SUTURE MATERIALS AND SUTURE PATTERNS .

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SUTURE MATERIALS AND SUTURE PATTERNSI-NEEDLES1-Classification According To The Eye: -A-Closed eye needle: -It
resembles the household sewing needle with one or two eyes. Double
strand of the suture passes through the tissue and causes much trauma.B-Swaged-on needle (Eyeless or Atraumatic needle): -It is permanently attached to the suture, and causes minimal trauma of the tissue.2-Classification According To The Body Or The Shaft: -A-Straight needle or long stemmed needle: -Like flessa needle or household sewing needle. It is no longer be used.B-Half curved needle: -Half of the needle is curved and the other half is straight.C-Curved needle: -It is ¼, 3/8, 1/2, or 5/8 circle, and it is the most famous type of needles.D-Hock needle (Heavy bound bodied): -The needle resembles hock.3-Classification According To The Point And The Shaft: -A-Conventional cutting or conventional sharp needle: -The point is sharp with the cutting edge being provided at the concave surface.B-Reverse cutting or reverse sharp needle: -The same as above but the cutting edge is provided on the convex surface to minimize cutting of the tissue.C-Taper cut needle: -The point is cutting but the body is round.D-Non-cutting needle (round needle): -The point is round and the body is oval, and it causes minimal traumatization of tissue.E-Blunt point needle (Ethiguard blunt taper point): -The tip of point is blunt.F-Spatulated needle: -This type of needle has wide body in relation to the length of the needle and it has two cutting edges.II-SUTURE MATERIALSSuture
materials are those filaments used to suture the edges of the wound to
permit healing. They should maintain their strength until the wound has
healed, have minimal tissue reaction, not favorable for bacteria
growth, non-capillary, non-allergic, non-carcinogenic, easily handled,
with good knot security, and cheap. Unfortunately, ideal suture
material has not been found yet and surgeon should be familiar with
advantages and disadvantages of suture material to be used.1-Absorbable Suture Materials: -A-Surgical catgut: -It
is a popular cheap suture material of collagen obtained from the
submucosa of sheep or serosa of beef intestine, sterilized by gamma
radiation and preserved in 85% alcohol, and can't be re-sterilized.
Plain catgut loses its strength rapidly (3-7 days) and so it can't be
used in certain regions. Chromic catgut is obtained by exposure of
plain catgut to chromium salts, that increases strength of the
filaments, decreases tissue reaction, and prolongs duration of
absorption (10-20 days). Factors affect absorption rate:1-The diameter of the filaments 2-Exposure to gastric enzymes3-Infection 4-Blood supply As
the knot-holding ability decreases when the suture material is wet, the
ends should be left slightly longer to minimize the chance of knot
untying. However, this type of suture material is a protein and has
high tissue reaction when compared with synthetic forms.B-Collagen: -It is a natural suture material related somewhat to catgut, and obtained from the flexor tendons of steers. Advantages:1-Smoother 2-Causes less inflammation than catgut3-More uniform than catgut 4-It has less fray tendency and used mainly in ophthalmic surgeryC-Polyglycolic acid (Dexon®) and Polygalactin 910 (Vicryl®): -They
are synthetic, polymers, multifilament, containing no proteins,
absorbable suture materials, and have minimal tissue reaction when
compared with catgut. They handle like silk and do not swell when they
are wet. They drag through tissues and cut soft organs, so they are
coated with absorbable lubricant to make them smoother, however,
dragging can be considered as advantage when continuous suture patterns
are used, as the suture material will not be slide out of the tissue.
Polyglycolic acid (Dexon®) is absorbed after 40-60 days while and
Polygalactin 910 (Vicryl®) is absorbed after 90 days.D-Polylactic acid: -It is a mono or multifilament, synthetic polymer, absorbable suture material (over 1 year).2-Non-Absorbable Suture Materials: -A-Silk: -It
is a protein filament produced by silkworm, braided, dyed, and coated
with wax or silicone. It is used mainly for suturing of the skin, but
it can't be used in infected wound because of its capillarity action.
Its absorption is so slaw and when used internally it may last years to
disappear. A synthetic form of silk was manufactured like Mersilk®.B-Cotton: -Advantages:Lower possibility of laceration so it is used for treatment of vaginal or uterine prolapse (vaginal tape)Disadvantages:It is a plant origin filament that has a higher tissue reaction and higher possibility of infection than silkC-Nylon (Dermalon®, Ethilon®& Nurolon®): -It
is a synthetic, inert, polymer that has poor knot security.
