SUTURES AND

LIGATURES

Definition

A surgical suture is a strand Thread used to constrict and

or fiber used to hold the
seal off the blood vessel, vein
edges of various tissues e.g.
or artery or used to stop
skin, fascia, muscle,
bleeding by tying off blood
tendon, peritoneum etc.
vessels
Suture
Ligature

History

Sutures were made of plant

materials (flax, hemp and cotton) or
animal material (hair, tendons,
arteries, muscle strips and nerves,
silk, catgut).

African cultures used thorns, and

others used ant sutures by coaxing
insects to bite wound edges with
their jaws and subsequently twisting
off the insects' heads
3

3000 BC

1100 BC

500 BC

Earliest reports of surgical suture from

ancient Egypt
The oldest known suture is found in a
mummy
A detailed description of a wound suture and
the suture materials used by Sushruta

st

Suture techniques described by Greek

century
AD
Hippocrates and Roman Celsus

nd

Roman physician Galen described gut

century
AD
sutures
4

 The manufacturing process involved harvesting

10th century sheep intestines developed
AD

1860s

1880s

1906

Joseph Lister introduced the routine sterilization of all

suture threads
Attempted sterilization - "carbolic catgut"

Chromic catgut

Sterile catgut was finally achieved with iodine treatment.

 The first synthetic absorbable suture was based

on polyvinyl alcohol made
1931

Polyesters developed
1950s Process of radiation sterilization was established

1960-70

Polyglycolic acid was discovered and implemented

Gut sutures have been banned in Europe and Japan

owing to concerns regarding Bovine Spongiform
2000s Encephalopathy
6

Stainless
steel wires

Polyesters

Nylon

Absorbable

Linen

Silk

Linen

Cotton

Atraumatic
Catgut

Chromicized
Catgut

Simple
Catgut

Classification

Sutures
Non
absorbable

Sutures

Absorbable

Natural eg.
Catgut,
Chromicised
catgut

Non-absorbable

Synthetic

Natural eg. Silk

Synthetic

Boilable

Monofilament eg.
Polyesters

Monofilament eg.
Steel,
polypropylene

Non-boilable

Multifilament eg.
Polyglycolic acid
and its derivatives

Braided eg. Nylon

Method of
manufacture

Small intestine of
young lamb

Everything other
than sub-mucosa
removed

Heavily infected
with microorganisms

Runners

Sterilisation

Fresh, or frozen
or dried runner
reaches the
manufacturer
10

Frozen block of lamb's "runners."

11

Process flowchart
Soaking

Splitting

Scrapping

Measuring

Grading and
gauzing

Polishing

Drying

Spinning

Chromicising

Sterilization

Filling

Sealing

Labeling
12

1. Soaking
The raw material on receipt, if
not fresh from the slaughterhouse, is made soft and pliable
by:

Thawing out

Washing free
from salt (if
this has
been used
as a
preservative)

Soaking in
dilute alkali
(if the raw
material is
dried gut)

Even
runners
which
have not
been
dried
usually
receive
this
soaking
13

Thawing out frozen "runners."

14

2. Splitting
This is the most expert operation in the whole
process of manufacture.

It consists of drawing the lumen of the intestine

over an ivory point behind which it comes up
against the blade of a very sharp knife, which splits
it longitudinally.
The difficulty consists in splitting the gut into two
equal "ribbons," and cutting in a longitudinal
direction and not spirally.
15

Splitting runners

16

3. Scrapping
The next operation consists in scraping off the
inner and outer layers of the intestine from the
"ribbons," leaving only the submucosa.
This operation is sometimes performed by hand,
but usually a machine is employed which can
deal with a large number of "ribbons" at a time.
In any case more than one scraping is required
to complete the cleaning of the gut
17

Scrapping ribbons

18

4. Measuring

The ribbons are next measured and

divided into suitable lengths for spinning

String loops are attached to the ends of

each ribbon

19

Measuring ribbons and attaching string loops to their ends

20

5. Spinning
The ribbons are then spun; that is two or more ribbons with string loops fixed to the
ends are attached to a hook which is made to revolve rapidly, thus twisting the
ribbons together to form a string, the loop at the other end of the gut being attached
to a stationary hook.
The number of revolutions is counted by means of a cyclometer or by counting the
turns given to the handle of the machine and knowing the gear ratio and so the
number of turns made by the revolving hook.

