Sutures

I. Introduction

 Sutures are probably the largest group

of devices implanted in humans.
Although they seem to be of small
concern to the medical community,
few devices have been made of so
many different materials. By definition,
a suture is a thread that either
approximates and maintains tissues until the natural healing process has
provided a sufficient level of wound strength or compresses blood
vessels in order to stop bleeding.
 II. History
 Since the beginning of surgical history
(5000-3000 BC), sutures have been used as the
means of repairing damaged tissues, cut vessels,
and surgical incisions. As time has passed, a
variety of suture materials have been used: flax,
hair, linen strips, pig bristles, grasses, mandibles
of pincher ants, cotton, silk, the gut of an animal,
nylons, polyesters, and metals. The earliest use of gut can be traced back to
the ancient Greek physician Galen. The eighteenth century brought the use of
buckskin and silver wire, and the nineteenth brought the ability to chemically
alter the properties of gut. By the twentieth century, cotton and treated
natural materials have come to be the most widely used materials for suturing.
After the invention of nylon and polyester propagated the popularity of cotton
and treated natural materials, polyethylene, polypropylene, polyglycolic acid,
polyglactin 910, and a large number of textile materials entered into the menu
of choices for sutures.
 III. Regulation

 The United States Pharmacopoeia

(USP) is the official compendium for
the suture industry. It sets standards
and guidelines for suture manufacture.
Suture sizes are given by a number
representing diameter ranging in
descending order from 10 to 1 and
then 1-0 to 12-0, 10 being the largest
and 12-0 being the smallest at a
diameter smaller than a human hair.
 IV. Classification
 Sutures can be classified into one of two
groups, absorbable and nonabsorbable.
Absorbable sutures are, as the name
implies, temporary due to their ability to
be “absorbed” or decomposed by the
natural reaction of the body to foreign
substances. It is important to note that
not all absorbable sutures have the same
resistance level to absorption, but each
can be formulated or treated in order to obtain a desired decomposition rate.
Nonabsorbable sutures are, in like manner, sutures that are not dissolved or
decomposed by the body’s natural action. Such sutures are generally not
naturally occurring materials (with the exception of silk). Silk & nylon, while
being classified as nonabsorbable, actually dissolve after a long period of time
compared to that of the absorbable materials
V. Manufacturing
 Sutures are manufactured with a wide
variety of parameters. They can be
monofilament or many filaments twisted
together, spun together, or braided.
They can also be dyed, un-dyed, coated,
or not coated. With the goal of
understanding the effects of so many
variations of suture type, the properties
and material of which they are composed
are and have been studied in depth. The
use of sutures is one of the most
common practices in the medical field
and thus has direct effect on a great
majority of the world’s population.
 VI. Design

 Currently, sutures are designed to result in the most

desirable effect for any given situation as determined by
those administering the sutures. Taken into consideration in
the manufacture and use of sutures are properties such as
stress-strain relationship, tensile strength, rate of retention,
flexibility, intrinsic viscosity, wettability, surface morphology,
degradation, thermal properties, contact angle of knots,
and elasticity. Properties such as stress-strain relationship
and tensile strength have a direct effect on how much force
at a given rate the closure will be able to withstand. For example, a cough
would impose a fast rate of elongation whereas edema or hemorrhage would
impose a slow rate of elongation. Knotting causes a severe decrease of
strength in the suture material. Thus when there is a break in the suture, it
occurs most frequently at the site of the knot. As you can see, there are
several factors biomedical engineers must consider when designing sutures.
 VII. Application

 Patient safety, as in every other area of the

medical field, is one of the major determining
factors of suture manufacture and use. As
mentioned before, the composition and
properties of a suture are the crucial elements
in the decision of what type to use. For example,
an incision into the lung would need to be closed
using a suture with a high elasticity level, slow degradation rate, and high tension
strength level. If a suture is applied in a situation in which it is not suitable, the patient’s
safety is endangered. In short, a surgery is never successful if the wound, insertion
point, or incision is not sutured or closed in a proper manner as to promote healing in a
timely and safe fashion.

 Another factor to be taken into consideration is the effect of inserting the suture into the
tissue. If the suture is of a rough morphology (e.g. braided), the tissue will swell more
and is more susceptible to infection than if a smooth suture (e.g. monofilament) is used.
A failure of a suture is simply its breaking or not meeting the requirements for which it
was intended.
 VIII. Testing

 As technology advances, testing techniques improve and

become more specific for the application of sutures. The
greatest percentage of testing is done on those suture materials
already existing in practice. This is due to the virtual newness
of the application of testing techniques to the suture product
although, a fairly small, yet increasingly important number of
tests are done on possible new suture materials.

