CHAPTER 46

Sutures and Anastomoses

MULTIPLE CHOICE QUESTIONS

11. Which one of the following is used as preservative for
SUTURES packing catgut suture? (AIIMS Nov 2002)
a. Isopropyl alcohol
1. Which of the following is a non absorbable suture? b. Colloidal iodine
 (NEET Pattern, All India 2008) c. Glutaraldehyde
a. Polypropylene b. Vicryl d. Hydrogen peroxide
c. Catgut d. Polydioxanone
12. Which of the following is ideal time to removal of scalp
2. Absorbable sutures are: (PGI June 2004) suture?  (MHSSMCET 2009)
a. Catgut b. Silk a. 3 days b. 5 days
c. Polypropylene d. Polyglycolic acid c. 7 days d. 10 days
e. Vicryl
13. Suture material used for laparoscopic choledochotomy
3. Surgically used suture material polydioxanone (PDS): repair:  (MHSSMCET 2010)
 (COMEDK 2014) a. Silk b. Catgut
a. A non-absorbable and remains encapsulated c. Polyethylene d. Vicryl
b. Undergoes hydrolysis and complete absorption
14. Catgut is preserved in: (Recent Questions 2013)
c. Undergoes phagocytosis and enzymatic degradation
a. Glutraldehyde b. Isopropyl alcohol
d. Is specifically used for heart valves of synthetic grafts
c. Iodine d. Certrimide
4. Catgut is prepared from submucosal layer of the intestine of: 15. Raw material used in nylon suture is: (APPG 2015)
a. Cat (DNB 2005, 2000, AIIMS 81, DNB 89) a. Polyethylene terephthalate
b. Sheep b. Polyamide polymer
c. Human being c. Polybutylene terephthalate
d. Rabbit d. Polyester polymer
5. Vicryl, the commonly used suture material is a: (UPSC 2000)
a. Homopolymer of polydiozanone ANASTOMOSIS
b. Co-polymer of glycolide and lactide
c. Homopolymer of glycolide 16. Disparity of the bowel ends during end to end anastomosis
d. Homopolymer of lactide is corrected by: (Karnataka 2004)
6. PDS is absorbed within: (WBPG 2012, MAHE 2001) a. Cheatles maneuver
a. 7 days b. 21 days b. Connell suture
c. 100 days d. 225 days c. Lambert suture
7. Surgically used suture material polydioxanone (PDS): d. Czerny technique
 (WBPG 2012, COMEDK 2005) 17. In abdominal surgery Lembert suture refers to:
a. Is non absorbable and remains encapsulated a. Single layer suturing  (Karnataka 2006)
b. Undergoes hydrolysis and complete absorption b. Sero-muscular sutures
c. Undergoes phagocytosis and enzymatic degradation c. All coat intestinal suturing
e. Is specifically used for heart valves or synthetic grafts d. Skin suturing
8. The surgeon who introduce catgut in surgery was 18. Colonic anastomosis is most likely to rupture on which post-
(MAHE 2005) op day?  (MHSSMCET 2005)
a. Astley Cooper b. Lord Lister a. 1-2 days b. 3-4 days
c. John Hunter d. Syme c. After 7 days d. After 14 day
19. Regarding vascular surgery distal to popliteal artery, which
9. Which of the following is a delayed absorbable synthetic
of the following is true? (MHSSMCET 2006)
suture material? (DPG 2009 Feb)
a. Suture with polypropylene
a. Chromic catgut b. Vicryl
b. 6-0 suture used
c. Silk d. Nylon
c. Needle pass from within outwards
10. Which of the following is not absorbable suture? d. All the above
a. Catgut  (DNB 2011, APPG 2008) 20. When knots are cut short, the free ends of ears should be
b. Polyamide left at least _____ mm long? (MHSSMCET 2008)
c. Polyglactin a. 1-2 mm b. 3-4 mm
d. Polyester c. 5-6 mm d. 7-8 mm

http://vip.persianss.ir/
 968 Surgery Essence

21. The single layer extramucosal anastomosis was popularized 23. Carrels triangle is used in: (MHSSMCET 2008)
by: (MHSSMCET 2008) a. Vascular anastomosis b. Bowel anastomosis
a. Carrel b. Antoine Lambert c. Tendon repair d. Nerve repair
c. Norman Matheson d. Emil Theodar Kocher 24. Intestinal anastomosis strength is provided by:
22. On table colonic lavage was used for first time in 1968 by: (JIPMER 2015)
a. Muir (MHSSMCET 2008) a. Mucosa b. Sub mucosa
b. Carrel c. Serosa d. Muscularis mucosa
c. Connell 25. Stapler used for MIPH: (Recent Questions 2013)
d. Lembert a. Linear cutting stapler b. Circular cutting stapler
c. Linear stapler d. Circular stapler
Section 10: Others

http://vip.persianss.ir/
 Sutures and Anastomoses 969

EXPLANATIONS
SUTURES
1. Ans. a. Polypropylene (Ref. Bailey 26/e p37-38, 25/e p236-239)
Suture Materials

