1. science
2. medicine
3. surgery

SUTURES & LIGATURES
SUTURES AND LIGATURES
A
FOR ELECTIVE SUBJECT
SUBMITTED TO THE
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PROJECT REPORT
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HEMCHANDRACHARYA NORTH GUJARAT UNIVERSITY, PATAN
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IN PARTIAL FULFILLMENT OF
THE REQUIREMENT FOR THE DEGREE OF
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BACHELOR OF PHARMACY
SUBMITTED BY
RASHMIN S. THAKOR
DEPARTMENT OF PHARMACEUTICS AND
PHARMACEUTICAL TECHNOLOGY
SHREE S.K.PATEL COLLEGE OF
PHARMACEUTICAL EDUCATION AND RESEARCH,
GANPAT VIDYANAGAR
KHERVA-GUJARAT
2004-2005
SUTURES & LIGATURES
CERTIFICATE
This is to certify that the project work for elective subject entitled “sutures and
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ligatures” Represents the bona fide work of Rashmin s. Thakor, carried out under my
guidance and supervision at the Department of pharmaceutics & pharmaceutical
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Technology, Shree S.K.Patel College of pharmaceutical Education and Research, Ganpat
Vidyanagar, during the Academic Year 2004-05. He has collected the literature very
sincerely and methodically. This work is up to my satisfaction.
GUIDE
Shri Rakesh. P.Patel
M.pharm
PRINCIPAL (I/C)
Dr N.J. Patel
M.pharm, Ph.D.
Lecturer
Head of the Department
Dept. of Pharmaceutics &
Dept. of Pharmacology
Pharmaceutical Technology
Shree S.K.Patel college of Pharmaceutical
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Shree S.K.Patel college of
education & research.
Ganpat
Ganpat Vidyanagar, Kherva
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Vidyanagar, Kherva
Pharmaceutical education& research
Date:
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Place: Ganpat Vidyanagar.
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ACKNOWLEDGEMENTS
This Thesis on “sutures and ligatures” has been prepared for partial fulfillment of the
academic requirements leading to the Bachelor‟s degree in pharmacy.
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Numerous people have been instrumental in enabling me to give a concrete shape
to my thesis. Constraints of time and space preclude the mention of all of them here.
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However, I must mention the names of a few people who have made a catalytic impact
on the development of this thesis.
First, and foremost, I would like to acknowledge the continuous encouragement
and help extended to me by Mr. Rakesh P. Patel for preparing this thesis. Right from the
day I started working on it till it was completed, he has been my sole guide, philosopher,
and friend throughout the period of my work. But for the spontaneous support and expert
guidance provided by him, this project would not have seen the light of day in its present
form. His extensive knowledge of the subject and the way he imparted the same to me
has enabled me to develop the thesis in a cohesive manner and has kindled within me a
passion for the subject.
I take this opportunity to place on record my indebtedness to Shree P.D. Bharadia,
Shree J.K. Patel, and all the other faculty members who have also contributed a lot, at
inputs.
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various stages of my academic career in the Institute, in terms of valuable knowledge
I also express my profound gratitude to Dr. M.M.Patel, our Ex. Principal, who has
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been a constant source of inspiration to steer me forward throughout the four years of my
study.
I am also thankful to the members of my family not only for their support and
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encouragement in my work. I owe a special thanks to my dad, whose help has been
invaluable at various stages, and especially during the finalization of the thesis. Lastly, I
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wish to thank my friends in the college, as well as, the administrative staff for their
kindness and support during the course of my studies.
RASHMIN.S. THAKOR
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SUTURES & LIGATURES
DEDICATED TO
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MY PARENTS,
KEYUR
AND BHAVIKA.
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SUTURES & LIGATURES
CONTENTS
CHAPTER
PAGE NO.
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2. Definition
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3. Classification
Non-absorbable
3
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4. Standards and legal requirements for sutures and ligatures
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5. Natural Absorbable material
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Surgical
catgut
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5.1 (i) standards for catgut
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5.1(ii) Sterilization of catgut
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5.1(iii) Absorption of catgut in body
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Kangaroo tendon
Ribbon gut
Fascia lata
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6. Synthetic absorbable material
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6.2 Chromic surgical gut
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6.3 Coated VICRYL (Polyglactin 910)
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6.4 Monocryl
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6.5 PDS-II
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6.6 VICRYL Rapide
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6.1 Plain surgical gut
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Absorbable
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1. Introduction
Non absorbable sutures
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7.1 Silk
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7.2 Linen
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7.3 Polyamides
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7.4 Polyesters
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7.5 Monofilament polyamide
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7.6 MERSILENE
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7.8 Monofilament stainless steel suture
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7.9 PROLENE MONOFILAMENT
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7.10
PROLENE MONOFILAMENT POLYPROPYLENE
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7.11
PERMA-HAND
8. Suture used in various body surgery
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8.1 Cardiovascular surgery
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7.7 Polybutylate coated braided polyester suture
8.2 G.I.Tract surgery suture
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8.3 General closure surgery suture
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8.4 OB-GYN Surgery suture
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8.5 Ophthalmic surgery suture
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8.6 Orthopedic surgery suture
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8.7 Plastic surgery suture
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8.8 Urology
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9 Miscellaneous product
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9.1 Stainless steel wire
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9.2 Suture clips
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9.3 Wire staples
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10 Surgical needles
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Needles type
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10.2
Needle shape
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10.1
10.3
Types of needles
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12 References
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Marketed preparation
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1.
INTRODUCTION
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Sutures and Ligatures
1. Introduction:
The use of strings made by twisting vegetable and animal materials is
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described in the most ancient of surviving records of the history of mankind. Animal
skins, intestines and sinews were used for musical instruments, bows and many other
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items. Vegetable fibres, Spun and Woven, date back to pre-historic times. Linen as spun
strand was well known by 5000 B.C. and probably was first prepared long prior to this
date.
In surgery Susruta (1500 B.C.) records the use of ligatures for tying umbilical cord
and celsus in the first century A.D. describes the ligatures of ancient origin. In the highly
developed civilization off ancient Egypt surgeons closed wound with sutures. Galen (c.
A.D. 200) used silk and hemp cords as ligatures and also recommended the use of animal
gut. The term „catgut‟ is said to be derived from the gut used to string a musical
instrument known as a kit, an Arabic word for a dancing master Arabian surgeon Rhazes
(c. A.D. 900) used harp strings made from sheep intestine to repair abdominal wounds,
but the use in surgery of twisted animal intestines was not generally practiced as the
patients nearly always became infected.
Ambroise Pare (1517-90) appears to have revived the use of ligature and there are
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numerous references in his works to their use, particularly in amputations where he
preferred them to the cautery, His valuable work, however appears not to have been
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generally recognized and surgeons continued with the old methods of the hot knife and
searing iron.
The credit for the reintroduction of catgut is given to P.S.Physick (1816) house
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surgeon to j. Hunter, and later Professor of Surgery in Philadelphia, but his observations,
and publications of other workers of the same period, did not persuade surgeons to adopt
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the material.
It was not until 1869 that Joseph Lister; as a result of his Observations on the
Ligature of Arteries on the Antiseptic system opened the way to the modern surgical
suture techniques. The first step had been to show that sepsis was due to the growth of
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microorganisms from the site of infection. From that time onwards the search to find
means of preventing infection has not ceased. The history of this work applied to surgical
sutures and ligatures during the past seventy years is too large a subject for this chapter
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procedures has led to the highly efficient methods being employed today.
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but the investigations by a host of dedicated workers into hundreds of different
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SUTURES & LIGATURES
DEFINITION &
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CLASSIFICATION
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2.DEFINATION
LIGATURE: A ligature is a thread used to constrict and seal off a blood vessel, vein or
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artery – hence to ligate.
SUTURE: The thread is a suture when it is used to stitch together the edges of various
tissues, e.g. skin, fascia, muscle, tendon, peritoneum, etc. Hence a needle is always used
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for a suture (sewing) but not for ligature.
3. CLASSIFICATION
Sutures and ligatures are classified as absorbable and non-absorbable, depending on the
materials on which they are made.
3.1 ABSORBABLE:
Absorbable sutures and ligatures are absorbed by the tissues in which
they are implanted and the time taken for complete disappearance is dependent on a
number of factors, which will be treated more fully later in this chapter. Absorbable
materials are catgut (non-boilalable and boilable), reconstituted collagen, synthetic
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absorbable polymers, kangaroo tendon, ribbon gut and fascia lata.
3.2 NON-ABSORBABLE:
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Non-absorbable sutures and ligatures are not absorbed by tissue
and unless they are on the surface, remain in the body after the wound has healed. Some,
notably silk, fragment after a long period of time; other is encapsulated by fibrous tissue,
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while others remain as inert implants. The most commonly used are silk, linen, nylon
(polyamides), polyester, polyolefin‟s and stainless steel wire, and to a very small extent:
cotton, horse hair, human hair, silk worm gut and wires of other metals, e.g. tantalum,
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silver, phosphor bronze, etc.
The polymeric materials are also used in the form of the woven meshes particularly
for hernia repair and silk and nylon in floss have specialist uses also.
Mention should also be made of the use of clips (Michel. Kifa, etc.) For surface
application and the past few years have seen a good deal of development, particularly in
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Russia and the USA, in the use of small wire staples (usually stainless steel) which are
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implanted by means of stapling guns.
