Look at a reel like a bike tire: have the tire on the outside
and the spokes on the inside
• Limited sutures come in reel style
• Examples include: vicryl, plain gut, chromic gut, silk,
nylon
• Gauge can be determined by packaging label and
flipping the reel over to where you can visualize the dots
in the reel’s spokes
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º =0
º º = 2-0
º º º =3-0
º º º º = 4-0
• Larger gauges come packaged in pre-cut strands as well
as these described above that come on reels
Needles
• Necessary to insert suture into tissue
• Variety of shapes and sizes to accommodate
specific tissues
• Certain designs necessary for certain tissues to
prevent tissue trauma when being used
• Anatomy includes: eye, body (shaft), point (see
page 314 textbook)
• Also describe by shape (curved (1/4, 3/8, ½, 5/8
circle, ½ curved, or straight)
Needles
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Can be swaged on
Single arm or double arm
Pop-offs or control-release
Individual
~ Individual that must be threaded like you would a
needle at thread at home
~ Eyes types vary with individual needles
~ Closed eye - thread through eye
~ French eye – snap through the eye
~ Unique loading of suture strand to secure it from
pulling out of the eye during usage
Needles
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Cutting
used for tough tissue that can withstand this design of
needle
Sclera, skin, tendons
Curved or straight (straight called “Keith needle”)
Tapered
Round shaft without a cutting edge
Can pierce or penetrate tissue but do not cut it
Vessels, gastrointestinal tissue, delicate tissue
Blunt
Round shaft with a blunt tip
Kidney or liver
Cutting Needles
1. Conventional
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Three cutting edges
2. Reverse cutting
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Opposing cutting edges in a triangular shape
3. Side cutting
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Primarily ophthalmic use as will not penetrate into
deep tissue
4. Trocar points •
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Three sharp edges ending in a sharp point
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Your trocars used for endoscopic delivery as well as
surgical wound drain insertion
Suture Book
• Textbook read pages 285-289
• Your Suture and Surgical Hemostasis
Pocket Guide is most helpful
• Please review this material given in this
slide show in this book as well
Most Commonly Used Sutures
To Follow
• Are primarily two manufacturers of suture in this
area:
• Ethicon (Johnson & Johnson)
• Davis & Geck (US Surgical)
• Suture materials are primarily the same with
maybe one chemical difference
• Trade names of suture are similar but not the
same
• This makes for confusion when learning suture
• Most institutions carry only one primary brand
• Most places here use Ethicon brand suture
Absorbable Suture
PLAIN GUT
Plain Gut
(bright yellow package)
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Monofilament
Natural
Submucosa of sheep intestine or beef intestine serosa
Comes in stick tie, pre-cut lengths, and reel
5-10 day wound support
Absorbs in 30-60 days
Inflammatory reaction
Used for superficial hemostasis and tissue that heals
quickly
• Stored in alcohol solution to maintain pliability and keep
from drying out
CHROMIC GUT
Chromic Gut
(beige package)
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Monofilament
Natural
Submucosa of sheep intestine or beef intestine serosa
Difference from plain gut is that it is treated with chromium salts to
delay absorption rate
Comes in stick tie, pre-cut lengths, and reel
10-14 day wound support
Absorbs in 60-90 days
Inflammatory reaction
Used for superficial hemostasis and tissue that heals quickly
Stored in alcohol solution to maintain pliability and keep from drying
out
PDS
PDS (polydioxanone)
(silver package)
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Monofilament
Synthetic
Comes in stick tie, pre-cut, and reels
6 week wound support
Absorbed in 6 months
Minimal tissue reaction
Dyed or clear
Monocryl (not shown)
(pink package)
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Monofilament
