Carry out surgical nursing routines

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Carry out surgical nursing routines

• SUTURES

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Purpose of sutures

• Appose edges of wounds/incisions
• Appose and stabilise muscles, tendons and
  ligaments
• Obliterate dead space pockets
• These accumulate fluid (causing seromas)
• Tie off (ligate) blood vessels

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Presentation

• Peel packets
• /- swaged needles
• Radiation or Gas sterilised
• Cassette reels
• Less wastage
• More risk of contamination

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Opening suture packs

• Peel apart evenly
• Surgeon may grasp, or
• Place onto sterile field (but unsterile hand
  should not pass over the sterile field)

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Opening suture packs
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Opening suture reels

• Draw up straight around 10 cm not touching
  sides
• Potential for contamination
• Of reel container
• Of suture as it is drawn out
• Leave capped until ready for use
• Could spray exposed seal with alcohol

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Whats wrong here?
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The Ideal Suture

• Easily handled and tied
• Minimal tissue reaction
• Minimal risk of hiding bacteria
• High tensile strength
• Good knot security
• Economical
• No allergic, neoplastic reactions etc
• Resorbs after tissue healed adequately

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2 Common Classifications

• 2 characteristics have been chosen for broad
  classification systems
• Structure (filaments)
• Absorption potential

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Classification by structure

• Single filament (monofilament)
• Multiple filaments (multifilament, or braided)

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Filaments

• Single Multiple

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Multifilament

• Advantages
• Relatively strong
• More flexible so easy to handle
• Good knot security
• Disadvantages
• More tissue reaction
• Sawing effect (tissue drag)
• Wicking effect (bacteria drawn from skin to SC)

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Monofilament

• Advantages
• Little tissue drag
• Little wicking effect
• Disadvantages
• Poor knot security (needs more throws)
• Memory (springiness gt difficult handling)

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Classification by absorbability

• When is most strength lost?
• If before 60 days gt Absorbable
• If after 60 days gt Non-Absorbable

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Other characteristics

• Size
• Flexibility
• Surface characteristics (coatings)
• Knot Tensile Strength (stretch breaking)
• Relative Knot Security
• Elasticity (stretch lengthening)
• Tissue reaction
• Capillarity (wicking)
• Memory (springiness)
• Chatter (roughness tying knot)
• Sterilization characteristics

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Size

• Ideally use smallest diameter effective
• No stronger than the tissue it is holding

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4 Size Systems

• Metric
• USP (United States Pharmacopeia)
• 10-0,9-0,8-0,7-0,6-0,5-0,4-0,3-0,2-0,0,1,2,3,4,5,6
  ,7
• There is no 1-0, just 0 !
• USP for catgut
• Safety margin because stated size of catgut is
  unreliable
• Brown Sharpe wire gauge
• For wire sutures

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Sizes
Metric   USP     USP for Catgut   BS Wire Gauge  
0.2 0.3 0.4 0.5 0.7 1 1.5 2 3 3.5 4 5 6 7 8 9 10/0 9/0 8/0 7/0 6/0 5/0 4/0 3/0 2/0 0 1 2 3 4 5 6 7       8/0 7/0 6/0 5/0 4/0 3/0 2/0 0 1 2 3 4     41  38-40 35 32-34 30 28 26 25 24 22 20 19 18
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Flexibility

• Want flexibility for
• Continuous sutures
• Ligating vessels
• Not very flexible are
• Stainless steel wire
• Nylon

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Surface Characteristics

• Determines Tissue drag
• tissue damage gt greater risk of infection
• Multifilament suture materials worse
• Special coatings can reduce tissue drag
• Teflon, silicone, wax, calcium sterate
• But smoother surfaces
• More Slippery knots
• More Stiffness

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Tissue reactivity

• Increasing reactivity
• Stainless steel
• Synthetic monofilament (PDS)
• Synthetic multifilament (Vicryl)
• Natural multifilament (Silk)
• Surgical gut

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Capillarity

• Ability to draw up (wick) moisture
• Multifilament sutures
• have higher capillarity than monofilament
• can also harbour bacteria amongst the filaments
• Greater risk of carrying infections e.g. from
  skin, gut lining etc
• Special coatings can reduce capillarity

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Knot Tensile strength

• Knot is the weak point of the suture loop
• Measured in weight a knot can hold before suture
  breaks

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Relative Knot Security

• Ability of a defined knot not to untie itself or
  break
• Related to tensile strength, memory,
  deformability, surface smoothness

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Absorbable Suture Materials

• Natural
• surgical gut (cf musical instrument gut!)
• Synthetic polymers
• polyglecaprone 25 (Monocryl)
• polyglycolic acid (Dexon)
• polyglactin 910 (Vicryl)
• polydioxanone (PDS)
• polyglyconate (Maxon)

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surgical gut

• Made from sheeps intestine (submucosa)
• Also known as catgut
• Originally violin kit gut gtgtgt catgut
• Breaks down via foreign body reaction i.e.
  inflammation reaction
• Breaks down more quickly if tissue already
  inflamed

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surgical gut

• Is made of collagen (90)
• Tanning (chromicising) reduces the inflammatory
  reaction
• Various grades of tanning
• None (know as plain catgut)
• Mild chromic
• Medium chromic (most common in vets)
• Extra chromic

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surgical gut absorption

Plain 3-7 d Severe reactions
Mild chrom. 14 d
Medium 21 d Most common
Prolonged 40 d
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poliglecaprone 25

