Professional Documents
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W O U N D C L O S U R E M A N UA L
WOUND HEALING
TO V I E W T H E E - C ATA L O G G O T O T H E
NEEDLES H E A LT H C A R E P R O F E S S I O N A L SECTION OF
W W W. E T H I C O N . C O M
ADHESIVES
SURGICAL MESH
* TRADEMARK
SM
ETHICON, INC.
©
2005, ETHICON, INC.
PREFACE
T
his manual has been prepared for the medical professional who
to customers. We hope you find this manual useful. But, above all,
we hope that it reflects our high regard for the men and women
~ ETHICON PRODUCTS
~
CONTRIBUTING EDITOR
Dr. Dunn has published over 400 articles and book chapters in the
Surgeons Foundation.
TABLE OF CONTENTS
WOUND HEALING Knot Tying ......................................................... 24
1 AND MANAGEMENT Knot Security............................................
Knot Tying Techniques Most Often Used ..........
24
25
The Wound.......................................................... 2 Square Knot ............................................. 25
Recovery of Tensile Strength............................ 2 Surgeon’s or Friction Knot ............................ 26
Patient Factors that Affect Wound Healing......... 2 Deep Tie ................................................. 26
Surgical Principles....................................... 4 Ligation Using a Hemostatic Clamp ............... 26
Classification of Wounds................................... 5 Instrument Tie .......................................... 26
Types of Wound Healing................................... 6 Endoscopic Knot Tying Techniques .................. 26
Healing by Primary Intention........................ 6 Cutting the Secured Sutures .......................... 26
Healing by Second Intention.......................... 7 Suture Removal ................................................. 26
Delayed Primary Closure.............................. 7 Suture Handling Tips ....................................... 27
Suture Selection Procedure ............................. 27
Surgery within the Abdominal Wall Cavity....... 28
OTHER SURGICAL
6 PRODUCTS
Adhesive Tapes................................................... 74
Indications and Usage................................. 74
Application .............................................. 74
After Care and Removal .............................. 74
Skin Closure Tapes ..................................... 75
Polyester Fiber Strip................................... 75
Umbilical Tape ........................................ 75
Surgical Staples ................................................. 75
Indications and Usage ................................. 76
Aftercare and Removal ................................ 76
PROXIMATE* Skin Staplers........................ 76
Looped Suture ................................................... 77
Retention Suture Devices ................................ 77
CHAPTER 1
WOUND HEALING
AND MANAGEMENT
2 WOUND HEALING & MANAGEMENT
THE WOUND point of rupture, relating to the thickness of tissue, the presence of
nature of the material rather than edema, and duration (the degree to
Injury to any of the tissues of its thickness. which the tissue has hardened in
the body, especially that caused • Breaking Strength—The load response to pressure or injury).
by physical means and with required to break a wound regard-
interruption of continuity is defined less of its dimension, the more
as a wound.1 Though most often PATIENT FACTORS THAT
clinically significant measurement. AFFECT WOUND HEALING
the result of a physical cause, a • Burst Strength—The amount of
burn is also considered a wound. The goal of wound management
pressure needed to rupture a
Both follow the same processes is to provide interventions that
viscus, or large interior organ.
towards the restoration to efficiently progress wounds through
health – otherwise known The rate at which wounds regain the biologic sequence of repair or
as healing.1 strength during the wound healing regeneration. The patient's overall
process must be understood as a health status will affect the speed of
Wound healing is a natural and basis for selecting the most the healing process. The following
spontaneous phenomenon. When appropriate wound closure material. are factors that should be considered
tissue has been disrupted so severely by the surgical team prior to and
that it cannot heal naturally during the procedure. 2,3,4
RECOVERY OF
(without complications or possible TENSILE STRENGTH
disfiguration) dead tissue and AGE — With aging, both skin
Tensile strength affects the tissue's
foreign bodies must be removed, and muscle tissue lose their tone
ability to withstand injury but is
infection treated, and the tissue and elasticity. Metabolism also
not related to the length of time it
must be held in apposition until the slows, and circulation may be
takes the tissue to heal. As collagen
healing process provides the wound impaired. But aging alone is not
accumulates during the reparative
with sufficient strength to withstand a major factor in chronic wound
phase, strength increases rapidly but
stress without mechanical support. healing. Aging and chronic
it is many months before a plateau
A wound may be approximated disease states often go together,
is reached.2 Until this time, the
with sutures, staples, clips, skin and both delay repair processes
wound requires extrinsic support
closure strips, or topical adhesives. due to delayed cellular response
from the method used to bring it
to the stimulus of injury, delayed
Tissue is defined as a collection of together – usually sutures. While
collagen deposition, and
similar cells and the intercellular skin and fascia (the layer of firm
decreased tensile strength in the
substances surrounding them. connective tissue covering muscle)
remodeled tissue. All of these
There are four basic tissues in the are the strongest tissues in the body,
factors lengthen healing time.
body: 1) epithelium; 2) connective they regain tensile strength slowly
tissues, including blood, bone and during the healing process. The WEIGHT — Obese patients
cartilage; 3) muscle tissue; and stomach and small intestine, on the of any age have, excess fat at the
4) nerve tissue. The choice of other hand, are composed of much wound site that may prevent
wound closure materials and the weaker tissue but heal rapidly. securing a good closure. In
techniques of using them are prime Variations in tissue strength may addition, fat does not have a rich
factors in the restoration of also be found within the same blood supply, making it the most
continuity and tensile strength to organ. Within the colon, for vulnerable of all tissues to trauma
the injured tissues during the example, the sigmoid region is and infection.
healing process. approximately twice as strong as the
cecum—but both sections heal at NUTRITIONAL STATUS —
The parameters for measuring the Overall malnutrition associated
the same rate. Factors that affect
strength of normal body tissue are: with chronic disease or cancer,
tissue strength include the size, age,
• Tensile Strength—The load per or specific deficiencies in
and weight of the patient, the
cross-sectional area unit at the
CHAPTER 1 3
* Trademark
4 WOUND HEALING
SURGICAL PRINCIPLES DISSECTION blood (hematomas) or fluid
Many factors that affect the healing TECHNIQUE — When incising (seromas) in the incision can
process can be controlled by the tissue, a clean incision should prevent the direct apposition of
surgical team in the operating room, be made through the skin with tissue needed for complete union
by the obstetrical team in labor and one stroke of evenly applied of wound edges. Furthermore,
delivery, or by the emergency team pressure on the scalpel. Sharp these collections provide an ideal
in the trauma center. Their first dissection should be used to cut culture medium for microbial
priority is to maintain a sterile through remaining tissues. The growth and can lead to serious
and aseptic technique to prevent surgeon must preserve the infection.
infection. Organisms found integrity of as many of the
When clamping or ligating a
within a patient's own body most underlying nerves, blood vessels,
vessel or tissue, care must be
commonly cause postoperative and muscles as possible.
taken to avoid excessive tissue
infection, but microorganisms damage. Mass ligation that
carried by medical personnel also TISSUE HANDLING —
involves large areas of tissue may
pose a threat. Whatever the source, Keeping tissue trauma to a
produce necrosis, or tissue death,
the presence of infection will deter minimum promotes faster
and prolong healing time.
healing. In addition to concerns healing. Throughout the
about sterility, the following must operative procedure, the surgeon
MAINTAINING MOISTURE
be taken into consideration when must handle all tissues very
IN TISSUES — During long
planning and carrying out an gently and as little as possible.
procedures, the surgeon may
operative procedure.3 Retractors should be placed with
periodically irrigate the wound
care to avoid excessive pressure,
with warm physiologic (normal)
THE LENGTH AND since tension can cause serious
saline solution, or cover exposed
DIRECTION OF THE complications: impaired blood
surfaces with saline-moistened
INCISION — A properly and lymph flow, altering of the
sponges or laparotomy tapes to
planned incision is sufficiently local physiological state of the
prevent tissues from drying out.
long to afford sufficient optimum wound, and predisposition to
exposure. When deciding upon microbial colonization.
REMOVAL OF NECROTIC
the direction of the incision, the TISSUE AND FOREIGN
surgeon must bear the following HEMOSTASIS — Various
MATERIALS — Adequate
in mind: mechanical, thermal, and
debridement of all devitalized
• The direction in which wounds chemical methods are available to
tissue and removal of inflicted
naturally heal is from side-to- decrease the flow of blood and
foreign materials are essential
side, not end-to-end. fluid into the wound site.
to healing, especially in traumatic
Hemostasis allows the surgeon to
• The arrangement of tissue fibers wounds. The presence of
work in as clear a field as possible
in the area to be dissected will fragments of dirt, metal, glass,
with greater accuracy. Without
vary with tissue type. etc., increases the probability
adequate control, bleeding from
• The best cosmetic results may be of infection.
transected or penetrated vessels
achieved when incisions are made or diffused oozing on large
parallel to the direction of the CHOICE OF CLOSURE
denuded surfaces may interfere
tissue fibers. Results may vary MATERIALS — The surgeon
with the surgeon's view of
depending upon the tissue must evaluate each case individu-
underlying structures.
layer involved. ally, and choose closure material
Achieving complete hemostasis which will maximize the
before wound closure also will opportunity for healing and
prevent formation of postopera- minimize the likelihood of
tive hematomas. Collections of infection. The proper closure
CHAPTER 1 5
material will allow the surgeon blood supply. Serum or blood Tendons and the extremities may
to approximate tissue with as may collect, providing an ideal also be subjected to excessive
little trauma as possible, and with medium for the growth tension during healing. The
enough precision to eliminate of microorganisms that cause surgeon must be certain that
dead space. The surgeon's infection. The surgeon may the approximated wound is
personal preference will play a elect to insert a drain or apply adequately immobilized to
large role in the choice of closure a pressure dressing to help prevent suture disruption
material; but the location of the eliminate dead space in the for a sufficient period of time
wound, the arrangement of tissue wound postoperatively. after surgery.
fibers, and patient factors influ-
ence his or her decision as well. CLOSING TENSION — IMMOBILIZATION —
While enough tension must be Adequate immobilization of the
CELLULAR RESPONSE TO applied to approximate tissue and approximated wound, but not
CLOSURE MATERIALS — eliminate dead space, the sutures necessarily of the entire anatomic
Whenever foreign materials such must be loose enough to prevent part, is mandatory after surgery
as sutures are implanted in tissue, exaggerated patient discomfort, for efficient healing and minimal
the tissue reacts. This reaction ischemia, and tissue necrosis scar formation.
will range from minimal to during healing.
moderate, depending upon the
type of material implanted. The POSTOPERATIVE
CLASSIFICATION
reaction will be more marked if DISTRACTION FORCES —
complicated by infection, allergy, The patient's postoperative OF WOUNDS
or trauma. activity can place undue stress The Centers for Disease Control
upon a healing incision. and Prevention (CDC), using an
nitially, the tissue will deflect the
Abdominal fascia will be placed adaptation of the American College
passage of the surgeon's needle
under excessive tension after of Surgeons’ wound classification
and suture. Once the sutures
surgery if the patient strains to schema, divides surgical wounds
have been implanted, edema of
cough, vomit, void, or defecate. into four classes: clean wounds,
the skin and subcutaneous tissues
clean-contaminated wounds,
will ensue. This can cause
significant patient discomfort
during recovery, as well as
scarring secondary to ischemic FIGURE
necrosis. The surgeon must take 2
these factors into consideration
when placing tension upon the DEAD SPACE
IN A WOUND
closure material.
ELIMINATION OF DEAD
SPACE IN THE WOUND —
Dead space in a wound results
from separation of portions of
the wound beneath the skin
edges which have not been
closely approximated, or from air
or fluid trapped between layers of
tissue. This is especially true in
the fatty layer which tends to lack
* Trademark
6 WOUND HEALING
contaminated wounds and dirty or contaminated by entry into a HEALING BY
infected wounds.5 A discussion of viscus resulting in minimal spillage PRIMARY INTENTION
each follows. of contents. Every surgeon who closes a wound
would like it to heal by primary
Seventy-five percent of all wounds Contaminated wounds include
union or first intention, with
(which are usually elective surgical open, traumatic wounds or injuries
minimal edema and no local
incisions) fall into the clean wounds such as soft tissue lacerations, open
infection or serious discharge. An
category—an uninfected operative fractures, and penetrating wounds;
incision that heals by primary
wound in which no inflammation operative procedures in which gross
intention does so in a minimum of
is encountered and the respiratory, spillage from the gastrointestinal
time, with no separation of the
alimentary, genital, or uninfected tract occurs; genitourinary or biliary
wound edges, and with minimal
urinary tracts are not entered. tract procedures in the presence
scar formation. This takes place in
These elective incisions are made of infected urine or bile; and
three distinct phases:2,3
under aseptic conditions and are operations in which a major break
not predisposed to infection. in aseptic technique has occurred Inflammatory (preparative) –
Inflammation is a natural part of (as in emergency open cardiac During the first few days, an
the healing process and should be massage). Microorganisms inflammatory response causes an
differentiated from infection in multiply so rapidly that within outpouring of tissue fluids, an
which bacteria are present and 6 hours a contaminated wound accumulation of cells and
produce damage. can become infected. fibroblasts, and an increased blood
supply to the wound. Leukocytes
Clean wounds are closed by primary Dirty and infected wounds have
and other cells produce proteolytic
union and usually are not drained. been heavily contaminated or
enzymes which dissolve and remove
Primary union is the most desirable clinically infected prior to the
damaged tissue debris. These are
method of closure, involving the operation. They include perforated
the responses which prepare the site
simplest surgical procedures and viscera, abscesses, or neglected
of injury for repair. The process
the lowest risk of postoperative traumatic wounds in which
lasts 3 to 7 days. Any factor which
complications. Apposition of tissue devitalized tissue or foreign material
interferes with the progress, may
is maintained until wound tensile have been retained. Infection
interrupt or delay healing. During
strength is sufficient so that sutures present at the time of surgery can
the acute inflammatory phase, the
or other forms of tissue apposition increase the infection rate of any
tissue does not gain appreciable
are no longer needed. wound by an average of four times.
tensile strength, but depends solely
Clean-contaminated wounds are upon the closure material to hold it
operative wounds in which the in approximation.
respiratory, alimentary, genital, or TYPES OF
urinary tracts are entered under WOUND HEALING Proliferative – After the
debridement process is well along,
controlled conditions and without The rate and pattern of healing falls fibroblasts begin to form a collagen
unusual contamination. Specifically, into three categories, depending matrix in the wound known as
operations involving the biliary upon the type of tissue involved granulation tissue. Collagen, a
tract, appendix, vagina, and and the circumstances surrounding protein substance, is the chief
oropharynx are included in this closure. Timeframes are generalized constituent of connective tissue.
category provided no evidence for well-perfused healthy soft Collagen fiber formation determines
of infection or major break in tissues, but may vary. the tensile strength and pliability of
technique is encountered.
the healing wound. As it fills with
Appendectomies, cholecystectomies,
new blood vessels, the granulation
and hysterectomies fall into this
becomes bright, beefy, red tissue.
category, as well as normally
The thick capillary bed which fills
clean wounds which become
CHAPTER 1 7
Damaged
tissue
debris Tissue fluids
FIGURE
3
PHASES OF
WOUND
HEALING
Proteolytic
Fibroblasts enzymes
the matrix, supplies the nutrients Remodelling – As collagen deposi- DELAYED PRIMARY
and oxygen necessary for the wound tion is completed, the vascularity of CLOSURE
to heal. This phase occurs from the wound gradually decreases and This is considered by many
day 3 onward. any surface scar becomes paler. The surgeons to be a safe method of
amount of collagen that is finally management of contaminated, as
In time, sufficient collagen is laid
formed – the ultimate scar – is well as dirty and infected traumatic
down across the wound so that it
dependent upon the initial volume wounds with extensive tissue loss
can withstand normal stress. The
of granulation tissue.2 and a high risk of infection. This
length of this phase varies with the
method has been used extensively in
type of tissue involved and the
HEALING BY the military arena and has proven
stresses or tension placed upon the
SECOND INTENTION successful following excessive
wound during this period.
When the wound fails to heal by trauma related to motor vehicle
Wound contraction also occurs dur- primary union, a more complicated accidents, shooting incidents, or
ing this phase. Wound contraction and prolonged healing process takes infliction of deep, penetrating
is a process that pulls the wound place. Healing by second intention knife wounds.3
edges together for the purpose of is caused by infection, excessive
The surgeon usually treats these
closing the wound. In essence, it trauma, tissue loss, or imprecise
injuries by debridement of
reduces the open area, and if approximation of tissue.3
nonviable tissues and leaves the
successful, will result in a smaller
In this case, the wound may be left wound open, inserting gauze
wound with less need for repair by
open and allowed to heal from the packing which is changed twice a
scar formation. Wound contraction
inner layer to the outer surface. day. Patients sedation or a return to
can be very beneficial in the closure
Granulation tissue forms and the operating room with general
of wounds in areas such as the but-
contains myofibroblasts. These anesthesia generally is only required
tocks or trochanter but can be very
specialized cells help to close the in the case of large, complex
harmful in areas such as the hand
wound by contraction. This wounds. Wound approximation
or around the neck and face, where
process is much slower than primary using adhesive strips, previously
it can cause disfigurement and
intention healing. Excessive placed but untied sutures, staples
excessive scarring.3
granulation tissue may build up after achieving local anesthesia can
Surgical wounds that are closed and require treatment if it protrudes occur within 3-5 days if the wound
by primary intention have minimal above the surface of the wound, demonstrates no evidence of
contraction response. Skin grafting preventing epithelialization. infection and the appearance of red
is used to reduce avoided contrac- granulation tissue. Should this not
tion in undesirable locations.
* Trademark
8 WOUND HEALING
occur, the wound is allowed to
heal by secondary intention. When
closure is undertaken, skin edges
and underlying tissue must be accu-
rately and securely approximated.
IN THE
NEXT SECTION
The materials, devices, and
techniques used to repair wounded
tissue will be discussed at length.
As you will see, the number of
options available is extensive. But
no matter how many choices the
surgeon has, his or her objective
remains singular: to restore the
patient to health with as little
operative trauma as possible and
an excellent cosmetic result.
REFERENCES
1. Stedman’s Medical Dictionary,
27th edition, 2000
2. Henry, Michael and Thompson,
Jeremy: Clinical Surgery, W.B.
Saunders, 2001
3. Skerris, David A.: Mayo Clinic
Basic Surgery Skills, Mayo Clinic
Scientific Press, 1999
4. Sussman, Carrie: Wound Care,
Aspen Publishers, 1998
5. NNIS Manual, CDC,
MHA, 2000
CHAPTER 2
THE SUTURE
10 THE SUTURE
WHAT IS • They must be secured in A number of factors may influence
packaging which presents them
A SUTURE? sterile for use, in excellent
the surgeon’s choice of materials:
The word "suture" describes any condition, and ensures the • His or her area of specialization.
strand of material used to ligate (tie) safety of each member of the • Wound closure experience during
blood vessels or approximate (bring surgical team. clinical training.
close together) tissues. Sutures are • Professional experience in the
used to close wounds. Sutures and The nurse must maintain the operating room.
ligatures were used by both the sterility of sutures when storing, • Knowledge of the healing
Egyptians and Syrians as far back as handling, and preparing them for characteristics of tissues and
2,000 B.C. Through the centuries, a use. The integrity and strength of organs.
wide variety of materials—silk, each strand must remain intact • Knowledge of the physical and
linen, cotton, horsehair, animal until it is in the surgeon's hands. biological characteristics of
tendons and intestines, and wire The surgeon must select suture various suture materials.
made of precious metals—have been materials appropriate for the • Patient factors (age, weight,
used in operative procedures. Some procedure and must place them overall health status, and the
of these are still in use today. in the tissues in a manner consistent presence of infection).
The evolution of suturing material with the principles that promote
has brought us to a point of refine- wound healing. Surgical specialty plays a primary role
ment that includes sutures designed in determining suture preference. For
With the manufacturer and example, obstetrician/gynecologists
for specific surgical procedures. surgical team working in concert, frequently prefer coated VICRYL*
Despite the sophistication of the patient reaps the final RAPIDE (polyglactin 910) suture
today's suture materials and surgical benefit...the wound is closed in a for episiotomy repair and coated
techniques, closing a wound still manner that promotes optimum VICRYL* (polyglactin 910) suture,
involves the same basic procedure healing in minimum time. coated VICRYL* Plus Antibacterial
used by physicians to the Roman (polyglactin 910) suture and
emperors. The surgeon still uses a MONOCRYL* (poliglecaprone 25)
surgical needle to penetrate tissue
PERSONAL SUTURE suture for all tissue layers except,
and advance a suture strand to its
desired location.
PREFERENCE possibly skin. Most orthopaedic
surgeons use coated VICRYL suture,
Most surgeons have a basic coated VICRYL Plus, PDS* II
Successful use of suture materials "suture routine," a preference for
depends upon the cooperation of (polydioxanone) suture, and
using the same material(s) unless ETHIBOND* EXCEL polyester
the suture manufacturer and the circumstances dictate otherwise.
surgical team. suture. Many plastic surgeons prefer
The surgeon acquires skill, ETHILON* nylon suture, VICRYL
The manufacturer must have a proficiency, and speed in handling suture, or MONOCRYL suture.
thorough knowledge of surgical by using one suture material Many neurosurgeons prefer coated
procedures, anticipate the surgical repeatedly—and may choose VICRYL suture or NUROLON*
team's needs, and produce suture the same material throughout his nylon suture. But no single suture
materials that meet these or her entire career. material is used by every surgeon who
stringent criteria: practices within a specialty.
• They must have the greatest
tensile strength consistent with The surgeon's knowledge of the
size limitations. physical characteristics of suture
• They must be easy to handle. material is important. As the
requirements for wound support vary
with patient factors, the nature of the
CHAPTER 2 11
procedure, and the type of tissue SIZE AND TENSILE MONOFILAMENT VS.
involved, the surgeon will select STRENGTH MULTIFILAMENT STRANDS
suture material that will retain its Size denotes the diameter of the Sutures are classified according to
strength until the wound heals suture material. The accepted the number of strands of which
sufficiently to withstand stress on surgical practice is to use the they are comprised. Monofilament
its own. smallest diameter suture that sutures are made of a single strand
will adequately hold the mending of material. Because of their
SUTURE wounded tissue. This practice simplified structure, they encounter
CHARACTERISTICS minimizes trauma as the suture is less resistance as they pass
passed through the tissue to effect through tissue than multifilament
The choice of suture materials gen- closure. It also ensures that the suture material. They also resist
erally depends on whether the minimum mass of foreign material harboring organisms which may
wound closure occurs in one or is left in the body. Suture size is cause infection.
more layers. In selecting the most stated numerically; as the number of
appropriate sutures, the surgeon These characteristics make
0s in the suture size increases, the
takes into account the amount of monofilament sutures well-suited
diameter of the strand decreases. For
tension on the wound, the number to vascular surgery. Monofilament
example, size 5-0, or 00000, is
of layers of closure, depth of suture sutures tie down easily. However,
smaller in diameter than size 4-0, or
placement, anticipated amount of because of their construction,
0000. The smaller the size, the less
edema, and anticipated timing of extreme care must be taken when
tensile strength the suture will have.
suture removal. handling and tying these sutures.
Knot tensile strength is measured by Crushing or crimping of this suture
Optimal suture qualities include: the force, in pounds, which the type can nick or create a weak spot
suture strand can withstand before in the strand. This may result in
1. High uniform tensile strength,
it breaks when knotted. The tensile suture breakage.
permitting use of finer sizes.
strength of the tissue to be mended
2. High tensile strength retention Multifilament sutures consist of
(its ability to withstand stress)
in vivo, holding the wound several filaments, or strands, twisted
determines the size and tensile
securely throughout the critical or braided together. This affords
strength of the suturing material the
healing period, followed by greater tensile strength, pliability, and
surgeon selects. The accepted rule is
rapid absorption. flexibility. Multifilament sutures may
that the tensile strength of the
3. Consistent uniform diameter. also be coated to help them pass rela-
suture need never exceed the tensile
4. Sterile. tively smoothly through tissue and
strength of the tissue. However,
5. Pliable for ease of handling and enhance handling characteristics.
sutures should be at least as strong
knot security. Coated multifilament sutures are
as normal tissue through which they
6. Freedom from irritating well-suited to intestinal procedures.
are being placed.
substances or impurities for
optimum tissue acceptance.
7. Predictable performance.
METRIC MEASURES AND U.S.P.
SUTURE DIAMETER EQUIVALENTS TABLE
1
U.S.P. Size 11-0 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
Natural
Collagen ––– 0.2 0.3 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 7.0 8.0 ––– –––
Synthetic
Absorbables ––– 0.2 0.3 0.4 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 6.0 7.0 –––
Nonabsorbable
Materials 0.1 0.2 0.3 0.4 0.5 0.7 1.0 1.5 2.0 3.0 3.5 4.0 5.0 6.0 6.0 7.0 8.0
* Trademark
12 THE SUTURE
ABSORBABLE VS.
