Sutures and Suturing
Techniques
Objectives




Discuss different types of suture and
suture needles
Describe the differences in suture
Describe characteristics of different types
of suture
Understand the terms related to suture
AN EXAMPLE
SIZE
2-0
TYPE
VICRYL
NEEDLE
CT-1
PACKAGING








Surgical application
Product code number
Suture length and color
Metric diameter equivalent of suture size and
length
Shape and quantity of needles (silhouette)
Needle point geometry
Lot number
Expiration date
SIZES







Referred to as the Gauge
Size range- #5 (largest) to 11-0 (smallest)
Different lengths
Skin / 3-0 to 6-0 / Adson with teeth
Sub-q / 3-0 / PU with teeth
Fascia/muscle / #1 or 0 / PU with teeth
Peritoneum / 0 or 2-0 / Debakey (non
traumatic)
Suture

Two basic types

Monofilament

Multifilament
Suture

Can also be classified as

Absorbable

Non-absorbable
Monofilament Suture

Monofilament sutures are more difficult to
handle and tie and require more throws for a
secure knot than multifilament sutures

Monofilament sutures are preferred for closing
an infected wound (no wicking)

Requires longer tag when cutting

Do not readily harbor bacteria and are relatively
inert
Multifilament Suture

Multifilament sutures are reactive and
prone to infection more than
monofilament suture because of capillarity
THE PERFECT SUTURE











Pliable and flexible
Easy to tie
Knots hold securely
It slides through tissue effortlessly
Never breaks
Does not cause tissue reaction
Absorbable suture absorbs the second the wound can
support itself
Absorption is predictable in every patient
Can be used in every wound
Inert
Inexpensive and easily sterilized
THE PERFECT SUTURE
Does not Exist yet!
Factors for Choosing a Suture






Type of procedure
Condition of patient’s tissue
Nature of the disease process
Surgeon’s preference
Suture availability
Cost
Common Sutures

Monofilament Absorbable




Plain Gut
Chromic Gut
PDS or Polydioxanone
Monocryl or Polyglecaprone
Common Sutures

Monofilament Nonabsorbable




Polypropylene, Prolene or Surgilene
Nylon or Ethilon
Stainless Steel
Polybutester or Novafil
Common Sutures

Multifilament Absorbable



Polyglactin 910 or Vicryl
Polyglycolic acid or Dexon
Multifilament Nonabsorbable






Surgical silk
Surgical cotton
Braided nylon
Poyethylene terephthalate or Mersilene
Ethibond
Tantalum
Silk
Nonabsorbable





High tissue reactivity
Braided multifilament and some risk of
infection if contaminated
Great knot holding and reliability
Easiest suture to handle and tie
"Permanent" but slowly hydrolyzed in the
body over years, not reliable for vascular
graft sutures for this reason
Vicryl
Absorbable





9 parts glycolic acid and 1 part galactan
Relatively non-reactive
Braided multifilament
Relative to silk, has been coated with
materials to improve handling but this
resulted in knots coming untied
Absorbs in about 70 days
Ethibond
Braided polyester
Non- absorbable





Fairly non-reactive
Strong, braided multifilament suture
Easy to handle
Lasts almost forever
Does not absorb tissue fluid which can
transmit infection
Nylon
non-absorbable



Monofilament (braided multifilament also
available)
Not very reactive
Fairly easy to handle and tie but not as
reliable as silk
Plain Gut
Absorbable





Actually sheep intestine submucosa or cow
intestine serosa
Reactive
Fairly easy to tie and knots are secure
Significant loss of strength in 7-10 days,
no strength in 2-3 weeks
Stored in alcohol solution
Chromic gut
Absorbable







Plain gut "tanned like leather“
Coated with Chromic salts
Reactive
Sometimes used in place of Vicryl
Easy to handle
Lasts longer than plain gut, last up to 21 days
Stored in alcohol solution
PDS, MAXON
Absorbable





Monofilament, absorbable, strong
Non-reactive
A little more “give” than Prolene
Handles a lot like Prolene, hard to tie
Good strength duration up to 1 to 2
months
Prolene
Non-absorbable





Very inert, least reactive
Strong, non-absorbable monofilament
Hard to tie, recommend at least six knots
for security
Lasts virtually forever
Used in vascular anastomosis
CHOICE OF TYPES OF SUTURES
cont.






