SUTURES

By

Dr. OYEBODE OYEYIOLA

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FEDERAL MEDICAL CENTRE ,AZARE
July 6, 2018
OUTLINE
• INTRODUCTION
• CLASSIFICATION
• INDICATION AND USES
• COMPLICATIONS
• NEEDLE AND PROPERTIES
• SUTURING TECHNIQUE AND NEW
ADVANCES
• ALTERNATIVES TO SUTURES
• CONCLUSION
• REFERENCES
 INTRODUCTION
• Suture is any strand of material used to approximate tissue or ligate
vessels.

• HISTORY:
Sutures - horsehair, linen ,silk, tendon, arteries, muscle strip ,animal
intestines and wire.
Needles- bone or metal( silver ,copper, alluminium bronze).
• Earliest report of surgical suture :3000BC in ancient egypt.
• SUSHRUTA (Indian sage and physcian): detailed description of a
wound suture and suture material used written in 500BC.
• HIPPOCRATES(greek father of medcine): described suture
techniques as did the later Roman AULUS CORNELIUS CELSUS.
• ABULCASIS: in 10th century catgut suture along with surgery
needle were developed.
• JOSEPH LISTEN: routine sterilization of suture threads
 TERMS
TERMS
Breaking
DEFINITION
Limit of tensile strength at which suture failure occurs.
strength
Knot pull Breaking strength of knotted suture material . Sutures are 10-40% weaker
tensile after deformation by knot placement.
strength

Knot Amount of force needed to cause a knot to slip. This is related to the
strength coefficient of static friction and plasticity of a given material.
Straight Linear breaking strength of suture material.
pull tensile
strength

Suture pull Measures strength of a particular tissue. Application of force to a loop of

out value suture where tissue failure occurs. Varies with anatomical site and
histologic composition.

Tensile Measure of the ability of a material or tissue to resist deformation and

strength breakage.
Wound Limit of tensile strength of a healing wound at which separation of
breaking wound edges occurs.
strength
 TERMS- NEEDLE
TERMS DEFINITION

Strength Resistance to deformation during repeated passes.

Ductility Resistance of a needle to breakage under a giving amount

of deformation or bending.

sharpness Measure of ability of a needle to penetrate tissue.

Factors affecting sharpness include the angle of point
and the taper ratio.

Clamping moment Stability of a needle in a needle holder, determined by

measuring interaction of the needle body with the jaws of
the needle holder.
 IDEAL SUTURE
• Lord Moynihan(1865-1936) . Yet to be created. Modern
sutures increasingly approach this ideal.
1-Completely inert/non-allergenic/little or no tissue
reaction
2-No adverse effect on tensile strength of the wound.
3- High tensile strength retention during wound healing.
4-Uniform tensile strength
5-Resistant to infection/not harbor micro-organisms
6-Should disappear as soon as function is accomplished.
7-Knot security-no sllipage ,no breakage
8-Suitable for all purposes (surgical procedures)
9-Minimal tissue injury
10-Easy to handle
 SIZES
• Size is the diameter of the suture.
• Appropriate size must be used.
• Measuring scale:
• -metric units( tenths of a millimeter) or
• -USP(United State Pharmacopoeia’s)
• -EP(European pharmacopoeia) 0.1-8
• USP Scale runs from 11-0(smallest) to 7 (largest)
• The lesser the number of O’s the thicker the suture.

• 11-O 5-O O 3 7
(Smallest) (largest)
Suture size and strenght
CLASSIFICATION
1-BASED ON DISSOLUTION: absorbable &
non-absorbable.
- Absorption process may be by hydrolysis which
is commoner( e.g dexon) or Enzymatic
digestion( e.g catgut)
2-BASED ON ORIGIN: Natural & Synthetic.
3-BASED ON NATURE OF SUTURE:
Monofilament(e.g dermalon) & Multifilament-
which is usually braided or twisted (e.g surgilon,
vicryl, dexon , silk)
4-BASED ON TEXTURE: Smooth & Barbed
ABSORBABLE- advantage/disadvantage

• Absorbable suture require no removal

• Potential advantage of synthetic absorbable:
-predictable loss of tensile strength (50% in 28-56
days)
-good handling ability
-less potentiation of sepsis than catgut
-less severe inflammatory reaction than other
biodegradable sutures –undergo hydrolysis rather
than proteolytic digestion. In a sense catgut is
actually getting obsolete.
 ABSORBABLE- Disadvantage

• In patients with fever, infection, poor nutritional

status, absorption of absorbable suture may accelerate
and lead to premature diminiture of tensile strength.

