You are on page 1of 7

Sahoo et al.

, Int J Med Lab Res 2017, 2(2): 46-52


ISSN 2456-4400

REVIEW ARTICLE INTERNATIONAL JOURNAL OF MEDICAL LABORATORY RESEARCH (IJMLR)

A DISCUSSION ON SUTURE AND LIGATURE


Chinmaya Keshari Sahoo*1, D.Venkata Ramana2, Kokkula Satyanarayana3
1
Associate Professor, Department of Pharmaceutics, Malla Reddy College of Pharmacy, Maisammaguda,
Secunderabad, Telangana-500014,
2
Professor, Department of Pharmaceutical Technology,Netaji Institute of Pharmaceutical
Sciences,Toopranpet,Yadadri Bhongir, Telangana-508252,
3
Professor, Department of Pharmacognosy, Princeton College of Pharmacy, Korremula, Ghatkesar,
Telangana-500088,

Received:8 May, 2017/Accepted:29 May, 2017


ABSTRACT:The aim of the study was to give information on properties of suture and ligature materials
in order to assist surgeons in their selection of adequate sutures for specific surgical applications. The
essential requirements and characteristics of suturing materials effects on properties of surgical sutures
and ligatures. Suturing consists of ensuring good adaptation of body tissues for proper wound healing.
Suturing is a skill that requires good technique and the right material. A ligature is a thread used to
constrict and seal off a blood vessel, vein or artery hence to ligate. Absorbable suture is used to close the
edges of a wound or incision and to repair damaged tissue. Non-absorbable sutures are designed to either
be left permanently in the body or are to be removed after a certain healing period.

KEYWORDS: Suture, ligature, absorbable, non-absorbable

INTRODUCTION:
for tying umbilical cord and Celsus in the first
The history of sutures is largely a reflection in
century A.D. describes the ligatures of ancient
miniature of the major phases in the history of
origin. Galen (A.D. 200) used silk and hemp
surgery itself. The earliest known text on
cords as ligatures and also recommended the use
surgery is found in the Edwin Smith papyrus
of animal gut.About the year 1000 B.C. giant ant
(circa 3000 E.C.) where it is recorded that the
or beetle were used, in India, to clip wound
ancient Egyptians were already aware of the
margins together these were the original skin
importance of approximating the edges of a
clips. By the sixth century B.C. several materials
created wound. For this purpose they used strips
had been modified and adapted for use as
of linen cloth. In India about this time- dried
sutures, including cotton, silk, animal tendons,
animal intestines were being used as ligatures
strips of leather and horse hair. Hippocrates (500
while in China silk threads were employed for
B.C.) stressed the importance of closing wounds
the same purpose. Even the origin of modern
and he further advocated the ligation of bleeding
skin clips is hallowed ·in antiquity. In surgery
vessels. Galen, whose teachings were destined to
Susruta (1500 B.C.) records the use of ligatures

*Address of correspondence:
Chinmaya keshari sahoo
Associate Professor, Department of Pharmaceutics, Malla Reddy College of Pharmacy, Maisammaguda,
Secunderabad, Telangana-500014,

www.ijmlr.com/IJMLR© All right are reserved


46
Sahoo et al., Int J Med Lab Res 2017, 2(2): 46-52
ISSN 2456-4400

dominate the practice of surgery, for the next 1908, Lister demonstrated that by soaking
fifteen centuries, also ligated arteries and makes catgut, in this carbolic solution it could be left
special mention of catgut:"Select from those ,in the tissues and the wound closed. He first
materials that substance which is least used plain catgut ligatures[1] but after extensive
putrescible, such as very ,thin catgut which rots research he developed chromic catgut.
easily and quickly falls from the vessels."In the The history of this work applied to
thirteen century A.D. there was reawakening of surgical sutures and ligatures during the past
interest in the techniques of wound suture and seventy years is too large a subject for this
vessel ligation.Theodoric (1205 - 1296 A.D.) chapter but the investigations by a host of
and Mundinus (1275 - 1326 A.D.) both wrote dedicated workers into hundreds of different
extensively on the subject. Ambroise Pare (1510 procedures has led to the highly efficient
- 1590) whose extensive experience of war methods being employed today. A ligature is a
wounds was unparalleled, advocated the thread used to constrict and seal off a blood
cleaning and dra;nage of wounds and the arrest vessel, vein or artery hence to ligate. The thread
of bleeding by ligature rather than cauterising is a suture when it is used to stitch together the
with boiling tar or hot irons as was then edges of various tissues, e.g. skin, fascia,
customary. muscle, tendon, peritoneum, etc. Hence a needle
John Hunter and his students favoured the is always used for a suture (sewing) but not for
ligation of arteries. Lembert dsscribed the ligature.The advances in organic chemistry, in
technique of successful suture of the intestine by the physical sciences and in engineering
apposition of serosa to serosa. At this time technology which characterize the last decades
ligatures were generally non absorbable and, of have led to the introduction of an array of new
course, non-sterile.The introduction of antisepsis suture materials particularly metallic wires and
by Lister revolutionized surgical technique. In the synthetic non-absorbable fibres.

