Sutures

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Sutures
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I. Introduction

• Sutures are probably the largest group of
  devices implanted in humans. Although they seem
  to be of small concern to the medical community,
  few devices have been made of so many different
  materials. By definition, a suture is a thread
  that either approximates and maintains tissues
  until the natural healing process has provided a
  sufficient level of wound strength or compresses
  blood vessels in order to stop bleeding.

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II. History

• Since the beginning of surgical history
  (5000-3000 BC), sutures have been used as the
  means of repairing damaged tissues, cut vessels,
  and surgical incisions. As time has passed, a
  variety of suture materials have been used
  flax, hair, linen strips, pig bristles, grasses,
  mandibles of pincher ants, cotton, silk, the gut
  of an animal, nylons, polyesters, and metals.
  The earliest use of gut can be traced back to the
  ancient Greek physician Galen. The eighteenth
  century brought the use of buckskin and silver
  wire, and the nineteenth brought the ability to
  chemically alter the properties of gut. By the
  twentieth century, cotton and treated natural
  materials have come to be the most widely used
  materials for suturing. After the invention of
  nylon and polyester propagated the popularity of
  cotton and treated natural materials,
  polyethylene, polypropylene, polyglycolic acid,
  polyglactin 910, and a large number of textile
  materials entered into the menu of choices for
  sutures.

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III. Regulation

• The United States Pharmacopoeia (USP) is the
  official compendium for the suture industry. It
  sets standards and guidelines for suture
  manufacture. Suture sizes are given by a number
  representing diameter ranging in descending order
  from 10 to 1 and then 1-0 to 12-0, 10 being the
  largest and 12-0 being the smallest at a diameter
  smaller than a human hair.

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IV. Classification

• Sutures can be classified into one of two
  groups, absorbable and nonabsorbable.
  Absorbable sutures are, as the name implies,
  temporary due to their ability to be absorbed
  or decomposed by the natural reaction of the
  body to foreign substances. It is important to
  note that not all absorbable sutures have the
  same resistance level to absorption, but each
  can be formulated or treated in order to obtain
  a desired decomposition rate. Nonabsorbable
  sutures are, in like manner, sutures that are not
  dissolved or decomposed by the bodys natural
  action. Such sutures are generally not naturally
  occurring materials (with the exception of silk).
  Silk nylon, while being classified as
  nonabsorbable, actually dissolve after a long
  period of time compared to that of the absorbable
  materials

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V. Manufacturing

• Sutures are manufactured with a wide variety of
  parameters. They can be monofilament or many
  filaments twisted together, spun together, or
  braided. They can also be dyed, un-dyed, coated,
  or not coated. With the goal of understanding
  the effects of so many variations of suture type,
  the properties and material of which they are
  composed are and have been studied in depth. The
  use of sutures is one of the most common
  practices in the medical field and thus has
  direct effect on a great majority of the worlds
  population.

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VI. Design

• Currently, sutures are designed to result in the
  most desirable effect for any given situation as
  determined by those administering the sutures.
  Taken into consideration in the manufacture and
  use of sutures are properties such as
  stress-strain relationship, tensile strength,
  rate of retention, flexibility, intrinsic
  viscosity, wettability, surface morphology,
  degradation, thermal properties, contact angle of
  knots, and elasticity. Properties such as
  stress-strain relationship and tensile strength
  have a direct effect on how much force at a
  given rate the closure will be able to withstand.
  For example, a cough would impose a fast rate of
  elongation whereas edema or hemorrhage would
  impose a slow rate of elongation. Knotting
  causes a severe decrease of strength in the
  suture material. Thus when there is a break in
  the suture, it occurs most frequently at the site
  of the knot. As you can see, there are several
  factors biomedical engineers must consider when
  designing sutures.

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VII. Application

• Patient safety, as in every other area of the
  medical field, is one of the major determining
  factors of suture manufacture and use. As
  mentioned before, the composition and
  properties of a suture are the crucial elements
  in the decision of what type to use. For
  example,an incision into the lung would need to
  be closed using a suture with a high elasticity
  level, slow degradation rate, and high tension
  strength level. If a suture is applied in a
  situation in which it is not suitable, the
  patients safety is endangered. In short, a
  surgery is never successful if the wound,
  insertion point, or incision is not sutured or
  closed in a proper manner as to promote healing
  in a timely and safe fashion.
• Another factor to be taken into consideration is
  the effect of inserting the suture into the
  tissue. If the suture is of a rough morphology
  (e.g. braided), the tissue will swell more and is
  more susceptible to infection than if a smooth
  suture (e.g. monofilament) is used. A failure of
  a suture is simply its breaking or not meeting
  the requirements for which it was intended.