• If exposed to moisture such as ascites absorption rates

are accelerated.
 ABSORBABLE SUTURES- natural
1. CATGUT- natural, sheep intestine or serosa layer of cattle
intestine. TYPES- plain , chromic.
• a-Plain Catgut: twisted ,dried & sterilized. Intense inflammatory
reaction , impairs wound tensile strength. Digested 5-6 days. Loose
tensile strength in 3-6 days.
• b-chromic catgut: tanned with chromic acid before sterilization.
Tissue reaction less than plain catgut. But sufficient to depress
wound tensile strength. Loose tensile strength in 21 days.(about
time absorbed)
• For reapproximating mucosa or peritoneal edges but lack strength
for fascial closure.

2. RECONSTITUTED COLLAGEN-natural. From sheep mucosa

or cattle tendon. Similar features to catgut but more predictable
pattern of tensile strength weakening. Used as fine suture in the eye
 ABSORBABLE SUTURE- synthetic
• Polyglycolic acid(dexon), polyglactin acid(vicryl),
polyglecaprone(monocryl), polydiaxonone(PDS, Quill),
polyglyconate(maxon)

• 1. POLIGLECAPRONE 25(MONOCRYL)-retains 50% of tensile

strength after 2wks. Should not be used to approximate abdominal wall
fascia.
• 2. POLYGLACTIN(VICRYL) & POLYGLYCOLIC
ACID(DEXON)-frequently used to ligate pedicle during hysterectomy.
Can be used to close transverse incision in healthy patients. Though
monofilament suture prefered by most surgeons for fascial closure of a
transverse incision.
-vicryl may be coated or uncoated.
-Vicryl Rapide: treated or coated for more rapid breakdown. Loose
tensile strength in 7-10 days. For rapidly healing wound such as mucosa
membrane, where only short term wound support is require.(7-10 days)
 ABSORBABLE -synthetic
• 1. POLYGLYCONATE(MAXON) &
POLYDIOXANONE(PDS)- Both invoke tissue
reaction. maintain 50% of their tensile strength at
4wks. Often used in midline incision closure in
gynaecology. They are DELAYED ABSORBABLE
SUTURES. Found to be safe and efficient in mass
closure of all layers of abdominal wall.
• 2. QUILL-a LONGER LASTING ABSORBABLE
SUTURE. Typically used for deeper tissue closures and
subcuticular closure. Has a helical barbed design that
does not require tying knot to secure the suture. Trials
in minilaparotomy myomectomy .
 NON-ABSORBABLE SUTURES- natural
• 1. SILK-natural, from silk worm. Multifilament. An animal protein , excites
moderate tissue reaction. May fragment and be extruded. Tensile strength
progressively lost. Multifilament nature-harbor infection, wick-lie action when
used as skin suture.
• 2. COTTON-natural , from cotton plant. Cause greater tissue reaction than
silk . Tensile strength diminishes more rapidly than silk. Reaches 50% in 2yrs.

• 3. METALIC SUTURES-Stainless steel wire & aluminium wire.

• -(i)STAINLESS STEEL WIRE: remarkably inert, retain tensile strength for
long period. Disadvantage is difficulty knotting & also it may eventually,
fragment and cause undue pain.
• -(ii)ALLUMINIUM WIRE: Equally inert, found to retain its tensile strength
for much longer. Advantage – tensile strength of wound sutured with
alluminium rises more rapidly & remains consistently higher long after suture
removed . Believed to be an electrochemical effect of the metal on tissue fluid
NON-ABSORBABLE- SYNTHETIC
• 1. NYLON(DERMALON)- only slight inflammatory
reaction. Remains intact and maintains tensile strength
almost indefinitely. Disadvantage: poor handling ability and
knot tend to slip. Braiding in form of
multifilament(SURGILON), improves this. But multifilament
nylon on the other hand causes severe tissue reaction , looses
its tensile strength more rapidly. May also harbor bacteria.
• 2. POLYPROPYLENE(PROLENE)- Little tissue reaction
to this suture but may occasionally fragment. Its tensile
strength is on the whole retained much longer than obtains
with nylon.
• 3. DACRON,TEFLON,ORLON- Very little tissue reaction
holding on to their tensile strength over long periods. They
are preferred to nylon in this respect.
Monofilament Multifilament (braided)
• Single strand of suture material • Fibers are braided or twisted
• Minimal tissue trauma together
• Smooth tying but more knots • More tissue resistance
needed • Easier to handle
• Harder to handle due to memory
• Fewer knots needed
• Examples: nylon, monocryl,
prolene, PDS • Examples: vicryl, silk, chromic

