wound closure manual

WOUND CLOSURE MANUAL

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ETHICON, INC. , PO BOX 151, SOMERVILLE, NJ 08876-0151

* TRADEMARKSM ETHICON, INC.© 2005, ETHICON, INC.

TO V I E W T H E E - C ATA L O G G O T O T H E

H E A LT H C A R E P RO F E S S I O NA L S E C T I O N O F

W W W. E T H I C O N . C O M

W O U N D H E A L I N G

S U T U R E S

N E E D L E S

A D H E S I V E S

S U R G I C A L M E S H

PREFACE

his manual has been prepared for the medical professional who

would like to learn more about the practice of surgery–the

dynamics of tissue healing, the principles of wound closure, and the

materials available to today’s practitioners. Most important, it

touches on some of the critical decisions which must be made on a

daily basis to help ensure proper wound closure.

ETHICON PRODUCTS, a Johnson & Johnson company, is the

world’s leading marketer of surgical sutures and is the only U.S.

company that offers an adhesive with microbial protection as an

alternative to sutures for topical skin closure.

ETHICON enjoys a reputation for developing quality products to

enhance the lives of patients and for providing outstanding service

to customers. We hope you find this manual useful. But, above all,

we hope that it reflects our high regard for the men and women

who have chosen the medical profession as a career.

ETHICON PRODUCTS

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CONTRIBUTING EDITOR

David, L. Dunn, M.D., Ph.D.Jay Phillips Professor and Chairman of Surgery,University of Minnesota

We thank Dr. Dunn for his contributions to the Wound Closure

Manual. Dr. Dunn is currently the Jay Phillips Professor and

Chairman of Surgery at the University of Minnesota. This

department has a long-standing tradition and has attained

national and international recognition for excellence in training

academic general surgeons and surgical scientists. He is also the

Division Chief of General Surgery, Head of Surgical Infectious

Diseases, Director of Graduate Studies, and Residency Program

Director of the Department of Surgery.

Dr. Dunn has published over 400 articles and book chapters in the

areas of Surgical Infectious Diseases and Transplantation. He has

received regional and nationwide recognition in several

academic organizations and is a Past-President of the Surgical

Infection Society, the Association for Academic Surgery, the

Minnesota Chapter of the American College of Surgeons, the

Society of University Surgeons and the Society of University

Surgeons Foundation.

TABLE OF CONTENTS

1WOUND HEALING AND MANAGEMENT

The Wound.......................................................... 2Recovery of Tensile Strength............................ 2Patient Factors that Affect Wound Healing......... 2Surgical Principles....................................... 4

Classification of Wounds................................... 5Types of Wound Healing................................... 6

Healing by Primary Intention........................ 6Healing by Second Intention.......................... 7Delayed Primary Closure .............................. 7

2 THE SUTURE

What is a Suture?............................................... 10Personal Suture Preference............................... 10Suture Characteristics....................................... 11

Size and Tensile Strength.............................. 11Monofilament vs. Multifilament.................... 11Absorbable vs. Nonabsorbable Sutures.............. 12

Specific Suturing Materials.............................. 13Synthetic Absorbable Sutures ......................... 14Nonabsorbable Sutures................................ 16Synthetic Nonabsorbable Sutures.................... 17

Common Suturing Techniques....................... 18Ligatures ................................................. 18The Primary Suture Line............................. 19Continuous Sutures.................................... 19Interrupted Sutures .................................... 22Deep Sutures ............................................ 22Buried Sutures .......................................... 22Purse-String Sutures................................... 22Subcuticular Sutures................................... 22The Secondary Suture Line........................... 23Stitch Placement........................................ 23

Knot Tying ......................................................... 24Knot Security............................................ 24Knot Tying Techniques Most Often Used .......... 25Square Knot............................................. 25Surgeon’s or Friction Knot............................ 26Deep Tie................................................. 26Ligation Using a Hemostatic Clamp............... 26Instrument Tie.......................................... 26Endoscopic Knot Tying Techniques.................. 26Cutting the Secured Sutures.......................... 26

Suture Removal................................................. 26Suture Handling Tips....................................... 27Suture Selection Procedure ............................. 27

Surgery within the Abdominal Wall Cavity....... 28Closing the Abdomen.................................. 30Closing Contaminated or Infected Wounds........ 40

3 THE SURGICAL NEEDLE

Elements of Needle Design ............................. 42Principles of Choosing a Surgical Needle..... 44Anatomy of a Needle........................................ 45

The Needle Eye......................................... 45The Needle Body....................................... 46Straight Needle......................................... 46Half-Curved Needle................................... 47Curved Needle.......................................... 47Compound Curved Needle........................... 47The Needle Point ...................................... 48

Types of Needles............................................... 48Conventional Cutting Needles....................... 49Reverse Cutting Needles ............................... 49Side Cutting Needles................................... 50Taper Point Needles ................................... 50Taper Surgical Needles ................................ 51Blunt Point Needles.................................... 52

Needleholders.................................................... 52Needleholder Use....................................... 52Placing the Needle in Tissue ......................... 53

Needle Handling Tips ...................................... 53

4 PACKAGING

An Integral Part of the Product ..................... 56RELAY* Suture Delivery System .................. . 56

Modular Storage Racks................................ 56Dispenser Boxes......................................... 57Primary Packets........................................ 57

E-PACK* Procedure Kit.................................. 59Expiration Date................................................. 60Suture Sterilization........................................... 60Anticipating Suture Needs............................... 61

Sterile Transfer of Suture Packets.................... 61Suture Preparation in the Sterile Field............. 62Suture Handling Technique.......................... 63

5 TOPICAL SKIN ADHESIVES

DERMABOND* Topical Skin Adhesive....... 68

6OTHER SURGICALPRODUCTS

Adhesive Tapes................................................... 74Indications and Usage................................. 74Application.............................................. 74After Care and Removal.............................. 74Skin Closure Tapes ..................................... 75Polyester Fiber Strip................................... 75Umbilical Tape ........................................ 75

Surgical Staples ................................................. 75Indications and Usage................................. 76Aftercare and Removal ................................ 76PROXIMATE* Skin Staplers........................ 76

Looped Suture................................................... 77Retention Suture Devices................................ 77

7PRODUCT TERMSAND TRADEMARKS

8 PRODUCT INFORMATION

9 INDEX

WOUND HEALINGAND MANAGEMENT

CHAPTER 1

WOUND HEALING & MANAGEMENT2

THE WOUNDInjury to any of the tissues of the body, especially that caused by physical means and with interruption of continuity is definedas a wound.1 Though most often the result of a physical cause, a burn is also considered a wound.Both follow the same processestowards the restoration to health – otherwise known as healing.1

Wound healing is a natural andspontaneous phenomenon. Whentissue has been disrupted so severely that it cannot heal naturally (without complications or possibledisfiguration) dead tissue and foreign bodies must be removed,infection treated, and the tissuemust be held in apposition until thehealing process provides the woundwith sufficient strength to withstandstress without mechanical support.A wound may be approximatedwith sutures, staples, clips, skin closure strips, or topical adhesives.

Tissue is defined as a collection ofsimilar cells and the intercellularsubstances surrounding them.There are four basic tissues in thebody: 1) epithelium; 2) connectivetissues, including blood, bone andcartilage; 3) muscle tissue; and 4) nerve tissue. The choice ofwound closure materials and thetechniques of using them are primefactors in the restoration of continuity and tensile strength tothe injured tissues during the healing process.

The parameters for measuring thestrength of normal body tissue are: • Tensile Strength—The load per

cross-sectional area unit at the

point of rupture, relating to the nature of the material rather than its thickness.

• Breaking Strength—The load required to break a wound regard-less of its dimension, the more clinically significant measurement.

• Burst Strength—The amount of pressure needed to rupture a viscus, or large interior organ.

The rate at which wounds regainstrength during the wound healingprocess must be understood as abasis for selecting the most appropriate wound closure material.

RECOVERY OF TENSILE STRENGTHTensile strength affects the tissue'sability to withstand injury but isnot related to the length of time ittakes the tissue to heal. As collagenaccumulates during the reparativephase, strength increases rapidly butit is many months before a plateauis reached.2 Until this time, thewound requires extrinsic supportfrom the method used to bring ittogether – usually sutures. Whileskin and fascia (the layer of firmconnective tissue covering muscle)are the strongest tissues in the body,they regain tensile strength slowlyduring the healing process. Thestomach and small intestine, on theother hand, are composed of muchweaker tissue but heal rapidly.Variations in tissue strength mayalso be found within the sameorgan. Within the colon, for example, the sigmoid region isapproximately twice as strong as thececum—but both sections heal atthe same rate. Factors that affect tissue strength include the size, age,and weight of the patient, the

thickness of tissue, the presence ofedema, and duration (the degree towhich the tissue has hardened inresponse to pressure or injury).

PATIENT FACTORS THATAFFECT WOUND HEALINGThe goal of wound management is to provide interventions that efficiently progress wounds throughthe biologic sequence of repair orregeneration. The patient's overallhealth status will affect the speed ofthe healing process. The followingare factors that should be consideredby the surgical team prior to andduring the procedure. 2,3,4

AGE — With aging, both skin and muscle tissue lose their tone and elasticity. Metabolism also slows, and circulation may be impaired. But aging alone is not a major factor in chronic wound healing. Aging and chronic disease states often go together, and both delay repair processes due to delayed cellular response to the stimulus of injury, delayed collagen deposition, and decreased tensile strength in the remodeled tissue. All of these factors lengthen healing time.

WEIGHT — Obese patients of any age have, excess fat at the wound site that may prevent securing a good closure. In addition, fat does not have a rich blood supply, making it the most vulnerable of all tissues to trauma and infection.

NUTRITIONAL STATUS — Overall malnutrition associated with chronic disease or cancer, or specific deficiencies in

carbohydrates, proteins, zinc, and vitamins A, B, and C can impair the healing process. Adequate nutrition is essential to support cellular activity and collagen synthesis at the wound site.

DEHYDRATION — If the patient's system has been depleted of fluids, the resulting electrolyte imbalance can affect cardiac function, kidney function, cellular metabolism, oxygenation of the blood, and hormonal function. These effects will not only impact upon the patient's overall health status and recovery from surgery but may also impair the healing process.

INADEQUATE BLOOD SUPPLY TO THE WOUND SITE — Oxygen is necessary for cell survival and, therefore,

healing. Skin healing takes place most rapidly in the face and neck, which receive the greatest blood supply, and most slowly in the extremities. The presence of any condition that compromises the supply of blood to the wound, such as poor circulation to the limbs in a diabetic patient or arteriosclerosis with vascular compromise, will slow and can even arrest the healing process.

IMMUNE RESPONSES — Because the immune response protects the patient from infection, immunodeficiencies may seriously compromise the outcome of a surgical procedure. Patients infected with HIV, as well as those who have recently undergone chemotherapy or who have taken prolonged high dosages of catabolic steroids, may

have debilitated immune systems. Some patients have allergies to specific suturing materials, metal alloys, or latex. These, on the other hand, will cause a height-ened immune response in the form of an allergic reaction. This may also interfere with the healing process. Therefore, the surgeon should always check beforehand on a patient's allergies.

CHRONIC DISEASE — A patient whose system has already been stressed by chronic illness, especially endocrine disorders, diabetes, malignancies, localized infection, or debilitating injuries will heal more slowly and will be more vulnerable to post surgical wound complications. All of these conditions merit concern, and the surgeon must consider their effects upon the tissues at the wound site, as well as their potential impact upon the patient's overall recovery from the procedure. Malignancies, in addition, may alter the cellular structure of tissue and influence the surgeon's choice of methods and closure materials.

RADIATION THERAPY — Radiation therapy to the surgical site prior to or shortly after surgery can produce considerable impairment of healing and lead to substantial wound complica-tions. Surgical procedures for malignancies must be planned to minimize the potential for these problems.

CHAPTER 1 3

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RELATIVETISSUESTRENGTH

Stomach(Weak)

Smallintestine(Weak)

Femalereproductiveorgans(Weak)

Bladder(Weak)

Lowerrespiratorytract (Weak)

Duodenum(Strong)

Cecum(Weak)

Ileum(Weak)

FIGURE1

SURGICAL PRINCIPLESMany factors that affect the healingprocess can be controlled by the surgical team in the operating room,by the obstetrical team in labor anddelivery, or by the emergency teamin the trauma center. Their first priority is to maintain a sterile and aseptic technique to preventinfection. Organisms found within a patient's own body mostcommonly cause postoperative infection, but microorganisms carried by medical personnel alsopose a threat. Whatever the source, the presence of infection will deterhealing. In addition to concernsabout sterility, the following mustbe taken into consideration whenplanning and carrying out an operative procedure.3

THE LENGTH AND DIRECTION OF THE INCISION — A properly planned incision is sufficiently long to afford sufficient optimum exposure. When deciding upon the direction of the incision, the surgeon must bear the following in mind:

• The direction in which wounds naturally heal is from side-to- side, not end-to-end.

• The arrangement of tissue fibers in the area to be dissected will vary with tissue type.

• The best cosmetic results may be achieved when incisions are made parallel to the direction of the tissue fibers. Results may vary depending upon the tissue layer involved.

DISSECTION TECHNIQUE — When incisingtissue, a clean incision should be made through the skin withone stroke of evenly applied pressure on the scalpel. Sharp dissection should be used to cutthrough remaining tissues. Thesurgeon must preserve theintegrity of as many of theunderlying nerves, blood vessels,and muscles as possible.

TISSUE HANDLING —Keeping tissue trauma to a minimum promotes faster healing. Throughout the operative procedure, the surgeonmust handle all tissues very gently and as little as possible.Retractors should be placed withcare to avoid excessive pressure,since tension can cause seriouscomplications: impaired bloodand lymph flow, altering of thelocal physiological state of thewound, and predisposition tomicrobial colonization.

HEMOSTASIS — Variousmechanical, thermal, and chemical methods are available todecrease the flow of blood andfluid into the wound site.Hemostasis allows the surgeon towork in as clear a field as possiblewith greater accuracy. Without adequate control, bleeding fromtransected or penetrated vesselsor diffused oozing on largedenuded surfaces may interferewith the surgeon's view of underlying structures.

Achieving complete hemostasisbefore wound closure also willprevent formation of postopera-tive hematomas. Collections of

blood (hematomas) or fluid (seromas) in the incision can prevent the direct apposition of tissue needed for complete unionof wound edges. Furthermore,these collections provide an idealculture medium for microbialgrowth and can lead to seriousinfection.

When clamping or ligating a vessel or tissue, care must betaken to avoid excessive tissuedamage. Mass ligation thatinvolves large areas of tissue mayproduce necrosis, or tissue death,and prolong healing time.

MAINTAINING MOISTUREIN TISSUES — During longprocedures, the surgeon mayperiodically irrigate the woundwith warm physiologic (normal)saline solution, or cover exposedsurfaces with saline-moistenedsponges or laparotomy tapes toprevent tissues from drying out.

REMOVAL OF NECROTICTISSUE AND FOREIGNMATERIALS — Adequatedebridement of all devitalized tissue and removal of inflictedforeign materials are essential to healing, especially in traumaticwounds. The presence of fragments of dirt, metal, glass,etc., increases the probability of infection.

CHOICE OF CLOSUREMATERIALS — The surgeonmust evaluate each case individu-ally, and choose closure materialwhich will maximize the opportunity for healing and minimize the likelihood of infection. The proper closure

WOUND HEALING4

material will allow the surgeon to approximate tissue with as little trauma as possible, and withenough precision to eliminatedead space. The surgeon's personal preference will play alarge role in the choice of closurematerial; but the location of thewound, the arrangement of tissuefibers, and patient factors influ-ence his or her decision as well.

CELLULAR RESPONSE TOCLOSURE MATERIALS —Whenever foreign materials suchas sutures are implanted in tissue,the tissue reacts. This reactionwill range from minimal to moderate, depending upon thetype of material implanted. Thereaction will be more marked ifcomplicated by infection, allergy,or trauma.

nitially, the tissue will deflect thepassage of the surgeon's needleand suture. Once the sutureshave been implanted, edema ofthe skin and subcutaneous tissueswill ensue. This can cause significant patient discomfortduring recovery, as well as scarring secondary to ischemicnecrosis. The surgeon must takethese factors into considerationwhen placing tension upon theclosure material.

ELIMINATION OF DEADSPACE IN THE WOUND —Dead space in a wound resultsfrom separation of portions ofthe wound beneath the skinedges which have not been closely approximated, or from airor fluid trapped between layers oftissue. This is especially true inthe fatty layer which tends to lack

blood supply. Serum or bloodmay collect, providing an idealmedium for the growth of microorganisms that causeinfection. The surgeon may elect to insert a drain or apply a pressure dressing to help eliminate dead space in thewound postoperatively.

CLOSING TENSION —While enough tension must beapplied to approximate tissue andeliminate dead space, the suturesmust be loose enough to preventexaggerated patient discomfort,ischemia, and tissue necrosis during healing.

POSTOPERATIVE DISTRACTION FORCES —The patient's postoperative activity can place undue stressupon a healing incision.Abdominal fascia will be placedunder excessive tension after surgery if the patient strains tocough, vomit, void, or defecate.

Tendons and the extremities mayalso be subjected to excessive tension during healing. The surgeon must be certain that the approximated wound is adequately immobilized to prevent suture disruption for a sufficient period of timeafter surgery.

IMMOBILIZATION —Adequate immobilization of theapproximated wound, but notnecessarily of the entire anatomicpart, is mandatory after surgeryfor efficient healing and minimalscar formation.

CLASSIFICATIONOF WOUNDSThe Centers for Disease Controland Prevention (CDC), using anadaptation of the American Collegeof Surgeons’ wound classificationschema, divides surgical woundsinto four classes: clean wounds,clean-contaminated wounds,

CHAPTER 1 5

DEAD SPACEIN A WOUND

FIGURE2

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contaminated wounds and dirty orinfected wounds.5 A discussion ofeach follows.

Seventy-five percent of all wounds(which are usually elective surgicalincisions) fall into the clean woundscategory—an uninfected operativewound in which no inflammation is encountered and the respiratory,alimentary, genital, or uninfectedurinary tracts are not entered.These elective incisions are madeunder aseptic conditions and are not predisposed to infection.Inflammation is a natural part ofthe healing process and should bedifferentiated from infection inwhich bacteria are present and produce damage.

Clean wounds are closed by primaryunion and usually are not drained.Primary union is the most desirablemethod of closure, involving thesimplest surgical procedures and the lowest risk of postoperativecomplications. Apposition of tissueis maintained until wound tensilestrength is sufficient so that suturesor other forms of tissue appositionare no longer needed.

Clean-contaminated wounds areoperative wounds in which the respiratory, alimentary, genital, orurinary tracts are entered undercontrolled conditions and withoutunusual contamination. Specifically,operations involving the biliarytract, appendix, vagina, andoropharynx are included in this category provided no evidence of infection or major break in technique is encountered.Appendectomies, cholecystectomies,and hysterectomies fall into this category, as well as normally clean wounds which become

contaminated by entry into a viscus resulting in minimal spillageof contents.

Contaminated wounds include open, traumatic wounds or injuriessuch as soft tissue lacerations, openfractures, and penetrating wounds;operative procedures in which grossspillage from the gastrointestinaltract occurs; genitourinary or biliary tract procedures in the presence of infected urine or bile; and operations in which a major breakin aseptic technique has occurred (as in emergency open cardiac massage). Microorganisms multiply so rapidly that within 6 hours a contaminated wound can become infected.

Dirty and infected wounds have been heavily contaminated or clinically infected prior to the operation. They include perforatedviscera, abscesses, or neglectedtraumatic wounds in which devitalized tissue or foreign materialhave been retained. Infection present at the time of surgery canincrease the infection rate of anywound by an average of four times.

TYPES OF WOUND HEALINGThe rate and pattern of healing fallsinto three categories, dependingupon the type of tissue involved and the circumstances surroundingclosure. Timeframes are generalizedfor well-perfused healthy soft tissues, but may vary.

HEALING BY PRIMARY INTENTIONEvery surgeon who closes a woundwould like it to heal by primaryunion or first intention, with minimal edema and no local infection or serious discharge. Anincision that heals by primary intention does so in a minimum oftime, with no separation of thewound edges, and with minimalscar formation. This takes place inthree distinct phases:2,3

Inflammatory (preparative) –During the first few days, aninflammatory response causes anoutpouring of tissue fluids, an accumulation of cells and fibroblasts, and an increased bloodsupply to the wound. Leukocytesand other cells produce proteolyticenzymes which dissolve and removedamaged tissue debris. These are the responses which prepare the siteof injury for repair. The processlasts 3 to 7 days. Any factor whichinterferes with the progress, mayinterrupt or delay healing. Duringthe acute inflammatory phase, thetissue does not gain appreciable tensile strength, but depends solelyupon the closure material to hold itin approximation.

Proliferative – After the debridement process is well along,fibroblasts begin to form a collagenmatrix in the wound known asgranulation tissue. Collagen, a protein substance, is the chief constituent of connective tissue.Collagen fiber formation determinesthe tensile strength and pliability ofthe healing wound. As it fills with new blood vessels, the granulationbecomes bright, beefy, red tissue.The thick capillary bed which fills

WOUND HEALING6

the matrix, supplies the nutrientsand oxygen necessary for the woundto heal. This phase occurs from day 3 onward.

In time, sufficient collagen is laiddown across the wound so that itcan withstand normal stress. Thelength of this phase varies with thetype of tissue involved and thestresses or tension placed upon thewound during this period.

Wound contraction also occurs dur-ing this phase. Wound contractionis a process that pulls the woundedges together for the purpose ofclosing the wound. In essence, itreduces the open area, and if successful, will result in a smallerwound with less need for repair byscar formation. Wound contractioncan be very beneficial in the closureof wounds in areas such as the but-tocks or trochanter but can be veryharmful in areas such as the hand or around the neck and face, whereit can cause disfigurement and excessive scarring.3

Surgical wounds that are closed by primary intention have minimalcontraction response. Skin graftingis used to reduce avoided contrac-tion in undesirable locations.

Remodelling – As collagen deposi-tion is completed, the vascularity ofthe wound gradually decreases andany surface scar becomes paler. Theamount of collagen that is finallyformed – the ultimate scar – isdependent upon the initial volumeof granulation tissue.2

HEALING BY SECOND INTENTIONWhen the wound fails to heal byprimary union, a more complicatedand prolonged healing process takesplace. Healing by second intentionis caused by infection, excessivetrauma, tissue loss, or impreciseapproximation of tissue.3

In this case, the wound may be leftopen and allowed to heal from theinner layer to the outer surface.Granulation tissue forms and contains myofibroblasts. These specialized cells help to close thewound by contraction. This process is much slower than primaryintention healing. Excessive granulation tissue may build up and require treatment if it protrudesabove the surface of the wound,preventing epithelialization.

DELAYED PRIMARY CLOSUREThis is considered by many surgeons to be a safe method ofmanagement of contaminated, aswell as dirty and infected traumaticwounds with extensive tissue lossand a high risk of infection. Thismethod has been used extensively inthe military arena and has provensuccessful following excessive trauma related to motor vehicleaccidents, shooting incidents, orinfliction of deep, penetrating knife wounds.3

The surgeon usually treats theseinjuries by debridement of nonviable tissues and leaves thewound open, inserting gauze packing which is changed twice aday. Patients sedation or a return tothe operating room with generalanesthesia generally is only requiredin the case of large, complexwounds. Wound approximationusing adhesive strips, previouslyplaced but untied sutures, staplesafter achieving local anesthesia canoccur within 3-5 days if the wounddemonstrates no evidence of infection and the appearance of redgranulation tissue. Should this not

CHAPTER 1 7

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PHASES OFWOUNDHEALING

FIGURE3

Damaged tissuedebris Tissue fluids

FibroblastsProteolyticenzymes

Increased blood supply Collagen fibers

PHASE 1–Inflammatory response and debridement process

PHASE 2–Collagen formation(scar tissue)

PHASE 3–Sufficient collagen laid down

occur, the wound is allowed to heal by secondary intention. Whenclosure is undertaken, skin edgesand underlying tissue must be accu-rately and securely approximated.

IN THENEXT SECTION

The materials, devices, and techniques used to repair woundedtissue will be discussed at length. As you will see, the number ofoptions available is extensive. Butno matter how many choices thesurgeon has, his or her objectiveremains singular: to restore thepatient to health with as little operative trauma as possible and an excellent cosmetic result.

REFERENCES1. Stedman’s Medical Dictionary,

27th edition, 20002. Henry, Michael and Thompson,

Jeremy: Clinical Surgery, W.B. Saunders, 2001

3. Skerris, David A.: Mayo Clinic Basic Surgery Skills, Mayo Clinic Scientific Press, 1999

4. Sussman, Carrie: Wound Care, Aspen Publishers, 1998

5. NNIS Manual, CDC, MHA, 2000

WOUND HEALING8

THE SUTURE

CHAPTER 2

WHAT IS A SUTURE?

The word "suture" describes anystrand of material used to ligate (tie)blood vessels or approximate (bringclose together) tissues. Sutures areused to close wounds. Sutures andligatures were used by both theEgyptians and Syrians as far back as2,000 B.C. Through the centuries, awide variety of materials—silk,linen, cotton, horsehair, animal tendons and intestines, and wiremade of precious metals—have beenused in operative procedures. Someof these are still in use today.

The evolution of suturing materialhas brought us to a point of refine-ment that includes sutures designedfor specific surgical procedures.

Despite the sophistication of today's suture materials and surgicaltechniques, closing a wound stillinvolves the same basic procedureused by physicians to the Romanemperors. The surgeon still uses asurgical needle to penetrate tissueand advance a suture strand to itsdesired location.

Successful use of suture materialsdepends upon the cooperation ofthe suture manufacturer and thesurgical team.

The manufacturer must have a thorough knowledge of surgical procedures, anticipate the surgicalteam's needs, and produce suturematerials that meet these stringent criteria:• They must have the greatest

tensile strength consistent with size limitations.

• They must be easy to handle.

• They must be secured in packaging which presents them sterile for use, in excellent condition, and ensures the safety of each member of the surgical team.

The nurse must maintain the sterility of sutures when storing,handling, and preparing them foruse. The integrity and strength ofeach strand must remain intact until it is in the surgeon's hands.

The surgeon must select suturematerials appropriate for the procedure and must place them in the tissues in a manner consistentwith the principles that promotewound healing.

With the manufacturer and surgical team working in concert,the patient reaps the final benefit...the wound is closed in amanner that promotes optimum healing in minimum time.

PERSONAL SUTUREPREFERENCEMost surgeons have a basic "suture routine," a preference forusing the same material(s) unlesscircumstances dictate otherwise.The surgeon acquires skill, proficiency, and speed in handlingby using one suture material repeatedly—and may choose the same material throughout his or her entire career.

A number of factors may influencethe surgeon’s choice of materials:

• His or her area of specialization.• Wound closure experience during

clinical training.• Professional experience in the

operating room.• Knowledge of the healing

characteristics of tissues and organs.

• Knowledge of the physical and biological characteristics of various suture materials.

• Patient factors (age, weight, overall health status, and the presence of infection).

Surgical specialty plays a primary rolein determining suture preference. Forexample, obstetrician/gynecologistsfrequently prefer coated VICRYL*RAPIDE (polyglactin 910) suture for episiotomy repair and coatedVICRYL* (polyglactin 910) suture,coated VICRYL* Plus Antibacterial(polyglactin 910) suture andMONOCRYL* (poliglecaprone 25)suture for all tissue layers except, possibly skin. Most orthopaedic surgeons use coated VICRYL suture,coated VICRYL Plus, PDS* II (polydioxanone) suture, and ETHIBOND* EXCEL polyestersuture. Many plastic surgeons preferETHILON* nylon suture, VICRYLsuture, or MONOCRYL suture.Many neurosurgeons prefer coatedVICRYL suture or NUROLON*nylon suture. But no single suturematerial is used by every surgeon whopractices within a specialty.

The surgeon's knowledge of thephysical characteristics of suturematerial is important. As therequirements for wound support varywith patient factors, the nature of the

THE SUTURE10

procedure, and the type of tissueinvolved, the surgeon will selectsuture material that will retain itsstrength until the wound heals sufficiently to withstand stress on its own.

SUTURECHARACTERISTICSThe choice of suture materials gen-erally depends on whether thewound closure occurs in one ormore layers. In selecting the mostappropriate sutures, the surgeontakes into account the amount oftension on the wound, the numberof layers of closure, depth of sutureplacement, anticipated amount ofedema, and anticipated timing ofsuture removal.

Optimal suture qualities include:

1. High uniform tensile strength, permitting use of finer sizes.

2. High tensile strength retention in vivo, holding the wound securely throughout the critical healing period, followed by rapid absorption.

3. Consistent uniform diameter.4. Sterile.5. Pliable for ease of handling and

knot security.6. Freedom from irritating

substances or impurities for optimum tissue acceptance.

7. Predictable performance.

SIZE AND TENSILESTRENGTHSize denotes the diameter of thesuture material. The accepted surgical practice is to use the smallest diameter suture that will adequately hold the mendingwounded tissue. This practice minimizes trauma as the suture ispassed through the tissue to effectclosure. It also ensures that the minimum mass of foreign materialis left in the body. Suture size isstated numerically; as the number of0s in the suture size increases, thediameter of the strand decreases. Forexample, size 5-0, or 00000, issmaller in diameter than size 4-0, or0000. The smaller the size, the lesstensile strength the suture will have.

Knot tensile strength is measured bythe force, in pounds, which thesuture strand can withstand beforeit breaks when knotted. The tensilestrength of the tissue to be mended(its ability to withstand stress) determines the size and tensilestrength of the suturing material thesurgeon selects. The accepted rule isthat the tensile strength of thesuture need never exceed the tensilestrength of the tissue. However,sutures should be at least as strongas normal tissue through which theyare being placed.

MONOFILAMENT VS.MULTIFILAMENT STRANDSSutures are classified according tothe number of strands of which they are comprised. Monofilamentsutures are made of a single strand of material. Because of their simplified structure, they encounterless resistance as they pass through tissue than multifilamentsuture material. They also resist harboring organisms which maycause infection.

These characteristics make monofilament sutures well-suited to vascular surgery. Monofilamentsutures tie down easily. However,because of their construction,extreme care must be taken whenhandling and tying these sutures.Crushing or crimping of this suturetype can nick or create a weak spotin the strand. This may result insuture breakage.

Multifilament sutures consist of several filaments, or strands, twistedor braided together. This affordsgreater tensile strength, pliability, andflexibility. Multifilament sutures mayalso be coated to help them pass rela-tively smoothly through tissue andenhance handling characteristics.Coated multifilament sutures arewell-suited to intestinal procedures.

CHAPTER 2 11

METRIC MEASURES AND U.S.P.SUTURE DIAMETER EQUIVALENTS TABLE

1

U.S.P. Size

NaturalCollagen

SyntheticAbsorbables

NonabsorbableMaterials

11-0

–––

–––

0.1

10-0

0.2

0.2

0.2

9-0

0.3

0.3

0.3

8-0

0.5

0.4

0.4

7-0

0.7

0.5

0.5

6-0

1.0

0.7

0.7

5-0

1.5

1.0

1.0

4-0

2.0

1.5

1.5

3-0

3.0

2.0

2.0

2-0

3.5

3.0

3.0

0

4.0

3.5

3.5

1

5.0

4.0

4.0

2

6.0

5.0

5.0

3

7.0

6.0

6.0

4

8.0

6.0

6.0

5

–––

7.0

7.0

6

–––

–––

8.0

* Trademark

ABSORBABLE VS.NONABSORBABLE SUTURESSutures are classified according totheir degradation properties.Sutures that undergo rapid degrada-tion in tissues, losing their tensilestrength within 60 days, are considered absorbable sutures.Sutures that generally maintain their tensile strength for longer than60 days are nonabsorbable sutures.

Absorbable sutures may be used tohold wound edges in approximationtemporarily, until they have healedsufficiently to withstand normalstress. These sutures are preparedeither from the collagen of healthymammals or from synthetic polymers. Some are absorbed rapidly, while others are treated orchemically structured to lengthenabsorption time. They may also beimpregnated or coated with agentsthat improve their handling properties, and colored with anFDA-approved dye to increase visibility in tissue. Naturalabsorbable sutures are digested bybody enzymes which attack andbreak down the suture strand.Synthetic absorbable sutures arehydrolyzed—a process by whichwater gradually penetrates thesuture filaments, causing the breakdown of the suture's polymerchain. Compared to the enzymaticaction of natural absorbables,hydrolyzation results in a lesserdegree of tissue reaction followingimplantation.

During the first stage of the absorption process, tensile strengthdiminishes in a gradual, almost linear fashion. This occurs over thefirst several weeks postimplantation.The second stage often follows with

considerable overlap, characterizedby loss of suture mass. Both stagesexhibit leukocytic cellular responseswhich serve to remove cellulardebris and suture material from theline of tissue approximation.

The loss of tensile strength and the rate of absorption are separatephenomena. A suture can lose tensile strength rapidly and yet beabsorbed slowly—or it can maintain adequate tensile strengththrough wound healing, followed by rapid absorption. In any case, the strand is eventually completelydissolved, leaving no detectabletraces in tissue.

Although they offer many advantages, absorbable sutures alsohave certain inherent limitations. If a patient has a fever, infection, or protein deficiency, the sutureabsorption process may accelerate,

causing too rapid a decline in tensilestrength. In addition, if the suturesbecome wet or moist during handling, prior to being implantedin tissue, the absorption processmay begin prematurely. Similarly,patients with impaired healing are often not ideal candidates for this type of suture. All of these situations predispose to postoperative complications, as the suture strand will not maintain adequate strength to withstandstress until the tissues have healed sufficiently.

Nonabsorbable sutures are thosewhich are not digested by bodyenzymes or hydrolyzed in body tissue. They are made from a varietyof nonbiodegradable materials andare ultimately encapsulated orwalled off by the body’s fibroblasts.Nonabsorbable sutures ordinarilyremain where they are buried

THE SUTURE12

ABSORBABLESUTURES:BASIC RAWMATERIALS

Surgical GutPlain ChromicFast Absorbing

Polyglactin 910Uncoated (VICRYL Suture)

Coated (coated VICRYL (polyglactin 910) suture, coated VICRYL Plus suture, coated VICRYL* RAPIDE(polyglactin 910) suture)

Polyglycolic Acid

Poliglecaprone 25 (MONOCRYL suture)

Polyglyconate

Polydioxanone (PDS* II suture)

TABLE2

Submucosa of sheep intestine or serosa of beef intestine

Copolymer of glycolide and lactide with polyglactin 370 and calcium stearate, if coated

Homopolymer of glycolide

Copolymer of glycolide and epsilon-caprolactone

Copolymer of glycolide andtrimethylene carbonate

Polyester of poly (p-dioxanone)

SUTURE RAW MATERIAL

within the tissues. When used forskin closure, they must be removedpostoperatively. Nonabsorbablesutures may be used in a variety of applications:

• Exterior skin closure, to be removed after sufficient healing has occurred.

• Within the body cavity, where they will remain permanently encapsulated in tissue.

• Patient history of reaction to absorbable sutures, keloidal tendency, or possible tissue hypertrophy.

• Prosthesis attachment (i.e., defibrillators, pacemakers, drug delivery mechanisms).

Nonabsorbable sutures are com-posed of single or multiple filamentsof metal, synthetic, or organic fibersrendered into a strand by spinning,twisting, or braiding. Each strand issubstantially uniform in diameterthroughout its length, conformingto the United States Pharmacopeia(U.S.P.) limitations for each size.Nonabsorbable sutures have beenclassified by the U.S.P. according totheir composition. In addition,these sutures may be uncoated or coated, uncolored, naturally colored, or dyed with an FDA-approved dye to enhance visibility.

SPECIFIC SUTURING MATERIALSThe materials and productsdescribed here embody the mostcurrent advances in the manufactureof surgical sutures. They aregrouped as either absorbable or nonabsorbable for easy reference.

Absorbable SuturesSurgical GutAbsorbable surgical gut is classifiedas either plain or chromic. Bothtypes consist of processed strands ofhighly purified collagen. The percentage of collagen in the suturedetermines its tensile strength andits ability to be absorbed by thebody without adverse reaction.Noncollagenous material can causea reaction ranging from irritation torejection of the suture. The morepure collagen throughout the length of the strand, the less foreignmaterial there is introduced into the wound.

ETHICON* surgical gut sutures aremanufactured from between 97%and 98% pure ribbons of collagen.To meet U.S.P. specifications,processed ribbons of the submucosalayer of sheep intestine or the serosa layer of beef intestine areelectronically spun and polishedinto virtually monofilament strandsof various sizes, with minimum and

maximum limits on diameter foreach size. The ETHICON exclusiveTRU-GAUGING process producesa uniform diameter to within anaccuracy of 0.0002 inch(0.0175mm) along the entire length of every strand, eliminatinghigh and low spots. High and lowspots can cause the suture to fray or chatter when knots are tieddown, resulting in a knot that is not positioned properly or tiedsecurely. Most protein-basedabsorbable sutures have a tendencyto fray when tied.

TRU-GAUGING ensures thatETHICON surgical gut suturespossess uniform high tensilestrength, virtually eliminating thepossibility of fray or breaking. Theirunexceeded strength and surfacesmoothness allow the surgeon to"snug down" the suture knot toachieve optimum tension.

The rate of absorption of surgicalgut is determined by the type of

CHAPTER 2 13

* Trademark

NON-ABSORBABLESUTURES: RAWMATERIALS

Surgical Silk

Stainless Steel Wire

Nylon (ETHILON* nylon suture, NUROLON* nylonsuture)

Polyester FiberUncoated (MERSILENE* polyester fiber suture)

Coated (ETHIBOND* EXCELpolyester suture

Polypropylene (PROLENE*polypropylene suture)

Poly(hexafluoropropylene-VDF)(PRONOVA* poly(hexafluoro-propylene-VDF) suture)

Raw silk spun by silkworm

Specially formulated iron-chromium-nickel-molybdenum alloy

Polyamide polymer

Polymer of polyethylene terephthalate (may be coated)

Polymer of propylene

Polymer blend of poly(vinylidenefluoride) and poly(vinylidene fluo-ride-cohexafluoropropylene)

SUTURE RAW MATERIAL

TABLE3

gut being used, the type and condition of the tissue involved, and the general health status of thepatient. Surgical gut may be used inthe presence of infection, althoughit may be absorbed more rapidlyunder this condition.

Plain surgical gut is rapidlyabsorbed. Tensile strength is maintained for only 7 to 10 dayspostimplantation, and absorption is complete within 70 days. Thesurgeon may choose plain gut foruse in tissues which heal rapidly and require minimal support (forexample, ligating superficial bloodvessels and suturing subcutaneousfatty tissue). Plain surgical gut canalso be specially heat-treated toaccelerate tensile strength loss andabsorption. This fast absorbing surgical gut is used primarily forepidermal suturing where suturesare required for only 5 to 7 days. These sutures have less tensilestrength than plain surgical gut of the comparable U.S.P. size. Fastabsorbing plain gut is not to beused internally.

Chromic gut is treated with achromium salt solution to resistbody enzymes, prolonging absorption time over 90 days. The exclusive CHROMICIZINGprocess used by ETHICON thoroughly bathes the pure collagenribbons in a buffered chrome tanning solution before spinninginto strands. After spinning, theentire cross section of the strand is evenly chromicized. The processalters the coloration of the surgicalgut from yellowish-tan to brown.Chromic gut sutures minimize tissue irritation, causing less reaction than plain surgical gut

during the early stages of woundhealing. Tensile strength may beretained for 10 to 14 days, withsome measurable strength remainingfor up to 21 days.

SYNTHETIC ABSORBABLE SUTURESSynthetic absorbable sutures offer thestrength needed for a wide range ofapplications, from abdominal andchest wound closure to ophthalmicand plastic surgery.

COATED VICRYL* RAPIDE(POLYGLACTIN 910) SUTUREThis braided suture is composed ofthe same copolymer as coatedVICRYL suture—lactide andglycolide—and is coated with acombination of equal parts ofcopolymer of lactide and glycolide(polyglactin 370) and calciumstearate. However, the absorptionrate and tensile strength profile aresignificantly different from coatedVICRYL suture, achieved by the useof a polymer material with a lowermolecular weight than coatedVICRYL suture. Coated VICRYLRAPIDE sutures are only availableundyed.

Coated VICRYL RAPIDE suture is the fastest-absorbing syntheticsuture and exhibits characteristicsthat model the performance of surgical gut suture. However, being a synthetic material. CoatedVICRYL RAPIDE suture elicits a lower tissue reaction than chromicgut suture. Coated VICRYL RAPIDE suture is indicated only for use in superficial soft tissueapproximation of the skin andmucosa, where only short-termwound support (7 to 10 days) is required. It is not to be used in

ligation, in ophthalmic, cardiovascu-lar, or neurological procedures,where extended approximation oftissues under stress is required, orwhere wound support beyond 7days is required.