The gauge of the finished gut depends upon:

The number of ribbons spun together, which is never less than two
Width of the individual ribbons
The number of times the ribbons are twisted

Sometimes a preliminary sterilizing or inhibiting process is carried out before spinning

by soaking the ribbons in a disinfectant solution.
21

Spinning ribbons to form strings

22

6. Drying

Carried out under tension by means of

wooden frames

23

7. Polishing
The dried strings (which at this stage are
identical with violin strings) are then
usually polished by means of:

Emery
paper

Pumicestone

Some
other
suitable
substance.

24

8. Grading and gauging

The strings of catgut are now graded by measuring
their caliber by means of a gauge of some kind
It is important that the gauge of any individual string
should vary only very slightly at different points in its
length.
The strings in which this variation is greater than the
maximum are rejected.
The different sizes into which the strings are classified,
viz. 00, 0, 1, 2 etc. but success depends very largely
upon the tensile strength of the gut
25

Sutures are sized by the USP scale

The available sizes and diameters are:
6-0 = 0.07 mm
5-0 = 0.10 mm
4-0 = 0.15 mm
3-0 = 0.20 mm
2-0 = 0.30 mm
0 = 0.35 mm
1 = 0.40 mm
2 = 0.5 mm
26

Suture Size
USP (United States Pharmacopoeia)

5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0
General
Thick

Thin

Volume % Reduction
With Decreasing
Size

2/0
3/0

51%

4/0
5/0

49%

6/0
7/0
8/0

40%

54%
50%
44%

Suture Selection
Bowel: 2/0 - 3/0
Fascia: 1 - 0
Skin: 2/0 - 5/0
Arteries: 2/0 - 8/0
Micro surgery 9/0 - 10/0
Corneal closure: 9/0 - 10/0

Gauging catgut strings by means of a wire gauze

30

9. Chromicising
The strings at this stage are immersed in a chrome
bath for a period which depends on the degree of
hardening required.
In order to prevent swelling and unravelling of the
gut this process is carried out under tension
secured by stretching the strings on metal frames.
This is the end of the pre-sterilization process and
the gut must now be sterilized.
31

Stretching strings of catgut on metal frames

preparatory to chromicizing

32

10. Sterilisation
The gut may be sterilised
by heat, chemicals or
ionising radiations.
Irradiation > Heat >
Chemicals
33

Iodine

Mercurial salts

Hydrogen
peroxide
Heat
Essential oils
Sterilisation

Chemicals
Formalin
Irradiation
Hypochorites

Glutaraldehyde

Ethylene oxide
34

Heat
Heat is the most efficient and reliable agent for
sterilizing catgut provided that the physical properties
of the catgut can be preserved unimpaired.
The heating of catgut should be done to a
temperature sufficient to destroy anaerobic spores,
and should not burn it and also the material should
not become hard and extremely brittle.
There might be temptation to reduce the temperature
or time of heating below the safety point and if at any
point tensile strength of the finished gut is found to be
unsatisfactory.
35

Sterilisation of catgut
36

Iodine
Solutions of iodine have been very largely used for the sterilization
of catgut, owing to their penetrating power.

Owing to its colour the degree of penetration of iodine solutions

can be verified easily by examining a cross section of the catgut,
and this gives the manufacturer a feeling of security.

It is important to note that there should be contact of sterilising

solution and material for sufficient time therefore, it is necessary to
exhaust the air in the jars containing the catgut immersed in the
solution, because the bubbles of air from solution would prevent
thorough contact.
37

Another point which requires special

attention when iodine solutions are
employed is the removal of excess iodine
at the end of the sterilizing process as,
excess of iodine has a rotting action on the
gut, reducing its tensile strength.
The excess iodine is usually removed by
means of spirit which should be membrane
filtered before use, as commercial spirit is
not necessarily sterile but often contains
the spores of anaerobes.
38

Exhausting air from jar containing iodine solution

39

Filtering spirit through Seitz filter

40

Mercurial solutions
Aqueous and alcoholic solutions of mercurial salts,
chiefly the per chloride and the bi-iodide are used for
the sterilization of catgut.

Such solutions are more bacteriostatic than

disinfectant, and they have some disinfectant action
on the exterior of the catgut and for this reason they
are often employed for "filling solutions " even when
another process has been used for the actual
sterilization of the gut.
41

Hydrogen peroxide
Hydrogen peroxide is a most efficient sterilizing agent for
catgut, but it has swelling effect upon spun gut, and
therefore it is used along with other agents for preliminary
action mostly when iodine is used as sterilization.
It effectively sterilizes the catgut but results in material of
poor quality.