NONABSORBABLE SUTURES SUTURE RAW MATERIAL
Sutures are classified according to
their degradation properties. Surgical Gut Submucosa of sheep TABLE
Plain intestine or serosa of beef 2
Sutures that undergo rapid degrada- Chromic intestine
tion in tissues, losing their tensile Fast Absorbing ABSORBABLE
strength within 60 days, are Polyglactin 910 SUTURES:
Copolymer of glycolide and
considered absorbable sutures. Uncoated (VICRYL Suture) lactide with polyglactin 370 BASIC RAW
Sutures that generally maintain and calcium stearate, if coated MATERIALS
Coated (coated VICRYL
their tensile strength for longer than (polyglactin 910) suture,
60 days are nonabsorbable sutures. coated VICRYL Plus suture,
coated VICRYL* RAPIDE
Absorbable sutures may be used to (polyglactin 910) suture)
hold wound edges in approximation
Polyglycolic Acid Homopolymer of glycolide
temporarily, until they have healed
Poliglecaprone 25 Copolymer of glycolide and
sufficiently to withstand normal (MONOCRYL suture) epsilon-caprolactone
stress. These sutures are prepared
either from the collagen of healthy Polyglyconate Copolymer of glycolide and
mammals or from synthetic trimethylene carbonate
polymers. Some are absorbed Polydioxanone Polyester of poly (p-dioxanone)
rapidly, while others are treated or (PDS* II suture)
chemically structured to lengthen
absorption time. They may also be
impregnated or coated with agents
considerable overlap, characterized causing too rapid a decline in tensile
that improve their handling
by loss of suture mass. Both stages strength. In addition, if the sutures
properties, and colored with an
exhibit leukocytic cellular responses become wet or moist during
FDA-approved dye to increase
which serve to remove cellular handling, prior to being implanted
visibility in tissue. Natural
debris and suture material from the in tissue, the absorption process
absorbable sutures are digested by
line of tissue approximation. may begin prematurely. Similarly,
body enzymes which attack and
patients with impaired healing
break down the suture strand. The loss of tensile strength and
are often not ideal candidates
Synthetic absorbable sutures are the rate of absorption are separate
for this type of suture. All of
hydrolyzed—a process by which phenomena. A suture can lose
these situations predispose to
water gradually penetrates the tensile strength rapidly and yet be
postoperative complications, as
suture filaments, causing the absorbed slowly—or it can
the suture strand will not maintain
breakdown of the suture's polymer maintain adequate tensile strength
adequate strength to withstand
chain. Compared to the enzymatic through wound healing, followed
stress until the tissues have
action of natural absorbables, by rapid absorption. In any case,
healed sufficiently.
hydrolyzation results in a lesser the strand is eventually completely
degree of tissue reaction following dissolved, leaving no detectable Nonabsorbable sutures are those
implantation. traces in tissue. which are not digested by body
enzymes or hydrolyzed in body
During the first stage of the Although they offer many
tissue. They are made from a variety
absorption process, tensile strength advantages, absorbable sutures also
of nonbiodegradable materials and
diminishes in a gradual, almost have certain inherent limitations.
are ultimately encapsulated or
linear fashion. This occurs over the If a patient has a fever, infection,
walled off by the body’s fibroblasts.
first several weeks postimplantation. or protein deficiency, the suture
Nonabsorbable sutures ordinarily
The second stage often follows with absorption process may accelerate,
remain where they are buried
CHAPTER 2 13
original strength lost by 28 days. VICRYL suture is essentially Staphylococcus epidermidis (MRSE).3
At 7 days, undyed MONOCRYL complete between 56 and 70 days. In vivo studies demonstrate that
suture retains approximately 50% VICRYL Plus Antibacterial suture
Lactide and glycolide acids are
to 60% of its original strength, and has no adverse effect on normal
readily eliminated from the body,
approximately 20% to 30% at wound healing.2
primarily in urine. As with
14 days postimplantation. All of
uncoated sutures, coated VICRYL Coated VICRYL Plus Antibacterial
the original tensile strength of
sutures elicit only a mild tissue suture performs and handles the same
undyed MONOCRYL suture is
reaction during absorption. Their as Coated VICRYL suture. Coated
lost by 21 days postimplantation.
safety and effectiveness in neural VICRYL Plus Antibacterial suture has
Absorption is essentially complete
and cardiovascular tissue have not the same dependable construction as
at 91 to 119 days.
been established. Transcutaneous or Coated VICRYL suture. In vivo
COATED VICRYL* conjunctival sutures remaining in testing by surgeons demonstrates the
(POLYGLACTIN 910) SUTURE place longer than 7 days may cause same excellence in performance
This material fills the need for a localized irritation and should be and handling.
smoother synthetic absorbable removed as indicated. Coated
The suture is available undyed
suture that will pass through tissue VICRYL sutures are available as
(natural) or dyed. Coated VICRYL
readily with minimal drag. Coated braided dyed violet or undyed
Plus suture is indicated for use in
VICRYL sutures facilitate ease of natural strands in a variety of
general soft tissue approximation
handling, smooth tie down and lengths with or without needles.
and/or ligation requiring medium
unsurpassed knot security. support, except for ophthalmic,
COATED VICRYL
The coating is a combination of PLUS ANTIBACTERIAL cardiovascular and neurological tissues.
equal parts of copolymer of lactide (POLYGLACTIN 910) SUTURE Frequent uses include general closure,
and glycolide (polyglactin 370), This synthetic, absorbable, sterile, sur- bowel, orthopedic, and plastic surgery.
plus calcium stearate which is gical suture is a copolymer made from
Coated VICRYL Plus Antibacterial
used extensively in pharmaceuticals 90% glycolide and 10% L-lactide.
suture retains approximately 75% of
and food. Calcium stearate is a salt Coated VICRYL Plus Antibacterial
the original tensile strength at two
of calcium and stearic acid, both Suture is coated with a mixture com-
weeks post implantation. At three
of which are present in the body posed of equal parts of copolymer of
weeks, approximately 50% of the
and constantly metabolized and glycolide and lactide (polyglactin 370)
original strength is retained. At four
excreted. The result of this mixture and calcium stearate. Coated VICRYL
weeks, approximately 25% of the
is an outstandingly absorbable, Plus Antibacterial suture contains
original strength is retained.
adherent, nonflaking lubricant. IRGACARE MP*, one of the
All of the original tensile strength is
purest forms of the broad-spectrum
At 2 weeks postimplantation, lost by five weeks post implantation.
antibacterial agent triclosan.
approximately 75% of the tensile Absorption of Coated VICRYL Plus
strength of coated VICRYL suture Coated VICRYL Plus Antibacterial Antibacterial Suture is essentially
remains. Approximately 50% of suture offers protection against complete between 56 and 70 days.
tensile strength is retained at 3 bacterial colonization of the suture.
weeks for sizes 6-0 and larger. At 3 In vivo studies demonstrate that PDS* II (POLYDIOXANONE)
weeks, 40% of tensile strength is Coated VICRYL Plus Antibacterial SUTURE
retained for sizes 7-0 and smaller. At suture has a zone of inhibition that Comprised of the polyester poly
4 weeks, 25% of the original is effective against the pathogens that (p-dioxanone), this monofilament
strength is retained for sizes 6-0 and most often cause surgical site infection represents a significant advance
larger. All of the original tensile (SSI) – Staphylococcus aureus, in suturing options. It combines
strength is lost by five weeks post methicillin-resistant Staphylococcus the features of soft, pliable,
implantation. Absorption of coated aureus (MRSA), Staphylococcus monofilament construction with
epidermidis, methicillin-resistant absorbability and extended wound
* Trademark
16 THE SUTURE
support for up to 6 weeks. It elicits especially due to its superior cannot be detected in tissue after
only a slight tissue reaction. This handling characteristics. Silk 2 years. Thus, it behaves in reality
material is well-suited for many filaments can be twisted or braided, as a very slowly absorbing suture.
types of soft tissue approximation, the latter providing the best
including pediatric cardiovascular, handling qualities. SURGICAL STAINLESS STEEL
orthopaedic, gynecologic, The essential qualities of surgical
Raw silk is a continuous filament
ophthalmic, plastic, digestive, stainless steel sutures include the
spun by the silkworm moth larva
and colonic surgeries. absence of toxic elements, flexibility,
to make its cocoon. Cream or
and fine wire size. Both monofila-
Like other synthetic absorbable orange-colored in its raw state, each
ment and twisted multifilament
sutures, PDS II sutures are silk filament is processed to remove
varieties are high in tensile strength,
absorbed in vivo through hydrolysis. natural waxes and sericin gum,
low in tissue reactivity, and hold
Approximately 70% of tensile which is exuded by the silkworm as
a knot well. Provided that the
strength remains 2 weeks it spins its cocoon. The gum holds
sutures do not fragment, there is
postimplantation, 50% at 4 weeks, the cocoon together, but is of no
little loss of tensile strength in
and 25% at 6 weeks. Absorption is benefit to the quality of braided
tissues. The 316L (low carbon)
minimal until about the 90th day surgical silk sutures.
stainless steel alloy formula used
postoperatively and essentially
ETHICON degums the silk for in the manufacture of these
complete within 6 months. The
most suture sizes before the sutures offers optimum metal
safety and effectiveness of PDS II
braiding process. This allows for a strength, flexibility, uniformity,
sutures in microsurgery, neural
tighter, more compact braid which and compatibility with stainless
tissue, and adult cardiovascular
significantly improves suture quality. steel implants and prostheses.
tissue have not been established.
After braiding, the strands are dyed, Stainless steel sutures may also be
PDS II sutures are available clear
scoured and stretched, and then used in abdominal wall closure,
or dyed violet to enhance visibility.
impregnated and coated with a sternum closure, retention, skin
mixture of waxes or silicone. Each closure, a variety of orthopaedic
of these steps is critical to the procedures, and neurosurgery.
NONABSORBABLE SUTURES
quality of the finished suture and
The U.S.P. classifies nonabsorbable Disadvantages associated with
must be carried out in precise order.
surgical sutures as follows: alloy sutures include difficulty in
Surgical silk is usually dyed black
• CLASS I—Silk or synthetic fibers handling; possible cutting, pulling,
for easy visibility in tissue.
of monofilament, twisted, or and tearing of the patient's tissue;
braided construction. Raw silk is graded according to fragmentation; barbing; and
• CLASS II—Cotton or linen strength, uniformity of filament kinking, which renders the stainless
fibers, or coated natural or diameter, and freedom from defects. steel suture useless. When used for
synthetic fibers where the coating Only top grades of silk filaments are bone approximation and fixation,
contributes to suture thickness used to produce PERMA-HAND* asymmetrical twisting of the wire
without adding strength. surgical silk sutures. will lead to potential buckling, wire
• CLASS III—Metal wire of fracture, or subsequent wire
Surgical silk loses tensile strength
monofilament or multifilament fatigue. Incomplete wire fixation
when exposed to moisture and
construction. under these circumstances will
should be used dry. Although silk
permit movement of the wire,
is classified by the U.S.P. as a
SURGICAL SILK resulting in postoperative pain
nonabsorbable suture, long-term
For many surgeons, surgical silk and possible dehiscence.
in vivo studies have shown that it
represents the standard handling loses most or all of its tensile Surgical stainless steel sutures
performance by which newer strength in about 1 year and usually should not be used when a
synthetic materials are judged, prosthesis of another alloy is
CHAPTER 2 17
* Trademark
18 THE SUTURE
dyed green, polyester fiber sutures Pledgets are used routinely in valve (vinylidene fluoride-cohexafluoro-
are among the most acceptable for replacement procedures (to prevent propylene). This suture resists
vascular synthetic prostheses. the annulus from tearing when the involvement in infection and has
prosthetic valve is seated and the been successfully employed in
MERSILENE* POLYESTER sutures are tied), and in situations contaminated and infected wounds
FIBER SUTURE where extreme deformity, distortion, to eliminate or minimize later sinus
The first synthetic braided suture or tissue destruction at the annulus formation and suture extrusion.
material shown to last indefinitely has occurred. Furthermore, the lack of adherence
in the body, MERSILENE sutures to tissues has facilitated the use
provide precise, consistent suture Polypropylene is an isostatic
of PRONOVA suture as a
tension. They minimize breakage crystalline stereoisomer of a
pull-out suture.
and virtually eliminate the need to linear hydrocarbon polymer
remove irritating suture fragments permitting little or no saturation. This material is well-suited for
postoperatively. Because it is Manufactured by a patented many types of soft tissue approxi-
uncoated, MERSILENE suture process which enhances pliability mation and ligation, including use
has a higher coefficient of friction and handling, polypropylene in cardiovascular, ophthalmic and
when passed through tissue. monofilament sutures are not neurological procedures.
subject to degradation or weakening
Table 5 gives an overview of the
ETHIBOND* EXCEL by tissue enzymes. They cause
many suturing options that have
POLYESTER SUTURE minimal tissue reaction and hold
been discussed in this section.
ETHIBOND EXCEL sutures are knots better than most other
(See attached chart )
uniformly coated with polybutilate, synthetic monofilament materials.
a biologically inert, nonabsorbable
compound which adheres itself to PROLENE* POLYPROPYLENE COMMON
the braided polyester fiber strand. SUTURE SUTURING
Polybutilate was the first synthetic Widely used in general, cardiovascu- TECHNIQUES
coating developed specifically as a lar, plastic, and orthopaedic surgery,
surgical suture lubricant. The coat- PROLENE sutures do not adhere to LIGATURES
ing eases the passage of the braided tissue and are therefore efficacious A suture tied around a vessel to
strands through tissue and provides as a pull-out suture. PROLENE occlude the lumen is called a ligature
excellent pliability, handling quali- sutures are relatively biologically or tie. It may be used to effect
ties, and smooth tie-down with each inert, offering proven strength, hemostasis or to close off a structure
throw of the knot. Both the suture reliability and versatility. to prevent leakage. There are two
material and the coating are PROLENE sutures are primary types of ligatures.
pharmacologically inactive. The recommended for use where
Free tie or freehand ligatures are
sutures elicit minimal tissue reaction minimal suture reaction is desired,
single strands of suture material
and retain their strength in vivo for such as in contaminated and
used to ligate a vessel, duct, or other
extended periods. ETHIBOND* infected wounds to minimize
structure. After a hemostat or other
EXCEL sutures are used primarily in later sinus formation and suture
similar type of surgical clamp has
cardiovascular surgery, for vessel extrusion. They are available clear
been placed on the end of the
anastomosis, and placement of or dyed blue.
structure, the suture strand is tied
prosthetic materials. around the vessel under the tip of
PRONOVA* POLY
ETHIBOND EXCEL sutures (HEXAFLUOROPROPYLENE-VDF) the hemostat. The hemostat is
are also available attached SUTURE removed after the first throw and
to TFE polymer felt pledgets. This monofilament nonabsorbable the surgeon tightens the knot using
Pledgets serve to prevent possible suture is a polymer blend of poly his or her fingertips, taking care to
tearing of adjacent friable tissue. (vinylidene fluoride) and poly avoid instrument damage to the
CHAPTER 2 19
CONTINUOUS SUTURES
Also referred to as running stitches,
FIGURE
1 continuous sutures are a series of
stitches taken with one strand of
LIGATURES material. The strand may be tied to
itself at each end, or looped, with
both cut ends of the strand tied
Free tie Stick tie together. A continuous suture line
can be placed rapidly. It derives its
strength from tension distributed
evenly along the full length of the
suture strand. However, care must
FIGURE be taken to apply firm tension,
2
rather than tight tension, to avoid
CONTINUOUS
SUTURING INTERRUPTED
Two strands knotted at TECHNIQUES SUTURING
Looped suture, knotted each end and knotted in TECHNIQUES
at one end the middle FIGURE
3
Simple interrupted
Over-and-over running
Running locked suture stitch
* Trademark
ABSORBABLE SUTURES
SUTURE TYPES COLOR OF RAW MATERIAL TENSILE STRENGTH ABSORPTION RATE TISSUE REACTION
MATERIAL RETENTION in vivo
Surgical Gut Plain Yellowish-tan Collagen derived from Individual patirent characteristics can Absorbed by proleolytic Moderate reaction
Suture healthy beef and sheep. affect rate of tensile strength loss. enzymatic digestive
Blue Dyed process.
Surgical Gut Chromic Brown Collagen derived from Individual patirent characteristics can Absorbed by proleolytic Moderate reaction
Suture healthy beef and sheep. affect rate of tensile strength loss. enzymatic digestive
Blue Dyed process.
Coated Braided Undyed Copolymer of lactide Approximately 50% remains at 5 Essentially complete Minimal to moderate
VICRYL* RAPIDE (Natural) and glycolide coated days. All tensile strength is lost at between 42 days. acute inflammatory
(polyglactin 910) with 370 and calcium approximately 14 days. Absorbed by hydrolysis. reaction
Suture stearate.
MONOCRYL* Monofilament Undyed Copolymer of Approximately 50-60% (violet: 60-70%) Complete at 91-119
Minimal acute
(poliglecaprone 25) (Natural) glycolide and remains at 1 week. Approximately 20- days. Absorbed by inflammatory reaction
Suture epsilon-caprolactone. 30% (violet: 30-40%) remains at 2 weeks. hydrolysis.
Violet Lost within 3 weeks (violet: 4 weeks).
Coated VICRYL* Braided Undyed Copolymer of lactide Approximately 75% remains at two Essentially complete Minimal acute
Plus Antibacterial (Natural) and glycolide coated weeks. Approximately 50% remains between 56-70 days. inflammatory reaction
(polyglactin 910) Monofilament with 370 and calcium at three weeks, 25% at four weeks. Absorbed by hydrolysis.
Suture Violet stearate.
Coated VICRYL* Braided Violet Copolymer of lactide Approximately 75% remains at two Essentially complete Minimal acute
(polyglactin 910) and glycolide coated weeks. Approximately 50% remains between 56-70 days. inflammatory reaction
Suture Monofilament Undyed with 370 and calcium at three weeks, 25% at four weeks. Absorbed by hydrolysis.
(Natural) stearate.
PDS* II Monofilament Violet Polyester polymer. Approximately 70% remains at 2 weeks. Minimal until about 90th Slight reaction
(polydioxanone) Approximately 50% remains at 4 weeks. day. Essentially complete
Blue
Suture Approximately 25% remains at 6 weeks. within 6 months. Absorbed
Clear by slow hydrolysis.
NONABSORBABLE SUTURES
PERMA-HAND* Braided Violet Organic protein called Progressive degradation of fiber may Gradual encapsulation Acute inflammatory
Silk Suture fibrin. result in gradual loss of tensile by fibrous connective reaction
White strength over time. tissue.
Surgical Stainless Monofilament Silver metallic 316L stainless steel. Indefinate. Nonabsorbable. Minimal acute
Steel Suture inflammatory reaction
Mulifilament
ETHILON* Monofilament Violet Long-chain aliphatic Progressive hydrolysis may result in Gradual encapsulation Minimal acute
Nylon Suture polymers Nylon 6 or gradual loss of tensile strength over by fibrous connective inflammatory reaction
Green
Nylon 6,6. time. tissue.
Undyed (Clear)
NUROLON* Braided Violet Long-chain aliphatic Progressive hydrolysis may result in Gradual encapsulation Minimal acute
Nylon Suture polymers Nylon 6 or gradual loss of tensile strength over by fibrous connective inflammatory reaction
Green
Nylon 6,6. time. tissue.
Undyed (Clear)
MERSILENE* Braided Green Poly (ethylene No significant change known to Gradual encapsulation Minimal acute
Polyester Fiber terephthalate). occur in vivo. by fibrous connective inflammatory reaction
Suture Monofilament Undyed (White) tissue.
ETHIBOND* Braided Green Poly (ethylene No significant change known to Gradual encapsulation Minimal acute
EXCEL Polyester terephthalate) coated occur in vivo. by fibrous connective inflammatory reaction
Fiber Suture Undyed (White) with polybutilate. tissue.
PROLENE* Monofilament Clear Isotactic crystalline No subject to degradation or Nonabsorbable. Minimal acute
Polypropylene stereoisomer of weakening by action of tissue inflammatory reaction
Suture Blue polypropylene. enzymes.
PRONOVA* Monofilament Blue Polymer blend of poly No subject to degradation or Nonabsorbable. Minimal acute
POLY (hexafluoro- (vinylidene fluoride) weakening by action of tissue inflammatory reaction
propylene-VDF) and poly (vinylidene enzymes.
Suture fluoride-cohexafluoro-
propylene).
CONTRAINDICATIONS FREQUENT USES HOW SUPPLIED COLOR CODE
OF PACKETS TABLE
Being absorbable, should not be used General soft tissue approximation 7-0 thru 3 with and without needles, Yellow 5
where extended approximation of tissues and/or ligation, including use in and on LIGAPAK dispensing reels
under stress is required. Should not be ophthalmic procedures. Not for use 0 thru 1 with CONTROL SUTURING
used in patients with known sensitivities in cardiovascular and neurological RELEASE needles
or allergies to collagen or chromium. tissues. OPTIONS:
MATERIALS,
Being absorbable, should not be used General soft tissue approximation 7-0 thru 3 with and without needles, Beige
where extended approximation of tissues and/or ligation, including use in and on LIGAPAK dispensing reels CHARACTERISTICS,
under stress is required. Should not be ophthalmic procedures. Not for use 0 thru 1 with CONTROL AND APPLICATIONS
used in patients with known sensitivities in cardiovascular and neurological RELEASE needles
or allergies to collagen or chromium. tissues.
Should not be used where extended Superficial soft tissue approximation 5-0 thru 1 with needles Red
approximation of tissue under stress is of skin and mucosa only. Not for use
required or where wound support beyond in ligation, ophthalmic, cardiovascu-
7 days is required. lar or neurological procedures.
Being absorbable, should not be used General soft tissue approximation 6-0 thru 2 with and without needles Coral
where extended approximation of tissue and/or ligation. Not for use in car- 3-0 thru 1 with CONTROL
under stress is required. Undyed not diovascular and neurological tissues, RELEASE needles
indicated for use in fascia. microsurgery, or ophthalmic surgery.
Being absorbable, should not be used General soft tissue approximation 5-0 thru 2 with and without needles Violet
where extended approximation of tissue and/or ligation. Not for use in cardio-
is required. vascular and neurological tissues.
Being absorbable, should not be used General soft tissue approximation 8-0 thru 3 with and without needles, Violet
where extended approximation of tissue and/or ligation, including use in and on LIGAPAK dispensing reels
ophthalmic procedures. Not for use in 4-0 thru 2 with CONTROL RELEASE
is required. needles; 8-0 with attached beads for
cardiovascular and neurological tissues. ophthalmic use
Being absorbable, should not be used where All types of soft tissue approxima- 9-0 thru 2 with needles Silver
prolonged approximation of tissues under tion, including pediatric cardiovascu- 4-0 thru 2 with CONTROL
stress is required. Should not be used with lar and ophthalmic procedures. Not RELEASE needles
prosthetic devices, such as heart valves or for use in adult cardiovascular tissue, 9-0 thru 7-0 with needles
synthetic grafts. microsurgery, and neural tissue. 7-0 thru 1 with needles
Should not be used in patients with General soft tissue approximation 9-0 thru 5 with and without needles, Light Blue
known sensitivities or allergies to silk. and/or ligation, including and on LIGAPAK dispensing reels
cardiovascular, ophthalmic and 4-0 thru 1 with CONTROL
neurological procedures. RELEASE needles
Should not be used in patients with Abdominal wound closure, hernia 10-0 thru 7 with and without needles Yellow-Ochre
known sensitivities or allergies to 316L repair, sternal closure and orthoaedic
stainless steel, or constituent metals such procedures including cerclage and
as chromium and nickel. tendon repair.
Should not be used where permanent General soft tissue approximation 11-0 thru 2 with and without needles Mint Green
retention of tensile strength is required. and/or ligation, including
cardiovascular, ophthalmic and
neurological procedures.
Should not be used where permanent General soft tissue approximation 6-0 thru 1 with and without needles Mint Green
retention of tensile strength is required. and/or ligation, including 4-0 thru 1 with CONTROL
cardiovascular, ophthalmic and RELEASE needles
neurological procedures.
