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Suture Manual

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Suture Manual Suture Manual REPAIR AND REGENERATE Suture Manual List of Contents Introduction Page 3 Principles Page 6 Surgical needles Page 12 Sutures Page 15 Manufacture and packaging Page 28 Organisational aids Page 33 No claim is made for the completeness of the information given about the suture material: this must be gathered from the relevant literature for healthcare specialists. More detailed information concerning the materials can be obtained from the information leaflets in each package. We shall be pleased to send these on request. Visit our website: www.resorba.com for constantly updated and comprehensive information on our products and developments. 2 Introduction In nature, damaged or destroyed tissue Absorbable materials, e.g. PGA RESORBA®, Requirements for an layers must be covered over quickly to support the natural healing process until ideal suture: preserve the integrity and functions of form and function are restored. Such • high tensile strength the organism. We humans have copied materials are subsequently metabolised • high knot security this response from nature. by the organism. • good tie down • no capillary function It is the aim of modern wound care, first Non-absorbable suture materials (e.g. • good tissue tolerance and foremost, to preserve intact tissues MOPYLEN®) guarantee lasting support • easy passage through tissue and support the damaged parts. Our su- and best biotolerance, which is especially • sterile presentation ture materials, based on biocompatible essential for long-term implants. raw materials, make possible the targeted application of every kind of wound care, A large number of suture materials are The optimum use of any and guarantees the best possible tissue nowadays used in wound closure. In many particular suture is determined acceptability. respects they are adapted to their specific by its: • absorption characteristics use (indication) and are chosen for the • thread structure, composition Surgical suture is a typical medical device particular properties of the tissue. and diameter for tissue repair. Most wound closures • elasticity and stability are still done with sutures. The mechanical • tissue acceptance properties of the inserted material are of • tensile strength the greatest importance in temporarily replacing the lost strength. 3 Introduction A journey into the history of surgical sutures The development of surgical suture 1100 BC 625 – 690 revisited Oldest surviving suture, placed about 1000 Paulus of Agina was the first physician BC in the abdomen of a mummy (Rodegra to treat a bone fracture by winding wire 1982). Linen was already being used as around it. suture material at that time. 1732 500 BC Various suturing techniques, still in com- Susruta, an Indian, was the first to describe mon use today, were drawn on animal in detail wound sutures and the material skin (exhibited at the Germanic National used for it, e.g. bowstring (earliest absorb- Museum in Nuremberg). able suture material?), linen thread, plant 1827 - 1912 fibres, tree bark sutures and thin strips Wound infections became preventable cut from tanned skin. after the introduction of the first usable Production of catgut around 1930 460 BC – 199 AD disinfection and sterilisation methods The great medical books by Hippocrates (antiseptics) by Lister (1827 – 1912) and 3000 BC (460 – 377 BC), the most famous physician Schimmelbusch (1860 – 1895). First reference to a wound suture in an- of antiquity, the Roman physician Celsus 1868 cient Egyptian texts. (25 – 50 AD), and the physician Galen Lister, a surgeon, discovered absorbable 1900 – 1600 BC (129 – 199 AD) already contain detailed sutures made of sheep gut string. He Oldest surviving description of wound descriptions of many suture techniques. disinfected the sutures with carbolic care in papyri named after F. Smith (1862) Celsus distinguished between single and acid to keep them germ-free. This is the and Ebers (1873), from about 1900 – 1600 continuous sutures. Galen was the first origin of resorbable catgut sutures. BC. to recommend thin strings made of gut for ligating bleeding vessels. 