But sometimes it is used to improve the colour of the

catgut by treating the collagen in the ribbon form i.e. before
spinning.
42

Essential oils
Essential oils, such as oil of
cloves and oil of eucalyptus,
have been largely used by
hospitals for the sterilization of
catgut for their own use, but
they have a negligible action
on spore-bearing bacteria.
43

Formalin
Formaldehyde solutions of
concentration of 5% are used to
destroy anthrax spores.
The problem with this solution was that
the catgut was so hardened that
delayed its absorption in the body and
also reduced its tensile strength.
44

Hypochlorites
Sodium and potassium solutions of
hypochlorites are sporicidal when
prepared in acid solution
But they are not suitable for catgut
sterilization because of their poor
penetration power, swelling and
resultant poor tensile strength of catgut.
45

Glutaraldehyde
They behave in the same way as that
of hypochlorites and is only active in
sodium bicarbonate buffered
solutions.
They retain the sporicidal activity for
about 2 weeks only.

46

Ethylene oxide
It may be employed in the gaseous form or
in solution.
The important factors to be controlled are
concentration, moisture time and
temperature employed.
Care must be taken to limit the residual
ethylene oxide in the suture material.
47

Irradiation
In this process the
prepared material is packed
in aluminium foil envelopes
containing 90% isopropyl
alcohol as a preservative.

The exterior of the packets

is sterilized before opening
by immersion in a solution
of 1% formaldehyde in 90%
isopropyl alcohol.

The envelopes are passed

through an irradiation area
on a conveyer system.

The irradiation dose is 40%

greater than that required
to destroy the most
resistant micro-organisms,
each suture receiving a
dose of 2.5 megarads.

Thus the catgut is sterilised

when sealed in its final
container.

This process is rapid as

there is no hold up of
material in this process.
48

Recontamination of
catgut

The following are the ways in which catgut may become recontaminated between the
completion of the sterilization process and the sealing of the container or packet:

By handling the
catgut, for the purpose
of winding the lengths
on slats prior
introducing it into the
container.
To avoid this source of
contamination sterilization of
the catgut inside the
container is highly desirable.

By the access of airborne organisms

(either in the form of
dust or in droplets
from the breath of
operatives) through
the open ends of the
containers before
sealing.
This may occur when the
containers are waiting to be
sealed or during the actual
sealing operations

By the use of unsterile

filling solutions. It
By the use of unsterile should be noted that
stoppers (such as
even antiseptic
By the use of unsterile
ordinary or rubber
solutions may provide
containers.
corks) to close the
such a source of
containers between
contamination if these
filling and sealing.
antiseptics are
incapable of killing the
spores of anaerobes

49

Filling tubes with catgut. Note face-masks, glass hooded table, rubber gloves,
metal boxes for holding tubes, and bowl of disinfectant into which operative's hands are
dipped periodically.
50

11. Filling

The sterilized gut are filled

into the containers in
which it will be sold
together with a filling
solution (unless the gut is
sold in a dry form).
51

Different types of container are used for filling, but the catgut
filled in any of these containers should pass the tests laid down
in the Therapeutic Substances Act.

Containers
used may
include:

Sealed glass tubes

Glass tubes closed with a rubber cork
Glass tubes closed with a metal screw cap
52

The container or packing from which there is

repeated extraction of portions of catgut
must be considered as highly unsatisfactory.

The filling solutions should be considered as

useful for killing organisms on the outside of
the gut which have got there as a result of
handling, subsequent to the main
sterilization process
53

12. Sealing
It consists of sealing of the only containers
which are made of glass tubes.

Such tubes are sealed in the ordinary way in the

flame of a blowpipe, but this process should be
carried out with due precautions, which to
prevent recontamination of the contents.
Efficient sealing of the tubes is verified, either by
examination in a good light or by immersion in
some coloured solution
54

Sealing glass tubes of catgut

55

13. Labeling
The label on
or in the
container
should state
the following
by indelible
marking or
perforation:

Length of the strand.

The gauze number.
Whether the strand is plain, hardened or
chromicized.
Container should not be subjected to heat
treatment.
The name and the percentage of any bactericide
in the fluid in which the sutures are immersed
56

Physical properties
Sterility testing

Quality control

57

Testing of physical
properties

Tensile strength and flexibility

Length
Gauge
Absorption of catgut by tissues

58

Tensile strength and flexibility

The test is carried out on a machine having a
moveable jaw with a constant rate of traverse of
30cm/min, and a capacity so that when the strands
break, the angle which the pendulum arm makes with
the vertical is not less than 9 and not more than 45.
The clamps head are specially designed and any
strands breaking within 12.5 mm of the clamps are
disregarded.