• Monocryl
• Monofilament
• Less memory
• Quick resorption

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polyglycolic acid

• Dexon
• Multifilament
• Coated or uncoated forms
• Tissue drag
• Quick resorption

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polyglactin 910

• Vicryl
• Multifilament
• Coated or uncoated forms
• Some tissue drag
• Quick resorption

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polydioxanone

• PDSII
• Monofilament
• Slower resorption than Dexon Vicryl

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polyglyconate

• Maxon
• Monofilament
• Slower resorption than Dexon Vicryl

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Effects of infection

• Natural materials (e.g. Surgical gut) break down
  much more quickly
• All the Synthetic materials are not much affected
  by the presence of infection (or digestive
  enzymes)

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Duration of Absorbables

• Short (resorbed within 2 mths)
• Surgical gut, Vicryl, Dexon, Monocryl
• Medium (resorbed within 6 mths)
• PDS, Maxon

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Non-Absorbable Suture Materials

• By definition retain maximum strength for gt 60
  days

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Non-Absorbable Suture Materials

• polyamide
• polypropylene
• polyester
• polybutester
• stainless steel
• silk

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polyamide

• Little tissue reaction, loses strength slowly
• Monofilament (Nylon, Dermalon, Ethilon,
  Supramid)
• Stiff, slippery, high memory mean difficult
  handling and poor knot security
• Multifilament (Surgilon, Nurolon, Supramid
  Extra, Braunamid, Vetafil)

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Note Vetafil/Braunamid/Supramid

• Are fine for skin surface sutures
• But, because the special coating is often broken
  during the knotting process, their multifilament
  nature carries a high risk of infection when they
  are buried under the skin
• or if any cut ends fall into the wound!
• So, cut ends after whole wound closed

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polypropylene

• Monofilament (Prolene)
• Least reactive suture
• Best suture for skin and vascular surgery
• Doesnt weaken with time (unlike Nylon)
• important for heart transplants!
• But high memory makes handling difficult

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polypropylene
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polyester

• Multifilament (Mersilene , Dacron)
• Easy to handle but may need extra throws for
  added knot security
• Significant tissue drag and reaction
• Chronic infections common
• May be Teflon coated to reduce drag

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polybutester

• Monofilament (Novafil)
• Elasticity and strength make it good for tendons
  and ligaments

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stainless steel

• Very inert - little reaction
• Poor flexibility
• Poor handling, tendency to kink, to cut tissue,
  fragment and migrate
• Monofilament or multifilament
• Diameters based not on USP scale but on Brown
  Sharpe (BS) wire gauge scale

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silk

• Multifilament
• Derived fromsilkworms
• Good handling knot security
• But moderate tissue reactivity
• Also harbours infection readily

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Common Selections

• Skin
• Subcutis
• Muscle Fascia
• Hollow organs
• Tendon and ligament
• Blood vessels
• Eyes
• Nerves

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Skin

• Non-Absorbable
• polyamide (Nylon, Supramid, Vetafil)
• polypropylene (Prolene)
• stainless steel staples

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Subcutis

• Absorbable
• polydioxanone (PDS)
• polyglactin 910 (Vicryl)
• polyglycolic acid (Dexon)

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Muscle Fascia

• Absorbable or Non-Absorbable according to
  longevity required
• polydioxanone (PDS)
• polyglactin 910 (Vicryl)
• polyglycolic acid (Dexon)
• Nylon

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Hollow organs

• Gut, uterus, bladder etc
• Absorbable or Non-Absorbable
• But always want bladder suture to be absorbable
  otherwise likely to produce bladder stones

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Blood Vessels

• Absorbable for small ligations
• surgical gut etc
• Non-Absorbable for vascular surgery
• polypropylene (Prolene)
• Matches elasticity of heart or arteries
• Less reactive (less likely to cause clots)

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Eyes

• Absorbable Non-Absorbable are used

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Nerves

• Non-Absorbable
• Minimal tissue reaction required thus
• polypropylene (prolene)
• nylon

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Autoclaving

• Destroys
• surgical gut, PDS, Vicryl
• Mildly damages
• silk, linen, cotton
• Tolerate at least 3 x autoclaving
• Nylon, polyester, polypropylene, st. steel

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Alternatives To Sutures
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Alternatives To Sutures

• Staples clips
• Ligation (Hemoclip, Versaclip)
• Apposition
• Tissue glue
• Cyanoacrylates (medical super glue)
• Activated by moisture
• Can cause tissue reactions (granulomas)
• Adhesive tapes

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Skin Stapler Staple Remover

• Apply
• Remove

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Suture Removal
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SUTURE SCENARIOS
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Spay

• Ovarian pedicles
• Uterine stump
• Linea alba
• Subcutis
• Skin

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Spay linea alba
external internal muscle sheaths

• Muscle sheaths have all the strength
• Suture sheaths
• Near umbilicus useboth int and extm sheaths
• Near pubis use just ext sheath

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Castration

• Spermatic cord (closed castration)
• Vas deferens
• Testicular vessels
• Subcutis
• Skin

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Hernia

• Umbilical
• Diaphragmatic
• Inguinal
• Perineal

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Exploratory laparotomy

• Linea alba of young healthy dog/cat
• Linea alba of old cachexic dog

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Orthopaedics

• Cruciate rupture
• Extracapsular stabilisation
• Tendon repair
• Ligament repair
• Bone fragment repair

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Manufacturers

• Ethicon

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The End