Coated VICRYL RAPIDE suturesretain approximately 50% of theoriginal tensile strength at 5 dayspostimplantation. All of the originaltensile strength is lost by approxi-mately 10 to 14 days. Absorption isessentially complete by 42 days.

Coated VICRYL RAPIDE suture is particularly well-suited for skinclosure, episiotomy repair, and closure of lacerations under casts. In addition, since the suture beginsto "fall off" in 7 to 10 days as thewound heals, the need for sutureremoval is eliminated.

MONOCRYL* (POLIGLECAPRONE 25) SUTUREThis monofilament suture features superior pliability for easyhandling and tying. Comprised of a copolymer of glycolide andepsilon-caprolactone, it is virtuallyinert in tissue and absorbs predictably. The surgeon may prefer MONOCRYL sutures forprocedures which require high initial tensile strength diminishingover 2 weeks postoperatively. Theseinclude subcuticular closure and soft tissue approximations and ligations, with the exception of neural, cardiovascular, ophthalmic,and microsurgical applications.

MONOCRYL suture is availabledyed (violet) and undyed (natural).Dyed MONOCRYL suture retains60% to 70% of its original strengthat 7 days postimplantation, reducedto 30% to 40% at 14 days, with all

THE SUTURE14

original strength lost by 28 days.At 7 days, undyed MONOCRYLsuture retains approximately 50% to 60% of its original strength, andapproximately 20% to 30% at 14 days postimplantation. All of the original tensile strength ofundyed MONOCRYL suture is lost by 21 days postimplantation.Absorption is essentially complete at 91 to 119 days.

COATED VICRYL*(POLYGLACTIN 910) SUTUREThis material fills the need for asmoother synthetic absorbablesuture that will pass through tissuereadily with minimal drag. CoatedVICRYL sutures facilitate ease ofhandling, smooth tie down andunsurpassed knot security.

The coating is a combination ofequal parts of copolymer of lactideand glycolide (polyglactin 370), plus calcium stearate which is used extensively in pharmaceuticalsand food. Calcium stearate is a saltof calcium and stearic acid, both of which are present in the bodyand constantly metabolized andexcreted. The result of this mixtureis an outstandingly absorbable,adherent, nonflaking lubricant.

At 2 weeks postimplantation,approximately 75% of the tensilestrength of coated VICRYL sutureremains. Approximately 50% oftensile strength is retained at 3weeks for sizes 6-0 and larger. At 3weeks, 40% of tensile strength isretained for sizes 7-0 and smaller. At4 weeks, 25% of the originalstrength is retained for sizes 6-0 andlarger. All of the original tensilestrength is lost by five weeks postimplantation. Absorption of coated

VICRYL suture is essentiallycomplete between 56 and 70 days.

Lactide and glycolide acids are readily eliminated from the body,primarily in urine. As with uncoated sutures, coated VICRYLsutures elicit only a mild tissue reaction during absorption. Theirsafety and effectiveness in neuraland cardiovascular tissue have notbeen established. Transcutaneous orconjunctival sutures remaining inplace longer than 7 days may causelocalized irritation and should beremoved as indicated. CoatedVICRYL sutures are available asbraided dyed violet or undyed natural strands in a variety oflengths with or without needles.

COATED VICRYL PLUS ANTIBACTERIAL(POLYGLACTIN 910) SUTUREThis synthetic, absorbable, sterile, sur-gical suture is a copolymer made from90% glycolide and 10% L-lactide.Coated VICRYL Plus AntibacterialSuture is coated with a mixture com-posed of equal parts of copolymer ofglycolide and lactide (polyglactin 370)and calcium stearate. Coated VICRYLPlus Antibacterial suture containsIRGACARE MP*, one of the purest forms of the broad-spectrumantibacterial agent triclosan.

Coated VICRYL Plus Antibacterialsuture offers protection against bacterial colonization of the suture. In vivo studies demonstrate thatCoated VICRYL Plus Antibacterialsuture has a zone of inhibition that is effective against the pathogens thatmost often cause surgical site infection(SSI) – Staphylococcus aureus, methicillin-resistant Staphylococcusaureus (MRSA), Staphylococcus epidermidis, methicillin-resistant

Staphylococcus epidermidis (MRSE).3

In vivo studies demonstrate thatVICRYL Plus Antibacterial suture has no adverse effect on normalwound healing.2

Coated VICRYL Plus Antibacterialsuture performs and handles the sameas Coated VICRYL suture. CoatedVICRYL Plus Antibacterial suture hasthe same dependable construction asCoated VICRYL suture. In vivotesting by surgeons demonstrates the same excellence in performance and handling.

The suture is available undyed (natural) or dyed. Coated VICRYLPlus suture is indicated for use in general soft tissue approximationand/or ligation requiring medium support, except for ophthalmic, cardiovascular and neurological tissues.Frequent uses include general closure,bowel, orthopedic, and plastic surgery.

Coated VICRYL Plus Antibacterialsuture retains approximately 75% ofthe original tensile strength at twoweeks post implantation. At threeweeks, approximately 50% of theoriginal strength is retained. At fourweeks, approximately 25% of theoriginal strength is retained. All of the original tensile strength islost by five weeks post implantation.Absorption of Coated VICRYL PlusAntibacterial Suture is essentiallycomplete between 56 and 70 days.

PDS* II (POLYDIOXANONE)SUTUREComprised of the polyester poly(p-dioxanone), this monofilamentrepresents a significant advance in suturing options. It combines the features of soft, pliable, monofilament construction withabsorbability and extended wound

CHAPTER 2 15

* Trademark

support for up to 6 weeks. It elicitsonly a slight tissue reaction. Thismaterial is well-suited for manytypes of soft tissue approximation,including pediatric cardiovascular,orthopaedic, gynecologic, ophthalmic, plastic, digestive, and colonic surgeries.

Like other synthetic absorbablesutures, PDS II sutures are absorbed in vivo through hydrolysis.Approximately 70% of tensilestrength remains 2 weeks postimplantation, 50% at 4 weeks,and 25% at 6 weeks. Absorption isminimal until about the 90th daypostoperatively and essentially complete within 6 months. Thesafety and effectiveness of PDS IIsutures in microsurgery, neural tissue, and adult cardiovascular tissue have not been established.PDS II sutures are available clear or dyed violet to enhance visibility.

NONABSORBABLE SUTURESThe U.S.P. classifies nonabsorbablesurgical sutures as follows:

• CLASS I—Silk or synthetic fibers of monofilament, twisted, or braided construction.

• CLASS II—Cotton or linen fibers, or coated natural or synthetic fibers where the coatingcontributes to suture thickness without adding strength.

• CLASS III—Metal wire of monofilament or multifilament construction.

SURGICAL SILKFor many surgeons, surgical silkrepresents the standard handlingperformance by which newer synthetic materials are judged,

especially due to its superior handling characteristics. Silk filaments can be twisted or braided,the latter providing the best handling qualities.

Raw silk is a continuous filamentspun by the silkworm moth larva to make its cocoon. Cream ororange-colored in its raw state, eachsilk filament is processed to removenatural waxes and sericin gum,which is exuded by the silkworm asit spins its cocoon. The gum holdsthe cocoon together, but is of nobenefit to the quality of braided surgical silk sutures.

ETHICON degums the silk formost suture sizes before the braiding process. This allows for atighter, more compact braid whichsignificantly improves suture quality.After braiding, the strands are dyed,scoured and stretched, and thenimpregnated and coated with a mixture of waxes or silicone. Eachof these steps is critical to the quality of the finished suture andmust be carried out in precise order.Surgical silk is usually dyed blackfor easy visibility in tissue.

Raw silk is graded according tostrength, uniformity of filamentdiameter, and freedom from defects.Only top grades of silk filaments areused to produce PERMA-HAND*surgical silk sutures.

Surgical silk loses tensile strengthwhen exposed to moisture andshould be used dry. Although silk is classified by the U.S.P. as a nonabsorbable suture, long-term in vivo studies have shown that itloses most or all of its tensilestrength in about 1 year and usually

cannot be detected in tissue after 2 years. Thus, it behaves in reality as a very slowly absorbing suture.

SURGICAL STAINLESS STEELThe essential qualities of surgicalstainless steel sutures include theabsence of toxic elements, flexibility,and fine wire size. Both monofila-ment and twisted multifilamentvarieties are high in tensile strength,low in tissue reactivity, and hold a knot well. Provided that thesutures do not fragment, there is little loss of tensile strength in tissues. The 316L (low carbon)stainless steel alloy formula used in the manufacture of these sutures offers optimum metalstrength, flexibility, uniformity, and compatibility with stainless steel implants and prostheses.Stainless steel sutures may also beused in abdominal wall closure, sternum closure, retention, skin closure, a variety of orthopaedicprocedures, and neurosurgery.

Disadvantages associated with alloy sutures include difficulty inhandling; possible cutting, pulling,and tearing of the patient's tissue;fragmentation; barbing; and kinking, which renders the stainlesssteel suture useless. When used forbone approximation and fixation,asymmetrical twisting of the wirewill lead to potential buckling, wirefracture, or subsequent wire fatigue. Incomplete wire fixationunder these circumstances will permit movement of the wire,resulting in postoperative pain and possible dehiscence.

Surgical stainless steel suturesshould not be used when a prosthesis of another alloy is

THE SUTURE16

implanted since an unfavorable electrolytic reaction may occur.

Above all, stainless steel sutures pose a safety risk. They easily tearsurgical gloves when handled and may puncture the surgeon'sown skin—putting both physician and patient at risk of transmitted immunodeficiencyvirus or hepatitis. Many surgeonsrefer to wire size by the Brown &Sharpe (B & S) gauge of 40 (smallest diameter) to 18 (largestdiameter). ETHICON labels surgical stainless steel with both the B & S and U.S.P. diameter sizeclassifications.

ETHICON packaging of surgicalstainless steel maintains the integrityof the product by eliminating kink-ing and bending of strands. Just as important, it presents the strands ina safe manner for all members ofthe surgical team who handle them.

SYNTHETIC NONABSORBABLE SUTURESNylon sutures are a polyamide poly-mer derived by chemical synthesis.Because of their elasticity, they areparticularly well-suited for retentionand skin closure. They may be clear, or dyed green or black for better visibility.

ETHILON* NYLON SUTUREThese sutures are extruded intononcapillary single or monofilamentstrands characterized by high tensilestrength and extremely low tissuereactivity. They degrade in vivo at arate of approximately 15% to 20%per year by hydrolysis. ETHILONsutures in sizes 10-0 and 6-0 andlarger are produced from a specialgrade of nylon 6. The medical gradepolyamide nylon 6-6 is used forsizes 7-0 and finer. While bothgrades permit good handling,monofilament nylon sutures have atendency to return to their originalstraight extruded state (a property

known as "memory"). Therefore,more throws in the knot arerequired to securely hold monofila-ment than braided nylon sutures.

Monofilament nylon in a wet ordamp state is more pliable and easier to handle than dry nylon. Alimited line of ETHILON sutures(sizes 3-0 through 6-0) are pre-moistened or "pliabilized" for use in cosmetic plastic surgery. Thisprocess enhances the handling and knot tying characteristics toapproximate that of braided sutures.

ETHILON sutures are frequentlyused in ophthalmology and micro-surgery procedures in very fine sizes. For this reason, sizes 9-0and 10-0 have an intensified blackdye for high visibility.

NUROLON* NYLON SUTUREThis suture is composed of filamentsof nylon that have been tightly braided into a multifilament strand.Available in white or dyed black,NUROLON sutures look, feel, andhandle like silk. However,NUROLON sutures have morestrength and elicit less tissue reaction than silk. Braided nylonmay be used in all tissues wheremultifilament nonabsorbable suturesare acceptable. Braided nylonsutures generally lose 15% to 20%of their tensile strength per year intissue by hydrolyzation.

Polyester fiber suture is comprised of untreated fibers of polyester(polyethylene terephthalate) closelybraided into a multifilament strand.They are stronger than naturalfibers, do not weaken when wettedprior to use, and cause minimal tissue reaction. Available white or

CHAPTER 2 17

* Trademark

SURGICALSTAINLESSSTEEL: WIREGAUGE EQUIVALENTS

DIAMETER U.S.P. B & S

.0031 inch

.0040

.0056

.0063

.0080

.0100

.0126

.0159

.0179

.0201

.0226

.0253

.0320

.0360

.0400

6-0

6-0

5-0

4-0

4-0

3-0

2-0

0

1

2

3

4

5

6

7

40

38

35

34

32

30

28

26

25

24

23

22

20

19

18

TABLE4

dyed green, polyester fiber suturesare among the most acceptable forvascular synthetic prostheses.

MERSILENE* POLYESTER FIBER SUTUREThe first synthetic braided suturematerial shown to last indefinitelyin the body, MERSILENE suturesprovide precise, consistent suturetension. They minimize breakageand virtually eliminate the need toremove irritating suture fragmentspostoperatively. Because it isuncoated, MERSILENE suture has a higher coefficient of frictionwhen passed through tissue.

ETHIBOND* EXCELPOLYESTER SUTUREETHIBOND EXCEL sutures areuniformly coated with polybutilate,a biologically inert, nonabsorbablecompound which adheres itself tothe braided polyester fiber strand.Polybutilate was the first syntheticcoating developed specifically as asurgical suture lubricant. The coat-ing eases the passage of the braidedstrands through tissue and providesexcellent pliability, handling quali-ties, and smooth tie-down with eachthrow of the knot. Both the suturematerial and the coating are pharmacologically inactive. Thesutures elicit minimal tissue reactionand retain their strength in vivo forextended periods. ETHIBOND*EXCEL sutures are used primarily incardiovascular surgery, for vesselanastomosis, and placement of prosthetic materials.

ETHIBOND EXCEL sutures are also available attached to TFE polymer felt pledgets.Pledgets serve to prevent possibletearing of adjacent friable tissue.

Pledgets are used routinely in valvereplacement procedures (to preventthe annulus from tearing when theprosthetic valve is seated and thesutures are tied), and in situationswhere extreme deformity, distortion,or tissue destruction at the annulushas occurred.

Polypropylene is an isostatic crystalline stereoisomer of a linear hydrocarbon polymer permitting little or no saturation.Manufactured by a patented process which enhances pliabilityand handling, polypropylenemonofilament sutures are not subject to degradation or weakeningby tissue enzymes. They cause minimal tissue reaction and holdknots better than most other synthetic monofilament materials.

PROLENE* POLYPROPYLENESUTUREWidely used in general, cardiovascu-lar, plastic, and orthopaedic surgery,PROLENE sutures do not adhere totissue and are therefore efficaciousas a pull-out suture. PROLENEsutures are relatively biologicallyinert, offering proven strength, reliability and versatility.PROLENE sutures are recommended for use where minimal suture reaction is desired,such as in contaminated and infected wounds to minimize later sinus formation and sutureextrusion. They are available clear or dyed blue.

PRONOVA* POLY (HEXAFLUOROPROPYLENE-VDF)SUTUREThis monofilament nonabsorbablesuture is a polymer blend of poly(vinylidene fluoride) and poly

(vinylidene fluoride-cohexafluoro-propylene). This suture resistsinvolvement in infection and hasbeen successfully employed in contaminated and infected woundsto eliminate or minimize later sinusformation and suture extrusion.Furthermore, the lack of adherenceto tissues has facilitated the use of PRONOVA suture as a pull-out suture.

This material is well-suited formany types of soft tissue approxi-mation and ligation, including usein cardiovascular, ophthalmic andneurological procedures.

Table 5 gives an overview of themany suturing options that havebeen discussed in this section.(See attached chart )

COMMON SUTURING TECHNIQUES

LIGATURESA suture tied around a vessel toocclude the lumen is called a ligatureor tie. It may be used to effect hemostasis or to close off a structureto prevent leakage. There are twoprimary types of ligatures.

Free tie or freehand ligatures are single strands of suture materialused to ligate a vessel, duct, or otherstructure. After a hemostat or othersimilar type of surgical clamp hasbeen placed on the end of the structure, the suture strand is tiedaround the vessel under the tip ofthe hemostat. The hemostat isremoved after the first throw andthe surgeon tightens the knot usinghis or her fingertips, taking care toavoid instrument damage to the

THE SUTURE18

* Trademark

suture. Additional throws are addedas needed to square and secure theknot. Stick tie, suture ligature, or transfixion suture is a strand ofsuture material attached to a needleto ligate a vessel, duct, or otherstructure. This technique is used ondeep structures where placement ofa hemostat is difficult or on vesselsof large diameter. The needle ispassed through the structure oradjacent tissue first to anchor thesuture, then tied around the structure. Additional throws areused as needed to secure the knot.

THE PRIMARY SUTURE LINEThe primary suture line is the line of sutures that holds the woundedges in approximation during healing by first intention. It mayconsist of a continuous strand ofmaterial or a series of interruptedsuture strands. Other types of primary sutures, such as deepsutures, buried sutures, purse-stringsutures, and subcuticular sutures,are used for specific indications.Regardless of technique, a surgicalneedle is attached to the suturestrand to permit repeated passesthrough tissue.

CONTINUOUS SUTURESAlso referred to as running stitches,continuous sutures are a series ofstitches taken with one strand ofmaterial. The strand may be tied toitself at each end, or looped, withboth cut ends of the strand tiedtogether. A continuous suture linecan be placed rapidly. It derives itsstrength from tension distributedevenly along the full length of thesuture strand. However, care mustbe taken to apply firm tension,rather than tight tension, to avoid

CHAPTER 2 19

LIGATURES

CONTINUOUSSUTURINGTECHNIQUES

FIGURE1

FIGURE2

Free tie Stick tie

Looped suture, knottedat one end

Two strands knotted ateach end and knotted inthe middle

Running locked sutureOver-and-over runningstitch

FIGURE3

INTERRUPTED SUTURING TECHNIQUES

Simple interrupted

Interrupted vertical mattress

Interrupted horizontalmattress

TYPES

Plain

Chromic

Braided

Monofilament

Braided

Monofilament

Braided

Monofilament

Monofilament

Braided

Monofilament

Mulifilament

Monofilament

Braided

Braided

Monofilament

Braided

Monofilament

Monofilament

ABSORBABLE SUTURESSUTURE

Surgical GutSuture

Surgical GutSuture

Coated VICRYL* RAPIDE(polyglactin 910)Suture

MONOCRYL*(poliglecaprone 25)Suture

Coated VICRYL*Plus Antibacterial(polyglactin 910)Suture

Coated VICRYL*(polyglactin 910)Suture

PDS* II(polydioxanone)Suture

PERMA-HAND*Silk Suture

Surgical StainlessSteel Suture

ETHILON*Nylon Suture

NUROLON*Nylon Suture

MERSILENE*Polyester FiberSuture

ETHIBOND*EXCEL PolyesterFiber Suture

PROLENE*PolypropyleneSuture

PRONOVA*POLY (hexafluoro-propylene-VDF)Suture

COLOR OFMATERIAL

Yellowish-tan

Blue Dyed

Brown

Blue Dyed

Undyed (Natural)

Undyed (Natural)

Violet

Undyed (Natural)

Violet

Violet

Undyed (Natural)

Violet

Blue

Clear

Violet

White

Silver metallic

Violet

Green

Undyed (Clear)

Violet

Green

Undyed (Clear)

Green

Undyed (White)

Green

Undyed (White)

Clear

Blue

Blue

RAW MATERIAL

Collagen derived fromhealthy beef and sheep.

Collagen derived fromhealthy beef and sheep.

Copolymer of lactideand glycolide coatedwith 370 and calciumstearate.

Copolymer of glycolide andepsilon-caprolactone.



Polyester polymer.

Organic protein calledfibrin.

316L stainless steel.

Long-chain aliphaticpolymers Nylon 6 orNylon 6,6.

Long-chain aliphaticpolymers Nylon 6 orNylon 6,6.

Poly (ethylene terephthalate).

Poly (ethylene terephthalate) coatedwith polybutilate.

Isotactic crystallinestereoisomer ofpolypropylene.

Polymer blend of poly(vinylidene fluoride)and poly (vinylidenefluoride-cohexafluoro-propylene).

TENSILE STRENGTHRETENTION in vivoIndividual patirent characteristics canaffect rate of tensile strength loss.

Individual patirent characteristics canaffect rate of tensile strength loss.

Approximately 50% remains at 5days. All tensile strength is lost atapproximately 14 days.

Approximately 50-60% (violet: 60-70%)remains at 1 week. Approximately 20-30% (violet: 30-40%) remains at 2 weeks.Lost within 3 weeks (violet: 4 weeks).

Approximately 75% remains at twoweeks. Approximately 50% remains at three weeks, 25% at four weeks.

Approximately 75% remains at twoweeks. Approximately 50% remains at three weeks, 25% at four weeks.

Approximately 70% remains at 2 weeks.Approximately 50% remains at 4 weeks.Approximately 25% remains at 6 weeks.

Progressive degradation of fiber mayresult in gradual loss of tensilestrength over time.

Indefinate.

Progressive hydrolysis may result ingradual loss of tensile strength overtime.

Progressive hydrolysis may result ingradual loss of tensile strength overtime.

No significant change known to occur in vivo.

No significant change known to occur in vivo.

No subject to degradation or weakening by action of tissueenzymes.

No subject to degradation or weakening by action of tissueenzymes.

ABSORPTION RATE

Absorbed by proleolyticenzymatic digestiveprocess.

Absorbed by proleolyticenzymatic digestiveprocess.

Essentially completebetween 42 days.Absorbed by hydrolysis.

Complete at 91-119days. Absorbed byhydrolysis.

Essentially completebetween 56-70 days.Absorbed by hydrolysis.

Essentially completebetween 56-70 days.Absorbed by hydrolysis.

Minimal until about 90thday. Essentially completewithin 6 months. Absorbedby slow hydrolysis.

Gradual encapsulationby fibrous connectivetissue.

Nonabsorbable.





Nonabsorbable.

Nonabsorbable.

TISSUE REACTION

Moderate reaction

Moderate reaction

Minimal to moderateacute inflammatoryreaction

Minimal acuteinflammatory reaction



Slight reaction

Acute inflammatoryreaction








NONABSORBABLE SUTURES

CONTRAINDICATIONS

Being absorbable, should not be usedwhere extended approximation of tissuesunder stress is required. Should not be used in patients with known sensitivities or allergies to collagen or chromium.

Being absorbable, should not be usedwhere extended approximation of tissuesunder stress is required. Should not be used in patients with known sensitivities or allergies to collagen or chromium.

Should not be used where extendedapproximation of tissue under stress isrequired or where wound support beyond7 days is required.

Being absorbable, should not be usedwhere extended approximation of tissueunder stress is required. Undyed not indicated for use in fascia.

Being absorbable, should not be usedwhere extended approximation of tissue is required.

Being absorbable, should not be usedwhere extended approximation of tissue is required.

Being absorbable, should not be used whereprolonged approximation of tissues understress is required. Should not be used withprosthetic devices, such as heart valves or synthetic grafts.

Should not be used in patients with known sensitivities or allergies to silk.

Should not be used in patients with known sensitivities or allergies to 316Lstainless steel, or constituent metals suchas chromium and nickel.

Should not be used where permanentretention of tensile strength is required.

Should not be used where permanentretention of tensile strength is required.

None known.

None known.

None known.

None known.

FREQUENT USES

General soft tissue approximationand/or ligation, including use inophthalmic procedures. Not for usein cardiovascular and neurologicaltissues.

General soft tissue approximationand/or ligation, including use inophthalmic procedures. Not for usein cardiovascular and neurologicaltissues.

Superficial soft tissue approximationof skin and mucosa only. Not for usein ligation, ophthalmic, cardiovascu-lar or neurological procedures.

General soft tissue approximationand/or ligation. Not for use in car-diovascular and neurological tissues,microsurgery, or ophthalmic surgery.

General soft tissue approximationand/or ligation. Not for use in cardio-vascular and neurological tissues.

General soft tissue approximationand/or ligation, including use inophthalmic procedures. Not for use incardiovascular and neurological tissues.

All types of soft tissue approxima-tion, including pediatric cardiovascu-lar and ophthalmic procedures. Notfor use in adult cardiovascular tissue,microsurgery, and neural tissue.

General soft tissue approximationand/or ligation, includingcardiovascular, ophthalmic and neurological procedures.

Abdominal wound closure, herniarepair, sternal closure and orthoaedicprocedures including cerclage andtendon repair.







COLOR CODEOF PACKETSYellow

Beige

Red

Coral

Violet

Violet

Silver

Light Blue

Yellow-Ochre

Mint Green

Mint Green

Turquoise

Orange

Deep Blue

Royal Blue

HOW SUPPLIED

7-0 thru 3 with and without needles,and on LIGAPAK dispensing reels 0 thru 1 with CONTROLRELEASE needles

7-0 thru 3 with and without needles,and on LIGAPAK dispensing reels 0 thru 1 with CONTROLRELEASE needles

5-0 thru 1 with needles

6-0 thru 2 with and without needles3-0 thru 1 with CONTROLRELEASE needles

5-0 thru 2 with and without needles

8-0 thru 3 with and without needles,and on LIGAPAK dispensing reels 4-0 thru 2 with CONTROL RELEASEneedles; 8-0 with attached beads forophthalmic use

9-0 thru 2 with needles4-0 thru 2 with CONTROLRELEASE needles9-0 thru 7-0 with needles7-0 thru 1 with needles

9-0 thru 5 with and without needles,and on LIGAPAK dispensing reels 4-0 thru 1 with CONTROLRELEASE needles



6-0 thru 1 with and without needles 4-0 thru 1 with CONTROLRELEASE needles

6-0 thru 5 with and without needles 10-0 and 11-0 for ophthalmic (greenmonofilament); 0 with CONTROLRELEASE needles

7-0 thru 5 with and without needles 4-0 thru 1 with CONTROLRELEASE needles; various sizesattached to TFE polymer pledgets

6-0 thru 2 (clear) with and without needles; 10-0 thru 8-0 and 6-0 thru 2 with and without needles; 0 thru 2 withCONTROL RELEASE needles; varioussizes attached to TFE polymer pledgets

6-0 through 5-0 with TAPERCUT*surgical needle8-0 through 5-0 with taper pointneedle

* Trademark

TABLE5

SUTURINGOPTIONS:MATERIALS,CHARACTERISTICS,AND APPLICATIONS

tissue strangulation. Excessive tension and instrument damageshould be avoided to prevent suture breakage which could disrupt theentire line of a continuous suture.

Continuous suturing leaves less foreign body mass in the wound. In the presence of infection, it maybe desirable to use a monofilamentsuture material because it has nointerstices which can harbormicroorganisms. This is especiallycritical as a continuous suture line can transmit infection along the entire length of the strand. Acontinuous one layer mass closuremay be used on peritoneum and/orfascial layers of the abdominal wallto provide a temporary seal duringthe healing process.

INTERRUPTED SUTURESInterrupted sutures use a number of strands to close the wound. Each strand is tied and cut afterinsertion. This provides a more secureclosure, because if one suture breaks,the remaining sutures will hold thewound edges in approximation.

Interrupted sutures may be usedif a wound is infected, becausemicroorganisms may be less likely to travel along a series ofinterrupted stitches.

DEEP SUTURESDeep sutures are placed completelyunder the epidermal skin layer.They may be placed as continuousor interrupted sutures and are notremoved postoperatively.

BURIED SUTURESBuried sutures are placed so that theknot protrudes to the inside, underthe layer to be closed. This tech-

nique is useful when using largediameter permanent sutures ondeeper layers in thin patients whomay be able to feel large knots thatare not buried.

PURSE-STRING SUTURESPurse-string sutures are continuoussutures placed around a lumen andtightened like a drawstring to invert the opening. They may beplaced around the stump of theappendix, in the bowel to secure anintestinal stapling device, or in an

organ prior to insertion of a tube (such as the aorta, to hold the cannulation tube in place during an open heart procedure).

SUBCUTICULAR SUTURESSubcuticular sutures are continuousor interrupted sutures placed in thedermis, beneath the epithelial layer.Continuous subcuticular sutures areplaced in a line parallel to thewound. This technique involves taking short, lateral stitches the fulllength of the wound. After the

THE SUTURE22

DEEP SUTURES

FIGURE4

PURSE-STRINGSUTURES

FIGURE5

suture has been drawn taut, the distal end is anchored in the samemanner as the proximal end. Thismay involve tying or any of a variety of anchoring devices.Subcuticular suturing may be performed with absorbable suturewhich does not require removal, orwith monofilament nonabsorbablesuture that is later removed by simply removing the anchoringdevice at one end and pulling theopposite end.

THE SECONDARY SUTURE LINEA secondary line of sutures may be used:• To reinforce and support the

primary suture line, eliminate dead space, and prevent fluid accumulation in an abdominal wound during healing by first intention. When used for this purpose, they may also be called retention, stay, or tension sutures.

• To support wounds for healing by second intention.

• For secondary closure following wound disruption when healing by third intention.

NOTE: If secondary sutures areused in cases of nonhealing, theyshould be placed in opposite fashionfrom the primary sutures (i.e., interrupted if the primarysutures were continuous, continuous if the primary sutureswere interrupted).

Retention sutures are placed approxi-mately 2 inches from each edge ofthe wound. The tension exerted lateral to the primary suture linecontributes to the tensile strength ofthe wound. Through-and-throughsutures are placed from inside theperitoneal cavity through all layersof the abdominal wall, including theperitoneum. They should be insert-ed before the peritoneum is closedusing a simple interrupted stitch.The wound may be closed in layersfor a distance of approximatelythree-fourths its length. Then theretention sutures in this area may bedrawn together and tied. It isimportant that a finger be placedwithin the abdominal cavity to prevent strangulation of the viscerain the closure. The remainder of thewound may then be closed. Prior to tightening and tying the finalretention sutures, it is important to explore the abdomen again witha finger to prevent strangulation of viscera in the closure. Theremainder of the wound may thenbe closed.

Retention sutures utilize nonabsorbable suture material. They should therefore be removedas soon as the danger of sudden

CHAPTER 2 23

* Trademark

SUBCUTANEOUSSUTURES

FIGURE6

RETENTIONSUTUREBOLSTER

FIGURE7

increases in intra-abdominal pressure is over— usually 2 to 6weeks, with an average of 3 weeks.

STITCH PLACEMENTMany types of stitches are used for both continuous and interruptedsuturing. In every case, equal "bites" of tissue should be taken on each side of the wound. Theneedle should be inserted from 1 to 3 centimeters from the edge of the wound, depending upon thetype and condition of the tissuebeing sutured.

KNOT TYINGOf the more than 1,400 differenttypes of knots described in THEENCYLCOPEDIA OF KNOTS,only a few are used in modern surgery. It is of paramount importance that each knot placed for approximation of tissues or ligation of vessels be tied with precision and each must hold withproper tension.

KNOT SECURITYThe construction of ETHICON*sutures has been carefully designed to produce the optimumcombination of strength, uniformity, and hand for each material. The term hand is themost subtle of all suture qualityaspects. It relates to the feel of thesuture in the surgeon’s hands, thesmoothness with which it passesthrough tissue and ties down, theway in which knots can be set andsnugged down, and most of all, tothe firmness or body of the suture.Extensibility relates to the way inwhich the suture will stretch slightlyduring knot tying and then recover.

The stretching characteristics provide the signal that alerts thesurgeon to the precise momentwhen the suture knot is snug.

The type of knot tied will dependupon the material used, the depthand location of the incision, and theamount of stress that will be placedupon the wound postoperatively.Multifilament sutures are generallyeasier to handle and tie thanmonofilament sutures, however, allthe synthetic materials require a specific knotting technique. Withmultifilament sutures, the nature ofthe material and the braided ortwisted construction provide a highcoefficient of friction and the knotsremain as they are laid down. Inmonofilament sutures, on the otherhand, the coefficient of friction isrelatively low, resulting in a greatertendency for the knot to loosenafter it has been tied. In addition,monofilament synthetic polymericmaterials possess the property ofmemory. Memory is the tendencynot to lie flat, but to return to agiven shape set by the material’sextrusion process or the suture’spackaging. The RELAY* suturedelivery system delivers sutures withminimal package memory due to itsunique package design.

Suture knots must be properlyplaced to be secure. Speed in knottying frequently results in less thanperfect placement of the strands. In addition to variables inherent inthe suture materials, considerablevariation can be found betweenknots tied by different surgeons and even between knots tied by the same individual on differentoccasions.

The general principles of knot tying which apply to all suturematerials are:

1. The completed knot must be firm, and so tied that slipping is virtually impossible. The simplest knot for the material is the most desirable.

2. The knot must be as small as possible to prevent an excessive amount of tissue reaction when absorbable sutures are used, or to minimize foreign body reaction to nonabsorbable sutures. Ends should be cut as short as possible.

3. In tying any knot, friction between strands ("sawing") must be avoided as this can weaken the integrity of the suture.

THE SUTURE24

COMMONLYUSED TYPESOF STITCHES

To appose skin and other tissueOver-and-over Over-and-overSubcuticular Vertical mattress

Horizontal mattress

To invert tissueLembert LembertCushing HalstedConnell Purse-string

To evert tissueHorizontal mattress Horizontal mattress

CONTINUOUS SUTURE INTERRUPTED SUTURES

TABLE6

4. Care should be taken to avoid damage to the suture material when handling. Avoid the crushing or crimping application of surgical instruments, such as needleholders and forceps, to the strand except when grasping the free end of the suture during an instrument tie.

5. Excessive tension applied by the surgeon will cause breaking of the suture and may cut tissue. Practice in avoiding excessive tension leads to successful use of finer gauge materials.

6. Sutures used for approximation should not be tied too tightly, because this may contribute to tissue strangulation.

7. After the first loop is tied, it is necessary to maintain traction on one end of the strand to avoid loosening of the throw if being tied under any tension.

8. Final tension on final throw should be as nearly horizontal as possible.

9. The surgeon should not hesitate to change stance or position in relation to the patient in order to place a knot securely and flat.

10. Extra ties do not add to the strength of a properly tied and squared knot. They only contribute to its bulk. With some synthetic materials, knot security requires the standard surgical technique to flat and square ties with additional throws if indicated by surgical circumstance and the experience of the surgeon.

KNOT TYING TECHNIQUESMOST OFTEN USEDAn important part of good suturingtechnique is correct method in knot tying. A seesaw motion, or the sawing of one strand down overanother until the knot is formed,may materially weaken sutures tothe point that they may break whenthe second throw is made, or evenworse, in the postoperative periodwhen the suture is further weakenedby increased tension or motion. Ifthe two ends of the suture arepulled in opposite directions withuniform rate and tension, the knotmay be tied more securely.

Some procedures involve tyingknots with the fingers, using one ortwo hands; others involve tying withthe help of instruments. Perhaps the most complex method of knottying is done during endoscopicprocedures, when the surgeon mustmanipulate instruments from welloutside the body cavity.

Following are the most frequentlyused knot tying techniques withaccompanying illustrations offinished knots.

SQUARE KNOTThe two-hand square knot is theeasiest and most reliable for tyingmost suture materials. It may beused to tie surgical gut, virgin silk,surgical cotton, and surgical stain-less steel. Standard technique of flatand square ties with additionalthrows if indicated by the surgicalcircumstance and the experience ofthe operator should be used to tieMONOCRYL* (poliglecaprone 25)suture, VICRYL* suture, CoatedVICRYL* suture, Coated VICRYL*RAPIDE (polyglactin 910) suture,

CHAPTER 2 25

* Trademark

FIGURE8

FINISHEDSUTURE TIES

Square knot

Surgeon’s knot–firstthrow

Surgeon’s knot–secondthrow

Deep tie

Instrument tie

PDS* II (polydioxanone) suture,ETHILON* nylon suture, ETHIBOND* EXCEL polyestersuture, PERMA-HAND* silksuture, PRONOVA* poly (hexafluo-ropropylene-VDF) suture, andPROLENE* polypropylene suture.

Wherever possible, the square knot is tied using the two-handtechnique. On some occasions itwill be necessary to use one hand,either the left or the right, to tie asquare knot.

CAUTION: If the strands of asquare knot are inadvertently incorrectly crossed, a granny knotwill result. Granny knots are notrecommended because they have atendency to slip when subjected toincreased stress.

SURGEON’S OR FRICTION KNOTThe surgeon's or friction knot isrecommended for tying VICRYL*suture, Coated VICRYL* suture,ETHIBOND* EXCEL polyestersuture, ETHILON* nylon suture, MERSILENE* polyester fibersuture, NUROLON* nylon suture,PRONOVA* poly (hexafluoro-propylene-VDF) suture, and PROLENE* polypropylene suture. The surgeon’s knot also may be performed using a one-hand technique.

DEEP TIETying deep in a body cavity can bedifficult. The square knot must befirmly snugged down as in all situations. However, the operatormust avoid upward tension whichmay tear or avulse the tissue.

LIGATION USING AHEMOSTATIC CLAMPFrequently it is necessary to ligate a blood vessel or tissue grasped in a hemostatic clamp to achievehemostasis in the operative field.

INSTRUMENT TIEThe instrument tie is useful whenone or both ends of the suturematerial are short. For best results,exercise caution when using aneedleholder with any monofila-ment suture, as repeated bendingmay cause these sutures to break.

ENDOSCOPIC KNOT TYING TECHNIQUESDuring an endoscopic procedure, a square knot or surgeon's knot maybe tied either outside the abdomenand pushed down into the bodythrough a trocar (extracorporeal) or directly within the abdominalcavity (intracorporeal).In extracorporeal knot tying, thesuture appropriately penetrates thetissue, and both needle and sutureare removed from the body cavity,bringing both suture ends outside of the trocar. Then a series of half-hitches are tied, each one being pushed down into the cavityand tightened with an endoscopicknot pusher.

Intracorporeal knot tying is performed totally within theabdominal cavity. After the suturehas penetrated the tissue, the needle

is cut from the suture and removed.Several loops are made with thesuture around the needleholder, and the end of the suture is pulledthrough the loops. This technique is then repeated to form a surgeon's knot, which is tightened by theknot pusher.

In both extracorporeal and intracor-poreal knot tying, the followingprinciples of suture manipulationon tissue should be observed:

1. Handle tissue as gently as possible to avoid tissue trauma.

2. Grasp as little tissue as possible.3. Use the smallest suture possible

for the task.4. Exercise care in approximating

the knot so that the tissue being approximated is not strangulated.

5. Suture must be handled with care to avoid damage.

CUTTING THE SECURED SUTURES

Once the knot has been securelytied, the ends must be cut. Beforecutting, make sure both tips of the scissors are visible to avoid inadvertently cutting tissue beyondthe suture.

Cutting sutures entails running the tip of the scissors lightly downthe suture strand to the knot. The ends of surgical gut are left relatively long, approximately 1/4" (6mm) from the knot.

THE SUTURE26

SUTUREREMOVAL

Skin on the face and neck 2 to 5 days

Other skin sutures 5 to 8 days

Retention sutures 2 to 6 weeks

SUTURE LOCATION TIME FOR SUTURE REMOVAL TABLE7

Other materials are cut closer to the knot, approximately 1/8" (3mm), to decrease tissue reaction and minimize the amount of foreignmaterial left in the wound. Toensure that the actual knot is notcut, twist or angle the blades of thescissors prior to cutting.Make certain to remove the cut ends of the suture from theoperative site.

SUTURE REMOVALWhen the external wound hashealed so that it no longer needs thesupport of nonabsorbable suturematerial, skin sutures must beremoved. The length of time thesutures remain in place dependsupon the rate of healing and thenature of the wound. General rulesare as follows.

Sutures should be removed usingaseptic and sterile technique. Thesurgeon uses a sterile suture removaltray prepared for the procedure. The following steps are taken:

• STEP 1—Cleanse the area with an antiseptic. Hydrogen peroxide can be used to remove dried serum encrusted around the sutures.

• STEP 2—Pick up one end of the suture with thumb forceps, and cut as close to the skin as possible where the suture enters the skin.

• STEP 3—Gently pull the suture strand out through the side oppo-site the knot with the forceps. To prevent risk of infection, the suture should be removed without pulling any portion that has been outside the skin back through the skin.

NOTE: Fast absorbing synthetic orgut suture material tend to lose alltensile strength in 5 to 7 days and can

be removed easily without cutting. A common practice is to cover theskin sutures with PROXI-STRIP*skin closures during the required healing period. After the wound edges have regained sufficient tensilestrength, the sutures may be removed by simply removing thePROXI-STRIP skin closures.

SUTURE HANDLING TIPS

These guidelines will help the surgicalteam keep their suture inventory upto date and their sutures in the bestpossible condition.