None known. General soft tissue approximation 6-0 thru 5 with and without needles Turquoise
and/or ligation, including 10-0 and 11-0 for ophthalmic (green
cardiovascular, ophthalmic and monofilament); 0 with CONTROL
neurological procedures. RELEASE needles
None known. General soft tissue approximation 7-0 thru 5 with and without needles Orange
and/or ligation, including 4-0 thru 1 with CONTROL
cardiovascular, ophthalmic and RELEASE needles; various sizes
neurological procedures. attached to TFE polymer pledgets
None known. General soft tissue approximation 6-0 thru 2 (clear) with and without Deep Blue
and/or ligation, including needles; 10-0 thru 8-0 and 6-0 thru 2
with and without needles; 0 thru 2 with
cardiovascular, ophthalmic and CONTROL RELEASE needles; various
neurological procedures. sizes attached to TFE polymer pledgets
None known. General soft tissue approximation 6-0 through 5-0 with TAPERCUT* Royal Blue
and/or ligation, including surgical needle
cardiovascular, ophthalmic and 8-0 through 5-0 with taper point
neurological procedures. needle
* Trademark
22 THE SUTURE
tissue strangulation. Excessive
tension and instrument damage
should be avoided to prevent suture FIGURE
breakage which could disrupt the 4
entire line of a continuous suture. DEEP
SUTURES
Continuous suturing leaves less
foreign body mass in the wound.
In the presence of infection, it may
be desirable to use a monofilament
suture material because it has no
interstices which can harbor
microorganisms. This is especially
critical as a continuous suture
line can transmit infection along
the entire length of the strand. A
continuous one layer mass closure
may be used on peritoneum and/or
fascial layers of the abdominal wall
to provide a temporary seal during FIGURE
5
the healing process.
PURSE-STRING
INTERRUPTED SUTURES SUTURES
Interrupted sutures use a number
of strands to close the wound.
Each strand is tied and cut after
insertion. This provides a more secure
closure, because if one suture breaks,
the remaining sutures will hold the
wound edges in approximation.
Interrupted sutures may be used
if a wound is infected, because
microorganisms may be less
likely to travel along a series of nique is useful when using large organ prior to insertion of a tube
interrupted stitches. diameter permanent sutures on (such as the aorta, to hold the
deeper layers in thin patients who cannulation tube in place during
DEEP SUTURES may be able to feel large knots that an open heart procedure).
Deep sutures are placed completely are not buried.
under the epidermal skin layer. SUBCUTICULAR SUTURES
They may be placed as continuous PURSE-STRING SUTURES Subcuticular sutures are continuous
or interrupted sutures and are not Purse-string sutures are continuous or interrupted sutures placed in the
removed postoperatively. sutures placed around a lumen and dermis, beneath the epithelial layer.
tightened like a drawstring to Continuous subcuticular sutures are
BURIED SUTURES invert the opening. They may be placed in a line parallel to the
Buried sutures are placed so that the placed around the stump of the wound. This technique involves
knot protrudes to the inside, under appendix, in the bowel to secure an taking short, lateral stitches the full
the layer to be closed. This tech- intestinal stapling device, or in an length of the wound. After the
CHAPTER 2 23
Other materials are cut closer to the be removed easily without cutting. 7. Don't store surgical gut
knot, approximately 1/8" (3mm), A common practice is to cover the near heat.
to decrease tissue reaction and skin sutures with PROXI-STRIP*
8. Moisten—but never soak—
minimize the amount of foreign skin closures during the required
surgical gut.
material left in the wound. To healing period. After the wound
ensure that the actual knot is not edges have regained sufficient tensile 9. Do not wet rapidly absorbing
cut, twist or angle the blades of the strength, the sutures may be sutures.
scissors prior to cutting. removed by simply removing the
10. Keep silk dry.
Make certain to remove the PROXI-STRIP skin closures.
cut ends of the suture from the 11. Wet linen and cotton to increase
operative site. their strength.
SUTURE
12. Don't bend stainless steel wire.
HANDLING TIPS
SUTURE REMOVAL These guidelines will help the surgical 13. Draw nylon between gloved
When the external wound has team keep their suture inventory up fingers to remove the packaging
healed so that it no longer needs the to date and their sutures in the best "memory."
support of nonabsorbable suture possible condition. 14. Arm a needleholder properly.
material, skin sutures must be 1. Read labels.
removed. The length of time the
sutures remain in place depends 2. Heed expiration dates and SUTURE SELECTION
upon the rate of healing and the rotate stock. PROCEDURE
nature of the wound. General rules 3. Open only those sutures needed PRINCIPLES OF
are as follows. for the procedure at hand. SUTURE SELECTION
Sutures should be removed using 4. Straighten sutures with a gentle The surgeon has a choice of suture
aseptic and sterile technique. The pull. Never crush or rub them. materials from which to select for
surgeon uses a sterile suture removal use in body tissues. Adequate
tray prepared for the procedure. 5. Don't pull on needles. strength of the suture material will
The following steps are taken: 6. Avoid crushing or crimping prevent suture breakage. Secure
• STEP 1—Cleanse the area with suture strands with surgical knots will prevent knot slippage.
an antiseptic. Hydrogen peroxide instruments. But the surgeon must understand
can be used to remove dried serum the nature of the suture material,
encrusted around the sutures.
• STEP 2—Pick up one end of the
suture with thumb forceps, and
cut as close to the skin as possible FIGURE
where the suture enters the skin. 9
• STEP 3—Gently pull the suture ARMING
strand out through the side oppo- A NEEDLE-
site the knot with the forceps. To HOLDER
prevent risk of infection, the suture PROPERLY
should be removed without pulling
any portion that has been outside
the skin back through the skin.
NOTE: Fast absorbing synthetic or
gut suture material tend to lose all
tensile strength in 5 to 7 days and can Grasp the needle one-third to one-half of the distance from
the swaged end to the point.
* Trademark
28 THE SUTURE
the biologic forces in the healing Therefore: closure. Wounds of the stomach and
wound, and the interaction of a. In the urinary and biliary intestine are rich in blood supply
the suture and the tissues. The tracts, use rapidly absorbed and may become edematous and
following principles should guide sutures. hardened. Tight sutures may cut
the surgeon in suture selection. 5. Regarding suture size: through the tissue and cause
1. When a wound has reached a. Use the finest size suture leakage. A leak-proof anastomosis
maximal strength, sutures are no commensurate with the can be achieved with either a
longer needed. Therefore: natural strength of the tissue. single or double-layer closure.
a. Tissues that ordinarily heal b. If the postoperative course of
For a single-layer closure, interrupt-
slowly such as skin, fascia, the patient may produce
ed sutures should be placed
and tendons should usually sudden strains on the suture
approximately 1/4" (6mm) apart.
be closed with nonabsorbable line, reinforce it with
Suture is placed through the
sutures. An absorbable suture retention sutures. Remove
submucosa, into the muscularis and
with extended (up to 6 them as soon as the patient’s
through the serosa. Because the
months) wound support may condition is stabilized.
submucosa provides strength in
also be used. the gastrointestinal tract, effective
b. Tissues that heal rapidly SURGERY WITHIN THE
closure involves suturing the
such as stomach, colon and ABDOMINAL WALL CAVITY
submucosal layers in apposition
bladder may be closed with Entering the abdomen, the surgeon
without penetrating the mucosa.
absorbable sutures will need to seal or tie off
A continuous suture line provides a
2. Foreign bodies in potentially subcutaneous blood vessels
tighter seal than interrupted sutures.
contaminated tissues may convert immediately after the incision is
However, if a continuous suture
contamination into infection. made, using either an electrosurgical
breaks, the entire line may separate.
3. Where cosmetic results are unit designed for this purpose or
important, close and prolonged free ties (ligatures). If ligatures are Many surgeons prefer to use a
apposition of wounds and used, an absorbable suture material double-layer closure, placing a
avoidance of irritants will is generally preferred. When second layer of interrupted sutures
produce the best results. preparing the ties, the scrub person through the serosa for insurance.
Therefore: often prepares one strand on a Absorbable VICRYL* sutures, or
a. Use the smallest inert needle for use as a suture ligature chromic gut sutures may be used
monofilament suture should the surgeon wish to in either a single or double-layer
materials such as nylon transfix a large blood vessel. closure. Surgical silk may also be
or polypropylene. Once inside, the type of suture used for the second layer of a
b. Avoid skin sutures and close double-layer closure.
subcuticularly whenever selected will depend upon the Inverted, everted, or end-to-end
possible. nature of the operation and the closure techniques have all been
c. Under certain circumstances, surgeon's technique. used successfully in this area, but
to secure close apposition of they all have drawbacks. The
THE GASTROINTESTINAL TRACT surgeon must take meticulous care
skin edges, a topical skin
adhesive or skin closure Leakage from an anastomosis in placing the sutures in the submu-
tape may be used. or suture site is the principal cosa. Even with the best technique,
4. Foreign bodies in the presence problem encountered performing some leakage may occur.
of fluids containing high concen- a procedure involving the Fortunately, the omentum usually
trations of crystalloids may act gastrointestinal tract. This problem confines the area, and natural body
as a nidus for precipitation and can lead to localized or generalized defenses handle the problem.
stone formation. peritonitis. Sutures should not be
tied too tightly in an anastomotic
CHAPTER 2 29
with absorbable suture material is always closed. The anterior layer monofilament absorbable material
is usually preferred. Interrupted may be cut and may also require like PDS II sutures or inert nonab-
sutures can also be used for suturing. Mass closure techniques sorbable sutures like stainless steel or
this procedure. are becoming the most popular. PROLENE* sutures may be used.
FIGURE
14
SURGICAL
OPTIONS IN
MUSCLE
* Trademark
32 THE SUTURE
and the anterior fascial layer. size of material used earlier to ligate of maintaining sufficient tensile
The interrupted sutures resemble a blood vessels in this layer. strength through the collagen
"figure of eight" when placed. synthesis stage of healing which
Absorbable PDS II sutures or SUBCUTICULAR TISSUE lasts approximately 6 weeks. The
VICRYL* sutures are usually used. To minimize scarring, suturing sutures must not be placed too
the subcuticular layer of tough close to the epidermal surface to
Stainless steel sutures may also be
connective tissue will hold the skin reduce extrusion. If the skin is
used. Monofilament PROLENE
edges in close approximation. In a nonpigmented and thin, a clear or
sutures also provide all the
single-layer subcuticular closure, less white monofilament suture such
advantages of steel sutures: strength,
evidence of scar gaping or expansion as MONOCRYL suture will be
minimal tissue reactivity, and
may be seen after a period of 6 to 9 invisible to the eye. MONOCRYL
resistance to bacterial contamination.
months than is evident with simple suture is particularly well-suited for
They are better tolerated than steel
skin closure. The surgeon takes this closure because, as a monofila-
sutures by patients in the late
continuous short lateral stitches ment, it does not harbor infection
postoperative months and are easier
beneath the epithelial layer of skin. and, as a synthetic absorbable
for the surgeon to handle and tie.
Either absorbable or nonabsorbable suture, tissue reaction is minimized.
However, both stainless steel and
sutures may be used. If nonab- After this layer is closed, the skin
PROLENE sutures may be
sorbable material is chosen, one end edges may then be approximated.
detectable under the skin of thin
of the suture strand will protrude
patients. To avoid this problem,
from each end of the incision, and SKIN
knots should be buried in fascia
the surgeon may tie them together Skin is composed of the epithelium
instead of in the subcutaneous space.
to form a "loop" or knot the ends and the underlying dermis. It is so
outside of the incision. tough that a very sharp needle is
SUBCUTANEOUS FAT
essential for every stitch to minimize
Neither fat nor muscle tolerate To produce only a hair-line scar
tissue trauma. (See Chapter 3: The
suturing well. Some surgeons (on the face, for example), the
Surgical Needle.)
question the advisability of placing skin can be held in very close
sutures in fatty tissue because it approximation with skin closure Skin wounds regain tensile strength
has little tensile strength due to tapes in addition to subcuticular slowly. If a nonabsorbable suture
its composition, which is mostly sutures. Tapes may be left on the material is used, it is typically
water. However, others believe it wound for an extended period of removed between 3 and 10 days
is necessary to place at least a time depending upon their location postoperatively, when the wound
few sutures in a thick layer of on the body. has only regained approximately
subcutaneous fat to prevent dead 5% to 10% of its strength. This is
When great tension is not placed
space, especially in obese patients. possible because most of the stress
upon the wound, as in facial or
Dead spaces are most likely to placed upon the healing wound is
neck surgery, very fine sizes of
occur in this type of tissue, so absorbed by the fascia, which the
subcuticular sutures may be used.
the edges of the wound must be surgeon relies upon to hold the
Abdominal wounds that must
carefully approximated. Tissue wound closed. The skin or
withstand more stress call for larger
fluids can accumulate in these subcuticular sutures need only be
suture sizes.
pocket-like spaces, delaying healing strong enough to withstand natural
and predisposing infection. Some surgeons choose to close skin tension and hold the wound
Absorbable sutures are usually both the subcuticular and epidermal edges in apposition.
selected for the subcutaneous layer. layers to achieve minimal scarring.
The use of coated VICRYL*
VICRYL* suture is especially suited Chromic surgical gut and polymeric
RAPIDE suture, a rapidly absorbed
for use in fatty, avascular tissue since materials, such as MONOCRYL*
synthetic suture, eliminates the
it is absorbed by hydrolysis. The suture, are acceptable for placement
need for suture removal. Coated
surgeon may use the same type and within the dermis. They are capable
CHAPTER 2 33
VICRYL RAPIDE suture, which a lower tissue reaction than chromic relatively rare if the skin sutures are
is indicated for superficial closure gut suture due to its accelerated not placed with excessive tension
of skin and mucosa, provides absorption profile.) The key to and are removed by the seventh
short-term wound support success is early suture removal postoperative day.
consistent with the rapid healing before epithelialization of the suture
The forces that create the distance
characteristics of skin. The sutures tract occurs and before contamina-
between the edges of the wound
begin to fall off in 7 to 10 days, tion is converted into infection.
will remain long after the sutures
with absorption essentially
A WORD ABOUT SCARRING
have been removed. Significant
complete at 42 days.
(EPITHELIALIZATION) collagen synthesis will occur from
Suturing technique for skin When a wound is sustained in 5 to 42 days postoperatively. After
closure may be either continuous the skin—whether accidentally or this time, any additional gain in
or interrupted. Skin edges should during a surgical procedure—the tensile will be due to remodeling,
be everted. Preferably, each suture epithelial cells in the basal layer at or crosslinking, of collagen fibers
strand is passed through the skin the margins of the wound flatten rather than to collagen synthesis.
only once, reducing the chance and move into the wound area. Increases in tensile strength will
of cross-contamination across the They move down the wound edge continue for as long as 2 years, but
entire suture line. Interrupted until they find living, undamaged the tissue will never quite regain its
technique is usually preferred. tissue at the base of the wound. original strength.
If surgeon preference indicates Then they move across the wound
CLOSURE WITH
the use of a nonabsorbable suture bed to make contact with similar
RETENTION SUTURES
material, several issues must be cells migrating from the opposite
We have already discussed the
considered. Skin sutures are exposed side of the wound. They move
techniques involved with placing
to the external environment, down the suture tract after if has
retention sutures, and using them
making them a serious threat been embedded in the skin. When
in a secondary suture line. (See the
to wound contamination and the suture is removed, the tract of
section on Suturing Techniques.)
stitch abscess. The interstices of the epithelial cells remains.
Heavy sizes (0 to 5) of nonabsorbable
multifilament sutures may provide Eventually, it may disappear, but
materials are usually used for
a haven for microorganisms. some may remain and form keratin.
retention sutures, not for strength,
Therefore, monofilament nonab- A punctate scar is usually seen on
but because larger sizes are less likely
sorbable sutures may be preferred for the skin surface and a "railroad
to cut through tissue when a sudden
skin closure. Monofilament sutures track" or "crosshatch" appearance
rise in intra-abdominal pressure
also induce significantly less tissue on the wound may result. This is
occurs from vomiting, coughing,
reaction than multifilament sutures.
For cosmetic reasons, nylon or
polypropylene monofilament sutures
may be preferred. Many skin FIGURE
wounds are successfully closed with 15
silk and polyester multifilaments
as well. Tissue reaction to nonab- THE RAILROAD
sorbable sutures subsides and TRACK SCAR
CONFIGURATION
remains relatively acellular as
fibrous tissue matures and forms a
dense capsule around the suture.
(Note, surgical gut has been known
to produce tissue reaction. Coated
VICRYL* RAPIDE suture elicits
* Trademark
34 THE SUTURE
straining, or distention. To prevent Retention sutures may be left in A drainage tube inserted into the
the heavy suture material from place for 14 to 24 days postopera- peritoneal cavity through a stab
cutting into the skin under stress, tively. Three weeks is an average wound in the abdominal wall
one end of the retention suture may length of time. Assessment of the usually is anchored to the skin with
be threaded through a short length patient's condition is the controlling one or two nonabsorbable sutures.
of plastic or rubber tubing called a factor in deciding when to remove This prevents the drain from
bolster or bumper before it is tied. A retention sutures. slipping into or out of the wound.
plastic bridge with adjustable
features may also be used to protect SUTURE FOR DRAINS SUTURE NEEDS IN OTHER
the skin and primary suture line If a drainage tube is placed in a BODY TISSUES NEUROSURGERY
and permit postoperative wound hollow organ or a bladder drain is Surgeons have traditionally used an
management for patient comfort. inserted, it may be secured to the interrupted technique to close the
wall of the organ being drained galea and dura mater.
Properly placed retention sutures with absorbable sutures. The surgeon
provide strong reinforcement for The tissue of the galea, similar to
may also choose to minimize the the fascia of the abdominal cavity,
abdominal wounds, but also cause distance between the organ and the
the patient more postoperative pain is very vascular and hemostatic.
abdominal wall by using sutures to Therefore, scalp hematoma is a
than does a layered closure. The tack the organ being drained to the
best technique is to use a material potential problem, and the surgeon
peritoneum and fascia. must be certain to close well.
with needles swaged on each end Sutures may be placed around the
(double-armed). They should be The dura mater is the outermost of
circumference of the drain, either the three meninges that protects the
placed from the inside of the wound two sutures at 12 and 6 o'clock
toward the outside skin to avoid brain and spinal cord. It tears with
positions, or four sutures at 12, 3, ease and cannot withstand too
pulling potentially contaminated 6, and 9 o'clock positions, and
epithelial cells through the entire much tension. The surgeon may
secured to the skin with temporary drain some of the cerebrospinal
abdominal wall. loops. When the drain is no longer fluid to decrease volume, easing the
The ETHICON retention needed, the skin sutures may be tension on the dura before closing.
suture line includes ETHILON* easily removed to remove the drain. If it is too damaged to close, a
sutures, MERSILENE* sutures, The opening can be left open to patch must be inserted and sutured
ETHIBOND* EXCEL sutures, and permit additional drainage until it in place.
PERMA-HAND* sutures. Surgical closes naturally.
steel sutures may also be used. Surgical silk is appropriate in this
area for its pliability and easy knot
tying properties. Unfortunately,
it elicits a significant foreign body
FIGURE tissue reaction. Most surgeons have
16 switched to NUROLON* sutures
or coated VICRYL* sutures because
PLACEMENT they tie easily, offer greater strength
OF SUTURES
than surgical silk, and cause less
AROUND
A DRAIN tissue reaction. PROLENE* sutures
have also been accepted by surgeons
who prefer a continuous closure
technique, who must repair
potentially infected wounds, or
who must repair dural tears.
CHAPTER 2 35
In peripheral nerve repair, precise OPHTHALMIC SURGERY surgical gut and behave dependably,
suturing often requires the aid of The eye presents special healing VICRYL sutures have proven useful
an operating microscope. Suture challenges. The ocular muscles, the in muscle and cataract surgery.
gauge and needle fineness must be conjunctiva, and the sclera have good
While some ophthalmic surgeons
consistent with nerve size. After blood supplies; but the cornea is an
promote the use of a "no-stitch"
the motor and sensory fibers are avascular structure. While epithelial-
surgical technique, 10-0 coated
properly realigned, the epineurium ization of the cornea occurs rapidly
VICRYL (polyglactin 910) violet
(the outer sheath of the nerve) is in the absence of infection, full
monofilament sutures offer distinct
sutured. The strength of sutures in thickness cornea wounds heal slowly.
advantages. They provide the securi-
this area is less of a consideration Therefore, in closing wounds such as
ty of suturing immediately follow-
than the degree of inflammatory cataract incisions, sutures should
ing surgery but eliminate the risks
and fibroplastic tissue reaction. remain in place for approximately
of suture removal and related
Fine sizes of nylon, polyester, and 21 days. Muscle recession, which
endophthalmitis.
poly-propylene are preferred. involves suturing muscle to
sclera, only requires sutures for The ophthalmologist has many
MICROSURGERY approximately 7 days. fine size suture materials to choose
The introduction of fine sizes of from for keratoplasty, cataract,
Nylon was the preferred suture
sutures and needles has increased and vitreous retinal microsurgical
material for ophthalmic surgery.
the use of the operating microscope. procedures. In addition to
While nylon is not absorbed,
ETHICON introduced the first VICRYL* sutures, other monofila-
progressive hydrolysis of nylon
microsurgery sutures—ETHILON* ment suture materials including
in vivo may result in gradual loss of
sutures—in sizes 8-0 through ETHILON sutures, PROLENE
tensile strength over time. Fine sizes
11-0. Since then, the microsurgery sutures, and PDS* II sutures may
of absorbable sutures are currently
line has expanded to include be used. Braided material such as
used for many ocular procedures.
PROLENE* sutures and coated virgin silk, black braided silk,
Occasionally, the sutures are
VICRYL* sutures. Literally all MERSILENE* sutures, and coated
absorbed too slowly in muscle
surgical specialties perform some VICRYL sutures are also available
recessions and produce granulomas
procedures under the operating for ophthalmic procedures.
to the sclera. Too rapid absorption
microscope, especially vascular and
has, at times, been a problem in UPPER ALIMENTARY
nerve anastomosis.
cataract surgery. Because they TRACT PROCEDURES
induce less cellular reaction than The surgeon must consider the
upper alimentary tract from the
mouth down to the lower
Skin Galea esophageal sphincter to be a
Skull
FIGURE potentially contaminated area.
17 The gut is a musculomembranous
canal lined with mucus membranes.
LAYERS
Final healing of mucosal wounds
OF SUTURES
SURROUNDING appears to be less dependent upon
A DRAIN suture material than on the wound
closure technique.
The oral cavity and pharynx
generally heal quickly if not infected.
Fine size sutures are adequate in this
Brain
Dura mater area as the wound is under little
tension. Absorbable sutures may be
* Trademark
36 THE SUTURE
preferred. Patients, especially
children, usually find them more
FIGURE
comfortable. However, the surgeon 18
Ocular muscles
may prefer a monofilament
nonabsorbable suture under certain THE EYE
circumstances. This option causes Conjunctiva
less severe tissue reaction than
multifilament materials in buccal Cornea
mucosa, but also requires suture
removal following healing. Sclera
In cases involving severe
periodontitis, VICRYL periodontal
mesh may be used to promote tissue
regeneration, a technique that
enhances the regeneration and
attachment of tissue lost due to
periodontitis. VICRYL periodontal
mesh, available in several shapes and Oral cavity FIGURE
sizes with a preattached VICRYL 19
ligature, is woven from the same
copolymer used to produce THE UPPER
absorbable VICRYL* suture. As a ALIMENTARY
synthetic absorbable, VICRYL* CANAL
periodontal mesh eliminates the
trauma associated with a second
surgical procedure and reduces the
risk of infection or inflammation
associated with this procedure.
The esophagus is a difficult organ Esophagus
to suture. It lacks a serosal layer.
The mucosa heals slowly. The thick
muscular layer does not hold sutures
well. If multifilament sutures are
used, penetration through the FIGURE
mucosa into the lumen should be 20
avoided to prevent infection.
BRONCHIAL
RESPIRATORY STUMP
TRACT SURGERY CLOSURE
Relatively few studies have been
done on healing in the respiratory
tract. Bronchial stump closure
following lobectomy or pneumonec-
tomy presents a particular challenge.
Infection, long stumps, poor
approximation of the transected
CHAPTER 2 37
CARDIOVASCULAR SURGERY
Although definitive studies are few,
blood vessels appear to heal rapidly.
Most cardiovascular surgeons prefer
to use synthetic nonabsorbable
sutures for cardiac and peripheral
vascular procedures. Lasting strength
FIGURE and leakproof anastomoses are essen-
23 tial. Wire sutures are used on the
sternum unless it is fragile, in which
THE BUNNELL case absorbable sutures can be used.