 The USP determines the procedures and parameters for

standard suture tests. Sutures are tested immediately after removal from their sterile
packages without drying or conditioning. Sutures are tested in a variety of areas
including accurate measurements, knot pull breaking strength, needle attachment,
viscoelastic properties, tissue reaction and cell response, allergenicity and more. In all
strength tests, it is important to keep in mind that the breaking strength retention of
absorbable and nonabsorbable sutures should be considered separately because the
strength retention of the absorbable sutures will be quite different than that of the
nonabsorbable suture.
 IX. Technological Advances
 The use and need for a suture is clearly not a
problem that needs a solution, but a solution
that needs improvement. Currently there are
many efforts to improve almost every aspect
of the suture and its use. Also, new techniques
for testing make it possible to gain a clearer
understanding of the properties of sutures.
This is necessary so that the most efficient and
best suited suture will be applied in every case where a suture is needed. If it
were not for the technological advances that have occurred in society, modern
suture production and use would not exist and sutures would not be
dependable.
 ABSORBABLE SUTURES
 Natural
 Natural suture are catgut of biological origin and are
protein in nature, their absorption and digestion is by
proteolytic enzymes present in tissue fluid. The source is
submueosa of sheep or serosa of intestine. Their fibres
are then chrome tanned to delay absorption and twisted
under tension and polished to achieve monofilament
profile. Chrome tanning also reduces inflammatory
response to tissue.
 Serilization is achieved by Gamma radiation or ethylene
oxide. Packing is done in fluid which retains its ideal
handling characteristics, the fluid is 89% Isopropanol,
10% water and 1% Triethanolamine.
 ABSORBABLE
SUTURES
Uses:
- Rapidly healing
tissue
- Hysterectomy
- Caesarian Section
- General Surgery
- Ophthalmology
 ABSORBABLE SUTURES
 Natural

 Collagen is also of biological origin from

ox Achilles tendom; rolled monofilament,
undyed and uncoted.
 Fascia Lata
 ABSORBABLE SUTURES
 Synthetic

 Polyglycolic acid (PGA) is available in two

forms, the braided form is “Dexon” while the
monofilament is “Maxon”. It is mane made
homopolymer of glycolide. In monofilament form
the flexibility in insufficient, therefore, braided
form is used for general surgical use. Recently
special coating of monofilament with
polycaprolacton and glycolide has provided
sufficient flexibility.
 ABSORBABLE
SUTURES

Uses:
Orthopaedics
Surgical
Oncology
Debilitated
Patients
Gen/Gyn
(Fascia)
Plastics
 ABSORBABLE SUTURES
 Synthetic
 Polygalactin 910 “Vicryl”. A man-made
copolymer of glycolide and lactate, is available in
braided form. To reduce the tissue drag, the
braided filaments are coated with calcium
stearate, glycolide and lactate. Absorption is
uniform and predictable, commencing at 40 days
and complete between 60 and 90 days after
implantation. Strength is greater than P.G.A.
especially after 14 days. The inflammatory
response is mild to moderate. Sterilization is by
ethylene oxide.
 ABSORBABLE
SUTURES

Uses:
- Rapidly healing
tissue
- Episiotomy Repair
- Skin Closure
(except face)
- Scalp
- Under casts
- Intra-oral mucosa
 ABSORBABLE SUTURES
 Synthetic
 Polydioxanone “PDS”: PDS is man-made new
copolymer, a polyester of paradioxanone, which
is melt and a monofilament profile is achieved. It
is the only suture which retains unique flexibility
in mono filament form. Its strength is greater
than that of all commonly used monofilament
sutures other than steel.
 Its monofilament profile makes it particularly
useful in potentially infected tissues like colon,
biliary system, stomach etc. Sterilization is by
ethylene oxide.
 ABSORBABLE
SUTURES