1. Read labels.

2. Heed expiration dates and rotate stock.

3. Open only those sutures needed for the procedure at hand.

4. Straighten sutures with a gentle pull. Never crush or rub them.

5. Don't pull on needles.

6. Avoid crushing or crimping suture strands with surgical instruments.

7. Don't store surgical gut near heat.

8. Moisten—but never soak—surgical gut.

9. Do not wet rapidly absorbing sutures.

10. Keep silk dry.

11. Wet linen and cotton to increase their strength.

12. Don't bend stainless steel wire.

13. Draw nylon between gloved fingers to remove the packaging "memory."

14. Arm a needleholder properly.

SUTURE SELECTION PROCEDURE

PRINCIPLES OF SUTURE SELECTIONThe surgeon has a choice of suturematerials from which to select foruse in body tissues. Adequatestrength of the suture material willprevent suture breakage. Secureknots will prevent knot slippage.But the surgeon must understandthe nature of the suture material,

CHAPTER 2 27

* Trademark

ARMING A NEEDLE-HOLDER PROPERLY

FIGURE9

Grasp the needle one-third to one-half of the distance fromthe swaged end to the point.

the biologic forces in the healingwound, and the interaction of the suture and the tissues. The following principles should guidethe surgeon in suture selection.

1. When a wound has reached maximal strength, sutures are no longer needed. Therefore:

a. Tissues that ordinarily heal slowly such as skin, fascia, and tendons should usually be closed with nonabsorbable sutures. An absorbable suture with extended (up to 6 months) wound support may also be used.

b. Tissues that heal rapidly such as stomach, colon and bladder may be closed with absorbable sutures

2. Foreign bodies in potentially contaminated tissues may convert contamination into infection.

3. Where cosmetic results are important, close and prolonged apposition of wounds and avoidance of irritants will produce the best results. Therefore:

a. Use the smallest inert monofilament suture materials such as nylon or polypropylene.

b. Avoid skin sutures and close subcuticularly whenever possible.

c. Under certain circumstances, to secure close apposition of skin edges, a topical skin adhesive or skin closure tape may be used.

4. Foreign bodies in the presence of fluids containing high concen- trations of crystalloids may act as a nidus for precipitation and stone formation.

Therefore:a. In the urinary and biliary

tracts, use rapidly absorbed sutures.

5. Regarding suture size:a. Use the finest size suture

commensurate with the natural strength of the tissue.

b. If the postoperative course of the patient may produce sudden strains on the suture line, reinforce it with retention sutures. Remove them as soon as the patient’s condition is stabilized.

SURGERY WITHIN THEABDOMINAL WALL CAVITYEntering the abdomen, the surgeonwill need to seal or tie off subcutaneous blood vessels immediately after the incision ismade, using either an electrosurgicalunit designed for this purpose orfree ties (ligatures). If ligatures areused, an absorbable suture materialis generally preferred. When preparing the ties, the scrub personoften prepares one strand on a needle for use as a suture ligatureshould the surgeon wish to transfix a large blood vessel. Once inside, the type of suture

selected will depend upon thenature of the operation and the surgeon's technique.

THE GASTROINTESTINAL TRACTLeakage from an anastomosis or suture site is the principal problem encountered performing a procedure involving the gastrointestinal tract. This problemcan lead to localized or generalizedperitonitis. Sutures should not betied too tightly in an anastomotic

closure. Wounds of the stomach andintestine are rich in blood supplyand may become edematous andhardened. Tight sutures may cutthrough the tissue and cause leakage. A leak-proof anastomosiscan be achieved with either a single or double-layer closure.

For a single-layer closure, interrupt-ed sutures should be placed approximately 1/4" (6mm) apart.Suture is placed through the submucosa, into the muscularis andthrough the serosa. Because the submucosa provides strength in the gastrointestinal tract, effectiveclosure involves suturing the submucosal layers in appositionwithout penetrating the mucosa. A continuous suture line provides atighter seal than interrupted sutures.However, if a continuous suturebreaks, the entire line may separate.

Many surgeons prefer to use a double-layer closure, placing a second layer of interrupted suturesthrough the serosa for insurance.Absorbable VICRYL* sutures, orchromic gut sutures may be used in either a single or double-layerclosure. Surgical silk may also be used for the second layer of a double-layer closure.Inverted, everted, or end-to-end closure techniques have all beenused successfully in this area, butthey all have drawbacks. The surgeon must take meticulous carein placing the sutures in the submu-cosa. Even with the best technique,some leakage may occur.Fortunately, the omentum usuallyconfines the area, and natural bodydefenses handle the problem.

THE SUTURE28

THE STOMACHFor an organ that contains freehydrochloric acid and potent proteolytic enzymes, the stomachheals surprisingly quickly. Stomach wounds attain maximumstrength within 14 to 21 days

postoperatively, and have a peak rate of collagen synthesis at 5 days.

Absorbable sutures are usually acceptable in the stomach, althoughthey may produce a moderate reaction in both the wound andnormal tissue. Coated VICRYL*sutures are most commonly used.PROLENE* sutures may also beused for stomach closure.

THE SMALL INTESTINEClosure of the small intestine presents the same considerations as the stomach. Proximal intestinalcontents, primarily bile or pancreatic juices, may cause a severe chemical (rather than bacterial) peritonitis.If using an inverted closure technique, care must be taken tominimize the cuff of tissue whichprotrudes into the small sized intestinal lumen in order to avoidpartial or complete obstruction.Absorbable sutures are usually preferred, particularly because theywill not permanently limit thelumen diameter. A nonabsorbablesuture may be used in the serosal

layer for added assurance.The small intestine heals very rapidly, reaching maximal strengthin approximately 14 days.

THE COLONThe high microbial content of the colon once made contaminationa major concern. But absorbablesutures, once absorbed, leave nochannel for microbial migration.Still, leakage of large bowel contents is of great concern as it is potentially more serious thanleakage in other areas of the gastrointestinal tract.

The colon is a strong organ—approximately twice as strong in thesigmoid region as in the cecum. Yet,wounds of the colon gain strengthat the same rate regardless of theirlocation. This permits the samesuture size to be used at either endof the colon. The colon heals at arate similar to that of the stomachand small intestine. A high rate ofcollagen synthesis is maintained fora prolonged period (over 120 days).The entire gastrointestinal tractexhibits a loss of collagen andincreased collagenous activity immediately following colon anastomosis. Both absorbable andnonabsorbable sutures may be usedfor closure of the colon. Placementof sutures in the submucosa, avoiding penetration of the mucosa,will help prevent complications.

THE RECTUMThe rectum heals very slowly.Because the lower portion is belowthe pelvic peritoneum, it has noserosa. A large bite of muscle shouldbe included in an anastomosis, andthe sutures should be tied carefullyto avoid cutting through the tissues.

CHAPTER 2 29

* Trademark

ANASTOMOTICCLOSURE TECHNIQUE

INVERTED CLOSURE TECHNIQUE

FIGURE10

FIGURE11

Single layer Double layer

Monofilament sutures reduce therisk of bacterial proliferation in the rectum.

THE BILIARY TRACT THE GALLBLADDERWithin the gallbladder, the cysticand common bile ducts heal rapidly.Their contents present special considerations for suture selection.The presence of a foreign body suchas a suture in an organ that is proneto crystal formation may precipitatethe formation of "stones."Multifilament sutures should probably not be used because it is not always possible to preventexposure of a suture in the ducts.The surgeon should choose anabsorbable suture in the finest sizepossible that leaves the least surfacearea exposed.

PARENCHYMATOUS ORGANS THE SPLEEN, LIVER AND KIDNEYOn occasion, a surgeon may becalled upon to repair a laceration of one of these vital organs. If large vessels, particularly arteries,within these organs have been severed, they must be located and ligated before attempting to close the defect. Otherwise,hematomas or secondary hemor-rhage may occur.

Because these organs are composedchiefly of cells with little connectivetissue for support, attempts must be made to coapt the outer fibrouscapsule of the torn tissue. In theabsence of hemorrhage, little tensionis placed on the suture line and onlysmall size sutures need to be used. Ifthe tissue cannot be approximated,tacking a piece of omentum over the defect will usually suffice to

provide closure. Sutures do not needto be placed close together or deeplyinto the organ.

Lacerations in this area tend to heal rapidly. New fibrous tissue willusually form over the wound with 7 to 10 days.

In a liver resection, suturing of thewedges in a horizontal through-and-through fashion should holdthe tissue securely. Large vesselsshould be tied using VICRYL*sutures or silk. Raw surfaces can beclosed or repaired using VICRYL(polyglactin 910) mesh.

CLOSING THE ABDOMENWhen closing the abdomen, the closure technique may be moreimportant than the type of suturematerial used.

THE PERITONEUMThe peritoneum, the thin membra-nous lining of the abdominal cavity,lies beneath the posterior fascia. Itheals quickly. Some believe that theperitoneum does not require sutur-ing, while others disagree. If theposterior fascia is securely closed,suturing the peritoneum may notcontribute to the prevention of anincisional hernia. Among surgeonswho choose to close the peri-toneum, a continuous suture line

THE SUTURE30

LIVER RESECTION

FIGURE12

THEABDOMINALWALL

FIGURE13

SkinSubcutaneous fat

PeritoneumMuscle tissue

Transversalis fascia

with absorbable suture materialis usually preferred. Interruptedsutures can also be used for this procedure.

FASCIAThis layer of firm, strong connectivetissue covering the muscles is themain supportive structure of thebody. In closing an abdominal incision, the fascial sutures musthold the wound closed and also help to resist changes in intra-abdominal pressure. Occasionally,synthetic graft material may be used when fascia is absent or weak.PROLENE* polypropylene mesh maybe used to replace abdominal wallor repair hernias when a great dealof stress will be placed on the sutureline during healing. Nonabsorbablesutures such as PROLENE suturemay be used to suture the graft tothe tissue.

Fascia regains approximately 40% of its original strength in 2 months.It may take up to a year or longer toregain maximum strength. Full original strength is never regained.

The anatomic location and type ofabdominal incision will influencehow may layers of fascia will besutured. The posterior fascial layer

is always closed. The anterior layermay be cut and may also requiresuturing. Mass closure techniquesare becoming the most popular.

Most suture materials have someinherent degree of elasticity. If nottied too tightly, the suture will"give" to accommodate postopera-tive swelling that occurs. Stainlesssteel sutures, if tied too tightly, willcut like a knife as the tissue swellsor as tension is placed upon thesuture line. Because of the slowhealing time and because the fascialsuture must bear the maximumstress of the wound, a moderate sizenonabsorbable suture may be used.An absorbable suture with longerlasting tensile strength, such asPDS* II sutures, may also provideadequate support. PDS II suturesare especially well-suited for use inyounger, healthy patients.

Many surgeons prefer the use ofinterrupted simple or figure-of eightsutures to close fascia, while othersemploy running suture or a combination of these techniques. In the absence of infection or gross contamination, the surgeon maychoose either monofilament or multifilament sutures. In the presence of infection, a

monofilament absorbable materiallike PDS II sutures or inert nonab-sorbable sutures like stainless steel or PROLENE* sutures may be used.

MUSCLEMuscle does not tolerate suturingwell. However, there are severaloptions in this area.

Abdominal muscles may be eithercut, split (separated), or retracted,depending upon the location andtype of the incision chosen. Wherepossible, the surgeon prefers toavoid interfering with the bloodsupply and nerve function by making a muscle-splitting incisionor retracting the entire muscletoward its nerve supply. During closure, muscles handled in thismanner do not need to be sutured.The fascia is sutured rather than the muscle.

The Smead-Jones far-and-near-technique for abdominal wound closure is strong and rapid, providesgood support during early healingwith a low incidence of wound disruption, and has a low incidenceof late incisional problems. This is a single-layer closure through bothlayers of the abdominal wall fascia,abdominal muscles, peritoneum,

CHAPTER 2 31

SURGICALOPTIONS INMUSCLE

FIGURE14

Cutting Splitting Retracting

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and the anterior fascial layer. The interrupted sutures resemble a "figure of eight" when placed.Absorbable PDS II sutures orVICRYL* sutures are usually used.

Stainless steel sutures may also beused. Monofilament PROLENEsutures also provide all the advantages of steel sutures: strength,minimal tissue reactivity, and resistance to bacterial contamination.They are better tolerated than steelsutures by patients in the late postoperative months and are easierfor the surgeon to handle and tie.However, both stainless steel andPROLENE sutures may bedetectable under the skin of thinpatients. To avoid this problem,knots should be buried in fasciainstead of in the subcutaneous space.

SUBCUTANEOUS FATNeither fat nor muscle toleratesuturing well. Some surgeons question the advisability of placingsutures in fatty tissue because it has little tensile strength due to its composition, which is mostlywater. However, others believe it is necessary to place at least a few sutures in a thick layer of subcutaneous fat to prevent deadspace, especially in obese patients.Dead spaces are most likely to occur in this type of tissue, so the edges of the wound must becarefully approximated. Tissue fluids can accumulate in these pocket-like spaces, delaying healingand predisposing infection.Absorbable sutures are usually selected for the subcutaneous layer.VICRYL* suture is especially suitedfor use in fatty, avascular tissue sinceit is absorbed by hydrolysis. Thesurgeon may use the same type and

size of material used earlier to ligateblood vessels in this layer.

SUBCUTICULAR TISSUETo minimize scarring, suturing the subcuticular layer of tough connective tissue will hold the skinedges in close approximation. In asingle-layer subcuticular closure, lessevidence of scar gaping or expansionmay be seen after a period of 6 to 9months than is evident with simpleskin closure. The surgeon takes continuous short lateral stitchesbeneath the epithelial layer of skin.Either absorbable or nonabsorbablesutures may be used. If nonab-sorbable material is chosen, one endof the suture strand will protrudefrom each end of the incision, andthe surgeon may tie them together to form a "loop" or knot the endsoutside of the incision.

To produce only a hair-line scar (on the face, for example), the skin can be held in very closeapproximation with skin closuretapes in addition to subcuticularsutures. Tapes may be left on thewound for an extended period oftime depending upon their locationon the body.

When great tension is not placedupon the wound, as in facial orneck surgery, very fine sizes of subcuticular sutures may be used.Abdominal wounds that must withstand more stress call for largersuture sizes.

Some surgeons choose to close both the subcuticular and epidermallayers to achieve minimal scarring.Chromic surgical gut and polymericmaterials, such as MONOCRYL*suture, are acceptable for placementwithin the dermis. They are capable

of maintaining sufficient tensilestrength through the collagen synthesis stage of healing which lasts approximately 6 weeks. Thesutures must not be placed too close to the epidermal surface toreduce extrusion. If the skin is nonpigmented and thin, a clear orwhite monofilament suture such as MONOCRYL suture will beinvisible to the eye. MONOCRYLsuture is particularly well-suited forthis closure because, as a monofila-ment, it does not harbor infectionand, as a synthetic absorbablesuture, tissue reaction is minimized.After this layer is closed, the skinedges may then be approximated.

SKINSkin is composed of the epitheliumand the underlying dermis. It is sotough that a very sharp needle isessential for every stitch to minimizetissue trauma. (See Chapter 3: TheSurgical Needle.)

Skin wounds regain tensile strengthslowly. If a nonabsorbable suturematerial is used, it is typicallyremoved between 3 and 10 dayspostoperatively, when the woundhas only regained approximately 5% to 10% of its strength. This ispossible because most of the stressplaced upon the healing wound isabsorbed by the fascia, which thesurgeon relies upon to hold thewound closed. The skin or subcuticular sutures need only bestrong enough to withstand naturalskin tension and hold the woundedges in apposition.

The use of coated VICRYL* RAPIDE suture, a rapidly absorbedsynthetic suture, eliminates the need for suture removal. Coated

THE SUTURE32

VICRYL RAPIDE suture, which is indicated for superficial closure of skin and mucosa, provides short-term wound support consistent with the rapid healingcharacteristics of skin. The suturesbegin to fall off in 7 to 10 days,with absorption essentially complete at 42 days.

Suturing technique for skin closure may be either continuous or interrupted. Skin edges should be everted. Preferably, each suturestrand is passed through the skinonly once, reducing the chance of cross-contamination across theentire suture line. Interrupted technique is usually preferred.

If surgeon preference indicates the use of a nonabsorbable suturematerial, several issues must beconsidered. Skin sutures are exposedto the external environment, making them a serious threat to wound contamination and stitch abscess. The interstices ofmultifilament sutures may provide a haven for microorganisms.Therefore, monofilament nonab-sorbable sutures may be preferred forskin closure. Monofilament suturesalso induce significantly less tissuereaction than multifilament sutures.For cosmetic reasons, nylon orpolypropylene monofilament suturesmay be preferred. Many skinwounds are successfully closed withsilk and polyester multifilaments as well. Tissue reaction to nonab-sorbable sutures subsides andremains relatively acellular as fibrous tissue matures and forms adense capsule around the suture.(Note, surgical gut has been knownto produce tissue reaction. CoatedVICRYL* RAPIDE suture elicits

a lower tissue reaction than chromicgut suture due to its acceleratedabsorption profile.) The key to success is early suture removalbefore epithelialization of the suturetract occurs and before contamina-tion is converted into infection.

A WORD ABOUT SCARRING(EPITHELIALIZATION)When a wound is sustained in the skin—whether accidentally orduring a surgical procedure—theepithelial cells in the basal layer atthe margins of the wound flattenand move into the wound area.They move down the wound edgeuntil they find living, undamagedtissue at the base of the wound.Then they move across the woundbed to make contact with similarcells migrating from the oppositeside of the wound. They movedown the suture tract after if hasbeen embedded in the skin. Whenthe suture is removed, the tract ofthe epithelial cells remains.Eventually, it may disappear, butsome may remain and form keratin.A punctate scar is usually seen onthe skin surface and a "railroadtrack" or "crosshatch" appearanceon the wound may result. This is

relatively rare if the skin sutures arenot placed with excessive tensionand are removed by the seventhpostoperative day.

The forces that create the distancebetween the edges of the woundwill remain long after the sutureshave been removed. Significant collagen synthesis will occur from 5 to 42 days postoperatively. Afterthis time, any additional gain intensile will be due to remodeling, or crosslinking, of collagen fibersrather than to collagen synthesis.Increases in tensile strength willcontinue for as long as 2 years, butthe tissue will never quite regain itsoriginal strength.

CLOSURE WITH RETENTION SUTURESWe have already discussed the techniques involved with placingretention sutures, and using them in a secondary suture line. (See thesection on Suturing Techniques.)Heavy sizes (0 to 5) of nonabsorbablematerials are usually used for retention sutures, not for strength,but because larger sizes are less likelyto cut through tissue when a suddenrise in intra-abdominal pressureoccurs from vomiting, coughing,

CHAPTER 2 33

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THE RAILROADTRACK SCARCONFIGURATION

FIGURE15

straining, or distention. To preventthe heavy suture material from cutting into the skin under stress,one end of the retention suture maybe threaded through a short lengthof plastic or rubber tubing called abolster or bumper before it is tied. Aplastic bridge with adjustable features may also be used to protectthe skin and primary suture line and permit postoperative woundmanagement for patient comfort.

Properly placed retention suturesprovide strong reinforcement forabdominal wounds, but also causethe patient more postoperative painthan does a layered closure. Thebest technique is to use a materialwith needles swaged on each end(double-armed). They should beplaced from the inside of the woundtoward the outside skin to avoidpulling potentially contaminatedepithelial cells through the entireabdominal wall.

The ETHICON retention suture line includes ETHILON*sutures, MERSILENE* sutures,ETHIBOND* EXCEL sutures, andPERMA-HAND* sutures. Surgicalsteel sutures may also be used.

Retention sutures may be left inplace for 14 to 24 days postopera-tively. Three weeks is an averagelength of time. Assessment of thepatient's condition is the controllingfactor in deciding when to removeretention sutures.

SUTURE FOR DRAINSIf a drainage tube is placed in a hollow organ or a bladder drain isinserted, it may be secured to thewall of the organ being drained with absorbable sutures. The surgeonmay also choose to minimize thedistance between the organ and theabdominal wall by using sutures totack the organ being drained to theperitoneum and fascia. Sutures may be placed around thecircumference of the drain, eithertwo sutures at 12 and 6 o'clockpositions, or four sutures at 12, 3,6, and 9 o'clock positions, andsecured to the skin with temporaryloops. When the drain is no longerneeded, the skin sutures may be easily removed to remove the drain.The opening can be left open topermit additional drainage until itcloses naturally.

A drainage tube inserted into theperitoneal cavity through a stabwound in the abdominal wall usually is anchored to the skin withone or two nonabsorbable sutures.This prevents the drain from slipping into or out of the wound.

SUTURE NEEDS IN OTHER BODY TISSUES NEUROSURGERYSurgeons have traditionally used aninterrupted technique to close thegalea and dura mater.

The tissue of the galea, similar tothe fascia of the abdominal cavity, is very vascular and hemostatic.Therefore, scalp hematoma is apotential problem, and the surgeonmust be certain to close well.The dura mater is the outermost ofthe three meninges that protects thebrain and spinal cord. It tears withease and cannot withstand toomuch tension. The surgeon maydrain some of the cerebrospinalfluid to decrease volume, easing thetension on the dura before closing.If it is too damaged to close, a patch must be inserted and suturedin place.

Surgical silk is appropriate in thisarea for its pliability and easy knottying properties. Unfortunately, it elicits a significant foreign bodytissue reaction. Most surgeons haveswitched to NUROLON* suturesor coated VICRYL* sutures becausethey tie easily, offer greater strengththan surgical silk, and cause less tissue reaction. PROLENE* sutureshave also been accepted by surgeonswho prefer a continuous closuretechnique, who must repair potentially infected wounds, or who must repair dural tears.

THE SUTURE34

PLACEMENT OF SUTURESAROUND A DRAIN

FIGURE16

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In peripheral nerve repair, precisesuturing often requires the aid of an operating microscope. Suturegauge and needle fineness must beconsistent with nerve size. After the motor and sensory fibers areproperly realigned, the epineurium(the outer sheath of the nerve) issutured. The strength of sutures inthis area is less of a considerationthan the degree of inflammatoryand fibroplastic tissue reaction. Fine sizes of nylon, polyester, andpoly-propylene are preferred.

MICROSURGERYThe introduction of fine sizes ofsutures and needles has increasedthe use of the operating microscope.ETHICON introduced the firstmicrosurgery sutures—ETHILON*sutures—in sizes 8-0 through 11-0. Since then, the microsurgeryline has expanded to include PROLENE* sutures and coatedVICRYL* sutures. Literally all surgical specialties perform someprocedures under the operatingmicroscope, especially vascular andnerve anastomosis.

OPHTHALMIC SURGERYThe eye presents special healing challenges. The ocular muscles, theconjunctiva, and the sclera have goodblood supplies; but the cornea is anavascular structure. While epithelial-ization of the cornea occurs rapidlyin the absence of infection, fullthickness cornea wounds heal slowly.Therefore, in closing wounds such ascataract incisions, sutures shouldremain in place for approximately 21 days. Muscle recession, whichinvolves suturing muscle to sclera, only requires sutures forapproximately 7 days.

Nylon was the preferred suturematerial for ophthalmic surgery.While nylon is not absorbed,progressive hydrolysis of nylon in vivo may result in gradual loss oftensile strength over time. Fine sizesof absorbable sutures are currentlyused for many ocular procedures.Occasionally, the sutures areabsorbed too slowly in muscle recessions and produce granulomasto the sclera. Too rapid absorptionhas, at times, been a problem incataract surgery. Because theyinduce less cellular reaction than

surgical gut and behave dependably,VICRYL sutures have proven usefulin muscle and cataract surgery.

While some ophthalmic surgeonspromote the use of a "no-stitch"surgical technique, 10-0 coatedVICRYL (polyglactin 910) violetmonofilament sutures offer distinctadvantages. They provide the securi-ty of suturing immediately follow-ing surgery but eliminate the risksof suture removal and relatedendophthalmitis.

The ophthalmologist has many fine size suture materials to choosefrom for keratoplasty, cataract, and vitreous retinal microsurgicalprocedures. In addition toVICRYL* sutures, other monofila-ment suture materials includingETHILON sutures, PROLENEsutures, and PDS* II sutures may be used. Braided material such asvirgin silk, black braided silk, MERSILENE* sutures, and coatedVICRYL sutures are also availablefor ophthalmic procedures.

UPPER ALIMENTARY TRACT PROCEDURESThe surgeon must consider theupper alimentary tract from themouth down to the loweresophageal sphincter to be a potentially contaminated area. The gut is a musculomembranouscanal lined with mucus membranes.Final healing of mucosal woundsappears to be less dependent uponsuture material than on the woundclosure technique.

The oral cavity and pharynx generally heal quickly if not infected.Fine size sutures are adequate in thisarea as the wound is under little tension. Absorbable sutures may be

CHAPTER 2 35

LAYERS OF SUTURESSURROUNDINGA DRAIN

FIGURE17

Skin GaleaSkull

Brain Dura mater

preferred. Patients, especially children, usually find them morecomfortable. However, the surgeonmay prefer a monofilament nonabsorbable suture under certaincircumstances. This option causesless severe tissue reaction than multifilament materials in buccalmucosa, but also requires sutureremoval following healing.

In cases involving severe periodontitis, VICRYL periodontalmesh may be used to promote tissueregeneration, a technique thatenhances the regeneration andattachment of tissue lost due to periodontitis. VICRYL periodontalmesh, available in several shapes andsizes with a preattached VICRYL ligature, is woven from the samecopolymer used to produceabsorbable VICRYL* suture. As asynthetic absorbable, VICRYL* periodontal mesh eliminates thetrauma associated with a second surgical procedure and reduces therisk of infection or inflammationassociated with this procedure.

The esophagus is a difficult organ to suture. It lacks a serosal layer. The mucosa heals slowly. The thickmuscular layer does not hold sutureswell. If multifilament sutures areused, penetration through themucosa into the lumen should beavoided to prevent infection.

RESPIRATORYTRACT SURGERYRelatively few studies have beendone on healing in the respiratorytract. Bronchial stump closure following lobectomy or pneumonec-tomy presents a particular challenge.Infection, long stumps, poorapproximation of the transected

THE SUTURE36

THE EYE

FIGURE18

BRONCHIALSTUMPCLOSURE

FIGURE20

THE UPPERALIMENTARYCANAL

FIGURE19

Ocular muscles

Conjunctiva

Cornea

Sclera

Esophagus

Oral cavity

bronchus, and incomplete closure(i.e., air leaks) may lead to bronchopleural fistula. Avoidance of tissue trauma and maintenance of the blood supply to the area ofclosure are critical to healing. Thebronchial stump heals slowly, andsometimes not at all. Unless it isclosed tightly with strong, closelyspaced sutures, air may leak into the thoracic cavity.

Closure is usually achieved withmechanical devices, particularly staples. When sutures are used,polypropylene monofilament nonab-sorbable sutures are less likely tocause tissue reaction or harbor infection. Silk suture is also commonly used. Surgeons usuallyavoid absorbable sutures becausethey may permit secondary leakageas they lose strength.

Monofilament nylon suture shouldalso be avoided because of its potential for knot loosening.

CARDIOVASCULAR SURGERYAlthough definitive studies are few,blood vessels appear to heal rapidly.Most cardiovascular surgeons preferto use synthetic nonabsorbablesutures for cardiac and peripheralvascular procedures. Lasting strengthand leakproof anastomoses are essen-tial. Wire sutures are used on thesternum unless it is fragile, in whichcase absorbable sutures can be used.

VESSELSExcessive tissue reaction to suturematerial may lead to decreasedluminal diameter or to thrombusformation in a vessel. Therefore, the more inert synthetics includingnylon and polypropylene are the materials of choice for vessel

CHAPTER 2 37

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CONTINUOUSSTRANDSUTURINGIN VASCULARSURGERY

FIGURE21

THE BUNNELLTECHNIQUE

FIGURE23

SEATING AHEART VALVEWITH ETHIBONDEXCEL SUTURE

FIGURE22

anastomoses. Multifilament polyester sutures allow clotting tooccur within the interstices whichhelps to prevent leakage at thesuture line. The advantages of amaterial such as ETHIBOND*EXCEL sutures are its strength,durability, and slippery surfacewhich causes less friction whendrawn through a vessel. Many surgeons find that PROLENE*sutures, PRONOVA* sutures, orsilk are ideal for coronary arteryprocedures because they do not"saw" through vessels.

Continuous sutures provide a moreleakproof closure than interruptedsutures in large vessel anastomosesbecause the tension along the suture strand is distributed evenlyaround the vessel's circumference.Interrupted monofilament suturessuch as ETHILON* sutures, PROLENE* sutures, or PRONOVA* sutures are used formicrovascular anastomoses.When anastomosing major vesselsin young children, special care must be taken to anticipate thefuture growth of the patient. Here, the surgeon may use silk to its best advantage, because it losesmuch of its tensile strength afterapproximately 1 year, and is usuallycompletely absorbed after 2 or moreyears. Continuous polypropylenesutures have been used in childrenwithout adverse effects. The continuous suture, when placed, is a coil which stretches as the child grows to accommodate thechanging dimensions of the bloodvessel. However, reports of stricturefollowing vessel growth have stimulated interest in use of a suture line which is one-half continuous, one-half interrupted.

Clinical studies suggest that a prolonged absorbable suture, such asPDS* II suture, may be ideal, giving adequate short-term support whilepermitting future growth.

Following vascular trauma, mycoticaneurysms from infection areextremely serious complications. A suture may act as a nidus for an infection. In the presence ofinfection, the chemical properties of suture material can cause extensive tissue damage which mayreduce the tissue's natural ability to combat infection. Localized sepsis can also spread to adjacentvascular structures, causing necrosisof the arterial wall. Therefore, thesurgeon may choose a monofilamentsuture material that causes only amild tissue reaction and resists bacterial growth.

VASCULAR PROSTHESESThe fixation of vascular prosthesesand artificial heart valves presents anentirely different suturing challengethan vessel anastomosis. The suturesmust retain their original physicalproperties and strength throughoutthe life of the patient. A prosthesisnever becomes completely incorpo-rated into the tissue and constantmovement of the suture line occurs.Coated polyester sutures are thechoice for fixation of vascular prostheses and heart valves becausethey retain their strength andintegrity indefinitely.

Either a continuous or interruptedtechnique may be used for vessel tograft anastomoses.

To assist in proper strand identifica-tion, many surgeons alternate greenand white strands of ETHIBOND*

EXCEL suture around the cuff ofthe valve before tying the knots.

Some surgeons routinely use pledgets to buttress sutures in valvesurgery. They are used mostcommonly in valve replacementprocedures to prevent the annulusfrom tearing when the prostheticvalve is seated and the sutures aretied. They may also be used in heartwall closure of penetrating injuries,excising aneurysms, vascular graftsurgery, and to add support whenthe surgeon encounters extremedeformity, distortion, or tissuedestruction at the annulus.

URINARY TRACT SURGERYClosure of tissues in the urinarytract must be leakproof to preventescape of urine into surrounding tissues. The same considerationsthat affect the choice of sutures forthe biliary tract affect the choice ofsutures for this area. Nonabsorbablesutures incite the formation of cal-culi, and therefore cannot be used.Surgeons use absorbable sutures as arule, especially MONOCRYL*sutures, PDS II sutures, VICRYL*sutures, Coated VICRYL* sutures,and chromic gut sutures.

The urinary tract heals rapidly. Thetransitional cell epithelium migratesover the denuded surfaces quickly.Unlike other epithelium, themigrating cells in the urinary tractundergo mitosis and cell division.Epithelial migration may be foundalong suture tracts in the body ofthe bladder. The bladder wallregains 100% of its original tensilestrength within 14 days. The rate ofcollagen synthesis peaks at 5 daysand declines rapidly thereafter.

THE SUTURE38

Thus, sutures are needed for only 7 to 10 days.

THE FEMALE GENITAL TRACTSurgery within this area presents certain challenges. First, it is usuallyregarded as a potentially contaminat-ed area. Second, the surgeon mustfrequently work within a veryrestricted field. Endoscopic techniqueis frequently used in this area. CoatedVICYL* suture is an excellent choiceto prevent bacterial colonization.

Most gynecological surgeons preferto use absorbable sutures for repair ofincisions and defects. Some preferusing heavy, size 1 surgical gutsutures, MONOCRYL sutures, orVICRYL sutures. However, thestresses on the reproductive organsand the rate of healing indicate thatthese larger-sized sutures may only berequired for abdominal closure.

Handling properties, especially pliability of the sutures used forinternal use, are extremely important. Synthetic absorbablesutures such as VICRYL* sutures insize 0 may be used for the tough,muscular, highly vascular tissues in the pelvis and vagina. These tissues demand strength duringapproximation and healing. CoatedVICRYL* RAPIDE suture, for example, is an excellent choice forepisiotomy repair.

TENDON SURGERYTendon surgery presents severalchallenges. Most tendon injuries aredue to trauma, and the wound maybe dirty. Tendons heal slowly. Thestriated nature of the tissue makessuturing difficult.

Tendon repair fibroblasts arederived from the peritendonous

tissue and migrate into the wound.The junction heals first with scartissue, then by replacement withnew tendon fibers. Close appositionof the cut ends of the tendon (especially extensor tendons) must be maintained to achieve good functional results. Both thesuture material and the closure technique are critical for successfultendon repair.

The suture material the surgeonchooses must be inert and strong.Because tendon ends can separatedue to muscle pull, sutures with agreat degree of elasticity should beavoided. Surgical steel is widely usedbecause of its durability and lack ofelasticity. Synthetic nonabsorbablematerials including polyester fibers,polypropylene, and nylon may beused. In the presence of potentialinfection, the most inert monofila-ment suture materials are preferred.The suture should be placed tocause the least possible interferencewith the surface of the tendon, asthis is the gliding mechanism. Itshould also not interfere with theblood supply reaching the wound.Maintenance of closed apposition of the cut ends of the tendons, particularly extensor tendons, iscritical for good functional results.The parallel arrangement of tendonfibers in a longitudinal directionmakes permanent and secure place-ment of sutures difficult. Variousfigure-of-eight and other types ofsuturing have been used successfullyto prevent suture slippage and the formation of gaps between the cutends of the tendon.

Many surgeons use the BunnellTechnique. The suture is placed tobe withdrawn when its function as a

holding structure is no longer neces-sary. Referred to as a pull-out suture,it is brought out through the skinand fastened over a polypropylenebutton. The Bunnell Techniquesuture can also be left in place.

NUROLON* sutures, PROLENE*sutures, PRONOVA* sutures andETHIBOND* EXCEL sutures maybe used for connecting tendon tobone. Permanent wire sutures alsoyield good results because healing isslow. In periosteum, which healsfairly rapidly, surgical gut or coatedVICRYL sutures may be used. Infact, virtually any suture may beused satisfactorily in the periosteum.

SUTURES FOR BONEIn repairing facial fractures, monofilament surgical steel has provenideal for its lack of elasticity. Facialbones do not heal by callus formation,but more commonly by fibrous union.The suture material must remain inplace for a long period of time—perhaps months—until the fibrous tissue is laid down and remodeled.Steel sutures immobilize the fracture line and keep the tissues ingood apposition.

Following median stemotomy, surgeons prefer interrupted steelsutures to close. Sternum closure maybe difficult. Appropriate tension mustbe maintained, and the surgeon mustguard against weakening the wire.Asymmetrical twisting of the wire maycause it to buckle, fatiguing the metal,and ultimately causing the wire tobreak. Motion between the sides ofthe sternum will result, causing postoperative pain and possibly dehiscence. Painful nonunion isanother possible complication. (Inosteoporotic patients, very heavy

CHAPTER 2 39

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VICRYL sutures may be used to closethe sternum securely.)

The surgeon may use a bone anchorto hold one end of a suture in placewhen needed (e.g., shoulder repair surgery). This involves drilling a holein the bone and inserting the anchor,which expands once completely inside the bone to keep it from beingpulled out.

OTHER PROSTHETIC DEVICESOften, it is necessary for the sur-geon to implant a prosthetic devicesuch as an automatic defibrillator ordrug delivery system into a patient.To prevent such a device frommigrating out of position, it may betacked to the fascia or chest wallwith nonabsorbable sutures.

CLOSING CONTAMINATEDOR INFECTED WOUNDSContamination exists when microorganisms are present, but ininsufficient numbers to overcome thebody's natural defenses. Infectionexists when the level of contamina-tion exceeds the tissue's ability todefend against the invadingmicroorganisms. Generally, contamination becomes infection

when it reaches approximately 106

bacteria per gram of tissue in animmunologically normal host.Inflammation without dischargeand/or the presence of culture-positive serous fluid indicate possibleinfection. Presence of purulent discharge indicates positive infection.

Contaminated wounds can becomeinfected when hematomas, necrotictissue, devascularized tissue, or largeamounts of devitalized tissue (especially in fascia, muscle, and bone)are present. Microorganisms multiplyrapidly under these conditions, wherethey are safe from cells that providelocal tissue defenses.

In general, contaminated woundsshould not be closed but should be leftopen to heal by secondary intentionbecause of the risk of infection.Foreign bodies, including sutures, perpetuate localized infection.Therefore, the surgeon's techniqueand choice of suture is critical.Nonabsorbable monofilament nylonsutures are commonly used in anticipation of delayed closure ofdirty and infected wounds. Thesutures are laid in but not tied.Instead, the loose suture ends are heldin place with PROXI-STRIP* skin

closures (sterile tape). The woundshould be packed to maintain a moistenvironment. When the infection has subsided, the surgeon can easilyreopen the wound, remove the packing and any tissue debris, andthen close using the previously inserted monofilament nylon suture.

IN THE NEXT SECTIONThe surgeon depends as much uponthe quality and configuration of theneedle used as on the suturingmaterial itself to achieve a successfulclosure. The relationship betweenneedles and sutures will be exploredon the pages that follow.

REFERENCES1. Mangram AJ, Horan TC, Pearson

ML, Silver LC, Jarvis WR. Guidelinefor prevention of surgical site infection, 1999. Infection Control and Hospital Epidemiology. 1999;20:247-278.

2. Gilbert P, McBain AJ, Storch ML, Rothenburger SJ, Barbolt TA. Literature-based evaluation of the potential risks associated with impregnation of medical devices andimplants with triclosan. Surg Infection J. 2002;3(suppl1):S55-S63.

3. Rothenburger S, Spangler D, Bhende S, Burkley D. In vitro antibacterial evaluation of Coated VICRYL* Plus Antibacterial suture (coated polyglactin 910 withtriclosan) using zone of inhibition assays. S Infection J.2002;3(suppl 1):S79-S87.

THE SUTURE40

TACKING APROSTHETICDEVICE INPOSITION TOPREVENTMIGRATION

FIGURE24

THE SURGICAL NEEDLE

CHAPTER 3

Necessary for the placement ofsutures in tissue, surgical needlesmust be designed to carry suturematerial through tissue with minimal trauma. They must besharp enough to penetrate tissuewith minimal resistance. Theyshould be rigid enough to resistbending, yet flexible enough tobend before breaking. They mustbe sterile and corrosion-resistant to prevent introduction of microorganisms or foreign bodiesinto the wound.

Comfort with needle security in theneedleholder, the ease of passagethrough tissue, and the degree oftrauma that it causes all have animpact upon the overall results ofsurgical needle performance. This isespecially true when precise cosmet-ic results are desired.

The best surgical needles are:

• Made of high quality stainless steel.

• As slim as possible without compromising strength.

• Stable in the grasp of a needleholder.

• Able to carry suture material through tissue with minimal trauma.

• Sharp enough to penetrate tissue with minimal resistance.

• Rigid enough to resist bending, yet ductile enough to resist breaking during surgery.

• Sterile and corrosion-resistant to prevent introduction of microorganisms or foreignmaterials into the wound.

Variations in needle geometries arejust as important as variations insuture sizes. Needle dimensionsmust be compatible with suturesizes, allowing the two to work in tandem.

ELEMENTS OFNEEDLE DESIGNNeedle design involves analyzing asurgical procedure and the densityof the tissue involved in great detail. ETHICON engineers workcontinuously to improve upon theirneedle line, sometimes making sub-tle alterations resulting in a positiveimpact upon the procedure itself.

The anatomy of the ideal surgicalneedle has three key factors thatmake up the ideal needle.

– Alloy– Geometry – tip and body– CoatingThe combination of these attributesis ETHICON MultiPass NeedleTechnology.

MultiPass needles are the highestperforming needles that ETHICONProducts offers; comprised of threeproprietary technologies which

ensure superior strength, tissue pen-etration and control; pass after pass.

NEW Advanced NeedleCoating—new silicone coatinghelps to maintain needle sharp-ness pass after pass and consisten-cy from needle to needle

PRIME Needle Geometry—needles have less mass andrequire less penetration force tominimize tissue trauma

ETHALLOY Needle Alloy—provides superior strength andductility (bending without breaking)

The various metal alloys used in themanufacture of surgical needlesdetermine their basic characteristicsto a great degree. ETHICON*stainless steel alloy needles are heat-treated to give them the maximumpossible strength and ductility.ETHALLOY* needle alloy (PatentNo. 5,000,912) was developed forunsurpassed strength in precisionneedles used in cardiovascular, ophthalmic, plastic, and microsurgi-cal procedures. It is produced economically without sacrificingductility or corrosion resistance.