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STANDARDS
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4. STANDARDS AND LEGAL REQIRMENTS FOR SUTURES AND
LIGATURES
Although the national Pharmacopoeias of most countries publish monographs on
surgical sutures, the European Pharmacopoeia establishes the standards nowadays for
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EEC countries, Denmark, Sweden, and Switzerland, i.e. the signatories to the
Convention. Volume II of the first edition published in 1971 contained monographs for
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Sterile Catgut, Sterile Reconstituted Collagen Strings and Sterile Non absorbable strands
including Braided Polyester, braided poly amide 6 and 6/6and linen thread. Some
amendments were introduced in volume III published in 1975 to the USP XIX (1975).
Both these compendia have adopted a metric numbering systems where by the gauge
number applied to the suture represent the actual diameter it the tenths of a millimeter.
Previously a so- called conventional system was used and, although in the case of the UK
and the USA the sizes represented were comparable, the value for diameter differed
between absorbable and non-absorbable materials. The conventional system employed by
the other countries themselves differed and there was a lack of flexibility as finer sutures
were developed for modern surgical techniques (see table.)
Sutures have always been the odd man out as far as legislation is concerned and have
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been classed sometimes as `drugs` and sometimes as `devices`. In the UK the
manufacture and sterilization of catgut and other products of animal origin became
subject to control by licensing under the Therapeutic Substances Act in 1929 largely as a
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result of the reports of T.J. Mackie and of Bulloch, Lampitt and Bushill. This control now
extends to various `Surgical materials` of animal origin and to synthetic materials capable
of being absorbed.
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The Medicines Act is in process of taking over from the Therapeutic Substance Act.
Anomalies still remain however those in meantime non-absorbable materials of vegetable
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or synthetic origin are not subject to such control.
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Former Convention size
Metric number
Catgut/Collagen
Non-absorbable
-
0.2
-
0.3
-
10/0
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Synthetic Absorbable
9/0
9/0
-
8/0
8/0
7/0
7/0
6/0
6/0
5/0
5/0
4/0
4/0
3/0
3/0
2/0
2/0
0
0
1
1
2
6
2
3&4
7
3
5
8
4
6
0.4
0.5
0.7
1
1.5
2
3
3.5
4
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5.
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ABSORBABLE
MATERIAL
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5. NATURAL ABSORBABLE MATERIALS
5.1SURGICAL CATGUT
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Sterilized surgical catgut consists of a strand prepared from collagen derived
from healthy mammals purified and sterilized. The most widely used source is the
sheep beef cattle.
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submucosa of the small intestine from sheep or lambs and to a lesser extent, the serosa
The length of ovine intestine is about 20 m and it is desirable in the preparation of
surgical catgut that the diameter of the intestine should not be more than 18 mm. A
number of factors are important in the selection of suitable intestinal material. Obviously
intestines will vary considerably depending on the age of the animal, the pasture, climate,
etc. and it is not uncommon to find that intestines from some animals have been affected
by scar tissue and are not suitable for preparing surgical catgut. Generally speaking the
younger the animal the smaller it‟s intestine, and less likely to be affected by feed.
A number of manufacturers of catgut use only the first 8 m of intestine measured
from the duodenum. In the meat trade such intestine are described as ligature casing or
runners.
In the slaughterhouse the gut is removed from the animal by the gut pullers and is
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first of all cleaned to remove faecal matter after which it is inspected, measured and the
preserved either in a frozen state or salted. The largest suppliers of intestines come from
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Australia and New Zealand and the slaughterhouses in these countries are well equipped
to deal with the vast number of animals involved. The intestine of any cadaver is the most
vulnerable to bacterial attack and decomposition of this part of the body always begins
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earlier then any other. It is, therefore, vitally important that the slaughterhouse technique
involves rapid cleaning and freezing or preservation by other methods in order to keep
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the bacterial growth as low as possible.
The ovine intestine consists of four layers (see figure). The outermost is known as
tunica serosa or serous layer, much of which is torn off in removal from the animal; next
the tunica musculosa made up of two layers, one longitudinal and the other circular; the
third layer is the tunica submucosa from which catgut is prepared and in the innermost
layer is the tunica mucosa or mucous coat which is the wall to the lumen of the intestine.
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The intestine receives its blood supply from the mesenteric artery and being some
twenty eight times the length of the sheep itself is twisted into a mass of convolutions
until near its end where it ascends to join the colon.
microphotographs of the submucosal layer.
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The Medical Research council report on the preparation of catgut contains interesting
The manufacturer of surgical catgut receives intestines either intact or rough scraped at
the abbatoir. Made up as knots or bundles which may be frozen, salted or in brine, and
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the first step is to soak these in water to thaw out or to remove salt and 0prepare them for
splitting. It may be noted in passing that the intestines destined for sausage skins are not
split but are cleaned and scraped in the tubular form and known as sausage casings. This
cleaning usually takes place in the abbatoir and the product is marketed in barrels or
casts.
Splitting
Inserting the curved horn of a cutting tool into the end of the intestine and
pulling the runner over cutting blades carry out the splitting or cutting operation. The
number of ribbons produced can be varied but is usually two or three. The horn follows
the curvature of the intestine and therefore can be said to locate down the track of the
mesenteric vein, which is often called the rough side as distinct from the upper part
known as the smooth side. The two parts of the intestine are kept separate throughout the
process as they behave in different ways physically and chemically.
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Cleaning of Submucosa
The next step is to remove the mucosa, muscle and any remaining serosa, or, if
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the material has been cleaned in the abbatoir, the remnants of these layers, and this are
facilitated by treatment with alkaline solution. The general method of scraping is to fix
the ribbons in a frame or on suitable flat surfaces so that the submucosa can be cleaned of
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unwanted material. Often this is carried out by hand and is a very skilled operation. In
other cases an apparatus known as a sliming machine is employed.
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Spinning
The apparatus used by manufacturers for spinning ribbons of catgut is largely
dependent on the manufacturer‟s choice. The number of hooks on the machine to which
the string loops are attached varies from 2 to 20. In some cases spinning takes place from
both ends of the strand and may take place immersed in water or alkaline solution. The
spinning of catgut destined for surgical use is a highly skilled operation. Multiples of
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ribbons, which are over spun, will tend to lack elasticity and will curl when dry. On the
other hand, if they are under spun the elasticity will too great and the tensile strength
reduced. The angle of ply to the horizontal is to some extent a guide as to whether a
string has been properly prepared, but many other factors can affect the ultimate quality
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of the catgut. Because catgut is a biological material it must of necessity vary
considerably and no one animal intestine is exactly the same as another. The spinning of
catgut is, therefore, still largely on art rather than a mechanical operation. After spinning,
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the catgut is mounted on drying frames, the conditions of drying time and humidity being
carefully controlled. The resulting strand of dried catgut is known at this stage as raw
catgut and is usually between 3 and 5 m long.
Polishing
Strands of catgut can be prepared with such care and attention to manufacturing
detail that they will vary only slightly in diameter and need only a light manual polishing,
but more usually the manufacturer employs a technique which produces an approximate
size and then polishes or grinds the string to a predetermined diameter. This process is
achieved by means of machines, either by; rotating the strings while a carriage bearing an
abrasive paper moves to and fro along their length, or by using a pair of grinding wheels
similar to those employed by engineers and setting the wheels the required distance apart.
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Both methods have to be very; carefully controlled to avoid damage to the plies of the
strand with consequent loss in tensile strength. The finish, moreover, must be such that
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the gut is neither „whiskery‟ nor so smooth that the surgeon‟s knots will slip and cause
the wound to re-open.
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Gauging
The methods of gauging carried out by various manufacturers vary with their own
particular preferences, but the final control instrument for checking diameter is a gauge of
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the dial reading type, in which the details of pressor food and weight loading are
specified. As the diameter of catgut will vary with the relative humidity of the
atmosphere, the control test as laid down is the diameter in a relative humidity between
60 and 80 per cent and at a temperature between 16 o and 21o.
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The normal gauge used in British surgery varies from the finest size 1 in
ophthalmic work to the thickest size 7, which is occasionally used for specialist surgery.
5.1 (i) Standards for catgut
Length.
This is determined immediately after removal of the strand from its container
length stated on the label.
The test is carried out on a machine of the deadweight type, having a
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Tensile Strength.
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and is measured without stretching. The length must be not less than 90 per cent of the
movable jaw with a constant rate of traverse of 30 cm/min, and a capacity so that when
the strand breaks, the angle which the pendulum arm makes with the vertical is not less
than 9 and not more than 45.The clamp heads are specially designed and any strands
breaking within 12.5 mm of the clamps are disregarded. The strands are tested within 15
min of removal from their container and in a temperature between 16 and 21 and in an
atmosphere in which the relative humidity is between 60 and 80. As catgut is inevitably
knotted in the patient, the test is always carried out on strands in which a surgeon‟s knot
has been formed at a point midway between the two clamps.
The knot strength is approximately half of the figure, which would be obtained on
an unknotted sample.
The label on or in the container must state by indelible marking or perforation
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Labeling.
the length of the strand, the gauge number, whether the strand is plain, hardened or
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chromicized, and that the container should not be subjected to heat treatment. The label
on the box must state the name and percentage of any bactericide in the fluid in which the
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sutures are immersed.
Storage.
Sterilized surgical catgut should be protected from light and stored in a cool
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place.
Packaging.
The British Pharmacopoeia states that sterilized surgical catgut is packed
either in glass tubes sealed by fusion of the glass, or in other suitable containers, which
once opened, cannot be resealed. Al though glass tubes are probably the ideal method of
packaging surgical sutures in that they are transparent, inert and impermeable, they are
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SUTURES & LIGATURES
nevertheless regarded as a nuisance in the operating theatre because they have to be
broken, and a large variety of flexible packages based on aluminum foil of plastic films
which can be torn open, have in the past few years tended to replace glass. The bottle
packs, which are still used to some extent in continental Europe, in which a continuous
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length in the form of a cocoon of catgut is packed in ingenious dispensing devices, is
considered to introduce an element of risk of contamination, and this form of packing is
Sterility testing.
