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Suture material & suturing technique


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GOALS OF SUTURING, CLASSIFICATION OF SUTURE MATERIALS According to source, CLASSIFICATION OF SUTURE MATERIALS According to Structure, CLASSIFICATION OF SURGICAL NEEDLES, IDEAL PROPERTIES OF NEEDLES, BODY OF NEEDLE, SUTURE SIZES, THE EYE OF THE NEEDLE, PRINCIPLES OF SUTURE SELECTION, Gut/ Chromic Gut, SILK, Collagen SUTURE, Vicryl (Polyglactin 910), Dexon and PGA, SURGICAL COTTON, GLYCOLIC ACID (MAXON) POLYGLYCONATE, NYLON, Polymerized Caprolactam, Polymerized Caprolactam, Polypropylene, Stainless Steel, Anesthetic Solutions, Wound Preparation, Principles And Techniques, Wound antisepsis and sterile technique, Wound antisepsis and sterile technique, Wound antisepsis and sterile technique, The interrupted suture, The full surgeon s knot, The full surgeon s knot, The simple or spiral continuous suture technique, The locked continuous suture, The locked and secured continuous suture, The external horizontal mattress suture The buried horizontal mattress suture, The buried vertical mattress suture, The simple anchored (sling) suture, The sliding anchored (sling) suture, The continuous sling suture, Suturing Tips and Approaches by Anatomic Location, How to Care for Stitches (Sutures), Removal of suture, Principle of suture removal, Reasons for failure of sutures, Possible complications of leaving sutures for many days, Other Methods of Wound Closure, Ligating Clips, Tissue Adhesives,

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Suture material & suturing technique

  1. 1. GOALS OF SUTURING Wound edge apposition. Provide adequate tension. Maintain hemostasis. Aid in wound healing. Avoid wound infection. Produce aesthetically pleasing scar by approximating skin edges.
  2. 2. CLASSIFICATION OF SUTURE MATERIALS According to source NATURAL SYNTHETIC Absorbable • Catgut • Chromic catgut • Collagen • Fascia lata • kangaroo tendon • Beef tendon • Cargile membrane Non Absorbable • Silk • Silk worm gut • Linen • Cotton • Ramie • Horse hair Absorbable • Polyglycolic Acid • Polyglactic Acid • Polyglactin 910(Vicryl) • Polydioxanone(PDS) • Polyglecaprone 25 • Non Absorbable • Nylon/ polyamide • PolyPropylene • Polyesters • Polyethelene • Polybutester • Polyvinylidene fluoride / PVDF Sutures
  3. 3. CLASSIFICATION OF SUTURE MATERIALS According To Structure MONOFILAMENT MULTI FILAMENT Advantages Smooth surface Less tissue trauma No bacterial harbors No capillarity Disadvantages Handling and knotting Stretch Any nick or crimp in the material leads to breakage. Advantages Strength Soft and pliable Good handling Good knotting Disadvantages Bacterial harbors Capillary action Tissue trauma
  4. 4. CLASSIFICATION OF SURGICAL NEEDLES ACCORDING TO EYE • Eye less needle • Needle with eye ACCORDING TO SHAPE • Straight • curved ACCORDING TO CUTTING EDGE • Round • Conventional cutting • Reverse cutting ACCORDIND TO ITS TIP • Triangular • Round • blunt OTHER • Plastic needle • Micro point needle • Cuticular needle • Spatula needle
  5. 5. IDEAL PROPERTIES OF NEEDLES • High quality stainless steel • Smallest diameter possible • Capable of implanting sutures with minimal trauma to tissues. • Stable in the needle holder • Should be sharp. • Sterile and corrosion resistant.
  6. 6. BODY OF NEEDLE •Body is the widest portion of the needle •It is known as grasping area. •Most commonly used are 3/8 circle. They can be easily manipulated in large and superficial wounds and require only less wrist movement. •1/2 circle used for suturing tissues in small wounds, and body cavities and orifices. Require less space, but more supination and pronation of wrist. •5/8 used in oral cavity.
  7. 7. SUTURE SIZES •Largest size 1-0 to extremely fine 11-0. •Increasing number of zeros correlates with decreasing suture diameter and strength. •Thicker sutures approximation of deeper layers, wounds in tension prone areas and ligation of blood vessels. •Thin sutures closing delicate tissues like conjunctiva and skin incisions of the face. •Size is chosen to correlate with the tensile strength of the tissue being sutured.
  8. 8. SUTURE Package Needle SHAPE Name Size NEEDLE TIP
  9. 9. THE POINT •Point runs from tip to the maximum cross sectional area of the body. •Can be-triangular tip/cutting -round tip -blunt tip •Cutting needles are ideal for suturing keratinized tissues like skin, palatal mucosa, subcuticular layers and for securing drains. •Round/tapered needles used for closing mesenchymal layers such as muscle or fascia that are soft and easily penetrable
  10. 10. THE POINT •The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle • The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle. • The tapered point is used primarily on soft, easily penetrated tissues . It leaves small hole and can be used in vascular surgery as well as facial soft tissue surgery. • The blunt point has a rounded end which does not cut through the tissue .It is used in friable tissue suturing or to the parotid duct or lacrimal canaliculi.
  11. 11. NEEDLES TIPS Cylindrical needle with rounded tip. Needle with triangular tip and three cutting edges. Reverse cutting needle: the third cutting edge is on the back of the needle, which helps to reduce tissue trauma.