Characteristics of suture[2] Absorbable suture


1. It should have no delaying effects in the Absorbable sutures and ligatures are absorbed
course of healing; by the tissues in which they are implanted and
2. It should retain its tensile strength unimpaired the time taken for complete disappearance is
for an indefinite period; dependent on a number of factors, which will be
3. It should be inert in the tissues. treated more fully later in this chapter.
4. It should cause minimal tissue injury or tissue Absorbable materials are catgut (non-boilalable
reaction (ie, non electrolytic, non capillary, non and boilable), reconstituted collagen, synthetic
allergenic, non carcinogenic) absorbable polymers, kangaroo tendon, ribbon
5. It should have favorable absorption profile. gut and fascia lata.
6. It should have all-purpose (composed of
material that can be used in any surgical  Natural absorbable materials
procedure) property. 1. Surgical catgut
Sterilized surgical catgut consists of a strand
Classification[3-8] prepared from collagen derived from healthy
Sutures and ligatures are classified as absorbable mammals purified and sterilized. The most
and non-absorbable, depending on the materials widely used source is the sub mucosa of the
on which they are made. small intestine from sheep or lambs and to a
lesser extent, the serosa sheep beef cattle. The

www.ijmlr.com/IJMLR© All right are reserved


47
Sahoo et al., Int J Med Lab Res 2017, 2(2): 46-52
ISSN 2456-4400

length of ovine intestine is about 20 m and it is 5. Fascia lata


desirable in the preparation of surgical catgut This may be excised from the patient, or
that the diameter of the intestine should not be prepared from bovine thigh muscle, cleaned and
more than 18 mm. A number of factors are sterilized. It is supplied in lengths of about 30
important in the selection of suitable intestinal cm × 6 mm wide and is used surgically for
material. Generally the younger the animal the hernia repair, urethral slings, etc.
smaller it is intestine and less likely to be  Synthetic absorbable material
affected by feed. A number of manufacturers of 1. Plain surgical gut
catgut use only the first 8 m of intestine Surgical gut is made from the intestinal sub
measured from the duodenum. In the mucosa tissue of sheep. These casings are split
slaughterhouse the gut is removed from the into ribbons, which are cleaned chemically as
animal by the gut pullers and is first of all well as mechanically and matched by computers
cleaned to remove faecal matter after which it is to meet the most exacting demands for diameter
inspected, measured and the preserved either in and tensile strength. Then an exclusive
a frozen state or salted. electronic spinning process creates a strand that
2. Reconstituted collagen is virtually a monofilament for dependable
Collagen is available from a large number of strength and holding power. Finally the strand is
sources. It is the major constituent of skin, polished to size to an accuracy of five thousand
tendon, ligament, etc. It is partially soluble in of a millimeter to produce an extremely smooth,
acids. The basic process has been to obtain an highly uniform suture. Surgical Gut draws
acidic solution of collagen prepared from hides through delicate tissue without sawing, ties
or tendons which can be extruded into a down securely and holds uniformly and
coagulation solution and the resulting fibers predictably, until the wound regains tensile
oriented by stretching. The filaments can then strength.
either be spun or rolled to make up the necessary 2. Chromic surgical gut suture
sizes of strand required. Reconstituted collagen Chromic gut is made from the intestinal sub
is produced mainly in the finer sizes 0.5, 1 and 2 mucosal tissue of sheep. These casing are split
for ophthalmic and cuticular surgery. into ribbons which are cleaned chemically as
3. Kangaroo tendon well as mechanically and matched by computers
This absorbable material consists of the tail in order to meet the most exacting demands for
tendons of the wallaby. The tendons, which were diameter and tensile strength. Then an exclusive
usually preserved with naphthalene, were electronic spinning process creates a strand that
prepared and graded into various sizes e.g. fine, is virtually a monofilament for dependable
medium, and stout. Lengths were 30-40 cm. strength and holding power. Finally the strand is
They were sterilized as for catgut and their main polished to size to an accuracy of five thousand
use was for hernia repair and bone surgery. of a millimeter to produce an extremely smooth,
4. Ribbon gut highly uniform suture. Surgical gut draws
Ribbon gut is in the form of ribbon through delicate tissue without ties down
approximately 12 mm wide and usually about 45 securely and holds uniformly and predictably
cm long. Its use is limited but is preferred by until the wounds regains tensile strength.
some surgeons for the repair of large ventral 3. Coated vicryl (Polyglactin 910)
hernia and in the closure of the kidney after Available as a braided suture in distinct violet as
nephrology. The material is prepared from well as undyed colures coated vicryl
bovine esophagus and is sterilized in the same (Polyglactin 910) is now the most widely used
way as catgut. coated braided synthetic absorbable suture. The