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no longer used in Great Britain.
The Therapeutic Substances Act in Great Britain lays down the
fundamental required for bacteriological testing of surgical catgut. Definitions are given
of the term batch, the percentage of samples from each batch, which are to be tested, and
broad definitions of the media and incubation times to be employed. The technique to be
adopted where any bactericides present are liable to inhibit growth in the medium is
specified. The medium is so designed that it will detect the presence both of aerobes and
anaerobes. If after an incubation period of 14 days no growth or microorganism is found
in any tube, the sample may be regarded as having passed the test,. If growth of
microorganisms is found in any tube a further sample may be taken from the batch and
the test repeated. If no growth occurs the sample shall be regarded as having passed the
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test, but if any microorganism is found the batch is treated as not sterile.
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5.1 (ii) STERILIZATION OF CATGUT
Lister‟s work on catgut in 1869 using aqueous phenol and later phenol and olive oil
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was the forerunner of antiseptic technique applied to sutures. His experiments and
resulting papers stimulated work in which a very large number of chemical compounds
were investigated with varying success to bring about a reduction in the number of
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microorganisms present in surgical catgut.
Mammalian intestine in the living animal is normally relatively free of
microorganisms but immediately after death growth of microorganism‟s proceeds at a
very rapid rate. Conditions in slaughterhouses, however clean, are moreover, not
conducive to aseptic techniques and the intestines inevitably carry a large bacterial
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SUTURES & LIGATURES
population. The freezing or salting of the material inhibits further growth but does not kill
these organisms. Staphylococci, streptococci, with a large proportion of Str. Faecalis, and
Escherichia coli are commonly found in intestinal material but although a number may
be pathologically significant they are relatively susceptible to sterilizing techniques. Even
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if they survive the manufacturing process, the alcohol in the final container would kill
many. Sporing aerobes mostly nonpathogenic, such as Bacillus subtilis and its phage
type, which used to be known as B. mesentericus rubber, or the catgut bacillus, are very
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numerous, but the potentially dangerous organisms are Bacillus anthracis and the
anaerobic spore bearing types, among them Clostridium sporogenes, Cl. Tetani, and Cl.
Welchii. The spores of both aerobes and anaerobes are not easily killed, the aerobic types
being generally more resistant. The fact that they revert to the spore form if conditions for
growth are unsatisfactory further complicates the situation. The difficultly is exacerbated
by the structure of the catgut strand where ribbons twisted together will carry any
contamination throughout their whole cross-section and at the center of the string any
organisms are well insulated. The successful means of attack on these microorganisms is
buy their chemicals (liquid or gaseous), heat or radiation. The choice of method must,
however, be related to other desiderata. It is useless, for instance, to use a method to
sterilize the material, which will ruin its physical characteristics such as tensile strength
and absorbability. Ideally, the aim will be to interfere as little as possible with the
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inherent structural advantages of collagen as a strong, flexible and elastic fiber that will
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be absorbed by; the body in a surgically acceptable manner.
Chemical
The three methods will now be discussed in further detail.
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The chemical method must employ a material, which is sopricidal as distinct from
bactericidal. Most inorganic or organic compounds in common use as antiseptics,
disinfectants or bactericides are active against microorganisms in the vegetative phase.
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Certain products such as the quaternary ammonium compounds are even more limited in
that they are specific, i.e. they will kill Gram positive organisms and leave Gram negative
types unaffected. Other preparations will be effective against most organisms bit certain
genera will not be killed and, most important of all, none of these compounds are
sporicidal and are therefore useless in bringing about sterility in catgut.
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The available sporicidal compounds are, in fact, relatively few. The main
substances are formaldehyde, hydrogen peroxide, hypochlorite, glutaraldehyde, ethyl
iodide, methyl bromide, iodine, ethylene oxide and B-propiolactone. Of these still fewer
are suitable for commercial sterilization of catgut.
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Histological techniques employing formalin introduced about 1893 led to its
application to catgut sterilization by Cunningham (1895). Although a number of workers
demonstrated that formaldehyde solutions of the order of 5 percent for prolonged periods
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were necessary to destroy anthrax spores and that this treatment seriously affected catgut,
the „formalin period‟ lasted for about 15 years and there is little doubt that a great deal of
unsterile material was used. The resulting catgut, moreover, was so hardened that its
absorption in the body was considerably delayed and its tensile strength much reduced.
Hydrogen peroxide will effectively sterilize catgut but results in a material, which is of
poor quality. The compound has, however, sometimes been used to improve the colout of
catgut by treating the collagen in the ribbon form, i.e. before spinning.
Solutions of sodium or potassium hypochlorites although sporicidal, particularly in
acid solution, are not suitable for catgut as their penetrative power is very poor and the
catgut is unduly swollen and of poor tensile strength.
Glutaraldehyde behaves very much in the same way and is only active iin sodium
bicarbonate buffered solutions. The solution only retains its sopricidal activity for about
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two weeks.
Iodine remains, as the only suitable chemical for large scale commercial sterilizing of
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catgut. Ethyle iodide and methyl bromide in alcohol and mixture of iodine and iodine
trichloride have also been used.
Basically the process consisted of immersion of standard lengths of catgut wound on
u.
frames or reels in a carefully standardized aqueous solution of iodine, potassium iodide
and potassium iodate, the pH being rigidly controlled. The catgut must absorb about 12
percent of its own weight of iodine and when this has taken place the catgut is transferred
gn
from the solution and excess iodine removed by sterile solvent often containing a
bacteriostatic. The sterile strands are then transferred under aseptic conditions to their
final container, sterile fluid is added (usually 95 percent ethanol or 90 percent
isopropanol) and the container sealed. Processes involving ethyl iodide or iodine and
19
SUTURES & LIGATURES
iodine trichloride are carried out in alcoholic solution but in their respect the process is
similar to the aqueous method.
Ethylene oxide may be employed as a sterilizing agent in the gaseous for or in solution.
The important factors to be controlled are concentration, moisture time and temperature
in
employed. It is an explosive gas and is usually supplied mixed with carbon dioxide or
Freon. The process is usually monitored with spore strips of B.subtilis var. niger (B.
globigii). Care must be taken to limit the residual ethylene oxide in the suture material. It
container.
Heat Sterilization
bn
et
.a
c.
is usually necessary to carry out an aseptic procedure for filling and sealing the final
Raw catgut contains 12 percent to 25 per cent by weight of combined moisture,
depending on storage conditions. Heating above 80 degree will result in hydrolysis of the
collagen and the resulting gelatine or glue would render it useless for surgical purposes.
All heat sterilizing processes, therefore, based on the fundamental necessity of removing
this combined moisture before the strings can be raised to sterilizing temperature of 150
degree to 165 degree. The process varies with different manufactures, but basically
consists in inserting gauged standard lengths of coiled catgut into lass tubes which are
then plugged, placed in ovens and the strings dehydrated by gradually raising the
fli
temperature. Baskets of tubes are then placed in a sterilizing chamber and the catgut
covered with an organic fluid of high boiling point and the temperature raised to about
in
160 degree.
Alternatively the tubes are subjected to the vapor of the organic fluid usually
toluene or xylol under pressure, the temperature again being held at about 160 degree for
u.
a suitable time. Any condensed fluid is removed by a further heating period. Most
variations in the methods have been aimed at reducing the fire and explosion hazards and
at the same time producing more acceptable catgut.
gn
After sterilizing the tubes are allowed to cool and are then drained if necessary. The
catgut is at this stage very brittle and could not be used in surgery. Under full aseptic
condition a suitably hydrated sterile alcoholic fluid is added in order to put back the
necessary moisture and the tubes are sealed. This origin of the term tubing fluid, which is
20
SUTURES & LIGATURES
still used by many manufactures even though the tubes has been replaced with other
forms of pack. After a few days the catgut is sufficiently re-hydrated to be usable.
Boilable catgut: Although catgut in Great Britain is now al of the non-boilable type. Up
in
to a few years ago a boilable Varity was prepared by some manufactures. The term was
used to indicate to operating theater staff that the external surface of the tubes could be
sterilized by boiling in water.
bn
et
.a
c.
Boilable catgut was prepared by the heat sterilizing method outlined above bat instead
of adding a hydrated tubing fluid the strands were immersed in a non-aqueous compound
such as toluene. The catgut, when removed from the tube, was hydrated by the operation
theater staff by soaking it in sterile saline or water some time before it was required for
use.
Radiation Sterilization
Currently by far the most commonly employed method of sterilization for suture is that
of irradiation by electron particles or by gamma rays. More than 50 percent of the suture
companies in Europe use this process. Whilst the original Commercial method in 1957
made use of electron machines, since 1961 most suture manufactures now employ
gamma radiation usually from cobalt 60 source. The recognized sterilizing dose for
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sutures is 2.5 megarad. The method has the advantage that sterilization is effected in final
in
sealed container, indeed some manufactures apply it to the complete sales package.