  12. 12. THE EYE OF THE NEEDLE The eye can be Shape of the eye may be - round Open French-eye needle is easy to load with varying caliber, but has additional bulk. Eyed require threading prior to use, results in pulling a double strand through tissue. Tying the suture to the eye increases bulk of suture material drawn through tissues. So they are also called ‘traumatic needles’. Most suture materials and needles are difficult to sterilize. Needles are also difficult to clean after use and become blunt and work hardened so that they snap - closed - swaged - chanelled/drilled - oblong - square
  13. 13. NEEDLE Cylindrical attachment between needle and thread: the step between needle and thread is dearly visible. Electron-microscopic image showing the importance of the congruity between needle and thread. After the needle has passed through the tissue. the space is almost entirely filled by the thread. If the diameter of the needle is markedly greater than that of the thread, there is a gap between tissue and thread which may cause problems with healing.
  14. 14. PRINCIPLES OF SUTURE SELECTION The selection of suture material by a surgeon must be based on a sound knowledge of : Healing characteristics of the tissues which are to be approximated  The physical and biological properties of the suture materials  The condition of the wound to be closed and  The probable post-operative course of the patient.
  15. 15. Gut/ Chromic Gut Chromic: tanned, lasts longer, less reactive Easy handling Plain: 3-5 days Chromic: 10-15 days Bacteria love this stuff!
  16. 16. SILK Braided or twisted Made from the filament spun by silkworm larva to form its cocoon. Processed to remove the natural waxes and gum. After braiding, the strands are dyed, stretched and impregnated with a mixture of waxes and silicone. Dry silk suture is stronger than wet silk suture.
  17. 17. Collagen SUTURE Natural, absorbable, monofilament Obtained by homogenous dispersion of pure collagen fibrils from the flexor tendons of cattle. Absorption – 56 days TS < 10% after 10 days. Used in ophthalmic surgery Disadvantage premature absorption.
  18. 18. Vicryl (Polyglactin 910) Braided, synthetic, absorbable Stronger than gut: retains strength 3 weeks Broken down by enzymes, not phagocytosis and be Absorbed at 56-70 days Break-down products inhibit bacterial growth Can use in contaminated wounds, unlike other multifilaments Minimal tissue reactivity and can be used in infected tissues Available in purple and undyed (Undyed face). Coated with polyglactin 370 and calcium stearate which allows easy passage through tissues as well as easier knot placement. On skin wounds, associated with delayed absorption as well as increased inflammation.
  19. 19. Dexon and PGA Polymer of glycolic acids with greater knot pull and TS than gut. Braided, synthetic, absorbable Broken down by enzymes which results in minimal tissue reactivity. dexon have increased tissue drag, good knot security Does not tolerate wound infection and not percutaneous suture.
  20. 20. SURGICAL COTTON Natural, multifilament, non absorbable From stable Egyptian cotton fibers Good knot security Not good in presence of contaminated wounds or infection Rarely used nowadays Uses: Most body tissues for ligating and suturing SURGICAL COTTON
  21. 21. GLYCOLIC ACID (MAXON) POLYGLYCONATE Monofilament- memory Synthetic ,Absorbable & Very little tissue drag. Polyglycolic acid and trimethylene carbonate TS : 14-21 days (>Dexon) Absorption : Hydrolysis in 180 days Degradation products of polyglycolic acid and nylon sutures : glycolic acid, 1,6-hexane diamine and adipic acid are antibacterial agents. Poor knot security and Very strong
  22. 22. PDS II (polydioxanone) Monofilament (less drag, worse knot security – lots of “memory”) Synthetic, absorbable Very good tensile strength (better than gut, vicryl, dexon) which lasts months Absorbed completely by 182 days
  23. 23. NYLON Synthetic Mono or Multifilament Memory Very little tissue reaction Poor knot security
  24. 24. Polymerized Caprolactam Vetafil, Braunamid, Supramid Multifilament suture with protein coating Synthetic Good knot security, easy handling Not very reactive Don’t use in contaminated wound Usually comes on a reel
  25. 25. Polypropylene Prolene, Surgilene Monofilament, Synthetic Won’t lose tensile strength over time Good knot security Very little tissue reaction
  26. 26. Stainless Steel Monofilament Strongest ! Great knot security Difficult handling Can cut through tissues Very little tissue reaction, won’t harbor bacteria
  27. 27. Anesthetic Solutions CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: ◦ Eyes, Ears, Nose ◦ Fingers Lidocaine (Xylocaine®) ◦ Most commonly used ◦ Rapid onset ◦ Strength: 0.5%, 1.0%, & 2.0% ◦ Maximum dose: ◦ 5 mg / kg, or Lidocaine (Xylocaine®) with epinephrine ◦ Vasoconstriction ◦ Decreased bleeding ◦ Prolongs duration ◦ Maximum individual dose: ◦ 7mg/kg
  28. 28. Anesthetic Solutions BUPIVACAINE: ◦ Slow onset ◦ Long duration ◦ Strength: 0.25% ◦ DOSE: maximum individual dose 3mg/kg
  29. 29. Injection Techniques Check for allergies Insert the needle at the inner wound edge Aspirate Inject agent into tissue SLOWLY Wait… After anesthesia has taken effect, suturing may begin
  30. 30. Wound Evaluation Time of incident Size of wound Depth of wound Tendon / nerve involvement Bleeding at site
  31. 31. When to Refer  Deep wounds of hands or feet, or unknown depth of penetration  Full thickness lacerations of eyelids, lips or ears  Injuries involving nerves, larger arteries, bones, joints or tendons  Crush injuries  Markedly contaminated wounds requiring drainage
  32. 32. Contraindications to Suturing • Redness • Edema of the wound margins • Infection • Fever • Puncture wounds • Animal bites • Tendon, nerve, or vessel involvement • Wound more than 12 hours old (body) and 24 hrs (face)
  33. 33. Wound Preparation Most important step for reducing the risk of wound infection. Remove all contaminants and devitalized tissue before wound closure. ◦ IRRIGATE w/ NS or TAP WATER (AVOID H2O2) ◦ CUT OUT DEAD, FRAGMENTED TISSUE If not, the risk of infection and of a cosmetically poor scar are greatly increased Personal Precautions
  34. 34. Principles And Techniques Minimize trauma in skin handling Gentle apposition with slight eversion of wound edges ◦ Visualization Make yourself comfortable ◦ Adjust the chair and the light Change the laceration ◦ Debride crushed tissue
  35. 35. Wound antisepsis and sterile technique It is rarely necessary to remove significant quantities of body hair prior to repair of a simple laceration. In fact, razor removal of hair has been shown to damage surface skin follicles and lead to increased rates of wound infection. Occasionally, for repair of scalp lacerations, for example, scissor trimming will allow for easier identification of wound margins and will facilitate later wound care. Due to inconsistent regrowth of eyebrow hair, it should never be shaved when repairing lacerations in that area. Actual preparation of the wound involves cleansing and debridement. The ideal wound cleanser should have broad antimicrobial activity, but should not delay healing or reduce tissue resistance to infection. There is controversy about the potentially adverse effects of the readily available skin cleansing antiseptic solutions when introduced directly into the wound. What is certain, however, is that 0.9% normal saline is a very effective and non-toxic irrigating solution. Therefore, 0.9% normal saline should be used as the final solution when cleaning a wound and one should minimize spillage of other solutions into the wound during preparation.