TECHNIQUE
VESSELS
Excessive tissue reaction to suture
material may lead to decreased
luminal diameter or to thrombus
formation in a vessel. Therefore,
the more inert synthetics including
nylon and polypropylene are
the materials of choice for vessel
* Trademark
38 THE SUTURE
anastomoses. Multifilament Clinical studies suggest that a EXCEL suture around the cuff of
polyester sutures allow clotting to prolonged absorbable suture, such as the valve before tying the knots.
occur within the interstices which PDS* II suture, may be ideal, giving
Some surgeons routinely use
helps to prevent leakage at the adequate short-term support while
pledgets to buttress sutures in valve
suture line. The advantages of a permitting future growth.
surgery. They are used most
material such as ETHIBOND*
Following vascular trauma, mycotic commonly in valve replacement
EXCEL sutures are its strength,
aneurysms from infection are procedures to prevent the annulus
durability, and slippery surface
extremely serious complications. from tearing when the prosthetic
which causes less friction when
A suture may act as a nidus for valve is seated and the sutures are
drawn through a vessel. Many
an infection. In the presence of tied. They may also be used in heart
surgeons find that PROLENE*
infection, the chemical properties wall closure of penetrating injuries,
sutures, PRONOVA* sutures, or
of suture material can cause excising aneurysms, vascular graft
silk are ideal for coronary artery
extensive tissue damage which may surgery, and to add support when
procedures because they do not
reduce the tissue's natural ability the surgeon encounters extreme
"saw" through vessels.
to combat infection. Localized deformity, distortion, or tissue
Continuous sutures provide a more sepsis can also spread to adjacent destruction at the annulus.
leakproof closure than interrupted vascular structures, causing necrosis
sutures in large vessel anastomoses of the arterial wall. Therefore, the URINARY TRACT SURGERY
because the tension along the surgeon may choose a monofilament Closure of tissues in the urinary
suture strand is distributed evenly suture material that causes only a tract must be leakproof to prevent
around the vessel's circumference. mild tissue reaction and resists escape of urine into surrounding
Interrupted monofilament sutures bacterial growth. tissues. The same considerations
such as ETHILON* sutures, that affect the choice of sutures for
PROLENE* sutures, or VASCULAR PROSTHESES the biliary tract affect the choice of
PRONOVA* sutures are used for The fixation of vascular prostheses sutures for this area. Nonabsorbable
microvascular anastomoses. and artificial heart valves presents an sutures incite the formation of cal-
When anastomosing major vessels entirely different suturing challenge culi, and therefore cannot be used.
in young children, special care than vessel anastomosis. The sutures Surgeons use absorbable sutures as a
must be taken to anticipate the must retain their original physical rule, especially MONOCRYL*
future growth of the patient. properties and strength throughout sutures, PDS II sutures, VICRYL*
Here, the surgeon may use silk to the life of the patient. A prosthesis sutures, Coated VICRYL* sutures,
its best advantage, because it loses never becomes completely incorpo- and chromic gut sutures.
much of its tensile strength after rated into the tissue and constant The urinary tract heals rapidly. The
approximately 1 year, and is usually movement of the suture line occurs. transitional cell epithelium migrates
completely absorbed after 2 or more Coated polyester sutures are the over the denuded surfaces quickly.
years. Continuous polypropylene choice for fixation of vascular Unlike other epithelium, the
sutures have been used in children prostheses and heart valves because migrating cells in the urinary tract
without adverse effects. The they retain their strength and undergo mitosis and cell division.
continuous suture, when placed, integrity indefinitely. Epithelial migration may be found
is a coil which stretches as the along suture tracts in the body of
Either a continuous or interrupted
child grows to accommodate the the bladder. The bladder wall
technique may be used for vessel to
changing dimensions of the blood regains 100% of its original tensile
graft anastomoses.
vessel. However, reports of stricture strength within 14 days. The rate of
following vessel growth have To assist in proper strand identifica- collagen synthesis peaks at 5 days
stimulated interest in use of a tion, many surgeons alternate green and declines rapidly thereafter.
suture line which is one-half and white strands of ETHIBOND*
continuous, one-half interrupted.
CHAPTER 2 39
Thus, sutures are needed for only tissue and migrate into the wound. holding structure is no longer neces-
7 to 10 days. The junction heals first with scar sary. Referred to as a pull-out suture,
tissue, then by replacement with it is brought out through the skin
THE FEMALE GENITAL TRACT new tendon fibers. Close apposition and fastened over a polypropylene
Surgery within this area presents of the cut ends of the tendon button. The Bunnell Technique
certain challenges. First, it is usually (especially extensor tendons) suture can also be left in place.
regarded as a potentially contaminat- must be maintained to achieve
ed area. Second, the surgeon must NUROLON* sutures, PROLENE*
good functional results. Both the
frequently work within a very sutures, PRONOVA* sutures and
suture material and the closure
restricted field. Endoscopic technique ETHIBOND* EXCEL sutures may
technique are critical for successful
is frequently used in this area. Coated be used for connecting tendon to
tendon repair.
VICYL* suture is an excellent choice bone. Permanent wire sutures also
to prevent bacterial colonization. The suture material the surgeon yield good results because healing is
chooses must be inert and strong. slow. In periosteum, which heals
Most gynecological surgeons prefer Because tendon ends can separate fairly rapidly, surgical gut or coated
to use absorbable sutures for repair of due to muscle pull, sutures with a VICRYL sutures may be used. In
incisions and defects. Some prefer great degree of elasticity should be fact, virtually any suture may be
using heavy, size 1 surgical gut avoided. Surgical steel is widely used used satisfactorily in the periosteum.
sutures, MONOCRYL sutures, or because of its durability and lack of
VICRYL sutures. However, the elasticity. Synthetic nonabsorbable SUTURES FOR BONE
stresses on the reproductive organs materials including polyester fibers, In repairing facial fractures,
and the rate of healing indicate that polypropylene, and nylon may be monofilament surgical steel has proven
these larger-sized sutures may only be used. In the presence of potential ideal for its lack of elasticity. Facial
required for abdominal closure. infection, the most inert monofila- bones do not heal by callus formation,
ment suture materials are preferred. but more commonly by fibrous union.
Handling properties, especially
The suture should be placed to The suture material must remain in
pliability of the sutures used for
cause the least possible interference place for a long period of time—
internal use, are extremely
with the surface of the tendon, as perhaps months—until the fibrous
important. Synthetic absorbable
this is the gliding mechanism. It tissue is laid down and remodeled.
sutures such as VICRYL* sutures in
should also not interfere with the Steel sutures immobilize the
size 0 may be used for the tough,
blood supply reaching the wound. fracture line and keep the tissues in
muscular, highly vascular tissues
Maintenance of closed apposition good apposition.
in the pelvis and vagina. These
tissues demand strength during of the cut ends of the tendons, Following median stemotomy,
approximation and healing. Coated particularly extensor tendons, is surgeons prefer interrupted steel
VICRYL* RAPIDE suture, for critical for good functional results. sutures to close. Sternum closure may
example, is an excellent choice for The parallel arrangement of tendon be difficult. Appropriate tension must
episiotomy repair. fibers in a longitudinal direction be maintained, and the surgeon must
makes permanent and secure place- guard against weakening the wire.
TENDON SURGERY ment of sutures difficult. Various Asymmetrical twisting of the wire may
Tendon surgery presents several figure-of-eight and other types of cause it to buckle, fatiguing the metal,
challenges. Most tendon injuries are suturing have been used successfully and ultimately causing the wire to
due to trauma, and the wound may to prevent suture slippage and the break. Motion between the sides of
be dirty. Tendons heal slowly. The formation of gaps between the cut the sternum will result, causing
striated nature of the tissue makes ends of the tendon. postoperative pain and possibly
suturing difficult. Many surgeons use the Bunnell dehiscence. Painful nonunion is
Tendon repair fibroblasts are Technique. The suture is placed to another possible complication. (In
derived from the peritendonous be withdrawn when its function as a osteoporotic patients, very heavy
* Trademark
40 THE SUTURE
closures (sterile tape). The wound
should be packed to maintain a moist
FIGURE environment. When the infection
24 has subsided, the surgeon can easily
reopen the wound, remove the
TACKING A packing and any tissue debris, and
PROSTHETIC then close using the previously
DEVICE IN
inserted monofilament nylon suture.
POSITION TO
PREVENT
MIGRATION
IN THE
NEXT SECTION
The surgeon depends as much upon
VICRYL sutures may be used to close when it reaches approximately 10 6 the quality and configuration of the
the sternum securely.) bacteria per gram of tissue in an needle used as on the suturing
immunologically normal host. material itself to achieve a successful
The surgeon may use a bone anchor closure. The relationship between
Inflammation without discharge
to hold one end of a suture in place needles and sutures will be explored
and/or the presence of culture-
when needed (e.g., shoulder repair on the pages that follow.
positive serous fluid indicate possible
surgery). This involves drilling a hole
infection. Presence of purulent
in the bone and inserting the anchor, REFERENCES
discharge indicates positive infection.
which expands once completely 1. Mangram AJ, Horan TC, Pearson
inside the bone to keep it from being Contaminated wounds can become ML, Silver LC, Jarvis WR. Guideline
pulled out. infected when hematomas, necrotic for prevention of surgical site
tissue, devascularized tissue, or large infection, 1999. Infection Control
OTHER PROSTHETIC DEVICES amounts of devitalized tissue and Hospital Epidemiology.
Often, it is necessary for the sur- (especially in fascia, muscle, and bone) 1999;20:247-278.
geon to implant a prosthetic device are present. Microorganisms multiply 2. Gilbert P, McBain AJ, Storch ML,
Rothenburger SJ, Barbolt TA.
such as an automatic defibrillator or rapidly under these conditions, where
Literature-based evaluation of the
drug delivery system into a patient. they are safe from cells that provide
potential risks associated with
To prevent such a device from local tissue defenses. impregnation of medical devices and
migrating out of position, it may be implants with triclosan. Surg
In general, contaminated wounds
tacked to the fascia or chest wall Infection J. 2002;3(suppl1):S55-S63.
should not be closed but should be left
with nonabsorbable sutures. 3. Rothenburger S, Spangler D,
open to heal by secondary intention
Bhende S, Burkley D. In vitro
because of the risk of infection.
CLOSING CONTAMINATED antibacterial evaluation of Coated
Foreign bodies, including sutures,
OR INFECTED WOUNDS VICRYL* Plus Antibacterial suture
perpetuate localized infection. (coated polyglactin 910 with
Contamination exists when
Therefore, the surgeon's technique triclosan) using zone of inhibition
microorganisms are present, but in
and choice of suture is critical. assays. S Infection J.
insufficient numbers to overcome the
Nonabsorbable monofilament nylon 2002;3(suppl 1):S79-S87.
body's natural defenses. Infection
sutures are commonly used in
exists when the level of contamina-
anticipation of delayed closure of
tion exceeds the tissue's ability to
dirty and infected wounds. The
defend against the invading
sutures are laid in but not tied.
microorganisms. Generally,
Instead, the loose suture ends are held
contamination becomes infection
in place with PROXI-STRIP* skin
CHAPTER 3
Manufacturers measure needle selected to achieve the highest Needle sharpness is especially
strength in the laboratory by possible surgical yield, which also important in delicate or cosmetic
bending them 90° to determine the optimizes needle strength. surgery. The sharper the needle,
needle's maximum strength. This is the less scarring that will result.
Ductility refers to the needle's
referred to as the needle's "ultimate However, the right balance must be
resistance to breaking under a given
moment," and is more important to found. If a needle is too sharp, a
amount of bending. If too great a
the needle manufacturer than to the surgeon may not feel he or she has
force is applied to a needle it may
surgeon. The most critical aspect of adequate control of needle passage
break, but a ductile needle will
needle strength to the surgeon is through tissue.
bend before breaking. Needle
the "surgical yield" point. Surgical
breakage during surgery can prevent Sharpness is related to the angle of
yield indicates the amount of
apposition of the wound edges as the point as well as the taper ratio
angular deformation the needle
the broken portion passes through of the needle. The ETHICON
can withstand before becoming
tissue. In addition, searching for sharpness tester incorporates a thin,
permanently deformed. This point
part of a broken needle can cause laminated, synthetic membrane
is usually 10° to 30° depending
added tissue trauma and add to the that simulates the density of human
upon the material and the manufac-
time the patient is anesthetized. A tissue, allowing engineers to gauge
turing process. Any angle beyond
piece that cannot be retrieved will exactly how much force is required
that point renders the needle
remain as a constant reminder to for penetration.
useless. Reshaping a bent needle
both the patient and surgeon.
may cause it to lose strength MultiPass needles have a micro-thin
Needle bending and breakage can
and be less resistant to bending coating comprised of a patented
be minimized by carefully passing
and breaking. silicone formulation that improves
needles through tissue in the
penetration performance over multiple
At ETHICON, the combination direction of the needle body.
passes. According to laboratory
of alloy selection and the needle Needles are not designed to be
tests, this coating serves several
manufacturing process are carefully used as retractors to lift tissue.
important functions:
It reduces the force needed to
make initial penetration through
FIGURE tissue; thus it is 58% sharper
12:1 ratio 1 (than other surgical needles) on
multiple passes in human tissue
TAPER
RATIO Significantly improves the consis-
tency of the needle penetration
(pass to pass, needle to needle)
Maintains sharpness for better
penetration and control over
FIGURE multiple passes while delivering
2
ongoing strength, sharpness and
control
ETHICON
RIBBED Needle performance is also
NEEDLE
influenced by the stability of the
needle in the grasp of a needlehold-
er. Most curved needles are
flattened in the grasping area to
enhance control. All ETHICON
* Trademark
44 THE SURGICAL NEEDLE
curved needles of 22 mil wire PRINCIPLES OF 1. Consider the tissue in which the
or heavier are ribbed as well as surgeon will introduce the
flattened. Longitudinal ribbing
CHOOSING A needle. Generally speaking, taper
or grooves on the inside or outside
SURGICAL NEEDLE point needles are most often used
curvatures of curved needles While there are no hard and fast to suture tissues that are easy
provides a crosslocking action in rules governing needle selection, the to penetrate. Cutting or
the needleholder for added needle following principles should be kept TAPERCUT* needles are
control. This reduces undesirable in mind. (Specific types of needles more often used in tough, hard-
rocking, twisting, and turning in mentioned here will be described in to-penetrate tissues. When in
the needleholder. full detail later on in this section.) doubt about whether to choose
a taper point or cutting needle,
choose the taper point for
everything except skin sutures.
2. Watch the surgeon's technique
FIGURE closely. Select the length,
3 diameter, and curvature of the
Point
needle according to the desired
NEEDLE placement of the suture and the
COMPONENTS space in which the surgeon
is working.
3. Consult frequently with the
Eye surgeon. Working with the same
(Swaged end) surgeon repeatedly leads to
familiarity with his or her
individual routine. However,
Body even the same surgeon may need
to change needle type or size to
meet specific requirements,
even during a single operative
procedure.
4. When using eyed needles, try to
match needle diameter to suture
size. Swaged needles, where the
needle is already attached to the
FIGURE suture strand, eliminate this
Needle Chord length 4 concern.
point Swage
5. The best general rule of thumb
ANATOMY for the scrub person to follow is
OF A NEEDLE
pay attention and remain alert to
Needle the progress of the operation.
radius
Observation is the best guide to
needle selection if the surgeon
Needle
diameter has no preference.
Needle length
Needle body
CHAPTER 3 45
THE ANATOMY The closed eye is similar to a be cut, or easily released from the
household sewing needle. The shape needle as is the case when using
OF A NEEDLE of the eye may be round, oblong, CONTROL RELEASE* needles
Regardless of its intended use, or square. French eye needles have a (Patent No. 3,980,177).
every surgical needle has three basic slit from inside the eye to the end
components: The diameter of a needle swaged
of the needle with ridges that catch
to suture material is no larger
The eye. and hold the suture in place.
than necessary to accommodate
The body. Eyed needles must be threaded, a the diameter of the suture strand
The point. time-consuming procedure for the itself. Swaged sutures offer several
scrub person. This presents the advantages to the surgeon, nurse,
The measurements of these
disadvantage of having to pull a and patient.
specific components determine,
double strand of suture material
in part, how they will be used 1. The scrub person does not have
through tissue, creating a larger hole
most efficiently. to select a needle when the
with additional tissue disruption.
surgeon requests a specific suture
Needle size may be measured in In addition, the suture may still
material since it is already
inches or in metric units. The become unthreaded while the
attached.
following measurements determine surgeon is using it. While tying the
the size of a needle. suture to the eye may minimize this 2. Handling and preparation are
CHORD LENGTH—The possibility, it also adds to the bulk minimized. The strand with
straight line distance from the of the suture. Another disadvantage needle attached may be used
point of a curved needle to of eyed needles is that repeated use directly from the packet. This
the swage. of these needles with more than helps maintain the integrity of
one suture strand causes the needle the suture strand.
NEEDLE LENGTH—The
to become dull, thereby making 3. Tissues are subjected to minimal
distance measured along the
suturing more difficult. trauma.
needle itself from point to end.
RADIUS—The distance from Virtually all needles used today are 4. Tissue trauma is further reduced
the center of the circle to the swaged. This configuration joins because a new, sharp, undamaged
body of the needle if the the needle and suture together as needle is provided with each
curvature of the needle were a continuous unit—one that is suture strand.
continued to make a full circle. convenient to use and minimizes
trauma. The method of attaching 5. Swaged sutures do not unthread
DIAMETER—The gauge or the suture to the needle varies with prematurely.
thickness of the needle wire. the needle diameter. In larger 6. If a needle is accidentally
Very small needles of fine gauge diameter needles, a hole is drilled dropped into a body cavity, the
are needed for microsurgery. in the needle end. In smaller attached suture strand makes it
Large, heavy gauge needles are diameter needles, a channel is easier to find.
used to penetrate the sternum made by forming a "U" at the
and to place retention sutures 7. Inventory and time spent
swage end or a hole is drilled in
in the abdominal wall. A broad cleaning, sharpening, handling,
the wire with a laser. Each hole or
spectrum of sizes are available and sterilizing reusable eyed
channel is specifically engineered
between the two extremes. needles is eliminated, thereby
for the type and size of suture
reducing cost as well as risk of
material it will hold, and crimped
THE NEEDLE EYE needle punctures.
or closed around the suture to hold
The eye falls into one of three cate- it securely. When the surgeon has 8. CONTROL RELEASE needles
gories: closed eye, French (split or finished placing the suture line in allow placement of many sutures
spring) eye, or swaged (eyeless). the patient's tissue, the suture may rapidly. This may reduce
* Trademark
46 THE SURGICAL NEEDLE
compared in laboratory tests— will release it. This needle/suture
THE NEEDLE EYE
FIGURE some with "split" channels and configuration was created originally
5 some with laser-drilled holes. The for abdominal closure and
needles with laser-drilled holes hysterectomies, but is now used
produced less drag force as they in a wide variety of procedures.
passed through a membrane that
simulated vascular tissue. This THE NEEDLE BODY
could be associated with less The body of the needle is the
trauma to the vessel walls. portion which is grasped by the
Closed eye needleholder during the surgical
procedure. The body of the needle
The swaged ATRALOC surgical
should be as close as possible to the
needles made by ETHICON
diameter of the suture material to
are supplied in a variety of sizes,
minimize bleeding and leakage.
shapes, and strengths. Some of
This is especially true for
them incorporate the CONTROL
cardiovascular, gastrointestinal,
RELEASE needle suture principle
and bladder procedures.
which facilitates fast separation
of the needle from the suture The curvature of the needle body
French eye when desired by the surgeon. may come in a variety of different
This feature allows rapid placement shapes. Each shape gives the needle
of many sutures, as in interrupted different characteristics.
suturing techniques. Even though
the suture is securely fastened STRAIGHT NEEDLE
to the needle, a slight, straight tug This shape may be preferred when
FIGURE
Swaged
6
suturing easily accessible tissue. suturing the gastrointestinal tract. limited because, while the curved
Most of these needles are designed portion passes through tissue easily,
Some microsurgeons prefer straight
to be used in places where direct the remaining straight portion of
needles for nerve and vessel repair.
finger-held manipulation can easily the body is unable to follow the
In ophthalmology, the straight tran-
be performed. curved path of the needle without
schamber needle protects endothe-
bending or enlarging its path in
The Keith needle is a straight lial cells and facilitates placement of
the tissue.
cutting needle. It is used primarily intraocular lenses.
for skin closure of abdominal
CURVED NEEDLE
wounds. Varying lengths are also HALF-CURVED NEEDLE
Curved needles allow predictable
used for arthroscopic suturing of The half-curved or "ski" needle
needle turnout from tissue, and
the meniscus in the knee. may be used for skin closure or in
are therefore used most often.
laparoscopy. Its low profile allows
Bunnell (BN) needles are used for This needle shape requires less
easy passage down laparoscopic
tendon repair. Taper point needle space for maneuvering than a
trocars. Its use in skin closure is
variations may also be used for straight needle, but the curve
necessitates manipulation with a
SHAPE APPLICATION needleholder. The curvature may
FIGURE be 1/4, 3/8, 1/2, or 5/8 circle.
Straight gastrointestinal tract, nasal
cavity, nerve, oral cavity, 7 The most common use for the 3/8
pharynx, skin, tendon, vessels circle is skin closure. The surgeon
NEEDLE can easily manipulate this curvature
SHAPES with slight pronation of the wrist in
AND TYPICAL
Half-curved skin (rarely used) a relatively large and superficial
laparoscopy APPLICATIONS
wound. It is very difficult to use
this needle in a deep body cavity or
restricted area because a larger arc of
1/4
manipulation is required.
Circle eye (primary application)
microsurgery
The 1/2 circle needle was designed
for use in a confined space,
although it requires more pronation
3/8 aponeurosis, biliary tract, cardiovascular
and supination of the wrist. But
Circle
system, dura, eye, gastrointestinal tract, even the tip of this needle may
muscle, myocardium, nerve, perichon- be obscured by tissue deep in
drium, periosteum, pleura, skin, tendon,
urogenital tract, vessels the pelvic cavity. A 5/8 circle
needle may be more useful in
1/2 Circle biliary tract, cardiovascular system, eye,
fascia, gastrointestinal tract, muscle, this situation, especially in some
nasal cavity, oral cavity, pelvis, peri- anal, urogenital, intraoral, and
toneum, pharynx, pleura, resporatory
tract, skin, tendon, subcutaneous fat, cardiovascular procedures.
urogenital tract
5/8 Circle anal (hemorrhoidectomy), nasal COMPOUND
cavity, pelvis, urogenital tract (primary
application) CURVED NEEDLE
The compound curved needle
(Patent No. 4,524,771) was
Compound eye (anterior segment)
laparoscopy originally developed for anterior
Curved
segment ophthalmic surgery. It
allows the surgeon to take precise,
* Trademark
48 THE SURGICAL NEEDLE
uniform bites of tissue. The tight
80° curvature of the tip follows into SHAPE APPLICATION
a 45° curvature throughout the Conventional Cutting skin, sternum FIGURE
remainder of the body. The initial 8
curve allows reproducible, short, Point
TYPES OF
NEEDLES CS ULTIMA* Ophthalmic Needle eye (primary application)
Point
* Trademark
52 THE SURGICAL NEEDLE
penetration. It also minimizes the
risk of leakage from friable vessels
or vascular graft material. FIGURE
11
BLUNT POINT NEEDLES
Blunt point (BP) needles can REVERSE
literally dissect friable tissue rather CUTTING
NEEDLE
than cutting it. They have a taper
body with a rounded, blunt point
that will not cut through tissue.
They may be used for suturing the
liver and kidney. Due to safety
considerations, surgeons also use Smooth Jaws Jaws with tungsten Jaws with
blunt point needles in obstetric carbide particles teeth
and gynecological procedures when
working in deep cavities which
are prone to space and visibility optimum needleholder stability. NEEDLEHOLDER USE
limitations. In addition, blunt Because this tool actually drives the The following guidelines are offered
point needles for general closure are needle, its performance will have an to the scrub person for needleholder
especially helpful when performing impact upon the entire suturing use:
procedures on at-risk patients. procedure. The surgeon has maxi- 1. Grasp the needle with the tip of
The ETHIGUARD* blunt point mum control only when the needle the needleholder jaws in an area
needle combines the safety of the sits well in the holder without wob- approximately one-third to
blunt point with the security of a bling as it is passed through tissue. one-half of the distance from the
ribbed and flattened design, and the Needleholders, like pliers, weaken swaged end to the point. Avoid
convenience of a swaged needle. with repeated use. Therefore, the placing the holder on or near the
scrub person should check before swaged area which is the weakest
each procedure to make sure that part of the needle.
the needleholder jaws align properly
NEEDLEHOLDERS and grasp securely.
2. Do not grasp the needle too
tightly as the jaws of the needle-
The surgeon uses the needleholder
When selecting a needleholder, holder may deform, damage, or
to pass a curved needle through
the following should be taken bend it irreversibly.
tissue. It must be made of noncor-
into consideration: 3. Always check alignment of the
rosive, high strength, good quality
steel alloy with jaws designed for It must be the appropriate size needleholder jaw to make certain
holding the surgical needle securely. for the needle selected. A very the needle does not rock, twist,
small needle should be held with or turn.
