E-ISSN 2454-2784 Major Review

Surgical Sutures - A Review Amit Goel Department of General , 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 as a suture material to repair damaged Keywords: sutures, monofilament, braided, absorbable, non-absorbable in gladiators.7,8 He also recommended using suture when available. Effective wound closure is important for success of Rhazes (850–923) in Baghdad, propagated lute any surgical procedure. An incomplete closure leads to for abdominal wall repair. He also utilized 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 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 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 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 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 -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 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 upper the normal flora. The authors concluded that because of the small intestine as suture for , , 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 string. A ‘kit’ was a three-stringed concept of approval of new suture material in the 1970s 3 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 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 like rough surface for things to adhere but have the disadvantage polyglycolic acid and 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 . Ethiflex® suture, is a polyester suture that had a as the time required for the tensile strength of a material to flexible 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 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 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 asthey 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 tensile strength to remove the gums within the fibre. This allows twisted from 5th day filaments of silk-worm fibre to stick together forming strong Plain Submucosal layer Half life is 5-7 Pale straw coloured fine suture material used in cataract surgery.19,20 catgut of sheep intestine days and loses or serosal layer of all its effective Other commonly used non- absorbable sutures made beef intestine strength by 15 up of synthetic material are nylon (), Dacron days (Merilene), prolene (), Polybutylate coated Chromic Plain catgut Half life is 17-21 Dark brown in colour. Causes catgut tanned in days and loses lesser reaction then plain braided polyester (Ethibond) and steel. chromic salts all its effective catgut Nylon is extremely inert but elastic and has a strength by 30 rate of 20% per year. Due to its late absorption it induces days with the wound astigmatism in cataract surgery. It is stiff Vicryl Polyglactin 910 60-90 days and Extremely high initial tensile (copolymer of tensile strength strength. Can be used in all and fractures easily. May cause corneal vascularization and glycolide and remains for 30 situations were absorbable follicular reaction in the upper lid. Nylon is available as both lactide) days suture need to be used. It is commonly used for monofilament and multifilament sutures. This is the suture suturing nasal mucosal flaps of choice for wound closure of corneal incisions. in dacryocystorhinostomy29, Polypropylene and Mersilene are made up of polyester, muscle reinsertion in squint surgery30 and lid margin are stiff, produce little tissue reaction and stretch less than repair.31 of comparable size. Monfilament polypropylene Dexon Polyglycolic acid 2-3 weeks Mild reaction, high tensile ties securely and handles well. Its smoothness allows easy strength placement and its release characteristics allow early removal. Since it is largely unaffected by body tissues, it is used for Table 2: Classification of sutures scleral fixation of intraocular lens, fixation of Cionne`s ring, according to thickness iridodialysis repair, brow lift and correction of involutional ectropion.20-24 USP Decimal Thread gauge in mm Polybutylate coated braided polyester(Ethibond) is made 12-0 0.01 0.001-0.009 by fine filaments of polyester and a special braiding process 11-0 0.1 0.010-0.019 produces a firm, strong suture which remains soft and pliable. Braiding is followed by polybutylate coating to 10-0 0.2 0.020-0.029 impart lubrication and smooth passage through scleral 9-0 0.3 0.030-0.039 tissues during retinal surgery and sling surgery. It is used 8-0 0.4 0.040-0.049 in scleral buckling surgery for securing the buckle. Bajaj et al studied the efficacy of polytetrafluoroethylene (Gore- 7-0 0.5 0.050-0.069 Tex) suture as compared to polybutylate-coated braided 6-0 0.7 0.070-0.099 polyester (Ethibond) suture as sling materials for frontalis 5-0 1 0.10-0.149 suspension in bilateral congenital ptosis. They found that Polytetrafluoroethylene suture achieved a statistically 4-0 1.5 0.15-0.199 significant better and more stable ptosis correction, with 3-0 2 0.20-0.249 slightly more lagophthalmos, than braided polyester suture 2-0 3 0.30-0.349 over a mean follow-up period of 16 +/- 3.24 months.25,26 Metallic steel sutures (30µ) have no elasticity. It was used 0 3.5 0.35-0.399 earlier for corneoscleral suturing.26-28 1 4 0.40-0.499 Absorbable Sutures 2 5 0.50-0.599 The commonly used absorbable sutures are Vicryl, plain 3+4 6 0.60-0.699 catgut, chromic catgut, dexon and collagen. Suture characteristics of some of the sutures are given in Table 1. 5 7 0.70-0.799 6 8 0.80-0.899 Size of Sutures 7 9 0.90-0.999 Size of sutures is measured by its width or diameter. The 8 10 1.00-1.099 bigger the number the smaller the size of suture. The European Pharmacopoeia (EP) decimal classification is used 9 11 1.10-1.199 as the standard for defining the thread gauge. The other 10 12 1.20-1.299 widely used system of classification is that of the United

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Conclusions 15. Davis & Geck Company Records Archives & Special material can be classified on the basis of Collections at the Thomas J Dodd Research Center. University of Connecticut; 2005 the characteristics like absorbability, origin of material and 16. Questell Z. Introduction to Sutures. Internal document. thread structure. In the last few decades, a wide variety of Mansfield, MA: Covidien Inc; 2009. sutures have been developed and the natural threads though 17. Edlich RF, Gubler K, Wallis AG, Clark JJ, Dahlstrom JJ, still being used, have largely been replaced by synthetic Long WB 3rd. Wound closure sutures and needles: a new sutures. Standardization of packaged suture material has perspective. J Environ Pathol Toxicol Oncol 2010; 29:339-61. 18. Bourne RB, Bitar H, Andreae PR, Martin LM, Finlay JB, effectively reduced suture related complications. Marquis F. In-vivo comparison of four absorbable sutures: Vicryl, Dexon Plus, Maxon and PDS. Can J Surg 1988; 31:43-5. 19. RoperHall MJ. Stallard`s eye surgery. Varghese Publishers, Cite This Article as: Goel A. Surgical Sutures - A Review. Delhi J Bombay, India. 7th ed; Introduction; pp 1-43. Ophthalmol 2016;26:159-62. 20. Seki M, Yamamoto S, Abe H, Fukuchi T. Modified ab externo method for introducing 2 polypropylene loops for scleral Acknowledgements: None suture fixation of intraocular lenses. J Cataract Refract Surg 2013; 39:1291-6. Date of Submission: 23.10.15 Date of Acceptance: 27.10.15 21. Gimbel HV, Amritanand A. Suture refixation and recentration of a subluxated capsular tension ring-capsular bag-intraocular Conflict of interest: None declared lens complex. J Cataract Refract Surg 2013; 39:1798-802. 22. Dağlioğlu MC, Coşkun M, Ilhan N, Ayintap E, Tuzcu EA, Ilhan Source of Funding: Nil O, Oksüz H. Repair of iridodialysis using 8-0 polypropylene. Semin Ophthalmol 2014; 29:159-62. 23. Pascali M, Avantaggiato A, Bocchini I, Carinci F, Cervelli References V. 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