  36. 36. Wound antisepsis and sterile technique Wound irrigation is a form of mechanical wound cleansing that is known to effectively remove bacteria and other debris. A 10 c.c. or 20 c.c. syringe can be fitted with a commercially available splash cover, and the wound can then be irrigated with either normal saline or Ringer's lactate. These solutions are used because they do not irritate body tissues. Following irrigation, remaining debris and devitalized tissue can be removed with fine forceps or with a scalpel. Ensuring sterile technique while repairing a wound is, perhaps, the most difficult concept for the inexperienced person to grasp. A break in sterile technique, with contamination of the field, is a common procedural error. It leads to an increased incidence of wound infection and breakdown.
  37. 37. Instruments for use in surgery procedures Castroviejo needle holder modified by Simion. Detail of the handle. Mayo needle holder. Sharp tipped scissors. Blunt tipped scissors.
  38. 38. Gripping needle holders and scissors The scissors grip, as shown in the photograph, enables the needle holder to be guided very precisely in the anterior part of the mouth and in areas of easy access. The instrument is stabilized with the index finger that guides the tip of the needle holder. Scissors may be gripped in a similar way, taking care to keep the index finger dose to the junction between the two blades, so as to guide the instrument and avoid acaaenta/ harm.
  39. 39. The interrupted suture The first step consists of passing the needle through the first flap from the outside inwards. Where there is one free flap and one fixed flap, the needle should pass first through the free flap The needle then pierces the second flap from the inside outwards. Approximately the same penetration distance of the flap must be maintained so as to avoid asymmetry between the two flaps, which might compromise the esthetic results. The depth of penetration and thus the distance from the margin, must be evaluated for each specific case. With healthy tissues, this is generally 1.5-2 mm from the free margin, while in more fragile tissues the distance may be increased. It is good practice in any case not to take this stitch too deep, as it can constrict smaller blood vessels. The single detached stitch is dosed with a full surgeon 5 knot, which should not be placed on the line of the incision but lateral to it.
  40. 40. The full surgeon s knot When the suture is completed (in the case illustrated, this is a single stitch), the full surgeon 5 knot begins. This knot should be made as follows: the thread is passed around the tip of the needle holder making a loop in the clockwise direction. This is then repeated, so that there are two loops around the tip of the needle holder. It is this step that differentiates the different types of surgical knots: the number of loops that are made around the needle holder (single, double or triple).
  41. 41. The full surgeon s knot A frequent error is applying traction to tighten the knot holding the thread at a distance from the center oft he knot. If this is done, its impossible to control tension and precision is lost ; there is also a risk of lacerating the flap. It is equally important to ensure that the thread has been pulled right through and the knot is tightening where desired Especially when using thread with poor gliding capabilities for example natural multifilament it will not be possible to tighten the knot correctly with subsequent maneuvers and its clinical utility will therefore be reduced or lost entirely. During this phase, it is important to check that the flaps have been properly approached, without superimposition or Invagination. The two ends of the thread are then pulled outwards, trying to maintain a constant pressure on them. From the technical standpoint it is important to grasp the proximal ends of the thread, that is those closest to the knot, using the needle holder and forceps or fingers.
  42. 42. The full surgeon s knot The knot must be positioned on one of the flaps, lateral to the line of the incision. After having tightened the first half knoct the next step is to secure the knot Another loop of thread is passed around the tip of the needle holder, but this time in the anticlockwise direction. The further subdivision of surgical knots depends on this phase, that is on how many loops are made around the tip of the needle holder (single or double) and what is the alternation (clockwise/anti- clockwise) they are given
  43. 43. The full surgeon s knot As described above, the two ends of the knot are tightened This step gives security and stability to the knot and stops it from coming undone. The intrinsic characteristics of the thread determine the type and number of steps required to achieve security. When, based on the type of thread used, the surgeon judges that good stability has been ensured, the operation is concluded If this procedure is repeated several times, security increases but, at the same time, so does the size of the knot. The correct balance must be achieved for each individual suture.
  44. 44. The simple or spiral continuous suture technique The starting point, common to all continuous sutures in this family is the single stitch with a surgeon's knot. After having cut only the short end of the thread the needle enters the first flap, which in actual clinical situations is generally the free or apical flap, at about 1.5-2 mm from the free margin. After passing across the free space between the two flaps, the needle pierces the second flap from inside outwards, the aim being to exit at a distance of 1.5-2 mm. Inreal clinical situations, this willbe the fixed or coronal flap. By piercing the flaps individually and not with one single movement, the stitch can be placed more precisely and a correct design can be given to the suture. The needle is passed externally ta the flap, it describes a loop and is turned through 180 . The purpose of this maneuver is to enable the needle to pierce the first flap again.
