SUTURE MATERIALS

Dr. Hiwa Omer Ahmed

Assistant Professor in general
surgery
 WOUND DRESSINGS
►
During the past decade, dressings for acute and chronic
wounds have
changed dramatically. As new material technologies have
evolved, new
products have inundated the market. Dressing products
should be selected
on the basis of the type and characteristics of the wound.
The acute wound that is closed primarily requires coverage
with a dry
sterile dressing for a few days. This helps to protect the
wound from
bacterial invasion and absorbs any wound fluid. The dressing
also may
provide some psychological benefit to the patient in keeping
the surgical
wound out of sight. When epithelialization is complete, the
dressing can be
removed.
►
Partial-thickness wounds—e.g., donor sites, abrasions, first-
and second-
degree burns—require semiocclusive dressings. These
products provide a
moist environment that enhances the reepithelialization of
partial-thickness
wounds. If a semiocclusive dressing is applied early to a
partial-thickness
wound, dry scab formation can be avoided. Scab formation
can damage the
underlying dermis, and removal of the scab may be painful,
cause bleeding,
damage new epithelium, and increase the deformity in the
final scar.
Semiocclusive dressings may not have enough absorption
capacity to
handle the amount of wound exudate produced in the early
phase of
healing. Wound fluid can become trapped and cause the area
around the
wound to macerate or leak, necessitating frequent dressing
changes.
Combining an absorbent dressing material, such as an
alginate, with the
polyurethane film or hydrocolloid alleviates this problem
►
. Occlusive/semiocclusive dressings may exacerbate
infection when covering areas in which the bacterial count is higher
than
100,000/g of tissue. This risk may be reduced by first controlling the
wound bacterial count with topical antimicrobial or systemic
antibodies. In
addition, several of the hydrogels can be used effectively with
antibiotic
creams. Hydrogels are thought to accelerate the rate of penetration
of the
antibiotic into the granulation tissue.
Dressings are used to debride. If the wound is dry, it is important
that a
slower and more gentle process be used, especially when tendons
are
exposed. This can be accomplished with hydrogels that have little
permeability and therefore tend to keep the wound moist. When
eschar is
present, a hydrocolloid may be more appropriate than a hydrogel
dressing.
This type of debridement occurs through autolysis. The hydrocolloid
traps
the wound exudate and creates a moist environment that softens
and lifts
or causes proteolytic digestion of the eschar. However, in most
cases, sharp
surgical debridement of eschar is the most efficacious treatment.
►
Wounds with a large volume of exudate require dressing with
a greater
capacity to absorb. When dressings do not adequately
absorb, the healthy
tissue around the wound may become macerated. The use of
a skin
protectant around the wound may alleviate this problem.
There has been
concern that hydrocolloids leave pectin base in wounds,
which forms
granulomas. There are, however, several non-pectin-based
hydrocolloids
that address this problem and also absorb wound secretions.
There are no
data to support the contention that one dressing promotes
healing better
than another. However, selection of dressings may be made
on the basis
of overall costs, efficacy, and ease of use. It is likely that
over the next
decade dressings will be designed to have “selective
absorption” properties
to remove only factors that impede the healing of chronic
wounds or
prevent scar hypertrophy in primarily closed wounds. Most of
the “new”
concepts in dressings are marketing gimmicks rather than
improvements
based on solid and objective scientific data.
MECHANICAL WOUND CLOSURE
►
The materials used for wound closure are much less important than the
techniques of closure. Sutures may be generally classified as absorbable
or
nonabsorbable. The absorbable sutures may be synthetic, such as
polyglycolic acid sutures, or biologic, such as “catgut” sutures, which
may
be plain or chromium-treated. Traditional teaching is that absorbable
sutures are buried and, as they absorb, will not be a nidus for late
infection. Nonabsorbable sutures are used on the skin because they are
less reactive and allegedly provide a better-appearing scar. These
dogma
make little sense in the schema of healing. Although it is true that gut
sutures are more reactive than polyglycolic acid, which is more reactive
than nylon, the argument that tissue reactivity to particular sutures is of
significance in the healing process has never been validated.
Nonabsorbable
sutures may be used in subcutaneous tissue as well as in fascia or for
organ
repair. By contrast, absorbable sutures often are used on the skin in
infants
and children; 6-0 plain gut sutures placed in the skin do not require
removal
in a child, thus avoiding the additional trauma of suture removal.
Similarly,
absorbable sutures are used commonly for closure of hand wounds—
even
in adults.
► The notion that nonabsorbable sutures in fascia are better
than long-
lasting absorbable sutures is partially myth, because tension
will gradually
cause remodeling of the connective tissue around the suture.
If fascia
wound strength has not developed adequately in the repair
process, the
suture material will not have an influence on outcome.
The most important fact about sutures is that any woven
suture is more
likely to facilitate infection than a smooth suture because
bacteria can
become entrapped in the interstices of a woven suture and
not be
destroyed by the normal host responses, thus leading to
bacterial
propagation and infection. Therefore, woven suture material
should not be
used in the closure of contaminated wounds
►
A few suture materials deserve special
comment. The nonabsorbable
polypropylene suture is extremely smooth
and is therefore the best
material to use when creating a subcuticular
pullout suture. The absorbable
polyglycolic dermal suture (PDS) is best for
areas in which long-term tensile
strength is required. Although stainless steel
sutures are still used, they
should be banned in the operating room
because they often cut through
gloves and create an environment where
the surgical team may be more
susceptible to pathogens such as hepatitis
or HIV.
SUTURE MATERIALS
CATGUT
PLAIN CATGUT
POLYESTER BRAIDED
SUTURE MATERIALS
NEEDLES
CURVED NEEDLE
DIFFERENT SIZES NEEDLES
NEEDLE HOLDERS
SUTURE HOLDING
SUTURING
DRUM
►DRESSING
COTTON
CREPE BANDAGE
CREPE BANDAGE
GUAZE
PLASTER
PLASTER DRESSING
PLASTER OF PARIS ( POP)
►Suture
material
 Silk
► SILK
► Naturalprotien
► 80-100 tensil strength lost by 6 month
► Absorbed slowly over 1-2 years
► Moderate to high tissue reaction
► Not adviced for vascular & longlasting
neddy areas, and in infected area
 Linen
► Linen
► Long staple flax fibres
► 50 tensil strength lost by 6 month,30
remains at 2 years
► Nonabsorbed
► Moderate tissue reaction
► Not adviced for vascular suturing
 Surgical steel
► An alloy of iron, nickel and chromium
► Infinit more than one year
► Nonabsorbed
► minimal tissue reaction
► No contraindications
 Nylon
► Polyamid polymer
► 15-20% tensil strength lost / year
► Nonabsorbed
► low tissue reaction
► No contraindications
 Chromic catgut
► Collagen derived from healthy sheep
or cattle tanned with chromium
► tensil strength lost by 21-28 days
► Absorbed
► Moderate tissue reaction
► Not adviced for trissues with slow
healing which needs prolonged
support
 Vicryl
► Polymer of polyglycolic acid
► 80% tensil strength lost by 3 weeks
► Absorbed completely by 60-90 days
► minimal tissue reaction
► Not adviced for trissues with slow
healing which needs prolonged
support
 PDS
► Polyester polymer
► 85% tensil strength lost by 8 weeks
► Absorbed completely by 180 days
► Mild tissue reaction
► Not adviced for trissues with slow
healing which needs prolonged
support, for heart valve and synthetic
graft suturing