Synthetic
14 day wound support
Absorbs in 91-119 days
Slight tissue reaction
Dyed or undyed
3-0 through #1 gauge swaged
6-0 through #2 pre-cut ties
Close skin or soft tissue such as subcutaneous
Vicryl
Vicryl (polyglactin 910)
(purple package)
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Multi-filament (braided)
Synthetic
Dyed or undyed
21 day wound support
56-70 day absorption
Swaged, control release, free ties, reels
Close fascia, subcutaneous (adipose), skin
(subcuticular), GYN procedures, peritoneum
Nonabsorbable Suture
Prolene
Prolene (polypropylene)
(Royal blue packaging)
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Monofilament
Synthetic
Least reactive of all synthetic suture
One of most inert sutures
CAN USE in presence of infection
Used for long term support of suture lines
such as vascular surgery or mesh support
in hernia repairs
ETHILON
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NYLON
Ethilon or Nylon
(mint green package)
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Monofilament
Synthetic
Minimal tissue reaction
One of most inert sutures
Used in ophthalmic, tendon repair, drain sew in,
skin closure (interupted/what you know as
“getting stitches”)
• Dyed or undyed
• Difficult to handle
• Knots poorly
Stainless Steel
(not shown)
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Monofilament
Synthetic – chromium and nickel alloy)
Gauge #7 to 6-0
Minimal tissue reaction
Uses tendon repair, bone repair, (sternal closure
(#7 wire)), cerclage (tying the cervix shut to
prevent premature abortion)
• Considered most inert of all suture materials
• Can use in presence of infection
• Not used in presence of other metal alloys!
SILK
Silk
(baby blue package)
• Multi-filament
• Natural – from cocoon of silk worm
• Usage GI tract in absence of infection and
vessel ligature
• Excellent knot holding and handling
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Nurolon (Nylon Braided)
NOT SHOWN
(mint green packaging)
Multi-filament
Synthetic
Dyed or undyed
Minimal tissue reaction
Soft tissue approximation, see in
neurosurgical closure
• Coated with silicone to reduce drag and
tissue trauma as pulled through tissue
ETHIBOND (Ethicon)
or
TICRON (Davis & Geck)
Ethibond (polyethylene terephthalate)
(orange packaging)
• Multi-filament (braided)
• Synthetic – polyester
• Available in pre-cut ties and swaged
suture
• Most commonly used for soft tissue and
heart surgery for valvular procedures
11-2 Load and Pass Staplers
• Read text p. 300-303 on stapling devices
• There are great pictures there as well
• Staplers can come with cutting blades
incorporated into the stapling device
• Care must be taken with these to avoid
personal injury especially when re-loading
• Staple and clips are made of stainless
steel or titanium
• Come disposable and non-disposable
Load and Pass Staplers
• Different stapling devices load differently
• Staplers are passed with the STSR holding the
stapling device by the business end and placing
the handles into the surgeon’s hand
• Always keep reloads available
• Will be shown different staplers in lab
• Used for skin closure like a staple gun
• Also come in linear, ligating and intra-luminal
designs for open and laparoscopic procedures
Load and Pass Staplers
• Clip appliers – a type of stapling device
• Passed with tips pointing down for general
surgeons and up for vascular surgeons
• Surgeon will tell you how he or she wants
them passed
• Take care NOT to squeeze shank/finger
rings together or the clip will fall out
• Passed by placing the shank into the palm
of the surgeon’s hand
CLIP or LIGACLIP APPLIERS
Regular length
MEDIUM
SMALL
LARGE
MEDIUM REGULAR
LONG REGULAR
Clip Appliers
Long Length
MEDIUM LONG
LARGE LONG
Ethicon laparoscopic clip applier
Davis & Geck AutoSuture Clip Applier
DISPOSABLE CLIP APPLIERS
Are pre-loaded with multiple clips
Each tells you how many clips it holds
Skill Assessment Review
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10-3 Load and Pass Needleholders (NH)
10-3 Load and Pass free needles
10-4 Ties, reels, free tie on a Passer
11-2 Load clip appliers and Pass Staplers