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Surgical Sutures - a Review Amit Goel Department of General Surgery, Jamia Hamdard Medical College, New Delhi

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Surgical Sutures - a Review Amit Goel Department of General Surgery, Jamia Hamdard Medical College, New Delhi E-ISSN 2454-2784 Major Review Surgical Sutures - A Review Amit Goel Department of General Surgery, Jamia Hamdard Medical College, New Delhi Abstract Edwin Smith (1822-1906) discovered papyrus which is the 5,6 A good suturing goes a long way in aesthetic as well as effective wound oldest known text describing sutures. Aurelius Cornelius closure. Selection of material varies with the tissue requirements. The Celsus (25 BCE–50 CE), came out with the eight-volume sutures have evolved considerably over the years and are classified De Re Medicina in which he described the use of braided according to their origin, material used, number of filaments and suture.6,7 He wrote about controlling haemostasis by ‘making thickness. In this article the characteristics and uses of various sutures ligatures in many places’ which would twist around the used in ophthalmic surgery shall be discussed. vessels. Later, Galen of Pergamon (131–211) introduced the use of gut string as a suture material to repair damaged Keywords: sutures, monofilament, braided, absorbable, non-absorbable tendons in gladiators.7,8 He also recommended using silk suture when available. Effective wound closure is important for success of Rhazes (850–923) in Baghdad, propagated catgut lute any surgical procedure. An incomplete closure leads to strings for abdominal wall repair. He also utilized horse hair separation of edges, providing a potential pathway for suture.8,9 Ali Ibn Sina, or Avicenna (980–1037) of Iran noticed bacterial contamination leading to infection and scarring. rapid dissolution of sutures in the presence of infection and Although tissue adhesives and staples are now being used described a natural monofilament suture, pig’s bristles.9,10 as alternatives, surgical sutures are still the mainstay for a The absorption properties of the suture material were secure wound. described by American physician Philip Syng Physick There are an increasing number of materials and suturing (1768–1837) who noted that fluids escaping from a wound 1 techniques described in the literature. An understanding dissolved leather and popularized chromic sutures.10,11 of the origin of sutures improves appreciation of use of Absorbable sutures made of ‘tendons from the ox, moose, contemporary sutures. In this article the various suture reindeer, etc, and the tails of rabbits, opossums, kangaroos materials have been discussed highlighting their utility in and whale were widely used.11,12 Silver suture was then different procedures and tissues. employed for closing tissue under tension, for infected surgical fields, and for fistulas. Historical Aspects Suture materials used for treating wounds were originally Standardization Practices natural materials, such as animal tendons and cotton fibres. Lister used carbolic acid to clean suture material, instruments Synthetic suture materials were used from 3000 BCE (Before and dressing material and developed catgut in 1881.12,13 The Common Era). Ancient Egyptians used plant fibres, hair, older methods have been replaced by ethylene oxide and tendons and wool threads, which have all been found in gamma irradiation for suture sterilization nowadays. The 2 mummified remains. The earliest document discussing concept of antibacterial coating of sutures was studied for suturing techniques is the Samhita, written by the Indian Vicryl Plus triclosan-coated sutures in the oral cavity. It 3 surgeon Susruta in 500 BCE. He proposed irrigating the was found that Vicryl Plus sutures had the disadvantage wound followed by application of black ants to the margins of not reducing the number of Gram-negative pathogenic 4 and then severing the bodies of the ants from their heads. bacteria while reducing the number of protective bacteria of He also described the use of bow string made of sheep upper the normal flora. The authors concluded that because of the small intestine as suture for rhinoplasty, tonsillectomy, costs, the possibility of allergy and developing resistance, amputation, and repair of anal fistulae. The process for the use of triclosan-coated sutures is not recommended.13,14 creating bow strings for musical instruments was called The US Food and Drug Administration (FDA) started the ‘kitgat’ meaning fiddle string. A ‘kit’ was a three-stringed concept of approval of new suture material in the 1970s 3 violin and from this word came ‘catgut’. followed by pre-market approval for manufacturers. A similar protocol is followed by the British Department Access this article online of Health that after approval, places the CE (Conformité Quick Response Code Européenne) mark on suture which conforms to ‘essential Website requirements’ for consumer safety in the European www.djo.org.in Economic Area. Currently used Suture Materials DOI http://dx.doi.org/10.7869/djo.161 Catgut, now called plain gut, is prepared from beef in United States and sheep or goats in India and Pakistan. Chromic gut is a modification aimed to extend