A needle's strength is determined by how it resists deformation during repeated passes through tissue. Tissue trauma can beinduced if a needle bends duringpenetration and compromises tissueapposition. Therefore, greater needlestrength equals less tissue trauma. A weak needle that bends too easilycan compromise the surgeon's control and damage surroundingtissue during the procedure. Inaddition, loss of control in needleplacement could result in an inadvertent needlestick.

THE SURGICAL NEEDLE42

ETHALLOY*Needle Alloy

PRIME*

Geometry

AdvancedNeedleCoating

MULTIPASS*

ETHICON

* Trademark

Manufacturers measure needlestrength in the laboratory by bending them 90° to determine theneedle's maximum strength. This isreferred to as the needle's "ultimatemoment," and is more important tothe needle manufacturer than to thesurgeon. The most critical aspect ofneedle strength to the surgeon is the "surgical yield" point. Surgicalyield indicates the amount of angular deformation the needle can withstand before becoming permanently deformed. This pointis usually 10° to 30° dependingupon the material and the manufac-turing process. Any angle beyondthat point renders the needle useless. Reshaping a bent needlemay cause it to lose strength and be less resistant to bending and breaking.

At ETHICON, the combination of alloy selection and the needlemanufacturing process are carefully

selected to achieve the highest possible surgical yield, which alsooptimizes needle strength.

Ductility refers to the needle's resistance to breaking under a givenamount of bending. If too great aforce is applied to a needle it maybreak, but a ductile needle will bend before breaking. Needle breakage during surgery can preventapposition of the wound edges asthe broken portion passes throughtissue. In addition, searching forpart of a broken needle can causeadded tissue trauma and add to thetime the patient is anesthetized. Apiece that cannot be retrieved willremain as a constant reminder toboth the patient and surgeon.Needle bending and breakage canbe minimized by carefully passingneedles through tissue in the direction of the needle body.Needles are not designed to be used as retractors to lift tissue.

Needle sharpness is especially important in delicate or cosmeticsurgery. The sharper the needle, the less scarring that will result.However, the right balance must befound. If a needle is too sharp, asurgeon may not feel he or she hasadequate control of needle passagethrough tissue.

Sharpness is related to the angle ofthe point as well as the taper ratioof the needle. The ETHICONsharpness tester incorporates a thin,laminated, synthetic membrane that simulates the density of humantissue, allowing engineers to gaugeexactly how much force is requiredfor penetration.

MultiPass needles have a micro-thincoating comprised of a patented silicone formulation that improvespenetration performance over multiplepasses. According to laboratorytests, this coating serves severalimportant functions:

It reduces the force needed tomake initial penetration throughtissue; thus it is 58% sharper(than other surgical needles) onmultiple passes in human tissue

Significantly improves the consis-tency of the needle penetration(pass to pass, needle to needle)

Maintains sharpness for betterpenetration and control overmultiple passes while deliveringongoing strength, sharpness andcontrol

Needle performance is also influenced by the stability of theneedle in the grasp of a needlehold-er. Most curved needles are flattened in the grasping area toenhance control. All ETHICON

CHAPTER 3 43

TAPER RATIO

FIGURE1

ETHICON RIBBEDNEEDLE

FIGURE2

12:1 ratio

curved needles of 22 mil wire or heavier are ribbed as well as flattened. Longitudinal ribbing or grooves on the inside or outsidecurvatures of curved needles provides a crosslocking action in the needleholder for added needlecontrol. This reduces undesirablerocking, twisting, and turning inthe needleholder.

PRINCIPLES OF CHOOSING A SURGICAL NEEDLEWhile there are no hard and fastrules governing needle selection, thefollowing principles should be keptin mind. (Specific types of needlesmentioned here will be described infull detail later on in this section.)

1. Consider the tissue in which the surgeon will introduce the needle. Generally speaking, taper point needles are most often used to suture tissues that are easy to penetrate. Cutting or TAPERCUT* needles are more often used in tough, hard-to-penetrate tissues. When in doubt about whether to choose a taper point or cutting needle, choose the taper point foreverything except skin sutures.

2. Watch the surgeon's technique closely. Select the length, diameter, and curvature of the needle according to the desired placement of the suture and the space in which the surgeon is working.

3. Consult frequently with the surgeon. Working with the same surgeon repeatedly leads to familiarity with his or herindividual routine. However, even the same surgeon may need to change needle type or size to meet specific requirements, even during a single operative procedure.

4. When using eyed needles, try to match needle diameter to suture size. Swaged needles, where the needle is already attached to the suture strand, eliminate this concern.

5. The best general rule of thumb for the scrub person to follow is pay attention and remain alert to the progress of the operation.

Observation is the best guide to needle selection if the surgeon has no preference.


NEEDLECOMPONENTS

FIGURE3

ANATOMYOF A NEEDLE

FIGURE4

Point

Eye(Swaged end)

Body

Needlepoint

Chord lengthSwage

Needleradius

Needle lengthNeedle body

Needlediameter

THE ANATOMY OF A NEEDLERegardless of its intended use, every surgical needle has three basiccomponents:

The eye.

The body.

The point.

The measurements of these specific components determine, in part, how they will be used most efficiently.

Needle size may be measured ininches or in metric units. The following measurements determinethe size of a needle.

CHORD LENGTH—The straight line distance from the point of a curved needle tothe swage.

NEEDLE LENGTH—The distance measured along the needle itself from point to end.

RADIUS—The distance from the center of the circle to the body of the needle if the curvature of the needle were continued to make a full circle.

DIAMETER—The gauge or thickness of the needle wire. Very small needles of fine gauge are needed for microsurgery. Large, heavy gauge needles are used to penetrate the sternum and to place retention sutures in the abdominal wall. A broad spectrum of sizes are available between the two extremes.

THE NEEDLE EYEThe eye falls into one of three cate-gories: closed eye, French (split orspring) eye, or swaged (eyeless).

The closed eye is similar to a household sewing needle. The shapeof the eye may be round, oblong, or square. French eye needles have aslit from inside the eye to the end of the needle with ridges that catchand hold the suture in place.

Eyed needles must be threaded, atime-consuming procedure for thescrub person. This presents the disadvantage of having to pull adouble strand of suture materialthrough tissue, creating a larger holewith additional tissue disruption. In addition, the suture may stillbecome unthreaded while the surgeon is using it. While tying thesuture to the eye may minimize thispossibility, it also adds to the bulkof the suture. Another disadvantageof eyed needles is that repeated useof these needles with more than one suture strand causes the needleto become dull, thereby makingsuturing more difficult.

Virtually all needles used today areswaged. This configuration joins the needle and suture together as a continuous unit—one that is convenient to use and minimizestrauma. The method of attachingthe suture to the needle varies withthe needle diameter. In larger diameter needles, a hole is drilled in the needle end. In smaller diameter needles, a channel is made by forming a "U" at the swage end or a hole is drilled in the wire with a laser. Each hole orchannel is specifically engineered for the type and size of suture material it will hold, and crimpedor closed around the suture to holdit securely. When the surgeon hasfinished placing the suture line inthe patient's tissue, the suture may

be cut, or easily released from theneedle as is the case when usingCONTROL RELEASE* needles(Patent No. 3,980,177).

The diameter of a needle swaged to suture material is no larger than necessary to accommodate the diameter of the suture stranditself. Swaged sutures offer severaladvantages to the surgeon, nurse,and patient.

1. The scrub person does not have to select a needle when the surgeon requests a specific suture material since it is already attached.

2. Handling and preparation are minimized. The strand with needle attached may be used directly from the packet. This helps maintain the integrity of the suture strand.

3. Tissues are subjected to minimal trauma.

4. Tissue trauma is further reduced because a new, sharp, undamaged needle is provided with each suture strand.

5. Swaged sutures do not unthread prematurely.

6. If a needle is accidentally dropped into a body cavity, the attached suture strand makes it easier to find.

7. Inventory and time spent cleaning, sharpening, handling, and sterilizing reusable eyed needles is eliminated, thereby reducing cost as well as risk of needle punctures.

8. CONTROL RELEASE needles allow placement of many sutures rapidly. This may reduce

* Trademark

CHAPTER 3 45

operating time and, ultimately, the length of time the patient is anesthetized.

9. The ATRALOC* surgical needle and CONTROL RELEASE needle ensure consistent quality and performance.

10. Swaged sutures eliminate suture fraying or damage due to sharp comers in the eye of eyed needles.

11. Needles are corrosion-free.

Small diameter ETHICON taperpoint needles commonly used in cardiovascular surgery were

compared in laboratory tests—some with "split" channels andsome with laser-drilled holes. Theneedles with laser-drilled holes produced less drag force as theypassed through a membrane thatsimulated vascular tissue. This could be associated with less trauma to the vessel walls.

The swaged ATRALOC surgicalneedles made by ETHICON are supplied in a variety of sizes, shapes, and strengths. Some of them incorporate the CONTROLRELEASE needle suture principlewhich facilitates fast separation of the needle from the suture when desired by the surgeon. This feature allows rapid placementof many sutures, as in interruptedsuturing techniques. Even thoughthe suture is securely fastened to the needle, a slight, straight tug

will release it. This needle/sutureconfiguration was created originally for abdominal closure and hysterectomies, but is now used in a wide variety of procedures.

THE NEEDLE BODYThe body of the needle is the portion which is grasped by theneedleholder during the surgicalprocedure. The body of the needleshould be as close as possible to thediameter of the suture material tominimize bleeding and leakage. This is especially true for cardiovascular, gastrointestinal, and bladder procedures.

The curvature of the needle bodymay come in a variety of differentshapes. Each shape gives the needledifferent characteristics.

STRAIGHT NEEDLEThis shape may be preferred when


FIGURE5

THE NEEDLE EYE

Closed eye

French eye

Swaged

CONTROLRELEASENEEDLESUTURE

FIGURE6

Holding the needle securely in the needleholder, the sutureshould be grasped securely and pulled straight and taut. Theneedle will be released with a straight tug of the needleholder.

* Trademark

suturing easily accessible tissue.Most of these needles are designedto be used in places where directfinger-held manipulation can easilybe performed.

The Keith needle is a straight cutting needle. It is used primarilyfor skin closure of abdominalwounds. Varying lengths are alsoused for arthroscopic suturing of the meniscus in the knee.

Bunnell (BN) needles are used fortendon repair. Taper point needlevariations may also be used for

suturing the gastrointestinal tract.

Some microsurgeons prefer straightneedles for nerve and vessel repair.In ophthalmology, the straight tran-schamber needle protects endothe-lial cells and facilitates placement ofintraocular lenses.

HALF-CURVED NEEDLEThe half-curved or "ski" needle may be used for skin closure or inlaparoscopy. Its low profile allowseasy passage down laparoscopic trocars. Its use in skin closure is

limited because, while the curvedportion passes through tissue easily,the remaining straight portion ofthe body is unable to follow thecurved path of the needle withoutbending or enlarging its path in the tissue.

CURVED NEEDLECurved needles allow predictableneedle turnout from tissue, and are therefore used most often. This needle shape requires less space for maneuvering than astraight needle, but the curve necessitates manipulation with aneedleholder. The curvature may be 1/4, 3/8, 1/2, or 5/8 circle.The most common use for the 3/8

circle is skin closure. The surgeoncan easily manipulate this curvaturewith slight pronation of the wrist ina relatively large and superficialwound. It is very difficult to use this needle in a deep body cavity or restricted area because a larger arc ofmanipulation is required.

The 1/2 circle needle was designedfor use in a confined space,although it requires more pronationand supination of the wrist. Buteven the tip of this needle may be obscured by tissue deep in the pelvic cavity. A 5/8 circle needle may be more useful in this situation, especially in someanal, urogenital, intraoral, and cardiovascular procedures.

COMPOUND CURVED NEEDLEThe compound curved needle(Patent No. 4,524,771) was originally developed for anteriorsegment ophthalmic surgery. Itallows the surgeon to take precise,

CHAPTER 3 47

NEEDLE SHAPES AND TYPICALAPPLICATIONS

FIGURE7

Straight

Half-curved

1/4 Circle

3/8 Circle

1/2 Circle

5/8 Circle

Compound Curved

gastrointestinal tract, nasal cavity, nerve, oral cavity, pharynx, skin, tendon, vessels

skin (rarely used)laparoscopy

eye (primary application) microsurgery

aponeurosis, biliary tract, cardiovascularsystem, dura, eye, gastrointestinal tract,muscle, myocardium, nerve, perichon-drium, periosteum, pleura, skin, tendon,urogenital tract, vessels

biliary tract, cardiovascular system, eye,fascia, gastrointestinal tract, muscle,nasal cavity, oral cavity, pelvis, peri-toneum, pharynx, pleura, resporatorytract, skin, tendon, subcutaneous fat, urogenital tract

anal (hemorrhoidectomy), nasal cavity, pelvis, urogenital tract (primaryapplication)

eye (anterior segment)laparoscopy

SHAPE APPLICATION

uniform bites of tissue. The tight80° curvature of the tip follows intoa 45° curvature throughout theremainder of the body. The initialcurve allows reproducible, short,deep bites into the tissue. The curvature of the remaining portionof the body forces the needle out ofthe tissue, everting the wound edgesand permitting a view into thewound. This ensures equidistance ofthe suture material on both sides ofthe incision. Equalized pressure onboth sides of the comeal-scleraljunction minimizes the possibilityof astigmatism following anteriorsegment surgery.

THE NEEDLE POINTThe point extends from the extremetip of the needle to the maximumcross-section of the body. Each nee-dle point is designed and producedto the required degree of sharpnessto smoothly penetrate specific typesof tissue.

TYPES OF NEEDLES

CUTTING NEEDLESCutting needles have at least twoopposing cutting edges. They aresharpened to cut through tough,difficult-to-penetrate tissue. Cutting needles are ideal for skinsutures that must pass throughdense, irregular, and relatively thick connective dermal tissue.Because of the sharpness of the cutting edge, care must be taken in some tissue (tendon sheath or oral mucous membrane) to avoid cutting through more tissuethan desired.


NEEDLEPOINTS ANDBODY SHAPESAND TYPICALAPPLICATIONS

FIGURE8

Conventional Cutting

Reverse Cutting

Precision Point Cutting

PC PRIME* Needle

MICRO-POINT* Reverse Cutting Needle

Side-Cutting Spatula

CS ULTIMA* Ophthalmic Needle

Taper

TAPERCUT* Surgical Needle

Blunt

skin, sternum

fascia, ligament, nasal cavity, oralmucosa, pharynx, skin, tendon sheath

skin (plastic or cosmetic)

skin (plastic or cosmetic)

eye

eye (primary application), microsurgery, ophthalmic(reconstructive)

eye (primary application)

aponeurosis, biliary tract, dura, fascia,gastrointestinal tract, laparoscopy, muscle, myocardium, nerve, peritoneum,pleura, subcutaneous fat, urogenitaltract, vessels, valve

bronchus, calcified tissue, fascia,laparoscopy, ligament, nasal cavity, oral cavity, ovary, perichondrium, periosteum, pharynx, sternum, tendon,trachea, uterus, valve, vessels (sclerotic)

Blunt dissection (friable tissue), cervix (ligating incompetent cervix), fascia, intestine, kidney, liver, spleen

SHAPE APPLICATION

Point

Point

Point

Body

Body

Body

Body

Body

Body

Body

Point

Point

Point

Point

Point

Point

Point

Body

Body

Body

CONVENTIONAL CUTTING NEEDLESIn addition to the two cutting edges,conventional cutting needles have athird cutting edge on the insideconcave curvature of the needle.The shape changes from a triangularcutting blade to that of a flattenedbody on both straight and curvedneedles. This needle type may beprone to cutout of tissue becausethe inside cutting edge cuts towardthe edges of the incision or wound.

The PC PRIME* needle (PrecisionCosmetic, Patent No. 5,030,228) is designed specifically for aestheticplastic surgery, and has conventionalcutting edges. Where cosmeticresults are important, the PCPRIME needle is superior to anyother for more delicate surgery,especially facial surgery. The narrow point, fine wire diameter,and fine taper ratio allow superiorpenetration of soft tissue. The insideand outside curvatures of the bodyare flattened in the needle graspingarea for greater stability in theneedleholder. Fattened sides reducebending that might occur due tothe fine wire diameter.

The tip configuration of the conven-tional cutting sternotomy needle isslightly altered to resist bending as itpenetrates the sternum. The alloy usedfor this needle provides the increasedstrength and ductility needed for itsfunction. The cutting edges of thepoint extend approximately 1/4" (6mm)from the round body and terminate ina triangular-shaped tip. This particularsternotomy needle maximizes cuttingefficiency and control in the needle-holder. TAPERCUT surgical needlesmay also be used for this procedure.

REVERSE CUTTING NEEDLESThese needles were created specifically for tough, difficult-to-penetrate tissue such as skin, tendonsheath, or oral mucosa. Reverse cutting needles are used in ophthalmic and cosmetic surgerywhere minimal trauma, early regeneration of tissue, and little scarformation are primary concerns.The reverse cutting needle is assharp as the conventional cuttingneedle, but its design is distinctivelydifferent. The third cutting edge is located on the outer convex curvature of the needle. This offersseveral advantages:

Reverse cutting needles have more strength than similar-sized conventional cutting needles.

The danger of tissue cutout is greatly reduced.

The hole left by the needle leaves a wide wall of tissue against which the suture is to be tied.

The MICRO-POINT* surgical needle for ophthalmic procedureshas a smooth surface and is honedto extreme sharpness. This allowsthe surgeon to suture the extremelytough tissues of the eye with optimum precision and ease.

A needle manufactured by the

* Trademark

CHAPTER 3 49

THE PCPRIMENEEDLE

FIGURE9

STERNOTOMYNEEDLE

FIGURE10

Narrow point

Fine wire diameter

Flattened inside curvature

Flattened outside curvature

Conventionalcutting tip

Flat sides

Conventional cutting edges (1/4 inch or 6mm)

exclusive ETHICON* PrecisionPoint Process may be used for plastic or cosmetic surgery, andpasses smoothly through tissue creating a minute needle path.

This results in superior apposition.The bottom third cutting edge on the Precision Point needle flattens out as it transitions to theneedle body for greater security inthe needleholder.

The OS (Orthopaedic Surgery) needles are curved, heavy bodied,reverse-cutting needles. Theorthopaedic surgeon may use theOS needle for extremely tough tissue, such as cartilage, where forceis required for penetration.

SIDE CUTTING NEEDLESAlso referred to as spatula needles,they feature a unique design whichis flat on both the top and bottom,eliminating the undesirable tissuecutout of other cutting needles. The side-cutting edges are designedfor ophthalmic procedures. Theypermit the needle to separate orsplit through the thin layers of scleral or comeal tissue and travelwithin the plane between them. The optimal width, shape, and precision sharpness of this needleensure maximum ease of penetra-tion, and gives the surgeon greater control of the needle as it passesbetween or through tissue layers.The position of the point varieswith the design of each specific type of spatulated needle.

The SABRELOC* spatula needlehas two cutting edges and a trapezoidal-shaped body.

The SABRELOC* needle with

the cobra-shaped tip has four equidistant defined edges.

The CS ULTIMA* ophthalmic needle (Corneal-Scleral, Patent No.5,002,564) is the sharpest needle in its category and is used forcorneal scleral closure. The smallerangles and increased cutting-edgelength result in superior sharpnessfacilitating easy tissue penetration.

The TG PLUS* needle (TransverseGround) has a long, ultra-sharp,slim tip. This needle undergoes aunique honing process which results

in a sharper needle. The surgeonencounters low penetration resist-ance with the TG PLUS needle, andgets excellent tactile feedback.

TAPER POINT NEEDLESAlso referred to as round needles,taper point needles pierce andspread tissue without cutting it. Theneedle point tapers to a sharp tip.The needle body then flattens to anoval or rectangular shape. Thisincreases the width of the body tohelp prevent twisting or turning inthe needleholder.


REVERSECUTTINGNEEDLE

FIGURE11

SPATULANEEDLECROSS-SECTION

FIGURE12

* Trademark

Taper point needles are usually used in easily penetrated tissue such as the peritoneum, abdominalviscera, myocardium, dura, and subcutaneous layers. They are preferred when the smallest possiblehole in the tissue and minimum tissue cutting are desired. They arealso used in internal anastomoses to prevent leakage which can subsequently lead to contaminationof the abdominal cavity. In the fascia, taper point needles minimizethe potential for tearing the thinconnective tissue lying between parallel and interlacing bands ofdenser, connective tissue.

The Mayo (MO) needle has a taperpoint, but a heavier and more flattened body than conventionaltaper needles. This needle wasdesigned for use in dense tissue;

particularly for gynecological procedures, general closure, andhernia repair.

TAPERCUT SURGICALNEEDLESETHICON* manufactures TAPER-CUT* needles which combine thefeatures of the reverse cutting edgetip and taper point needles. Threecutting edges extend approximately1/32" back from the point. Theseblend into a round taper body. Allthree edges are sharpened to provideuniform cutting action. The point,sometimes referred to as a trocarpoint, readily penetrates dense,tough tissue. The objective shouldbe for the point itself not to exceedthe diameter of the suture material.The taper body portion providessmooth passage through tissue andeliminates the danger of cutting

into the surrounding tissue.

Although initially designed for use in cardiovascular surgery onsclerotic or calcified tissue, theTAPERCUT* needle is widely used for suturing dense, fibrousconnective tissue— especially in fascia, periosteum, and tendonwhere separation of parallel connective tissue fibers could occurwith a conventional cutting needle.

ETHICON* developed a modifiedTAPERCUT CC needle (CalcifiedCoronary) for anastomosis of smallfibrotic and calcified blood vessels.The calcified portion of an arteryrequires a cutting tip only for initialpenetration to avoid tearing the vessel. This needle configuration hasa slimmer geometry than otherTAPERCUT needles from the bodythrough the point which facilitates

CHAPTER 3 51

ETHICONNEEDLECODES& OTHERMEANING

BB Blue BabyBIF Intraocular FixationBN BunnellBP Blunt PointBV Blood VesselBVH Blood Vessel HalfC CardiovascularCC Calcified CornaryCCS Conventional Cutting SternotomyCE Cutting EdgeCFS Conventional for SkinCIF Cutting Intraocular FixationCP Cutting PointCPS Conventional Plastic SurgeryCPX Cutting Point Extra LargeCS Corneal-ScleralCSB Corneal-Scleral Bi-CurveCSC Corneal-Scleral Compound CurveCT Circle TaperCTB Circle Taper BluntCTX Circle Taper Extra LargeCTXB Circle Taper Extra Large BluntCV CardiovascularDC Dura ClosureDP Double PointEN Endoscopic NeedleEST Eyed Straight TaperFN For TonsilFS For SkinFSL For Skin Large

CODE MEANING

FSLX For Skin Extra LargeG GreishaberGS Greishaber SpatulaJ ConjunctiveKS Keith StraightLH Large HalfLR Larger RetentionLS Large SternotomyM MuscleMF Modified FergusanMH Medium Half (circle)MO MayoMOB Mayo BluntOPS Ocular Plastic SurgeryOS Orthopaedic SurgeryP PlasticPC Precision CosmeticPS Plastic SurgeryRB Renal (artery) BypassRD Retinal DetachmentRH Round Half (circle)RV Retinal-VitreousS SpatulaSC Straight CuttingSFS Spatulated for SkinSH Small Half (circle)SIF Ski Intraocular FixationSKS Sternotomy Keith StraightSM Spatulated ModuleST Straight Taper

CODE MEANING

STB Straight BluntSTC Straight CuttingSTP Straight Taper PointTE Three-EighthsTF Tetralogy of FallotTG Transverse GroundTGW Transverse Ground WideTN Trocar NeedleTP Taper Pericostal / PointTPB Taper Pericostal /Point BluntTS Tendon StraightTQ Twisty QUCL 5/8 Circle Colateral LigamentUR UrologyURB Urology BluntV TAPERCUT Surgical NeedleVAS Vas DeferensX or P Exodontal (dental)XLH Extra Large Half (circle)XXLH Extra Extra Large Half (circle)

CODE MEANING

TABLE1

penetration. It also minimizes the risk of leakage from friable vessels or vascular graft material.

BLUNT POINT NEEDLESBlunt point (BP) needles can literally dissect friable tissue ratherthan cutting it. They have a taperbody with a rounded, blunt pointthat will not cut through tissue.They may be used for suturing theliver and kidney. Due to safety considerations, surgeons also useblunt point needles in obstetric and gynecological procedures whenworking in deep cavities which are prone to space and visibility limitations. In addition, blunt point needles for general closure areespecially helpful when performingprocedures on at-risk patients.

The ETHIGUARD* blunt pointneedle combines the safety of theblunt point with the security of aribbed and flattened design, and theconvenience of a swaged needle.

NEEDLEHOLDERSThe surgeon uses the needleholderto pass a curved needle through tissue. It must be made of noncor-rosive, high strength, good qualitysteel alloy with jaws designed forholding the surgical needle securely.

Needleholder jaws may be short orflat, concave or convex, smooth orserrated. Smooth jaws may allow theneedle to wobble or twist. Jaws withteeth hold most securely but maydamage the suture or needle if toomuch pressure is applied. Most, butnot all, needleholders have a ratchetlock near to thumb and finger rings.

Surgical needles are designed for

optimum needleholder stability.Because this tool actually drives theneedle, its performance will have animpact upon the entire suturingprocedure. The surgeon has maxi-mum control only when the needlesits well in the holder without wob-bling as it is passed through tissue.Needleholders, like pliers, weakenwith repeated use. Therefore, thescrub person should check beforeeach procedure to make sure thatthe needleholder jaws align properlyand grasp securely.

When selecting a needleholder, the following should be taken into consideration:

It must be the appropriate size for the needle selected. A very small needle should be held with small, fine jaws. The larger and heavier the needle, the wider and heavier the jaws of the needle-holder should be.

It should be an appropriate size for the procedure. If the surgeon is working deep inside the body cavity, a longer needleholder is in order.

NEEDLEHOLDER USEThe following guidelines are offeredto the scrub person for needleholderuse:

1. Grasp the needle with the tip of the needleholder jaws in an area approximately one-third to one-half of the distance from the swaged end to the point. Avoid placing the holder on or near the swaged area which is the weakest part of the needle.

2. Do not grasp the needle too tightly as the jaws of the needle-holder may deform, damage, or bend it irreversibly.

3. Always check alignment of the needleholder jaw to make certainthe needle does not rock, twist, or turn.

4. Handle the needle and needle-holder as a unit.

5. Pass the needleholder to the surgeon so that he or she will not have to readjust it before placing the suture in tissue. Make sure the needle is pointing in the direction in which it will be used and that the suture strand is


REVERSECUTTINGNEEDLE

FIGURE11

Smooth Jaws Jaws with tungstencarbide particles

Jaws with teeth

* Trademark

not entangled.

6. Always provide a needleholder—never a hemostat—to pull the needle out through tissue. A hemostat or other clamp can damage the needle.

7. Immediately after use, every needle should be returned to the scrub person while clamped in a needleholder. Needles are less likely to be lost if they are passed one-for-one (one returned for each one received).

PLACING THE NEEDLE IN TISSUEThe actual placement of the needle in the patient's tissue cancause unnecessary trauma if doneincorrectly. Keep the following inmind during suturing:

1. Apply force in the tissue to be sutured in the same direction as the curve of the needle.

2. Do not take excessively large bites of tissue with a small needle.

3. Do not force a dull needle through tissue. Take a new needle.

4. Do not force or twist the needle in an effort to bring the point out through the tissue. Withdraw the needle completely and then replace it in the tissue, or use a larger needle.

5. Avoid using the needle to bridge or approximate tissues for suturing.

6. Do not damage taper points or cutting edges when using the needleholder to pull the needle through tissue. Grasp as far back on the body as possible.

7. Depending upon the patient, the tissue may be tougher or more

fibrous than anticipated and require the use of a heavier gauge needle. Conversely, a smaller needle may be required when tissue is more friable than usual.

8. In a deep, confined area, ideal positioning of the needle may not be possible. Under these circumstances, proceed with caution. A heavier gauge needle or a different curvature may help and a second needleholder should be used to locate a needle in a confined body cavity.

9. If a glove is punctured by a needle, the needle must be discarded immediately and the glove must be changed for the safety of the patient, as well as the surgical team. Appropriate

serological testing of the patient should be undertaken for transmissable agents such as hepatitis B and C and HIV.

NEEDLE HANDLING TIPSNeedles should be protected frombacterial contamination and damageduring handling by adhering to thefollowing guidelines:

1. Open needle packets and prepare sutures carefully, protecting needle sharpness.

2. Make sure the needle is free of corrosion.

3. If using eyed needles, make sure they do not have rough or sharp

CHAPTER 3 53

PLACEMENTOF THE NEEDLE INTISSUE1. The surgeon receives the

needleholder with the needle point toward the thumb to prevent unnecessary wrist motion. The scrub person controls the free end of the suture to prevent dragging it across the sterile field, and to keep the suture from entering the surgeon’s hand along with the needleholder.

2. The surgeon begins closurewith theswaged suture.

3. The needle is passed into the tissue. The surgeon releases the needle from the holder and reclamps the holder onto the body of the needle near the point end to pull the needle and strand through tissue. The needle is released or cut from the suture strand. The surgeon leaves the needle clamped in the same position and returns it to the scrub person. The scrub person immediately passes another prepared suture to the surgeon, one-for-one.

FIGURE14


edges inside the eye to fray or break suture strands. Also check the eyes for burrs or bluntness to ensure easy penetration and passage through tissue.

4. If a needle is defective, discard it.

5. Pass needles on an exchange basis; one is passed to the surgeon for one returned.

6. Employ the nontransfer technique to avoid inadvertent needlesticks: the surgeon places the needle and needleholder down in a neutral area of the sterile field; the scrub person then picks up the needleholder.

7. Secure each needle as soon as it is used. Do not allow needles to lie loose on the sterile field or Mayo stand. Keep them away from sponges and tapes so they will not inadvertently be dragged into the wound.

8. If a needle breaks, all pieces mustbe accounted for.

9. Count all needles before and after use according to hospital procedure. Retain the packets containing descriptive information on quantity and needle type for swaged needles to help determine if all are accounted for.

Follow these steps for safe needlehandling:

1. Use sterile adhesive pads with or without magnets or disposable magnetic pads to facilitate counting and safe disposal.

2. Swaged needles can be inserted through or into their original packet after use. An empty packet indicates a missing needle. If using an E-PACK* procedure kit, compare the count of needles

used to the number preprinted on the kit label.

3. Return eyed needles to the needle rack. If eyed needles are to be reused, they must be cleaned and reprocessed at the end of the operation.

4. Do not collect used needles in a medicine cup or other container since they must then be handled individually to count them. This can potentially contaminate gloves and increase the risk of an accidental puncture.

5. Discard used needles in a "sharps" container.

IN THE NEXT SECTIONIn the section that follows, the dual role that suture and needlepackaging plays will be covered.Packaging does much more thankeep the needle and suture sterile.Package design can help or seriously hinder the efficiency of the surgical procedure.

PACKAGING

CHAPTER 4

AN INTEGRAL PART OF THE PRODUCT

The purpose of a package is to protect its contents and provideconvenience to the user.ETHICON* wound closure packaging is an integral part of each product. Over the past half acentury, packaging has evolved from glass tubes packed in jars,to multi-layered foil and paperpackages, to new materials thatreflect concern for both the environment and the individualswho must maintain operative sterility and efficiency. Packaginghas kept pace with the technologicaldevelopments of wound closureproducts themselves. Several factorshave influenced these developments:

Increasing product diversity

Technological advances in packaging materials

Stringent regulatory requirements

To prevent infection in an operativewound, all instruments and suppliesthat come in contact with thewound must be sterile (free of living microorganisms and spores)including sutures, needles, ligatingclips, stapling instruments, adhesivetapes and topical skin adhesives.High standards and criteria are setfor all components in the packagingof sterile products:

1. Protect and preserve product stability and sterility from potential deterioration from outside forces such as oxygen, moisture, light, temperature, dust, and vermin.

2. Prevent product damage or microbial contamination in transit and storage.

3. Provide identifiable product

information.4. Permit convenient, safe, and

sterile transfer of the product from the package to the sterile field.

5. Meet the functional needs of all members of the surgical team.

RELAY* SUTUREDELIVERY SYSTEMMost suture materials are packagedand sterilized by the manufacturer.They arrive ready for use in boxeswhich can be stored until needed.The RELAY* suture delivery system,developed by ETHICON withhuman, clinical, and environmentalfactors in mind, stores and deliverssutures in a time-efficient mannerand reduces unnecessary handlingto access sutures. The system also provides control over suturestorage, usage, inventory rotation,needle counting, and cost contain-

ment. The RELAY suture systemconsists of three basic, interrelatedcomponents: modular suture storage racks, dispenser boxes, and primary packets.

MODULAR STORAGE RACKSThe modular storage racks aredesigned for maximum convenienceand versatility to meet the individ-ual needs of a particular specialty,nurse, surgeon, or department.Modules can be easily assembled to accommodate both vertical andhorizontal suture dispenser boxes.Any number of modules can be fastened together to meet both small and large storage needs. Once assembled, the racks may beused on shelves, mounted on walls,placed on mobile carts, or connected to IV poles. Racks canalso be fitted with a rotating basefor more convenient access, as wellas with a handle for easy carrying.Each module has a built-in

PACKAGING56

ETHICONMODULARSTORAGERACKS

FIGURE1

Full-vertical boxes Half-vertical boxes

Horizontal boxes Combination of boxes

inventory control area to facilitaterestocking. This feature enablesunused suture packets to be systematically fed back into theproper rotational flow without mixing lots within the boxes.Sutures may be grouped within the modular system by material type or size, or by use (i.e., generalclosure, gastrointestinal surgery,plastic surgery, etc.).

DISPENSER BOXESGravity-fed dispenser boxes dispensesuture packets from the opening atthe bottom of the box. The openingcan accommodate the removal ofseveral suture packets at one time.

All ETHICON* dispenser boxes are made of recyclable paper and printed with either water orsoy-based inks. Each box providesclear product identification throughstreamlined graphics, product color coding, bold label copy, and descriptive symbols. The information required for quick reference and easy selection ofsuture materials is highlighted in alogical sequence. The three mostimportant criteria necessary forproper identification and sutureselection are:1. Suture size2. Suture material3. Type and size of needle

Other important product information found on all sutureboxes includes:1. Surgical application2. Product code number3. Suture length and color4. Metric diameter equivalent of

suture size and length5. Shape and quantity of needles

(single- or double-armed, shown

by silhouette)6. Needle point geometry7. Lot number8. Expiration date

A package insert with detailed infor-mation about the suture material isinserted in every dispenser box. Usersshould be familiar with this informa-tion as it contains FDA-approvedindications, contraindications, andall appropriate warnings and precau-tionary statements for each product.

Dispenser boxes should be restockedwhen the last few suture packetsappear in the box opening, beforethe box is completely empty. Theunused packets from the previousbox should be used before a newdispenser box is opened. This willhelp to avoid mixing lot numbersand ensure proper stock rotation.ETHICON advocates rotation of the entire dispenser box. In addition to ensuring the use of theoldest suture materials first, thishelps to maintain a fresh stock ofdispenser boxes.

Most dispenser boxes contain three dozen suture packets. Othersmay contain one or two-dozenpackets. The product code numbersuffix and a statement on the boxindicate the quantity of suture packets in the box (product codesuffix G = 1 dozen, D = 1 dozen, T = 2 dozen, H = 3 dozen). Thedispenser boxes are held securely foreasy dispensing by firmly pushingthe box into a "lock" in the back ofthe rack module.

PRIMARY PACKETSIndividual sutures and multiplesuture strands are supplied sterilewithin a primary packet. The exterior surfaces of the overwrap are

not sterile. ETHICON primarypackaging is designed to permit fastand easy opening in one peelablemotion. The single layer overwrapof primary packaging is made ofeither foil or coated Tyvek® on oneside heat-sealed to polyethylene filmon the other. Absorbable sutures arealways encased in foil to provide asafe and durable moisture barrierand to withstand sterilization in the manufacturing process. Mostnonabsorbable sutures are encasedin coated Tyvek® overwraps.

In a continuous effort to be moreenvironmentally conscious,ETHICON has chosen materials in the manufacture of primary packets which generate minimalnegative impact to the environmentupon incineration or disposal.Furthermore, wherever possible, the number of primary packaginglayers has been reduced by as much as 50 percent, thus reducingthe volume of environmental wasteper OR procedure.

Each primary packet provides critical product information and the same color-coding as its dispenser box. The packet also identifies the product code number,material, size, needle type, and thenumber of needles per packet tosimplify needle counts.

Primary packets of suture materialmay contain sutures in one of five styles:1. Standard lengths of non-needled

material: 54 inches (135cm) of absorbable or 60 inches (150cm) of nonabsorbable suture, which may be cut in half, third, or quarter lengths for ligating or threading.

2. SUTUPAK* pre-cut sterile suture * Trademark

CHAPTER 4 57

is nonneedled material for ligating or threading. These lengths may be supplied in a multistrand labyrinth packet or in a folder packet, both of which are designed to deliver one strand at a time. SUTUPAK sutures may be removed from the packet and placed in the suture book.

3. One single strand of material with single- or double-armed swaged needle(s). Needles for one-step RELAY suture packets, micro-surgery, and some ophthalmic needles are secured in a "needle park." The needle park is designed to provide a standard location for, and easy access to, the needle. All other needles are protected within an inner folder or other specific channel within a paper folder.

Most single strand needled sutures are sealed in convenient one-step RELAY delivery packages. One-step RELAY pack-ages allow the needle to be armed in the needleholder from any angle without touching the needle. This increases the safety of handling needles intraopera-tively. If it is preferred to locate the needle by hand, this can be accomplished with the one-step RELAY package by pushing up the flap behind the needle park, thereby elevating the needle so it can be grasped by hand.

4. Multiple suture strands, either swaged to a single needle or double-armed. This type is appropriate for procedures requiring numerous interrupted sutures of the same type. It saves valuable operative time by enabling the surgeon to use one

PACKAGING58

MOST COMMONETHICONSUTURE PACKAGING

TABLE1

Surgical Gut Suture

Coated VICRYL* RAPIDE(polyglactin 910) suture

MONOCRYL*(poliglecaprone 25) suture

Coated VICRYL* Plus(polyglactin 910) suture

Coated VICRYL*(polyglactin 910) suture

PDS* II (polydioxanone) suture

PERMA-HAND* Silk Suture

Stainless Steel Suture

ETHILON* nylon suture

NUROLON* nylon suture

MERSILENE* polyester fiber suture

ETHIBOND* EXCELpolyester fiber suture

PROLENE* polypropylene suture

PRONOVA* poly (hexafluoropropylene-VDF) suture

ABSORBABLE SUTURE LAYERS

Tyvek® overwrap, foil primary package containing one-step RELAY* suture delivery system tray

Tyvek® overwrap, foil primary package,paper folder

Peelable foil overwrap, one-step RELAY tray




Tyvek® overwrap, one-step RELAY tray

Tyvek® overwrap, paper folder







NONABSORBABLE SUTURE LAYERS

METHOD FORPREPARING ONE-STEP RELAY PACKAGESUTURES

FIGURE2

Arm the needle directly from the one-step RELAY tray anddeliver the single suture to the surgeon.

Tyvek® is a registered trademark of E.I. du Pont de Nemours and Company

* Trademark

suture while the next is being armed—without delay of open-ing packets or threading needles.

Multistrand packets are labeled with the symbol MS/ that denotes multiple strands/number of strands of surgical needles per packet. Multistrand packets may contain 3 to 10 swaged sutures. The inner folder for these products is white.

All packets containing CONTROL RELEASE* needle sutures have multiple strands (8, 5, 4, 3, or 1) and are designated CR/8, CR/5, CR/4, CR/3, or CR/1. CONTROL RELEASE sutures may be available in foil or Tyvek®

overwrap packets for single strand delivery. The single strand delivery folder is used for some coated VICRYL* (polyglactin 910) sutures, MONOCRYL* (poliglecaprone 25) sutures, PDS* II (polydioxanone) sutures, ETHIBOND* EXCEL polyester sutures, NUROLON* nylon sutures, MERSILENE* polyester sutures, and PERMA-HAND* silk sutures. The suture material straightens as it is delivered from the folder. Each suture may be delivered to the surgeon individ-ually from the opening packet or removed from the folder and placed in the suture book. The inner folder for these products is either red with a black C/R symbol or white with red lettering. The safety organizer tray is used for coated VICRYL sutures, MONOCRYL sutures, PDS II sutures, ETHIBOND EXCEL sutures, PERMA-HAND silk sutures, NUROLON nylon

sutures, MERSILENE sutures, and surgical gut sutures. The safety organizer tray allows for single strand arming and dispensing. The needles are situated in individually num-bered needle parks and may be armed and dispensed with little or no hand-to-needle contact.