• PSEUDOMONOFILAMENT:
Braided core material coated with
extruded material.
-Fair flexibility, less tissue drag,
low knot security.
SUTURE SELECTION - principle
• Smallest suture that adequately holds wound edges.
• Tensile strength of suture should not exceed tensile
strength of tissue. Should be closely matched.
• As wound heals, relative loss of suture strength overtime
should be slower than gain of tissue tensile strength.
• Non-absorbable for slowly healing tissue e.g fascia , tendon
• Absorbable for rapidly healing wounds e.g mucosal surface
• Aesthetic concern( e.g head & neck)- less concern on tensile
strength. Smaller suture size preferred.
• Potential contaminate tissue- smallest inert monofilament
suture.
Suture Sizes Indication
 GOALS/ USES OF SUTURES
• 1. Closure of dead space
• 2. Supporting and strengthening wounds until healing,
increasing their tensile strength.
• 3. Approximation of skin edges for aesthetically
pleasing and functional result.

• EXAMPLES OF PROCEDURES: secure drain e.g

after a myomectomy, cervical cerclage( mersilene tape
in mac donald procedure, purse string), management
of PPH( B-Lynch ), episiorraphy, caesarean section,
amputation, tubal ligation
Contraindications & Precautions to suturing
CONTRAINDICATIONS:
- Features of inflammation and infection: Redness,
Edema of the wound margins, Fever
-Puncture wounds
-Animal bites
-Tendon, verve, or vessel involvement
-Wound more than 12 hours old (body) and 24 hrs
old (face)
COMPLICATIONS
• Hypertrophy scar
• Wound dehiscence
• Wide scar
• Knot slipage/ breakage
• Cross hatching(rail tracks)
• Infection
• Suture reaction
• Stitch granuloma
• Hypersensitivity reactions
• Slow wound healing
NEEDLE SELECTION
• No standardized sizing system / nomenclature for
needles
• Taper point needles sufficient for easily penetrated
tissue while cutting needles are used for tough tissue.
• General rule; taper point needle may be used for
all closure, except skin.
• Length, diameter & curvature of needle influence
surgeons ability to place suture
• Ideally needle body, diameter matches suture size.
NEEDLE TYPES : 3 parts: point, body,swage
point body swage

1. cutting 1. straight 1. channel

2. Taper-point(round) 2. Half curved ski 2. drill

3. beveled 3. Curved 3. Non-swage

4. blunt 4. Compound curve

NEEDLE
NEEDLE -cutting
• CUTTING NEEDLE- Atleast 2 opposing cutting edges. Sharpness
due to cutting edge. For dense irregular, relatively thick tissue.
Ideal for skin. 3 types:

-CONVENTIONAL-Triangular crossection,3rd cutting edge on

inner concave curvature (surface seeking)
-REVERSE-3rd cutting edge on outer convex curvature (depth
seeking). For tough tissue like skin,tendon. Stronger than
conventional needles, and reduced risk of cutting out tissue
causing minimal trauma. Hence also useful in ophthalmic surgery.
-SIDE (SPATULA)- flat on top and bottom surfaces to reduce
tissue injury. Allow maximum ease of tissue penetration as they
pass through and between tissue layers. Initially for ophthalmic
procedures.
NEEDLE- taper, blunt
• TAPER-POINT(ROUND) NEEDLE: Penetrate
and pass through tissue by stretching without
cutting. Sharp tip at point flattens into an oval or
rectangular shape. Sharpness determined by the
taper ratio(8-12:1) & tip angle(20-35 degrees).
Needle is sharper if it has higher taper ratio and a
lower tip angle . Used for easily penetrated tissue
e.g abdominal viscera, subcutaneous tissue.