5.1 (iii) ABSORPTION OF CATGUT IN THE BODY
Catgut is used in surgery because it is capable of being absorbed by animal and human
u.
tissue. This concept was propounded by Lister who recognized that the continued
presence of a non-absorbable material presented a focus for infection. The term
´absorption` is often wrongly used to described the loss of tensile strength of holding
gn
power of the suture in the wound and this is more rapid than the disappearance of the
material itself. Formerly, terms such as ´10 day` , ´20 day` ,´´30 day`, and even ´40 day`
were applied to catgut sutures. The basis for such claims was never stated and indeed in
1940 Holder showed that in the case of iodine sterilized catgut the terms were
meaningless since the iodine process was greater than that of any treatment applied to
21
SUTURES & LIGATURES
catgut. These descriptions are now obsolete although they occasionally occur in surgical
papers. When the term ´20 day` is used the term is taken to refer tom the present day
´medium chromic material`. Medium chromic, now often abbreviated to ´chromic`, or
string to a mild basic chrome tanning.
in
hardened material is catgut which has been subjected either in the ribbon form or as a
Lawrie (1955), working mainly with heat sterilized material implanted in the lumbar
muscle of the rat, followed the rate of loss of tensile strength and evolved the concept of
bn
et
.a
c.
Half Strength Time (HST) which was the time required for the strength of the material to
be reduced to 50 percent of its original strength in vivo. Plain catgut was shown to
possess a HST of 5-7 days and to reach zero strength in 3-4 weeks, while medium
chromic catgut had a HST of 19 days and took about 5 weeks to reach zero strength.
The process, which takes place in the body when catgut implants are made, has been
extensively studied by histological observation from the day complete disappearance in
the tissue (Lawrie et ai. 1959, 1960). It is undoubtedly the reaction of the tissues to the
foreign body protein that brings about what is the termed the absorption process.
Although catgut prepared and sterilized by different method tends to show different
behavior in the body, nevertheless the general histological picture is similar.
At first, around the site of the implant there is a fairly rapid gathering of
polymorph nuclear leucocytes together with varying proportion of fibrinous exudates.
fli
These cells are evident as early as one day after implantation of plain catgut which tends
to excite a grater reaction in the tissue than chromicized material which does not being to
in
10 days after implantation. It should be understood that tissue reaction, i.e. inflammation,
is the inevitable result of leucocytic concentration (pus).
With plain catgut the polymorph phase begins to die down after about 5 days and
u.
there is an increasing accumulation of macrophages, by which time the catgut is
considerably fragmented and any ultimate suture material is absorbed by phagocytosis.
With chromic catgut the mechanism is not necessarily exactly the same although with
gn
certain types of suture material very little difference can be observed. Where a difference
is present thee longer absorption usually involves fragmentation by phagocytes
histiocytes and foreign body giant cells. These observations do not, of course, explain
why the catgut disappears and although a considerable amount of research has taken
place the actual proteolytic enzymes responsible have not been isolated. At the present
22
SUTURES & LIGATURES
the leucocytes or histiocytes themselves are believed to carry their own protection
enzyme system, and at one time this was thought to be very closely related to αchymotrypsin. The cellular reaction varies somewhat in different animals but the process
in the rat is very similar to that which occurs in human tissue although absorption periods
in
are somewhat longer. Very many attempts have been made by manufactures of surgical
catgut to try to relate the in vivo absorption of catgut to a standardized in vitro control.
These latter methods have generally been based on exposing catgut to standard solution
bn
et
.a
c.
of proteolytic enzymes such as trypsin, pepsin, papain, etc., and although the results
obtained are of some practical use, it has not been possible to incorporate them into a
reliable system of evaluation.
RECONSTITUTED COLLAGEN
The limitation on length imposed by the length of intestinal material combined with
natural biological variation in thickness and character have led manufactures to search for
many years for a means of overcoming these disadvantage. Collagen is available from a
large number of sources. It is the major constituent of skin, tendon, ligament, etc. As a
protein built up of 11 amino acids, it is partially soluble in acids. The basic process has
been to obtain an acidic solution of collagen prepared from hides or tendons which can be
extruded into a coagulation solution and the resulting fibres oriented by stretching. The
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filaments can then either be spun or rolled to make up the necessary sizes of strand
required. Reconstituted collagen is produced mainly in the finer sizes 0.5, 1 and 2 for
in
ophthalmic and cuticular surgery.
5.2KANGAROO TENDON
This absorbable material consists of the tail tendons of the wallaby. The tendons, which
u.
were usually preserved with naphthalene, were prepared and graded into various sizes,
e.g. fine, medium, and stout. Lengths were 30-40 cm. They were sterilized as for catgut
and their main use was for hernia repair and bone surgery. This material is virtually
gn
unobtainable today.
5.3 RIBBON GUT
Ribbon gut as its name suggest is in the form of ribbon approximately 12 mm wide and
usually about 45 cm long. Its use is limited but is preferred by some surgeons for the
23
SUTURES & LIGATURES
repair of large ventral hernia and in the closure of the kidney after nephrology. The
material is prepared from bovine esophagus and is sterilized in the same way as catgut.
5.4FASCIA LATA
in
This may be excised from the patient, or prepared from bovine thigh muscle, cleaned
and sterilized. It is supplied in lengths of about 30 cm × 6 mm wide and is used surgically
gn
u.
in
fli
bn
et
.a
c.
for hernia repair, urethral slings, etc.
24
SUTURES & LIGATURES
6. SYNTHETIC ABSORBABLE MATERIAL
The search for evenness and continuous length has also been pursued among synthetic
organic compounds. A number of patient obtained for filaments produced from the
polymerization of certain lactides, hydroxy acids, etc. and two such products are gaining
in
acceptance in surgery. The USP XIX describes Absorbable Surgical Suture as a sterile
strand prepared from collagen derived from healthy mammals or from a synthetic
bn
et
.a
c.
polymer.
6.1 PLAIN SURGICAL GUT
Available as a straw coloured suture. Surgical gut is made from the intestinal
submucosa tissue of sheep. These casings are split into ribbons, which are cleaned
chemically as well as mechanically and matched by computers to meet the most exacting
demands for diameter and tensile strength. Then an exclusive electronic spinning process
creates a strand that is virtually a monofilament for dependable strength and holding
power. Finally the strand is polished to size to an accuracy of five thousand of a
millimeter to produce an extremely smooth, highly uniform suture. Surgical Gut draws
through delicate tissue without sawing, ties down securely and holds uniformly and
predictably, until the wound regains tensile strength.
fli
6.2 CHROMIC SURGICAL GUT SUTURE
Available as a tan coloured suture. Chromic gut is made from the intestinal
submucosal tissue of sheep. These casing are split into ribbons, which are cleaned
in
chemically as well as mechanically and matched by computers in order to meet the most
exacting demands for diameter and tensile strength. Then an exclusive electronic
u.
spinning process creates a strand that is virtually a monofilament, for dependable strength
and holding power. Finally the strand is polished to size to an accuracy of five thousand
of a millimeter to produce an extremely smooth, highly uniform suture. Surgical gut
gn
draws through delicate tissue without sawing, ties down securely and holds uniformly
and predictably until the wounds regains tensile strength.
Virtually a monofilament
For smooth tissue passage. Smooth tie down and knot security.
Natural
25
SUTURES & LIGATURES
Produced from intestinal submucosal tissue of sheep. Highest level of collagen purity.
This enhances strength, minimizes tissue reaction and promotes greatest patient comfort.
Wound support
Absorption
By enzymatic digestion. Complete in 90 days.
Co lour
bn
et
.a
c.
Tan
in
Chromic Gut retains tensile strength for approximately 20 days.
Range
Eyeless needled Sutures: Sizes 6-0 to 2 (USP)
Standard and short lengths in sterile foil
Over wrap Packs: Sizes 5-0 to 4 (USP)
6.3 COATED VICRYL (Polyglactin 910)
Braided Synthetic Absorbable Suture
u.
in
fli
Available as a braided suture in distinct violet as well as undyed colures.
COATED VICRYL (Polyglactin 910) is now the most widely used Coated Braided
Synthetic Absorbable Suture. The braided construction ensures that handling and
gn
knotting are excellent and the unique lubricant coating remains effectively bonded to the
material throughout its use, ensuring smooth passage through tissue and easy knot tie
down. The unique molecular structure of coated VICRYL allows it to retain strength
during the critical wound healing period, yet, be absorbed rapidly after the suture has
excellent handling characteristic and its distinctive violet colour is highly visible in the
26
SUTURES & LIGATURES
wound. Coated VICRYL is also available in undyed form, especially for cuticular and
plastic surgery.
6.4 MONOCRYL (Poliglecaprone 25)
bn
et
.a
c.
Available as a golden colour monofilament
in
Monofilament Synthetic Absorbable Suture
MONOCRYL (Poliglecaprone 25) is a monofilament, synthetic absorbable suture. A
copolymer of 75% glycoside and 25% caprolactone, MONOCRYL is undyed, presenting
as a natural golden coloured monofilament.
MONOCRYL is the most pliable synthetic absorbable monofilament suture ever, has
virtually no memory when dispensed and its exceptionally smooth surface ensure
TISSUE GLIDDE when passed through tissue. This added to the fact that it elicts only
minimal tissue reaction makes this suture an ideal choice for plastic and cosmetic surgery
fli
and for Gastrointestinal surgery.
6.5 PDS II
in
Monofilament Synthetic Absorbable Suture
gn
u.
Available as a distinct violet Suture.
27
SUTURES & LIGATURES
PDS II suture is a Monofilament Synthetic absorbable suture made of Polydioxanone.