5. Ligating material used as either single strand (free or freehand) ties, or as continuous ties unwound from a reel or other device. The length of single strand ties is determined by the depth of the wound. In subcuta-neous tissue, quarter lengths (approximately 14 inches) are usually long enough for ligating. Single strand ligating material is available in pre-cut lengths or 18, 24, and 30 inch strands.

Many surgeons prefer continuous ties. Some prefer LIGAPAK* ligature, which is supplied on disc like plastic radiopaque dispensing reels that are color coded by material. The size of the ligature material is indicated by the number of holes visible on the side of the reel (e.g., 3 holes= 3-0 suture). The reel is held in the palm of the hand as blood vessels are ligated. Other surgeons may prefer the ligating material rewound onto a rubber reel, gauze sponge, metal bobbin, or other device.

The number of packets of ligating material required to tie off subcutaneous vessels (bleeders) will vary with patient size and age, the amount of bleeding, the type of operation, the length of the incision, and the surgical technique. An

abdominal incision 8 to 12 inches long might require one to three packets to ligate the subcutaneous blood vessels.

All suture material is packaged dry with the exception of surgicalgut and pliabilized ETHILONsutures. Natural absorbable suturematerials are packaged with a small amount of sterile fluid, usually alcohol with water, to maintain pliability. They shouldtherefore be opened over a basin toprevent any solution from spillingonto the sterile field.

All needles should be countedafter packets of swaged sutures are opened, according to established hospital procedure. The packets should be retained to facilitate verification of the final needle count after the surgical procedure.

E-PACK* PROCEDURE KITThe E-PACK procedure kit contains numerous sutures andother products for a specific procedure, surgeon, or surgical specialty. The packaging conceptsaves valuable time in the OR byeliminating the need to open andcoordinate multiple individualsuture packages. The E-PACK procedure kit is also an effectivemeans of reducing inventory levels of individual product codes, and providing a record for determining the suture costs associated with a given surgical procedure.The suture packages are secured

CHAPTER 4 59

PACKAGING60

in an organizer sleeve to facilitatesterile transfer to the sterile field.The procedure kit label provides allthe pertinent information regardingthe number and types of needles, aswell as sizes and types of suture.Suture quantities are listed on thelabel, making it easy to quicklydetermine how many needles havebeen used and thus simplifying needle accountability at the end ofthe procedure. The organizer sleeveis delivered in a Tyvek® pouch.

EXPIRATION DATE

The expiration date of a product isdetermined by product stabilitystudies. The Food and DrugAdministration (FDA) requires that all synthetic absorbable sutureproducts have an expiration datestamped on each dispenser box and primary packet to indicate the known shelf life of the material,provided the physical integrity of the package is maintained. Tests conducted by ETHICON*show conclusively that syntheticabsorbable suture products such as Coated VICRYL* suture and PDS* II suture continue to meet all product requirements even at five years of storage.

In addition, all ETHICON nonabsorbable suture products contain a five-year expiry dating on each dispenser box and primary packet. This expiry dating is necessary to comply with various international regulatory guidelines and is an aidin inventory management.

The RELAY suture delivery systemis designed as a "first-in, first-out"inventory control system. Dispenserboxes are rotated, permitting theoldest sutures to be used first. Theexpiration date stamped on the outside of each box and every packet clearly indicates the monthand year of product expiration.

SUTURE STERII IZATIONSutures sterilized by ETHICON areeither irradiated with cobalt 60 orexposed to ethylene oxide gas. Bothprocesses alter proteins, enzymes,and other cellular components tothe extent that microorganisms areunable to survive or cause infection.Irradiation and ethylene oxide gasare considered cold sterilizationprocesses because radiation sterilizesat room temperature and ethyleneoxide gas sterilizes at much lowertemperatures than other sterilizationmethods such as dry heat or steamunder pressure.

Irradiation sterilization exposesproducts to ionizing radiation—either beta rays produced by highenergy electron accelerators orgamma rays from radioisotopes—until absorbed in appropriate sterilizing dose. ETHICON was a pioneer in both beta and gamma irradiation and routinelysterilizes products with cobalt 60 which emits gamma rays. Cobalt 60 irradiation is the simplestof all sterilization processes.

Some suture materials cannot withstand the effects of irradiationsterilization, becoming unusable.Instead, they are gas sterilized.

Gas sterilization uses ethylene oxide gas. As an environ-mental measure, ETHICONreplaced chlorofluorocarbons(CFCs) with more environmentallyfriendly compounds in all gas sterilization processes. The combination of ethylene oxide gas concentration, temperature,humidity, and exposure time mustbe carefully controlled to ensurereliable sterilization.

WARNING: Surgical sutures arelabeled as disposable, single-usemedical devices. Suture productsmanufactured by ETHICON areprovided in easy-to-use packagesdesigned to maintain the stabilityand sterility of the suture and needle materials. The componentlayers of packaging materials donot permit exposure to high temperatures or extremes of pres-sure without affecting package andproduct integrity. For this reason,all sterile products manufacturedby ETHICON are clearly labeled,"DO NOT RESTERILIZE."

Manufacturers cannot be heldresponsible for the quality, effectiveness, or integrity of suture materials resterilized in the hospital, office, or by outsidevendors. Therefore, if customersutilize the services of a sterilizationreprocessor for suture, ETHICONwill disclaim any responsibility forsterilization and/or other productfailures resulting from the resteril-ization process. The practice ofresterilization is not recommended,except for ETHI-PACK* pre-cutsteel sutures and spools or cardreelsof nonabsorbable materials supplied nonsterile.

* Trademark

CHAPTER 4 61

ANTICIPATING SUTURE NEEDS

Today's healthcare environment dictates that hospitals continue tomaintain quality standards whilelowering costs to remain financiallyviable. Through total quality man-agement initiatives, many hospitalshave identified material use as anopportunity to lower cost. Toincrease the efficiency of suture utilization during a surgical procedure, it is important to determine and anticipate the surgeon's needs more precisely. For this reason, a file system of preference cards for each surgeon on staff is usually maintained in theoperating suite. The cards containsuch information as the surgeon's"suture routine," suture materials,sizes, needles, and/or product code numbers customarily used inspecific procedures.

Becoming more aware of each surgeon's routine through goodcommunication and regularlyupdated preference cards can helpreduce preparation time, minimizewaste, and assure cost effectiveness.Prior to dispensing suture packets,the circulating nurse should have abrief discussion with the surgeon toascertain whether a change in sutureroutine is anticipated due to a specific patient's needs.

While it is difficult to say preciselyhow many suture packets areenough, three major factors shouldbe considered in deciding howmany packets to open:

1. Fewer packets will be needed if products with multiple strands of suture material are used.

2. Opening sufficient suture packets to prevent prolonging operative time and causing surgeon inconvenience.

3. Leftover suture on the surgical field must be discarded. Therefore, opening too many suture packets should be avoided to reduce waste and to lower cost.

Although it is important to be prepared to answer requests at a moment's notice, it is not necessaryto overload the table with sutures.The introduction of single-layerpeelable packaging, such as one-stepRELAY* packaging, helps encourageless handling to access the suture,enhancing quick delivery of suturematerials to the surgeon in the sterile field. Unexpected sutureneeds can also be obtained rapidlyfrom the storage racks.

STERILE TRANSFER OFSUTURE PACKETSAt some point, suture packets must cross the sterile barrier—theinvisible line of demarcationbetween the sterile and the nonster-ile. In all settings (e.g., operatingroom, delivery room, emergencydepartment, or physician's office),the individual who removes the nonsterile overwrap mustremember these three points aboutsterile transfer:

1. Outer surfaces of the overwrap are not sterile and may be handled with nonsterile hands.

2. The sterile inner packet or tray must be transferred to the sterile field without being touched or contacting any nonsterile object or surface.

3. Nonsterile hands over the sterile field violate aseptic technique.

There are two methods commonlyused for achieving sterile transfer of suture packets: handing-off thesterile inner one-step RELAY traydirectly to the scrub person or "flipping" the inner contents of theprimary packet onto the sterile field.Regardless of the aseptic techniqueperformed, all items introducedonto the sterile field should beopened, dispensed, and transferredby methods that maintain productsterility and integrity. AORNGuidelines recommend the “hand-off” method, since itemstossed or flipped have a greaterpotential to roll off the edge of thesterile field, causing contaminationor other items to be displaced.

METHOD I: STERILE TRANSFER TOTHE SCRUB PERSONGrasp the two flaps of the peelableoverwrap between the knuckles ofthe thumbs and forefingers. With a rolling-outward motion, peel the flaps apart to approximatelyone- third of the way down thesealed edges. Keeping pressurebetween the knuckles for control,offer the sterile inner packet or tray to the scrub person, who takesit with a gloved hand or sterileinstrument. Care must be taken toavoid contact with the nonsterileoverwrap as the packet or tray is withdrawn.

This method must be used toremove paper folder packets of sur-gical steel and PROLENE* suturesfrom long straight overwraps, and toremove the organizer sleeves fromE-PACK* procedure kits. It shouldalso be used for transfer of flexible,

lightweight, transparent packetscontaining microsurgery and oph-thalmic products.

METHOD II: STERILE TRANSFER TOTHE STERILE FIELD"Flipping" is a rapid and efficientmethod of ejecting sterile productfrom its overwrap onto the sterilefield without contacting the unsterile outer packet or reachingover the field. However, skill mustbe acquired to ensure its effectiveuse. The circulating nurse muststand near enough to the steriletable to project the suture packet or tray onto it, but not too close as to risk contaminating the tableby touching it or extending

nonsterile hands over it. To accomplish this, grasp the flapsof the overwrap as described inMethod I and peel the flaps apartwith the same rolling-outwardmotion. The sterile packet or tray is projected onto the sterile table as the overwrap is completely peeled apart. NOTE: DO NOT attempt to proj-ect the inner folder of long straightpackets onto the sterile table.

Instead, present them to the scrubperson as outlined in Method I.

SUTURE PREPARATION IN THE STERILE FIELDSuture preparation may be moreconfusing than virtually any otheraspect of case preparation.Familiarity and understanding ofthe sequence in which tissue layersare handled by the surgeon will helpto eliminate this confusion. (See theSuturing Section, Chapter 2.)

Once the suture packets are openedand prepared according to the surgeon's preference card, suturescan be organized in the sequence inwhich the surgeon will use them.Ligatures (ties) are often used firstin subcutaneous tissue shortly afterthe incision is made, unless ligatingclips or an electrosurgical cauterydevice is used to coagulate severedblood vessels.

After the ligating materials havebeen prepared, the suturing(sewing) materials can be preparedin the same manner. Preparing largeamounts of suture material in

PACKAGING62

STERILETRANSFERTO THESCRUB PERSON

FIGURE3 FIGURE

4

PREPARATION OF STANDARD LENGTH LIGATURE STRANDS

1. Prepare cut lengths of ligature material, coil around fingers of left hand, grasp free ends with right hand, and unwind to full length.

2. Maintain loop in left hand and two free ends in right hand. Gently pull the strand to straighten.

3. To make 1/3 lengths: Pass one free end of strand from right to left hand. Simultaneously catch a loop around third finger of right hand. Make strands equal in thirds and cut the loops with scissors.

4. To make 1/4 lengths: Pass both free ends from right to left hand. Simultaneously catch a double loop around third finger of right hand. Cut the loops.

5. Place packets or strands in suture book (folded towel)—or under Mayo tray—with ends extended far enough to permit rapid extraction.

advance should be avoided. Forexample, if the surgeon opens theperitoneum (the lining of theabdominal cavity) and discovers disease or a condition that altersplans for the surgical procedureand anticipated use of sutures,opened packets would be wasted. At closure following abdominal surgery, remembering the lettersPFS (peritoneum, fascia, skin) will be helpful for organizing sutures.

By watching the progress of the procedure closely, listening to comments between the surgeon and assistants, and evaluating the situation; suture needs can be anticipated. Free moments can

be used to prepare sufficient suturematerial to stay one step ahead ofthe surgeon. The goal should be tohave no unused strands at the endof the procedure.

Ligature material which remainstoward the end of the proceduremay be the same material and sizespecified by the surgeon for suturesin the subcutaneous layer of woundclosure. In this case, the remainingligating material should be usedrather than opening an additionalsuture packet.

If the surgeon requires "only one more suture," and strands ofsuitable material remain which

are shorter than those prepared originally, do not be reluctant to ask the surgeon if one of the strands will serve the purpose before opening a new packet. Most surgeons are cooperative inefforts to conserve valuable supplies.

SUTURE HANDLING TECHNIQUEDuring the first postoperative week,the patient's wound has little or nostrength. The sutures or mechanicaldevices must bear the responsibilityof holding the tissues together during this period. They can onlyperform this function reliably if thequality and integrity of the wound

* Trademark

CHAPTER 4 63

FIGURE5

PEPARATION OF PRE-CUTSUTURES FOR TIES OR LIGATURESUTURES

PREPARATION OF CONTINUOUS TIES ON A LIGAPAK DISPENSING REEL

3. Hand reel to surgeon asneeded, being certain thatthe end of the ligatingmaterial is free to grasp.

4. Surgeon holds reel in palm, feeds strand beween fingers, and places around tip of hemostat.

1. Open the packet contain-ing the appropriate material on a reel. Transfer the inner contents of the primary packet to the sterile field using aseptic technique.

2. Extend the strand end slightly for easy grasp-ing. Place reel conviently on the Mayo tray.

FIGURE6

1. Remove one pre-cut length from nonabsorbable suture at a time from the labrinth packet as it is needed by the surgeon.

2. Extract pre-cut strands of SUTUPAK* sterile absorbable or nonabsorbable suture. Straighten surgical gut with a gentle pull. Place strands in the suture book or under Mayo tray.

closure materials are preserved during handling and preparationprior to use. It is therefore essentialfor everyone who will handle thesuture materials to understandproper procedure to preserve suture tensile strength.

In general, avoid crushing or crimping sutures with surgicalinstruments such as needleholdersand forceps, except as necessary to grasp the free end of a sutureduring an instrument tie. There are also specific procedures to follow to preserve suture tensilestrength which depend uponwhether the material is absorbableor nonabsorbable. The followingsummarizes the most importantpoints for each member of the surgical team to remember andobserve in handling suture materialsand surgical needles.

FOR THE CIRCULATING NURSE

1. Consult the surgeon's preference card for suture routine.

2. Check the label on the dispenser box for type and size of suture material and needle(s). Note the number of strands per packet. Fewer packets will be needed if multistrand or CONTROL RELEASE* sutures are used.

3. Estimate suture requirements accurately and dispense only the type and number of sutures required for the procedure.

4. Read the label on the primary packet or overwrap before using to avoid opening the wrong packet.

5. Use aseptic technique whenpeeling the overwrap. Transfer the inner contents of the primary packet to the sterile field by offering it to the scrub person or

by projecting (flipping) it onto the sterile table, avoiding contamination.

6. To open long straight packets, peel overwrap down 6 to 8 inch-es and present to the scrub person. Do not attempt to project the inner folder of long straight packets onto the sterile table.

7. Maintain an adequate supply of the most frequently used sutures readily accessible.

8. Rotate stock using the "first-in, first-out" rule to avoid expira-tion of dated products and keep inventories current.

9. Suture packets identify the number of needles per packet to simplify needle counts. Retain this information during the procedure and/or until final needle counts are completed.

10. Count needles with the scrub person, per hospital procedure.

FOR THE SCRUB PERSON

1. If appropriate, remove the inner one-step RELAY* tray or folder containing suture materials from the primary packet being offered from the circulating nurse.

2. Hold the one-step RELAY tray or folder in gloved hand and arm the needle using the "no-touch" technique. Gently dispense the suture.

3. Leave pre-cut suture lengths in labyrinth packet on the Mayo tray. Strands can then be removed one at a time as needed.

4. Surgical gut and collagen sutures for ophthalmic use must first be rinsed briefly in tepid water to avoid irritating sensitive tissues.

PACKAGING64

ETHICONMODULARSTORAGERACKS

FIGURE7

1. With a rolling-outward motion, peel the flaps apart to approxi-mately ont-third the way down the sealed edges. Keeping pres-sure beween the knuckles for control, offer the sterile inner RELAY tray to the scrub person.

2. Clamp the needleholder approx-imately one-third to one-half of the distance from the swage area to the needle point. Do not clamp the swaged area. Gently pull the suture to the right in a straight line.

3. Additional suture straightening should be minimal. If the strand must be straightened, hold the armed needleholder and gently pull the strand making certain not to disarm the needle from the suture.

If the surgeon prefers to use sutures wet, dip only momentar-ily. Do not soak. Silk sutures should be used dry.

5. Do not pull or stretch surgical gut or collagen. Excessive handling with rubber gloves can weaken and fray these sutures.

6. Count needles with the circulating nurse, per hospital procedure.

7. Hold single strands taut for surgeon to grasp and use as a freehand tie.

8. Do not pull on needles to straighten as this may cause premature separation of CONTROL RELEASE needle suture.

9. Always protect the needle to prevent dulling points and cutting edges. Clamp the needle-holder forward of the swaged area, approximately one-third to one-half the distance from the swage to the point.

10. Microsurgery sutures and needles are so fine that they may be difficult to see and handle. They are packaged with the needles parked in foam to protect delicate points and edges. The needles may be armed directly from the foam needle park. If the microsurgeon prefers to arm the needle, the removable orange colored tab may be used to transport the needle into the microscopic field.

11. Handle all sutures and needles as little as possible. Sutures should be handled without using instruments unless absolutely necessary. Clamping instruments

on strands can crush, cut, and weaken them.

12. Cut sutures only with suture scissors. Cut surgical steel with wire scissors.

13. When requesting additional suture material from the circulating nurse, estimate usage as accurately as possible to avoid waste.

FOR THE SURGEON

1. Avoid damage to the suture strand when handling. This is particularly critical when handling fine sizes of monofila-ment material. Touch strands only with gloved hand or closed blunt instrument. Do not crush or crimp sutures with instru-ments, such as needleholders or forceps, except when grasping the free end of the suture during an instrument tie.

2. Clamp a rubber shod hemostat onto the suture to anchor the free needle on a double-armed strand until the second needle is used. Never clamp the portion of suture that will be incorporated into the closure or the knot.

3. Use a closed needleholder or nerve hook to distribute tension along a continuous suture line. Be careful not to damage the suture.

4. Use knot tying techniques that are appropriate for the suture material being used.

* Trademark

CHAPTER 4 65

PACKAGING66

PRESERVATIONOF TENSILESTRENGTH:ABSORBABLESUTURES

TABLE2

1. Protect absorbable sutures from heat and moisture.

a. Store suture packets at room temperature. Avoid prolonged storage in hot areas such as near steam pipes or sterilizers.

b. Do not soak absorbable sutures. Also avoid prolonged placement of sutures in a moist suture book.

c. Surgical gut can be dipped momentarily in tepid (room temperature) water or saline to restore pliability if strands dry out before use. Surgical gut or collagen for use in ophthalmic surgery should be rinsed briefly in tepid water before use, as they are packed in a solution usually consisting of alcohol and water to maintain pliability.

d. Synthetic absorbable sutures must be kept dry. Use strands directly from packet when possible. Store sutures in a dry suture book if necessary.

2. Straighten strands with a gently, steady, even pull. Jerking and tugging can weaken sutures.

3. Do not "test" suture strength.

4. Do not resterilize.

PRESERVATIONOF TENSILESTRENGTH:NONABSORBABLESUTURES

TABLE3

SILK – Store strands in a dry towel. Dry strands are stronger than wet strands. Wet silkloses up to 20% in strength. Handle carefully to avoid abrasion, kinking, nicking, orinstrument damage. Do not resterilize.

SURGICAL STAINLESS STEEL – Handle carefully to avoid kinks and bends. Repeatedbending can cause breakage. Stainless steel suture can be steam sterilized without anyloss of tensile strength. However, DO NOT steam sterilize on spool or in contact withwood. Lignin is leached from wood subjected to high temperature and may cling tosuture material. Handle carefully to avoid abrasion, kinking, nicking, or instrument dam-age.

POLYESTER FIBER – Unaffected by moisture. May be used wet or dry. Handle carefullyto avoid abrasion, kinking, nicking, or instrument damage. Do not resterilize.

NYLON – Straighten kinks or bends by "caressing" strand between gloved fingers a fewtimes. Handle carefully to avoid abrasion, kinking, nicking, or instrument damage.

POLYPROPYLENE – Unaffected by moisture. May be used wet or dry. Straightenstrands with a gentle, steady, even pull. Handle with special care to avoid abrasion,kinking, nicking, or instrument damage. Do not resterilize.

TOPICAL SKIN ADHESIVES

CHAPTER 5

Low tension wounds (those wherethe skin edges lie close togetherwithout significant tension) can beclosed by gluing the skin edgestogether with a skin adhesive.Butylcyanoacrylate adhesives havebeen available in Europe, Israel, andCanada for decades.1 They havebeen used successfully for the closure of traumatic lacerations andsurgical incisions. Application ofbutylcyanoacrylate was found to bemore rapid and cost effective thansuturing, but only recently has itbeen evaluated in well-designedclinical trials for wound closure.1

The most significant advance in the field of topical skin adhesiveshas been the development of 2-octyl cyanoacrylate, marketed as DERMABOND* Topical Skin Adhesive by ETHICON Products.This topical skin adhesive forms atransparent and flexible bond,unlike the opaque and brittle bondformed by butylcyanoacrylate adhesives. The flexibility of octyl cyanoacrylate allows it to beapplied over nonuniform surfaces.This flexibility also combats thetopical shear forces exerted on theadhesive, reducing the risk of premature sloughing and wounddehiscence. Additionally, octylcyanoacrylate adhesive has beenfound to have three times thebreaking strength of butylcyano-acrylate, so it can be used on longerincisions and lacerations.1

DERMABOND* TOPICAL SKIN ADHESIVE (2-OCTYL CYANOACRYLATE)is a sterile, liquid topical adhesivedesigned to hold closed, easilyapproximated skin edges of lacerations and surgical incisions.

It utilizes the moisture on the skin'ssurface to form a strong, flexiblebond and can be used in manyinstances where sutures, staples orskin strips have been traditionallyused. DERMABOND adhesive isideally suited for wounds on theface, torso and limbs. It can be usedin conjunction with, but not inplace of, deep dermal sutures.

Approved by the FDA in 1998,DERMABOND adhesive has been used extensively by health professionals in the fields of trauma and other surgeries, emergency medicine, and pediatrics.Since its approval, DERMABONDadhesive has been proven effectivein closing a variety of surgical incisions and wounds. Unlikesutures, the adhesive does not pro-duce suture or "track" marks alongthe healed incision and a patientcan shower right away without fearof compromising the incision.

HIGH VISCOSITY DERMABOND* TOPICAL SKIN ADHESIVE (2-OCTYL CYANOACRYLATE)High Viscosity DERMABONDadhesive is 6 times thicker 2 for better control, especially whererunoff is most likely to occur, suchas around the eyes and nose.

Dome-, Precision-Tip and NEWDERMABOND ProPen adhesiveapplicators allow for fine-line deliv-ery of adhesive2 – ideal for delicateskin closures on the face and nearthe eyes.

New DERMABOND ProPen adhesive and DERMABONDProPen XL adhesive deliver the highviscosity formulation with greaterease of use. DERMABOND

ProPen XL adhesive delivers twice asmuch adhesive for use on longerincisions and lacerations.

STRENGTH AND SECURITYIn less than three minutes, DERMABOND adhesive providesthe strength of healed tissue at7 days.2 A strong, flexible 3-dimensional bond makes it suitable for use in closing easily approximated incisions of manytypes (example—deep, short, long).3

SEALS OUT BACTERIADERMABOND adhesive isapproved to protect wounds and incisions from common microbes thatcan lead to infection. For trauma andpost-surgical patients, infections are often the most common, and insome cases, the most serious complications. DERMABONDadhesive helps protect against thepenetration of bacteria commonlyassociated with surgical siteinfections.2 In vitro studiesdemonstrated that DERMABONDacts as a barrier againstStaphylococcus epidermidis,Staphylococcus aureus, Escherichiacoli, Pseudomonas aeruginosa andEnterococcus faecium as long as theadhesive film remains intact.2

PROMOTES A MOIST,WOUND HEALING ENVIRONMENTDERMABOND adhesive creates aprotective seal and is an occlusivedressing that helps the wound staymoist.2 Maintaining a moist woundhealing environment around thewound has been shown to speed therate of epithelialization.4 As thewound heals, DERMABONDadhesive will gradually slough off(generally between 5 to 10 days).2

TOPICAL SKIN ADHESIVES68

PROVIDES EXCELLENT COSMETIC RESULTSIn a prospective, randomized, controlled, unmasked study of 818patients, DERMABOND adhesiveprovided cosmesis equivalent to thatof sutures. At 3 months, it producedoptimal cosmesis in 80% ofpatients, using the ModifiedHollander Cosmesis Scale.2

ADDITIONAL PHYSICIAN ANDPATIENT BENEFITSIn most cases, DERMABONDadhesive allows for significantlyfaster closure than sutures.3,5,6

DERMABOND adhesive application requires fewer surgicalsupplies, reduced equipment needs, and eliminates the need forsuture removal.6,7

DERMABOND adhesive is alsomore convenient and comfortablefor the patient because it often does not require anesthetic, is gentler to the skin than sutures orstaples, and does not require sutureremoval. DERMABOND adhesivealso reduces the risk of needle stick injury.

INDICATIONS ANDCONTRAINDICATIONSDERMABOND adhesive is intendedfor topical application only to holdclosed easily approximated skin edgesof wounds from surgical incisions,including punctures from minimallyinvasive surgery, and simple,thoroughly cleansed, trauma-inducedlacerations. DERMABOND adhesivemay be used in conjunction with, butnot in place of, deep dermal sutures. Topical skin adhesives are notappropriate for closing wounds thatare subject to significant static or

dynamic tensions unless deepsutures, immobilization, or both are also used.

DERMABOND adhesive is contraindicated for use on anywounds with evidence of activeinfection or gangrene. It should alsonot be used on mucosal surfaces oracross mucocutaneous junctions(e.g., lips, oral cavity), or on skinthat is regularly exposed to body fluids or with dense hair (e.g., scalp). DERMABOND adhe-sive should not be used on patientswith a known hypersensitivity tocyanoacrylate or formaldehyde.

APPLICATIONMastery of tissue adhesive use is generally quite rapid. Properwound selection, evaluation andpreparation before closure is important. Wounds must be thoroughly cleansed and debrided in accordance with standard practicebefore using adhesives. The woundedges must be tightly apposed sothat the adhesive is not placed into the wound. Patient positioningis also important to reduce runoff of tissue adhesive. The patientshould be positioned so that thewound surface is parallel to thefloor, taking special care that any runoff does not flow in thedirection of vital structures such as the eye.

TECHNIQUE1.Follow standard surgical practice

for wound preparation and achieve hemostasis.

2.Approximate skin edges and use deep sutures to relieve tension if necessary.

3.Crack the DERMABONDadhesive vial in the upright position, invert, and apply pressure to saturate the tip. Release pressure, then reapply pressure to express adhesive. When using the NEW DERMABOND ProPen adhesive applicator, simply twist the collar to crack the vial and lightly press the button to saturate the tip and express the adhesive.

4.Apply 2 thin layers of adhesive, waiting approximately 30 secondsbetween layers (NOTE: 3 layers of adhesive are required when using original DERMABOND adhesive.)

DIRECTIONS FOR USE1. The application of high viscosity

DERMABOND adhesive requires thorough wound cleansing. Follow standard surgical practice for wound preparation before application of high viscosity DERMABOND adhesive (i.e., anesthetize, irrigate, debride, obtain hemostasis and close deep layers).

2. Pat the wound dry with dry, sterile gauzeto assure direct tissue contact for adherence of the high viscosity DERMABOND adhesive to the skin. Moisture accelerates high viscosity DERMABOND adhesive’s polymerization and may affect wound closure results.

3. To prevent inadvertent flow of liquid high viscosity DERMABOND adhesive to unintended areas of the body, the wound should be held in a horizontal position and the high viscosity DERMABOND adhesive should be applied from above the wound.

* Trademark

CHAPTER 5 69

TOPICAL SKIN ADHESIVES70

DERMABOND Topical Skin Adhesive (2-octyl cyanoacrylate) is a sterile, liquid skin adhesive thatholds wound edges together. The film will usuallyremain in place for 5 to 10 days, then naturally fallsoff the skin.

The following provides instructions for proper care ofthe wound while it is healing:

CHECK WOUND APPEARANCESome swelling, redness and pain are common with allwounds and normally will go away as the woundheals. If swelling, redness, or pain increases or if thewound feels warm to the touch, instruct patients tocontact a doctor. A doctor should also be contacted ifthe wound edges reopen or separate.

REPLACE BANDAGESIf the wound is bandaged, the patient should beinstructed to keep the bandage dry. The dressingshould be replaced daily until the adhesive film hasfallen off or if the bandage should become wet, unlessotherwise instructed by the physician.

When changing the dressing, tape should not beplaced directly over the DERMABOND adhesivefilm, because removing the tape later may also remove the film.

AVOID TOPICAL MEDICATIONSInstruct patients not to apply liquid or ointment medications or any other product to the wound whilethe DERMABOND adhesive film is in place. Thesemay loosen the film before the wound is healed.

KEEP WOUND DRY AND PROTECTEDPatients may occasionally and briefly wet the woundin the shower or bath. They should not soak or scrubthe wound. They should not swim and should avoid periods of heavy perspiration until the DERMABOND adhesive has naturally fallen off.After showering or bathing, the patient should blot the wound dry with a soft towel. If a protective dressing is being used, a fresh, dry bandage should be applied, being sure to keep the tape off the DERMABOND adhesive film.

Additional instructions for patients include:

• Apply a clean, dry bandage over the wound if necessary to protect it.

• Protect the wound from injury until the skin hashad sufficient time to heal.

• Do not scratch, rub or pick at the DERMABOND adhesive film. This may loosen the film before the wound is healed.

• Protect the wound from prolonged exposure to sunlight or tanning lamps while the film is in place.

HOW TO CARE FOR A WOUND AFTER IT’S TREATED WITH DERMABOND* TOPICAL SKIN ADHESIVE

TABLE1

* Trademark

CHAPTER 5 71

4. High viscosity DERMABOND adhesivehould be used immediately after crushing the glass ampule, since the liquid high viscosity DERMABOND adhesive will flow freely from the tip for only a few minutes. Remove the applicator from the blister pouch. Hold the applicator with the thumb andfinger and away from the patient to prevent any unintentional placement of the liquid high viscosity DERMABOND adhesive into the wound or on the patient. While holdingthe applicator, and with the applicator tip pointed upward, apply pressure at the midpoint of the ampule to crush theinner glass ampule. Invert and gently squeeze the applicator just sufficiently toexpress the liquid high viscosity DERMABOND adhesive to moisten the applicator.

5. Approximate wound edges with gloved fingers or sterile forceps. Slowly apply the liquid high viscosity DERMABOND adhesive in multiple (at least 3) thin layers to the surface of the approximated wound edges using a gentle brushing motion. Wait approximately 30 seconds between applications or layers. Maintain manual approximation of the wound edges for approximately 60 seconds after the final layer.

NOTE: High viscosity DERMABOND adhesive polymerizes through an exothermic reaction. If the liquid high viscosity DERMABOND adhesive is applied so that large droplets are allowedto remain without being evenly spread, the patient may experience a sensation of heat or discomfort. The sensation may be higher on sensitive tissues. This can be minimized by applying high viscosity DERMABOND adhesive in multiple thin layers (at least 3).

NOTE: Excessive pressure of the applicator tip against the wound edges or surrounding skin can result in forcingthe wound edges apart and allowing high viscosity DERMABOND adhesive into the wound. High viscosity DERMABOND adhesive withing the wound could delay wound healing and/or result in adverse cosmetic outcome.

NOTE: Full apposition strength is expected to be achieved about 2.5 minutes after the final layer is applied, although the top adhesive layer may remain tacky for up to approximately 5 minutes. Full polymerization is expected when the tophigh viscosity DERMABOND adhesive layer is no longer sticky.

6. Do not apply liquid or ointment medications onto wounds closed with high viscosity DERMABOND adhesive because these substances can weaken thepolymerized film, leading to wound dehiscence.

7. Protective dry dressing such as gauze, may be applied only after high viscosity DERMABOND adhesive film is completely solid/polymerized: not tacky to the touch (approximately five minutesafter application). Allow the top layer to fully polymerize before applying a bandage.

If a dressing, bandage, adhesive backing or tape is applied before complete polymerization, the dressing can adhere to the film. The film can be disrupted from the skin when the dressing is removed, and wound dehiscence can occur.

8. Patients should be instructed to not pickat the polymerized film of high viscosity DERMABOND adhesive. Picking at the film can disrupt its adhesion to the skin and cause dehiscence of the wound.Picking at the film can be discouraged by an overlying dressing.

9. Apply a dry protective dressing for children or other patients who may not be able to follow instructions for proper wound care.

10. Patients treated with high viscosity DERMABOND adhesive should be provided the printed instruction sheet entitled, How to Care for Your Wound After It’s Treated With high viscosity DERMABOND Topical Skin Adhesive. This instruction sheet should be reviewed with each patient or guardian to assure understanding of the proper care for the treatment site.

11. Patients should be instructed that until the polymerized film of high viscosity DERMABOND adhesive has sloughed naturally (usually in 5-10 days), there

should be only transient wetting of the treatment site. Patients may shower and bathe the site gently. The site should notbe scrubbed, soaked, or exposed to prolonged wetness until after the film has sloughed naturally and the wound has healed closed. Patients should be instructed not to go swimming during this period.

12. If removal of high viscosity DERMABOND adhesive is necessary for any reason, carefully apply petroleumjelly or acetone to the high viscosity DERMABOND film to help loosen the bond. Peel off the film, do not pull the skin apart.

REFERENCES1. Singer, Adam J., Lacerations and

Acute Wounds, An Evidence-Based Guide; F.A. Davis Company, 2003, p. 83-97.

2. Data on file, ETHICON, INC.3. Quinn, G Wells, T Sutcliffe,

et al. A Randomized Trial Comparing Octyl Cyanoacrylate Tissue Adhesive and Sutures in the Management of Lacerations. JAMA 1997;227(19):1527-1530.

4. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med. 1997;337(16):1142-1148.

5. Bruns TB, Robinson BS, Smith RJ et al. A new tissue adhesive for laceration repair in children. J Pediatr. 1998;132:1067-1070.

6. Theodore N, et al. The Economics of DERMABOND in Neurosurgical Wound Closure. Phoenix, Ariz: Neuroscience Publications, Barrow Neurological Institute. March 2001:2-10.

7. Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr. 1995; 126:892-895.

OTHER SURGICAL PRODUCTS

CHAPTER 6

ADHESIVE TAPESThere are many surgical productsavailable which may be used duringwound closure and other operativeprocedures which involve suturing.Each of these products has specificindications for use. Adhesive tapesare used for approximating theedges of lacerations, skin closures,repair and/or support in selectedoperative procedures.

Adhesive tapes are associated withminimal tissue reactivity and yieldthe lowest rate of infection, but they tend to slough off in the presence of tension or moisture.1

Advantages of adhesive tapesinclude rapid application, little orno patient discomfort, low cost, andno risk of needle-stick injuries. Theyare associated with minimal tissuereactivity and yield the lowest infec-tion rates of any wound closuremethod. They may be left on forlong periods without resulting insuture hatch marks.

Surgical tapes are not commonlyrecommended as the sole modalityfor primary wound closure due to the high probability of

dislodgement and dehiscence, the inability to use them in hair-bearing areas, and the need to keep them dry. Their use is typically reserved for linear lacera-tions under minimal tension.Furthermore, surgical tapes do notapproximate deeper tissues and donot control bleeding.

INDICATIONS AND USAGESkin closure tapes are an effectivealternative to sutures or stapleswhen tensile strength and resistanceto infection are not critical factors.Skin closure tapes can also be used to complement suture or staple closures. Stress is applied uniformly to the collagen fibers,aiding in rapid fiber orientation and increased tensile strength.

APPLICATIONSkin closure tapes may be applied tothe skin over a subcuticular closurein lieu of skin sutures or used as aprimary closure in conjunction withsutures in an alternating pattern.The tape is placed on one side ofthe wound at its midpoint, whilegrasping it with forceps in the dominant hand. The opposite

wound edge is then gently apposedby pushing with a finger of the nondominant hand. The woundedges should not be apposed bypulling on the free end of the tape. This can result in unequal distribution of skin tensions, causing erythema or even blisteringof the skin. Additional strips arethen placed perpendicular to thelaceration on either side of the original tape, bisecting the remaining open wound with eachstrip until the space between tapes is no more than about 2 to 5 mm.Additional strips are then placedover the ends of the other strips,parallel to the laceration.

Skin closure tapes may also be usedas a replacement for sutures or staples which are removed on thefirst to fourth postoperative day.Effective skin closure tapes providegood porosity in terms of air inflowto the wound and water vaportransmission escaping from thewound during the healing process.

AFTER CARE AND REMOVALAdhesive tapes should be left inplace as long as possible, at least aslong as sutures would be left beforeremoval. To prevent the tapes fromprematurely coming loose, patientsmust be warned to keep them as dry as possible and not to coverthem with ointments. Showering is permitted and during the first week many surgeons recommend that patients cover their wounds and tape with a nonadherent dressing.

OTHER SURGICAL PRODUCTS74

ADVANTAGESAND DISADVANTAGESOF ADHESIVETAPES FOR SKIN CLOSURE1

TABLE1

ADVANTAGES DISADVANTAGES

• Rapid and simple closure

• Least damage to host defenses

• No risk of needle-stick injuries

• Do not cause tissue ischemia or necrosis

• Relatively poor adherence

• Easily removed by patient

• Must be kept dry

• Cannot be used over oily or hair-bearing areas

* Trademark

SKIN CLOSURE TAPESPROXI-STRIP* skin closures arelong, narrow, sterile strips of tapewith an adhesive backing. They areused for approximating the edges oflacerations and for closing skin fol-lowing many operative procedures.

PROXI-STRIP skin closures have ahigh degree of porosity to allow thewound to breathe, but have suffi-cient adhesive strength to negate theuse of adjunct applications, such astincture of benzoin. Their antistaticproperties minimize the tendency ofthe tape strips to curl up.

POLYESTER FIBER STRIPMERSILENE* polyester fiber stripis comprised of a double thicknessof MERSILENE polyester fiber that is 5mm wide. The strips are

available with and without needles and may be used instead of large-sized suture for ligation,repair, and/or support in selectedoperative procedures.

Incompetence of the cervix is a condition characterized by thehabitual premature, spontaneousabortion of the fetus. A ligature isplaced around the cervix in a collar-like fashion, drawn tight, and either sutured together or tiedclosed. A MERSILENE strip is then woven carefully with a swageblunt needle in and out of themucosa. When placed properly, the flatness of the ligature will notcut or damage the wall of the cervix.

MERSILENE strip attached to a heavy reverse cutting needle provides a wide band of strong

material for orthopaedic proceduressuch as rotator cuff repair and support. The blunt needles used forthe incompetent cervix ligation mayalso be used for this purpose.

UMBILICAL TAPEUmbilical tape is a white woven cotton ligature, 1/8 or 1/4 inch (0.32 or 0.64cm) wide that is strongenough to tie off the umbilical cordof the newborn infant. While thiswas its original use, umbilical tape is also used in pediatric and cardiovascular procedures to suspend small structures and vesselsduring the operation, but is not leftin place.

Umbilical tape easily absorbs blood when used in an area of gross bleeding. The 1/8-inch(0.32cm) tape is available with aradiopaque thread woven into thelength of the fabric to facilitate x-ray identification.

SURGICAL STAPLESThe staple closure is mainly used for large wounds that are not on theface. Stapling is especially useful for closing scalp wounds. Staples are also used for linear lacerations of the torso and extremities, especially if they are relatively long.

Many surgeons routinely use skinstaples for closure of standardabdominal, thorax and extremityincisions. Advantages of staplinginclude ease of use, rapidity, cost effectiveness, and minimal damageto host defenses.1

CHAPTER 6 75

SKIN CLOSURETAPES

FIGURE1

1. Using sterile technique, remove card from sleeve and tear off tab.

2. Peel off tapes as needed in diagonal direction.

3. Apply tapes at 1/8-inch intervals as needed to complete wound apposition. Make sure the skin surface is dry before applying each tape.

4. When healing is judged to be adequate, remove each tape by peeling off each half from the outside toward the wound margin. Then, gently lift the tape away from the wound surface.