Monofilament (Dermalon®, Ethilon®) is preferred than multifilament when
infection of the wound is expected although the multifilament braided
nylon (Nurolon®) has some degree of roughness, better knot retention,
and better handling properties.D-Polypropylene (Prolene®) and Polyethylene: -They
are polyolefins that are usually represented in monofilament form. They
have greater knot security and better handling than nylon. They are
preferred than braided synthetic materials in infected wounds and can
be absorbed over two yearsE-Polymerized caprolactam (Supramid ®& Vetafil®): -It
is a synthetic multifilamentous suture material made from materials
related to nylon and coated to minimized capillarity, so it can be used
for suturing of skin but it has poor knot security compared with silk.
Like all multifilamentous suture materials, it shouldn't be used in
infected wounds.F-Polyesters: -It
is multifilamentous polyester that consists of Dacron, which may be
plain or uncoated (Mersilene® & Dacron®), Teflon-coated Dacron
(Polydek®) or polybutylate-coated Dacron (Ethibond®), or
Teflon-impregnated Dacron (Tevdek® & Ethiflex®). The uncoated form
has more tissue drag, more capillarity action, and higher knot-holding
ability than coated or impregnated forms. It must not be used in
infected wound.G-Stainless steel: -It
is a non-reactive, monofilament or multifilament of iron alloy
(iron-nickel-chromium), difficult to be handled because it kinks, and
it has good knot security but the knot tends to be bulky. It can be
re-sterilized but it has great tendency for cutting the tissues or the
gloves.Considerations in choosing suture materials: -1-Physical Properties: -A-Durability: -Durability of the suture in the wound is affected by many factors like; 1-The diameter of the filament The smaller the diameter of the filament, the faster the absorption and the lower the durability2-Exposure to gastric enzymesExposure to gastric juice increases absorption rate and decreases durability.3-InfectionPresence
of infection increases the rate of absorption and decreases durability,
as the body will get rid of the suture materials rapidly, so one should
choose suture materials of low absorption rate. 4-Blood supply of the woundThe
higher the blood supply the greater the rate of absorption and the
lower the durability, as the body will get rid of the suture materials
rapidly, so one should choose suture materials of low absorption rate.

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5-Rate of healing 6-Tension of the suture line The
wounds with high healing rate and low suture line tension need less
durable suture materials, while those with slow healing rate and high
suture line tension, need more durable suture materials.B-Handling ability and knot security: -Good
suture material should has good handling ability, minimal capillarity,
and good knot security, unfortunately, there is no suture material yet
has all phenomena.C-Sterilization: -Most of suture materials are represented already sterile. Ethylene oxide gas: - It is a suitable method of sterilization of all suture materials.Autoclaving: -It
is a suitable method of sterilization of most suture materials (except
for catgut), but multiple autoclaving for more than three times reduces
the strength of the suture material. Gamma irradiation: - Gamma irradiation adversely affects polyglycolic acid and polypropylene. 2-Biological Properties: -Tissue reaction ensues as a result of; 1-Traumatization of the tissue by the needle, so atraumatic needle is preferred.2-Dragging of the suture material, so monofilament suture materials are preferred than multifilament3-Chemical
structure of the suture material, as most of synthetic absorbable
materials hydrolyzed into chemical components that adversely affect
multiplication of bacteria controversial to catgut, which is a protein
that is suitable for bacterial growth.4-Physical
structure of the filament, as monofilament suture materials are
preferred than multifilament materials as the former has lower chance
of keeping microorganism inside it than the later.III-SUTURE PATTERNS1-Basic Suture Patterns: -A-Simple interrupted suture: -Technique:It
is a simple pattern by which the needle is inserted perpendicular at a
right angle at one side of the wound (1 cm far from the edge of the
wound in large animals and 3 mm in small animals), passes through the
wound, drown to the other side of the wound at the same distance, and
the two free ends knotted, so this pattern opposes the skin. This
pattern is used in tissues that will not be subjected to a lot of
tension. Advantages: 1-Simplicity 2-Opposition of the skin 3-When a knot is untied; the other sutures maintain the strength of the suture lineDisadvantages: 1-Time consuming because of the high number of knots 2-Consuming of large amount of silk material3-Not suitable for areas subjected to tensionB-Simple continuous suture: -Technique:It
is the same as simple interrupted but it has only two knots, one at the