www.ijmlr.com/IJMLR© All right are reserved


48
Sahoo et al., Int J Med Lab Res 2017, 2(2): 46-52
ISSN 2456-4400

braided construction ensures that handling and  Non-absorbable suture


knotting are excellent and the unique lubricant Non-absorbable sutures and ligatures are not
coating remains effectively bonded to the absorbed by tissue and unless they are on the
material throughout its use, ensuring smooth surface, remain in the body after the wound has
passage through tissue and easy knot tie down. healed.
The unique molecular structure of coated vicryl 1. Silk
allows it to retain strength during the critical Silk consists of strands prepared from filaments
wound healing period, yet, be absorbed rapidly of the cocoon spun by the silk worm of the
after the suture has excellent handling Bombyx family before it enters the chrysalis
characteristic and its distinctive violet colour is stage. Three forms are used in surgery- twisted
highly visible in thewound. Coated vicryl is also (sometimes known as Chinese twist). Floss and
available in undyed form, especially for plaited or braided silk. DSilk in its natural state
cuticular and plastic surgery. contains up to 25 percent of natural gum and
4. Monocryl (Poliglecaprone 25) strands prepared from unbleached, un
It is monofilament synthetic absorbable suture. discharged. Twisted silk suture material is
Available as a golden colour prepared from unbleached, un discharged
monofilament.Monocryl (Poliglecaprone 25) is a filaments spun in multiples to the British
monofilament, synthetic absorbable suture. A Pharmaceutical Codex range of diameters and
copolymer of 75% glycoside and 25% may be dyed with non-toxic dyestuffs. The
caprolactone, Monocryl is undyed, presenting as surgical use of twisted silk has very much
a natural golden coloured declined in favor of the braided type.Floss silk is
monofilament.Monocryl is the most pliable prepared from the coarser filaments on the outer
synthetic absorbable monofilament suture ever, surface of the silkworm cocoon and is used in its
has virtually no memory when dispensed and its spun glossy white form mainly in the repair of
exceptionally smooth surface ensure tissue hernia. Its use is diminishing fast as the plastic
glidde when passed through tissue. This added polymer meshes gain in popularity. Plaited or
to the fact that it elicts only minimal tissue braided silk is the material in large-scale use in
reaction makes this suture an ideal choice for modern surgery. It is prepared from discharged
plastic and cosmetic surgery and for silk and the range of sizes is dependent on the
Gastrointestinal surgery. number of strands braded together. As the gum
5. PDS II has been removed it is not serum proof or non
It is monofilament synthetic absorbable suture. capillary and for most surgical purposes it
Available as a distinct violet Suture.PDS II therefore treated with proofing waxes or
suture is a monofilament synthetic absorbable silicones.
suture made of polydioxanone.PDS II has the 2. Linen
characteristic of extremely high initial tensile Linen sutures consist of selected fibers made
strength, coupled with extended wound support. into a twisted strand from flax (Linum
Also being a monofilament handling is usitatissinum). The strand is normally prepared
extremely easy and knotting is secure. Passage by spinning three cords together, the size of the
through tissue is smooth, eliminating tissue drag. cords being chosen to produce the ultimate
It is indicated for use in areas such as closure of desired gauge of thread. For surgical use it must
fascia and sheath, in pediatric cardiovascular be firmly and evenly spun and free from
surgery, in the gastro intestinal tract, in fuzziness. Linen may be dyed with any non-
obstretrics/gynaecology, in orthopedic surgery toxic dyestuff but although a certain amount of
and for sub cuticular closure. black thread is used the majority of surgeons