A variety of stapling devices isavailable for wound closure. With

all devices, the staple creates anincomplete rectangle: the legs of thestaple extend into the skin, and thecross-limb lies on the skin surfaceacross the wound. Each device maydiffer in its handling characteristics,visual access, the angle at which the staples enter tissues, the ease of position and the pre-cockingmechanism. Optimal visibility asthe staple is placed in the skin isimportant, as is the angle at whichthe staple enters the skin becauseinsertion of the staple perpendicularto the surface of the skin results indeep penetration that increases thelikelihood of tissue strangulationand permanent cross-hatching ofthe wound. The ability of the staple end to swivel allows the headto be adjusted for use in deeprecesses. Finally, the presence of apre-cocking mechanism allows thepractitioner to maintain constantcontrol while stapling the skin.1

Before inserting staples, it is impor-tant to line up the wound edgeswith the centerline indicator on thehead of the stapler to make sure thatthe legs of the staple will enter theskin at equal distances on either sideof the wound edge. Each edge istypically picked up with a forceps,everted and precisely lined up. The surgeon then places the staplesto close the wound while the firstassistant advances the forceps, everting the edges of the wound.This technique is continued untilthe entire wound is everted andclosed with staples.2

INDICATIONS AND USAGEWound closure with staples is indicated for scalp lacerations that do not require extensive hemostasis and do not involve tearsin the underlying frontooccipitalaponeurosis (galea). They are also indicated for linear nonfaciallacerations caused by shear forces(e.g., sharp objects).

AFTERCARE AND REMOVALSkin staples should be removed at the same time that sutures would be removed, based on woundlocation and tension. For scalpwounds, staples should be removedon day 7 after insertion. For trunkand extremity wounds, staplesshould be removed between days 7and 14. Wounds closed with staplesmay be covered with a topicalantibiotic cream or ointment.Patients may bathe or shower the next day, but should avoid prolonged exposure to moisture. When used on the scalp, patientsshould be very careful about combing or brushing their hair. A specially designed, single-handed,disposable staple remover should beused to remove the staples by ahealth care provider.

PROXIMATE* Skin StaplersPROXIMATE Skin Staplers placesingle staples to close surgical incisions. Staples are made of lubricant-coated stainless steel;


PROXIMATE*SKIN STAPLERS TABLE

2PROXIMATE* RH Skin Staplers(Rotating Head Skin Staplers)

Rectangular staples

Head rotates 360°; cartridge is clear

Staples are coated with lubricant

Pistol-grip handle

PROXIMATE* PX Skin Staplers PROXIMATE* PLUS MD Skin Staplers(Multi-Directional Skin Staplers)

Features Benefits Features Benefits Features Benefits

Minimizes staplerotation

Improves visibilityand access

Easy staple extraction

Comfortable to use

Ergonomic pistolgrip

Positive ratchetmechanism

Staples are coatedwith lubricant

Intuitive and comfortable to use

Easy staple placement


Improved kick-offspring design

Ergonomic design

Alignment indicator

Staples are coatedwith lubricant

Multi-directionrelease

Comfortable forsmaller hands

Improves visibility


* Trademark

the staplers are not reloadable. ETHICON Endo-Surgery makes three different skins staplers to meet surgeons’ needs.

PROXIMATE* PX skin stapler provides many of the same featuresas the PROXIMATE RH skin stapler but in a fixed-head format.

PROXIMATE* PLUS MD is ahigh-value, low-cost skin staplerthat permits multi-directionalrelease in an ergonomic design.

LOOPED SUTUREETHICON looped sutures range inlength up to a 60-inch strand withboth ends swaged to a single taperpoint needle. Available in variousmaterials and suture sizes, they provide a simple, reliable techniquefor continuous closure of the fasciaof the abdominal wall. The needleof the looped suture is passedthrough the fascia from inside outat one end of the incision, thenthrough the opposite wound edgefrom outside in, and then passedthrough the loop. The locking stitchlies beneath the wound edge. Thedouble strand is run over and overto the other end of the incision. The final stitch is completed bypassing the needle from the outsidein, cutting one strand, and passingthe needle through the oppositewound edge from the outside in.The needle is then cut off and the loose suture ends tied together,leaving the knot inverted underthe fascia.

RETENTION SUTURE DEVICES

Retention sutures, if not placedcarefully without excessive tension,can cut the skin. Devices such asbolsters and bridges are used to prevent such complications andeliminate pressure. However, careshould also be taken in the use ofthese devices.

Retention suture bolsters are sterile 2 1/2-inch (6cm) lengths of 3/16-inch

(0.48cm) diameter surgical latextubing with a 1/32-inch (0.08cm)wall. The suture is threaded throughthe bolster and tied. Suturessheathed in this manner can causean inflammatory response withreaction both at the site of thesuture exit from the skin and alongthe entire length of the suture itself.Also, the skin may become necroticbeneath the bolsters if the suturesare too tight. This invariably occursif the sutures are tightly tied at thetime of the operation, as subsequenttissue edema ensues.

CHAPTER 6 77

ADJUSTMENTOFRETENTIONSUTURE BRIDGE

FIGURE1

1. Pass the retention suture through appropriate holes in the bridge.

2. Place the suture with tension over the slit in the capstan, and tie.

3. To adjust tension, lift capstan. 4. Rotate capstan until desired tension is attained.

5. To lock, press capstan down into bridge.

The retention suture bridge is astrong plastic truss that can beadjusted to relieve the pressure ofthe retention suture on the skinduring, and subsequent to, initialsuture placement. After the desirednumber of sutures is placed in thewound, a sterile bridge is positionedover each retention suture. Eachside of the bridge has six holesspaced 1/4 inch (0.64cm) apart toaccommodate many patient sizes.The ends of the sutures are passedthrough the appropriate holes andtied loosely over the bridge. Thesuture strand is then slipped intothe capstan located in the middle of the bridge, and the capstan isrotated to apply the desired tension before locking into place.The bridge permits easy tensionreadjustment by raising and rotatingthe capstan to compensate for postoperative wound edema, andagain when the edema subsides. The suture remains elevated awayfrom the skin while the bridge hascontact along its entire 4 3/8-inch(11cm) length. Pressure is evenlydistributed over the area, and thetransparent bridge facilitates com-plete visualization of the wound.

REFERENCES1. Singer, Adam J., Lacerations and

Acute Wounds, An Evidence-Based Guide; F.A. Davis Company, ©2003, p. 64-71, 73-82.

2. Skerris, David A., Mayo Clinic Basic Surgery Skills, Mayo Clinic Scientific Press, 1999; p.117.


PRODUCT TERMS AND TRADEMARKS

CHAPTER 7

ABSORBABLE SUTURESutures which are broken down andeventually absorbed by eitherhydrolysis (synthetic absorbablesutures) or digestion by lysosomalenzymes elicited by white bloodcells (surgical gut and collagen).

APPROXIMATEBring together sides or edges.

ATRALOC* SURGICAL NEEDLESETHICON* trademark for eyelessneedles permanently attached(swaged) to suture strands.

B & S GAUGEBrown and Sharpe gauge commonlyused in hospitals to identify wirediameter. ETHICON stainless steelsuture products are labeled withboth B & S gauge and U.S.P. size.

BURIED SUTUREAny stitch made and tied so that it remains completely under the surface.

CALCIFIED CORONARYNEEDLE (CC)A TAPERCUT* surgical needlewith a 1/16" cutting tip and slimtaper ratio for significant ease ofpenetration when suturing toughvalve cuffs or atherosclerotic vessels.

CARDIOVASCULAR SUTURESSwaged sutures designed to meet thespecific needs of heart and bloodvessel surgery.

CATGUTOutmoded term for surgical gut suture.

CHROMIC SURGICAL GUTGut suture which has been treatedby chromium salts to resist digestion by lysosomal enzymes.

CHROMICIZINGETHICON process for producingchromic gut. Each ribbon of surgical gut is bathed in a chromium salt solution before spinning into strands to provideuniform controlled absorption.

COATED VICRYL*(POLYGLACTIN 910) SUTUREETHICON trademark for syntheticabsorbable suture extruded from acopolymer of glycolide and lactideand coated with a mixture ofpolyglactin 370 and calciumstearate.

COATED VICRYL* PlusANTIBACTERIAL (POLYGLACTIN 910) SUTUREETHICON trademark for syntheticabsorbable suture extruded from acopolymer of glycolide and lactide(polyglactin 370) and calciumstearate. The first and only suturethat protects against bacterial colonization of the suture.

COATED VICRYL* RAPIDE(POLYGLACTIN 910) SUTUREETHICON trademark for braided,rapidly absorbing synthetic sutureextruded from a copolymer of glycolide and lactide and coatedwith a mixture of polyglactin 370and calcium stearate.

COBALT 60Source of irradiation used byETHICON, INC., to sterilize somesuture materials. Also used in hospitals to treat some cancerpatients.

COMPOUND CURVED NEEDLENeedle that incorporates two curvatures in one needle: a tightcurve at the tip, and a more gradualcurve through the body. Used forprecise positioning of sutures forcomeal/scleral closure and forskin suturing.

CONTAMINATETo cause a sterile object or surfaceto become unsterile.

CONTINUOUS SUTURETECHNIQUESingle suture strand passed back andforth between the two edges of thewound to close a tissue layer; tiedonly at each end of the suture line.

CONTROL RELEASE* NEEDLEETHICON trademark for swagingmethod which permits fast and controlled separation of the needlefrom the suture material.

CONVENTIONAL CUTTING NEEDLENeedle with triangular point andcutting edge along inner curvatureof needle body.

CORNEAL BEADEDRETRACTION SUTURESwaged suture strand with a smallbead of epoxy used to elevate corneafor placement of intraocular lens.

CS ULTIMA* OPHTHALMIC NEEDLE (CS)ETHICON trademark for needlewith reduced side edge angles providing excellent penetration necessary for ophthalmic surgery.Design facilitates knot rotation during surgery.

PRODUCT TERMS AND TRADEMARKS80

CUTICULAR SUTURESSutures designed for skin closure.

DEAD SPACEPockets left in a tissue layer whentissues are not in close approximation.

DECONTAMINATIONProcess used to destroy microorganisms known or thoughtto be present on a surface or object.

DEHISCENCETotal or partial separation ofwound edges.

DERMABOND* TOPICAL SKIN ADHESIVE (2-OCTYL CYANOACRYLATE)ETHICON trademark for sterile,liquid topical skin adhesive forapproximation of wound edges oftrauma-induced lacerations orsurgical incisions.

DISPENSER BOXESGravity-fed vertical or horizontalboxes that readily dispense woundclosure products. Labels on boxesinclude product information.

DOUBLE-ARMED SUTURESuture strand with a needle swagedat each end.

EASY ACCESS* PACKAGINGETHICON trademark for patenteddelivery system that presents theneedle in position for immediatearming in the needleholder as soonas the primary packet is opened.

E-PACK* PROCEDURE KITETHICON trademark for singleoverwrapped organizer traycontaining multiple ETHICONsuture products. Each E-PACK kitmay be customized with choice ofsutures for specific procedures orsurgeon preferences.

ETHALLOY* NEEDLE ALLOYETHICON trademark for exclusivepatented stainless steel alloy that is40 percent stronger than needlesmade of 300 Series stainless steel. Provides improved tissue penetration, smoother needle-to-suture transition, and better flowthrough tissue.

ETHIBOND* EXCELPOLYESTER SUTUREETHICON trademark for braidedpolyester suture coated withpolybutilate coating.

ETHIGUARD* BLUNTPOINT NEEDLEETHICON trademark for speciallydesigned needle which has arounded tip.

ETHILON* NYLON SUTUREETHICON trademark for suturesmade of monofilament nylon.

ETHI-PACK* PRE-CUT SUTUREETHICON trademark for pre-cut strands of nonabsorbablesutures without needles, sterile and nonsterile.

ETHYLENE OXIDE GASChemical agent used to sterilizesome suture materials.

EVISCERATIONProtrusion of bowel throughseparated edges of abdominalwound closure.

EXPIRATION DATEDate on a suture product representing the time throughwhich satisfactory stability studieshave been carried out.

EXTRUSION OF KNOTS, KNOTEXTRUSION, OR "SPITTING"Attempt by the human body to riditself of nonabsorbable sutures orabsorbable sutures which are notcompletely absorbed (“foreign bodies”). Suture knots encapsulatedby cells may work their way to theskin surface months or even yearsafter surgery.

FASCIAAreolar tissue layers under the skin(superficial fascia) or fibrous tissuebetween muscles and forming thesheaths of muscles or investingother structures such as nerves orblood vessels (deep fascia).

FDAAbbreviation for federal Food andDrug Administration.

GASTROINTESTINAL SUTURESSutures designed for use in anastomosis of bowel and stomachsurgery.

GAUGETerm used to express diameter ofsuture strand.

GENERAL CLOSURE SUTURESSutures used in closing fascia, particularly in the abdominal wall.Also for hernia repair and other fascial defects.

* Trademark

CHAPTER 7 81

GENTLE BEND* PACKAGEETHICON trademark for packaging designed to delivermonofilament PROLENE*polypropylene suture to the surgicalfield in a straight usable form.

HEMO-SEAL* NEEDLE SUTUREETHICON trademark for aneedle/suture combination manufactured using a swagingmethod that provides a smootherneedle-to-suture transition.Beneficial in reducing leakage from the suture line, especially incardiovascular procedures.

HYDROLYSISChemical process whereby a compound or polymer reacts withwater to cause an alteration orbreakdown of the molecular structure. Synthetic absorbablesutures are degraded in vivo by this mechanism.

INFECTIONInvasion of body tissue by apathogen.

INTERRUPTED SUTURETECHNIQUESingle stitches separately placed,tied, and cut.

KEITH NEEDLE (KS)Straight needle with cutting edges,used primarily for abdominal skinclosure. Named for a Scottish surgeon, Dr. Thomas Keith, whomade the needle popular.

KINKUndesirable deformation of astrand, such as a sharp bend in wire.

LABYRINTH* PACKAGEETHICON trademark for uniquepackage that dispenses straight,kink-free, pre-cut nonabsorbablesutures.

LIGAPAK* DISPENSING REELETHICON trademark for disc-likeplastic reel that contains and dispenses suture for ligation.

LIGAPAK LIGATUREETHICON trademark for a lengthof suture material wound on a reel,primarily used for ligating.

LIGATING REELTube, plastic disc, or other devicefrom which continuous ligatingmaterial is unwound as blood vesselsare tied.

LIGATUREStrand of material used to tie off ablood vessel.

LOOPED SUTURESingle strand of suture material with both ends swaged onto a single needle.

MERSILENE* POLYESTERFIBER MESHETHICON trademark for machine-knitted fabric which is used in hernia repair and other fascial deficiencies that require addition ofa reinforcing or bridging material.

MERSILENE* POLYESTER FIBERSTRIP/TAPEETHICON trademark for a flatband 5mm wide. Useful as a cerclage ligature in patients with anincompetent cervix. Also used forbladder support or repair and support of the rotator cuff in the shoulder.

MERSILENE* POLYESTERFIBER SUTUREETHICON trademark for uncoatedbraided nonabsorbable suture material made of polyester polymer.

MICRO-POINT* SPATULA NEEDLEETHICON trademark for side-cutting ophthalmic needleswhich are thin and flat in profileand specially honed for exceptionalsharpness.

MICRO-POINT*SURGICAL NEEDLEETHICON trademark for ophthalmic needles which arehoned and polished to an extremelyfine finish and sharpness.

MICROSURGERY SUTURESSutures for surgeries in which anoperating microscope may be usedto visualize the very small structuresinvolved, e.g., blood vessels and nerves.

MILUnit of linear measurement, equivalent to 0.001 inch. Frequentlyused to express wire diameter of surgical needles.


MODULAR SUTURESTORAGE RACKPlastic modules of expandable interlocking units that provide neat,convenient storage of ETHICONsuture dispenser boxes.

MONOCRYL* (POLIGLCAPRONE 25) SUTUREETHICON trademark for monofilament synthetic absorbablesuture prepared from a copolymerof glycolide and e-caprolactone.

MONOFILAMENTA single filament strand.

MULTIFILAMENTStrand made of more than onetwisted or braided filament.

MULTIPASS NEEDLEETHICON trademark for patentedcoating process that enhances needleperformance over multiple penetrations.

MULTI-STRAND PACKAGEMultiple swaged sutures of one typesupplied in a single packet.

NEEDLEHOLDERSurgical instrument used to holdand drive a surgical needle duringsuturing.

NEEDLE/SUTUREJUNCTION (SWAGE)Point at which eyeless needles andsuture strands are joined.

NUROLON* BRAIDEDNYLON SUTUREETHICON trademark for multifilament braided nylon suture.

NONABSORBABLE SUTUREMaterial which tissue enzymes can-not dissolve. Remains encapsulatedwhen buried in tissues. Removedpostoperatively when used as skinsuture.

NYLONSynthetic suture material made ofpolyamide polymer.

OB-GYN SUTURESNeedle/suture combinations particularly useful in obstetric andgynecological operations.

OPHTHALMIC SUTURESSmall gauge sutures attached toultrafine needles that meet exactingneeds in ophthalmic surgery.

OVERWRAPExterior packet which protects thesterility of inner suture packet.

PACKAGE INSERTComplete product informationinserted in every box of wound closure products, as required by the FDA.

PC PRIME* NEEDLE (PC)ETHICON trademark for a conventional cutting needle with ageometry that reduces the angle ofthe cutting edge. Requires less forceto penetrate tissue, minimizing tissue trauma in precision cosmetic surgery.

PDS* II (POLYDIOXANONE)SUTUREETHICON trademark for monofilament synthetic absorbablesuture prepared from the polyesterpoly (p-dioxanone).

PERMA-HAND* SILK SUTUREETHICON trademark for suturesspecially processed to remove gumand impurities from raw silk beforebraiding selected sizes into strands.Also treated with mismo beeswax toreduce capillarity.

PLAIN SURGICAL GUTUntreated absorbable suture withshort-term absorption profile.

PLASTIC SURGERY SUTURESSutures specifically designed toassist the surgeon in obtainingexcellent cosmetic results in plasticand reconstructive surgery.

PLEDGETSSmall pieces of TFE polymer feltused as a buttress under sutures incardiovascular surgery.

POLYBUTILATEA nonabsorbable nonreactive polyester lubricant developed byETHICON, INC., as a coating forETHIBOND EXCEL sutures.

POLYESTER FIBERSynthetic material made of a polyester polymer of polyethyleneterephthalate.

POLYPROPYLENESynthetic material of an isotacticcrystalline stereoisomer of a linearhydrocarbon polymer which willnot absorb fluids.

POLYPROPYLENE BUTTONSSynthetic material made into buttons. Useful in orthopaedic procedures such as tendon repair.Sutures are tied over buttons torelieve underlying skin of excessivepressure.

* Trademark

CHAPTER 7 83

PRECISION COSMETICNEEDLE (PC)Conventional cutting needles specially polished and carefullyhoned for aesthetic plastic surgery.

PRECISION POINT NEEDLEReverse-cutting needles speciallypolished and carefully honed forplastic surgery.

PRE-CUT SUTURESStrands of suture material packagedpre-cut into various lengths.

PRIMARY PACKETSuture packet which contains thesterile suture.

PRIMARY WOUND CLOSUREThe approximation of wound edgesto facilitate rapid healing.

PRODUCT CODENumbers or combination of lettersand numbers which identify aspecific product.

PROLENE* POLYPROPYLENEHERNIA SYSTEMETHICON trademark for a sterile,pre-shaped, three-dimensionaldevice constructed of an onlay patchconnected by a mesh cylinder to acircular underlay patch. Used forthe repair of indirect and directinguinal hernia defects.

PROLENE* POLYPROPYLENEMESHETHICON trademark for meshmade of polypropylene which isknitted by a process which inter-links each fiber juncture. Used forthe repair of abdominal wall defectsand tissue deficiencies.

PROLENE* POLYPROPYLENESUTUREETHICON trademark for syntheticnonabsorbable suture material madeof monofilament polypropylene.

PRONOVA* POLY(HEXAFLUOROPROPYLENE-VDF)SUTUREETHICON trademark for syntheticnonabsorbable suture material madeof a polymer blend of poly(vinylidene fluoride) and poly(vinylidene fluoride-cohexafluoro-propylene).

PROXI-STRIP* SKIN CLOSURESETHICON trademark for adhesivestrips used for skin closure.

RELAY* SUTUREDELIVERY SYSTEMETHICON trademark for the packaging of single strand and multistrand sutures. Provides delivery of one suture at a time,one-step arming, individual needleparks, and straight, tangle-freesutures ready for use.

RETENTION SUTURE BOLSTERSSurgical tubing used to sheathretention sutures to prevent cuttingthe skin. Also known as "Booties."

RETENTION SUTURE BRIDGEClear plastic device designed with acapstan to permit postoperativewound management by adjustingthe tension of retention sutures, preventing suture crosshatching onthe skin.

REVERSE CUTTING NEEDLENeedles produced by ETHICONProducts, which have triangularshapethroughout their entire lengthand cutting edge along the outside needle curvature to prevent tissue cutout. Needles with longitudinal grooves on the innerand outer flattened curvatures. Ribsengage the needleholder jaw andhelp to minimize movement of theneedle in the needleholder.

SABRELOC* SPATULA NEEDLEETHICON trademark for ophthalmic needles. Side-cuttingspatula-shaped edges separate theultrathin layers of scleral or comealtissue without cutting through.

SAFETY ORGANIZER TRAYETHICON design for a suture traywhich delivers multistrand products.Offers single strand delivery, and asingulated needle park which permits one-step arming and tanglefree straight suture strands.

SECONDARY CLOSURERetention sutures placed approximately 2 inches from woundedges to reinforce primary closureand protect it from stress.

SIDE-FLATTENED NEEDLESConfiguration of stainless steel alloyneedles designed to increasestrength and reduce bending whenpenetrating vascular prostheses orcalcified tissues.

SINGLE STRAND DELIVERYTerminology used to describe thedelivery of one straight suture at atime from the RELAY suturedelivery system.


STERILEFree of living microorganisms (bacteria and their spores, viruses, etc.).

STERILE TECHNIQUECollectively, all the efforts made andprocedures followed to excludemicroorganisms from the operativewound and field.

STERILIZATIONProcess by which all living microorganisms on an object aredestroyed.

SUPER-SMOOTH FINISHAn exclusive process that provides afinish on most ETHICON needles,enabling the needles to penetrateand pass through the toughest tissuewith minimal resistance.

SURGICAL GUTAbsorbable suture made from serosal layer of beef intestine or submucosal layer of sheep intestine.

SURGICAL STAINLESSSTEEL SUTURENonabsorbable suture made of316L steel alloy.

SUTUPAK* PRE-CUTSTERILE SUTURESETHICON trademark for packetcontaining multiple pre-cut lengthsof suture material without needles,sterile and ready for immediate use.

SUTUREMaterial used to approximate(sew) tissues or tie off (ligate)blood vessels.

SUTURE BOOKSterile towel folded by the scrubperson and used to contain multiplesutures.

SWAGED SUTUREStrand of material with eyeless nee-dle attached by the manufacturer.

TAPERCUT* SURGICAL NEEDLEETHICON trademark for a needlewhich has a 1/16" triangular tip withthree cutting edges. Remainder ofneedle has a gradually tapered body.

TAPER POINT NEEDLE (TP)Needle with a body that graduallytapers to a sharp point, making thesmallest possible hole in tissue.

TENSILE STRENGTHAmount of tension or pull,expressed in pounds, which a suture strand will withstand beforeit breaks.

TIES (LIGATURES)Strands of suture used to tie off theends of severed blood vessels: freeor freehand—single strands used asindividual ties; continuous—longstrands unwound from a reel orother device as blood vessels aretied; suture ligature—strand on aneedle used to transfix (suture) alarge blood vessel to ensure securityagainst knot slippage; stick tie—asuture ligature or a single strandhanded to surgeon for ligating witha hemostat clamped on one sutureend; transfixion suture—suture ligature.

TRANSVERSE GROUNDNEEDLES (TG)Spatulated ophthalmic needlesspecially honed to a long, sharp,slim tip.

TRU-GAUGINGETHICON process which ensuresuniform diameter and uniformlyhigher tensile strength of surgical gut.

TRU-PERMANIZINGETHICON process of treating silkfor noncapillarity.

TUBING FLUIDSolution inside packets of surgicalgut and collagen. Purpose is tomaintain material (and needle, ifattached) in optimum condition forimmediate use upon withdrawalfrom the packet.

UMBILICAL TAPEWoven cotton tape, classified as aligature, used as a gentle means ofretracting vessels in cardiovascularand pediatric surgery and for tyingoff the umbilicus of the newbom.

UROLOGICAL SUTURESSutures designed to meet the needsof surgery performed by urologists.Features 5/8 circle needles whichturn out of tissue quickly.

VICRYL* (POLYGLACTIN 910)MESHETHICON trademark for meshprepared from a copolymer of glycolide and lactide. An absorbablematerial used as a buttress to provide temporary support duringhealing.

* Trademark

CHAPTER 7 85

VICRYL* (POLYGLACTIN 910)PERIODONTAL MESHETHICON trademark for meshprepared from a copolymer of gly-colide and lactide. An absorbablematerial used in periodontal surgeryfor guided tissue regeneration.

VISI-BLACK* SURGICAL NEEDLESETHICON trademark for surgicalneedles with a black surfacefinish to enhance visibility in theoperative site.

WOUND DISRUPTIONSeparation of wound edges.


* Trademark

PRODUCT INFORMATION

CHAPTER 8

PRODUCT INFORMATION88

Coated VICRYL*(Polyglactin 910) SutureU.S.P., EXCEPT FOR DIAMETER

DESCRIPTIONCoated VICRYL* (polyglactin 910) suture is a synthetic absorbable sterilesurgical suture composed of a copolymer made from 90% glycolide and 10%L-lactide. Coated VICRYL suture is prepared by coating VICRYL suture materialwith a mixture composed of equal parts of copolymer of glycolide and lactide(polyglactin 370) and calcium stearate. Polyglactin 910 copolymer andpolyglactin 370 with calcium stearate have been found to be nonantigenic,nonpyrogenic and elicit only a mild tissue reaction during absorption.The sutures are available dyed and undyed (natural).

Coated VICRYL sutures are U.S.P. except for diameters in the following sizes:

MAXIMUM SUTURE OVERSIZE IN DIAMETER (mm) FROM U.S.P.

U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm)

6-0 .0085-0 .0164-0 .0173-0 .0182-0 .0040 .022

INDICATIONSCoated VICRYL suture is indicated for use in general soft tissue approximationand/or ligation, including use in ophthalmic procedures, but not for use incardiovascular and neurological tissues.

ACTIONSCoated VICRYL suture elicits a minimal acute inflammatory reaction in tissueand ingrowth of fibrous connective tissue. Progressive loss of tensile strengthand eventual absorption of coated VICRYL suture occurs by means ofhydrolysis, where the copolymer degrades to glycolic and lactic acids which aresubsequently absorbed and metabolized in the body. Absorption begins as aloss of tensile strength followed by a loss of mass. Implantation studies in ratsindicate that coated VICRYL suture retains approximately 75% of the origi-nal tensile strength at two weeks post implantation. At three weeks, approxi-mately 50% of the original strength is retained for sizes 6-0 and larger andapproximately 40% of its original strength is retained for sizes 7-0 and smaller.At four weeks, approximately 25% of the original strength is retained for sizes6-0 and larger. All of the original tensile strength is lost by five weeks postimplantation. Absorption of coated VICRYL suture is essentially completebetween 56 and 70 days.

APPROXIMATE % ORIGINALDAYS IMPLANTATION STRENGTH REMAINING

14 Days 75%21 Days (6-0 and larger) 50%21 Days (7-0 and smaller) 40%28 Days 25%

CONTRAINDICATIONSThis suture, being absorbable, should not be used where extendedapproximation of tissue is required.

WARNINGSUsers should be familiar with surgical procedures and techniques involvingabsorbable sutures before employing coated VICRYL suture for woundclosure, as risk of wound dehiscence may vary with the site of application andthe suture material used. Physicians should consider the in vivo performance(under ACTIONS section) when selecting a suture. The use of this suture maybe inappropriate in elderly, malnourished, or debilitated patients, or in patientssuffering from conditions which may delay wound healing. As this is anabsorbable suture material, the use of supplemental nonabsorbable suturesshould be considered by the surgeon in the closure of the sites whichmay undergo expansion, stretching or distention, or which may requireadditional support.

Do not resterilize. Discard opened packages and unused sutures.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. As an absorbable suture, coated VICRYL suture may acttransiently as a foreign body. Acceptable surgical practice should be followedfor the management of contaminated or infected wounds.

PRECAUTIONSSkin sutures which must remain in place longer than 7 days may causelocalized irritation and should be snipped off or removed as indicated.

Under some circumstances, notably orthopaedic procedures, immobilization ofjoints by external support may be employed at the discretion of the surgeon.

Consideration should be taken in the use of absorbable sutures in tissues withpoor blood supply as suture extrusion and delayed absorption may occur.

In handling this or any other suture material, care should be taken to avoiddamage from handling. Avoid crushing or crimping damage due to applicationof surgical instruments such as forceps or needle holders. Coated VICRYLsutures, which are treated to enhance handling characteristics, require theaccepted surgical technique of flat and square ties with additional throws aswarranted by surgical circumstance and the experience of the surgeon.

Avoid prolonged exposure to elevated temperatures.

To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end to thepoint. Reshaping needles may cause them to lose strength and be less resistentto bending and breaking. Users should exercise caution when handlingsurgical needles to avoid inadvertent needle sticks. Discard used needles in"sharps" container.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, failure to provide adequate wound support in closure of the siteswhere expansion, stretching, or distension occur, failure to provide adequatewound support in elderly, malnourished or debilitated patients or in patientssuffering from conditions which may delay wound healing, infection, minimalacute inflammatory tissue reaction, localized irritation when skin sutures areleft in place for greater than 7 days, suture extrusion and delayed absorption intissue with poor blood supply, calculi formation in urinary and biliary tractswhen prolonged contact with salt solutions such as urine and bile occurs, andtransitory local irritation at the wound site. Broken needles may result inextended or additional surgeries or residual foreign bodies. Inadvertent needlesticks with contaminated surgical needles may result in the transmission ofbloodborne pathogens.

HOW SUPPLIEDCoated VICRYL sutures are available sterile, as braided dyed (violet) andundyed (natural) strands in sizes 8-0 through 3 (metric sizes 0.4-6), in a varietyof lengths, with or without needles, and on LIGAPAK*dispensing reels.

Coated VICRYL sutures are also available in size 8-0 with attached beads foruse in ophthalmic procedures. Coated VICRYL sutures are also available in sizes4-0 through 2 (metric sizes 1.5-5.0) attached to CONTROL RELEASE* removableneedles. Coated VICRYL sutures are available in one, two, and three dozenboxes.

389389 *Trademark ©ETHICON,INC. 1996

CHAPTER 8 93

ETHILON* NYLON SUTURENONABSORBABLE SURGICAL SUTURES, U.S.P.

DESCRIPTIONETHILON* nylon suture is a nonabsorbable, sterile surgical monofilamentsuture composed of the long-chain aliphatic polymers Nylon 6 and Nylon 6,6.ETHILON sutures are dyed black or green to enhance visibility in tissue. Thesuture is also available undyed (clear).

ETHILON suture meets all requirements established by the United StatesPharmacopoeia (U.S.P.) for nonabsorbable surgical suture.

INDICATIONSETHILON suture is indicated for use in general soft tissueapproximation and/or ligation, including use in cardiovascular,ophthalmic and neurological procedures.

ACTIONSETHILON suture elicits a minimal acute inflammatory reaction in tissue, whichis followed by gradual encapsulation of the suture by fibrous connective tissue.While nylon is not absorbed, progressive hydrolysis of the nylon in vivo mayresult in gradual loss over time of tensile strength.

CONTRAINDICATIONSDue to the gradual loss of tensile strength which may occur over prolongedperiods in vivo, nylon suture should not be used where permanent retention oftensile strength is required.

WARNINGS Users should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing ETHILON suture for wound closure,as the risk of wound dehiscence may vary with the site of application and thesuture material used.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. Acceptable surgical practice should be followed for the managementof contaminated or infected wounds.

Do not resterilize. Discard open packages and unused sutures.

PRECAUTIONSIn handling this or any other suture material, care should be taken to avoiddamage from handling. Avoid crushing or crimping damage due to applicationof surgical instruments such as forceps or needle holders.

As with any suture material, adequate knot security requires the accepted sur-gical technique of flat and square ties, with additional throws as warranted bysurgical circumstance and the experience of the surgeon. The use of additionalthrows may be particularly appropriate when knotting monofilaments.

To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end to the point.Reshaping needles may cause them to lose strength and be less resistant tobending and breaking. Users should exercise caution when handling surgicalneedles to avoid inadvertent needle sticks. Discard used needles in "sharps"containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wound dehis-cence, gradual loss of tensile strength over time, calculi formation in urinaryand biliary tracts when prolonged contact with salt solutions such as urine andbile occurs, infection, minimal acute inflammatory tissue reaction, and transi-tory local irritation at the wound site. Broken needles may result in extended oradditional surgeries or residual foreign bodies. Inadvertent needle sticks withcontaminated surgical needles may result in the transmission of bloodbornepathogens.

HOW SUPPLIEDETHILON sutures are available as sterile monofilament strands in U.S.P. sizes11-0 through 2 (metric sizes 0.1-5.0) in a variety of lengths, with and withoutpermanently attached needles. ETHILON sutures are available in one, two andthree dozen boxes.

389355 *Trademark ©ETHICON, INC. 1995

Coated VICRYL* RAPIDE (Polyglactin 910)Braided Coated Synthetic AbsorbableSuture, UndyedNon-U.S.P.

DESCRIPTIONCoated VICRYL* RAPIDE (polyglactin 910) suture is a synthetic absorbable ster-ile surgical suture composed of a copolymer made from 90% glycolide and 10%L-lactide. The empirical formula of the copolymer is (C2H2O2)m(C3H4O2)n. The

characteristic of rapid loss of strength is achieved by use of a polymer materi-al with a lower molecular weight than coated VICRYL* (polyglactin 910) suture.

Coated VICRYL RAPIDE sutures are obtained by coating the braided suturematerial with a mixture composed of equal parts of copolymer of glycolide andlactide (polyglactin 370) and calcium stearate. Polyglactin 910 copolymer andpolyglactin 370 with calcium stearate have been found to be nonantigenic,nonpyrogenic and elicit only a mild tissue reaction during absorption.

Coated VICRYL RAPIDE sutures are only available undyed.

Although this suture is a synthetic absorbable suture, its performance charac-teristics are intended to model the performance of collagen (surgical gut)suture. The knot tensile strength of coated VICRYL RAPIDE suture meets U.S.P.knot tensile strength requirements for collagen sutures, however, CoatedVICRYL RAPIDE suture strength is up to 26% less than knot tensile strengthrequirements for synthetic absorbable sutures.


U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE(mm)

5-0 .0164-0 .0173-0 .0182-0 .0100 .022

INDICATIONSCoated VICRYL RAPIDE synthetic absorbable suture is indicated only for use insuperficial soft tissue approximation of the skin and mucosa, where only shortterm wound support (7-10 days) is required. Coated VICRYL RAPIDE suture isnot intended for use in ligation, ophthalmic, cardiovascular or neurologicalprocedures.

ACTIONSCoated VICRYL RAPIDE suture, when used in closure of skin and mucous mem-branes, typically begins to fall off 7-10 days post-operatively and can be wipedoff subsequently with sterile gauze. Natural mechanical abrasion of the sutureswhile in situ may also accelerate this disappearance rate. Rapid loss of tensilestrength may preclude the need for stitch removal.

Coated VICRYL RAPIDE elicits a minimal to moderate acute inflammatoryreaction in tissue. Progressive loss of tensile strength and eventual absorptionof coated VICRYL RAPIDE occurs by means of hydrolysis, where the copolymerdegrades to glycolic and lactic acids which are subsequently absorbed andmetabolized in the body. Absorption begins as a loss of tensile strengthfollowed by a loss of mass.

Subcutaneous tissue implantation studies of coated VICRYL RAPIDE sutures inrats show that 5 days post-implantation approximately 50% of the originaltensile strength remains. All of the original tensile strength is lost by approxi-mately 10 to 14 days post-implantation. Intramuscular implantation studies inrats show that the absorption of these sutures occurs thereafter and isessentially complete by 42 days.

CONTRAINDICATIONSDue to the rapid loss of tensile strength, this suture should not be used whereextended approximation of tissues under stress is required or where woundsupport beyond 7 days is required.

WARNINGS

Users should be familiar with surgical procedures and techniques involvingabsorbable sutures before employing coated VICRYL RAPIDE suture for woundclosure, as a risk of wound dehiscence may vary with the site of application andthe suture material used. Physicians should consider the in vivo performancewhen selecting a suture. The use of this suture may be inappropriate inelderly, malnourished, or debilitated patients, or in patients suffering fromconditions which may delay wound healing.


As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. As an absorbable suture, coated VICRYL RAPIDE suture may acttransiently as a foreign body.

Acceptable surgical practice should be followed for the management ofcontaminated or infected wounds.

As this is an absorbable suture material, the use of supplemental nonab-sorbable sutures should be considered by the surgeon in the closure of siteswhich may undergo expansion, stretching or distention, or which may requireadditional support.

PRECAUTIONSSkin sutures which remain in place longer than 7 days may cause localizedirritation and should be snipped off or removed as indicated.


Consideration should be taken in the use of absorbable sutures in tissues withpoor blood supply as suture extrusion and delayed absorption may occur.

In handling this or any other suture material, care should be taken to avoiddamage from handling. Avoid crushing or crimping damage due to applicationof surgical instruments such as forceps or needle holders.

Coated VICRYL RAPIDE suture, which is treated with coating to enhancehandling characteristics, requires the accepted surgical technique of flat andsquare ties with additional throws as warranted by surgical circumstance andthe experience of the surgeon.


To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end to thepoint. Reshaping needles may cause them to lose strength and be lessresistant to bending and breaking.

Users should exercise caution when handling surgical needles to avoid inadvertent needle sticks. Discard used needles in “sharps” containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wound dehis-cence, failure to provide adequate wound support in closure of the sites whereexpansion, stretching, or distension occur, failure to provide adequate woundsupport in elderly, malnourished or debilitated patients or in patients sufferingfrom conditions which may delay wound healing, infection, minimal acuteinflammatory tissue reaction, localized irritation when skin sutures are left inplace for greater than 7 days, suture extrusion and delayed absorption in tissuewith poor blood supply, calculi formation in urinary and biliary tracts when pro-longed contact with salt solutions such as urine and bile occurs, and transitorylocal irritation at the wound site. Broken needles may result in extended oradditional surgeries or residual foreign bodies. Inadvertent needle sticks withcontaminated surgical needles may result in the transmission of bloodbornepathogens.

HOW SUPPLIEDCoated VICRYL RAPIDE sutures are available sterile, undyed and attached tostainless steel needles of varying types and sizes.

Coated VICRYL RAPIDE sutures are available in various lengths in sizes 5-0 to 1(1.0 to 4.0 metric) in one and three dozen boxes.



CHAPTER 8 91

ETHIBOND* EXCEL POLYESTER SUTURENONABSORBABLE SURGICAL SUTURE, U.S.P.Except for size 6-0 diameter

DESCRIPTIONETHIBOND* EXCEL polyester suture is a nonabsorbable, braided, sterile,surgical suture composed of Poly (ethylene terephthalate). It is prepared fromfibers of high molecular weight, long-chain, linear polyesters having recurrentaromatic rings as an integral component. ETHIBOND EXCEL suture is uniform-ly coated with polybutilate or poly {oxy-1, 4 butanediyloxy (1, 6-dioxo-1,6 hexanediyl)}. The highly adherent coating is a relatively nonreactivenonabsorbable compound which acts as a lubricant to mechanically improvethe physical properties of the uncoated suture by improving ease of passagethrough tissues and by providing overall improved handling qualities ascontrasted to the braided, uncoated fiber.

ETHIBOND EXCEL sutures are braided for optimal handling properties, and forgood visibility in the surgical field, are dyed green.

Size 6-0 ETHIBOND EXCEL sutures are U.S.P., except for diameter.



6-0 0.024

INDICATIONSETHIBOND EXCEL suture is indicated for use in general soft tissueapproximation and/or ligation, including use in cardiovascular, ophthalmic andneurological procedures.

ACTIONSETHIBOND EXCEL suture elicits a minimal acute inflammatory reaction intissue, followed by a gradual encapsulation of the suture by fibrous connectivetissue. Implantation studies in animals show no meaningful decline inpolyester suture strength over time. Both polyester fiber suture material andthe polybutilate coating are pharmacologically inactive.