beginning and the other at the end of the wound. This pattern is used n
tissues that will not be subjected to a lot of tension. Advantages: 1-Simplicity 2-Opposition of the skin 3-It is performed faster than simple interrupted pattern 4-Consumption of lesser amount of silkDisadvantage: 1-When one stitch is untied, the strength of the suture line can't be maintained2-Not suitable for areas subjected to tensionC-Continuous lock stitch (Ford interlocking suture): -Technique:It
is a modification of continuous suture pattern. After the needle is
inserted perpendicular on the wound and being drawn from the other
side, it is drawn through the performed loop and tightened.Advantages: 1-Simplicity 2-Opposition of the skin 3-Relative maintenance of the strength of the suture line when one stitch is untiedDisadvantage: 1-It is not as simple as the previously mentioned patterns2-Time consuming than simple continuous pattern3-Not suitable for areas subjected to tension

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D-Horizontal mattress suture: - Techniques:The
needle passes through the right side of the wound and drawn from the
left side, then about 1 cm lower to the site where the needle was
drawn, the needle is reinserted and passes to the right side again,
thus, two pieces of the silk can be seen parallel to the incision. The
needle should be inserted with angle through the skin to prevent
eversion of the skin. This pattern can be used in an interrupted or
continuous manner.Advantages: It can be used in areas where much tension is placed on the skinDisadvantages:It interferes with blood supply to the skin and interferes with healingE-Vertical mattress suture: -Technique:In
this type of suture pattern, the needle is inserted 1.5 cm far from the
wound edge in the right side, passes through the wound and drawn 1.5 cm
from the left side of the wound, then the needle is reinserted 0.75 cm
from the left side (medial to the site where it was drawn) and passes
to the right side through the wound, then it is drawn 0.75 cm from the
wound edge (medial to the 1st bite). This type of suture can be used in
areas where much tension is placed on the skin. Two silk lines
perpendicular on the suture line can be seen, one on each side of the
wound.Advantages:It doesn't interfere with blood supply of the skin like horizontal type.Disadvantages:It consumes much suture material and more time.F-Cruciate suture (Cross mattress): -Technique:In
this type of suture, the needle is inserted 1 cm from the edge of the
wound on the right side, passes to the left side, drawn 1 cm form the
wound edge, then the needle is reinserted 1 cm below the 1st bite on
the right side and 1 cm from the skin edge, and passes through the
wound to the left side and drawn 1 cm ventral to the 2nd bite on the
left side and 1 cm lateral to the wound, and finally the two free ends
are knotted.G-Near-far-far-near suture: -Technique:This
type is a mixture of cross mattress and vertical mattress sutures. The
needle is inserted 0.75 cm from the wound edge on right side and drawn
1.5 cm from the left side with 0.5 cm higher level, then the needle
passes to the right side in the same level, and inserted 1.5 cm far
from the wound edge, then drawn 0.75 cm from the wound edge (on the
left side) at 0.5 cm lower level. Finally, two silk lines can be seen
perpendicular on the wound, the upper long one is about 0.5 cm higher
in level than the lower short line.Advantages: It is a good tension sutureDisadvantages: It is a time consuming sutureH-Subcuticular suture: -Technique:This
type of suture is used to avoid the small scars produced around suture
holes in other patterns. The needle is inserted into the subcutaneous
tissue in the apex of the wound and passes to the other side and a
knots is tied subcutaneously, then the suture is advanced like
continuous horizontal mattress, but the needle is inserted in one side
and drawn at lower level in the same side, the advanced to the other
side and inserted then drawn at lower level till the end of the wound.
No suture materials can be seen after suturing of the wound and the
knots should be subcutaneous.2-Suture Patterns For Hollow Organs: -These
patterns are either opposing or inverting patterns and can be applied
in as single or double rows. Single row patterns have high incidence of
leakage, dehiscence, adhesion and peritonitis, while double row
patterns associated with high incidence of stenosis. Whither single row
or double row is the best, stills questionable.A-Lembert suture: -Technique:This
pattern can be used in an interrupted or continuous manner. The needle
passes through the serosa, muscularis and submucosa but it doesn't
involve the mucosa. The needle is inserted perpendicular on the wound
0.8 cm from the wound and passes the mentioned layers then it is drawn
0.4 cm from the wound edge in the same side, then it passes to the
other side and inserted 0.4 cm and drawn 0.8 cm from the wound edges.