  45. 45. The simple or spiral continuous suture technique As described above, if the needle is taken through both flaps at the same time, the precision of symmetry of the suture is reduced, which is not advisable. The figure shows the two flaps being pierced in a single movement simply to avoid an excessive number of diagrams. The reader Will please take the technical indications given here into account. After repeating this step, with the help of surgical forceps- the surgeon applies traction to the end of the thread so as to make the tension uniform throughout the suture and avoid areas where the thread remains loose.
  46. 46. The simple or spiral continuous suture technique The needle and thread are again passed external to the wound, and having inverted the direction of the needle by 180 degree , the first and second flaps are again pierced separately. The correct design of this suture can be evaluated after having placed at least three consecutive stitches. Ideally , all the entry holes in the free flap and all the exit holes in the fixed flap lie along two imaginary parallel lines. These two lines should also be parallel to the line of the incision and equidistant from it. The axis of the portion of thread lying external to the flaps, which joins the two ideal lines must not be perpendicular to the margin of the incision, but at 45° or 135 ° This inclination provides a slight repositioning effect to the flap, in the first case with slight traction mesially and in the second case distally. The arrangement of the simple continuous spiral suture performed according to these principles guarantees the uniform distribution of forces along the entire line of the incision. Obviously at each step the thread must be pulled through carefully using surgical forceps on the long end of thread
  47. 47. The simple or spiral continuous suture technique The steps described are repeated until the entire length of the flaps involved is covered and protected by the suture. The long end is now held with the surgical forceps without pulling the last portion of thread completely through leaving the last loop loose, dearly visible and accessible. With the long end a first loop is made around the tip of the needle holder to begin a three-end surgical knot. The thread is passed around the tip of the needle holder a second time, and the tip of the needle holder is aimed towards the loop that was left loose at the end of the spiral suture.
  48. 48. The simple or spiral continuous suture technique This loop is now grasped firmly between the jaws of the needle holder and, taking care to pull the ends in opposite directions in the correct manner, the procedure to tighten the knot is begun. The ends of thread are pulled through until the knot is properly positioned A series of half knots may now be tied in alternating directions to provide the suture with stability. One knot is generally enough, and avoids producing an excessively voluminous knot. This is the appearance of the simple continuous suture or spiral suture at completion. For reasons of clarity we have left the ends of the thread rather long, whereas in clinical practice they should be shortened (1.5 mm). The knot should be positioned lateral to the line of incision and not on the line.
  49. 49. The locked continuous suture This stitch must be positioned at one of the two ends of the incision line. In clinical practice, this is the most distal end, because technically it is easier to work from distal to mesial. The second stitch enters the free flap from the outside inwards, and the needle emerges in the free space between the two flaps. Maintaining perpendicular axis with regard to the incision line, the needle enters the second flap from the inside and passes outwards. Having passed through the second flap, the needle is now turned and moved backwards so that it can pass beneath the loop formed by the thread, situated external to the planes to be sutured This step differentiates the continuous locked suture from the continuous spiral suture.
  50. 50. The locked continuous suture Using the needle holder and forceps, the surgeon must pull the thread through completely to provide constant and correct tension, so as not to leave any areas with a poor seal. The third stitch begins exactly as the second and is its continuation. Again a loop is formed that will later be pulled back in to block the suture. The needle again passes beneath the second loop to lock the suture.
  51. 51. The locked continuous suture Using the needle holder, a certain tension is given to the thread, as was done at the first step. Only in this way can the surgeon approach the flaps properly, and be sure to pull the thread through completely. At each step this must be repeated: it cannot be left until the end of the procedure- as the final result would be unstable. The final anchorage stitch begins in the usual way, with the needle passing through the two flops. For simplicity of presentation, the diagram shows the needle passing through both flops together, but in reality it should be passed through one flop at a time, as described earlier. Initially the needle holder can be passed inside the lost loop to check that the tension of the suture is properly uniform. At the some time the surgeon must apply traction to the long end (that attached to the needle) with a pair of forceps, while the tip of the needle holder holds the lost loop tight After having removed the needle holder from the loop, the surgeon's knot is begun; this requires the long end of the thread to be wound around the tip of the needle holder twice.
  52. 52. The locked continuous suture The technique continues exactly as described for the full surgeons knot associated with the single stitch. The tip of the needle holder is now aimed towards the last remaining loop, which it grasps. With the needle holder. the loop, which is treated as a "double short end'; is now grasped, and the suture is tightened This knot may be secured following the classic procedures described for securing the full surgeons knot, that is by making a series of half-knots in clockwise and anticlockwise directions alternately. In this case too, the number of half knots should be reduced to the minimum so as not to make the knot excessively voluminous. This is the appearance of the finished locked continuous suture. In clinical practice the ends of the knot wilI be shortened and the knot will be given a lateral position with regard to the incision line.
  53. 53. The locked and secured continuous suture The difference between these two techniques lies in the positioning of surgeon s knots along the line of the suture. Instead of waiting until the suture is completed before placing a surgeons knot, in this case knots are tied at intervals along the line of the suture. Only the short end of the thread is cut off short for the knots situated at intermediate positions along the line of the suture. The thread should be cut fairly short (1-2 mm) to decrease the patient's post- operative discomfort. The knot along the suture line is placed so as to subdivide the suture into smaller portions, minimizing the risk of the suture opening completely should a part of it give way Technically, this suture is performed by repeating the phases described above. After positioning each surgeon's knot, suturing is continued in the same manner.