CONTRAINDICATIONSNone known.

WARNINGSUsers should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing ETHIBOND EXCEL suture for woundclosure, as risk of wound dehiscence may vary with the site of application andthe suture material used.


As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. Acceptable surgical practice should be followed for themanagement of infected or contaminated wounds.

PRECAUTIONS


As with any suture material, adequate knot security requires the acceptedsurgical technique of flat and square ties with additional throws as warrantedby surgical circumstance and the experience of the surgeon.

To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end to thepoint. Reshaping needles may cause them to lose strength and be lessresistant to bending and breaking. Users should exercise caution whenhandling surgical needles to avoid inadvertent needle sticks. Discard usedneedles in "sharps" containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, calculi formation in urinary and biliary tracts when prolongedcontact with salt solutions such as urine and bile occurs, infection, minimalacute inflammatory tissue reaction and transitory local irritation at the woundsite. Broken needles may result in extended or additional surgeries or residualforeign bodies. Inadvertent needle sticks with contaminated surgical needlesmay result in the transmission of bloodborne pathogens.

HOW SUPPLIEDETHIBOND EXCEL sutures are available as sterile, braided, green and undyed(white) strands in sizes 7-0 through 5 (metric sizes 0.5-7) in a variety of lengths,with and without permanently attached needles.

ETHIBOND EXCEL sutures, green, braided, in sizes 4-0 through 1 (metric sizes1.5-4) are also available attached to CONTROL RELEASE* removable needles.

ETHIBOND EXCEL sutures, green and undyed, are also available attached toTFE polymer pledgets measuring 1/8" x 1/8" x 1/16" (3.0mm x 3.0mm x 1.5mm),1/4" x 1/8" x 1/16" (7.0mm x 3.0mm x 1.5mm).

ETHIBOND EXCEL sutures are available in one, two and three dozen boxes.



CHAPTER 8 93

ETHILON* NYLON SUTURENONABSORBABLE SURGICAL SUTURES, U.S.P.

DESCRIPTIONETHILON* nylon suture is a nonabsorbable, sterile surgical monofilamentsuture composed of the long-chain aliphatic polymers Nylon 6 and Nylon 6,6.ETHILON sutures are dyed black or green to enhance visibility in tissue. Thesuture is also available undyed (clear).

ETHILON suture meets all requirements established by the United StatesPharmacopoeia (U.S.P.) for nonabsorbable surgical suture.

INDICATIONSETHILON suture is indicated for use in general soft tissueapproximation and/or ligation, including use in cardiovascular,ophthalmic and neurological procedures.

ACTIONSETHILON suture elicits a minimal acute inflammatory reaction in tissue, whichis followed by gradual encapsulation of the suture by fibrous connective tissue.While nylon is not absorbed, progressive hydrolysis of the nylon in vivo mayresult in gradual loss over time of tensile strength.


WARNINGS Users should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing ETHILON suture for wound closure,as the risk of wound dehiscence may vary with the site of application and thesuture material used.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. Acceptable surgical practice should be followed for the managementof contaminated or infected wounds.



As with any suture material, adequate knot security requires the accepted sur-gical technique of flat and square ties, with additional throws as warranted bysurgical circumstance and the experience of the surgeon. The use of additionalthrows may be particularly appropriate when knotting monofilaments.

To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end to the point.Reshaping needles may cause them to lose strength and be less resistant tobending and breaking. Users should exercise caution when handling surgicalneedles to avoid inadvertent needle sticks. Discard used needles in "sharps"containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wound dehis-cence, gradual loss of tensile strength over time, calculi formation in urinaryand biliary tracts when prolonged contact with salt solutions such as urine andbile occurs, infection, minimal acute inflammatory tissue reaction, and transi-tory local irritation at the wound site. Broken needles may result in extended oradditional surgeries or residual foreign bodies. Inadvertent needle sticks withcontaminated surgical needles may result in the transmission of bloodbornepathogens.

HOW SUPPLIEDETHILON sutures are available as sterile monofilament strands in U.S.P. sizes11-0 through 2 (metric sizes 0.1-5.0) in a variety of lengths, with and withoutpermanently attached needles. ETHILON sutures are available in one, two andthree dozen boxes.



FAST ABSORBING SURGICAL GUT (PLAIN)ABSORBABLE SURGICAL SUTURESNon-U.S.P.

DESCRIPTIONFast absorbing surgical gut suture is a strand of collagenous material preparedfrom the submucosal layers of the small intestine of healthy sheep, or from theserosal layers of the small intestine of healthy cattle.

Fast absorbing surgical gut sutures are sterile and elicit only a slight tominimal tissue reaction during absorption.

Fast absorbing surgical gut sutures differ from U.S.P. minimum strengthrequirements by less than 30%.

INDICATIONSFast absorbing surgical gut sutures are intended for dermal (skin) suturingonly. They should be utilized only for external knot tying procedures.

ACTIONSThe results of implantation studies of fast absorbing surgical gut sutures in theskin of animals indicate that nearly all of its original strength is lost withinapproximately seven (7) days of implantation.

When surgical gut suture is placed in tissue, a moderate tissue inflammationoccurs which is characteristic of foreign body response to a substance. This isfollowed by a loss of tensile strength followed by a loss of suture mass, as theproteolytic enzymatic digestive process dissolves the surgical gut. This processcontinues until the suture is completely absorbed. Many variable factors mayaffect the rate of absorption. Some of the major factors which can affect tensilestrength loss and absorption rates are:1. Type of suture - plain gut generally absorbs more rapidly than chromic gut.2. Infection - surgical gut is absorbed more rapidly in infected tissue than in

non-infected tissue.3. Tissue sites - surgical gut will absorb more rapidly in tissue where increased

levels of proteolytic enzymes are present, as in the secretions exhibited inthe stomach, cervix and vagina.

Data obtained from implantation studies in rats show that the absorption ofthese sutures is essentially complete by the twenty-first (21st) to forty-second(42nd) post implantation day.

CONTRAINDICATIONSThese sutures, being absorbable, should not be used where prolongedapproximation of tissue under stress is required. These sutures have beendesigned to absorb at a rapid rate and must be used on dermal tissue only.These sutures should never be used on internal tissue. The use of this suture iscontraindicated in patients with known sensitivities or allergies to collagen, asgut is a collagen based material.

WARNINGSUsers should be familiar with surgical procedures and techniques involving gutsuture before using fast absorbing surgical gut suture for wound closure, asthe risk of wound dehiscence may vary with the site of application and thesuture material used. Physicians should consider the in vivo performance whenselecting a suture for use in patients.

The use of this suture may be inappropriate in elderly, malnourished, or debil-itated patients, or in patients suffering from conditions which may delay woundhealing. As this is an absorbable material, the use of supplemental nonab-sorbable sutures should be considered by the surgeon in the closure of siteswhich may undergo expansion, stretching or distention or which may requireadditional support.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. As an absorbable suture, fast absorbing surgical gut may act tran-siently as a foreign body. Acceptable surgical practice should be followed forthe management of contaminated or infected wounds.

Do not resterilize. Discard open packages and unused sutures. Store at roomtemperature.

Certain patients may be hypersensitive to collagen and might exhibit animmunological reaction resulting in inflammation, tissue granulation or fibro-sis, wound suppuration and bleeding, as well as sinus formation.

PRECAUTIONSIn handling this or any other suture material, care should be taken to avoiddamage from handling. Avoid crushing or crimping damage due to applicationof surgical instruments such as forceps or needle holders. Surgical gut suturesrequire the accepted surgical technique of flat and square ties with additionalthrows as warranted by surgical circumstance and the experience of thesurgeon.


The surgeon should avoid unnecessary tension when running down knots, toreduce the occurrence of surface fraying and weakening of the strand.


To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end tothe point. Reshaping needles may cause them to lose strength and be lessresistant to bending and breaking. Users should exercise caution whenhandling surgical needles to avoid inadvertent needle sticks. Discard usedneedles in "sharps" containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, variable rates of absorption over time (depending on such factorsas the type of suture used, the presence of infection and the tissue site), failureto provide adequate wound support in closure of sites where expansion,stretching or distention occur, etc., unless additional support is suppliedthrough the use of nonabsorbable suture material, failure to provide adequatewound support in elderly, malnourished or debilitated patients or in patientssuffering from cancer, anemia, obesity, diabetes, infection or other conditionswhich may delay wound healing, allergic response in patients with knownsensitivities to collagen which may result in an immunological reaction result-ing in inflammation, tissue granulation or fibrosis, wound suppuration andbleeding, as well as sinus formation, infection, moderate tissue inflammatoryresponse characteristic of foreign body response, calculi formation in urinaryand biliary tracts when prolonged contact with salt solutions such as urine andbile occurs, and transitory local irritation at the wound site. Broken needlesmay result in extended or additional surgeries or residual foreign bodies.Inadvertent needle sticks with contaminated surgical needles may result in thetransmission of bloodborne pathogens.

HOW SUPPLIEDFast absorbing surgical gut sutures are available in sizes 5-0 (metric size 1.5)and 6-0 (metric size 1.0) with needles attached in one, two and three dozenboxes.


CHAPTER 8 95

MERSILENE* POLYESTER FIBER SUTURENONABSORBABLE SURGICAL SUTURE, U.S.P.Except for size 6-0 diameter

DESCRIPTIONMERSILENE* polyester suture is a nonabsorbable, braided, sterile, surgicalsuture composed of Poly (ethylene terephthalate). It is prepared from fibers ofhigh molecular weight, long-chain, linear polyesters having recurrent aromaticrings as an integral component. MERSILENE sutures are braided for optimalhandling properties, and for good visibility in the surgical field, are dyed green.

Size 6-0 MERSILENE sutures are U.S.P., except for diameter.



6-0 0.024

INDICATIONSMERSILENE suture is indicated for use in general soft tissue approximationand/or ligation, including use in cardiovascular, ophthalmic and neurologicalprocedures.

ACTIONSMERSILENE suture elicits a minimal acute inflammatory reaction in tissue,followed by a gradual encapsulation of the suture by fibrous connectivetissue. Implantation studies in animals show no meaningful decline inpolyester suture strength over time. The polyester fiber suture material ispharmacologically inactive.


WARNINGSUsers should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing MERSILENE suture for woundclosure, as risk of wound dehiscence may vary with the site of application andthe suture material used.


As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. Acceptable surgical practice should be followed for the managementof infected or contaminated wounds.

PRECAUTIONSIn handling this or any other suture material, care should be taken to avoiddamage from handling. Avoid crushing or crimping damage due to applicationof surgical instruments such as forceps or needle holders. The use of addition-al throws is particularly appropriate when knotting monofilament sutures.



ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, calculi formation in urinary and biliary tracts when prolongedcontact with salt solutions such as urine and bile occurs, infection, minimalacute inflammatory tissue reaction and transitory local irritation at the woundsite. Broken needles may result in extended or additional surgeries or residualforeign bodies. Inadvertent needle sticks with contaminated surgical needlesmay result in the transmission of bloodborne pathogens.

HOW SUPPLIEDMERSILENE sutures are available as sterile, braided, green and undyed (white)strands in sizes 6-0 through 5 (metric sizes 0.7-7) in a variety of lengths, withand without permanently attached needles.

MERSILENE sutures are also available in green monofilament in sizes 10-0 and11-0 (metric sizes 0.2-0.1).

MERSILENE sutures, green, braided in U.S.P. size 0 (metric size 3.5) are alsoavailable attached to CONTROL RELEASE* removable needles.

MERSILENE sutures are available in one, two and three dozen boxes.



MERSILENE* POLYESTER FIBER MESHNonabsorbable Synthetic Surgical MeshSTERILE

DESCRIPTIONMERSILENE* Polyester Fiber Mesh is constructed from polyethyleneterephthalate, the same material used to make MERSILENE* Polyester FiberSuture, Nonabsorbable Surgical Suture, U.S.P. (ETHICON, INC.) MERSILENEPolyester Fiber Mesh affords excellent strength, durability and surgicaladaptability, along with maximal porosity for necessary tissue ingrowth.The mesh is approximately 0.010 inches thick and is a highly flexible andcompliant material.

MERSILENE mesh is knitted by a process which interlinks each fiber junctionand which provides for elasticity in both directions. This construction permitsthe mesh to be cut into any desired shape or size without unraveling. The fiberjunctions are not subject to the same work fatigue exhibited by more rigidmetallic meshes. This bi-directional elastic property allows adaption to variousstresses encountered in the body.

ACTIONSMERSILENE mesh is a nonabsorbable mesh used to span and reinforcetraumatic or surgical wounds to provide extended support during andfollowing wound healing. Animal studies show that implantation ofMERSILENE mesh elicits a minimum to slight inflammatory reaction, which istransient and is followed by the deposition of a thin fibrous layer of tissuewhich can grow through the interstices of the mesh, thus incorporating themesh into adjacent tissue. The mesh remains soft and pliable, and normalwound healing is not noticeably impaired. The material is not absorbed nor isit subject to degradation or weakening by the action of tissue enzymes.

INDICATIONSThis mesh may be used for the repair of hernia and other fascial deficienciesthat require the addition of a reinforcing or bridging material to obtain thedesired surgical result.

CONTRAINDICATIONSWhen this mesh is used in infants or children with future growth potential, thesurgeon should be aware that this product will not stretch significantly as thepatient grows.

MERSILENE polyester fiber mesh in contaminated wounds should be usedwith the understanding that subsequent infection may require removal ofthe material.

WARNINGSMERSILENE mesh is provided by ETHICON, INC. as a sterile product. UnusedMERSILENE Mesh which has been removed from the package may be resteril-ized not more than one time by a conventional stream autoclaving processat conditions of 250˚F (121˚C) for 20 minutes. MERSILENE mesh may also beflash autoclaved not more than one time at conditions of 270˚F (132˚C) for10 minutes. Resterilization under any other conditions or by any other meansis neither recommended nor endorsed by ETHICON, INC.

If this product should become stained with blood or soiled, it should not beresterilized for reuse.

PRECAUTIONSA minimum of 6.5mm (1/4 inch) of mesh should extend beyond the suture line.

ADVERSE REACTIONSNo significant adverse clinical reactions to MERSILENE mesh have beenreported. The use of nonabsorbable MERSILENE mesh in a wound that iscontaminated or infected could lead to fistula formation and/or extrusion ofthe mesh.

INDICATIONS FOR USEIt is recommended that nonabsorbable sutures be placed 6.5 to 12.5mm (1/4 to1/2 inch) apart at a distance approximately 6.5mm (1/4 inch) from edge of themesh. Some surgeons prefer to suture and uncut section of mesh that isconsiderably large than the defect into position over the wound. The oppositesides are then sutured to assure proper closure under correct tension. Whenthe margin sutures have all been placed, the extra mesh is trimmed away.

HOW SUPPLIEDMERSILENE mesh is available in single packets as sterile, undyed (white)sheets in two sizes. The sizes available are 6 x 11cm (2.5 x 4.5 inches) and 30 x30cm (12 x 12 inches). Each sheet is 0.25mm (0.010 inch) thick.


CHAPTER 8 97

MONOCRYL* (Poliglecaprone 25) SutureSYNTHETIC ABSORBABLE SUTURE, U.S.P., EXCEPT FOR DIAMETER

DESCRIPTIONMONOCRYL* (poliglecaprone 25) suture is a monofilament syntheticabsorbable surgical suture prepared from a copolymer of glycolide andepsilon-caprolactone. Poliglecaprone 25 copolymer has been found to benonantigenic, nonpyrogenic and elicits only a slight tissue reaction duringabsorption.

MONOCRYL sutures are U.S.P. except for diameters in the following sizes:



6-0 0.0495-0 0.0334-0 0.0453-0 0.0672-0 0.0550 0.0881 0.0662 0.099

INDICATIONSMONOCRYL sutures are indicated for use in general soft tissue approximationand/or ligation, but not for use in cardiovascular or neurological tissues,microsurgery or ophthalmic surgery.

ACTIONSMONOCRYL suture is a monofilament which elicits a minimal acute inflamma-tory reaction in tissues and ingrowth of fibrous connective tissue. Progressiveloss of tensile strength and eventual absorption of MONOCRYL sutures occursby means of hydrolysis. Absorption begins as a loss of tensile strengthfollowed by a loss of mass. Implantation studies in rats indicate thatMONOCRYL suture retains approximately 50 to 60% of its original strength7 days post implantation, and approximately 20 to 30% of its original tensilestrength at 14 days post implantation. All of the original tensile strength is lostby 21 days post implantation. The absolute strength remaining 14 days postimplantation meets or exceeds that historically observed with plain or chromicsurgical gut sutures. Absorption of MONOCRYL absorbable synthetic suture isessentially complete between 91 and 119 days.

APPROXIMATE % ORIGINAL

DAYS IMPLANTATION STRENGTH REMAINING

7 DAYS 50 TO 60%14 DAYS 20 TO 30%

CONTRAINDICATIONSThis suture, being absorbable, should not be used where extended approxi-mation of tissue under stress is required, such as in fascia.

WARNINGSUsers should be familiar with surgical procedures and techniques involvingabsorbable sutures before employing MONOCRYL suture for wound closure,as risk of wound dehiscence may vary with the site of application and thesuture material used. Physicians should consider the in vivo performance(under ACTIONS section) when selecting a suture for use in patients. The use ofthis suture may be inappropriate in elderly, malnourished, or debilitatedpatients, or in patients suffering from conditions which may delay woundhealing.


As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. As an absorbable suture, MONOCRYL suture may act transiently asa foreign body. Acceptable surgical practice should be followed for themanagement of contaminated or infected wounds.

As this is an absorbable suture material, the use of supplementalnonabsorbable sutures should be considered by the surgeon in the closure ofthe sites which may undergo expansion, stretching or distention, or which mayrequire additional support.

PRECAUTIONSSkin sutures which must remain in place longer than 7 days may cause local-ized irritation and should be snipped off or removed as indicated. Subcuticularsutures should be placed as deeply as possible to minimize the erythema andinduration normally associated with absorption.Under some circumstances, notably orthopaedic procedures, immobilization ofjoints by external support may be employed at the discretion of the surgeon.

Consideration should be taken in the use of absorbable sutures in tissue withpoor blood supply as suture extrusion and delayed absorption may occur.


MONOCRYL suture knots must be properly placed to be secure. Adequate knotsecurity requires the accepted surgical technique of flat and square ties withadditional throws as warranted by surgical circumstance and the experience ofthe surgeon. The use of additional throws may be particularly appropriate whenknotting monofilaments.

Avoid prolonged exposure to elevated temperature.


ADVERSE REACTIONSAdverse effects associated with the use of synthetic absorbable sutures includewound dehiscence, failure to provide adequate wound support in closure of thesites where expansion, stretching, or distension occur, failure to provide ade-quate wound support in elderly, malnourished or debilitated patients or inpatients suffering from conditions which may delay wound healing, infection,minimal acute inflammatory tissue reaction, localized irritation when skinsutures are left in place for greater than 7 days, suture extrusion and delayedabsorption in tissue with poor blood supply, calculi formation in urinary andbiliary tracts when prolonged contact with salt solutions such as urine and bileoccurs, and transitory local irritation at the wound site. Broken needles mayresult in extended or additional surgeries or residual foreign bodies.Inadvertent needle sticks with contaminated surgical needles may result in thetransmission of bloodborne pathogens.

HOW SUPPLIEDMONOCRYL sutures are available as sterile, monofilament, undyed (natural)strands in sizes 6-0 through 2 (metric sizes 0.7-5), in a variety of lengths, withor without needles.

MONOCRYL sutures are also available in sizes 3-0 through 1 (metricsizes 2-4)attached to CONTROL RELEASE* removable needles.

MONOCRYL sutures are available in one and three dozen boxes.



MONOCRYL* VIOLET MONOFILAMENT(Poliglecaprone 25) SutureSYNTHETIC ABSORBABLE SUTURE, U.S.P., EXCEPT FOR DIAMETER

DESCRIPTIONMONOCRYL* (poliglecaprone 25) suture is a monofilament syntheticabsorbable surgical suture prepared from a copolymer of glycolide andepsilon-caprolactone. Poliglecaprone 25 copolymer has been found to benonantigenic, nonpyrogenic and elicits only a slight tissue reaction duringabsorption.

MONOCRYL sutures are U.S.P. except for diameters in the following sizes:


U.S.P. SUTURE SIZE DESIGNATION MAXIMUM OVERSIZE (mm)6-0 0.0495-0 0.0334-0 0.0453-0 0.0672-0 0.0550 0.0881 0.0662 0.099

INDICATIONSMONOCRYL sutures are indicated for use in general soft tissue approximationand/or ligation, but not for use in cardiovascular or neurological tissues,microsurgery or ophthalmic surgery.

ACTIONSMONOCRYL suture is a monofilament which elicits a minimal acute inflamma-tory reaction in tissues and ingrowth of fibrous connective tissue. Progressiveloss of tensile strength and eventual absorption of MONOCRYL sutures occursby means of hydrolysis. Absorption begins as a loss of tensile strengthfollowed by a loss of mass. Implantation studies in rats indicate thatMONOCRYL suture retains approximately 60 to 70% of its original strength7 days post implantation, and approximately 30 to 40% of its original tensilestrength at 14 days post implantation. Essentially all of the original tensilestrength is lost by 28 days post implantation. Absorption of MONOCRYLabsorbable synthetic suture is essentially complete between 91 and 119 days.

APPROXIMATE % ORIGINAL

DAYS IMPLANTATION STRENGTH REMAINING

7 DAYS 60 TO 70%14 DAYS 30 TO 40%

CONTRAINDICATIONSThis suture, being absorbable, should not be used where extended approxi-mation of tissue under stress is required.

WARNINGSUsers should be familiar with surgical procedures and techniques involvingabsorbable sutures before employing MONOCRYL suture for wound closure,as risk of wound dehiscence may vary with the site of application and thesuture material used. Physicians should consider the in vivo performance(under ACTIONS section) when selecting a suture for use in patients. Theuse of this suture may be inappropriate in elderly, malnourished, or debilitatedpatients, or in patients suffering from conditions which may delay woundhealing.Do not resterilize. Discard opened packages and unused sutures.As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculusformation. As an absorbable suture, MONOCRYL suture may act transiently asa foreign body. Acceptable surgical practice should be followed for themanagement of contaminated or infected wounds.

As this is an absorbable suture material, the use of supplementalnonabsorbable sutures should be considered by the surgeon in the closure ofthe sites which may undergo expansion, stretching or distention, or which mayrequire additional support.

PRECAUTIONSSkin sutures which must remain in place longer than 7 days may cause local-ized irritation and should be snipped off or removed as indicated. Subcuticularsutures should be placed as deeply as possible to minimize the erythema andinduration normally associated with absorption.


Consideration should be taken in the use of absorbable sutures in tissue withpoor blood supply as suture extrusion and delayed absorption may occur.


MONOCRYL suture knots must be properly placed to be secure. Adequate knotsecurity requires the accepted surgical technique of flat and square ties withadditional throws as warranted by surgical circumstance and the experience ofthe surgeon. The use of additional throws may be particularly appropriate whenknotting monofilaments.

Avoid prolonged exposure to elevated temperature.


ADVERSE REACTIONSAdverse effects associated with the use of synthetic absorbable sutures includewound dehiscence, failure to provide adequate wound support in closure of thesites where expansion, stretching, or distension occur, failure to provideadequate wound support in elderly, malnourished or debilitated patients or inpatients suffering from conditions which may delay wound healing, infection,minimal acute inflammatory tissue reaction, localized irritation when skinsutures are left in place for greater than 7 days, suture extrusion and delayedabsorption in tissue with poor blood supply, calculi formation in urinary andbiliary tracts when prolonged contact with salt solutions such as urine and bileoccurs, and transitory local irritation at the wound site. Broken needles mayresult in extended or additional surgeries or residual foreign bodies.Inadvertent needle sticks with contaminated surgical needles may result in thetransmission of bloodborne pathogens.

HOW SUPPLIEDMONOCRYL sutures are available as sterile, monofilament, dyed (violet)strands in sizes 6-0 through 2 (metric sizes 0.7-5), in a variety of lengths, withor without needles. MONOCRYL sutures are also available in sizes 3-0 through1 (metric sizes 2-4) attached to CONTROL RELEASE* removable needles.

MONOCRYL sutures are available in one and three dozen boxes.

389310 *Trademark © ETHICON, INC. 1996

CHAPTER 8 99

NUROLON* NYLON SUTURENONABSORBABLE SURGICAL SUTURE, U.S.P.

DESCRIPTIONNUROLON* nylon suture is a nonabsorbable sterile surgical braided suturecomposed of the long-chain aliphatic polymers Nylon 6 or Nylon 6,6.NUROLON sutures are dyed black to enhance visibility in tissue. The suture isalso available undyed (clear).

NUROLON suture meets all requirements established by the United StatesPharmacopoeia (U.S.P.) for nonabsorbable surgical suture.

INDICATIONSNUROLON suture is indicated for use in general soft tissueapproximation and/or ligation, including use in cardiovascular,ophthalmic and neurological procedures.

ACTIONSNUROLON suture elicits a minimal acute inflammatory reaction intissue, which is followed by a gradual encapsulation of the suture by fibrousconnective tissue. While nylon is not absorbed, progressive hydrolysis of thenylon in vivo may result in gradual loss of tensile strength over time.


WARNINGSUsers should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing NUROLON suture for wound closure,as risk of wound dehiscence may vary with the site of application and thesuture material used.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. Acceptable surgical practices should be followed for the managementof infected or contaminated wounds.





ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, gradual loss of tensile strength over time, calculi formation inurinary and biliary tracts when prolonged contact with salt solutions such asurine and bile occurs, infection, minimal acute inflammatory tissue reaction,and transitory local irritation at the wound site. Broken needles may result inextended or additional surgeries or residual foreign bodies. Inadvertent needlesticks with contaminated surgical needles may result in the transmission ofbloodborne pathogens.

HOW SUPPLIEDNUROLON sutures are available in U.S.P. sizes 6-0 through 1 (metric sizes0.7-4.0) in a variety of lengths with and without permanently attached needles.

NUROLON sutures are available in U.S.P. sizes 4-0 through 1 (metric sizes1.5-4.0) attached to CONTROL RELEASE* removable needles.

NUROLON sutures are available in one, two and three dozen boxes.



PDS* II (POLYDIOXANONE) SutureDYED and CLEAR MONOFILAMENTSYNTHETIC ABSORBABLE SUTURES, U.S.P., EXCEPT FOR DIAMETER.

DESCRIPTIONPDS* II (polydioxanone) monofilament synthetic absorbable suture is preparedfrom the polyester, poly (p-dioxanone). The empirical molecular formula of thepolymer is (C4H603)x.

Polydioxanone polymer has been found to be nonantigenic, nonpyrogenic andelicits only a slight tissue reaction during absorption.PDS II sutures are U.S.P., except for diameter.


U.S.P. SUTURESIZE DESIGNATION MAXIMUM OVERSIZE (mm)

9-0 .0058-0 .0087-0 .0206-0 .0155-0 .0294-0 .0293-0 .0562-0 .0290 .0711 .0472 .023

ACTIONSTwo important characteristics describe the in vivo performance of absorbablesutures: first, tensile strength retention, and second, the absorption rate (lossof mass). PDS II synthetic absorbable suture has been formulated to minimizethe variability of these characteristics and to provide wound support throughan extended healing period.

The results of implantation studies of PDS II monofilament suture in animalsindicate that approximately 70% of its original strength remains two weeksafter implantation. At four weeks post-implantation, approximately 50% of itsoriginal strength is retained, and at six weeks, approximately 25% of the origi-nal strength is retained.

Data obtained from implantation studies in rats show that the absorption ofthese sutures is minimal until about the 90th post-implantation day. Absorptionis essentially complete within six months.

INDICATIONSPDS II monofilament synthetic absorbable sutures are indicated for use in alltypes of soft tissue approximation, including use in pediatric cardiovascular tis-sue where growth is expected to occur and opthalmic surgery. PDS II suture isnot indicated in adult cardiovascular tissue, microsurgery and neural tissue.These sutures are particularly useful where the combination of an absorbablesuture and extended wound support (up to six weeks) is desirable.

CONTRAINDICATIONSThese sutures, being absorbable, are not to be used where prolonged (beyondsix weeks) approximation of tissues under stress is required are not to be usedin conjunction with prosthetic devices, i.e., heart valves or synthetic grafts.

WARNINGSThe safety and effectiveness of PDS II (polydioxanone) sutures have not beenestablished in neural tissue, adult cardiovascular tissue or for use in micro-surgery.

Under certain circumstances, notably orthopaedic procedures, immobilizationby external support may be employed at the discretion of the surgeon.

Do not resterilize.

PRECAUTIONSThe PDS II suture knots must be properly placed to be secure. As with othersynthetic sutures, knot security requires the standard surgical technique of flatand square ties with additional throws if indicated by surgical circumstanceand the experience of the operator.

As with any suture, care should be taken to avoid damage when handling.Avoid the crushing or crimping application of surgical instruments, such asneedle holders and forceps, to the strand except when grasping the free end ofthe suture during an instrument tie.

Conjunctival and vaginal mucosal sutures remaining in place for extendedperiods may be associated with localized irritation and should be removed asindicated.

Subcuticular sutures should be placed as deeply as possible in order tominimize the erythema and induration normally associated with absorption.

Acceptable surgical practice should be followed with respect to drainage andclosure of infected wounds.

ADVERSE REACTIONSDue to prolonged suture absorption, some irritation and bleeding has beenobserved in the conjunctiva and mild irritation has been observed in thevaginal mucosa.

DOSAGE AND ADMINISTRATIONUse as required per surgical procedure.

HOW SUPPLIEDPDS II sutures are available as sterile, monofilament dyed (violet) strands insizes 9-0 thru 2 (metric sizes 0.3-5), and sterile, monofilament dyed (blue)strands in size 9-0 thru 7-0 (metric size 0.3-0.5) in a variety of lengths, with avariety of needles.

PDS II monofilament dyed (violet) sutures, sizes 4-0 thru 1 (metric size 1.5-4) arealso available attached to CONTROL RELEASE* removable needles.

PDS II Clear suture strands are available in sizes 7-0 thru 1 (metric size 0.5-4) ina variety of lengths with permanently attached needles.

388W91 *Trademark ©ETHICON, INC. 1992

CHAPTER 8 101

PERMA-HAND* SILK SUTURENONABSORBABLE SURGICAL SUTURE, U.S.P.

DESCRIPTIONPERMA-HAND* silk suture is a nonabsorbable, sterile, surgical suturecomposed of an organic protein call fibroin. This protein is derived from thedomesticated species Bombyx mori (b. More) of the family Bombycidae.PERMA-HAND sutures are processed to remove the natural waxes and gums.PERMA-HAND suture is dyed black and coated with a special was mixture.PERMA-HAND suture is also available in its natural color. PERMA-HAND Virginsilk suture is available in which the sericin gum is not removed and serves tohold the filaments together.

PERMA-HAND suture meets requirements established by the United StatesPharmacopoeia (U.S.P.) for nonabsorbable surgical suture.

INDICATIONSPERMA-HAND suture is indicated for use in general soft tissue approximationand/or ligation, including use in cardiovascular, ophthalmic and neurologicalprocedures.

ACTIONSPERMA-HAND suture elicits an acute inflammatory reaction in tissue, which isfollowed by a gradual encapsulation of the suture by fibrous connective tissue.While silk sutures are not absorbed, progressive degradation of the proteina-ceous silk fiber in vivo may result in gradual loss of all of the suture’s tensilestrength over time.

CONTRAINDICATIONSThe use of this suture is contraindicated in patients with known sensitivities orallergies to silk.

Due to the gradual loss of tensile strength which may occur over prolongedperiods in vivo, silk should not be used where permanent retention of tensilestrength is required.

WARNINGSUsers should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing PERMA-HAND suture for woundclosure, as risk of wound dehiscence may vary with the site of application andthe suture material used.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. Acceptable surgical practice should be followed for the managementof infected or contaminated wounds.

Do not sterilize. Discard opened packages and unused sutures.



To avoid damaging needles points and swage areas, grasp the needle in anarea one-third (1/3) to one-half (1/2) of the distance from the swaged end to thepoint. Reshaping needles may cause them to lose strength and be lessresistant to bending and breaking g. Users should exercise caution whenhandling surgical needles to avoid inadvertent needle sticks. Discard usedneedles in "sharps" containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, gradual loss of all tensile strength over time, allergic response inpatients that are know to be sensitive to silk, calculi formation in urinary andbiliary tracts when prolonged contact with salt solutions such as urine and bileoccurs, infection, acute inflammatory tissue reaction, and transitory localirritation at the wound site. Broken needles may result in extended oradditional surgeries or residual foreign bodies. Inadvertent needle sticks withcontaminated surgical needles may result in the transmission of bloodbornepathogens.

HOW SUPPLIEDPERMA-HAND sutures are available in U.S.P. sizes 9-0 through 5 (metric sizes0.3-7.0) in a variety of lengths with and without permanently attached needlesand on LIGAPAK* dispensing reels.

PERMA-HAND sutures are also available in U.S.P. sizes 4-0 through 1 (metricsizes 1.5-4.0) attached to CONTROL RELEASE* removable needles.

PERMA-HAND sutures are available in one, two, and three dozen boxes.



PROLENE* POLYPROPYLENE SUTURENONABSORBABLE SURGICAL SUTURE, U.S.P.Except for size 7-0 diameter and HEMO-SEAL* Needle Suture Attachment

DESCRIPTIONPROLENE* polypropylene suture (clear or pigmented) is a nonabsorbable,sterile surgical suture composed of an isotactic crystalline stereoisomer ofpolypropylene, a synthetic linear polyolefin. The suture is pigmented blue toenhance visibility.

Size 7-0 PROLENE sutures are U.S.P., except for diameter.



7-0 .007

PROLENE suture, available as HEMO-SEAL* needle suture, is a needle suturecombination in which the diameter of the needle swage area has been reducedto facilitate attachment of finer wire diameter needles. The diameter of thesuture strand and the needle wire have been more closely aligned to reduce thedegree of needle hole bleeding. HEMO-SEAL needle suture differs from U.S.P.in needle attachment requirements only.

INDICATIONSPROLENE suture is indicated for use in general soft tissue approximationand/or ligation, including use in cardiovascular, ophthalmic and neurologicalprocedures.

ACTIONSPROLENE suture elicits a minimal acute inflammatory reaction in tissue, whichis followed by gradual encapsulation of the suture by fibrous connective tissue.PROLENE suture is not absorbed, nor is it subject to degradation or weakeningby the action of tissue enzymes. As a monofilament, PROLENE suture, U.S.P.resists involvement in infection and has been successfully employed in con-taminated and infected wounds to eliminate or minimize later sinus formationand suture extrusion. The lack of adherence to tissues has facilitated the use ofPROLENE suture as a pull-out suture.


WARNINGSUsers should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing PROLENE suture for wound closure,as risk of wound dehiscence may vary with the site of application and thesuture material used.


As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. Acceptable surgical practice must be followed for the management ofinfected or contaminated wounds.

PRECAUTIONSIn handling this suture material, care should be taken to avoid damage fromhandling. Avoid crushing or crimping damage due to application of surgicalinstruments such as forceps or needle holders.

Adequate knot security requires the accepted surgical technique of flat, squareties of single suture strands. The use of additional throws is particularly appro-priate when knotting polypropylene sutures.

To avoid damaging needle points and swage areas, grasp the needle in an areaone-third (1/3) to one-half (1/2) of the distance from the swaged end to thepoint. Reshaping needles may cause them to lose strength and be less resist-ant to bending and breaking. Users should exercise caution when handling sur-gical needles to avoid inadvertent needle sticks. Discard used needles in"sharps" containers.

ADVERSE REACTIONSAdverse effects associated with the use of this device include wounddehiscence, calculi formation in urinary and biliary tracts when prolongedcontact with salt solutions such as urine and bile occurs, infection, minimalacute inflammatory tissue reaction, and transitory local irritation at the woundsite. Broken needles may result in extended or additional surgeries or residualforeign bodies. Inadvertent needle sticks with contaminated surgical needlesmay result in the transmission of bloodborne pathogens.

HOW SUPPLIEDPROLENE sutures, pigmented, are available as sterile strands in U.S.P. sizes10-0 through 8-0 (metric sizes 0.2-0.4) and 6-0 through 2 (metric sizes 0.7-5.0).

PROLENE sutures, clear, are available as sterile strands in U.S.P. sizes 6-0through 2 (metric sizes 0.7-5.0). Size 7-0 (metric size 0.5) PROLENE sutures, pig-mented and clear are U.S.P. except for diameter. All PROLENE sutures are avail-able in a variety of lengths, with permanently attached needles.

PROLENE sutures, pigmented and clear are also available as sterile strands inU.S.P. sizes 0 through 2 (metric sizes 3.5-5.0) attached to CONTROL RELEASE*removable needles.

PROLENE sutures, pigmented and clear are also available as sterile strands inU.S.P. sizes 0 through 5-0, attached to TFE pledgets measuring 1/4" x 1/8" x 1/16"(7.0mm x 3.0mm x 1.5mm).

PROLENE sutures, pigmented and clear are also available in sterile strands asHEMO-SEAL* needle sutures in the following sizes:

PROLENE Suture HEMO-SEAL HEMO-SEAL Needle Suture LimitsU.S.P. Size Needle Suture on Needle Attachment

Avg. (Kgf) Individual (Kgf)Min. Min.

5-0 HS-7 0.17 0.084-0 HS-6 0.23 0.113-0 HS-5 0.45 0.23

USP Limits on Needle Attachment

Avg. (Kgf) Individual (Kgf)U.S.P. Size Min. Min.

5-0 0.23 0.114-0 0.45 0.233-0 0.68 0.34

PROLENE sutures are available in one, two, and three dozen boxes.


CHAPTER 8 103

PROLENE* (POLYPROPYLENE) HERNIA SYSTEMNonabsorbable Synthetic Surgical Mesh

DESCRIPTIONThe PROLENE* (Polypropylene) Hernia System is a sterile, pre-shaped, threedimensional device constructed of an onlay patch connected by a meshcylinder to a circular underlay patch. The material is undyed PROLENE*(Polypropylene) MESH constructed of knitted nonabsorbable polypropylenefilaments.

ACTIONS/PERFORMANCEThe PROLENE Hernia System is a nonabsorbable mesh used to reinforce orbridge inguinal hernia deficiencies to provide extended support during andfollowing wound healing. Animal studies show that implantation of PROLENEMesh elicits a minimum to slight inflammatory reaction, which is transient and isfollowed by the deposition of a thin fibrous layer of tissue which can grow throughthe interstices of the mesh, thus incorporating the mesh into adjacent tissue.The mesh remains soft and pliable, and normal wound healing is not noticeablyimpaired. The material is neither absorbed nor is it subject to degradation orweakening by the action of tissue enzymes.

INDICATIONSThis product is indicated for the repair of indirect and direct inguinal herniadefects.

WARNINGSThe PROLENE Hernia System is provided by ETHICON, INC. as a sterileproduct. This device is for single use only. Do not resterilize. Discard openedpackages and unused product.

When this device is used in infants or children with future growth potential, thesurgeon should be aware that this product will not stretch significantly as thepatient grows.

The PROLENE Hernia System should only be used in contaminated woundswith the understanding that subsequent infection may require removal of thedevice.

PRECAUTIONSSutures or clips, if necessary, should be placed such that a minimum of 6.5 mm(1/4") of mesh should extend beyond the suture line.

ADVERSE REACTIONSPotential adverse reactions are those typically associated with surgicallyimplantable materials which include infection potentiation, inflammation,adhesion formation, fistula formation and extrusion.

INSTRUCTIONS FOR USEFor indirect hernia, a high dissection of the neck of the hernia sac to utilize thepotential of the preperitoneal space can be performed to insert the PROLENEHernia System. The circular or bottom underlay portion of the PROLENE HerniaSystem is folded and is inserted through the internal ring allowing the mesh toexpand to the underlay position. Surgical manipulation may be used tofacilitate the expansion of the device to the underlay position. No sutures arenecessary in the bottom underlay patch. The top onlay patch, which is designedto cover the posterior wall (floor of the canal), is then modified as needed toaccommodate the cord structures. If one end of the oval onlay patch is longerthan the other, the PROLENE Hernia System is positioned so that the longerend covers the posterior wall (floor of the canal) and overlaps the publictubercle.

For direct hernia, the defect is circumscribed at its base, the contents fullyreduced, and the preperitoneal space is actualized prior to the insertion of thePROLENE Hernia System. The circular or bottom underlay portion of thePROLENE Hernia System is folded and is inserted through the defect or theinternal ring allowing the mesh to expand to the underlay position. Theunderlay portion should expand under the defect in the floor of the canal.Surgical manipulation may be used to facilitate the expansion of the device tothe underlay position. Sutures or clips may be used to secure the top onlaypatch in place.