• BLUNT POINT NEEDLES: Dissect friable tissue

rather than cut it. Point are rounded and blunt.
Ideal for suturing liver and kidney. Reduces needle
stick injuries.
NEEDLE –beveled conventional cutting
• BEVELED CONVENTIONAL CUTTING:
performance characteristic is supperior to other
conventional cutting needle.
• Composed of unique stainless steel ASTM 45500
that has been heat treated after the curving
process to enhance its resistance to bending.
• Angle of presentation also reduced to increase
the sharpness.
• Recommended for closure of lacerations.
NEEDLE-body
• The body of the needle interact with the needle holder.
Transmits force to point. Types include:
• STRAIGHT BODY- Easily accessible tissue . e.g Keith needle
used in abdominal skin closure.
• HALF CURVED SKI NEEDLE: difficult to handle, straight
portion of body does not follow curve point resulting in enlarge
curved point.
• CURVED NEEDLE: Predictable part through tissue and
requires less space for maneuvering compared to straight
needle. Semicircular part is ultimate course. Provide even
tension distribution. e,.g o.375 use in skin closure, 0.5-in used
in confined spaces.
• COMPOUND CURVE NEEDLE: Originally for anterior
segment ophthalmic surgery. Also used in microvascular
surgery. Tight 30 degrees at tip becomes 45 degrees through
out rest of body
NEEDLE-SWAGE
• Suture attachment end creates single continious unit of
suture and needle known as swage.
• 3 types: channel , Drill, Non-swage
• Channel : suture inserted in channel of needle &
needle is crimped over the suture to secure it in place.
Diameter of channel is greater than diameter of needle
body.
• Drill: material removed from needle sometimes with
laser. Diameter of drill swage less than diameter of
body.
• Non-swaged: suture may be passed through an eye
similar to sewing needle. Disadvantage- passage of
double strand of suture through tissue leads to more
tissue trauma. Also easily unthreaded prematurely.
NEEDLE -MEASUREMENT
• CHORD LENTH(BITE WIDTH): is the
linear distance from point of curve needle to the
swage.
• NEEDLE LENGTH: distance measured along
needle from point to swage. It is the length on
suture packages.
• RADIUS OR BITE DEPTH: distance from
body of needle to centre of circle along which
needle curves.
• The diameter is considered the guage or
thickness of the needle.
measurement
INFORMATION ON OUTSIDE
Latest advance in sutures
• Knottless barbed sutures
• Antimicrobial sutures
• Bioactive sutures e.g stem cells seeded
sutures, drug-eluting sutures
• Smart sutures including elastic and
• Electronic sutures

• These new strategies expand the versatility of sutures

to a more biologically active component ,enabling
delivery of drugs and cells to the desired site with
applications in both therapeutics and diagnostics.
LATEST ADVANCE IN SUTURES
SUTURING TECHNIQUE
• Choice of suture technique depend on :
1-Type and anatomic location of wound.
2-Thickness of the skin
3-Degree of tension
4-Desired cosmetic result
5-Proper approximation

• Effective suturing technique depends on appropriate

selection of suture , knot technique, surgical gloves,
needle and needle holder.
SUTURING TECHNIQUES
Continous Interrupted
1. Simple running sutures 1. Simple interrupted sutures
2. Running locked sutures. 2. Vertical mattress suture
3. Running horizontal mattress suture 3. Half-buried vertical mattress suture
4. Running subcuticular sutures 4. Pulley suture
5. Running subcutaneous suture 5. Far-near, near-far modified vertical
mattress suture
6. Running subcutaneous corset 6. Horizontal mattress suture
plication stitch
7. Half buried horizontal suture
8. . Dermal subdermal suture
9. Buried horizontal mattress suture.
10. Variation of tip(corner) stitch
 SUTURING TECHNIQUE
• RUNNING SUBCURTICULAR : Absorbable suture is
placed at dermal epidermal junction . Used where tension
is minimal and dead space has been eliminated and best
possible cosmetic result is desired. Eliminates risk of cross-
hatching. Does not provide significant wound strength.
Reserved for wound in which tension has been eliminated
by deep sutures and wound edges are of approximately
equal thickness.
• SIMPLE INTERRUPTED: Easy to place, have great
tensile strength ,less potential wound edema and impaired
cutaneous circulation. Allow for adjustment to align wound
edges. Disadvantage include length of time required, cross
hatch marks(train track) which can be prevented by
removing sutures early.
Subcuticular suture
 SUTURING TECHNIQUE
• SIMPLE RUNNING (CONTINOUS): single line of suture
used without cutting. For long wounds in which tension has been
eliminated or minimized by deep sutures and has good
approximation of edges. E.g skin graft.
• Advantage- causes less scarring compared to interrupted suture
because fewer knots are made. But number of needle insertion
remain the same.
• Disadvantage- difficulty making fine adjustment along suture
line. Cross-hatching, risk of dehiscence. Puckering of suture line
when stiches placed in skin.