Uses:
- long term
healing
applications
(diabetics /
oncology)
- Plastics
- Orthopaedics
 ABSORBABLE SUTURES
 Synthetic
 Polyglyconate – “Monocryl”: it is a man-
made copolymer of glycolide and caprolactone,
in ratio of 72:25; it has clear, undyed
monofilament.
Uses: - Skin / Ob-Gyn / General / Urology
 Polyglyconate – “Maxon”: it ia man-made
copolymer of 1,4-dioxane 2,5-dione and
trimethylene carbonate; monofilament, dyed or
undyed.
NONABSORBABLE SUTURES
 Natural
 Silk: It is derived from thread spun by larva of silk worm
by degumming of surface albumin layer. The braided
multifilament, dyed or undyed, coated or uncoated silk is
known for excellent handling properties and knot
security. Marked inflammatory reaction, tissue drag and
braiding are its main disabilities as braiding induces
capillary attraction and hence harbor the infective agent
in interstices. Tissue drag is overcome by waxing or
silicon coating reducing knot security, a third throw is
always necessary. Fragmentation occurs and all tensile
strength is lost by 9 months Sterilization is by Gamma
radiation, however boiling and autoclaving may also be
used.
NONABSORBABLE SUTURES
 Natural
NONABSORBABLE SUTURES
 Natural
 Cotton. It is cellulose in nature and occurs as
multifilament. Most of the properties are similar to those
of silk except that strength of cotton increases when
wet, where as silk loses 20% of strength when wet.
Cotton is cheaper than all other sutures. It is available as
dyed or undyed and uncoated.
 Linen, It derived from falx plant; twisted multifilament,
dyed or undyed and uncoated.
NONABSORBABLE SUTURES
 Natural
NONABSORBABLE SUTURES
 Synthetic
 Polyamide: "Nylon". It can be monofilament
or multifilament dyed or undyed, generic name
Nylon 6 or Nylon 66; trade name Ethilon
(Uses: - ophthalmology - Skin Closure) or
Dermalon (monofilament) and Nurolon
(braided) or Surgilon (braided nylon).
 Sterilization is by Gamma radiation but can
tolerate autoclaving up to three times.
NONABSORBABLE SUTURES
 Synthetic
NONABSORBABLE SUTURES
 Synthetic
 Polyester; monofilament or multifilament, dyed
or undyed, coated or uncoated; trade name
Ethibond (polybutylate coating) or Tri. Cron
(silicon coating), and Mersilene orDacron
(uncoated).' Polyesters are known for having
high and permanent tensile strength, inducing
only modest tissue reaction and having good
knot security. They are widely used in
cardiovascular surgery.
NONABSORBABLE SUTURES
 Synthetic
NONABSORBABLE SUTURES
 Synthetic
 Polybutylester: monofilament, dyed or un-dyed,
polybutylene terphthalate and polytetramethylent
ether glycol; trade name Novafil. Its "Mesh" forms
are used for pair of vascular defects and Hernias.
 Polyethylene: It is available in monofilament form
as a strong suture, induces minima] tissue reaction,
excellent knotting and handling due to its soft
surface. Mesh form is also available. Progressive loss
of strength occurs by fragmentation. Sterilization is
done by Ethylene oxide or Gamma radiation. It
melts at 132 С so autocaving can not be done.
NONABSORBABLE SUTURES
 Synthetic
 Polypropylene: monofilament dyed or undyed;
trade name is Prolene. It has a permanent high
tensile strength, the most inert suture, better
handling properties of knot security than Nylon.
It has no memory to untie. Fragmentation does
not occur within tissues. Its mesh forms are
used in the repair of prolapse rectum. When
used to suture blood vessels the blood loss is
much less. Available in vivid blue colour which
facilitates visualization during surgery.
Sterilization is by Ethylene oxide.
NONABSORBABLE SUTURES
 Synthetic
NONABSORBABLE SUTURES
 Synthetic
 PVDF. (Polyvinylidene fluoride)
monofilament, dyed or undyed. Its trade name
is Trofilene.
 Uses: Peripheral Vascular
Coronary Artery Bypass
(Skin stage two)
 NON ABSORBABLE METAL
SUTURES.
 Stainless steel. Maintain tensile strength
indefinitely- Monofilament or muftifilament.
 i. Vitadium
 ii. Tantalum
 iii. Silver
 D. SURGICAL STAPLES AND CLIPS
 i. Absorbable. The concept of
Viscerosynthesis.
 ii. Non-Absorbable
SURGICAL NEEDLES

Requirements to surgical
needles:
Minimal tissue trauma
High sharpness (acuity)
Corrosion resistance
High strength
Stable shape
Abrasion resistance
Smooth profile
Surgical needles are divided in two
groups:
 Traumatic needles
 Atraumatic needles
 Traumatic needles - are needles with holes
or eyes which are supplied to the hospital
separate from their suture thread. In
traumatic needles with eyes, the thread
comes out of the needle's hole on both sides.
When passing through the tissues, this type
of suture rips the tissue to a certain extent,
thus the name traumatic.
 Atraumatic needles with sutures -
comprise an eyeless needle attached to a
specific length of suture thread. Important
thing is that the suture end of a swaged
needle is smaller than the needle body.

Atraumatic needle with attached suture

thread
THANK YOU FOR ATTENTION!