STERILITYThe PROLENE Hernia System is sterilized by Ethylene Oxide. Do not resterilize.Do not use if package is opened or damaged. Discard open, unused product.

STORAGERecommended storage conditions: below 25°C, 77°F, away from moisture anddirect heat. Do not use after expiry date.

HOW SUPPLIEDThe PROLENE Hernia System is available sterile, undyed in several sizes.

CAUTIONFederal (U.S.A.) Law restricts this device to sale by or on the order of aphysician.

* Trademark ©ETHICON, INC. 1997


PROLENE* POLYPROPYLENE MESHNONABSORBABLE SYNTHETIC SURGICAL MESHSTERILE

DESCRIPTIONPROLENE* polypropylene mesh is constructed of knitted filaments of extrudedpolypropylene identical in composition to that used in PROLENE*Polypropylene Suture, Nonabsorbable Surgical Sutures, U.S.P. (ETHICON,INC.). The mesh is approximately 0.020 inches thick. This material, when usedas a suture, has been reported to be non-reactive and to retain its strengthindefinitely in clinical use.

PROLENE mesh is knitted by a process which interlinks each fiber junction andwhich provides for elasticity in both directions. This construction permits themesh to be cut into any desired shape or size without unraveling. The fiber junc-tions are not subject to the same work fatigue exhibited by more rigid metallicmeshes. This bi-directional elastic property allows adaption to various stressesencountered in the body.

ACTIONSPROLENE mesh is a nonabsorbable mesh used to span and reinforce traumat-ic or surgical wounds to provide extended support during and following woundhealing. Animal studies show that implantation of PROLENE mesh elicits a min-imum to slight inflammatory reaction, which is transient and is followed by thedeposition of a thin fibrous layer of tissue which can grow through the inter-stices of the mesh, thus incorporating the mesh into adjacent tissue. The meshremains soft and pliable, and normal wound healing is not noticeably impaired.The material is not absorbed nor is it subject to degradation or weakening bythe action of tissue enzymes.

INDICATIONSThis mesh may be used for the repair of hernia and other fascial deficienciesthat require the addition of a reinforcing or bridging material to obtain thedesired surgical result.

CONTRAINDICATIONSWhen this mesh is used in infants or children with future growth potential, thesurgeon should be aware that this product will not stretch significantly as thepatient grows.

PROLENE mesh in contaminated wounds should be used with the understand-ing that subsequent infection may require removal of the material.

WARNINGSPROLENE mesh is provided by ETHICON, INC. as a sterile product.Resterilization of the device is NOT recommended. However, testing hasdemonstrated that reprocessing of unused PROLENE mesh which has beenremoved from the package will not be adversely affected when exposed notmore than one time to conventional steam autoclave conditions of 250° F(121° C) for 20 minutes. Reprocessing under any other condition or by anyother means is neither recommended nor endorsed by ETHICON, INC.PROLENE mesh should not be flash autoclaved.

If this product should become stained with blood or soiled, it should not beresterilized for reuse.

When reprocessed as outlined above, it is the responsibility of the end-user toassure sterility of the product via a validated sterilization process as ETHICON,INC. has no control over environmental conditions the product may encounterprior to - during - or after reprocessing.

PRECAUTIONSA minimum of 6.5mm (1/4") of mesh should extend beyond the suture line.

ADVERSE REACTIONSPotential adverse reactions are those typically associated with surgicallyimplantable materials which include infection potentiation, inflammation,adhesion formation, fistula formation and extrusion.

INSTRUCTIONS FOR USEIt is recommended that nonabsorbable sutures be placed 6.5mm to 12.5mm(1/4" to 1/2") apart at a distance approximately 6.5mm (1/4") from edge of themesh. Some surgeons prefer to suture an uncut section of mesh that isconsiderably larger than the defect into position over the wound. The oppositesides are then sutured to assure proper closure under correct tension. Whenthe margin sutures have all been placed, the extra mesh is trimmed away.

HOW SUPPLIEDPROLENE mesh is available in single packets as sterile, undyed (clear) sheetsin seven sizes. The sizes available are 2.5cm x 10cm (1" x 4"), 4.6cm x 10.2cm(1.8" x 4"), 6cm x 11cm (2.5" x 4.5"), 6.1cm x 13.7cm (2.4" x 5.4"), 7.6cm x 12.7cm(3" x 5"), 15cm x 15cm (6" x 6") and 30cm x 30cm (12" x 12"). Each sheet isapproximately 0.5mm (0.020") thick.

389392.R01 *Trademark ©ETHICON, INC. 1996

CHAPTER 8 105

PRONOVA* POLY (HEXAFLUOROPROPY-LENE-VDF) SUTURENONABSORBABLE SURGICAL SUTURE, U.S.P.EXCEPT FOR SIZE 7-0 DIAMETER

DESCRIPTIONPRONOVA* suture (clear or pigmented) is a nonabsorbable, sterile surgicalsuture made from a polymer blend of poly(vinylidene fluoride) and poly(vinylidene fluoride-co-hexafluoropropylene). The suture is pigmented blue toenhance visibility.

Size 7-0 PRONOVA sutures are U.S.P., except for diameter.



7-0 .007

INDICATIONSPRONOVA suture is indicated for use in general soft tissue approximationand/or ligation, including use in cardiovascular, ophthalmic and neurologicalprocedures.

ACTIONSPRONOVA suture elicits a minimal to mild inflammatory reaction in tissue,which is followed by gradual encapsulation of the suture by fibrous connectivetissue. PRONOVA suture is not absorbed, nor is it subject to degradation orweakening by the action of tissue enzymes. As a monofilament, PRONOVAsuture, U.S.P. resists involvement in infection and has been successfullyemployed in contaminated and infected wounds to eliminate or minimize latersinus formation and suture extrusion. Furthermore, the lack of adherence totissues has facilitated the use of PRONOVA suture as a pull-out suture.


WARNINGSUsers should be familiar with surgical procedures and techniques involvingnonabsorbable sutures before employing PRONOVA suture for wound closure,as risk of wound dehiscence may vary with the site of application and thesuture material used.


As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. Acceptable surgical practice must be followed for the management ofinfected or contaminated wounds.

PRECAUTIONSIn handling this suture material, care should be taken to avoid damage fromhandling. Avoid crushing or crimping damage due to application of surgicalinstruments such as forceps or needle holders.

Adequate knot security requires the accepted surgical technique of flat, squareties of single suture strands. The use of additional throws is particularlyappropriate when knotting monofilament sutures.


ADVERSE REACTIONSAdverse effects associated with the use of this device include wound dehis-cence, calculi formation in urinary and biliary tracts when prolonged contactwith salt solutions such as urine and bile occurs, infection, minimal to mildinflammatory tissue reaction, and transitory local irritation at the wound site.Broken needles may result in extended or additional surgeries or residual for-eign bodies. Inadvertent needle sticks with contaminated surgical needles mayresult in the transmission of bloodborne pathogens.

HOW SUPPLIEDPRONOVA sutures, pigmented, are available as sterile strands in U.S.P. sizes 10-0 through 8-0 (metric sizes 0.2-0.4) and 6-0 through 2 (metric sizes 0.7-5.0).

PRONOVA sutures, clear, are available as sterile strands in U.S.P. sizes 6-0through 2 (metric sizes 0.7-5.0). Size 7-0 (metric size 0.5) PRONOVA sutures, pig-mented and clear are U.S.P. except for diameter. All PRONOVA sutures areavailable in a variety of lengths, with permanently attached needles.

PRONOVA sutures, pigmented and clear are also available as sterile strands inU.S.P. sizes 0 through 2 (metric sizes 3.5-5.0) attached to CONTROL RELEASE*removable needles.

PRONOVA sutures are available in one, two, and three dozen boxes.



PROXIMATE®

SKIN STAPLER

INDICATIONSThe Skin Stapler has application for routine skin closure in a wide variety ofsurgical procedures.

CONTRAINDICATIONSWhen it is not possible to maintain at least a 5 mm distance from the stapledskin to underlying bones, vessels, or internal organs, the use of staples for skinclosure is contraindicated.

DEVICE DESCRIPTIONThe Skin Stapler is a sterile, single patient use instrument designed to deliverrectangular, stainless steel staples for routine wound closure.

INSTRUCTIONS FOR USEVerify compatibility of all instruments and accessories prior to using theinstrument.

1 Using sterile technique, remove the instrument from the package.To avoid damage, do not flip the instrument into the sterile field.

2 Suggested Eversion Techniques: With two tissue forceps, pick up eachwound edge individually and approximate the edges (Illustration 1).Or, with one tissue forceps, pull skin edges together until edges evert(Illustration 2).Or, apply tension to either end of the incision, such that the tissue edgesbegin to approximate themselves. One forceps can be used to ensure thatthe edges are everted (Illustration 3).

3 Position the instrument with moderate pressure over the everted skinedges. The instrument should be held at a 60° angle to the skin (Illustration4).

4 Squeeze the trigger until the trigger motion is halted, then release thetrigger and move the instrument off the incision in any direction(Illustration 5).Alternate Release: If desired, before releasing the trigger lift up on theinstrument. This will help to evert the skin edges, which can then be moreeasily grasped with the tissue forceps. Release the trigger after theforceps are in place, and repeat the sequence to fire the next staple.(Illustration 6)Alternate Technique: The instrument can also be precocked (partially fired)so that the staple points are visible at the nose of the instrument. This fea-ture, in conjunction with the clear nose and alignment arrow, ensures pre-cise staple placement in the skin (Illustration 7).Note: If desired, after the instrument has been precocked, one leg of thestaple can be hooked onto one side of the tissue. This will aid in drawingthe tissue together. This technique may be suitable for attaching skin graftsunder moderate tension (Illustration 8).

WARNINGS AND PRECAUTIONS• Dispose of all opened products whether used or unused. Do Not

Resterilize the instrument. Resterilization may compromise the integrity ofthe instrument which may result in unintended injury.

HOW SUPPLIEDThe PROXIMATE Skin Stapler is supplied sterile and preloaded for singlepatient use. Discard after use.

FORMED STAPLE DIMENSIONSRegular staples have an approximate diameter of 0.53 mm, span of 5.7 mm,and leg length of 3.9 mm.

Wide staples have an approximate diameter of 0.58 mm, span of 6.9 mm, andleg length of 3.9 mm.

P40334P02 *Trademark ©ETHICON ENDO-SURGERY, INC. 1999

CHAPTER 8 107

PROXIMATE®

SKIN STAPLER EXTRACTOR

INDICATIONSThe PROXIMATE Skin Staple Extractor has application for routine skin closurein a wide variety of surgical procedures.


DEVICE DESCRIPTIONThe PROXIMATE Skin Staple Extractor is a sterile, single patient use, stainlesssteel device specifically designed to completely open skin staples for removal.The function of the Skin Staple Extractor is to remove Proximate Regular orWide Skin Staples from skin wounds.

Illustration and Nomenclature

1. Safety Cap2. Jaws3. Upper Handle4. Lower Handle

INSTRUCTIONS FOR USEVerify compatibility of all instruments and accessories prior to using the device.

1 Using sterile technique, remove the device from the package. To avoiddamage, do not flip the device into the sterile field.

2 Remove the safety cap from the device.

3 Slide lower jaw of extractor under regular or wide staple until staple issecured in slot in lower jaw. (Illustration 1)

4 Squeeze down with thumb to open staple until handles are firmlytouching. (Illustration 2)

5 Ensure staple is completely opened before lifting extractor from skin.Never pull up before extractor is fully closed. (Illustration 3)

Warnings and Precautions• Dispose of all opened products whether used or unused. Do Not

Resterilize the device. Resterilization may compromise the integrity of thedevice which may result in unintended injury.

• Instruments or devices which come into contact with bodily fluids mayrequire special disposal handling to prevent biological contamination.

HOW SUPPLIEDThe PROXIMATE Skin Staple Extractor is supplied sterile for single patient use.Discard after use.



PROXIMATE® PLUS MDMULTI-DIMENTIONAL RELEASE SKIN STAPLER

INDICATIONSThe PROXIMATE PLUS MD Skin Stapler has application for routine skin closurein a wide variety of surgical procedures.


DEVICE DESCRIPTIONThe PROXIMATE PLUS MD Skin Stapler is a sterile, single patient useinstrument designed to deliver rectangular, stainless steel staples for routinewound closure.

INSTRUCTIONS FOR USEVerify compatibility of all instruments and accessories prior to using the instru-ment (refer to Warnings and Precautions).

1 Using sterile technique, remove the instrument from the package.To avoid damage, do not flip the instrument into the sterile field.

2 Evert and approximate skin edges as desired. Several techniques aresuggested:a) With one tissue forcep, pull skin edges together until edges evert.(Illustration 1)ORb) With two tissue forceps, pick up each wound edge individually andapproximate the edges. (Illustration 2)ORc) Apply tension to either end of the incision, such that the tissue edgesbegin to approximate themselves. One forcep can be used to ensure thatthe edges are everted.

3 Position the instrument over the everted skin edges, aligning theinstrument arrow with the incision. (Illustration 3)

4 Squeeze the trigger until the trigger motion is halted. Release the triggerand remove the instrument from the fired staple. (Illustration 4)

WARNINGS AND PRECAUTIONS• Dispose of all opened instruments, whether used or unused. Do Not

Resterilize the instrument. Resterilization may compromise the integrity ofthe stapler which may result in unintended injury.

HOW SUPPLIEDThe PROXIMATE PLUS MD Skin Stapler is supplied sterile and preloaded forsingle patient use. Discard after use.

FORMED STAPLE DIMENSIONSRegular staples have a diameter of 0.53 mm, a span of 5.7 mm, and a leg lengthof 3.9 mm.

Wide staples have a diameter of 0.58 mm, a span of 6.9 mm, and a leg lengthof 3.9 mm.

Caution: Federal (USA) law restricts this device to sale by or on the orderof a physician.


CHAPTER 8 109

SURGICAL GUT SUTUREABSORBABLE SURGICAL SUTURES, U.S.P.

DESCRIPTIONSurgical gut suture is an absorbable, sterile surgical suture composed ofpurified connective tissue (mostly collagen) derived from either the serosallayer of beef (bovine) or the submucosal fibrous layer of sheep (ovine)intestines. Surgical gut sutures are available in plain or chromic. Chromic gutis processed to provide greater resistance to absorption. Surgical gut ispackaged in tubing fluid. Blue dyed chromic gut suture is also available.

Surgical gut suture meets all requirements established by the United StatesPharmacopoeia (U.S.P.) for absorbable surgical sutures.

INDICATIONS Surgical gut suture is indicated for use in general soft tissue approximationand/or ligation, including use in ophthalmic procedures, but not for use incardiovascular and neurological tissues.

ACTIONS When surgical gut suture is placed in tissue, a moderate tissue inflammationoccurs which is characteristic of foreign body response to a substance. This isfollowed by a loss of tensile strength and a loss of suture mass, as the prote-olytic enzymatic digestive process dissolves the surgical gut. This processcontinues until the suture is completely absorbed. Many variable factors mayaffect the rate of absorption. Some of the major factors which can affect tensilestrength loss and absorption rates are:

1. Type of suture - plain gut generally absorbs more rapidly than chromic gut.

2. Infection - surgical gut is absorbed more rapidly in infected tissue than in non-infected tissue.

3. Tissue sites - surgical gut will absorb more rapidly in tissue where increased levels of proteolytic enzymes are present, as in the secre-tions exhibited in the stomach, cervix and vagina.

CONTRAINDICATIONS This suture, being absorbable, should not be used where extended approxi-mation of tissue is required.

The use of this suture is contraindicated in patients with known sensitivities orallergies to collagen or chromium, as gut is a collagen based material, andchromic gut is treated with chromic salt solutions.

WARNINGS Users should be familiar with surgical procedures and techniques involving gutsuture before using surgical gut suture for wound closure, as the risk of wounddehiscence may vary with the site of application and the suture material used.Physicians should consider the in vivo performance when selecting a suture.The use of this suture may be inappropriate in elderly, malnourished, or debil-itated patients, or in patients suffering from conditions which may delay woundhealing. As this is an absorbable material, the use of supplemental nonab-sorbable sutures should be considered by the surgeon in the closure of siteswhich may undergo expansion, stretching or distention or which may requireadditional support.

As with any foreign body, prolonged contact of any suture with salt solutions,such as those found in the urinary or biliary tracts, may result in calculus for-mation. As an absorbable suture, surgical gut may act transiently as a foreignbody. Acceptable surgical practice should be followed for the management ofcontaminated or infected wounds.


Certain patients may be hypersensitive to collagen or chromium and mightexhibit an immunological reaction resulting in inflammation, tissue granulation orfibrosis, wound suppuration and bleeding, as well as sinus formation.

PRECAUTIONSIn handling this or any other suture material, care should be taken to avoiddamage from handling. Avoid crushing or crimping damage due to applicationof surgical instruments such as forceps or needle holders. Surgical gut suturesrequire the accepted surgical technique of flat and square ties withadditional throws as warranted by surgical circumstance and the experience ofthe surgeon.


The surgeon should avoid unnecessary tension when running down knots, toreduce the occurrence of surface fraying and weakening of the strand.



ADVERSE REACTIONSAdverse effects associated with the use of this device include wound dehis-cence, variable rates of absorption over time (depending on such factors as thetype of suture used, the presence of infection and the tissue site), failure to pro-vide adequate wound support in closure of sites where expansion, stretchingor distension occur, etc., unless additional support is supplied through the useof nonabsorbable suture material, failure to provide adequate wound supportin elderly, malnourished or debilitated patients or in patients suffering fromcancer, anemia, obesity, diabetes, infection or other conditions which maydelay wound healing, allergic response in patients with known sensitivities tocollagen or chromium which may result in an immunological reaction resultingin inflammation, tissue granulation or fibrosis, wound suppuration and bleed-ing, as well as sinus formation, infection, moderate tissue inflammatoryresponse characteristic of foreign body response, calculi formation in urinaryand biliary tracts when prolonged contact with salt solutions such as urine andbile occurs, and transitory local irritation at the wound site. Broken needlesmay result in extended or additional surgeries or residual foreign bodies.Inadvertent needle sticks with contaminated surgical needles may result in thetransmission of bloodborne pathogens.

HOW SUPPLIEDSurgical gut sutures are available in U.S.P. sizes 7-0 through 3 (metric sizes0.7-7.0) in a variety of lengths with and without permanently attached needlesand on LIGAPAK* dispensing reels. Surgical gut sutures are also available inU.S.P. sizes 0 through 1 (metric sizes 4.0-5.0) attached to CONTROL RELEASE*removable needles. The suture is supplied sterile in one, two and threedozen boxes.



SURGICAL STAINLESS STEEL SUTURENONABSORBABLE SURGICAL SUTURES, U.S.P.

DESCRIPTIONSurgical stainless steel suture is a nonabsorbable, sterile surgical suturecomposed of 316L stainless steel. Surgical stainless steel suture is available asa monofilament and multifilament suture.

Surgical stainless steel suture meets all requirements established by the UnitedStates Pharmacopoeia (U.S.P.) for nonabsorbable surgical sutures. Surgicalstainless steel suture is also labeled with the B&S gauge classifications.

INDICATIONS Surgical stainless steel suture is indicated for use in abdominal wound closure,hernia repair, sternal closure and orthopaedic procedures including cerclageand tendon repair.

ACTIONSSurgical stainless steel suture elicits a minimal acute inflammatory reaction intissue and is not absorbed.

CONTRAINDICATIONSThe use of this suture is contraindicated in patients with known sensitivities orallergies to 316L stainless steel, or constituent metals such as chromium andnickel.

WARNINGS Users should be familiar with surgical procedures and techniques involvingnonabsorbable, stainless steel sutures before employing for wound closure, asthe risk of wound dehiscence may vary with the site of application and thesuture material used.

Acceptable surgical practice must be followed for the management of contam-inated or infected wounds.

PRECAUTIONSIn handling this or any other suture material, care should be taken to avoiddamage from handling, such as kinking or excessive twisting.


ADVERSE REACTIONSAdverse effects associated with the use of this device include wound dehis-cence, allergic response in patients with known sensitivities to 316L stainlesssteel, or constituent metals such as chromium and nickel, infection, minimalacute inflammatory tissue reaction, pain, edema and local irritation at thewound site. Broken needles may result in extended or additional surgeries orresidual foreign bodies. Inadvertent needle sticks with contaminated surgicalneedles may result in the transmission of bloodborne pathogens.

HOW SUPPLIEDSurgical stainless steel sutures are available in sizes 7 through 10-0 (metricsizes 9.0-0.2) in a variety of lengths with and without permanently attached nee-dles in one, two and three dozen boxes.


CHAPTER 8 111

VICRYL* Knitted Mesh

DESCRIPTIONVICRYL* (polyglactin 910) knitted mesh is prepared from a synthetic absorbablecopolymer of glycolide and lactide, derived respectively from glycolic and lac-tic acids. This knitted mesh is prepared from uncoated, undyed fiber identical incomposition to that used in VICRYL (polyglactin 910) synthetic absorbablesuture, which has been found to be inert, nonantigenic, nonpyrogenic and toelicit only a mild tissue reaction during absorption.

VICRYL knitted mesh is intended for use as a buttress to provide temporary sup-port during the healing process.

ACTIONSTwo important characteristics describe the in vivo function and behavior ofVICRYL knitted mesh: reinforced wound strength and the rate of absorption(loss of mass).

The dehiscence force of healing abdominal wounds in rats closed with size 4-0absorbable sutures was compared with corresponding wounds closed with size4-0 absorbable sutures and reinforced with VICRYL knitted mesh. In this animalmodel, the strength of the incision, when supported by the mesh, was signifi-cantly greater than the sutured incisional wound. Explanted VICRYL knittedmesh, which, before implantation had an initial average burst strength of 63lbs., was found to have 80% of its original burst strength remaining afterfourteen days in vivo.

Subcutaneous implantation studies in rats indicate that the absorption ofVICRYL mesh material is minimal until about six weeks post implantation andessentially complete between 60 and 90 days.

INDICATIONSVICRYL knitted mesh may be used wherever temporary wound or organ supportis required, particularly in instances in which compliant and stretchable supportmaterial is desired and containment of wound transudate is not required.VICRYL knitted mesh may be cut to the shape or size desired for each specificapplication.

CONTRAINDICATIONSBecause VICRYL knitted mesh is absorbable, it should not be used whereextended wound or organ support is required.

WARNINGS DO NOT RESTERILIZE.

The safety and effectiveness of VICRYL knitted mesh in neural tissue and in car-diovascular tissue has not been established.

PRECAUTIONSNone.

ADVERSE REACTIONSNo significant clinical adverse reactions to the mesh have been reported.

DIRECTIONS FOR USEIt is recommended that absorbable or nonabsorbable sutures by placed 1/4 to1/2 inch (6 to 12mm) apart at a distance approximately 1/4 inch (6mm) form theedge of the mesh. Some surgeons prefer to suture a mesh larger than thedefect into position over the defect. The edges are then sutured to assure aproper closure under correct tension. When all margin sutures have beenplaced, the excess mesh is trimmed away, leaving at least 1/4 inch of meshextending beyond the suture line.

HOW SUPPLIEDVICRYL knitted mesh is available in single packets as a sterile, undyed fabricmesh in single sheet sizes of approximately 6 x 6 inches and 12 x 12 inches(15 x 15 centimeters and 30 x 30 centimeters).



VICRYL* Woven Mesh

DESCRIPTIONVICRYL* (polyglactin 910) woven mesh is prepared from a synthetic absorbablecopolymer of glycolide and lactide, derived respectively from glycolic and lac-tic acids. This tightly woven mesh is prepared from uncoated, undyed fiberidentical in composition to that used in VICRYL* (polyglactin 910) syntheticabsorbable suture, which has been found to be inert, nonantigenic, nonpyro-genic and to elicit only a mild tissue reaction during absorption.

VICRYL woven mesh is intended for use as a buttress to provide temporary sup-port during the healing process.

ACTIONSTwo important characteristics describe the in vivo function and behavior ofVICRYL woven mesh: reinforced wound strength and the rate of absorption(loss of mass).

The dehiscence force of healing abdominal wounds in rats closed with size 4-0absorbable sutures was compared with corresponding wounds closed with size4-0 absorbable sutures and reinforced with VICRYL woven mesh. In this animalmodel, the strength of the incision, when supported by the mesh, was signifi-cantly greater than the sutured incisional wound. Explanted VICRYL wovenmesh, which, before implantation had an initial average burst strength ofapproximately 121 lbs., was found to have approximately 23% of its originalburst strength remaining after fourteen days in vivo.

Subcutaneous implantation studies in rats indicate that the absorption ofVICRYL mesh material is minimal until about six weeks post implantation andessentially complete between 60 and 90 days.

INDICATIONSVICRYL woven mesh may be used wherever temporary wound or organ supportis required. The woven mesh structure is less porous than VICRYL knitted mesh.It is indicated in instances in which containment of wound transudate is desir-able. VICRYL woven mesh may be cut to the shape or size desired for each spe-cific application.

CONTRAINDICATIONSBecause VICRYL woven mesh is absorbable, it should not be used whereextended wound or organ support is required.

WARNINGSDO NOT RESTERILIZE.

The safety and effectiveness of VICRYL woven mesh in neural tissue and in car-diovascular tissue has not been established.

PRECAUTIONSNone.

ADVERSE REACTIONSNone known.

DIRECTIONS FOR USEIt is recommended that absorbable or nonabsorbable sutures be placed 1/4 to1/2 inch (6 to 12mm) apart at a distance at least 1/4 inch (6mm) from the edge ofthe mesh. Some surgeons prefer to suture a mesh larger than the defect intoposition over the defect. The edges are then sutured to assure proper closureunder correct tension. When all margin sutures have been placed, the excessmesh is trimmed away, leaving at least 1/4 inch of mesh extending beyond thesuture line.

HOW SUPPLIEDVICRYL woven mesh is available in single packets as a sterile, undyed, fabricmesh in single sheet sizes of approximately 6 x 6 inches and 12 x 12 inches(15 x 15 centimeters and 30 x 30 centimeters).


INDEX

CHAPTER 9

INDEX114

ABDOMEN, 23, 26, 28, 30abdominal cavity, 23, 26, 30, 34,

51, 63abdominal wall, 16, 19, 23, 28,

30-31, 33-34, 77, 82, 84fascia, 2, 5, 21, 30-32, 34, 39-40,

47-48, 51, 63, 77, 82, 96muscle tissue, 2, 30peritoneum, 19, 23, 29-31, 34,

47-48, 51, 63skin, 2, 31-33subcutaneous fat, 30-32, 47-48subcuticular tissue, 32transversalis fascia, 30

ALIMENTARY TRACT, 35esophagus, 36oral cavity, 35-36, 47-48, 69, 89pharynx, 35, 47-48upper alimentary tract, 35

BILIARY TRACT, 6, 29, 38, 47-48gallbladder, 29

BONE, 2, 16, 39-40, 80anchor, 18, 39, 65sternum, 39

BRAIN, 34cerebrospinal fluid, 34dura mater, 34-35galea, 34, 76peripheral nerve repair, 34skull, 35

CARDIOVASCULAR SURGERY, 18, 37, 46, 51, 83

heart valves, 21, 38, 99pledgets, 18, 21, 38, 91, 101sternum, 16, 37, 39, 48

COATED VICRYL* (POLYGLACTIN 910) SUTURE, 15, 25,

88, 111COATED VICRYL* PLUS(POLYGLACTIN 910) SUTURE, 10, 12,

26, 28, 38, 58, 80, 89

A

B

C

COATED VICRYL RAPIDE*(POLYGLACTIN 910) SUTURE, 14,

32-33, 39, 90

DEAD SPACE, 5, 22, 32, 81DERMABOND* TOPICAL SKIN ADHESIVE (2-OCTYL CYANOACRYLATE), 68-71,

81, 91-92DISSECTION, 4, 48, 103

ETHIBOND* EXCEL POLYESTERSUTURE, 10, 17-18, 20, 25, 33, 37-38,

58-59, 81, 83, 93ETHILON* NYLON SUTURE, 10, 17, 20, 25, 33-36, 58-59, 81, 94EYE, 35-36

conjunctiva, 35-36, 100cornea, 35-36, 80ocular muscles, 35-36sclera, 35-36

FEMALE GENITAL TRACT, 38

GASTROINTESTINAL TRACT, 6, 28-29, 47-48colon, 2, 27, 29rectum, 29small intestine, 2, 28-29, 94stomach, 2-3, 27-29, 81, 94, 110

HIGH VISCOSITY DERMABOND* TOPICAL SKIN ADHESIVE (2-OCTYL CYANOACRYLATE), 69,

91-92

INCISION, 4-6, 24, 28, 30-32, 49, 59, 62,68

INFLAMMATORY RESPONSE, 6-7, 77, 94, 110

D

E

F

H

G

I

CHAPTER 9 115

KNOT SECURITY, 11, 15, 24, 92-93, 95, 97-103, 105

KNOT TENSILE STRENGTH, 11, 89KNOT TYING, 17, 23-26, 34, 65, 94

endoscopic, 25-26, 38, 51monofilament sutures, 11, 18,

24, 29, 32-33, 35, 37, 95, 105

multifilament sutures, 11, 24, 29,31-33, 36

techniques, 18, 25-26deep tie, 25-26

instrument tie, 24-26square knot, 25-26surgeon’s knot, 25-26

LIGATURES, 10, 18-19, 28, 62, 85free tie, 18-19, 28LIGAPAK* dispensing reel, 21,

59, 63, 82, 101, 110stick tie, 18-19, 85

MERSILENE* POLYESTER FIBER MESH, 82, 97MERSILENE* POLYESTER FIBER STRIP, 75, 82MERSILENE* POLYESTER FIBER SUTURE, 13, 17, 20, 25, 33, 35, 58-59, 82, 96MESH, 30, 35, 82, 84, 86, 96

See also MERSILENE* polyester fiber mesh; PROLENE* Polypropylene Hernia System; PROLENE* polypropylene mesh;VICRYL* (polyglactin 910) knitted mesh; VICRYL* (polyglactin 910) periodontal mesh; VICRYL* (polyglactin 910)

woven meshMICROSURGERY, 15, 21, 34, 47-48, 62,65, 82, 97-98, 100MONOCRYL* (POLIGLECAPRONE 25)SUTURE, 10, 12, 14-15, 20, 25, 32, 38, 58-59, 70-71, 83, 98

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L

M

NECROTIC TISSUE, 4, 40NEEDLE, 10, 42-54

anatomy, 44body, 43-54eye, 44-46point, 42-44, 47, 48-50

applications, 47-48shape, 45-50

compound curved, 47curved, 46-48half-curved, 47

ski, 47straight, 46-47

Bunnell, 47, 51Keith, 47, 51

sharpness, 43, 48-50, 54, 82stability, 43strength, 42

ETHALLOY* needle alloy, 42, 81

swage, 44-45, 65, 83CONTROL RELEASE* needle, 21, 45, 59, 80

types, 48-52blunt point, 52

ETHIGUARD* blunt point needle, 52, 81

cutting, 43, 46-50, 51conventional cutting,

49, 83PC PRIME* needle,

48-49, 83sternotomy, 49

reverse cutting, 49-50, 75, 84MICRO-POINT* needle, 49, 82OS, 50, 51

side-cutting, 50, 82CS ULTIMA* needle, 48, 50, 80SABRELOC* needle, 50, 84spatula, 50-51, 82TG PLUS* needle,

50

N

INDEX116

taper point, 21, 43, 46, 50-51, 77, 85MAYO, 51

TAPERCUT, 44, 48, 50-51TAPERCUT needle,

44, 48, 51-52, 85

trocar point, 51NEEDLEHOLDER, 26-27, 42-43, 46-53

arming, 27, 59jaws, 52

NEUROSURGERY, 16, 34NUROLON* BRAIDED NYLONSUTURE, 10, 13, 17, 20, 25, 34, 39,

58-59, 83, 100

OPHTHALMIC SURGERY, 15, 35, 47, 4966, 80, 83

ORTHOPAEDIC SURGERY, 18, 50, 51

PARENCHYMATOUS ORGANS, 29kidney, 3, 29, 52liver, 29-30, 52spleen, 29

PDS* II (POLYDIOXANONE) SUTURE,10, 15-16, 25, 31, 35, 38, 59-60, 83, 101PERMA-HAND* SILK SUTURE, 16, 25,

33, 59, 83, 102PLASTIC SURGERY, 14, 17, 48, 51, 57, 83-84PRIMARY SUTURE LINE, 18, 22-23, 33

buried sutures, 22, 80continuous sutures, 19, 22, 37

Connell Technique, 24Cushing Technique, 24Lembert Technique, 24

deep sutures, 19, 22, 69interrupted sutures, 19, 22, 28,

30-31, 38interrupted horizontal mattress suture, 19, 24interrupted vertical mattress suture, 19, 24

O

P

purse-string sutures, 19, 22running stitches, 19subcuticular sutures, 19, 22,

32, 90PROLENE* POLYPROPYLENE HERNIASYSTEM, 30, 70, 84, 104PROLENE* POLYPROPYLENE MESH,

30, 70, 84, 105PROLENE* POLYPROPYLENE SUTURE,

18, 20, 25-26, 28, 30-31, 34-35, 37, 39, 61, 84, 103

PRONOVA* POLY(HEXAFLUOROPROPYLENE-VDF)SUTURE, 18, 20, 25-26, 37, 39, 84PROXI-STRIP* SKIN CLOSURES, 27,

40, 75, 84

RESPIRATORY TRACT, 36bronchial stump closure, 36thoracic cavity, 36

RETENTION SUTURE DEVICES, 33, 77-78, 84

SECONDARY SUTURE LINE, 33continuous sutures, 19, 22, 24,

37interrupted sutures, 19, 22, 24,

28, 30-31, 37railroad track scar, 33retention sutures, 33, 77-78, 84

SKIN, 2-5, 8, 10, 13-14, 16-17, 22,27-28, 31-34, 46-47

STITCH PLACEMENT, 23STITCHES AND TYPES, 18-23

Connell Technique, 24Cushing Technique, 24Halsted Technique, 24horizontal mattress technique,

19, 24Lembert Technique, 24over-and-over technique, 19, 24purse-string technique, 19, 22running technique, 19

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S

CHAPTER 9 117

* Trademark

subcuticular technique, 19, 22vertical mattress technique,

19, 24SURGICAL GUT SUTURE, 14, 20, 58,

94, 110chromic, 13-14, 20, 28, 32-33, 38,

80, 94, 97, 110CHROMICIZING process,

14collagen pure, 12-14fast absorbing, 14, 27, 94plain, 12-14, 20, 83, 94, 110TRU-GAUGING process, 13, 85tubing fluid, 85

SURGICAL SILK SUTURE, 16, 28, 34See also PERMA-HAND* silk suture

SURGICAL STAINLESS STEELSUTURE, 16-17, 20, 25, 66, 111SUTURE, 10-40

absorbable suture, 15, 22, 27-32, 38, 58-60, 80, 83, 85, 89

See also Coated VICRYL* (polyglactin 910) suture; Coated VICRYL RAPIDE* (polyglactin 910) suture; MONOCRYL* (poliglecaprone 25) suture; PDS* II (polydioxanone) suture; surgical gut suture

alloy suture, 16, 42, 49, 51, 81wire gauge equivalents,

17See also surgical stain-

less steel suture; temporary cardiac pacing wire

antibacterial suture, 10, 15, 20-21VICRYL* (polyglactin 910)

plus suturecharacteristics, 10-11, 14, 16-17,

24, 32absorption profile, 20-21

hydrolysis, 15, 17, 32, 35

absorption rate, 14, 20-21braided strands, 18breaking strength, 2,

20-21in vivo strength,

20-21burst strength, 2monofilament strands, 11,

15, 17, 24, 31-32, 35multifilament strands, 11,

16-17, 24, 29, 31-33size, 10-11, 13-16, 28tensile strength, 2, 6,

10-17, 23, 27, 31-33, 35, 38, 66, 85tissue reaction, 12, 14-15,

17-18, 26, 32-38labeling, 56-60

expiration date, 57, 60, 81Food and Drug Administration (FDA), 12,

57, 60, 68, 81lot number, 57package insert, 57, 83product code, 57, 84

manufacture, 13, 16, 42, 57, 90nonabsorbable suture, 16, 18,

22-23, 26, 29, 31-32, 35, 57, 60, 63, 82-83

See also ETHIBOND* EXCELpolyester suture; ETHILON* nylon suture; MERSILENE* polyester fiber suture; NUROLON*

braided nylon suture; PROLENE* polypropylene

suture; PRONOVA* poly(hexafluoropropy-lene-VDF) suture; surgical silk suture

nylon suture, 10, 13, 17, 20, 25, 36, 40, 81, 83, 93, 99

See also ETHILON* nylon suture; NUROLON* braided nylon suture

packaging, 10, 16, 56-65

INDEX118

dispenser boxes, 56-57, 60, 81, 83

environmentally conscious, 57primary packets, 56-57overwrap, 57, 59, 61-62,

64, 83peelable foil, 58single strand and multi-strand packaging packets,

58, 82-83E-PACK* procedure kit, 54, 59, 61, 81EASY ACCESS* packaging, 81ETHI-PACK* pre-cutsuture, 81GENTLE BEND* package, 82LABYRINTH* package, 82looped suture, 19,

77, 82RELAY* suture delivery system,

56-58, 60-61, 64, 84

SUTUPAK* pre-cut sterile suture, 58,

63, 85storage racks, 56

IV pole racks, 56modular storage racks, 56-57

polyester fiber suture, 13, 17, 20,25, 58, 92, 95, 96

See also ETHIBOND* EXCEL polyester suture

polypropylene suture, 18, 25-26, 28, 30, 32, 36-39, 66, 82-84, 102-103

See also PROLENE* polypropylene suture

sterilization, 57, 60, 85, 90, 104SUTURE CUTTING, 26SUTURE HANDLING, 10-11, 26-27, 63

sterile barrer, 61sterile field, 53, 56, 59-62, 64

T

sterile technique, 26, 75, 85sterile transfer, 56, 60-62sterile sterilization, 60

SUTURE PREPARATION, 62SUTURE REMOVAL, 11, 14, 26, 32-33, 35, 68-69SUTURE TECHNIQUES, 28-34, 45

double-layer closure, 28inverted closure technique, 28single-layer closure, 28, 31

Smaed-Jones far-and-near technique, 31

See also ligatures; primary suture line; secondary suture line

TAPES, 4, 32, 52, 56, 74-75skin closure tapes, 32, 74-75umbilical tape, 75, 85

See also MERSILENE* polyester fiber strip; PROXI-STRIP* skin closures

TENDON SURGERY, 39Bunnell Technique, 37, 39periosteum, 39, 51

TISSUE ADHESIVES, 68-71See also DERMABOND* Topical

Skin Adhesive (2-Octyl Cyanoacrylate)

TISSUE STRENGTH, 2breaking strength, 2burst strength, 2tensile strength, 2, 6, 11-17, 23

URINARY TRACT SURGERY, 38U

CHAPTER 9 119

* Trademark

VASCULAR SURGERY, 11heart valves, 21, 38, 99

VESSELS, 4, 6, 10, 14, 18, 24, 32, 37-38, 51, 59, 62, 75pediatric, 15, 21, 75, 85

VICRYL* (POLYGLACTIN 910) KNITTED MESH, 30, 86, 112VICRYL* (POLYGLACTIN 910) PERIODONTAL MESH, 35-36, 86VICRYL* (POLYGLACTIN 910) SUTURE,

10, 14-15, 25, 34-35VICRYL* (POLYGLACTIN 910) PLUSSUTURE, 10, 15, 20-21VICRYL* (POLYGLACTIN 910) WOVEN MESH, 30, 86, 113

WOUND CLASSIFICATION, 5-6clean, 4-5clean-contaminated, 5contaminated, 6-7, 18dirty and infected, 5-7, 18

WOUND COMPLICATIONS, 3dehiscence, 16, 38, 68, 74, 81dehydration, 3edema, 2, 5-6, 11, 78epithelialization, 7, 33, 35, 68infection, 2-7, 10-12, 27, 31-32,

35, 35-36, 38-40wound disruption, 23, 86

WOUND HEALING, 2-7, 10collagen formation, 7dehydration, 3primary intention, 6second intention, 6delayed primary closure, 6

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WOUND CLOSURE MANUAL

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ETHICON, INC. , PO BOX 151, SOMERVILLE, NJ 08876-0151

* TRADEMARKSM ETHICON, INC.© 2005, ETHICON, INC.

TO V I E W T H E E - C ATA L O G G O T O T H E

H E A LT H C A R E P RO F E S S I O NA L S E C T I O N O F

W W W. E T H I C O N . C O M

W O U N D H E A L I N G

S U T U R E S

N E E D L E S

A D H E S I V E S

S U R G I C A L M E S H

wound closure manual

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