Needleholder jaws may be short or small, fine jaws. The larger and
flat, concave or convex, smooth or heavier the needle, the wider and 4. Handle the needle and needle-
serrated. Smooth jaws may allow the heavier the jaws of the needle- holder as a unit.
needle to wobble or twist. Jaws with holder should be.
teeth hold most securely but may 5. Pass the needleholder to the
It should be an appropriate size surgeon so that he or she will not
damage the suture or needle if too
for the procedure. If the surgeon have to readjust it before placing
much pressure is applied. Most, but
is working deep inside the body the suture in tissue. Make sure
not all, needleholders have a ratchet
cavity, a longer needleholder is the needle is pointing in the
lock near to thumb and finger rings.
in order. direction in which it will be
Surgical needles are designed for used and that the suture strand is
CHAPTER 3 53
not entangled.
6. Always provide a needleholder— FIGURE
never a hemostat—to pull the 14
needle out through tissue. A
hemostat or other clamp can PLACEMENT
damage the needle. OF THE
NEEDLE IN
7. Immediately after use, every 1. The surgeon receives the 2. The surgeon begins closure TISSUE
needle should be returned to the needleholder with the needle with theswaged suture.
point toward the thumb to
scrub person while clamped in a prevent unnecessary wrist
needleholder. Needles are less motion. The scrub person
controls the free end of the
likely to be lost if they are passed suture to prevent dragging it
across the sterile field, and to
one-for-one (one returned for keep the suture from entering
each one received). the surgeon’s hand along
with the needleholder.
PACKAGING
56 PACKAGING
information. ment. The RELAY suture system
AN INTEGRAL PART
4. Permit convenient, safe, and consists of three basic, interrelated
OF THE PRODUCT sterile transfer of the product components: modular suture
The purpose of a package is to from the package to the storage racks, dispenser boxes,
protect its contents and provide sterile field. and primary packets.
convenience to the user. 5. Meet the functional needs of all
ETHICON* wound closure members of the surgical team. MODULAR STORAGE RACKS
packaging is an integral part of The modular storage racks are
each product. Over the past half a designed for maximum convenience
century, packaging has evolved RELAY* SUTURE and versatility to meet the individ-
from glass tubes packed in jars,
to multi-layered foil and paper
DELIVERY SYSTEM ual needs of a particular specialty,
nurse, surgeon, or department.
packages, to new materials that Most suture materials are packaged Modules can be easily assembled
reflect concern for both the and sterilized by the manufacturer. to accommodate both vertical and
environment and the individuals They arrive ready for use in boxes horizontal suture dispenser boxes.
who must maintain operative which can be stored until needed. Any number of modules can be
sterility and efficiency. Packaging The RELAY* suture delivery system, fastened together to meet both
has kept pace with the technological developed by ETHICON with small and large storage needs.
developments of wound closure human, clinical, and environmental Once assembled, the racks may be
products themselves. Several factors factors in mind, stores and delivers used on shelves, mounted on walls,
have influenced these developments: sutures in a time-efficient manner placed on mobile carts, or
Increasing product diversity and reduces unnecessary handling connected to IV poles. Racks can
to access sutures. The system also be fitted with a rotating base
Technological advances in also provides control over suture for more convenient access, as well
packaging materials storage, usage, inventory rotation, as with a handle for easy carrying.
Stringent regulatory requirements needle counting, and cost contain- Each module has a built-in
To prevent infection in an operative
wound, all instruments and supplies
that come in contact with the
FIGURE
wound must be sterile (free of 1
living microorganisms and spores)
including sutures, needles, ligating ETHICON
clips, stapling instruments, adhesive MODULAR
tapes and topical skin adhesives. STORAGE
High standards and criteria are set RACKS
for all components in the packaging
Full-vertical boxes Half-vertical boxes
of sterile products:
1. Protect and preserve product
stability and sterility from
potential deterioration from
outside forces such as oxygen,
moisture, light, temperature,
dust, and vermin.
2. Prevent product damage or
microbial contamination in
transit and storage.
3. Provide identifiable product Horizontal boxes Combination of boxes
CHAPTER 4 57
suture while the next is being sutures, MERSILENE sutures, abdominal incision 8 to 12
armed—without delay of open- and surgical gut sutures. The inches long might require
ing packets or threading needles. safety organizer tray allows for one to three packets to
single strand arming and ligate the subcutaneous
Multistrand packets are labeled
dispensing. The needles are blood vessels.
with the symbol MS/ that
situated in individually num-
denotes multiple strands/number All suture material is packaged
bered needle parks and may be
of strands of surgical needles per dry with the exception of surgical
armed and dispensed with little
packet. Multistrand packets may gut and pliabilized ETHILON
or no hand-to-needle contact.
contain 3 to 10 swaged sutures. sutures. Natural absorbable suture
The inner folder for these 5. Ligating material used as either materials are packaged with a
products is white. single strand (free or freehand) small amount of sterile fluid,
ties, or as continuous ties usually alcohol with water, to
All packets containing unwound from a reel or other maintain pliability. They should
CONTROL RELEASE* needle device. The length of single therefore be opened over a basin to
sutures have multiple strands strand ties is determined by the prevent any solution from spilling
(8, 5, 4, 3, or 1) and are depth of the wound. In subcuta- onto the sterile field.
designated CR/8, CR/5, CR/4, neous tissue, quarter lengths
CR/3, or CR/1. CONTROL (approximately 14 inches) are All needles should be counted
RELEASE sutures may be usually long enough for ligating. after packets of swaged sutures
available in foil or Tyvek® Single strand ligating material is are opened, according to
overwrap packets for single available in pre-cut lengths or 18, established hospital procedure.
strand delivery. The single strand 24, and 30 inch strands. The packets should be retained
delivery folder is used for some to facilitate verification of the
coated VICRYL* (polyglactin Many surgeons prefer continuous final needle count after the
910) sutures, MONOCRYL* ties. Some prefer LIGAPAK* surgical procedure.
(poliglecaprone 25) sutures, ligature, which is supplied on
PDS* II (polydioxanone) sutures, disc like plastic radiopaque
dispensing reels that are color
ETHIBOND* EXCEL polyester
coded by material. The size of
E-PACK*
sutures, NUROLON* nylon
the ligature material is indicated PROCEDURE KIT
sutures, MERSILENE* polyester
sutures, and PERMA-HAND* by the number of holes visible on The E-PACK procedure kit
silk sutures. The suture material the side of the reel (e.g., 3 holes= contains numerous sutures and
straightens as it is delivered from 3-0 suture). The reel is held in other products for a specific
the folder. Each suture may be the palm of the hand as blood procedure, surgeon, or surgical
delivered to the surgeon individ- vessels are ligated. Other specialty. The packaging concept
ually from the opening packet or surgeons may prefer the ligating saves valuable time in the OR by
removed from the folder and material rewound onto a rubber eliminating the need to open and
placed in the suture book. The reel, gauze sponge, metal bobbin, coordinate multiple individual
inner folder for these products is or other device. suture packages. The E-PACK
either red with a black C/R The number of packets of procedure kit is also an effective
symbol or white with red ligating material required to tie means of reducing inventory
lettering. The safety organizer off subcutaneous vessels levels of individual product
tray is used for coated VICRYL (bleeders) will vary with patient codes, and providing a record
sutures, MONOCRYL sutures, size and age, the amount of for determining the suture
PDS II sutures, ETHIBOND bleeding, the type of operation, costs associated with a given
EXCEL sutures, PERMA-HAND the length of the incision, and surgical procedure.
silk sutures, NUROLON nylon the surgical technique. An The suture packages are secured
* Trademark
60 PACKAGING
in an organizer sleeve to facilitate The RELAY suture delivery system Gas sterilization uses
sterile transfer to the sterile field. is designed as a "first-in, first-out" ethylene oxide gas. As an environ-
The procedure kit label provides all inventory control system. Dispenser mental measure, ETHICON
the pertinent information regarding boxes are rotated, permitting the replaced chlorofluorocarbons
the number and types of needles, as oldest sutures to be used first. The (CFCs) with more environmentally
well as sizes and types of suture. expiration date stamped on the friendly compounds in all gas
Suture quantities are listed on the outside of each box and every sterilization processes. The
label, making it easy to quickly packet clearly indicates the month combination of ethylene oxide
determine how many needles have and year of product expiration. gas concentration, temperature,
been used and thus simplifying humidity, and exposure time must
needle accountability at the end of be carefully controlled to ensure
the procedure. The organizer sleeve SUTURE reliable sterilization.
is delivered in a Tyvek® pouch. STERII IZATION WARNING: Surgical sutures are
labeled as disposable, single-use
Sutures sterilized by ETHICON are
medical devices. Suture products
EXPIRATION DATE either irradiated with cobalt 60 or
manufactured by ETHICON are
exposed to ethylene oxide gas. Both
provided in easy-to-use packages
The expiration date of a product is processes alter proteins, enzymes,
designed to maintain the stability
determined by product stability and other cellular components to
and sterility of the suture and
studies. The Food and Drug the extent that microorganisms are
needle materials. The component
Administration (FDA) requires unable to survive or cause infection.
layers of packaging materials do
that all synthetic absorbable suture Irradiation and ethylene oxide gas
not permit exposure to high
products have an expiration date are considered cold sterilization
temperatures or extremes of pres-
stamped on each dispenser box processes because radiation sterilizes
sure without affecting package and
and primary packet to indicate at room temperature and ethylene
product integrity. For this reason,
the known shelf life of the material, oxide gas sterilizes at much lower
all sterile products manufactured
provided the physical integrity temperatures than other sterilization
by ETHICON are clearly labeled,
of the package is maintained. methods such as dry heat or steam
"DO NOT RESTERILIZE."
Tests conducted by ETHICON* under pressure.
show conclusively that synthetic Manufacturers cannot be held
Irradiation sterilization exposes
absorbable suture products such responsible for the quality,
products to ionizing radiation—
as Coated VICRYL* suture and effectiveness, or integrity of
either beta rays produced by high
PDS* II suture continue to meet suture materials resterilized in
energy electron accelerators or
all product requirements even at the hospital, office, or by outside
gamma rays from radioisotopes—
five years of storage. vendors. Therefore, if customers
until absorbed in appropriate
utilize the services of a sterilization
In addition, all ETHICON sterilizing dose. ETHICON was
reprocessor for suture, ETHICON
nonabsorbable suture products a pioneer in both beta and
will disclaim any responsibility for
contain a five-year expiry dating gamma irradiation and routinely
sterilization and/or other product
on each dispenser box and sterilizes products with cobalt
failures resulting from the resteril-
primary packet. This expiry 60 which emits gamma rays.
ization process. The practice of
dating is necessary to comply Cobalt 60 irradiation is the simplest
resterilization is not recommended,
with various international of all sterilization processes.
except for ETHI-PACK* pre-cut
regulatory guidelines and is an aid
Some suture materials cannot steel sutures and spools or cardreels
in inventory management.
withstand the effects of irradiation of nonabsorbable materials
sterilization, becoming unusable. supplied nonsterile.
Instead, they are gas sterilized.
CHAPTER 4 61
ANTICIPATING 2. Opening sufficient suture packets 3. Nonsterile hands over the sterile
to prevent prolonging operative field violate aseptic technique.
SUTURE NEEDS time and causing surgeon
There are two methods commonly
Today's healthcare environment inconvenience.
used for achieving sterile transfer
dictates that hospitals continue to 3. Leftover suture on the surgical of suture packets: handing-off the
maintain quality standards while field must be discarded. sterile inner one-step RELAY tray
lowering costs to remain financially Therefore, opening too many directly to the scrub person or
viable. Through total quality man- suture packets should be "flipping" the inner contents of the
agement initiatives, many hospitals avoided to reduce waste and to primary packet onto the sterile field.
have identified material use as an lower cost. Regardless of the aseptic technique
opportunity to lower cost. To
Although it is important to be performed, all items introduced
increase the efficiency of suture
prepared to answer requests at a onto the sterile field should be
utilization during a surgical
moment's notice, it is not necessary opened, dispensed, and transferred
procedure, it is important to
to overload the table with sutures. by methods that maintain product
determine and anticipate the
The introduction of single-layer sterility and integrity. AORN
surgeon's needs more precisely.
peelable packaging, such as one-step Guidelines recommend the
For this reason, a file system of
RELAY* packaging, helps encourage “hand-off ” method, since items
preference cards for each surgeon
less handling to access the suture, tossed or flipped have a greater
on staff is usually maintained in the
enhancing quick delivery of suture potential to roll off the edge of the
operating suite. The cards contain
materials to the surgeon in the sterile field, causing contamination
such information as the surgeon's
sterile field. Unexpected suture or other items to be displaced.
"suture routine," suture materials,
sizes, needles, and/or product needs can also be obtained rapidly
METHOD I: STERILE TRANSFER TO
code numbers customarily used in from the storage racks.
THE SCRUB PERSON
specific procedures. Grasp the two flaps of the peelable
STERILE TRANSFER OF
Becoming more aware of each overwrap between the knuckles of
SUTURE PACKETS
surgeon's routine through good the thumbs and forefingers. With
At some point, suture packets
communication and regularly a rolling-outward motion, peel
must cross the sterile barrier—the
updated preference cards can help the flaps apart to approximately
invisible line of demarcation
reduce preparation time, minimize one- third of the way down the
between the sterile and the nonster-
waste, and assure cost effectiveness. sealed edges. Keeping pressure
ile. In all settings (e.g., operating
Prior to dispensing suture packets, between the knuckles for control,
room, delivery room, emergency
the circulating nurse should have a offer the sterile inner packet or
department, or physician's office),
brief discussion with the surgeon to tray to the scrub person, who takes
the individual who removes
ascertain whether a change in suture it with a gloved hand or sterile
the nonsterile overwrap must
routine is anticipated due to a instrument. Care must be taken to
remember these three points about
specific patient's needs. avoid contact with the nonsterile
sterile transfer:
overwrap as the packet or tray
While it is difficult to say precisely 1. Outer surfaces of the overwrap is withdrawn.
how many suture packets are are not sterile and may be
enough, three major factors should handled with nonsterile hands. This method must be used to
be considered in deciding how remove paper folder packets of sur-
2. The sterile inner packet or tray
many packets to open: gical steel and PROLENE* sutures
must be transferred to the sterile
1. Fewer packets will be needed if from long straight overwraps, and to
field without being touched or
products with multiple strands of remove the organizer sleeves from
contacting any nonsterile object
suture material are used. E-PACK* procedure kits. It should
or surface.
also be used for transfer of flexible,
* Trademark
62 PACKAGING
PREPARATION OF
STANDARD LENGTH
FIGURE LIGATURE STRANDS
3 FIGURE
4
STERILE
TRANSFER
TO THE
SCRUB
PERSON 1. Prepare cut lengths of ligature
material, coil around fingers of left
hand, grasp free ends with right
hand, and unwind to full length.
lightweight, transparent packets Instead, present them to the scrub 2. Maintain loop in left hand and two
free ends in right hand. Gently pull
containing microsurgery and oph- person as outlined in Method I. the strand to straighten.
thalmic products.
SUTURE PREPARATION
METHOD II: STERILE TRANSFER TO IN THE STERILE FIELD
THE STERILE FIELD Suture preparation may be more
"Flipping" is a rapid and efficient confusing than virtually any other
method of ejecting sterile product aspect of case preparation.
from its overwrap onto the sterile Familiarity and understanding of 3. To make 1/3 lengths: Pass one free
field without contacting the the sequence in which tissue layers end of strand from right to left hand.
Simultaneously catch a loop around
unsterile outer packet or reaching are handled by the surgeon will help third finger of right hand. Make
over the field. However, skill must to eliminate this confusion. (See the strands equal in thirds and cut the
loops with scissors.
be acquired to ensure its effective Suturing Section, Chapter 2.)
use. The circulating nurse must
stand near enough to the sterile Once the suture packets are opened
table to project the suture packet and prepared according to the
or tray onto it, but not too close surgeon's preference card, sutures
as to risk contaminating the table can be organized in the sequence in
by touching it or extending which the surgeon will use them.
4. To make 1/4 lengths: Pass both free
nonsterile hands over it. To Ligatures (ties) are often used first ends from right to left hand.
accomplish this, grasp the flaps in subcutaneous tissue shortly after Simultaneously catch a double loop
around third finger of right hand.
of the overwrap as described in the incision is made, unless ligating Cut the loops.
Method I and peel the flaps apart clips or an electrosurgical cautery
with the same rolling-outward device is used to coagulate severed
motion. The sterile packet or tray blood vessels.
is projected onto the sterile table After the ligating materials have
as the overwrap is completely been prepared, the suturing
peeled apart. (sewing) materials can be prepared
NOTE: DO NOT attempt to proj- in the same manner. Preparing large 5. Place packets or strands in suture
book (folded towel)—or under Mayo
ect the inner folder of long straight amounts of suture material in tray—with ends extended far
packets onto the sterile table. enough to permit rapid extraction.
CHAPTER 4 63
1. Open the packet contain- 2. Extend the strand end 3. Hand reel to surgeon as 4. Surgeon holds reel in
ing the appropriate slightly for easy grasp- needed, being certain that palm, feeds strand
material on a reel. Transfer ing. Place reel conviently the end of the ligating beween fingers, and
the inner contents of the on the Mayo tray. material is free to grasp. places around tip of
primary packet to the hemostat.
sterile field using aseptic
technique.
FIGURE
6
PEPARATION
OF PRE-CUT
SUTURES
FOR TIES OR
LIGATURE
SUTURES
1. Remove one pre-cut length from nonabsorbable 2. Extract pre-cut strands of SUTUPAK* sterile
suture at a time from the labrinth packet as it is absorbable or nonabsorbable suture. Straighten
needed by the surgeon. surgical gut with a gentle pull. Place strands in
the suture book or under Mayo tray.
advance should be avoided. For be used to prepare sufficient suture are shorter than those prepared
example, if the surgeon opens the material to stay one step ahead of originally, do not be reluctant to
peritoneum (the lining of the the surgeon. The goal should be to ask the surgeon if one of the
abdominal cavity) and discovers have no unused strands at the end strands will serve the purpose
disease or a condition that alters of the procedure. before opening a new packet.
plans for the surgical procedure Most surgeons are cooperative in
Ligature material which remains
and anticipated use of sutures, efforts to conserve valuable supplies.
toward the end of the procedure
opened packets would be wasted.
may be the same material and size
At closure following abdominal SUTURE HANDLING
specified by the surgeon for sutures
surgery, remembering the letters TECHNIQUE
in the subcutaneous layer of wound
PFS (peritoneum, fascia, skin) will During the first postoperative week,
closure. In this case, the remaining
be helpful for organizing sutures. the patient's wound has little or no
ligating material should be used
strength. The sutures or mechanical
By watching the progress of the rather than opening an additional
devices must bear the responsibility
procedure closely, listening to suture packet.
of holding the tissues together
comments between the surgeon
If the surgeon requires "only during this period. They can only
and assistants, and evaluating
one more suture," and strands of perform this function reliably if the
the situation; suture needs can
suitable material remain which quality and integrity of the wound
be anticipated. Free moments can
* Trademark
64 PACKAGING
closure materials are preserved FOR THE CIRCULATING NURSE by projecting (flipping) it onto
during handling and preparation 1. Consult the surgeon's preference the sterile table, avoiding
prior to use. It is therefore essential card for suture routine. contamination.
for everyone who will handle the 6. To open long straight packets,
2. Check the label on the dispenser
suture materials to understand peel overwrap down 6 to 8 inch-
box for type and size of suture
proper procedure to preserve es and present to the scrub
material and needle(s). Note the
suture tensile strength. person. Do not attempt to
number of strands per packet.
In general, avoid crushing or Fewer packets will be needed if project the inner folder of long
crimping sutures with surgical multistrand or CONTROL straight packets onto the
instruments such as needleholders RELEASE* sutures are used. sterile table.
and forceps, except as necessary 3. Estimate suture requirements 7. Maintain an adequate supply of
to grasp the free end of a suture accurately and dispense only the the most frequently used sutures
during an instrument tie. There type and number of sutures readily accessible.
are also specific procedures to required for the procedure. 8. Rotate stock using the "first-in,
follow to preserve suture tensile first-out" rule to avoid expira-
4. Read the label on the primary
strength which depend upon tion of dated products and keep
packet or overwrap before using
whether the material is absorbable inventories current.
to avoid opening the wrong
or nonabsorbable. The following
packet. 9. Suture packets identify the
summarizes the most important
5. Use aseptic technique when number of needles per packet to
points for each member of the
peeling the overwrap. Transfer simplify needle counts. Retain
surgical team to remember and
the inner contents of the primary this information during the
observe in handling suture materials
packet to the sterile field by procedure and/or until final
and surgical needles.
offering it to the scrub person or needle counts are completed.
10. Count needles with the scrub
person, per hospital procedure.
FIGURE
7 FOR THE SCRUB PERSON
1. If appropriate, remove the inner
ETHICON one-step RELAY* tray or folder
MODULAR containing suture materials from
STORAGE
RACKS
the primary packet being offered
from the circulating nurse.
1. With a rolling-outward motion, 2. Clamp the needleholder approx- 2. Hold the one-step RELAY tray or
peel the flaps apart to approxi- imately one-third to one-half of
mately ont-third the way down the distance from the swage folder in gloved hand and arm
the sealed edges. Keeping pres- area to the needle point. Do not the needle using the "no-touch"
sure beween the knuckles for clamp the swaged area. Gently
control, offer the sterile inner pull the suture to the right in a technique. Gently dispense the
RELAY tray to the scrub person. straight line. suture.
3. Additional suture straightening
3. Leave pre-cut suture lengths in
should be minimal. If the strand labyrinth packet on the Mayo
must be straightened, hold the
armed needleholder and gently
tray. Strands can then be
pull the strand making certain removed one at a time as needed.
not to disarm the needle from
the suture. 4. Surgical gut and collagen sutures
for ophthalmic use must first be
rinsed briefly in tepid water to
avoid irritating sensitive tissues.
CHAPTER 4 65
* Trademark
66 PACKAGING
1. Protect absorbable sutures from heat and moisture.
a. Store suture packets at room temperature. Avoid prolonged storage in hot TABLE
areas such as near steam pipes or sterilizers. 2
b. Do not soak absorbable sutures. Also avoid prolonged placement of sutures
in a moist suture book. PRESERVATION
c. Surgical gut can be dipped momentarily in tepid (room temperature) water OF TENSILE
or saline to restore pliability if strands dry out before use. Surgical gut or STRENGTH:
collagen for use in ophthalmic surgery should be rinsed briefly in tepid ABSORBABLE
water before use, as they are packed in a solution usually consisting of SUTURES
alcohol and water to maintain pliability.
d. Synthetic absorbable sutures must be kept dry. Use strands directly from
packet when possible. Store sutures in a dry suture book if necessary.
2. Straighten strands with a gently, steady, even pull. Jerking and tugging can
weaken sutures.
3. Do not "test" suture strength.
4. Do not resterilize.
SILK – Store strands in a dry towel. Dry strands are stronger than wet strands. Wet silk
loses up to 20% in strength. Handle carefully to avoid abrasion, kinking, nicking, or TABLE
instrument damage. Do not resterilize. 3
SURGICAL STAINLESS STEEL – Handle carefully to avoid kinks and bends. Repeated PRESERVATION
bending can cause breakage. Stainless steel suture can be steam sterilized without any OF TENSILE
loss of tensile strength. However, DO NOT steam sterilize on spool or in contact with STRENGTH:
wood. Lignin is leached from wood subjected to high temperature and may cling to NONABSORBABLE
suture material. Handle carefully to avoid abrasion, kinking, nicking, or instrument dam- SUTURES
age.
POLYESTER FIBER – Unaffected by moisture. May be used wet or dry. Handle carefully
to avoid abrasion, kinking, nicking, or instrument damage. Do not resterilize.
NYLON – Straighten kinks or bends by "caressing" strand between gloved fingers a few
times. Handle carefully to avoid abrasion, kinking, nicking, or instrument damage.