4 Introduction 1900 1939 In principle, different types of suture Beginning of the industrial manufacture Perlon was specially treated to produce packaging have been available since the of suture material (catgut), based on the synthetic thread Supramid to meet beginning of the industrial manufacture technical experience gathered in the the particular requirements in surgery. of sutures. But it was only with the meantime in making strings for musical After World War II, this was joined by instruments. synthetic threads made from polyester 1908 and polypropylene. In 1908 F. Kuhn (1866-1929), a German Until 1960 surgeon, demanded the exclusive use of Sutures were sterilized by bactericidal surgical sutures made of catgut that had chemical solutions or by heating (steam). been made under especially clean, partly Since 1960 sterile conditions. This catgut (sterilized Introduction of safe modern methods of with potassium iodide) became the most sterilization with ethylene oxide gas or commonly used surgical suture material gamma irradiation. Early packaging of sutures next to twine and silk. After the introduc- 1968 tion of catgut an intensive search began First synthetic suture threads made from development of packaging techniques for other absorbable suture materials. An polyglycolic acid. with synthetic materials around 1960, unsuccessful attempt was made to obtain The production of ”atraumatic sutures” and of new methods of sterilisation that absorbable thread from animal tissues was also further developed and improved it became possible to make the sterile (tendon from kangaroo tails; skin, arteries, starting at the beginning of 1970. The and ready-for-use packs available nowa- strips of muscle, tendon and nerves from basic idea of a minimal transition in dia- days. whale, rabbit, dog, deer, camel, turtle and meter from needle to thread for providing others). the most sparing way of passing a suture 1931 through tissues was put forward over First production of synthetic threads from 100 years ago (Gaillard) and has been polyvinyl alcohol. used since about 1920. 5 Principles Historical classification according to raw materials Natural starting materials: Silk, linen (twine), animal gut (catgut) Synthetic starting materials: Polyglycolic acid, polylactide, polyamide, polyester, polypropylene, PVDF Modern classification according to absorption characterstics Non-absorbable SILK, RESOPREN®, MOPYLEN®, POLYESTER, SUPOLENE, WIRE Pseudo-absorbable Monofilament material Multifilament material Properties no capillarity very high tensile strength RESOLON®*, NYLON*, SUPRAMID* no sawing action high knot security Slow absorption easily knotted very supple easy passage through tissue simple handling CAPROLON® CAPROLON® PGA TM Medium-term absorption Absorbable resoquick material: GLYCOLON® PGA RESORBA® PGA RESORBA® Non-absorbable MOPYLEN® POLYESTER Fast absorption material: RESOPREN® SUPRAMID PGA resoquick TM, GLYCOLON® NYLON SUPOLENE RESOLON® SILK STAINLESS STEEL STAINLESS STEEL *Polyamide is not fully inert, but a pseudo-absorbable material, early hydrolytic degradation having been observed after more than 6 months. 6 Principles Absorption dation into (smaller) pieces and thus loses rent sutures can be achieved by the choice its strength (e.g. polyamide) of the material and modifying the pro- Absorbable sutures approximate the Dissolution duction process. In addition to the imme- tissues during the healing process. During The period during which the suture com- diate, moderately quick or delayed loss this time the suture’s tensile strength pletely dissolves within the tissue. of tensile strength, there is also the cor- gradually diminish. Absorbable suture responding duration of absorption. Any material is metabolised by endogenous given thread material can only fulfil its proteolytic enzymes or by hydrolysis Characteristics of purpose as long as it has the desired (in the case of PGA RESORBA®, absorption tensile strength. PGA resoquickTM, CAPROLON® and GLYCOLON®). Different indications also require different Non-absorbable suture remains almost tensile strength and absorption characte- unchanged when placed within body ristics. These particular features of diffe- tissues, and is encapsulated within the wound scar by the organism. The sutures 100 used for skin closure are removed once 90 CAPROLON® 80 PGA RESORBA® the scar tissue has become sufficiently 70 PGA resoquickTM firm to hold the wound edges together 60 GLYCOLON® (usually after 7 –14 days). It has to be 50 distinguished: 40 30 Absorption time 20 The period in which the suture loses 50% Knot tensile strength % 10 of its knot tensile strength. 0 0 7 14 21 28 35 42 49 56 63 70 77 84 days Disintegration The period during which essentially non- In-vitro trial of suture degradation by measuring the knot tensile strengths of GLYCOLON®, PGA resoquickTM, PGA RESORBA® and CAPROLON®. absorbable suture breaks down by degra- Suture size: 3-0 USP (2 metric). 7 Principles Thread structure The structure of a thread affects its passage through tissue and its capillarity. We distinguish between four basic thread structures: Monofilament GLYCOLON® CAPROLON® MOPYLEN® RESOPREN® RESOLON® A monofilament consists of only NYLON one thread filament. STAINLESS STEEL, monofilament Multifilament A multifilament consists of many thin STAINLESS STEEL, multifilament elementary fibres which are either twisted, POLYESTER entwined or braided into bundles. SILK
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