PDS II has the characteristic of extremely high initial tensile strength, coupled with
extended wound support. Also, being a monofilament, handling is extremely easy and
in
knotting is secure. Passage through tissue is smooth, eliminating tissue drag. It is
indicated for use in areas such as closure of fascia and sheath, in Pediatric Cardiovascular
surgery, in the Gastro intestinal tract, in Obstretrics/Gynaecology, in orthopedic surgery
6.6 VICRYL rapid
bn
et
.a
c.
and for subcuticular closure.
Braided Synthetic Absorbable suture
fli
Available as an undyed suture
VICRYL rapide is a braided suture made of the same material as that of Coated
in
VICRYL. i.e. Polyglactin 910. It is the specific manufacturing process which gives
VICRYL rapide its low molecular weight and hence its unique absorption characteristic.
VICRYL rapide is available in undyed form.
u.
VICRYL rapide is indicated for the closure of skin and mucosa. Its rapid absorption
ensures that patient does not have to come back for removal of skin sutures. Absorption
gn
of VICRYL rapide is predictable and with minimal tissue reaction.
28
bn
et
.a
c.
in
SUTURES & LIGATURES
7.
NON-
fli
ABSORBABLE
gn
u.
in
MATERIAL
29
SUTURES & LIGATURES
7 NON- ABSORBABLE SUTURES
7.1 SILK
Silk consists of strands prepared from filaments of the cocoon spun by the silk worm
in
of the Bombyx family before it enters the chrysalis stage. Three forms are used in
surgery- twisted (sometimes known as Chinese twist). Floss and plaited or braided silk.
ĎSilk in its natural state contains up to 25 percent of natural gum and strands prepared
bn
et
.a
c.
from unbleached, undischarged. Twisted silk suture material is prepared from
unbleached, undischarged filaments spun in multiples to the British Pharmaceutical
Codex range of diameters and may be dyed with non-toxic dyestuffs. The surgical use of
twisted silk has very much declined in favour of the braided type.
Floss silk is prepared from the coarser filaments on the outer surface of the silkworm
cocoon and is used in its spun glossy white form mainly in the repair of hernia. Its use is
diminishing fast as the plastic polymer meshes gain in popularity.
Plaited or braided silk is the material in large-scale use in modern surgery. It is
prepared from discharged silk and the range of sizes is dependent on the number of
strands braded together. As the gum has been removed it is not serum proof or noncapillary and for most surgical purposes it therefore treated with proofing waxes or
silicones.
fli
Silk is identified chemically by warming with mercuric nitrate solution when a brickred colour is produced and it is stained yellow by trinitro-phenol solution. Silk, because
in
of its strength softness and general ease of handling is used in many sites of surgical
operation, the fine strand being particularly suited to ophthalmic and neurosurgery. Silk
sutures are classified as non-absorbable in the body and are normally encapsulated by
u.
fibrous tissue. However, many cases have been reported where after a considerable length
of time the silk has fragmented or even migrated from the original site of implantation.
Silk is sterilized either by autoclaving, which causes a certain loss in its tensile
gn
strength, or by radiation or ethylene oxide sterilization.
It is normally supplied by suture manufactures to comply with the monographs
published in the British Pharmaceutical Codex.
30
SUTURES & LIGATURES
7.2 LINEN
Linen sutures consist of selected fibers made into a twisted strand from flax (Linum
usitatissinum). The strand is normally prepared by spinning three cords together, the size
of the cords being chosen to produce the ultimate desired gauge of thread. For surgical
microscopic examination.
in
use it must be firmly and evenly spun and free from fuzziness. Identification is by
Linen may be dyed with any non-toxic dyestuff but although a certain amount of black
bn
et
.a
c.
thread is used the majority of surgeons prefer off-white or ivory colour.
It is extensively used in many surgical techniques and frequently needs to be noncapillary and serum proof by treatment with suitable proofing agents similarly to braided
silk.
It can be sterilized by autoclaving or ethylene oxide. Radiation sterilization does
however cause a considerable loss of strength.
It is the subject of a monograph in the British Pharmaceutical Codex to which all
British manufactures conform.
7.3 POLYAMIDES
fli
In the U.K. these polymers are better known by the word Nylon but as this is a registered
trademark in certain European countries, it is likely that the word polyamide will be used
in the future. These compounds are formed from the polymerization of the reaction
in
product of an acids and an amine. Hitherto, they have been known by suffixing the word
Nylon with a number, e.g. Nylon 6, Nylon 66, Nylon 10, 11, 12 etc. Polyamide 66 is
formed by the combination of hexamethylenediamine and adipic acid. Polyamide 6 is
u.
formed by the polymerization of caprolactam.
All the polyamides and suture materials are produced by an extrusion process, the
gn
size of the orifice on the extruder head determining the size of the filament. The bulk of
the material used in surgery is produced in the form of monofilament. Its main use is in
skin suturing although it is sometimes used internally. Polyamide mesh finds a use in
hernia repair.
31
SUTURES & LIGATURES
Finer filament of polyamide is braided together to form braided nylon on nonabsorbable surgical sutures. Monofilament polyamide is normally colored with distinctive
non-toxic dyestuffs or pigments in order to improve its visibility. It may be sterilized by
autoclaving, by ethylene oxide or by radiation treatment, but is incompatible with phenol
in
and its homologues and other phenolic substances. The knotting of polyamide requires a
7.4 POLYESTER
bn
et
.a
c.
special knot.
This suture material is usually prepared in the plainted or braided form and
consists of filaments prepared by polymerizing the ester formed by a combination of
ethylene glycol and terephthalic acid. In its commercial form it is known under the
trademarks Terylene (I.C.I.) and Dacron (Dupont). The number of filaments in the braid
determines the size of the completed strand.
The polymer has a softening temperature of not less than 255 degree and may be
sterilized by autoclaving, ethylene oxide or radiation treatments, in order to improve its
visibility in tissue it is often dyed or pigmented with non-toxic materials.
7.5 Monofilament Polyamide
Available as black monofilament. The suture use in this product is an extremely
fli
strong, very pliable surgical nylon produced by a special, closely controlled extrusion and
polishing process that assures uniformity through out its length. It has high in-vivo tensile
in
strength, does not support bacterial growth and has the further advantages of being
minimally irritating to tissue and remarkably smooth and easy to handle. The smoothness
of suture makes it suitable for closing skin and subcuticular layers. Its high degree of
u.
elasticity contributes to its great strength in the fine sizes, enabling the plastic surgeon;
the micro surgeon and the ophthalmologist to tie secure knots.
gn
7.6 MERSILENE Braided and Monofilament Polyester
Available as a highly visible black or white braided suture alternatively, available as
a green monofilament.
32
bn
et
.a
c.
in
SUTURES & LIGATURES
MERSILENE suture is made from fine filaments of pure polyester, an extremely strong
synthetic material. It is specially processed to render it noncapillary. A special process to
produce a tight, smooth, uniform strand braids it. The tensile strength of MERSILINE
suture is considerably higher than that of natural non-absorbable sutures. It is not
weakened by wetting. It has excellent handling characteristics, draws easily through
tissue and knots hold securely with standard synthetic knotting technique. As a synthetic,
MERSILENE suture retains its strength in tissue and well tolerated in the body.
MERSILINE suture is also available as a Monofilament Green suture specifically meant
for ophthalmic surgery.
7.7 Polybutylate coated braided polyester suture
Available as a highly visible green or white coated braided suture
fli
Suture is made of fine filaments of polyester fiber, braided by a special process to
produce a firm suture that remains soft and pliable. For added lubricity and smoothness,
the suture is coated with a highly adherent, biologically inert Polybutylate. The unique
in
process gives suture a number of advantages. Flaking is virtually eliminated and the
suture is smooth to plave and tie down making it an excellent choice for cardiovascular
u.
and ophthalmic work. Knots hold securely when standard synthetic technique is used.
Suture is virtually non reactive and will retain its strength in tissue.
Braided and coated
gn
Suture, a braided polyester, is coated with a highly adherent, biologically inert,
Polybutylate which acts as a lubricant. Since both the suture as well as the coating are
both made of polyester materials, there is a natural affinity between the two and hence, an
excellent bond between the suture and coating. With the uniform coating of Polybutylate,
33
SUTURES & LIGATURES
suture has a soft pliable hand, ensures smooth passage through tissue, and knotting is
secure.
Available in highly visible green or white colours.
Range
in
Colour
combinations.
Minimal reaction
bn
et
.a
c.
Eyeless needled sutures: sizes 6-0 to 5 (USP) on a variety of needled suture
The thin and uniform surgical grade Polybutylate coating virtually eliminates flaking,
shredding or bending common to sutures coated with commercial lubricants. Tissue
reaction is minimal.
Strong and secure
Suture is strong and secure and is ideal for use where extended approximation of tissue
under stress is required.
fli
Smooth handling
Polybutylate coating imparts superior lubrication to polyester braided materials. Hence
in
handling is extremely easy and passage through tissue is smooth.
Knot tying technique
u.
As with other synthetic sutures, knot security requires the standard surgical technique of
flat and square ties with additional throws as indicated by surgical circumstances and the
experience of the operator.
gn
7.8 Monofilament stainless steel suture
Available as sterile monofilament eyeless needled sutures
34
SUTURES & LIGATURES
Surgical stainless steel is made from premium grade steel, formulated specifically for
surgical use. This grade of surgical stainless steel must undergo many more quality
control steps than ordinary commercial steel. Surgical steel is the strongest suture
virtually no tissue reaction.
Monofilament
Synthetic
bn
et
.a
c.
Inert, will have virtually no tissue reaction. Knot security is exceptional.
in
material that makes. It offers the ultimate in knot security. As a inert material it will elicit
Made of surgical grade stainless steel. Provides supple “hand” while retaining high
tensile strength.