4. High viscosity DERMABOND adhesive NOTE: Full apposition strength is should be only transient wetting of the
hould be used immediately after expected to be achieved about treatment site. Patients may shower and
crushing the glass ampule, since the 2.5 minutes after the final layer is bathe the site gently. The site should not
liquid high viscosity DERMABOND applied, although the top adhesive be scrubbed, soaked, or exposed to
adhesive will flow freely from the tip for layer may remain tacky for up to prolonged wetness until after the film
only a few minutes. Remove the approximately 5 minutes. Full has sloughed naturally and the wound
applicator from the blister pouch. polymerization is expected when the top has healed closed. Patients should be
Hold the applicator with the thumb and high viscosity DERMABOND adhesive instructed not to go swimming during
finger and away from the patient to layer is no longer sticky. this period.
prevent any unintentional placement 6. Do not apply liquid or ointment 12. If removal of high viscosity
of the liquid high viscosity medications onto wounds closed with DERMABOND adhesive is necessary
DERMABOND adhesive into the high viscosity DERMABOND adhesive for any reason, carefully apply petroleum
wound or on the patient. While holding because these substances can weaken the jelly or acetone to the high viscosity
the applicator, and with the applicator polymerized film, leading to wound DERMABOND film to help loosen the
tip pointed upward, apply pressure at dehiscence. bond. Peel off the film, do not pull the
the midpoint of the ampule to crush the 7. Protective dry dressing such as gauze, skin apart.
inner glass ampule. Invert and gently may be applied only after high viscosity
squeeze the applicator just sufficiently to DERMABOND adhesive film is
express the liquid high viscosity completely solid/polymerized: not tacky REFERENCES
DERMABOND adhesive to moisten to the touch (approximately five minutes 1. Singer, Adam J., Lacerations and
the applicator. after application). Allow the top layer to Acute Wounds, An Evidence-
5. Approximate wound edges with gloved fully polymerize before applying
Based Guide; F.A. Davis
fingers or sterile forceps. Slowly a bandage.
apply the liquid high viscosity
Company, 2003, p. 83-97.
If a dressing, bandage, adhesive backing 2. Data on file, ETHICON, INC.
DERMABOND adhesive in multiple or tape is applied before complete
(at least 3) thin layers to the surface of 3. Quinn, G Wells, T Sutcliffe,
polymerization, the dressing can adhere
the approximated wound edges using a et al. A Randomized Trial
to the film. The film can be disrupted
gentle brushing motion. Wait from the skin when the dressing is Comparing Octyl Cyanoacrylate
approximately 30 seconds between removed, and wound dehiscence Tissue Adhesive and Sutures in
applications or layers. Maintain manual can occur. the Management of Lacerations.
approximation of the wound edges for 8. Patients should be instructed to not pick JAMA 1997;227(19):1527-1530.
approximately 60 seconds after the at the polymerized film of high viscosity 4. Singer AJ, Hollander JE, Quinn
final layer. DERMABOND adhesive. Picking at JV. Evaluation and management
NOTE: High viscosity DERMABOND the film can disrupt its adhesion to the of traumatic lacerations.
adhesive polymerizes through an skin and cause dehiscence of the wound. N Engl J Med.
exothermic reaction. If the liquid high Picking at the film can be discouraged
1997;337(16):1142-1148.
viscosity DERMABOND adhesive is by an overlying dressing.
5. Bruns TB, Robinson BS, Smith
applied so that large droplets are allowed 9. Apply a dry protective dressing for
to remain without being evenly spread, children or other patients who may not RJ et al. A new tissue adhesive
the patient may experience a sensation be able to follow instructions for proper for laceration repair in children.
of heat or discomfort. The sensation wound care. J Pediatr. 1998;132:1067-1070.
may be higher on sensitive tissues. This 10. Patients treated with high viscosity 6. Theodore N, et al. The
can be minimized by applying high DERMABOND adhesive should be Economics of DERMABOND
viscosity DERMABOND adhesive in provided the printed instruction sheet in Neurosurgical Wound
multiple thin layers (at least 3). entitled, How to Care for Your Wound Closure. Phoenix, Ariz:
NOTE: Excessive pressure of the After It’s Treated With high viscosity Neuroscience Publications,
applicator tip against the wound edges DERMABOND Topical Skin Adhesive.
Barrow Neurological Institute.
or surrounding skin can result in forcing This instruction sheet should be
March 2001:2-10.
the wound edges apart and allowing reviewed with each patient or guardian
to assure understanding of the proper 7. Osmond MH, Klassen TP,
high viscosity DERMABOND adhesive Quinn JV. Economic comparison
into the wound. High viscosity care for the treatment site.
11. Patients should be instructed that until of a tissue adhesive and suturing
DERMABOND adhesive withing
the wound could delay wound the polymerized film of high viscosity in the repair of pediatric facial
healing and/or result in adverse DERMABOND adhesive has sloughed lacerations. J Pediatr. 1995;
cosmetic outcome. naturally (usually in 5-10 days), there 126:892-895.
* Trademark
CHAPTER 6
OTHER SURGICAL
PRODUCTS
74 OTHER SURGICAL PRODUCTS
ADHESIVE TAPES dislodgement and dehiscence, wound edge is then gently apposed
the inability to use them in by pushing with a finger of the
There are many surgical products hair-bearing areas, and the need nondominant hand. The wound
available which may be used during to keep them dry. Their use is edges should not be apposed by
wound closure and other operative typically reserved for linear lacera- pulling on the free end of the
procedures which involve suturing. tions under minimal tension. tape. This can result in unequal
Each of these products has specific Furthermore, surgical tapes do not distribution of skin tensions,
indications for use. Adhesive tapes approximate deeper tissues and do causing erythema or even blistering
are used for approximating the not control bleeding. of the skin. Additional strips are
edges of lacerations, skin closures, then placed perpendicular to the
repair and/or support in selected INDICATIONS AND USAGE laceration on either side of the
operative procedures. Skin closure tapes are an effective original tape, bisecting the
Adhesive tapes are associated with alternative to sutures or staples remaining open wound with each
minimal tissue reactivity and yield when tensile strength and resistance strip until the space between tapes
the lowest rate of infection, but to infection are not critical factors. is no more than about 2 to 5 mm.
they tend to slough off in the Skin closure tapes can also be Additional strips are then placed
presence of tension or moisture.1 used to complement suture or over the ends of the other strips,
Advantages of adhesive tapes staple closures. Stress is applied parallel to the laceration.
include rapid application, little or uniformly to the collagen fibers,
Skin closure tapes may also be used
no patient discomfort, low cost, and aiding in rapid fiber orientation
as a replacement for sutures or
no risk of needle-stick injuries. They and increased tensile strength.
staples which are removed on the
are associated with minimal tissue first to fourth postoperative day.
reactivity and yield the lowest infec- APPLICATION
Effective skin closure tapes provide
tion rates of any wound closure Skin closure tapes may be applied to
good porosity in terms of air inflow
method. They may be left on for the skin over a subcuticular closure
to the wound and water vapor
long periods without resulting in in lieu of skin sutures or used as a
transmission escaping from the
suture hatch marks. primary closure in conjunction with
wound during the healing process.
sutures in an alternating pattern.
Surgical tapes are not commonly The tape is placed on one side of
recommended as the sole modality AFTER CARE AND REMOVAL
the wound at its midpoint, while
for primary wound closure due Adhesive tapes should be left in
grasping it with forceps in the
to the high probability of place as long as possible, at least as
dominant hand. The opposite
long as sutures would be left before
removal. To prevent the tapes from
prematurely coming loose, patients
ADVANTAGES DISADVANTAGES
must be warned to keep them as
TABLE dry as possible and not to cover
• Rapid and simple • Relatively poor 1
closure adherence them with ointments. Showering
is permitted and during the
• Least damage to • Easily removed by ADVANTAGES
AND first week many surgeons
host defenses patient
DISADVANTAGES recommend that patients cover
• No risk of needle-stick • Must be kept dry OF ADHESIVE their wounds and tape with a
injuries TAPES FOR nonadherent dressing.
• Cannot be used over
• Do not cause tissue oily or hair-bearing SKIN CLOSURE 1
ischemia or necrosis areas
CHAPTER 6 75
PROXIMATE*
SKIN STAPLERS
TABLE
2
PROXIMATE* RH Skin Staplers PROXIMATE* PX Skin Staplers PROXIMATE* PLUS MD Skin Staplers
(Rotating Head Skin Staplers) (Multi-Directional Skin Staplers)
Head rotates 360°; Improves visibility Positive ratchet Easy staple Ergonomic design Comfortable for
cartridge is clear and access mechanism placement smaller hands
Staples are coated Easy staple Staples are coated Easy staple Alignment indicator Improves visibility
with lubricant extraction with lubricant extraction
LOOPED SUTURE
ETHICON looped sutures range in
length up to a 60-inch strand with
both ends swaged to a single taper 3. To adjust tension, lift capstan. 4. Rotate capstan until desired
tension is attained.
point needle. Available in various
materials and suture sizes, they
provide a simple, reliable technique
for continuous closure of the fascia
of the abdominal wall. The needle
of the looped suture is passed
through the fascia from inside out
at one end of the incision, then
through the opposite wound edge
from outside in, and then passed
5. To lock, press capstan down
through the loop. The locking stitch into bridge.
lies beneath the wound edge. The
double strand is run over and over (0.48cm) diameter surgical latex
to the other end of the incision. RETENTION tubing with a 1/32-inch (0.08cm)
The final stitch is completed by SUTURE DEVICES wall. The suture is threaded through
passing the needle from the outside the bolster and tied. Sutures
in, cutting one strand, and passing Retention sutures, if not placed sheathed in this manner can cause
the needle through the opposite carefully without excessive tension, an inflammatory response with
wound edge from the outside in. can cut the skin. Devices such as reaction both at the site of the
The needle is then cut off and bolsters and bridges are used to suture exit from the skin and along
the loose suture ends tied together, prevent such complications and the entire length of the suture itself.
leaving the knot inverted under eliminate pressure. However, care Also, the skin may become necrotic
the fascia. should also be taken in the use of beneath the bolsters if the sutures
these devices. are too tight. This invariably occurs
Retention suture bolsters are sterile if the sutures are tightly tied at the
time of the operation, as subsequent
2 1/2-inch (6cm) lengths of 3/16-inch
tissue edema ensues.
* Trademark
78 OTHER SURGICAL PRODUCTS
The retention suture bridge is a
strong plastic truss that can be
adjusted to relieve the pressure of
the retention suture on the skin
during, and subsequent to, initial
suture placement. After the desired
number of sutures is placed in the
wound, a sterile bridge is positioned
over each retention suture. Each
side of the bridge has six holes
spaced 1/4 inch (0.64cm) apart to
accommodate many patient sizes.
The ends of the sutures are passed
through the appropriate holes and
tied loosely over the bridge. The
suture strand is then slipped into
the capstan located in the middle
of the bridge, and the capstan is
rotated to apply the desired
tension before locking into place.
The bridge permits easy tension
readjustment by raising and rotating
the capstan to compensate for
postoperative wound edema, and
again when the edema subsides.
The suture remains elevated away
from the skin while the bridge has
contact along its entire 4 3/8-inch
(11cm) length. Pressure is evenly
distributed over the area, and the
transparent bridge facilitates com-
plete visualization of the wound.
REFERENCES
1. Singer, Adam J., Lacerations and
Acute Wounds, An Evidence-Based
Guide; F.A. Davis Company,
©2003, p. 64-71, 73-82.
2. Skerris, David A., Mayo Clinic
Basic Surgery Skills, Mayo Clinic
Scientific Press, 1999; p.117.
CHAPTER 7
PRODUCT TERMS
AND TRADEMARKS
80 PRODUCT TERMS AND TRADEMARKS
ABSORBABLE SUTURE CHROMIC SURGICAL GUT COMPOUND CURVED NEEDLE
Sutures which are broken down and Gut suture which has been treated Needle that incorporates two
eventually absorbed by either by chromium salts to resist curvatures in one needle: a tight
hydrolysis (synthetic absorbable digestion by lysosomal enzymes. curve at the tip, and a more gradual
sutures) or digestion by lysosomal curve through the body. Used for
enzymes elicited by white blood CHROMICIZING precise positioning of sutures for
cells (surgical gut and collagen). ETHICON process for producing comeal/scleral closure and for
chromic gut. Each ribbon of skin suturing.
APPROXIMATE surgical gut is bathed in a
Bring together sides or edges. chromium salt solution before CONTAMINATE
spinning into strands to provide To cause a sterile object or surface
ATRALOC* uniform controlled absorption. to become unsterile.
SURGICAL NEEDLES
ETHICON* trademark for eyeless COATED VICRYL* CONTINUOUS SUTURE
needles permanently attached (POLYGLACTIN 910) SUTURE TECHNIQUE
(swaged) to suture strands. ETHICON trademark for synthetic Single suture strand passed back and
absorbable suture extruded from a forth between the two edges of the
B & S GAUGE copolymer of glycolide and lactide wound to close a tissue layer; tied
Brown and Sharpe gauge commonly and coated with a mixture of only at each end of the suture line.
used in hospitals to identify wire polyglactin 370 and calcium
diameter. ETHICON stainless steel stearate. CONTROL RELEASE* NEEDLE
suture products are labeled with ETHICON trademark for swaging
both B & S gauge and U.S.P. size. COATED VICRYL* Plus method which permits fast and
ANTIBACTERIAL controlled separation of the needle
BURIED SUTURE (POLYGLACTIN 910) SUTURE from the suture material.
Any stitch made and tied so that ETHICON trademark for synthetic
it remains completely under absorbable suture extruded from a CONVENTIONAL
the surface. copolymer of glycolide and lactide CUTTING NEEDLE
(polyglactin 370) and calcium Needle with triangular point and
CALCIFIED CORONARY stearate. The first and only suture cutting edge along inner curvature
NEEDLE (CC) that protects against bacterial of needle body.
A TAPERCUT* surgical needle colonization of the suture.
with a 1/16" cutting tip and slim CORNEAL BEADED
COATED VICRYL* RAPIDE RETRACTION SUTURE
taper ratio for significant ease of
(POLYGLACTIN 910) SUTURE Swaged suture strand with a small
penetration when suturing tough
ETHICON trademark for braided, bead of epoxy used to elevate cornea
valve cuffs or atherosclerotic vessels.
rapidly absorbing synthetic suture for placement of intraocular lens.
extruded from a copolymer of
CARDIOVASCULAR SUTURES
glycolide and lactide and coated CS ULTIMA*
Swaged sutures designed to meet the
with a mixture of polyglactin 370 OPHTHALMIC NEEDLE (CS)
specific needs of heart and blood
and calcium stearate. ETHICON trademark for needle
vessel surgery.
with reduced side edge angles
COBALT 60 providing excellent penetration
CATGUT
Outmoded term for surgical Source of irradiation used by necessary for ophthalmic surgery.
gut suture. ETHICON, INC., to sterilize some Design facilitates knot rotation
suture materials. Also used in during surgery.
hospitals to treat some cancer
patients.
CHAPTER 7 81
* Trademark
86 PRODUCT TERMS AND TRADEMARKS
VICRYL* (POLYGLACTIN 910)
PERIODONTAL MESH
ETHICON trademark for mesh
prepared from a copolymer of gly-
colide and lactide. An absorbable
material used in periodontal surgery
for guided tissue regeneration.
VISI-BLACK* SURGICAL
NEEDLES
ETHICON trademark for surgical
needles with a black surface
finish to enhance visibility in the
operative site.
WOUND DISRUPTION
Separation of wound edges.
* Trademark
CHAPTER 8
PRODUCT INFORMATION
88 PRODUCT INFORMATION
Coated VICRYL* Do not resterilize. Discard opened packages and unused sutures.
(Polyglactin 910) Suture As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
U.S.P., EXCEPT FOR DIAMETER formation. As an absorbable suture, coated VICRYL suture may act
transiently as a foreign body. Acceptable surgical practice should be followed
DESCRIPTION for the management of contaminated or infected wounds.
Coated VICRYL* ( polyglactin 910) suture is a synthetic absorbable sterile
surgical suture composed of a copolymer made from 90% glycolide and 10%
PRECAUTIONS
L-lactide. Coated VICRYL suture is prepared by coating VICRYL suture material
with a mixture composed of equal parts of copolymer of glycolide and lactide Skin sutures which must remain in place longer than 7 days may cause
(polyglactin 370) and calcium stearate. Polyglactin 910 copolymer and localized irritation and should be snipped off or removed as indicated.
polyglactin 370 with calcium stearate have been found to be nonantigenic, Under some circumstances, notably orthopaedic procedures, immobilization of
nonpyrogenic and elicit only a mild tissue reaction during absorption. joints by external support may be employed at the discretion of the surgeon.
The sutures are available dyed and undyed (natural).
Consideration should be taken in the use of absorbable sutures in tissues with
Coated VICRYL sutures are U.S.P. except for diameters in the following sizes: poor blood supply as suture extrusion and delayed absorption may occur.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P. In handling this or any other suture material, care should be taken to avoid
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm) damage from handling. Avoid crushing or crimping damage due to application
of surgical instruments such as forceps or needle holders. Coated VICRYL
6-0 .008 sutures, which are treated to enhance handling characteristics, require the
5-0 .016 accepted surgical technique of flat and square ties with additional throws as
4-0 .017 warranted by surgical circumstance and the experience of the surgeon.
3-0 .018
2-0 .004 Avoid prolonged exposure to elevated temperatures.
0 .022
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
INDICATIONS point. Reshaping needles may cause them to lose strength and be less resistent
to bending and breaking. Users should exercise caution when handling
Coated VICRYL suture is indicated for use in general soft tissue approximation surgical needles to avoid inadvertent needle sticks. Discard used needles in
and/or ligation, including use in ophthalmic procedures, but not for use in "sharps" container.
cardiovascular and neurological tissues.
ADVERSE REACTIONS
ACTIONS
Adverse effects associated with the use of this device include wound
Coated VICRYL suture elicits a minimal acute inflammatory reaction in tissue dehiscence, failure to provide adequate wound support in closure of the sites
and ingrowth of fibrous connective tissue. Progressive loss of tensile strength where expansion, stretching, or distension occur, failure to provide adequate
and eventual absorption of coated VICRYL suture occurs by means of wound support in elderly, malnourished or debilitated patients or in patients
hydrolysis, where the copolymer degrades to glycolic and lactic acids which are suffering from conditions which may delay wound healing, infection, minimal
subsequently absorbed and metabolized in the body. Absorption begins as a acute inflammatory tissue reaction, localized irritation when skin sutures are
loss of tensile strength followed by a loss of mass. Implantation studies in rats left in place for greater than 7 days, suture extrusion and delayed absorption in
indicate that coated VICRYL suture retains approximately 75% of the origi- tissue with poor blood supply, calculi formation in urinary and biliary tracts
nal tensile strength at two weeks post implantation. At three weeks, approxi- when prolonged contact with salt solutions such as urine and bile occurs, and
mately 50% of the original strength is retained for sizes 6-0 and larger and transitory local irritation at the wound site. Broken needles may result in
approximately 40% of its original strength is retained for sizes 7-0 and smaller. extended or additional surgeries or residual foreign bodies. Inadvertent needle
At four weeks, approximately 25% of the original strength is retained for sizes sticks with contaminated surgical needles may result in the transmission of
6-0 and larger. All of the original tensile strength is lost by five weeks post bloodborne pathogens.
implantation. Absorption of coated VICRYL suture is essentially complete
between 56 and 70 days.
APPROXIMATE % ORIGINAL
HOW SUPPLIED
DAYS IMPLANTATION STRENGTH REMAINING Coated VICRYL sutures are available sterile, as braided dyed (violet) and
undyed (natural) strands in sizes 8-0 through 3 (metric sizes 0.4-6), in a variety
14 Days 75% of lengths, with or without needles, and on LIGAPAK*dispensing reels.
21 Days (6-0 and larger) 50%
21 Days (7-0 and smaller) 40% Coated VICRYL sutures are also available in size 8-0 with attached beads for
28 Days 25% use in ophthalmic procedures. Coated VICRYL sutures are also available in sizes
4-0 through 2 (metric sizes 1.5-5.0) attached to CONTROL RELEASE* removable
needles. Coated VICRYL sutures are available in one, two, and three dozen
CONTRAINDICATIONS boxes.
This suture, being absorbable, should not be used where extended
approximation of tissue is required.
389389 *Trademark ©ETHICON,INC. 1996
WARNINGS
Users should be familiar with surgical procedures and techniques involving
absorbable sutures before employing coated VICRYL suture for wound
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used. Physicians should consider the in vivo performance
(under ACTIONS section) when selecting a suture. The use of this suture may
be inappropriate in elderly, malnourished, or debilitated patients, or in patients
suffering from conditions which may delay wound healing. As this is an
absorbable suture material, the use of supplemental nonabsorbable sutures
should be considered by the surgeon in the closure of the sites which
may undergo expansion, stretching or distention, or which may require
additional support.
CHAPTER 8 93
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing ETHILON suture for wound closure, 389355 *Trademark ©ETHICON, INC. 1995
as the risk of wound dehiscence may vary with the site of application and the
suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. Acceptable surgical practice should be followed for the management
of contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures.
90 PRODUCT INFORMATION
Coated VICRYL* RAPIDE (Polyglactin 910) Users should be familiar with surgical procedures and techniques involving
absorbable sutures before employing coated VICRYL RAPIDE suture for wound
Braided Coated Synthetic Absorbable closure, as a risk of wound dehiscence may vary with the site of application and
the suture material used. Physicians should consider the in vivo performance
Suture, Undyed when selecting a suture. The use of this suture may be inappropriate in
elderly, malnourished, or debilitated patients, or in patients suffering from
Non-U.S.P. conditions which may delay wound healing.
WARNINGS
CHAPTER 8 91
92 PRODUCT INFORMATION
ETHIBOND* EXCEL POLYESTER SUTURE PRECAUTIONS
In handling this or any other suture material, care should be taken to avoid
NONABSORBABLE SURGICAL SUTURE, U.S.P. damage from handling. Avoid crushing or crimping damage due to application
Except for size 6-0 diameter of surgical instruments such as forceps or needle holders.
As with any suture material, adequate knot security requires the accepted
DESCRIPTION surgical technique of flat and square ties with additional throws as warranted
ETHIBOND* EXCEL polyester suture is a nonabsorbable, braided, sterile, by surgical circumstance and the experience of the surgeon.
surgical suture composed of Poly (ethylene terephthalate). It is prepared from To avoid damaging needle points and swage areas, grasp the needle in an area
fibers of high molecular weight, long-chain, linear polyesters having recurrent one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
aromatic rings as an integral component. ETHIBOND EXCEL suture is uniform- point. Reshaping needles may cause them to lose strength and be less
ly coated with polybutilate or poly {oxy-1, 4 butanediyloxy (1, 6-dioxo-1, resistant to bending and breaking. Users should exercise caution when
6 hexanediyl)}. The highly adherent coating is a relatively nonreactive handling surgical needles to avoid inadvertent needle sticks. Discard used
nonabsorbable compound which acts as a lubricant to mechanically improve needles in "sharps" containers.
the physical properties of the uncoated suture by improving ease of passage
through tissues and by providing overall improved handling qualities as
contrasted to the braided, uncoated fiber.
ADVERSE REACTIONS
ETHIBOND EXCEL sutures are braided for optimal handling properties, and for
good visibility in the surgical field, are dyed green. Adverse effects associated with the use of this device include wound
dehiscence, calculi formation in urinary and biliary tracts when prolonged
Size 6-0 ETHIBOND EXCEL sutures are U.S.P., except for diameter. contact with salt solutions such as urine and bile occurs, infection, minimal
acute inflammatory tissue reaction and transitory local irritation at the wound
site. Broken needles may result in extended or additional surgeries or residual
foreign bodies. Inadvertent needle sticks with contaminated surgical needles
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
may result in the transmission of bloodborne pathogens.
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm)
6-0 0.024
HOW SUPPLIED
ETHIBOND EXCEL sutures are available as sterile, braided, green and undyed
INDICATIONS
(white) strands in sizes 7-0 through 5 (metric sizes 0.5-7) in a variety of lengths,
ETHIBOND EXCEL suture is indicated for use in general soft tissue with and without permanently attached needles.
approximation and/or ligation, including use in cardiovascular, ophthalmic and
ETHIBOND EXCEL sutures, green, braided, in sizes 4-0 through 1 (metric sizes
neurological procedures.
1.5-4) are also available attached to CONTROL RELEASE* removable needles.
ETHIBOND EXCEL sutures, green and undyed, are also available attached to
ACTIONS TFE polymer pledgets measuring 1/8" x 1/8" x 1/16" (3.0mm x 3.0mm x 1.5mm),
1/4" x 1/8" x 1/16" (7.0mm x 3.0mm x 1.5mm).
ETHIBOND EXCEL suture elicits a minimal acute inflammatory reaction in
ETHIBOND EXCEL sutures are available in one, two and three dozen boxes.
tissue, followed by a gradual encapsulation of the suture by fibrous connective
tissue. Implantation studies in animals show no meaningful decline in
polyester suture strength over time. Both polyester fiber suture material and
the polybutilate coating are pharmacologically inactive.
389397 *Trademark ©ETHICON,INC. 1996
CONTRAINDICATIONS
None known.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing ETHIBOND EXCEL suture for wound
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. Acceptable surgical practice should be followed for the
management of infected or contaminated wounds.
