SUTURES

Characteristicsofidealsuture
Sterile
Composedofmaterialthatcanbeusedinanysurgicalprocedure
Causesminimaltissueinjuryorreaction
Easytohandle
Holdssecurelywhenknotted
Hightensilestrength
Predictableabsorptionprofile
Minimisesinfection
Unfortunately,nosinglematerialpossessesallofthesecharacteristics.Indifferentsituationsand
tissuecomposition,therequirementsforadequatewoundclosurenecessitatedifferentsutures.
Propertiesofsutures
Thefollowingpropertiesareusedtocharacterisesutures:
AbsorbableProgressivelossofmass/volume.Doesnotcorrelatewithinitialtensilestrength
BreakingstrengthLimitoftensilestrengthatwhichthesuturefails
CapillarityExtenttowhichabsorbedfluidistransferredalongthesuture
ElasticityMeasureoftheabilityofthematerialtoregainitsoriginalformandlengthafter
deformation
FluidabsorptionAbilitytotakeupfluidafterimmersion
KnotpulltensilestrengthBreakingstrengthofknottedsuturematerial(1040%weakerafter
deformationbyknotplacement)
KnotstrengthAmountofforcenecessarytocauseaknottoslip
MemoryInherentcapabilityofsuturetoreturntoormaintainitsoriginalgrossshape.Sutures
withgoodmemoryaremoredifficulttotieandtheknotsarelesssecure
PlasticityMeasureoftheabilitytodeformwithoutbreakingandtomaintainanewformafter
reliefofthedeformingforce
PliabilityEaseofhandlingofsuturematerialabilitytoadjustknottensionandtosecureknots
(relatedtosuturematerial,filamenttype,anddiameter)
TensilestrengthMeasureofabilitytoresistdeformationandbreakage
Tissuedragthefrictiongeneratedasthesuturepassesthroughtissue
Thicknessorcalibreconventionallydescribedas'number1','number2'increasingthickness,
or'0','2/0'decreasingthickness
Diameter(mm)Size(No)
0.5mm=Number2
0.4mm=Number1
0.35mm=0
0.3mm=2/0(00)
0.2mm=3/0(000)
Number1vicryliswiderthan0vicrylwhichiswiderthan2/0(00)vicryl....
SutureClassification

NaturalorSynthetic.Tissuereactionandsutureantigenicityleadtoinflammatoryreactions
withnaturalmaterials
ThesetwoclassesaresubdividedintoAbsorbableandNonabsorbable.Sutureabsorption
occursbyenzymaticdegradation(natural)orhydrolysis(synthetic).Lossoftensilestrength
doesnotcorrelatewithrateofabsorption.Absorptionisincreasedbypyrexia,infection,protein
deficiency,fluidfilledbodycavitiesandifsuturesbecomewetpriortoinsertion
Withinthese,suturescanbemonofilamentormultifilament(twistedorbraided).
Monofilamentonestrand,lessflexible,moreslippery,moredifficulttohandleandknot,knots
needmorethrowstobesecure.Lessresistancetopassagethroughtissuethanwith
multifilamentsuture.Crushingorcrimpingcanweakenthesutureandleadtoprematuresuture
failure.Twistedseparatestrandstwistedaroundeachothereasiertohandleandknot.
Braidedstrandsplaitedveryflexible,easytohandleandknot,knotssecure.Theinterstices
oftheyarnmayprovideanidusformicrobes.
ABSORBABLESUTURES
Catgut
Strandsofcollagenfromsheep/cowintestineabsorbedbyproteases
Plaincatgutlosestensilestrengthin~5days.Usedforrepairingrapidlyhealingtissuesthat
requireminimalsupport,ligatingsuperficialbloodvessels,andsuturingsubcutaneousfatty
tissue.
Chromiccatgutcoatedinpotassiumdichromatelosestensilestrengthin1421daysand
absorbedby90days
Causesignificanttissuereactionandinflammationandassociatedwithmorewoundinfections
lesswithchromiccatgut
Dexon(polyglycolicacid)
Braided,loses50%oftensilestrengthin20days,absorbedbyhydrolysisat100120days,good
knotsecurity
Vicryl(polygalactin)
Braidedandcausesminimaltissuereaction
Loses35%oftensilestrengthafter14days,60%afterin21and90%after35days.
Absorbedbyhydrolysisat6090days,goodknotsecurity
PDS(Polydioxanone)
Monofilament,causesminimaltissuereaction
Losestensilestrengthslowerthanvicrylordexon30%at14days,50%at28daysand86%at
56days
Absorbedbyhydrolysisat~180days
Maxon(Polyglyconate)
Monofillament,strongerthanPDSbutlosestensilestrengthfasterthanPDS.
SuperiortoPDSinlackoftissuedrag,tensilestrengthandfirstthrowknotsecurity,similarin
otherrespects

Monocryl(Poliglecaprone)
SimilartoMaxonbuthandlesbetter(lessmemory)andisabsorbedquicker(2128days).

NONABSORBABLESUTURES
Prolene(polypropylene)
Monofilament
Doesnotadheretotissuesandisusefulasapulloutsuture(subcuticularclosure)
Knotsbetterthanothermonofilamentsyntheticmaterials
Minimaltissuereaction
Notsubjecttodegradationorweakeningandmaintainstensilestrengthforupto2years
Polyesterfibre(Mersilene/DacronEthibond)
Mersilene/DacronuncoatedEthibondcoated(withpolybutilate)
Multifilamentbraided
Coatingreducesfrictionforeaseoftissuepassageandimprovedsuturepliability
Minimaltissuereaction
Lastsindefinitelyinthebody
Doesnotweakenwithmoistening,providespreciseconsistentsuturetensionandretainstensile
strength
Commonlyusedforvesselanastomosisandtheplacementofprostheticmaterials
Silk
Madeofrawsilkandmaybecoatedwithbeeswaxorsilicone
Althoughclassifiedasanonabsorbable,silkbecomesabsorbedbyproteolysisandis
undetectableby2years
Tensilestrengthdecreaseswithmoistureabsorptionandislostby1year
Causesacuteinflammatoryreactionleadingtoencapsulationbyfibrousconnectivetissue
Nylon
Polyamidepolymer,canbemonofilamentorbraided
Commonlyusedforskinclosure
Goodhandlingcharacteristicsbutitsmemorytendstoreturnthematerialtoitsoriginalstraight
form
81%tensilestrengthat1year,72%at2years,and66%at11years
Strongerthansilkandelicitsminimalinflammatoryreaction
Hydrolyzedslowly,butremainingmaterialisstableat2years,duetogradualencapsulationby
fibroustissue

Theincidenceofwounddehiscenceandherniaissimilarforabsorbableandnonabsorbablesutures

Theincidenceofprolongedwoundpainandsuturesinusissignificantlyhigherwithnonabsorbable
sutures

STAPLES

Maybeabsorbableornonabsorbable
Nonabsorbablestaplesmadeofstainlesssteelandhavelowtissuereactivity
contaminatedwoundsclosedwithstapleshavealowerincidenceofinfectioncomparedtothose
closedwithsutures
Disadvantagesincludestapletrackformation,bacterialmigrationintowoundbedand
discomfortduringremoval
Absorbablesuturesarebeingintroducedintosurgicalpractice

GLUE
Tissueadhesivesbeingintroducedasanalternativetostaples/sutures
Canbebiological(fibrinorgelatinbased)orsynthetic
Arefastertoapplyanddonotneedtoberemoved
Somesyntheticglues(cyanoacrylates)haveantimicrobialproperties