Colour
Silver.
Range
Available in a range of eyeless needled sutures: gauges 5-0 to 6(USP)
Also specially imported are multistrand straight packs. The straight packs are available in
sizes 1,4,5,6,(USP). They are multistrand packs with 4 strands per foil pack. This
specially designed packaging minimizes kinks and aids easy handling of the suture in the
operating theatre.
fli
Superior strength
Suture is the strongest suture material made. Its applications are in orthopedic surgery
in
(tendon repair), as well as in cardiovascular surgery (as a sternal closure suture).
Inert
Suture when implanted in vivo elicits virtually no tissue reaction.
u.
Knot security
Knotting with suture offers excellent security
gn
7.9 PROLENE MONO FILAMENT POLYPROPYLENE
Available as a bright blue monofilament suture.
35
bn
et
.a
c.
in
SUTURES & LIGATURES
PROLENE Polypropylene suture is made from a polymer of propylene, which is
extruded by the special ETHICON a very strong, smooth, uniform suture. The unique
combination of qualities in the suture material itself makes PROLENE suture one of the
most versatile non- remarkable smoothness remarkable smoothness absorbable sutures
available. Its makes it desirable as a cosmetic suture. The same quality is valuable in
cardiovascular work. It real, which is important in vascular surgery. The long term
holding power of is the least thrombogenic suture matePROLENE suture – it will retain
its in vivo tensile strength for years makes it the choice when extended approximation is
a must. As a monofilament, it has no interstices to harbour microorganisms. It is
unwetted by blood, unweakened by tissue enzymes, offers prolonged tensile strength
even in infected areas. PROLENE suture is pliable, ties securely and handles well
fli
because of its controlled elongation.
7.10 PROLENE Monofilament Polypropylene Non Absorbable Suture
Monofilament
in
High degree of smoothness requires much less force to draw through tissue; easy to
place, easy to pull out. PROLENE suture being a monofilament has no interstices to
harbour microorganisms. It handles exceptionally well. It is as steel, resists break down
u.
by infection. It is unaffected by tissue fluids and can be used even in presence of
gn
infection.
Non-absorbable
Provides prolonged tensile strength retention in tissue, even in presence of infection.
Synthetic
36
SUTURES & LIGATURES
PROLENE suture are made from a specially formulated surgical grade of polypropylene.
It is made of isotactic form of propylene polymer called isotactic polypropylene resin.
Colour
Suture is available in a bright blue Colour. It makes PROLENE suture the easiest to seen
in
in the wound.
bn
et
.a
c.
Extensibility
PROLENE suture has the characteristic of controlled linear elongation as a result of
which it is ploiable, ties securely and handles well.
Range
Eyeless needled sutures: gauges 8-0 to 1 (USP). Available in a variety of needled suture
combinations.
Knot security
Plastic deformity enables knot to flatten out and lock against itself.
fli
Knot tying technique
As with other synthetic sutures, knot security requires the standard surgical technique of
in
flat and square ties with additional throws as indicated by surgical circumstances and the
experience of the operator.
CAUTION: care should be taken to avoid damaging the surface of the material with
gn
u.
surgical instruments in use, as this could lead to fracture of the material.
37
SUTURES & LIGATURES
7.11 PERMA-HAND
bn
et
.a
c.
Available as a black braided suture
in
Surgical silk
PERMA – HAND surgical silk begins as a filament of natural silk. Natural silk is
composed of approximately 70 % protein fibers and 30% extraneous material or gum. A
specially developed degumming process removes extraneous material amounting to 30%
of the original volume of raw silk. This process is essential for a compact braid whilst
ensuring that the filaments retain their natural body and elasticity. These filaments are
then tightly braided at a sloe controlled rate and electronically Inspented during the
fli
processing. Finally, proofed to give “hand” to the suture, it will neither soak up fluids nor
become limp or brittle. Knots tie down smoothly and securely whilst its natural elasticity
in
signals when optimum knot placement has been achieved. The enduring popularity of
PERMA-HAND braided silk in all surgical specialties is reflected in the wide range of
u.
needles to which the material is attached.
PERMA-HAND
gn
Braided silk suture
Braided
For easy handling and knot tying. Uniform tension during braiding makes each knot hold
fast, so suture does not slip back between throws.
38
SUTURES & LIGATURES
Natural
PERMA-HAND surgical silk begins as a filament of natural silk. This silk goes through
in
degumming process; it is then braided under slow control. It is then TRUPERMANIZED
for non-capillarity. This results in a suture material with exceptional hand, uniform
Colour
bn
et
.a
c.
strength and diameter, which is smooth, ties down easily, and knots securely.
Black. Twisted virgin silk however is available in blue.
Range
Eyeless needled sutures braided
: Sizes 7-0 to 1 (USP)
Eyeless needled sutures (twisted virgin silk)
: Size 9-0 to 8-0 (USP)
Sutupak pre cut sutures
: Size 6-0 to 3 (USP)
Reels (non sterile)
: Size 6-0 to 4 (USP)
ASSURED NONCAPILLARITY
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PERMA-HAND surgical silk does not transfer pathogens from one place to another.
UNIFORMITY OF STRENGTH AND DIAMETER
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Controlled uniformity of diameter results in high uniform tensile strength.
EXTENSIBILITY
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PERMA-HAND surgical silk signals to the surgeon that “optimum” knot.
39
SUTURES & LIGATURES
SURGERY
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8.1 CARDIOVASCULAR
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8 Suture used in various body surgery
Cardiovascular Surgery requires highly specialized needles and selected suture materials.
The suture used in this purpose its own suture combination and this allows for reliable
quality control. Eyeless needles made of a unique stainless steel alloy, which permits a
reduced wire diameter – closely, approximately the diameter of the suture material-
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without sacrificing ductility and strength. It is in the process of introducing a patented
needle alloy specially for cardiovascular surgery in many product added strength and
improved penetration- time after time.
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In ETHICON`s company collection of suture material for cardiovascular work, like
PROLENE which offers strength, inertness, unsurpassed tissue passage properties and
secure knotting make it the leading suture material as far as cardiovascular work is
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concerned. Newer suture materials such as PDS II, which offer prolonged wound support,
make it the suture of choice for vascular anastomosis in small vessels in pediatric
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vascular surgery.
The product has a range of needles for cardiovascular work namely CC needles, BV
Series needles which requires significantly less penetration force, pass easily through
tissue thereby reducing tissue trauma. Other material such as ETHIBOND and
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SUTURES & LIGATURES
ETHISTELL offer the cardiovascular surgeon the complete range of precision product to
make exacting tasks go more smoothly.
For the specialist, by the specialists
SURGERY
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8.2 GASTRO-INTESTINAL
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In short the cardiovascular surgery used sutures are:
Anastomosis is the most common procedure in Gastro-intestinal Surgery. Therefore the
use of Eyeless Needled Suture is essential to minimize tissue trauma, prevent leakage and
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contamination and therefore achieve optimum results. Some company marketed product
offers a wide range of Super Smooth Needles that penetrate easily time after time through
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tissues with minimum pressure, thus eliminating tissue drag.
Stainless Steel Needles are rendered Super Smooth by the exclusive Micro graining
process developed by many companies.
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Many companies have introduced the new range of JB needles for anastomosis in the
Gastro-intestinal tract. These needles, which have a slim round-bodied tip, have an oval
cross section to facilitate separation of the tissue layer. They are blackened for improved
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visibility in the operating field. These needled are available on MONOCRYL suture
material.
ETHICON like company offer a range of newer suture materials like MONOCRYL,
Coated VICRYL, in addition to the conventional suture materials like surgical Gut,
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SUTURES & LIGATURES
PERMA HAND Surgical Silk for exceptional performance during surgery in the Gastro-
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et
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8.3 GENERAL CLOSURE
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intestinal tract.
All surgical procedure ends with the closure of a wound. The wound may be on the
Abdominal wall or an extremity: Different procedures need different techniques of
closure and various tissue layers demand varying suture materials and needles for their
approximation. Eyeless needled sutures for general closure provide a full range to face
any situation. Use of eyeless needled sutures prevents unthreading during surgery,
ensures easy passage through tissues and provides comfort and convenience during
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surgery.
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8.4 OB-GYN SURGERY
In Obstetric and Gynecological Surgery, concern for the healing process and for patient
comfort has traditionally idea surgeons to select a suture with non- capillarity (For
42
SUTURES & LIGATURES
placement in or near contaminated areas), monofilament construction (For smooth pliable
action to minimize tissue tearing and promote patient comfort during healing) and knot
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security (to hold ligaments and vessels to ensure ligation is secure).
ETHICON`s has introduced, in addition to coated VICRYL, the range of synthetic
absorbable sutures viz. VICRYL rapid and PDS II for the OB-GYN surgeons. These
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et
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suture materials are available with special needles of choice meant to approximate
different tissues during various OB-GYN procedures. These special needles of allow
smooth and easy penetration through tissues with minimal tissue trauma and the different
suture materials provide the necessary wound support required to carry out different
procedures with ease and comfort. An example of this is the special Episiotomy code on
VICRYL rapid, offering the surgeon the benefit of rapid and predictable absorption, also
improving patient comfort. The new synthetic absorbable suture, PDS II, offers long term
wound support which is ideal for the closure if fascia.
ETHICON Company continued commitment to the safety of the surgeon has resulted in
the introduction of the revolutionary ETHIGUARD needle. This needle with its unique
Dolphin Nose profile passes through the tissue yet does not penetrate the gloves hence
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preventing the transmission of blood borne infections through needle stick injuries.