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VIII. Testing

• As technology advances, testing techniques
  improve and become more specific for the
  application of sutures. The greatest percentage
  of testing is done on those suture materials
  already existing in practice. This is due to
  the virtual newness of the application of
  testing techniques to the suture product
  although, a fairly small, yet increasingly
  important number of tests are done on possible
  new suture materials.
• The USP determines the procedures and parameters
  for standard suture tests. Sutures are tested
  immediately after removal from their sterile
  packages without drying or conditioning. Sutures
  are tested in a variety of areas including
  accurate measurements, knot pull breaking
  strength, needle attachment, viscoelastic
  properties, tissue reaction and cell response,
  allergenicity and more. In all strength tests,
  it is important to keep in mind that the breaking
  strength retention of absorbable and
  nonabsorbable sutures should be considered
  separately because the strength retention of the
  absorbable sutures will be quite different than
  that of the nonabsorbable suture.

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IX. Technological Advances

• The use and need for a suture is clearly not a
  problem that needs a solution, but a solution
  that needs improvement. Currently there are
  many efforts to improve almost every aspect of
  the suture and its use. Also, new techniques
  for testing make it possible to gain a clearer
  understanding of the properties of sutures.
  This is necessary so that the most efficient
  and best suited suture will be applied in every
  case where a suture is needed. If it were not
  for the technological advances that have occurred
  in society, modern suture production and use
  would not exist and sutures would not be
  dependable.

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ABSORBABLE SUTURES

• Natural

• Natural suture are catgut of biological origin
  and are protein in nature, their absorption and
  digestion is by proteolytic enzymes present in
  tissue fluid. The source is submueosa of sheep or
  serosa of intestine. Their fibres are then chrome
  tanned to delay absorption and twisted under
  tension and polished to achieve monofilament
  profile. Chrome tanning also reduces
  inflammatory response to tissue.
• Serilization is achieved by Gamma radiation or
  ethylene oxide. Packing is done in fluid which
  retains its ideal handling characteristics, the
  fluid is 89 Isopropanol, 10 water and 1
  Triethanolamine.

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ABSORBABLE SUTURES

• Uses
• - Rapidly healing tissue
• - Hysterectomy
• - Caesarian Section
• - General Surgery
• - Ophthalmology

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ABSORBABLE SUTURES

• Natural

• Collagen is also of biological origin from ox
  Achilles tendom rolled monofilament, undyed and
  uncoted.
• Fascia Lata

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ABSORBABLE SUTURES

• Synthetic

• Polyglycolic acid (PGA) is available in two
  forms, the braided form is Dexon while the
  monofilament is Maxon. It is mane made
  homopolymer of glycolide. In monofilament form
  the flexibility in insufficient, therefore,
  braided form is used for general surgical use.
  Recently special coating of monofilament with
  polycaprolacton and glycolide has provided
  sufficient flexibility.

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ABSORBABLE SUTURES

• Uses
• Orthopaedics
• Surgical Oncology
• Debilitated Patients
• Gen/Gyn (Fascia)
• Plastics

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ABSORBABLE SUTURES

• Synthetic

• Polygalactin 910 Vicryl. A man-made copolymer
  of glycolide and lactate, is available in braided
  form. To reduce the tissue drag, the braided
  filaments are coated with calcium stearate,
  glycolide and lactate. Absorption is uniform and
  predictable, commencing at 40 days and complete
  between 60 and 90 days after implantation.
  Strength is greater than P.G.A. especially after
  14 days. The inflammatory response is mild to
  moderate. Sterilization is by ethylene oxide.

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ABSORBABLE SUTURES

• Uses
• - Rapidly healing tissue
• - Episiotomy Repair
• - Skin Closure (except face)
• - Scalp
• - Under casts
• - Intra-oral mucosa

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ABSORBABLE SUTURES

• Synthetic

• Polydioxanone PDS PDS is man-made new
  copolymer, a polyester of paradioxanone, which is
  melt and a monofilament profile is achieved. It
  is the only suture which retains unique
  flexibility in mono filament form. Its strength
  is greater than that of all commonly used
  monofilament sutures other than steel.
• Its monofilament profile makes it particularly
  useful in potentially infected tissues like
  colon, biliary system, stomach etc. Sterilization
  is by ethylene oxide.

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ABSORBABLE SUTURES

• Uses
• - long term healing applications (diabetics /
  oncology)
• - Plastics
• - Orthopaedics

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ABSORBABLE SUTURES

• Synthetic

• Polyglyconate Monocryl it is a man-made
  copolymer of glycolide and caprolactone, in ratio
  of 7225 it has clear, undyed monofilament.
• Uses - Skin / Ob-Gyn / General / Urology
• Polyglyconate Maxon it ia man-made copolymer
  of 1,4-dioxane 2,5-dione and trimethylene
  carbonate monofilament, dyed or undyed.