www.ijmlr.com/IJMLR© All right are reserved


49
Sahoo et al., Int J Med Lab Res 2017, 2(2): 46-52
ISSN 2456-4400

prefer off-white or ivory colour. It is extensively has the further advantages of being minimally
used in many surgical techniques and frequently irritating to tissue and remarkably smooth and
needs to be non capillary and serum proof by easy to handle. The smoothness of suture makes
treatment with suitable proofing agents similarly it suitable for closing skin and sub cuticular
to braided silk. layers. Its high degree of elasticity contributes to
3. Polyamides[9] its great strength in the fine sizes, enabling the
In the U.K. these polymers are better known by plastic surgeon; the micro surgeon and the
the word Nylon but as this is a registered ophthalmologist to tie secure knots.
trademark in certain European countries, it is 6. Mersilene Braided and Monofilament
likely that the word polyamide will be used in Polyester
the future. These compounds are formed from Mersilene suture is made from fine filaments of
the polymerization of the reaction product of an pure polyester, an extremely strong synthetic
acids and an amine. All the polyamides and material. It is specially processed to render it
suture materials are produced by an extrusion non capillary. A special process to produce a
process, the size of the orifice on the extruder tight, smooth, uniform strand braids it. The
head determining the size of the filament. The tensile strength of mersiline suture is
bulk of the material used in surgery is produced considerably higher than that of natural non-
in the form of monofilament. Its main use is in absorbable sutures. It is not weakened by
skin suturing although it is sometimes used wetting. It has excellent handling characteristics,
internally. Polyamide mesh finds a use in hernia draws easily through tissue and knots hold
repair.Finer filament of polyamide is braided securely with standard synthetic knotting
together to form braided nylon on nonabsorbable technique.
surgical sutures. 7. Polybutylate coated braided polyester suture
4. Polyester It is available as a highly visible green or white
This suture material is usually prepared in the coated braided suture. Suture is made of fine
plainted or braided form and consists of filaments of polyester fiber, braided by a special
filaments prepared by polymerizing the ester process to produce a firm suture that remains
formed by a combination of ethylene glycol and soft and pliable. For added lubricity and
terephthalic acid. In its commercial form it is smoothness, the suture is coated with a highly
known under the trademarks Terylene (I.C.I.) adherent, biologically inert Polybutylate. The
and Dacron (Dupont). The number of filaments unique process gives suture a number of
in the braid determines the size of the completed advantages. Flaking is virtually eliminated and
strand.The polymer has a softening temperature the suture is smooth to plave and tie down
of not less than 255 degree and may be sterilized making it an excellent choice for cardiovascular
by autoclaving, ethylene oxide or radiation and ophthalmic work. Knots hold securely when
treatments, in order to improve its visibility in standard synthetic technique is used.
tissue it is often dyed or pigmented with non- Suture is virtually non reactive and will retain its
toxic materials. strength in tissue.
5. Monofilament Polyamide 8. Monofilament stainless steel suture
The suture use in this product is an extremely Available as sterile monofilament eyeless
strong, very pliable surgical nylon produced by a needled sutures.Surgical stainless steel is made
special, closely controlled extrusion and from premium grade steel, formulated
polishing process that assures uniformity specifically for surgical use. This grade of
throughout its length. It has high in-vivo tensile surgical stainless steel must undergo many more
strength, does not support bacterial growth and quality control steps than ordinary commercial