CHAPTER 8 93
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing ETHILON suture for wound closure, 389355 *Trademark ©ETHICON, INC. 1995
as the risk of wound dehiscence may vary with the site of application and the
suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. Acceptable surgical practice should be followed for the management
of contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures.
94 PRODUCT INFORMATION
FAST ABSORBING PRECAUTIONS
SURGICAL GUT (PLAIN) In handling this or any other suture material, care should be taken to avoid
damage from handling. Avoid crushing or crimping damage due to application
ABSORBABLE SURGICAL SUTURES of surgical instruments such as forceps or needle holders. Surgical gut sutures
require the accepted surgical technique of flat and square ties with additional
Non-U.S.P. throws as warranted by surgical circumstance and the experience of the
surgeon.
DESCRIPTION Under some circumstances, notably orthopaedic procedures, immobilization of
Fast absorbing surgical gut suture is a strand of collagenous material prepared joints by external support may be employed at the discretion of the surgeon.
from the submucosal layers of the small intestine of healthy sheep, or from the The surgeon should avoid unnecessary tension when running down knots, to
serosal layers of the small intestine of healthy cattle. reduce the occurrence of surface fraying and weakening of the strand.
Fast absorbing surgical gut sutures are sterile and elicit only a slight to Avoid prolonged exposure to elevated temperatures.
minimal tissue reaction during absorption.
To avoid damaging needle points and swage areas, grasp the needle in an area
Fast absorbing surgical gut sutures differ from U.S.P. minimum strength one-third (1/3) to one-half (1/2) of the distance from the swaged end to
requirements by less than 30%. the point. Reshaping needles may cause them to lose strength and be less
resistant to bending and breaking. Users should exercise caution when
handling surgical needles to avoid inadvertent needle sticks. Discard used
INDICATIONS needles in "sharps" containers.
Fast absorbing surgical gut sutures are intended for dermal (skin) suturing
only. They should be utilized only for external knot tying procedures.
ADVERSE REACTIONS
Adverse effects associated with the use of this device include wound
ACTIONS dehiscence, variable rates of absorption over time (depending on such factors
The results of implantation studies of fast absorbing surgical gut sutures in the as the type of suture used, the presence of infection and the tissue site), failure
skin of animals indicate that nearly all of its original strength is lost within to provide adequate wound support in closure of sites where expansion,
approximately seven (7) days of implantation. stretching or distention occur, etc., unless additional support is supplied
When surgical gut suture is placed in tissue, a moderate tissue inflammation through the use of nonabsorbable suture material, failure to provide adequate
occurs which is characteristic of foreign body response to a substance. This is wound support in elderly, malnourished or debilitated patients or in patients
followed by a loss of tensile strength followed by a loss of suture mass, as the suffering from cancer, anemia, obesity, diabetes, infection or other conditions
proteolytic enzymatic digestive process dissolves the surgical gut. This process which may delay wound healing, allergic response in patients with known
continues until the suture is completely absorbed. Many variable factors may sensitivities to collagen which may result in an immunological reaction result-
affect the rate of absorption. Some of the major factors which can affect tensile ing in inflammation, tissue granulation or fibrosis, wound suppuration and
strength loss and absorption rates are: bleeding, as well as sinus formation, infection, moderate tissue inflammatory
1. Type of suture - plain gut generally absorbs more rapidly than chromic gut. response characteristic of foreign body response, calculi formation in urinary
and biliary tracts when prolonged contact with salt solutions such as urine and
2. Infection - surgical gut is absorbed more rapidly in infected tissue than in
bile occurs, and transitory local irritation at the wound site. Broken needles
non-infected tissue.
may result in extended or additional surgeries or residual foreign bodies.
3. Tissue sites - surgical gut will absorb more rapidly in tissue where increased
Inadvertent needle sticks with contaminated surgical needles may result in the
levels of proteolytic enzymes are present, as in the secretions exhibited in
transmission of bloodborne pathogens.
the stomach, cervix and vagina.
Data obtained from implantation studies in rats show that the absorption of
these sutures is essentially complete by the twenty-first (21st) to forty-second HOW SUPPLIED
(42nd) post implantation day.
Fast absorbing surgical gut sutures are available in sizes 5-0 (metric size 1.5)
and 6-0 (metric size 1.0) with needles attached in one, two and three dozen
boxes.
CONTRAINDICATIONS
These sutures, being absorbable, should not be used where prolonged
approximation of tissue under stress is required. These sutures have been
designed to absorb at a rapid rate and must be used on dermal tissue only. 389359 *Trademark ©ETHICON, INC. 1995
These sutures should never be used on internal tissue. The use of this suture is
contraindicated in patients with known sensitivities or allergies to collagen, as
gut is a collagen based material.
WARNINGS
Users should be familiar with surgical procedures and techniques involving gut
suture before using fast absorbing surgical gut suture for wound closure, as
the risk of wound dehiscence may vary with the site of application and the
suture material used. Physicians should consider the in vivo performance when
selecting a suture for use in patients.
The use of this suture may be inappropriate in elderly, malnourished, or debil-
itated patients, or in patients suffering from conditions which may delay wound
healing. As this is an absorbable material, the use of supplemental nonab-
sorbable sutures should be considered by the surgeon in the closure of sites
which may undergo expansion, stretching or distention or which may require
additional support.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. As an absorbable suture, fast absorbing surgical gut may act tran-
siently as a foreign body. Acceptable surgical practice should be followed for
the management of contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures. Store at room
temperature.
Certain patients may be hypersensitive to collagen and might exhibit an
immunological reaction resulting in inflammation, tissue granulation or fibro-
sis, wound suppuration and bleeding, as well as sinus formation.
CHAPTER 8 95
ACTIONS
MERSILENE suture elicits a minimal acute inflammatory reaction in tissue, HOW SUPPLIED
followed by a gradual encapsulation of the suture by fibrous connective MERSILENE sutures are available as sterile, braided, green and undyed (white)
tissue. Implantation studies in animals show no meaningful decline in strands in sizes 6-0 through 5 (metric sizes 0.7-7) in a variety of lengths, with
polyester suture strength over time. The polyester fiber suture material is and without permanently attached needles.
pharmacologically inactive.
MERSILENE sutures are also available in green monofilament in sizes 10-0 and
11-0 (metric sizes 0.2-0.1).
CONTRAINDICATIONS
MERSILENE sutures, green, braided in U.S.P. size 0 (metric size 3.5) are also
None known. available attached to CONTROL RELEASE* removable needles.
MERSILENE sutures are available in one, two and three dozen boxes.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing MERSILENE suture for wound 389395 *Trademark ©ETHICON,INC. 1996
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practice should be followed for the management
of infected or contaminated wounds.
96 PRODUCT INFORMATION
MERSILENE* POLYESTER FIBER MESH WARNINGS
MERSILENE mesh is provided by ETHICON, INC. as a sterile product. Unused
Nonabsorbable Synthetic Surgical Mesh MERSILENE Mesh which has been removed from the package may be resteril-
STERILE ized not more than one time by a conventional stream autoclaving process
at conditions of 250˚F (121˚C) for 20 minutes. MERSILENE mesh may also be
flash autoclaved not more than one time at conditions of 270˚F (132˚C) for
DESCRIPTION 10 minutes. Resterilization under any other conditions or by any other means
MERSILENE* Polyester Fiber Mesh is constructed from polyethylene is neither recommended nor endorsed by ETHICON, INC.
terephthalate, the same material used to make MERSILENE* Polyester Fiber
Suture, Nonabsorbable Surgical Suture, U.S.P. (ETHICON, INC.) MERSILENE If this product should become stained with blood or soiled, it should not be
Polyester Fiber Mesh affords excellent strength, durability and surgical resterilized for reuse.
adaptability, along with maximal porosity for necessary tissue ingrowth.
The mesh is approximately 0.010 inches thick and is a highly flexible and
compliant material. PRECAUTIONS
A minimum of 6.5mm (1/4 inch) of mesh should extend beyond the suture line.
MERSILENE mesh is knitted by a process which interlinks each fiber junction
and which provides for elasticity in both directions. This construction permits
the mesh to be cut into any desired shape or size without unraveling. The fiber
ADVERSE REACTIONS
junctions are not subject to the same work fatigue exhibited by more rigid
No significant adverse clinical reactions to MERSILENE mesh have been
metallic meshes. This bi-directional elastic property allows adaption to various
reported. The use of nonabsorbable MERSILENE mesh in a wound that is
stresses encountered in the body.
contaminated or infected could lead to fistula formation and/or extrusion of
the mesh.
ACTIONS
MERSILENE mesh is a nonabsorbable mesh used to span and reinforce
INDICATIONS FOR USE
traumatic or surgical wounds to provide extended support during and
It is recommended that nonabsorbable sutures be placed 6.5 to 12.5mm (1/4 to
following wound healing. Animal studies show that implantation of
1/2 inch) apart at a distance approximately 6.5mm (1/4 inch) from edge of the
MERSILENE mesh elicits a minimum to slight inflammatory reaction, which is
mesh. Some surgeons prefer to suture and uncut section of mesh that is
transient and is followed by the deposition of a thin fibrous layer of tissue
considerably large than the defect into position over the wound. The opposite
which can grow through the interstices of the mesh, thus incorporating the
sides are then sutured to assure proper closure under correct tension. When
mesh into adjacent tissue. The mesh remains soft and pliable, and normal
the margin sutures have all been placed, the extra mesh is trimmed away.
wound healing is not noticeably impaired. The material is not absorbed nor is
it subject to degradation or weakening by the action of tissue enzymes.
HOW SUPPLIED
INDICATIONS MERSILENE mesh is available in single packets as sterile, undyed (white)
sheets in two sizes. The sizes available are 6 x 11cm (2.5 x 4.5 inches) and 30 x
This mesh may be used for the repair of hernia and other fascial deficiencies
30cm (12 x 12 inches). Each sheet is 0.25mm (0.010 inch) thick.
that require the addition of a reinforcing or bridging material to obtain the
desired surgical result.
MONOCRYL* (Poliglecaprone 25) Suture As this is an absorbable suture material, the use of supplemental
nonabsorbable sutures should be considered by the surgeon in the closure of
SYNTHETIC ABSORBABLE SUTURE, the sites which may undergo expansion, stretching or distention, or which may
require additional support.
U.S.P., EXCEPT FOR DIAMETER
DESCRIPTION PRECAUTIONS
Skin sutures which must remain in place longer than 7 days may cause local-
MONOCRYL* (poliglecaprone 25) suture is a monofilament synthetic
ized irritation and should be snipped off or removed as indicated. Subcuticular
absorbable surgical suture prepared from a copolymer of glycolide and
sutures should be placed as deeply as possible to minimize the erythema and
epsilon-caprolactone. Poliglecaprone 25 copolymer has been found to be
induration normally associated with absorption.
nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during
absorption. Under some circumstances, notably orthopaedic procedures, immobilization of
joints by external support may be employed at the discretion of the surgeon.
MONOCRYL sutures are U.S.P. except for diameters in the following sizes:
Consideration should be taken in the use of absorbable sutures in tissue with
poor blood supply as suture extrusion and delayed absorption may occur.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
In handling this or any other suture material, care should be taken to avoid
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm) damage from handling. Avoid crushing or crimping damage due to application
6-0 0.049 of surgical instruments such as forceps or needle holders.
5-0 0.033 MONOCRYL suture knots must be properly placed to be secure. Adequate knot
4-0 0.045 security requires the accepted surgical technique of flat and square ties with
3-0 0.067 additional throws as warranted by surgical circumstance and the experience of
2-0 0.055 the surgeon. The use of additional throws may be particularly appropriate when
0 0.088 knotting monofilaments.
1 0.066 Avoid prolonged exposure to elevated temperature.
2 0.099
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to
INDICATIONS the point. Reshaping needles may cause them to lose strength and be less
MONOCRYL sutures are indicated for use in general soft tissue approximation resistant to bending and breaking. Users should exercise caution when
and/or ligation, but not for use in cardiovascular or neurological tissues, handling surgical needles to avoid inadvertent needle sticks. Discard used
microsurgery or ophthalmic surgery. needles in "sharps" containers.
WARNINGS
Users should be familiar with surgical procedures and techniques involving 389385 *Trademark ©ETHICON, INC. 1995
absorbable sutures before employing MONOCRYL suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the
suture material used. Physicians should consider the in vivo performance
(under ACTIONS section) when selecting a suture for use in patients. The use of
this suture may be inappropriate in elderly, malnourished, or debilitated
patients, or in patients suffering from conditions which may delay wound
healing.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. As an absorbable suture, MONOCRYL suture may act transiently as
a foreign body. Acceptable surgical practice should be followed for the
management of contaminated or infected wounds.
98 PRODUCT INFORMATION
MONOCRYL* VIOLET MONOFILAMENT PRECAUTIONS
(Poliglecaprone 25) Suture Skin sutures which must remain in place longer than 7 days may cause local-
ized irritation and should be snipped off or removed as indicated. Subcuticular
sutures should be placed as deeply as possible to minimize the erythema and
SYNTHETIC ABSORBABLE SUTURE, U.S.P., induration normally associated with absorption.
EXCEPT FOR DIAMETER Under some circumstances, notably orthopaedic procedures, immobilization of
joints by external support may be employed at the discretion of the surgeon.
DESCRIPTION Consideration should be taken in the use of absorbable sutures in tissue with
MONOCRYL* (poliglecaprone 25) suture is a monofilament synthetic poor blood supply as suture extrusion and delayed absorption may occur.
absorbable surgical suture prepared from a copolymer of glycolide and In handling this or any other suture material, care should be taken to avoid
epsilon-caprolactone. Poliglecaprone 25 copolymer has been found to be damage from handling. Avoid crushing or crimping damage due to application
nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during of surgical instruments such as forceps or needle holders.
absorption.
MONOCRYL suture knots must be properly placed to be secure. Adequate knot
MONOCRYL sutures are U.S.P. except for diameters in the following sizes: security requires the accepted surgical technique of flat and square ties with
additional throws as warranted by surgical circumstance and the experience of
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P. the surgeon. The use of additional throws may be particularly appropriate when
knotting monofilaments.
U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm)
Avoid prolonged exposure to elevated temperature.
6-0 0.049
5-0 0.033 To avoid damaging needle points and swage areas, grasp the needle in an area
4-0 0.045 one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
3-0 0.067 point. Reshaping needles may cause them to lose strength and be less
2-0 0.055 resistant to bending and breaking. Users should exercise caution when
0 0.088 handling surgical needles to avoid inadvertent needle sticks. Discard used
1 0.066 needles in "sharps" containers.
2 0.099
ADVERSE REACTIONS
INDICATIONS
Adverse effects associated with the use of synthetic absorbable sutures include
MONOCRYL sutures are indicated for use in general soft tissue approximation wound dehiscence, failure to provide adequate wound support in closure of the
and/or ligation, but not for use in cardiovascular or neurological tissues, sites where expansion, stretching, or distension occur, failure to provide
microsurgery or ophthalmic surgery. adequate wound support in elderly, malnourished or debilitated patients or in
patients suffering from conditions which may delay wound healing, infection,
minimal acute inflammatory tissue reaction, localized irritation when skin
ACTIONS
sutures are left in place for greater than 7 days, suture extrusion and delayed
MONOCRYL suture is a monofilament which elicits a minimal acute inflamma- absorption in tissue with poor blood supply, calculi formation in urinary and
tory reaction in tissues and ingrowth of fibrous connective tissue. Progressive biliary tracts when prolonged contact with salt solutions such as urine and bile
loss of tensile strength and eventual absorption of MONOCRYL sutures occurs occurs, and transitory local irritation at the wound site. Broken needles may
by means of hydrolysis. Absorption begins as a loss of tensile strength result in extended or additional surgeries or residual foreign bodies.
followed by a loss of mass. Implantation studies in rats indicate that Inadvertent needle sticks with contaminated surgical needles may result in the
MONOCRYL suture retains approximately 60 to 70% of its original strength transmission of bloodborne pathogens.
7 days post implantation, and approximately 30 to 40% of its original tensile
strength at 14 days post implantation. Essentially all of the original tensile
strength is lost by 28 days post implantation. Absorption of MONOCRYL HOW SUPPLIED
absorbable synthetic suture is essentially complete between 91 and 119 days. MONOCRYL sutures are available as sterile, monofilament, dyed (violet)
strands in sizes 6-0 through 2 (metric sizes 0.7-5), in a variety of lengths, with
APPROXIMATE % ORIGINAL or without needles. MONOCRYL sutures are also available in sizes 3-0 through
DAYS IMPLANTATION STRENGTH REMAINING 1 (metric sizes 2-4) attached to CONTROL RELEASE* removable needles.
MONOCRYL sutures are available in one and three dozen boxes.
7 DAYS 60 TO 70%
14 DAYS 30 TO 40%
WARNINGS
Users should be familiar with surgical procedures and techniques involving
absorbable sutures before employing MONOCRYL suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the
suture material used. Physicians should consider the in vivo performance
(under ACTIONS section) when selecting a suture for use in patients. The
use of this suture may be inappropriate in elderly, malnourished, or debilitated
patients, or in patients suffering from conditions which may delay wound
healing.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus
formation. As an absorbable suture, MONOCRYL suture may act transiently as
a foreign body. Acceptable surgical practice should be followed for the
management of contaminated or infected wounds.
As this is an absorbable suture material, the use of supplemental
nonabsorbable sutures should be considered by the surgeon in the closure of
the sites which may undergo expansion, stretching or distention, or which may
require additional support.
CHAPTER 8 99
HOW SUPPLIED
CONTRAINDICATIONS
NUROLON sutures are available in U.S.P. sizes 6-0 through 1 (metric sizes
Due to the gradual loss of tensile strength which may occur over prolonged 0.7-4.0) in a variety of lengths with and without permanently attached needles.
periods in vivo, nylon suture should not be used where permanent retention of
tensile strength is required. NUROLON sutures are available in U.S.P. sizes 4-0 through 1 (metric sizes
1.5-4.0) attached to CONTROL RELEASE* removable needles.
NUROLON sutures are available in one, two and three dozen boxes.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing NUROLON suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the 389354 *Trademark ©ETHICON, INC. 1995
suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practices should be followed for the management
of infected or contaminated wounds.
Do not resterilize. Discard opened packages and unused sutures.
100 PRODUCT INFORMATION
PDS* II (POLYDIOXANONE) Suture WARNINGS
DYED and CLEAR MONOFILAMENT The safety and effectiveness of PDS II (polydioxanone) sutures have not been
established in neural tissue, adult cardiovascular tissue or for use in micro-
SYNTHETIC ABSORBABLE SUTURES, U.S.P., surgery.
EXCEPT FOR DIAMETER. Under certain circumstances, notably orthopaedic procedures, immobilization
by external support may be employed at the discretion of the surgeon.
DESCRIPTION
Do not resterilize.
PDS* II (polydioxanone) monofilament synthetic absorbable suture is prepared
from the polyester, poly (p-dioxanone). The empirical molecular formula of the
polymer is (C4H603)x.
PRECAUTIONS
Polydioxanone polymer has been found to be nonantigenic, nonpyrogenic and
elicits only a slight tissue reaction during absorption. The PDS II suture knots must be properly placed to be secure. As with other
PDS II sutures are U.S.P., except for diameter. synthetic sutures, knot security requires the standard surgical technique of flat
and square ties with additional throws if indicated by surgical circumstance
and the experience of the operator.
MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.
As with any suture, care should be taken to avoid damage when handling.
U.S.P. SUTURE
Avoid the crushing or crimping application of surgical instruments, such as
SIZE DESIGNATION MAXIMUM OVERSIZE (mm)
needle holders and forceps, to the strand except when grasping the free end of
9-0 .005 the suture during an instrument tie.
8-0 .008
7-0 .020 Conjunctival and vaginal mucosal sutures remaining in place for extended
6-0 .015 periods may be associated with localized irritation and should be removed as
5-0 .029 indicated.
4-0 .029 Subcuticular sutures should be placed as deeply as possible in order to
3-0 .056 minimize the erythema and induration normally associated with absorption.
2-0 .029
0 .071 Acceptable surgical practice should be followed with respect to drainage and
1 .047 closure of infected wounds.
2 .023
ADVERSE REACTIONS
ACTIONS Due to prolonged suture absorption, some irritation and bleeding has been
Two important characteristics describe the in vivo performance of absorbable observed in the conjunctiva and mild irritation has been observed in the
sutures: first, tensile strength retention, and second, the absorption rate (loss vaginal mucosa.
of mass). PDS II synthetic absorbable suture has been formulated to minimize
the variability of these characteristics and to provide wound support through
an extended healing period.
DOSAGE AND ADMINISTRATION
The results of implantation studies of PDS II monofilament suture in animals
Use as required per surgical procedure.
indicate that approximately 70% of its original strength remains two weeks
after implantation. At four weeks post-implantation, approximately 50% of its
original strength is retained, and at six weeks, approximately 25% of the origi-
nal strength is retained. HOW SUPPLIED
Data obtained from implantation studies in rats show that the absorption of PDS II sutures are available as sterile, monofilament dyed (violet) strands in
these sutures is minimal until about the 90th post-implantation day. Absorption sizes 9-0 thru 2 (metric sizes 0.3-5), and sterile, monofilament dyed (blue)
is essentially complete within six months. strands in size 9-0 thru 7-0 (metric size 0.3-0.5) in a variety of lengths, with a
variety of needles.
PDS II monofilament dyed (violet) sutures, sizes 4-0 thru 1 (metric size 1.5-4) are
INDICATIONS also available attached to CONTROL RELEASE* removable needles.
PDS II monofilament synthetic absorbable sutures are indicated for use in all
PDS II Clear suture strands are available in sizes 7-0 thru 1 (metric size 0.5-4) in
types of soft tissue approximation, including use in pediatric cardiovascular tis-
a variety of lengths with permanently attached needles.
sue where growth is expected to occur and opthalmic surgery. PDS II suture is
not indicated in adult cardiovascular tissue, microsurgery and neural tissue.
These sutures are particularly useful where the combination of an absorbable
suture and extended wound support (up to six weeks) is desirable. 388W91 *Trademark ©ETHICON, INC. 1992
CONTRAINDICATIONS
These sutures, being absorbable, are not to be used where prolonged (beyond
six weeks) approximation of tissues under stress is required are not to be used
in conjunction with prosthetic devices, i.e., heart valves or synthetic grafts.
CHAPTER 8 101
DESCRIPTION As with any suture material, adequate knot security requires the accepted
surgical technique of flat and square ties with additional throws as warranted
PERMA-HAND* silk suture is a nonabsorbable, sterile, surgical suture
by surgical circumstance and the experience of the surgeon.
composed of an organic protein call fibroin. This protein is derived from the
domesticated species Bombyx mori (b. More) of the family Bombycidae. To avoid damaging needles points and swage areas, grasp the needle in an
PERMA-HAND sutures are processed to remove the natural waxes and gums. area one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
PERMA-HAND suture is dyed black and coated with a special was mixture. point. Reshaping needles may cause them to lose strength and be less
PERMA-HAND suture is also available in its natural color. PERMA-HAND Virgin resistant to bending and breaking g. Users should exercise caution when
silk suture is available in which the sericin gum is not removed and serves to handling surgical needles to avoid inadvertent needle sticks. Discard used
hold the filaments together. needles in "sharps" containers.
PERMA-HAND suture meets requirements established by the United States
Pharmacopoeia (U.S.P.) for nonabsorbable surgical suture.
ADVERSE REACTIONS
Adverse effects associated with the use of this device include wound
INDICATIONS dehiscence, gradual loss of all tensile strength over time, allergic response in
patients that are know to be sensitive to silk, calculi formation in urinary and
PERMA-HAND suture is indicated for use in general soft tissue approximation
biliary tracts when prolonged contact with salt solutions such as urine and bile
and/or ligation, including use in cardiovascular, ophthalmic and neurological
occurs, infection, acute inflammatory tissue reaction, and transitory local
procedures.
irritation at the wound site. Broken needles may result in extended or
additional surgeries or residual foreign bodies. Inadvertent needle sticks with
contaminated surgical needles may result in the transmission of bloodborne
ACTIONS pathogens.
PERMA-HAND suture elicits an acute inflammatory reaction in tissue, which is
followed by a gradual encapsulation of the suture by fibrous connective tissue.
While silk sutures are not absorbed, progressive degradation of the proteina- HOW SUPPLIED
ceous silk fiber in vivo may result in gradual loss of all of the suture’s tensile
PERMA-HAND sutures are available in U.S.P. sizes 9-0 through 5 (metric sizes
strength over time.
0.3-7.0) in a variety of lengths with and without permanently attached needles
and on LIGAPAK* dispensing reels.