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8.5 OPTHALMIC SURGERY
Perhaps no other surgical discipline requires as many specialized needles and specially
designed suture material as Ophthalmic Surgery. To meet this need, some company offers
the Ophthalmic Surgeon, a comprehensive array of precisely manufactured fine MICRO-
43
SUTURES & LIGATURES
POINT and Spatula needles and suture material such as Surgical gut, coated VICRYL,
Black Braided Silk, Monofilament Polyamide, PROLENE, MERSILENE and
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ETHIBOND.
The introduction of the CS-ULTIMA family of Ophthalmic needles with its
innovative Concave Spatula design and its breakthrough needle geometry offers the
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et
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Ophthalmic surgeon the “Shape of Sharpness” The cutting edge for a superior
performance time after time.
ETHICON company has also introduced a CATARACT KIT, a combination of 10-0
ETHICON on an Advanced MICRO-POINT, 6 mm cured needle, with a 4-0 Braided Silk
Suture on a TAPERCUT, 17 mm, half circle needle offering the benefit of improved
operation theatre management, less time wastage and less material wastage.
Specialized Needles and Sutures
For Ophthalmic Surgery
Corneal and Scleral tissue is very tough in order to fulfill its role in protecting the
optimal unction of the eye. Needles must, therefore, be both strong and sharp. The ideal
needle for suturing of the eye allows easy initial penetration and exact control of the
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depth of penetration.
ETHICON`s range of Ophthalmic surgery Needles includes:
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CS ULTIMA
Features

Dramatically reduced edge angles

Innovative concave spatula geometry
44
SUTURES & LIGATURES

Superior strength
Less force to penetrate

Burial of knot made easier

Resist bending, maintains curvature
bn
et
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
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BENEFITS
Specialized Suture Materials
VIRGIN SILK
Virgin Silk is widely and extensively used in cataract surgery it has excellent handling
qualities.
It is smooth, soft, has no tissue drag and is very easy to tie. It has god visibility in tissue
and provides secure knots. It gives to optimum tissue reaction and being soft, has no
tissue drag and is very easy to tie. It has good visibility in tissue and provides secure
knots. It gives rise to optimum tissue reaction and being soft in nature, does not cause any
irritation in the eye. It gradually fragmented and disappears and results in satisfactory
ETHILON
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wound healing.
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Polyamide Monofilament
ETHILON suture is strong, smooth, inert and in fine sizes, enables the surgeon to
produce a small, tight, non-slipping knot-a knot so fine, it can be buried in the needle
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tract. There is no tissue drag and it does not fray.
It needs a specific synthetic knot-tying technique and results in good wound healing. It is
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an ideal suture for keratoplasty.
VICRYL (Polyglactin 910)
Synthetic Absorbable Suture
Tissue-timed for predictable performance. A copolymer of lactide and glycolide,
VICRYL suture has a unique molecular structure, which causes the suture to retain its
45
SUTURES & LIGATURES
strength over the critical wound healing period, and then allows rapid absorption after the
suture has served its purpose. Minimal tissue reaction for a “quiet” eye- makes VICRYL
Colour for high visibility.
SURGERY
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et
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8.6 ORTHOPADIC
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suture an excellent choice for cataract and strabismus surgery. Has distinctive violet
Orthopedic Surgical procedures are carried out from head to foot. These include surgery
of the spine, joints, bones and soft tissues. Various tissue layers, from bone to skin
require to be approximated during these procedures. Some tissue need absorbable suture
while some need non-absorbable sutures. ETHICON provides a full range of suture on
appropriate needles. ETHICON`s Family of Synthetic Absorbable with materials such as
PDS II, recommended for extended wound support would be ideal for these procedure
like surgery of the spine and other joints. PDS II, recommended for extended wound
support would be ideal for these procedures. It also has the advantage of being an
absorbable suture.
All suture materials are available on Round Bodies needles, Cutting needles, special
Mayo needles, Trocar needles, and TAPERCUT needles as per the surgeon‟s preference.
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ETHICON has also introduced a new absorbable suture material, VICRYL rapid, for
suturing of skin. The advantage offers by this unique suture material is, that it offers short
term wound support and the sutures begin to fall off after the critical wound healing
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period, hence there is need of suture removal.
u.
ETICON Suture Materials for usage in
Orthopedic Surgery Procedures.
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Coated VICRYL (Polyglactin 910) synthetic Absorbable Suture
Coated VICRYL provides medium term wound support for up to 30 days. Absorption
is predictable, 63 days on an average and with minimal tissue reaction. This suture knots
well and handles well. It is available on a variety of Needle suture combination for
orthopedic surgery procedures.
46
bn
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SUTURES & LIGATURES
VICRYL rapid (Polyglactin 910) synthetic absorbable suture
VICRYL rapide is recommended for those areas where short term wound support is
required like suturing of skin. It provides just the right strength at the start and loses
tensile strength rapidly. Sutures begin to fall of between 10-12 days as the skin wound
heals. It is recommended for use under POP casts. Since sutures fall off between 10-12
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days, there is no need for patient to come back for suture removal.
u.
in
PDS II (Polydioxanone) Synthetic Absorbable Suture
PDS II offers extended wound support for up o 56 day. Also being a monofilament,
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handling is exceptionally easy. It is recommended for closure of fasica and also for
elderly; dehabitated patients where the slow healing requires extended wound support.
47
SUTURES & LIGATURES
in
ETHISTEEL Monofilament Stainless Steel
bn
et
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Surgical Stainless Steel is the strongest suture material made by ETHICON. It offers
excellent knot security. It is inert and elicits virtually no tissue reaction. It is available in
finer sizes for tendon repair.
8.7 PLASTIC
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SURGERY
THE surgeon who wishes to achieve the finest cosmetic results must have a complete
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range of “tools” in his armoury. ETHICON has taken a quantum leap in the field of
plastic surgery needle technology by introducing the Top of the line ETHIPRIME plastic
surgery needle. This superior needle a result of numerous years of research has given the
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plastic surgeon today the 4 S‟s formula:Sharp
Stays Sharp
Strong
Secure
48
SUTURES & LIGATURES
The ETHICON needles backed by the Family of Synthetic Absorbable and non
Absorbable Suture ensure that each layer of tissue has that appropriate support to ensure a
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beautiful scar.
Suture such as MONOCRYL- which allow a phenomenon called “Tissue Glide”,
PROLENE, ETHILON, and Coated VICRYL (now available in its undyed version in
bn
et
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those fine gauges) ensure superlative cosmetic results.
Suture materials such as VICRYL rapide- a rapidly absorbing skin closure suture that
obviates the need for removal of suture materials offer numerous benefits to the plastic
surgeon.
Finally ETHICON`s PROXI-STRIP range of skin closure designed specially for the
plastic surgeon are an asset to any skin closure technique.
8.8 UROLOGY
Urology procedure involves the usage of Absorbable suture: both Natural as well as
Synthetic Absorbable Suture. ETHICON offers suture materials such as Plain and
Chromic Catgut, and coated VICRYL. The range of sutures is available on a variety of
needles specially designed for surgery in the urinary tract.
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Since the bladder wound regains 100 percent of its strength by 21 days, VICRYL
suture would be ideally suited for closure of the urinary bladder. Special needled suture
have been made available for surgery on Prostrate, Ureter, Pelvis of the kidney, Urethra
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etc. Very fine-needled sutures have been made available for procedures like VasoVasostomy, A-V Fistula for Renal Dialysis, Uretroplasty and Hypospadius. Use of these
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specially designed eyeless needled sutures ensures minimal tissue trauma and provides
immense comfort, convenience and safety during surgery. It helps the surgeon perform
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fast and efficient surgery.
49
SUTURES & LIGATURES
9 Miscellaneous Products
Mesh Products
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Non- Absorbable Tissue Support Products
Where permanent, or extended tissue support is a surgical requirement, ETHICON
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et
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offers PROLENE Mesh Products
PROLENE Polypropylene Mesh
Monofilament Polypropylene knitted PROLENE Mesh is constructed from the same
material as that of PROLENE suture. It is well recognized for its biological inertness and
strength. In the mesh form, it provides a lasting and permanent solution for a “Tension
Free” Hernia Repair. PROLENE Mesh may be resterilised once by conventional steam
autoclaving process at a temperature of 121º for 20 minutes
Code
PM-S
PM-M
Packaging
6 cm x 11 cm
3 sheets per box
15 cm x 15 cm
3 sheets per box
30 cm x 30 cm
1 sheet per box
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PM-L
Presentation
in
Absorbable Tissue Support Products
VICRYL (Polyglactin 910) Synthetic
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Absorbable Mesh
The proven benefits of the VICRYL Copolymer are now available in the form of an
absorbable mesh product designed to provides temporary support during the wound
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healing phase. VICRYL mesh is indicated for traumatized spleen, kidney, and treatment
of abdominal eviscerations. The VICRYL mesh retains approximately 80 % of the initial
tensile strength at 14 days and 17 % at 28 days.

Impressive Mechanical Properties

Excellent Handling
50

Essential Permeability

Predictable Absorption
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SUTURES & LIGATURES
Presentation
Packaging
VKM-M
15 cm x 15 cm
3 sheets per box
VKM-L
30 cm x 30 cm
3 sheets per box
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et
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Code
9.1 STAINLESS STEEL WIRE
Stainless steel wire has largely replaced the various wires which have been used in
surgery in past years, such as silver, tantalum, phosphor bronze, etc. it is supplied for
surgical purpose in three forms, namely, monofilaments, twisted and plaited or braided.