  54. 54. The locked and secured continuous suture At each step, the needle and thread pass through the loop, taking care to pull the ends through properly so as to maintain constant tension on the thread and, in consequence, on the flaps. To optimize this step, the surgeon may employ both the needle holder and appropriate surgical forceps. The steps described above are repeated until the end of the incision line is reached For preference, the needle is passed through the two flaps separately. A full surgeon's knot is then tied, and secured with half knots, clockwise and anti clockwise, to provide stability to the locked and secured continuous suture. Appearance of the locked and secured continuous suture on completion.
  55. 55. The external horizontal mattress suture The technique entails piercing the first flap from the external mucosa side, at approximately 3 mm from the incision line. The needle passes across the free space between the two flaps and pierces the second flap, attempting to maintain the same distance from the incision line. Identical distances from the wound margins ensure uniform traction on the two juxtaposed flaps The needle is turned on a plane parallel to that of the free margin of the flap, and pierces the second flap from the mucosa side inwards. The optimal distance from the exit hole is approximately 2-3 mm, so as not to open the 'V“ shape of this suture excessively Lastly, the needle pierces the first flap from the inside outwards, seeking to emerge at the same distance from the margin of the incision and parallel to the first passage of the thread
  56. 56. The external horizontal mattress suture The proper horizontal "U“ shape of this suture can easily be recognized A full surgeon 5 knot is now begun; this will seal the suture in a conventional manner. Two clockwise loops are made with the long end of the thread around the tip of the needle holder, the long and short ends of thread are pulled simultaneously, closing the wound. The ends are pulled in opposite directions, taking care always to grasp them close to the knot, and not at a distance.
  57. 57. The external horizontal mattress suture The horizontal mattress suture in section: the moderate introflection (apicalizing) of the suture and its coronal gap may be seen. If properly tied, the full surgeon's knot provides stability to this suture/ however, the most coronal portion is not completely dosed
  58. 58. The buried horizontal mattress suture The buried horizontal mattress suture has only a slight extroflecting action on the flaps, but holds together large surfaces starting from the deeper planes. Since these sutures will remain in situ resorbable thread must be used. The needle pierces the first flap on its inner face and comes out in the space between the two flaps. The deeper this initial stitch is placed, the greater will be the extroflection of the flaps, but also the coronal gaping will be more pronounced If the entrance of this stitch is kept at approximately 2 mm from the external margin the extroflecting action will be moderate, but the coronal gaping will be minimal. The thread is pulled through the first flop and the second flop is extroflected with forceps, to enable it to be pierced.
  59. 59. The buried horizontal mattress suture The needle must enter the second flop at approximately the some depth as the exit hole from the first flop. This is necessary to give a correct plane to the suture with regard to the line of the incision and so as not to create internal traction. Needle and thread do not pierce the external side of the flops, but remain within the tissues throughout the entire procedure. The thread is again pulled through the second flop to enable proper visual control, The needle is turned and the second flap is again pierced The entrance hole is situated at the same depth as the exit hole so that the two form a single plane parallel to the plane of the line of the incision. The distance between these two holes affects the extroflection of the flaps: a greater distance produces more accentuated extroflection. The needle and thread now pierce the first flap for the second time. In this case, too, the entrance hole of the first step and the exit hole of the last step are on a plane parallel to that of the wound The thread remains intramural.
  60. 60. The buried horizontal mattress suture The portion of flap pierced by the needle and thread must be at least I mm for each of the four steps performed Otherwise the amount of tissue embraced by the thread is too little and it may lacerate. For buried sutures. this is a serious risk since it may cause laceration at a depth where any bleeding is only later apparent, with negative repercussions on the healing process. The surgeon s knot is started, taking care to position forceps and needle holder very dose to the knot This is to ensure that the knot is situated deep within the tissues. After a final careful check, the knot is tightened Holding the surgeons knot up with forceps, that is trying delicately to extroflect it from the wound for better visibility, the ends are cut off as short as possible.
  61. 61. The buried horizontal mattress suture A section view from above shows the steps that have been performed and the proper position of needle and thread with regard to the thickness of the flaps. The first flap is pierced at 2 mm from the free margin, and after the needle has traveled approximately 2 mm inside that flap, its brought out with a rotary movement With regard to the free margin of the flap, a depth of about 4 mm is reached The needle and thread leave the tissue to pass across the free space between the two flaps. The second flap is pierced at a depth of approximately 4mm; the needle runs in the apico-coronal direction and emerges 2 mm from the free margin. This pathway is again completely intramural. After re-emerging the needle follows a path parallel to the free margin of the wound and again enters the second flap in the corona- apical direction. This intramural pathway is parallel to that just described but runs in the opposite direction. The needle is made to rotate and pierces the first flap at approximately 4 mm from its free margin, emerging again at 2mm. Thus the thread has intramural portions and portions that lie between the two flaps that it is employed to stabilize. The amount of tissue engaged by the intramural stretches of the thread is crucial both for a proper seal and for proper positioning of the flap. If the intramural portion is too deep, correct repositioning will not be achieved; on the contrary, ifit is too superficial there is a risk of erosion of the suture and the seal will be poor or lacking, with consequent dehiscence. The tissue embraced by the suture in its intramural portions must be at least 1 mm.
  62. 62. The buried horizontal mattress suture The tension exercised on the ends of the threads with needle holder and forceps in dosing the wound must be gradual and continuous. The instruments used must be placed in the immediate vicinity of the ends to avoid lacerating the internal portions of the flaps. The entire suture is completely buried las/de the flaps and will not be accessible from the outside. Thus the threads must be cut off very short to avoid excess material having to be resorbed unnecessarily. The coronal part gapes open, which is unfavorable in the oral environment
  63. 63. The buried vertical mattress suture The buried vertical mattress suture is derived from dermatological surgery, and produces an extroflecting action that can be modulated depending on the position of the knot. There are several different variants of the buried vertical mattress suture, and these differ in the final position of the knot on the internal plane, the degree of extroflection of the flaps, and the amount of tissue embraced by the suture. We will describe the two most widely-used techniques to modify the final position of the knot. The first variant concludes With a more superficial knot. The first flap is therefore pierced by the needle and thread at a depth approximately 4-6 mm from the free margin in its internal portion. The path is intramural. The thread is pulled gently through the first flap, taking care that the intramural portion embraced by the thread is sufficient to avoid laceration.