www.ijmlr.com/IJMLR© All right are reserved


50
Sahoo et al., Int J Med Lab Res 2017, 2(2): 46-52
ISSN 2456-4400

steel. Surgical steel is the strongest suture silk. Natural silk is composed of approximately
material that makes. It offers the ultimate in knot 70 % protein fibers and 30% extraneous material
security. As a inert material it will elicit virtually or gum. A specially developed degumming
no tissue reaction. process removes extraneous material amounting
9. Prolene mono filament polypropylene to 30% of the original volume of raw silk. This
It is available as a bright blue monofilament process is essential for a compact braid whilst
suture. Prolene polypropylene[10] suture is made ensuring that the filaments retain their natural
from a polymer of propylene, which is extruded body and elasticity. These filaments are then
by the special ethicon a very strong, smooth, tightly braided at a slow controlled rate and
uniform suture. The unique combination of electronically inspected during the processing.
qualities in the suture material itself makes
prolene suture one of the most versatile non- CONCLUSION:
remarkable smoothness remarkable smoothness
absorbable sutures available. It makes it Proper designing of sutures make it possible to
desirable as a cosmetic suture. The same quality sharply reduce the percentage of postoperative
is valuable in cardiovascular work. It is un complications and correspondingly to reduce the
wetted by blood, un weakened by tissue number of repeated operations. The ideal suture
enzymes, offers prolonged tensile strength even material would be a perfect union of easy
in infected areas. prolene suture is pliable, ties sterilization, adequate tensile strength, handling
securely and handles well because of its ease, absence of foreign body reaction, and
controlled elongation. complete tissue absorption. Simultaneously, the
10. Perma-hand time for treating surgical patients will be
It is available as a black braided suture. Perma shortened and expenses for treatment will be
hand surgical silk begins as a filament of natural reduced.

REFERENCES:

1) Patel KA, Thomas WEG. Sutures, ligatures 4) Azhahia Manavalan R , Mukhopadhyay A.


and Staples. The Medicine Publishing Company, Surgical sutures:Performance, development and
Surgery 2005;2:23. use. Journal of biometics, Biomaterials and
tissue engg. 2008;1:1-36.
2) Srinivasulu K, Dhiraj Kumar N. A review on
properties of surgical sutures and applications in 5) Tomihata K, Suzuki M,Oka T, Ikada Y. A
medical field. IMPACT: International Journal of New Resorbable Monofilament Suture. Polymer
Research in Engineering & Technology 2014; Degradation and Stability 1998;59:13-19.
2(2):85-96.
6) Wollinaa U, Heideb M, Müller-Litzb W,
3) Ajmeri JR, Ajmeri CJ. Surgical Sutures: The Obenaufb D, Ashc J. Functional Textiles in
Largest Textile Implant Material.Proceedings of Prevention of Chronic Wounds, Wound Healing
Medical Textiles and Biomaterials for Health and Tissue Engineering. Textiles and the Skin.
care. Edited by Anand SC, Kennedy JF, Curr Probl Dermatol. Basel, Karger 2003;31:82.
Miraftab M, Rajendran S.1999.

www.ijmlr.com/IJMLR© All right are reserved


51
Sahoo et al., Int J Med Lab Res 2017, 2(2): 46-52
ISSN 2456-4400

7) Carcia paez JM etal. Resistance and 9) Hockenberger AS, Karaca E. Effect of Suture
Elasticity of the Suture Threads employed In Structure on the Knot Performance of Polyamide
Cardiac Bioprostheses.Biomaterials 1994; Sutures. Indian Journal of Fiber and Textile
15(12):981-984. Research, 2004;29:271-277.

8) Mckenzie AR. An Experimental Multiple 10) Faulkner BC, Tribble CG, Thacker JG,
Barbed Suture for the Long Flexor Tendon of Rodeheaver GT, Edlich RF, Knot Performance
the Palm and Finger, Preliminary Report. of Polypropylene Sutures, Journal of Biomedical
Journal of Bone Joint Surg Br1967;49(3): 440. Materials Research 1996; 33:187-192.

CONFLICT OF INTEREST: Authors declared no conflict of interest.

V la

www.ijmlr.com/IJMLR© All right are reserved


52