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NONABSORBABLE SUTURES

• Natural

• Silk It is derived from thread spun by larva of
  silk worm by degumming of surface albumin layer.
  The braided multifilament, dyed or undyed, coated
  or uncoated silk is known for excellent handling
  properties and knot security. Marked inflammatory
  reaction, tissue drag and braiding are its main
  disabilities as braiding induces capillary
  attraction and hence harbor the infective agent
  in interstices. Tissue drag is overcome by
  waxing or silicon coating reducing knot security,
  a third throw is always necessary. Fragmentation
  occurs and all tensile strength is lost by 9
  months Sterilization is by Gamma radiation,
  however boiling and autoclaving may also be used.

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NONABSORBABLE SUTURES

• Natural

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NONABSORBABLE SUTURES

• Natural

• Cotton. It is cellulose in nature and occurs as
  multifilament. Most of the properties are
  similar to those of silk except that strength of
  cotton increases when wet, where as silk loses
  20 of strength when wet. Cotton is cheaper than
  all other sutures. It is available as dyed or
  undyed and uncoated.
• Linen, It derived from falx plant twisted
  multifilament, dyed or undyed and uncoated.

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NONABSORBABLE SUTURES

• Natural

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NONABSORBABLE SUTURES

• Synthetic

• Polyamide "Nylon". It can be monofilament or
  multifilament dyed or undyed, generic name Nylon
  6 or Nylon 66 trade name Ethilon (Uses -
  ophthalmology - Skin Closure) or Dermalon
  (monofilament) and Nurolon (braided) or Surgilon
  (braided nylon).
• Sterilization is by Gamma radiation but can
  tolerate autoclaving up to three times.

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NONABSORBABLE SUTURES

• Synthetic

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NONABSORBABLE SUTURES

• Synthetic

• Polyester monofilament or multifilament, dyed or
  undyed, coated or uncoated trade name Ethibond
  (polybutylate coating) or Tri. Cron (silicon
  coating), and Mersilene orDacron (uncoated).'
  Polyesters are known for having high and
  permanent tensile strength, inducing only modest
  tissue reaction and having good knot security.
  They are widely used in cardiovascular surgery.

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NONABSORBABLE SUTURES

• Synthetic

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NONABSORBABLE SUTURES

• Synthetic

• Polybutylester monofilament, dyed or un-dyed,
  polybutylene terphthalate and polytetramethylent
  ether glycol trade name Novafil. Its "Mesh"
  forms are used for pair of vascular defects and
  Hernias.
• Polyethylene It is available in monofilament
  form as a strong suture, induces minima tissue
  reaction, excellent knotting and handling due to
  its soft surface. Mesh form is also available.
  Progressive loss of strength occurs by
  fragmentation. Sterilization is done by Ethylene
  oxide or Gamma radiation. It melts at 132 ? so
  autocaving can not be done.

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NONABSORBABLE SUTURES

• Synthetic

• Polypropylene monofilament dyed or undyed trade
  name is Prolene. It has a permanent high tensile
  strength, the most inert suture, better handling
  properties of knot security than Nylon. It has no
  memory to untie. Fragmentation does not occur
  within tissues. Its mesh forms are used in the
  repair of prolapse rectum. When used to suture
  blood vessels the blood loss is much less.
  Available in vivid blue colour which facilitates
  visualization during surgery. Sterilization is
  by Ethylene oxide.

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NONABSORBABLE SUTURES

• Synthetic

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NONABSORBABLE SUTURES

• Synthetic

• PVDF. (Polyvinylidene fluoride) monofilament,
  dyed or undyed. Its trade name is Trofilene.
• Uses Peripheral Vascular
• Coronary Artery Bypass
• (Skin stage two)

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NON ABSORBABLE METAL SUTURES.

• Stainless steel. Maintain tensile strength
  indefinitely- Monofilament or muftifilament.
• i. Vitadium
• ii. Tantalum
• iii. Silver
• D. SURGICAL STAPLES AND CLIPS
• i. Absorbable. The concept of
  Viscerosynthesis.
• ii. Non-Absorbable

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SURGICAL NEEDLES

• Requirements to surgical needles
• Minimal tissue trauma
• High sharpness (acuity)
• Corrosion resistance
• High strength
• Stable shape
• Abrasion resistance
• Smooth profile

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• Surgical needles are divided in two groups
• Traumatic needles
• Atraumatic needles

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• Traumatic needles - are needles with holes or
  eyes which are supplied to the hospital separate
  from their suture thread. In traumatic needles
  with eyes, the thread comes out of the needle's
  hole on both sides. When passing through the
  tissues, this type of suture rips the tissue to a
  certain extent, thus the name traumatic.

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• Atraumatic needles with sutures - comprise an
  eyeless needle attached to a specific length of
  suture thread. Important thing is that the suture
  end of a swaged needle is smaller than the needle
  body.
• Atraumatic needle with attached suture thread

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THANK YOU FOR ATTENTION!