Absorbable Non-absorbable
These sutures get absorbed in the tissues either These sutures remain in the tissues for
by enzymatic digestion or by phagocytosisQ. indefinite period.
1. Natural absorbable: 1. Natural non-absorbable:
Plain and chromic catgutQ LinenQ
2. Synthetic absorbable: SilkQ
Polyglycolic acid (Dexon)Q 2. Synthetic non-absorbable:
Polyglactin (Vicryl)Q Polypropylene (Prolene)Q
Polydioxanone (PDS)Q Monofilament polyamide (Ethilon)Q
Polyglycaprone PolyesterQ (ethibond)
NylonQ

Section 10: Others

Depending upon Number of Strands

Monofilament Polyfilament
Consist of single strandQ of fiber Consist of multiple strandsQ braided together
Sutures are smooth and strongQ Easier to handle and knot tied doesnt slipQ
Chances of bacterial contamination is lessQ Bacteria may lodge in the crevices of the suture, so not
Knot tied may become looseQ suitable in presence of infectionQ
Prolene, polyamide, catgut Silk, linen, polyglycollic acid

2. Ans. a. Catgut, d. Polyglycolic acid, e. Vicryl

3. Ans. b. Undergoes hydrolysis and complete absorption
4. Ans. b. Sheep (Ref. Bailey 26/e p37-38, 25/e p236-239)

Sutures

John Hunter discovered catgutQ.

Plain catgut is derived from submucosa of sheeps intestineQ.
Plain catgut loses 50% tensile strength in 3 daysQ and all tensile strength in 15 days and absorbed in 60 daysQ.
Isopropyl alcoholQ is used as preservative for packing catgut sutures.

Vicryl (Co-polymer of glycolide and lactide) maintains tensile strength for 28-30 daysQ and gets absorbed
in 80-90 days (Delayed absorption)Q
Vicryl is used for bile duct surgeriesQ.
PDS sutures exhibit the lowest affinity to the adherence of E. coli and Staphylococcus aureus; Dexon sutures exhibit the highest
affinity to these species.
Polydioxanone (PDS) undergoes hydrolysis and complete absorption within 180 days.
Raw material used in nylon suture: Polyamide polymer

5. Ans. b. Co-polymer of glycolide and lactide

6. Ans. d. 225 days
7. Ans. b. Undergoes hydrolysis and complete absorption (Ref. Bailey 25/e p237)

http://vip.persianss.ir/
 970 Surgery Essence

Suture Types Raw material Tensile strength Absorption rate

Silk Braided or twisted Natural protein Loses 20% when wet; 80- Fibrous encapsulation in
multifilament; Coat- Raw silk from silkworm 100% lost by 6 months body at 2-3 weeks ; Ab-
ed (with wax or sili- sorbed slowly over 1-2
cone) or uncoated yearQ
Catgut Plain Collagen derived from Lost within 7-10 days Phagocytosis &
healthy sheep or catle enzymatic degradation
within 7-10 daysQ
Catgut Chromic Tanned with chromium Lost within 21-28 days Phagocytosis & enzymatic
salts to improve handling degradation within 90
& resist degradation in days
tissueQ
Polyglactin (Vicryl) Braided multifilament Copolymer of lactide & Approx, 60% remains at 2 Hydrolysis minimal until
glycolideQ in a ratio of 90:10, weeks; 30% remains at 3 5-6 weeks; Complete
coated with polyglactin & weeks absorption 60-90 daysQ
calcium stearate
Polyglyconate Monofilament Dyed or Copolymer of glycolic acid Approx, 70% remains at 2 Hydrolysis minimal until
undyed & trimethylene carbonateQ weeks; 55% remains at 3 8-9 weeks; Complete
weeks absorption 180 daysQ
Polyglycaprone Monofilament Coplymer of glycolite & 21 days maximum 90-120 daysQ
caprolactoneQ
Polyglycolic acid Braided multifilament Polymer of polyglycolic Approx, 40% remains at 1 HydrolysisQ minimal at
(Dexon) Dyed or undyed acidQ weeks; 20% remains at 3 2 weeks; significant at 4
weeks weeks; Complete absorp-
Section 10: Others