the time the suture retains its strength in the body, by treating www.djo.org.in 159 ISSN 0972-0200 Major Review the catgut sutures with chromium salts to cross-link the prone to becoming infected because they lack grooves and collagen molecules. New synthetic absorbable polymers like rough surface for things to adhere but have the disadvantage polyglycolic acid and polylactic acid were developed.14,15 to loosen at the surgical knot with the lack of grip. Synthetic suture materials were named according to the Sutures that undergo rapid degradation lose their tensile corporation, materials, or scientists who formulated them. strength early, are considered absorbable. Absorption can Mersilene is a combination of Dr George Merson’s name, occur enzymatically, as with catgut, or hydrolytically, as and Terylene®, a common European trade name for with the absorbable synthetic polymers. Half- life is defined polyester. Ethiflex® suture, is a polyester suture that had a as the time required for the tensile strength of a material to flexible polytetrafluoroethylene coating placed to improve be reduced to half its original value. Dissolution time is the its handling properties. Ethibond® is the trade name for a time that elapses before a thread is completely dissolved. polyester suture with a coating that is tightly bonded to the These times are influenced by a large number of factors suture made by Ethicon, Inc (Somerville, NJ, USA). Early including thread thickness, type of tissue, and the general braided polyester sutures were taken over by nylon suture condition of the patient. due to better handling. Davis & Geck (Danbury, CT, USA) produced a synthetic absorbable suture called Dexon®. A coating that lowered the coefficient of friction during suturing was introduced as Dexon II® suture.16,17 Classification of Suture Materials An ideal suture material should be comfortable to handle, incite minimal tissue reaction, should not favour bacterial growth, should have high tensile strength, hold knots securely, easy to sterilize, should have no electrolytic, capillary, allergenic or carcinogenic action and should be absorbed after serving its function. There is no single suture encompassing all these properties and different sutures are required depending upon the tissue involved. The choice of the suture material is based on the biological interaction of the materials employed, the tissue configuration, and the biomechanical properties of the wound.17,18 The sutures are available in different colours. The colour acts as an indicator, which can be particularly useful in certain cases (e.g. vascular surgery) for distinguishing the different anatomical structures. The colour enhances suture visibility, even if steeped in blood, making stitch removal easier.18,19 Elasticity is the capacity of a material to regain its initial length after stretching. This property enables the suture to stretch with oedematous tissue but also to regain its original length and shape on remission of the oedema. Suture glide is the capacity of the suture thread to pass smoothly through the tissue during placement, and is a function of its coefficient of friction. Threads with a high coefficient of friction can have a saw effect as they pass through the tissues. Therefore, a low coefficient of friction is preferable, but has the disadvantage of slipping. Monofilament threads usually glide very well, whereas braided threads with their uneven surface have a higher Figure 1: Types of Sutures coefficient of friction. To minimise tissue trauma caused 1. Monofilament by braided threads, they are usually `coated`. Absorbable 2. Multifilament with coating 3. Multifilament braided monofilament sutures have good glide characteristics 4. Multifilament twisted and cause minimal tissue damage because of the smooth structure of the thread and its gradual bio-absorption. Non-Absorbable Sutures Sutures are classified as absorbable or non-absorbable, Non absorbable sutures made from natural fibres are silk monofilament or multifilament and whether they are made sutures. Silk sutures are made from threads of cocoon of from natural or synthetic material. Braided or multifilament silkworm. It may be virgin or braided, relatively inelastic and sutures have a number of strands woven together. The non- because it produces tissue necrosis resulting in early release braided sutures cause less reactivity in the body and are less of the wound, it induces less with the rule astigmatism Del J Ophthalmol - Vol 26 No: 3 January-March 2016 160 E-ISSN 2454-2784 Major Review when used in cataract surgery. The braided silk is prepared States Pharmacopeia (USP) . (Table2) by degumming process that removes the extraneous material amounting to 30% of the original volume of the Table 1: Characteristics of Commonly used Absorbable Sutures raw silk. This is essential for compactness. The advantage Suture Material Duration Characteristics is that neither the suture soaks up fluid nor becomes limp Collagen Homogenous 16-25 days with Loses strength like catgut, but dispersion of decrease in is less irritating or brittle. On the other hand the virgin silk is not processed bovine tendon tensile strength to remove the gums within the fibre.
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