• RUNNING LOCKED SUTURES: Where additional

hemostasis needed. Can cause impaired microcirculation, tissue
strangulation so should only be used in areas with good
vascularization e.g scalp, post auricular sulcus.
Continuous Locking and Nonlocking Sutures
 SUTURING TECHNIQUE
• VERTICAL MATTRESS SUTURE: useful in
maximizing wound eversion, reducing dead space,
minimizing tension across wounds.
• Disadv-crosshatching. Prevent by removing suture in 5-7
days and use of bolsters between suture and skin to
minimize contact.
• HORIZONTAL MATTRESS SUTURE: useful for
wound under high tension because it provide strength and
wound eversion. May be used as a stay stitch for temporary
approximation of wound edges allowing placement of
simple interrupted or subcurticular stitches. Have risk of
producing suture marks after 7 days. May be placed before
a proposed skin excision, as a skin expansion technique.
Improved eversion may be achieved.
SUTURING TECHNIQUE- horizontal
mattress
• Disadvantage- high risk of tissue strangulation and
wound edge necrosis if tied too tightly
• Prevention- taking generous bite , early removal,
using bolsters, cinching sutures only as tightly as
necessary for approximation of edges.
Suture technique
 ALTERNATIVES TO SUTURES
1. CLIPS & STAPLES: useful where non-absorbable
material needed e.g billiary & renal tract. Used in
bowel closure and vascular anastomosis. Staples are
particularly useful in closure of skin wounds not
penetrating deeper than the dermis and therefore less
likely to leave permanent marks across wound.
• E.g Hulka-clemens clip(stainless steel & polycarbonal)
and filshie clip(titanium lined with silicon rubber)
used in female sterilization(tubal occlusion)
• Disadvantages- easily dislodge if caught up in swab
during subsequent discection . High cost has limited
use in developing countries.
 ALTERNATIVES TO SUTURES
2. SKIN TAPES: non-suture method of closing wound
edges. Tape is microporous and adhesive and is applied to
the skin after adequate subcuticular closure of the deeper
layers of the wound. Advantage- Infection is minimal, as
there is no burried suture through the skin to excite tissue
reaction. Tendency to epithelial down growth along needle
tract is also avoided.
3. ADHESIVES: most common is 2-octylcyanoacrylate
(dermabond). Also used as skin bolster in suturing thin
atrophic skin. Advantages- rapid wound closure , painless
application, reduced needle stick injury, absence of suture
marks. Eliminates need for removal. Disadvantages-
increase cost and less tensile strength compared to sutures
CONCLUSION
• Use the right suture, for the right indication, for
the right duration , using the appropriate
instrument and the right technique to achieve
best possible result.
 REFERENCES
1. E.A Badoe, E.O Archampong,J.T da Rocha-Afodu. Principles
and practice of surgery. 3rd edition. Page 63
2. Medscape: Suturing techniques;Julian Mackay-
wiggan,MD,MS. Co-author:Desiree Ratner,MD.
3. Medscape. Robert V Higgins. Co-authorR. Wendel
Naumano..Abdominal incissions and sutures in
gynaecological oncological surgery.
4. Prof Rene Remie & Dr. klaas Kramer Suture materials and
technique PDF
5. Denis c, Sethu S, Nayak S, Mohan L, Morsi Y(y), Manivasagam
G. 2016. Suture material- current and emerging
trends. J biomed mater res part A 2016:104A:1544-1559
6. Wikipedia en.m.wikipedia.org/wiki/surgical-suture last
edited 11th may 2018.
7. University of Ibadan surgery lecture notes.
• THANK YOU.