Only one line of the suture material can be seen perpendicular on the
wound.Advantages: It
is the simplest pattern for the internal organs, relatively rapidly
performed, inverts lips of the wound, and never involves the mucosa so
the possibility of contamination is low.Disadvantages: It produces slight stenosis of the bowel.B-Halsted suture (interrupted Quilt): -Technique:It
is a modification of Lembert pattern. The needle is inserted
perpendicular on the wound 0.8 cm from the wound edge of the right side
and drawn 0.4 cm from the edge in the same side, then it passes to the
left side (in the same level) then it penetrates 0.4 cm from the wound
edge and drawn 0.8 cm from the edge. At the left side and with a lower
level (0.4 cm) the needle is inserted 0.8 cm from the edge and drawn
0.4 cm, then it passes to the right side and inserted 0.4 cm from the
edge and drawn 0.8 cm. Two lines of suture material can be seen
parallel to the wound (one on each side).

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C-Interrupting inverting mattress suture: -Technique:This
pattern is similar to the horizontal mattress suture. The needle is
inserted 0.5 cm from the wound edge parallel to the wound, penetrates
muscularis, and passes downward for 0.5 cm, then drawn. At the same
level where the needle is drawn (but on the other side of the wound)
the needle is reinserted 0.5 cm from the wound edge, penetrates
muscularis, and passes upward, then drawn at the same level of the 1st
bite. Two lines of suture material can be seen perpendicular on the
wound, parallel to each other's, and of the same length.D-Cushing suture: -Technique:It
resembles inverting mattress suture but it is performed in continuous
manner, and the mucosa is not involved. The needle is inserted 0.4 cm
from the wound edge and passes parallel to the wound for 0.4 cm and
drawn, and then it passes to the other side at the same level and re
inserted in a manner similar to subcuticular suture. E-Connell suture: -Technique:It resembles cushing suture, but the needle passes all intestinal layers, so the possibility of contamination is higher.F-Schemieden's suture: -Technique:It
is an inverting suture pattern that doesn't involve the mucosa.
Stitches are brought through from inside the gut into the muscularis
and drawn from the serosa.G-Simple interrupted suture: -Technique:It
involves the mucosa and can be performed in two manners, either simple
interrupted that doesn't interfere with circulation, or crushing manner
that interferes with blood supply.H-Gambee suture: -Technique:In
this pattern, the needle is inserted 0.5 cm from the edge of one side
into the serosa and drawn form the mucosa, then it passes to the mucosa
of the same side and drawn from the submucosa, then it passes to the
submucosa of the other side, and drawn from the mucosa, then passes
from the mucosa to the serosa.I-Parker-Kerr oversew: -Technique:It
is a mixture of cushing flowed by Lembert pattern. A haemostatic
forceps is applied perpendicular on the hollow organ, the organ is
severed, then a layer of cushing is applied, the forceps is removed,
then Lembert pattern is applied.J-Purse string suture: -Technique:This
pattern can be used to close small holes used to evacuate gas from the
bowel or to keep cannulae in situ, but it is mostly used with anus to
retain rectum during rectal prolapse. The needle is inserted parallel
to the anal opening, 1.5 cm far, and advances subcutaneously for 1.5 cm
then drawn, then reinserted with the direction of watch 360 degree,
then the two ends of the suture material are tied.3-Suture Patterns For Severed Tendons: -A-Bunnell suture: -Technique:Most
of suture materials are kept inside the tendon to maintain the gliding
function of the tendon and the suture is parallel to the tendon. Double
round needle suture materials are used in this pattern. One needle is
inserted at considerable distance from the edge of the severed tendon
at right angle, then the needle is reinserted 0.2 cm far to this site
in diagonal or oblique direction toward the other surface of the tendon
and drawn at a point about 40% of the left distance, the same needle is
reinserted 0.2 cm far and diagonally to be drawn at about 80% of the
left distance and on the original surface. The other needle is advanced
in the same manner, so finally an eight figure is formed inside one end
of the tendon. All what u can see are four 0.2 cm long suture material
parallel to the tendon (2 at each surface). In the other side of the
severed tendon, the two needles are advanced from the end of the tendon
and in the same mentioned manner.B-Locking-loop tendon suture: -Technique:The
needle is inserted through the cut surface of the tendon and advanced
in the tendon to a considerable distance then drawn from one surface,
at a point 0.3 cm lower and lateral to the point of puling of the
needle, the needle is reinserted and passes perpendicular on the tendon
then drawn from the same surface. The needle is reinserted 0.3 cm
higher and medial to the point of drawing, and then the needle is
advanced parallel to the tendon and drawn form the cut edge at the same
level of the 1st bite. The needle is advanced in the other side of the
severed tendon in the same manner and the knot is made in the cut
surface of the tendon.