  64. 64. The buried vertical mattress suture The needle pierces the second flap, again from its internal side, in the apico-coronat direction at about 4-6 mm from its free margin. The thread is pulled through taking care to check that it engages correctly in the depth of the flap. The needle again pierces the second flap from the inside in a more coronal position taking care to come out at least 7-7.5 mm from the free margin. A variant of the buried vertical mattress suture avoids this step, concluding with the step described above.
  65. 65. The buried vertical mattress suture The path followed by the thread thus comprises two intramural passages and one extramural passage that, although not within the tissue, is within the flap. There is a technique for performing these buried mattress sutures. which we will not describe in detail, in which the needle enters and leaves the tissues with a single movement In other words, the needle and thread describe a half circle within the tissue of the second flap with a single point of entrance and a single exit point In this case the path of the suture maintains the apico- corona! direction, but the pathway is entirely intramural. This variant is quicker to perform and in many clinical situations it is easier, but it is also less secure. In the variant we have described there are two buried anchorage points on each side, and thus four in all,-in the other variant there are only two. This means that in the first case, should an intramural stretch of the suture give way, there are three others that can replace it, whereas in the other variant this would not be the case. Since the greatest risk in all buried sutures is late recognition of their having given way, the recommended technique is preferable in all conditions where it is possible to employ it
  66. 66. The buried vertical mattress suture The needle is turned and engages the first flap apical of the entrance hole, taking care to remain at a minimum distance of 1 .5 mm from the free flap. The needle is turned and engages the first flap apical of the entrance hole, taking care to remain at a minimum distance of 1 .5 mm from the free flap. The two ends of thread must be held with appropriate instruments as dose as possible to their points of emergence from the tissue, to avoid lacerating thread or tissues, and to improve precision of movement A full surgeon 5 knot is now begun; it should be positioned at the center of the margin of the incision of the wound.
  67. 67. The buried vertical mattress suture The ends of the knot are cut off very short, since they Will be concealed within the tissues. This section view shows the potential advantages and disadvantages of this variant of the buried vertical mattress suture. The full surgeon 5 knot remains closer to the gaping margin of the suture and may act as a source of disturbance to healing. However, during the maneuvers to tighten the knot, its coronal position accentuates the coronal displacement this suture can provide, making it appropriate in regeneration techniques. The coronal gap can be sealed with additional sutures, as will be described in the following pages.
  68. 68. The buried vertical mattress suture The path of the suture in this variant is shown in this diagram. The inner part of the first flap is pierced, at depth, in the corona-apical direction (first intramural 'port/on): the thread passes across the free space between the two flaps to enter the second flap, at depth, running in the apico-corona! direction (second intramural portion). After emerging from the second flap it enters the same flap again more apically (third intramural portion) taking care to remain at least 1mm from the free margin. The needle is turned and pierces the first flap, coronally with respect to the first hole, running in the apico-coronal direction (fourth intramural portion) again remaining at the recommended distance from the free margin. The two ends of thread are brought to the center of the wound in a coronal position.
  69. 69. The buried vertical mattress suture Tightening the full surgeons knot helps to displace the flaps in the coronal direction. As was already mentioned, this technique may also be performed with a different sequence, shown below in section. The first entrance hole is on the inner face of the external flap in an apical position. Otherwise the pathway through the flaps is the same as that described above. On completion, however, the two ends are at depth with regard to the margins of the wound.
  70. 70. The buried vertical mattress suture Traction on these two ends will enable the full surgeon 5 knot to be positioned at depth, where there is less risk of its becoming exposed; however, it will interfere with deep-tissue healing to a greater extent. The knot positioned apically with regard to the free margin of the wound decreases the extroflecting effect of this suture.
  71. 71. The buried vertical mattress suture The point at which the buried vertical mattress suture will begin is not chosen at random; it enables the degree of extroflection of the flaps to be modulated. As we have said, the resistance of the suture to traction of the tissues can be increased or reduced by varying the number of steps as well as the number of intramural portions in this technique For the reasons given, these sutures may be made with a smaller number of steps and with a simpler technique, to the detriment of stability, as will be shown on the following pages.
  72. 72. The buried vertical mattress suture These three diagrams show another variant of the buried vertical mattress suture with the knot placed superficially. The first step is the same as described above, while the second flap is only pierced once/ thus in this variant there are only three intramural portions. These three diagrams show the buried vertical mattress suture with the knot at depth in the variant with two intramural portions. Needle and thread only enter each flap once, making the steps simpler and quicker to perform. However; there are only two intramural portions, and should one of these give way, that seal of the suture is not guaranteed.
  73. 73. The simple anchored (sling) suture The advantages of the simple sling suture lie in its relative speed, and in the simplicity of repositioning the flap, which is adapted closely to the tooth to which it is attached . The compressive action applied by this method, although less marked than that of other types of anchored suture, enables bleeding and post-operative edema to be checked. The most significant disadvantage is that a considerable portion of thread is passed around the neck of the tooth , which may increase the formation of bacterial plaque and thus potentially increase the risk of infection, as well as the risk of damaging the tooth. Where both a vestibular and a palatine flap are present, the flap not stabilized by this suture must subsequently be sutured, which increases the duration of surgery . For the sake of clarity, a theoretical wound is illustrated to simplify description of the clinical steps. The needle pierces the flop from the vestibular side at approximately 1.5 mm from the coronal margin of the line of the incision. If this suturing technique is begun from the mesial side of the tooth, the situation will then be favorable to position the full surgeon s knot at completion of the suture.
