Carry out surgical nursing routines

1. Carry out surgical nursing routines SUTURES

2. 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

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

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

5. Opening suture packs

6. 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

7. What’s wrong here?

10. 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

11. 2 Common Classifications • 2 characteristics have been chosen for broad classification systems • Structure (filaments) • Absorption potential

12. Classification by structure • Single filament (monofilament) • Multiple filaments (multifilament, or braided)

13. Filaments Single Multiple

14. 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)

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

16. Classification by absorbability • When is most strength lost? • If before 60 days > Absorbable • If after 60 days > Non-Absorbable

17. 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

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

19. 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

20. Eye Small animal Large animal Sizes

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

22. Surface Characteristics • Determines Tissue drag • tissue damage > 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

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

24. 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

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

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

27. 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®)

28. surgical gut • Made from sheep’s intestine (submucosa) • Also known as catgut • Originally “violinkit gut” >>> catgut • Breaks down via foreign body reaction i.e. inflammation reaction • Breaks down more quickly if tissue already inflamed

30. 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

31. surgical gut absorption

32. poliglecaprone 25 • Monocryl® • Monofilament • Less memory • Quick resorption

33. polyglycolic acid • Dexon® • Multifilament • Coated or uncoated forms • Tissue drag +++ • Quick resorption

34. polyglactin 910 • Vicryl® • Multifilament • Coated or uncoated forms • Some tissue drag • Quick resorption

35. polydioxanone • PDSII® • Monofilament • Slower resorption than Dexon & Vicryl

36. polyglyconate • Maxon® • Monofilament • Slower resorption than Dexon & Vicryl

37. 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)

38. Duration of Absorbables • Short (resorbed within 2 mths) • Surgical gut, Vicryl, Dexon, Monocryl • Medium (resorbed within 6 mths) • PDS, Maxon

39. Non-Absorbable Suture Materials • By definition retain maximum strength for > 60 days

40. Non-Absorbable Suture Materials • polyamide • polypropylene • polyester • polybutester • stainless steel • silk

41. 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®)

43. 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

44. polypropylene • Monofilament (Prolene®) • Least reactive suture • Best suture for skin and vascular surgery • Doesn’t weaken with time (unlike Nylon®) • important for heart transplants! • But high memory makes handling difficult

45. polypropylene

46. 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

47. polybutester • Monofilament (Novafil®) • Elasticity and strength make it good for tendons and ligaments

48. 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 (B&S) wire gauge scale

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

50. Common Selections • Skin • Subcutis • Muscle & Fascia • Hollow organs • Tendon and ligament • Blood vessels • Eyes • Nerves