Vicryl – general tissue
approximation or ligation
Monocryl – subcuticular,
sub-Q
Chromic gut – ligation,
peritoneum
Plain gut – sub-Q, fast
absorbing
PDS – fascia
Nylon – skin, retention,
drains






Prolene – skin, vessels,
drains
Silk – GI, stick ties
Dexon - general tissue
approximation or ligation
Maxon – fascia
Ethibond – heart
incisions
Mersilene – tendons,
ligaments
TYPES








Vicryl
Monocryl
Chromic gut
Plain gut
PDS
Nylon
Prolene
Silk
Purple
ABS
Peach
ABS
Brown
ABS
Yellow
ABS
Silver
Slow ABS
Green
Non-ABS
Dk Blue Non-ABS
Lt Blue
Non-ABS
Multi
Mono
Mono
Mono
Mono
Both
Mono
Multi
TYPES cont.




Dexon
Gold & White
Maxon Silver & Green
Ethibond Orange
Mersilene Turquoise
ABS
Multi
Slow ABS Mono
Non-ABS Multi
Non-ABS Multi
How long should Sutures last?



Dissolving skin sutures need to last 2 -3
weeks
Fascial sutures need to last 3 -6 months
Vascular sutures need to last forever
Skin sutures





Mostly Nylon
Silk around the eye (suture knots and
ends lie flat after tying)
Subcuticular absorbable sutures:
Braided- Vicryl, Dexon
Monofilament- PDS, Monocryl
Subcutaneous tissue



Purpose is to obliterate dead space and
prevent blood and fluid collection between
skin and deeper structures
Any absorbable suture (Plain gut, chromic
gut, Vicryl, Dexon, Monocryl)
Avoid nonabsorbable sutures although silk
and braided polyester were used a lot in
the past
Ligating Methods

Free-tie


Stick tie (suture ligature)


Sutures with a swaged needle loaded onto a
needle holder
Ligature reels


Placed into open hand of surgeon
Must be counted
Instrument tie (tie-on-a-pass)
NEEDLES






Page 314, figure 11-24
Swaged – attached to suture
Closed – free needle
French – free needle
Double armed – needle swaged to both ends
CR – control release, commonly called pop-off,
shorter than full length, for single stitch
NEEDLES cont.

Cutting


Taper


Skin, tendons, sclera – tough tissue
Penetrate without cutting, all closure layers
below the skin
Blunt

Liver, kidney
SUTURE SETUP





Only open what is needed, sutures are
expensive
Sutures should be placed on back table in
the order needed
First 1 or 2 sutures should be loaded
Ties should be placed on mayo
Pull out memory
MESHES

Polypropylene


Polyglactin 910


Not absorbable, should not used in the presence of infection
Stainless steel


Absorbable, temporary support during healing
Polytetrafluoroethylene (PTFE)


Relatively inert, can be used in the presence of infection,
excellent elasticity and high tensile strength
The most inert, but uncomfortable for the patient
Polyester fiber

Least inert, should never be used in the presence of infection
ACCESSORY DEVICES

Bridges and bolsters





Page 310, figure 11-14
Umbilical tape (pink)
Vessel loops
Buttons
Steri-strips (1/8, ¼, ½ , 1 inch)

Page 311, figure 11-15
Alternatives to Sutures




Steri-Strips:
Used over absorbable skin sutures
Great for facial lacerations, small cuts,
children, and matching skin edges
Sometimes they fall off or are pulled off
prematurely
SUTURING TECHNIQUES






Primary suture line
Continuous or running
Interrupted
Traction sutures
Pursestring (page 309, figure 11-12)
Retention
Principles of Suturing the Skin


Technique is more important than suture
size
A large suture placed with good technique
can achieve an excellent cosmetic result
while a small suture placed with poor
technique can produce a bad cosmetic
result
Technical Aspects of Suturing


Avoid excessive tension on the suture, just
enough to bring the skin edges together
If tension is unavoidable, use inverted
subcuticular sutures to relieve the tension
Technical Aspects of Suturing




Careful, non-traumatic handling of the
tissues
Hooks are less traumatic than forceps
Careful matching of skin edges
Early suture removal
Left=Correct Approximation
Right=Incorrect Approximation
Technical Aspects of Suturing

Application of Neosporin ointment

May reduce stitch tracks by reducing epithelial
growth along the sutures as they penetrate
the dermis
Go to QuickTime






Two Hand Square Knot
http://cal.vet.upenn.edu/surgery/images
/videos/l2sq.mov
One Hand Square Knot
http://cal.vet.upenn.edu/surgery/images
/videos/sq1hr.mov
Instrument Tie
http://cal.vet.upenn.edu/surgery/images
/videos/rinst.mov
Driving the Needle Through
Drive Through the Other Side
Instrument Tie
Simple Interrupted
Simple Interrupted
Vertical Mattress
Horizontal Mattress
Horizontal mattress
Running, or Continuous Stitch
Continuous Locking, or Blanket