Coated or Uncoated
tion 60-90 daysQ
Polydioxanone Monofilament dyed or Polyester polymerQ Approx, 70% remains at 2 Hydrolysis minimal at 90
(PDS) undyed weeks; 50% remains at 4 days; Complete absorption
weeks; 14% remains at 8 180 daysQ
weeks

8. Ans. c. John Hunter 9. Ans. b. Vicryl 10. Ans. d. Polyester

11. Ans. a. Isopropyl alcohol
12. Ans. c. 7 days (Ref. Sabiston 18/e p2134)

Guidelines for Day of Suture Removal by Area

Body Regions Removal Body Regions Removal
Eyelid 3-4 Chest, abdomen 8-10
Eyebrow 3-5 Ear 10-14
Nose 3-5 Back 12-14
Lip 3-4Q Extremities 12-14
Face (other) 3-4Q Hand 10-14
Scalp 6-8Q Foot, sole 12-14
13. Ans. d. Vicryl
14. Ans. b. Isopropyl alcohol
15. Ans. b. Polyamide polymer

ANASTOMOSES
16. Ans. a. Cheatles maneuver (Ref. Bailey 26/e p42-44, 25/e p242-246)
The Cheatle split (making a cut into the anti-mesenteric border) may help to enlarge the lumen of distal, collapsed bowelQ.

Wound Closure & Anastomoses

As a general rule, each suture should be separated by a gap that is twice the thickness of the skinQ.
When knots are cut short, the free ends or ears should be left at least 1-2 mm longQ. This is particularly important with
monofilament non-absorbablesQ.

It has been suggested by Jenkins that a suture length to wound length ratio of 4:1 indicates the optimum size
of tissue bites and of suture spacingQ.
Anastomosis of vessels was pioneered by CarrelQ.

http://vip.persianss.ir/
 Sutures and Anastomoses 971

Bowel Anastomoses

Lembert described seromuscular suture technique for bowel anastomosis in 1826Q.

Senn advocated a two-layer technique for closureQ
Halsted favoured a one-layer extramucosal closureQ.
Connell used a single layer of interrupted sutures incorporating all layers of the bowelQ.
Kochers method, a twolayer anastomosis, first a continuous all-layer suture using catgut, then an inverting
continuous (or interrupted) seromuscular layer suture using silk, became the standard. There is evidence that
inversion is safest in bowel (least likely to leak), although end-to-end staplers give an everted anastomosis
without complication.
The single-layer extramucosal anastomosis, advocated by MathesonQ, causes the least tissue necrosis or
luminal narrowing.
The Cheatle split (making a cut into the anti-mesenteric border) may help to enlarge the lumen of distal,
collapsed bowelQ.
Bowel anastomotic leaks are generally occur on day 7Q.

17. Ans. b. Sero-muscular sutures

18. Ans. c. After 7 days
19. Ans. d. All of the above (Ref. Bailey 26/e p44-45, 25/e p244-246)

Vascular Anastomoses
Vascular anastomoses require more precision than bowel anastomoses as they must be immediately watertightQ at the end of the
operation when the clamps are removed.

Section 10: Others

Suture size depends on vessel calibre:
2/0 for aortaQ
4/0 for femoral arteryQ
6/0 for popliteal to distal arteriesQ
Microvascular anastomoses are made using a loupe and an interrupted suture down to 10/0 size
Anastomosis of Vessels

Polypropylene-like sutures with indefinite integrity give the best resultsQ

Intimal suture line must be smoothQ
Knots must be secureQ
Needle must pass from within outwardsQ

20. Ans. a. 1-2 mm

21. Ans. c. Norman Matheson
22. Ans. a. Muir (Ref. www.ncbi.nlm.nih.gov ... Ann R Coll Surg Englv.75(3); May 1993)
On table colonic lavage was used for first time in 1968 by MuirQ.

23. Ans. a. Vascular anastomosis

24. Ans. b. Sub mucosa
25. Ans. b. i.e. Circular cutting stapler(Ref: Schwartz 9/e p1058)
Procedure for prolapse and hemorrhoidectomy (PPH) aka MIPH aka stapled emorrhoidectomy
Minimally invasive proctoscopic hemorrhoidectomy
In this procudure, a circular cutting stapler (PPH3) is used to excise a short. Circumferential segment of rectal mucosa proximal
to dentate line, thus ligating venules feeding the hemorrhoides.

http://vip.persianss.ir/