CONTRAINDICATIONS PERMA-HAND sutures are also available in U.S.P. sizes 4-0 through 1 (metric
sizes 1.5-4.0) attached to CONTROL RELEASE* removable needles.
The use of this suture is contraindicated in patients with known sensitivities or
allergies to silk. PERMA-HAND sutures are available in one, two, and three dozen boxes.
Due to the gradual loss of tensile strength which may occur over prolonged
periods in vivo, silk should not be used where permanent retention of tensile
strength is required.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable sutures before employing PERMA-HAND suture for wound
closure, as risk of wound dehiscence may vary with the site of application and
the suture material used.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practice should be followed for the management
of infected or contaminated wounds.
WARNINGS
Users should be familiar with surgical procedures and techniques involving 389361 *Trademark ©ETHICON, INC. 1995
nonabsorbable sutures before employing PROLENE suture for wound closure,
as risk of wound dehiscence may vary with the site of application and the
suture material used.
Do not resterilize. Discard opened packages and unused sutures.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. Acceptable surgical practice must be followed for the management of
infected or contaminated wounds.
PRECAUTIONS
In handling this suture material, care should be taken to avoid damage from
handling. Avoid crushing or crimping damage due to application of surgical
instruments such as forceps or needle holders.
Adequate knot security requires the accepted surgical technique of flat, square
ties of single suture strands. The use of additional throws is particularly appro-
priate when knotting polypropylene sutures.
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
point. Reshaping needles may cause them to lose strength and be less resist-
ant to bending and breaking. Users should exercise caution when handling sur-
gical needles to avoid inadvertent needle sticks. Discard used needles in
"sharps" containers.
CHAPTER 8 103
ADVERSE REACTIONS
Potential adverse reactions are those typically associated with surgically
implantable materials which include infection potentiation, inflammation,
adhesion formation, fistula formation and extrusion.
104 PRODUCT INFORMATION
PROLENE* POLYPROPYLENE MESH PRECAUTIONS
A minimum of 6.5mm (1/4") of mesh should extend beyond the suture line.
NONABSORBABLE SYNTHETIC SURGICAL MESH
STERILE
ADVERSE REACTIONS
DESCRIPTION Potential adverse reactions are those typically associated with surgically
implantable materials which include infection potentiation, inflammation,
PROLENE* polypropylene mesh is constructed of knitted filaments of extruded adhesion formation, fistula formation and extrusion.
polypropylene identical in composition to that used in PROLENE*
Polypropylene Suture, Nonabsorbable Surgical Sutures, U.S.P. (ETHICON,
INC.). The mesh is approximately 0.020 inches thick. This material, when used
as a suture, has been reported to be non-reactive and to retain its strength
INSTRUCTIONS FOR USE
indefinitely in clinical use. It is recommended that nonabsorbable sutures be placed 6.5mm to 12.5mm
(1/4" to 1/2") apart at a distance approximately 6.5mm (1/4") from edge of the
PROLENE mesh is knitted by a process which interlinks each fiber junction and mesh. Some surgeons prefer to suture an uncut section of mesh that is
which provides for elasticity in both directions. This construction permits the considerably larger than the defect into position over the wound. The opposite
mesh to be cut into any desired shape or size without unraveling. The fiber junc- sides are then sutured to assure proper closure under correct tension. When
tions are not subject to the same work fatigue exhibited by more rigid metallic the margin sutures have all been placed, the extra mesh is trimmed away.
meshes. This bi-directional elastic property allows adaption to various stresses
encountered in the body.
HOW SUPPLIED
PROLENE mesh is available in single packets as sterile, undyed (clear) sheets
ACTIONS
in seven sizes. The sizes available are 2.5cm x 10cm (1" x 4"), 4.6cm x 10.2cm
PROLENE mesh is a nonabsorbable mesh used to span and reinforce traumat- (1.8" x 4"), 6cm x 11cm (2.5" x 4.5"), 6.1cm x 13.7cm (2.4" x 5.4"), 7.6cm x 12.7cm
ic or surgical wounds to provide extended support during and following wound (3" x 5"), 15cm x 15cm (6" x 6") and 30cm x 30cm (12" x 12"). Each sheet is
healing. Animal studies show that implantation of PROLENE mesh elicits a min- approximately 0.5mm (0.020") thick.
imum to slight inflammatory reaction, which is transient and is followed by the
deposition of a thin fibrous layer of tissue which can grow through the inter-
stices of the mesh, thus incorporating the mesh into adjacent tissue. The mesh
remains soft and pliable, and normal wound healing is not noticeably impaired. 389392.R01 *Trademark ©ETHICON, INC. 1996
The material is not absorbed nor is it subject to degradation or weakening by
the action of tissue enzymes.
INDICATIONS
This mesh may be used for the repair of hernia and other fascial deficiencies
that require the addition of a reinforcing or bridging material to obtain the
desired surgical result.
CONTRAINDICATIONS
When this mesh is used in infants or children with future growth potential, the
surgeon should be aware that this product will not stretch significantly as the
patient grows.
WARNINGS
PROLENE mesh is provided by ETHICON, INC. as a sterile product.
Resterilization of the device is NOT recommended. However, testing has
demonstrated that reprocessing of unused PROLENE mesh which has been
removed from the package will not be adversely affected when exposed not
more than one time to conventional steam autoclave conditions of 250° F
(121° C) for 20 minutes. Reprocessing under any other condition or by any
other means is neither recommended nor endorsed by ETHICON, INC.
PROLENE mesh should not be flash autoclaved.
If this product should become stained with blood or soiled, it should not be
resterilized for reuse.
PRONOVA sutures are available in one, two, and three dozen boxes.
CONTRAINDICATIONS
None known.
INDICATIONS
The Skin Stapler has application for routine skin closure in a wide variety of
surgical procedures.
CONTRAINDICATIONS
When it is not possible to maintain at least a 5 mm distance from the stapled
skin to underlying bones, vessels, or internal organs, the use of staples for skin
closure is contraindicated.
DEVICE DESCRIPTION
The Skin Stapler is a sterile, single patient use instrument designed to deliver
rectangular, stainless steel staples for routine wound closure.
HOW SUPPLIED
The PROXIMATE Skin Stapler is supplied sterile and preloaded for single
patient use. Discard after use.
PROXIMATE®
SKIN STAPLER EXTRACTOR
INDICATIONS
The PROXIMATE Skin Staple Extractor has application for routine skin closure
in a wide variety of surgical procedures.
CONTRAINDICATIONS
When it is not possible to maintain at least a 5 mm distance from the stapled
skin to underlying bones, vessels, or internal organs, the use of staples for skin
closure is contraindicated.
DEVICE DESCRIPTION
The PROXIMATE Skin Staple Extractor is a sterile, single patient use, stainless
steel device specifically designed to completely open skin staples for removal.
The function of the Skin Staple Extractor is to remove Proximate Regular or
Wide Skin Staples from skin wounds.
1 Using sterile technique, remove the device from the package. To avoid
damage, do not flip the device into the sterile field.
2 Remove the safety cap from the device.
3 Slide lower jaw of extractor under regular or wide staple until staple is
secured in slot in lower jaw. (Illustration 1)
4 Squeeze down with thumb to open staple until handles are firmly
touching. (Illustration 2)
5 Ensure staple is completely opened before lifting extractor from skin.
Never pull up before extractor is fully closed. (Illustration 3)
• Instruments or devices which come into contact with bodily fluids may
require special disposal handling to prevent biological contamination.
HOW SUPPLIED
The PROXIMATE Skin Staple Extractor is supplied sterile for single patient use.
Discard after use.
INDICATIONS
The PROXIMATE PLUS MD Skin Stapler has application for routine skin closure
in a wide variety of surgical procedures.
CONTRAINDICATIONS
When it is not possible to maintain at least a 5 mm distance from the stapled
skin to underlying bones, vessels, or internal organs, the use of staples for skin
closure is contraindicated.
DEVICE DESCRIPTION
The PROXIMATE PLUS MD Skin Stapler is a sterile, single patient use
instrument designed to deliver rectangular, stainless steel staples for routine
wound closure.
HOW SUPPLIED
The PROXIMATE PLUS MD Skin Stapler is supplied sterile and preloaded for
single patient use. Discard after use.
Caution: Federal (USA) law restricts this device to sale by or on the order
of a physician.
ADVERSE REACTIONS
ACTIONS Adverse effects associated with the use of this device include wound dehis-
When surgical gut suture is placed in tissue, a moderate tissue inflammation cence, variable rates of absorption over time (depending on such factors as the
occurs which is characteristic of foreign body response to a substance. This is type of suture used, the presence of infection and the tissue site), failure to pro-
followed by a loss of tensile strength and a loss of suture mass, as the prote- vide adequate wound support in closure of sites where expansion, stretching
olytic enzymatic digestive process dissolves the surgical gut. This process or distension occur, etc., unless additional support is supplied through the use
continues until the suture is completely absorbed. Many variable factors may of nonabsorbable suture material, failure to provide adequate wound support
affect the rate of absorption. Some of the major factors which can affect tensile in elderly, malnourished or debilitated patients or in patients suffering from
strength loss and absorption rates are: cancer, anemia, obesity, diabetes, infection or other conditions which may
1. Type of suture - plain gut generally absorbs more rapidly than chromic gut. delay wound healing, allergic response in patients with known sensitivities to
collagen or chromium which may result in an immunological reaction resulting
2. Infection - surgical gut is absorbed more rapidly in infected tissue in inflammation, tissue granulation or fibrosis, wound suppuration and bleed-
than in non-infected tissue. ing, as well as sinus formation, infection, moderate tissue inflammatory
response characteristic of foreign body response, calculi formation in urinary
3. Tissue sites - surgical gut will absorb more rapidly in tissue where and biliary tracts when prolonged contact with salt solutions such as urine and
increased levels of proteolytic enzymes are present, as in the secre- bile occurs, and transitory local irritation at the wound site. Broken needles
tions exhibited in the stomach, cervix and vagina. may result in extended or additional surgeries or residual foreign bodies.
Inadvertent needle sticks with contaminated surgical needles may result in the
transmission of bloodborne pathogens.
CONTRAINDICATIONS
This suture, being absorbable, should not be used where extended approxi-
mation of tissue is required. HOW SUPPLIED
Surgical gut sutures are available in U.S.P. sizes 7-0 through 3 (metric sizes
The use of this suture is contraindicated in patients with known sensitivities or
0.7-7.0) in a variety of lengths with and without permanently attached needles
allergies to collagen or chromium, as gut is a collagen based material, and
and on LIGAPAK* dispensing reels. Surgical gut sutures are also available in
chromic gut is treated with chromic salt solutions.
U.S.P. sizes 0 through 1 (metric sizes 4.0-5.0) attached to CONTROL RELEASE*
removable needles. The suture is supplied sterile in one, two and three
dozen boxes.
WARNINGS
Users should be familiar with surgical procedures and techniques involving gut
suture before using surgical gut suture for wound closure, as the risk of wound
dehiscence may vary with the site of application and the suture material used. 389360 *Trademark ©ETHICON, INC. 1995
Physicians should consider the in vivo performance when selecting a suture.
The use of this suture may be inappropriate in elderly, malnourished, or debil-
itated patients, or in patients suffering from conditions which may delay wound
healing. As this is an absorbable material, the use of supplemental nonab-
sorbable sutures should be considered by the surgeon in the closure of sites
which may undergo expansion, stretching or distention or which may require
additional support.
As with any foreign body, prolonged contact of any suture with salt solutions,
such as those found in the urinary or biliary tracts, may result in calculus for-
mation. As an absorbable suture, surgical gut may act transiently as a foreign
body. Acceptable surgical practice should be followed for the management of
contaminated or infected wounds.
Do not resterilize. Discard open packages and unused sutures.
Certain patients may be hypersensitive to collagen or chromium and might
exhibit an immunological reaction resulting in inflammation, tissue granulation or
fibrosis, wound suppuration and bleeding, as well as sinus formation.
110 PRODUCT INFORMATION
SURGICAL STAINLESS STEEL SUTURE PRECAUTIONS
In handling this or any other suture material, care should be taken to avoid
NONABSORBABLE SURGICAL SUTURES, U.S.P. damage from handling, such as kinking or excessive twisting.
To avoid damaging needle points and swage areas, grasp the needle in an area
one-third (1/3) to one-half (1/2) of the distance from the swaged end to the
DESCRIPTION point. Reshaping needles may cause them to lose strength and be less
Surgical stainless steel suture is a nonabsorbable, sterile surgical suture resistant to bending and breaking. Users should exercise caution when
composed of 316L stainless steel. Surgical stainless steel suture is available as handling surgical needles to avoid inadvertent needle sticks. Discard used
a monofilament and multifilament suture. needles in "sharps" containers.
Surgical stainless steel suture meets all requirements established by the United
States Pharmacopoeia (U.S.P.) for nonabsorbable surgical sutures. Surgical ADVERSE REACTIONS
stainless steel suture is also labeled with the B&S gauge classifications. Adverse effects associated with the use of this device include wound dehis-
cence, allergic response in patients with known sensitivities to 316L stainless
INDICATIONS steel, or constituent metals such as chromium and nickel, infection, minimal
acute inflammatory tissue reaction, pain, edema and local irritation at the
Surgical stainless steel suture is indicated for use in abdominal wound closure, wound site. Broken needles may result in extended or additional surgeries or
hernia repair, sternal closure and orthopaedic procedures including cerclage residual foreign bodies. Inadvertent needle sticks with contaminated surgical
and tendon repair. needles may result in the transmission of bloodborne pathogens.
WARNINGS
Users should be familiar with surgical procedures and techniques involving
nonabsorbable, stainless steel sutures before employing for wound closure, as
the risk of wound dehiscence may vary with the site of application and the
suture material used.
CONTRAINDICATIONS
Because VICRYL knitted mesh is absorbable, it should not be used where
extended wound or organ support is required.
112 PRODUCT INFORMATION
VICRYL* Woven Mesh WARNINGS
DO NOT RESTERILIZE.
The safety and effectiveness of VICRYL woven mesh in neural tissue and in car-
DESCRIPTION diovascular tissue has not been established.
VICRYL* (polyglactin 910) woven mesh is prepared from a synthetic absorbable
copolymer of glycolide and lactide, derived respectively from glycolic and lac-
tic acids. This tightly woven mesh is prepared from uncoated, undyed fiber PRECAUTIONS
identical in composition to that used in VICRYL* (polyglactin 910) synthetic None.
absorbable suture, which has been found to be inert, nonantigenic, nonpyro-
genic and to elicit only a mild tissue reaction during absorption.
VICRYL woven mesh is intended for use as a buttress to provide temporary sup- ADVERSE REACTIONS
port during the healing process. None known.
CONTRAINDICATIONS
Because VICRYL woven mesh is absorbable, it should not be used where
extended wound or organ support is required.
CHAPTER 9
INDEX
114 INDEX
COATED VICRYL RAPIDE*
A ABDOMEN, 23, 26, 28, 30
(POLYGLACTIN 910) SUTURE, 14,
32-33, 39, 90
abdominal cavity, 23, 26, 30, 34,
51, 63
abdominal wall, 16, 19, 23, 28,
30-31, 33-34, 77, 82, 84 D DEAD SPACE, 5, 22, 32, 81
DERMABOND*
fascia, 2, 5, 21, 30-32, 34, 39-40,
TOPICAL SKIN ADHESIVE
47-48, 51, 63, 77, 82, 96
(2-OCTYL CYANOACRYLATE), 68-71,
muscle tissue, 2, 30
81, 91-92
peritoneum, 19, 23, 29-31, 34,
DISSECTION, 4, 48, 103
47-48, 51, 63
skin, 2, 31-33
E
subcutaneous fat, 30-32, 47-48
ETHIBOND* EXCEL POLYESTER
subcuticular tissue, 32
SUTURE, 10, 17-18, 20, 25, 33, 37-38,
transversalis fascia, 30
58-59, 81, 83, 93
ALIMENTARY TRACT, 35 ETHILON* NYLON SUTURE, 10, 17, 20,
esophagus, 36 25, 33-36, 58-59, 81, 94
oral cavity, 35-36, 47-48, 69, 89 EYE, 35-36
pharynx, 35, 47-48 conjunctiva, 35-36, 100
upper alimentary tract, 35 cornea, 35-36, 80
ocular muscles, 35-36
B
sclera, 35-36
BILIARY TRACT, 6, 29, 38, 47-48
gallbladder, 29
BONE, 2, 16, 39-40, 80
anchor, 18, 39, 65
F FEMALE GENITAL TRACT, 38
sternum, 39
BRAIN, 34
cerebrospinal fluid, 34
dura mater, 34-35
G GASTROINTESTINAL TRACT, 6, 28-29,
47-48
galea, 34, 76 colon, 2, 27, 29
peripheral nerve repair, 34 rectum, 29
skull, 35 small intestine, 2, 28-29, 94
stomach, 2-3, 27-29, 81, 94, 110
L
stability, 43
LIGATURES, 10, 18-19, 28, 62, 85 strength, 42
free tie, 18-19, 28 ETHALLOY* needle alloy,
LIGAPAK* dispensing reel, 21, 42, 81
59, 63, 82, 101, 110 swage, 44-45, 65, 83
stick tie, 18-19, 85 CONTROL RELEASE*
needle, 21, 45, 59, 80
M
types, 48-52
MERSILENE* blunt point, 52
POLYESTER FIBER MESH, 82, 97 ETHIGUARD* blunt
MERSILENE* point needle, 52, 81
POLYESTER FIBER STRIP, 75, 82 cutting, 43, 46-50, 51
MERSILENE* conventional cutting,
POLYESTER FIBER SUTURE, 13, 17, 20, 49, 83
25, 33, 35, 58-59, 82, 96 PC PRIME* needle,
MESH, 30, 35, 82, 84, 86, 96 48-49, 83
See also MERSILENE* polyester sternotomy, 49
fiber mesh; PROLENE* reverse cutting, 49-50, 75,
Polypropylene Hernia System; 84
PROLENE* polypropylene mesh; MICRO-POINT*
VICRYL* (polyglactin 910) needle, 49, 82
knitted mesh; VICRYL* OS, 50, 51
(polyglactin 910) periodontal side-cutting, 50, 82
mesh; VICRYL* (polyglactin 910) CS ULTIMA*
woven mesh needle, 48, 50, 80
MICROSURGERY, 15, 21, 34, 47-48, 62, SABRELOC*
65, 82, 97-98, 100 needle, 50, 84
MONOCRYL* (POLIGLECAPRONE 25) spatula, 50-51, 82
SUTURE, 10, 12, 14-15, 20, 25, 32, 38, TG PLUS* needle,
58-59, 70-71, 83, 98 50
116 INDEX
taper point, 21, 43, 46, purse-string sutures, 19, 22
50-51, 77, 85 running stitches, 19
MAYO, 51 subcuticular sutures, 19, 22,
TAPERCUT, 44, 48, 50-51 32, 90
TAPERCUT needle, PROLENE* POLYPROPYLENE HERNIA
44, 48, 51-52, SYSTEM, 30, 70, 84, 104
85 PROLENE* POLYPROPYLENE MESH,
trocar point, 51 30, 70, 84, 105
NEEDLEHOLDER, 26-27, 42-43, 46-53 PROLENE* POLYPROPYLENE SUTURE,
arming, 27, 59 18, 20, 25-26, 28, 30-31, 34-35,
jaws, 52 37, 39, 61, 84, 103
NEUROSURGERY, 16, 34 PRONOVA* POLY
NUROLON* BRAIDED NYLON (HEXAFLUOROPROPYLENE-VDF)
SUTURE, 10, 13, 17, 20, 25, 34, 39, SUTURE, 18, 20, 25-26, 37, 39, 84
58-59, 83, 100 PROXI-STRIP* SKIN CLOSURES, 27,
40, 75, 84
P PARENCHYMATOUS ORGANS, 29
RETENTION SUTURE DEVICES, 33,
77-78, 84
kidney, 3, 29, 52
S
liver, 29-30, 52
spleen, 29 SECONDARY SUTURE LINE, 33
PDS* II (POLYDIOXANONE) SUTURE, continuous sutures, 19, 22, 24,
10, 15-16, 25, 31, 35, 38, 37
59-60, 83, 101 interrupted sutures, 19, 22, 24,
PERMA-HAND* SILK SUTURE, 16, 25, 28, 30-31, 37
33, 59, 83, 102 railroad track scar, 33
PLASTIC SURGERY, 14, 17, 48, 51, 57, retention sutures, 33, 77-78, 84
83-84 SKIN, 2-5, 8, 10, 13-14, 16-17, 22,
PRIMARY SUTURE LINE, 18, 22-23, 33 27-28, 31-34, 46-47
buried sutures, 22, 80 STITCH PLACEMENT, 23
continuous sutures, 19, 22, 37 STITCHES AND TYPES, 18-23
Connell Technique, 24 Connell Technique, 24
Cushing Technique, 24 Cushing Technique, 24
Lembert Technique, 24 Halsted Technique, 24
deep sutures, 19, 22, 69 horizontal mattress technique,
interrupted sutures, 19, 22, 28, 19, 24
30-31, 38 Lembert Technique, 24
interrupted horizontal over-and-over technique, 19, 24
mattress suture, 19, 24 purse-string technique, 19, 22
interrupted vertical running technique, 19
mattress suture, 19, 24
CHAPTER 9 117
* Trademark
118 INDEX
dispenser boxes, 56-57, sterile technique, 26, 75, 85
60, 81, 83 sterile transfer, 56, 60-62
environmentally conscious, 57 sterile sterilization, 60
primary packets, 56-57 SUTURE PREPARATION, 62
overwrap, 57, 59, 61-62, SUTURE REMOVAL, 11, 14, 26, 32-33,
64, 83 35, 68-69
peelable foil, 58 SUTURE TECHNIQUES, 28-34, 45
single strand and multi- double-layer closure, 28
strand packaging packets, inverted closure technique, 28
58, 82-83 single-layer closure, 28, 31
E-PACK* procedure Smaed-Jones far-and-
kit, 54, 59, 61, 81 near technique, 31
EASY ACCESS* See also ligatures; primary suture
packaging, 81 line; secondary suture line
ETHI-PACK* pre-cut
T
suture, 81
GENTLE BEND* TAPES, 4, 32, 52, 56, 74-75
package, 82 skin closure tapes, 32, 74-75
LABYRINTH* umbilical tape, 75, 85
package, 82 See also MERSILENE* polyester
looped suture, 19, fiber strip; PROXI-STRIP* skin
77, 82 closures
RELAY* suture TENDON SURGERY, 39
delivery system, Bunnell Technique, 37, 39
56-58, 60-61, periosteum, 39, 51
64, 84 TISSUE ADHESIVES, 68-71
SUTUPAK* pre-cut See also DERMABOND* Topical
sterile suture, 58, Skin Adhesive (2-Octyl
63, 85 Cyanoacrylate)
storage racks, 56 TISSUE STRENGTH, 2
IV pole racks, 56 breaking strength, 2
modular storage burst strength, 2
racks, 56-57 tensile strength, 2, 6, 11-17, 23
polyester fiber suture, 13, 17, 20,
U
25, 58, 92, 95, 96
See also ETHIBOND* EXCEL URINARY TRACT SURGERY, 38
polyester suture
polypropylene suture, 18, 25-26,
28, 30, 32, 36-39, 66,
82-84, 102-103
See also PROLENE*
polypropylene suture
sterilization, 57, 60, 85, 90, 104
SUTURE CUTTING, 26
SUTURE HANDLING, 10-11, 26-27, 63
sterile barrer, 61
sterile field, 53, 56, 59-62, 64
CHAPTER 9 119
V VASCULAR SURGERY, 11
heart valves, 21, 38, 99
VESSELS, 4, 6, 10, 14, 18, 24, 32,
37-38, 51, 59, 62, 75
pediatric, 15, 21, 75, 85
VICRYL* (POLYGLACTIN 910)
KNITTED MESH, 30, 86, 112
VICRYL* (POLYGLACTIN 910)
PERIODONTAL MESH, 35-36, 86
VICRYL* (POLYGLACTIN 910) SUTURE,
10, 14-15, 25, 34-35
VICRYL* (POLYGLACTIN 910) PLUS
SUTURE, 10, 15, 20-21
VICRYL* (POLYGLACTIN 910)
WOVEN MESH, 30, 86, 113
* Trademark
NOTES
NOTES
NOTES
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W O U N D C L O S U R E M A N UA L
WOUND HEALING
TO V I E W T H E E - C ATA L O G G O T O T H E
NEEDLES H E A LT H C A R E P R O F E S S I O N A L SECTION OF
W W W. E T H I C O N . C O M
ADHESIVES
SURGICAL MESH
* TRADEMARK
SM
ETHICON, INC.
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2005, ETHICON, INC.