  74. 74. The simple anchored (sling) suture The thread passes around the palatal or lingual part of the tooth without engaging the flaps. This portion of tooth provides attachment The needle is turned through 1800 and pierces the vestibular flap distal to the tooth in exactly the same manner as on the mesial side. Needle and thread again pass to the palatal side without piercing the tissues. Before emerging again on the vestibular side, the suture thread passes through the flap from the palatal to the vestibular side at approximately 1.5 mm from the first entrance hole.
  75. 75. The simple anchored (sling) suture The second hole, that is the exit hole of the suture thread, is on the some horizontal plane as the first entrance hole . Before tying the full surgeon 5" knot to stabilize the suture, the two ends of the thread must be pulled through, taking core to check that on the palatal side both ends are positioned apical of the cingulum. Otherwise the suture may slip off the tooth, passing over the incisal margin of the tooth coronal/y View of the completed suture: it is dear that the greater is the tension applied to the filament which is attached around the tooth, the greater will be the compression applied to the flop.
  76. 76. The sliding anchored (sling) suture This suturing technique combines the characteristic compression of all anchored sutures with an ability to reposition the flap, making it particularly indicated in periodontal surgery, such as, for example, in lengthening the clinical crown. The flaps must be of partial thickness. The suturing technique is generally reserved for operations on the maxilla . The flexibility of this technique with regard to achieving individualized flap repositioning makes it the first choice in many cases. both in periodontal surgery (regenerative tedmiques. reseaive techniques) and in general oral surgery It is important to remember here that surgery must be planned ahead of time with regard to many parameters. The choice of type of incision, type of flap, the need for a reconstructive or resective approach and, on completion, the suturing technique to be used, are all factors that can improve and accelerate the healing processes.
  77. 77. The sliding anchored (sling) suture After having completed the phase of reconstruction or demolition, depending on the type of operation, flap repositioning begins. This is a crucial phase because, before applying sutures. it is necessary to check carefully that the margins of the wound are well adapted to each other, that there is no interposition of tissue and that no areas are under tension. The sliding sling suture begins when the needle enters from the vestibular side. The needle is held perpendicular to the underlying bone, it pierces the periosteum and comes out at least 2 mm from the entrance hole. The path is similar to an external vertical mattress suture, in terms of orientation of the suture plane with regard to the line of the flaps. Bypassing beneath the periosteum, the suture can be anchored and thus attached. The thread passes completely outside the flap to reach the palatal side. Here it pierces the flap from the outside inwards, again engaging the periosteum. The flap may be pierced more coronally and the needle can leave more apically, or the entrance hole can be more apical and the exit hole more coronal. Both methods are correct, although the second is easier to perform. Anchorage to the palatal periosteum is the second anchorage point to attach this suture.
  78. 78. The sliding anchored (sling) suture If the full surgeon's knot is placed more apically on the vestibular side, the vestibular flap will be displaced apically. This suturing technique is indicated in resective periodontal therapy, where the suture helps to reposition the flap apically If the knot is positioned at the level of the cemento-enamel junction, the flap will be passive with no tendency to displacement. If the knot is positioned palatally, the suture will displace the vestibular flap coronally. This type of flap displacement is preferable when the tooth in question has undergone regenerative surgery
  79. 79. The continuous sling suture The continuous sling suture is the ideal suturing technique when resective periodontal surgery involving two or more contiguous teeth has left extensive areas that require remodeling. After, for example: having completed resective periodontal treatment on two or more contiguous teeth and having remodeled the bone ramps, the needle pierces the vestibular flap at its most mesial part. This should be about 1.5 mm from the line of the incision. The needle and thread are pulled through to the palatal side without piercing the tissues and return through the next contiguous inter-dental space distally. The needle is turned through 180 ° passes through the vestibular flap from the outside inwards, and again passes through the inter-dental space. These steps are repeated in exactly the same way along the mesio-distal extension of the flap. During this phase, the suture is attached to the teeth at the palatal or lingual side, while it is the vestibular flap that is adapted.
  80. 80. The continuous sling suture The suture continues in the same way until the distal face of the last tooth involved by the flap is reached. The needle then passes to the palatal side of the most distal tooth involved, is turned through 180 ° and engages the palatal flap. The needle and thread now pass to the vestibular side without engaging the vestibular flap; they pass around the first vestibular face of the last tooth and emerge on the palatal side. The needle is turned through 180° and pierces the reduced-thickness palatal flap, leaving it through the inter-dental space and emerging on the vestibular side.
  81. 81. The continuous sling suture The procedure continues as described During this phase, attachment is only on the vestibular face of the teeth, while adaptation involves the reduced thickness palatal flap To optimize the distribution of tension on the two flaps, the thread must be completely pulled through at each step Having reached the tooth from which suturing began, the procedure is continued until the palatal side is reached If desired a full surgeon s knot can now be tied to fasten the suture. We have not shown this variant, the procedure being well understood .
  82. 82. The continuous sling suture However, it is preferable to pierce the vestibular flap once more with the needle as for an external horizontal mattress suture. In other words, the vestibular flap is pierced at the same height at which the first stitch entered, at a distance of approximately 2mm. After a final check that all the thread has been pulled through properly, the surgeons knot is begun. This variant provides better tissue seal in the most critical part of the suture. The completed suture.