The British Pharmaceutical Codex includes monographs on all three types and lays down
standards for diameter and tensile strength.
In all three cases the wire is prepared from austenitic chromium-nickel stainless steel
and is fully annealed. The austenitic steels are nonmagnetic and only capable of being
1967.
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hardened by cold working. The wire is made to British Standards Specification 4106:
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It may be sterilized by dry heat, autoclaving, ethylene oxide or radiation but it is
important that the wire should be fully degreased when heat treatment is used.
Its main use is in orthopedic work, but very fine wire is also used in plastic surgery
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and for repair of tendons.
9.2 SUTURE CLIPS
Michel and Kifa clips are used to some extent for long skin wound approximation and
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find a considerable use in research work on animals where they are less irritating in the
skin surface than suture.
9.3 WIRE STAPLES
A considerable amount of experimental and clinical work is now being carried
out, particularly in the U.S.S.R. and the U.S.A., on the use of very small wire staples,
51
SUTURES & LIGATURES
usually of stainless steel. The field of investigation is very wide and papers have been
published on their use in orthopedic, cardiovascular and arterial work and in the U.S.S.R.
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in
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bn
et
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in
the results of many thousands of cases of gastric resection have been reported.
52
bn
et
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in
SUTURES & LIGATURES
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SURGICAL
NEEDLES
53
SUTURES & LIGATURES
10 SURGICAL NEEDLES
Whenever a suture is required to close a wound, needles to arm the suture material are
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necessary. The number of sizes and the variety of different shapes of needles run into
many thousand. The range supplied by manufactures is usually classified into types for
specific surgery, as for example, arterial, general purpose, intestinal, obstetric,
½
circle,5/8
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et
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ophthalmic, plastic, retention. Shapes are designated as: straight, curved,
circle, etc. and the section as round bodied, triangular cutting edge, triangular reverse
cutting, cutting point, trocar point. In addition the length of the needle from point to hilt
is specified in millimeters and the hilts are designed to take the various diameters of
suture material employed. Needles are chosen by the surgeon to suit his operating
technique and it is largely because of the surgeon‟s interest in improving suture
efficiency that the development of surgical needles has taken place. In very many cases
the surgeon himself has caused needles to be made to his own design and a large number
of commonly used needles are referred to by the name of the inventing surgeon.
Surgical needles are of two types; those which have an eye through which have an
eye through which the suture is threaded, and eyeless needles where the suture is inserted
into the hollow hilt and held in position by swaging the metal around it. The late Sir
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Henery Souttar obtained the first patent on an eyeless needle in 1921, but in the U.K.
their use has only increased appreciably in the past few years. In the U.S.A. 70 percent of
the suture needles are of the eyeless type.
in
The needles themselves are made either of stainless steel or of carbon steel, the latter
usually being plated to resist corrosion. At one time the carbon steel needle had a better
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resistance to bending than its counterpart in stainless steel, but recent technological
advances have the added advantage that they will not corroded and do not present the
surgeon with the dreaded emergency of having to locate and extract the broken point of a
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needle embedded somewhere in the tissue of an unfortunate patient.
10.1 NEEDLE TYPE
The basic classification for needle is normally by needle type such as round bodied,
conventional cutting, reverse cutting, Trocar Point or Tape cut cutting round-bodied
needles. All the type of needles available is discussed in under.
54
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SUTURES & LIGATURES
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10.2 NEEDLE SHAPE
The choice of needle shape is frequently governed by the accessibility of the tissue to
be sutured, and normally the more confined the operative site the greater the curvature
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required. The basic shapes involved are: straight, ¼ circle, 3/8circle or curved, ½ circle and
circle.
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5/8
10.3 TYPES OF NEEDLES
Super smooth
55
SUTURES & LIGATURES
Virtually all needles have a micro-thin Super- Smooth finish that permits the needle to
penetrate and pass through the toughest tissue with an almost fluid-like flow, with
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et
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minimal resistance and virtually no drag, giving the surgeon a feeling of control.
Strong, sharp Micro grain Stainless Steel
This needle is made from premium grade stainless steel formulated specifically for
surgical use. An exclusive process controls the orientation of the micro grains so that
ductility and strength are closely sharp, and stay sharp, thus assuring easy passage
through tissue.
Needle Swaging
Needles are permantely attached to the suture materials, eliminating the need for
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threading and providing a new, sharp needle each time. A good needle give perfect
swaging gives the surgeon a needle with an unbroken surface from end to end; without
double strands, it draws through tissue easier and with less tissue trauma.
in
Ribbed for Security and Control
Longitudinal ribbing on the inside and outside curvatures of most needles has a cross-
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locking action in the needle holder, minimizing turning, rocking or twisting, and thus
providing unsurpassed needle control.
Round Bodied
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For soft, easily penetrated tissues.
56
SUTURES & LIGATURES
Conventional Cutting
Two opposing cutting edges, with a third on inside curve. Change in cross-section from a
TAPERCUT Needle
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et
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in
triangular cutting tip to a flattened body.
Cutting tip, taper body. For tough tissue, like two needles in one.
Dolphin nosed needle
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For greater surgeon safety while operating in potentially infected areas.
Reverse Cutting
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Cutting edge on outer curve. For tough, difficult to penetrate tissues.
Blunt point Needle
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Taper Body. For suturing friable tissue e.g. Liver, Kidney.
57
SUTURES & LIGATURES
MICRO-POINT Spatula needle
bn
et
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CS ULTIMA Spatula needle
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Thin, flat profile. Specially designed for ophthalmic anterior segment surgery.
Reduced edge-angles provide better penetration. Readily facilitates knot rotation in
ophthalmic surgery.
ETHIPRIME
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Hollow form design enhances penetration for delicate plastic and cosmetic surgery.
VISI-BLACK Needle
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Slim taper point needles with a black finish for improved visibility and penetration.
58
SUTURES & LIGATURES
11. MARKETED PREPARATION with trade name
MONOCRYL (Poliglecaprone 25) suture
PDS II (Polydioxone) suture
ETHIGUARD surgical needles
bn
et
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ETHIBOND polyester suture
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VICRYL (Polyglactin 910) suture
MERSILINE polyester suture
PDS II (Polydioxanone) suture
CS ULTIMA ophthalmic needles
ETHICON surgical steel suture
VISI-BLACK surgical needles
VICRYL (Polyglactin 910) suture
ETHALLOY needle alloy
ETHIPRIME surgical needles
PROXI-STRIP skin closure
VICRYL RAPIDE suture
TAPERCUT surgical needles
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MONOCRYL (Poliglecaprone 25) suture
VICRYL (Polyglactin 910) suture
PDS II (Polydioxanone) suture
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ETHIGUARD surgical needles
ETHALLOY needle alloy
PERMA-HAND silk suture
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ETHIBOND polyester suture
MERSILENE polyester suture
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PDS II (Polydioxanone) suture
ETHICON surgical steel suture
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SUTURES & LIGATURES
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REFERENCE
60
SUTURES & LIGATURES
12.REFERENCES
for surgical Use. Medical Research Council Special Report No 138.
2. CUNNINGHAM, R.H. (1895) New York med. J. 61, 494.
in
1. BULLOCH .W, LAMPITI, L.H. & BUSHILL, J.H. (1929) The Preparation of Catgut
Suppl., 121 T.
bn
et
.a
c.
3. DAWSON, J.O., ROYLANCE, T.W. & SMITH, T. (1964) j. Pharm. Pharmacol. 16
4. FANDRE.A. (1944) Le Catgut. Paris: Masson et Cie.
5. HOLDER, E.J.(1955) Studies in the Absorption of Surgical Catgut. Edinburgh:
William Blackwood & Sons Ltd.
6. LAWRIE.P. (1955) Studies in the Absorption of Surgical Catgut. Einburgh: William
Blackwood & Sons Ltd.
7. LAWRIE, P., ANGUS, E.A.& REESE, A.J.M. (1959) Br.j.Surg. 46, 638.
8. LAWRIE, P., ANGUS, E.A..& REESE, A.J.M. (1960) Br.j.Surg. 47,551.
9. LISTER, J. (1869) Lancet 1869,I.451.
10. MACKIE, T.J. (1928) An inquiry into Post-Operative Tetanus-A Report to the
Scottish
Board of Health.
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11. ETHICON PRODUCT CATLOGUE gohnson&gohnson professional Product
12. GROSS, M.2. The Ethic on book of sutures. Ethic on Suture Laboratories, Ebinburgh.
HOLDER, E.J. (1939) surgical sutures and ligatures. Livingston, Ebinburgh.
14.
HOLDER, E.J. (1946) Desirable Factor in surgical sutures. Blackwood.
in
13.
Edinburgh.
DAWSONE, J.O. (1962) Ligatures and sutures chemist drug., 160, 177-179.
u.
15.
16.
LAWRIE, P. (1959) A Survey of the absorbality of surgical catgut. Br.J. surg
46,634-637
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17.
OS, D.VAN. (1946) A new surgical suture. Pharm .j., 103, 164
18.
Bentley‟s Textbook of pharmaceutics Edited by E.A. RAWLINS 36, 626-641
19.
A textbook of tutorial pharmacy by cooper & gun‟s.
20.
Indian journal of clinical practice volume 15 number 2: the matters sutures:
vertical, horizontal and corner stitch.
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SUTURES & LIGATURES
21.
Lawrie p Angus g. e. and Reese a.j.m. (1959) The absorption of surgical catgut
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u.
in
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in
B.R.J surg. 46, 638-642.
62
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in
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SUTURES & LIGATURES
63