  83. 83. Suturing Tips and Approaches by Anatomic Location The Chest, Back, and Shoulders :
  84. 84. Suturing Tips and Approaches by Anatomic Location The Arms :
  85. 85. Suturing Tips and Approaches by Anatomic Location The Legs :
  86. 86. Suturing Tips and Approaches by Anatomic Location The Hands and Feet :
  87. 87. Suturing Tips and Approaches by Anatomic Location The Scalp :
  88. 88. Suturing Tips and Approaches by Anatomic Location The Forehead :
  89. 89. Suturing Tips and Approaches by Anatomic Location The Eyelids :
  90. 90. Suturing Tips and Approaches by Anatomic Location The Nose :
  91. 91. Suturing Tips and Approaches by Anatomic Location The Lips :
  92. 92. Suturing Tips and Approaches by Anatomic Location The Ears :
  93. 93. How to Care for Stitches (Sutures) Patients should be instructed to keep their wounds clean. Most wounds should be covered with a protective, non-adherent dressing for at least 24-48 hours to ensure sufficient epithelialisation to protect them from gross contamination . After this period, patients may wash their wounds but should not scrub or soak them. The routine use of prophylactic antibiotics is not recommendedAntibiotic use should be tailored to the individual on the basis of:  degree of bacterial contamination  presence of infection-potentiating factors, such as soil  mechanism of injury  host factors
  94. 94. How to Care for Stitches (Sutures) Trott (1997) also found that the use of adhesive tapes was associated with decreased infection rates. Wound adhesives are also associated with less microbial growth than sutures, partly because they lack invasive matter. Antibiotic selection should be based on the suspected microorganism. Over 90% of wound infections are caused by Staphylococcus aureus or streptococcal bacteria. Soil contamination may result in infection with clostridium and gram- negative organisms. Tetanus prophylaxis must be considered for tetanus-prone wounds and also in relation to the immunisation status of the patient
  95. 95. Removal of suture  All sutures, being foreign bodies, cause irritation to the tissues & hence have the potential to cause scarring.  Skin sutures are removed as soon as tissue healing allows.  Non-absorbable sutures are best removed from the face after a period of 5-6 days. Tissues such as the scalp may require a longer period(7-10 day) Time of removal of suture according to place :  Face 3-5 days  Lip 3-5 days  Oral cavity 6-8 days  Neck 5-6 days  Scalp 7-10 days  Chest 10-14 days  Abdomen 10-14 days  Leg 10-14 days
  96. 96. Principle of suture removal  Suture area is first clean with normal saline.  The suture is grasped with non tooth dissecting forceps & lifted above the epithelial surface.  Scissors are then passed through one loop & then transected close to the surface to avoid dragging contaminated suture materials through tissues.  The suture is then pulled towards the incision line to prevent dehiscence. If suture entrapped in a scab, application of hydrogen per oxide/normal saline is necessary  If pieces of suture left infection may occur. Reasons for failure of sutures  Breakage  Cuts out  Knot slips  Extruded suture  Resorbs too rapidly  Removed too early
  97. 97. Possible complications of leaving sutures for many days Sutural abscess.  Scar or stitch mark.  Dermoid cyst.
  98. 98. Other Methods of Wound Closure • Ligating clips • Skin staples • Surgical tape • Surgical adhesives Ligating Clips • Essentially “clips” to replace sutures when occluding (closing) the lumen (central canal) of a vessel or tubular organ Blood vessels Gynecological & urological (GU) procedures • Metallic or polymeric • Requirements  Nontoxic and biocompatible  Absence of allergic and immunogenic effects  Tolerated by wide range of tissue types  High strength and low solubility  Finite longevity  Secure
  99. 99. Metallic Clips First – Cushing neurosurgery clip, 1910 ◦ Ag wire formed in the shape of a “U” and closed around blood vessel ◦ Tantulum (1940) ◦ Tubule ligation ◦ Others ◦ Co-Cr ◦ Titanium ◦ Stainless Steel ◦ “Memory metal” – Ni-Ti alloy Desirable properties in metallic clips ◦ High strength ◦ Malleability & ductility – can make fine wire ◦ Capacity for work-hardening ◦ Corrosion resistance Some problems ◦ Allergic reaction ◦ Radio-opaque – can cause problems with CT, X- ray, and MRI examinations
  100. 100. Polymeric Clips Absorbable and non-absorbable Viscoelastic ◦ Creep ◦ Stress-relaxation
  101. 101. Surgical Stapling Introduced in the late 1970s Used widely in human and veterinary medicine ◦ Gynecological ◦ Cardiovascular ◦ Gastrointestinal ◦ Esophageal ◦ Pulmonary Staples originally stainless but now Ti and polymeric used ◦ Polymeric – 2 parts ◦ “U”-shaped fastener ◦ Figure “8” retainer
  102. 102. Surgical Staples Staple Staple Gun Staple Remover
  103. 103. Staples & Clips vs. Sutures  Speed  Convenience  Reduced infection rate  Lower cost  If done properly, no cosmetic difference
  104. 104. Tissue Adhesives Sterilizable Easy in preparation Viscous liquid or liquid possible for spray Nontoxic Rapidly curable under wet physiological conditions (pH 7.3, 37°C, 1 atm) Reasonable cost Strongly bondable to tissues Biostable union until wound healing Tough and pliable Resorbable after wound healing Nontoxic Nonobstructive to wound healing or promoting wound healing Before Curing After Curing
  105. 105. Natural Tissue – Fibrin Glue First reported in 1940 Mimics blood clot – major component fibrin network Excellent tissue adhesive but insufficient in amount for larger wounds Nontoxic if human protein sources are used to obtain fibrin
  106. 106. Synthetic Systems: Poly-Alkyl-2-Cyanoacrylates Discovered in 1951 “Crazy Glue” H2C=C―CO2―R CN R = alkyl group ◦ CH3 (methyl) ◦ H3CCH2 (ethyl) Release small amount of formaldehyde when curing ◦ amount lessens with length of alkyl chain
  107. 107. Characteristics of Currently Available Adhesive Systems Fibrin Glue Cyanoacrylate Handling Excellent Poor Set time Medium Short Tissue bonding Poor Good Pliability Excellent Poor Toxicity Low Medium Resorbability Good Poor Cell infiltration Excellent Poor