59

The strands are tested within 15 min. of

removal from their container and in a temp.
between 16 to 21 with relative humidity of
60 to 80%.
As catgut is knotted in patients the test is
always carried out on strands in which
surgeons knot has been formed at a point
midway between the two clamps.
The knot strength is approximately half of
which would be obtained on an unknotted
sample.
60

Surgeons knot

61

Length
This is determined immediately after
removal of the strand from its container
and is measured without stretching.
The length must be not less than 90%
of the length stated on the label.

62

Gauge

This is measured by means of a dial

reading micrometer at several points
along the strand.

63

Absorption of catgut in tissues

No standards are given for

absorption time.
Both in-vitro an in-vivo methods
has been utilized and the latter
giving more satisfactory results.
64

Sterility tests

The chief purpose of the Therapeutic

Substances Act is to ensure that the product
should be free from pathogenic microorganisms which may cause disease or
infection when the catgut is introduced into
the human body during an operation, and in
order to achieve this measure of safety, catgut
sold under license is required to pass certain
sterility tests.
65

Sterility tests are carried out on not less

than 1% of the material constituting a
batch, and the contents of at least one
whole container or packet drawn at
random from the whole number of
containers or packets constituting the
batch.

66

Microorganisms in
bovine gut

Gut of living animals is generally free of microorganisms

But after the death of the animals, the proliferation of
microbes is rapid.
The various bacteria found in the gut are:
Sr. no. Pathogenic

Sporulating

Easily
sterilizable

Example

E. coli and Str.

faecalis

B. anthracis

B. subtilis

Cl. tetanii, Cl.

sporogenes, Cl.
welchii
(anaerobic)
67

Opening the
container or
packet with sterile
precautions

Pouring the filling

solution

Placing the whole

of the contents in
a large test tube
containing sterile
DW

Incubating for
twenty-four hours
at 37 C

Transferring to a
tube containing a
solution of 1%
NaS2O3 and 1%
Na2CO3 in DW

Incubating at 37
C for 24 hours

Remove disinfectants
which might, by their
bacteriostatic action,
interfere with the
cultural test

Remove the whole

sample from the
last solution

DO NOT WASH

Examining it for the

presence of microorganisms by the
aerobic and anaerobic
methods prescribed
68

Inoculation in media

2 media

Aerobic
test
peptone
broth

Anaerobic
test
nutrient
broth

1 combined
media

Nutrient
agar

Incubat
ed for
14 days
at 37 C

Examined daily for the

growth of bacteria

If no
growth of
microorganism
s is found
in any
tube

The
sample
may be
regarded
as
having
passed
the test

If the growth of
the microorganisms is
found in any
tube a further
sample may be
taken from the
batch and test
is repeated

If no
growth
occurs
the
sample
shall be
regarded
as
having
passed
the test,

But if
any
microorganis
m is
found
the
batch
is
treated
as not
sterile
69

Partially sterilized
sutures
The partial sterilization process is carried out before spinning by
certain manufacturers of catgut.

The gut treated in this way and not subjected to a sterilizing process
after spinning, is often sold as "internally sterile" or " partially sterilized
" catgut
As it is not called "sterilized surgical catgut " or claimed to be ready for
surgical use, it does not come under the control established
substances by the Therapeutic Substances Act.
Purchasers of such "internally sterile" or "partially sterile'" catgut
assume that this product requires less sterilization than raw catgut
and some of the wound infections following the use of catgut sterilized
by hospitals for their own use are directly attributable to this belief.
70

Types of sutures

71

Stainless
steel wires

Polyesters

Nylon

Linen

Absorbable

Silk

Collagen

Atraumatic
Catgut

Chromicized
Catgut

Simple
Catgut

Classification

Sutures
Non absorbable

72

Properties of suture
material

Must be sterile
Tensile strength must be adequate for the
purpose for which they are used
They must cause as little irritation as
possible
Their gauge should be as fine as possible
If absorbable, the approximate time for
absorption should be known

73

Absorbable sutures

They are digested and absorbed by

tissues
They are used for suturing internal
wounds
More expensive

74

Absorption of catgut in
body
Site of implant

Breakdown of catgut

Fibrous exudates

Increasing amount of
macrophages

Rapid proliferation of
polymorphonulcear
leucocytes

Plain catgut
attracts polymorphs
in 1 day
Chromicised catgut
10 days

Phagocytosis
75

Simple catgut (Violin

gut)

Name derived from kitgut (kit = small

violin)
Made from the submucosa of sheep
gastrointestinal tract
Broken down within about a week
Not treated to lengthen its absorption
time
Completely digested and absorbed by
tissues
Sizes vary from 5-0 to 2
76

Chromicized catgut

Simple catgut is treated with chromic oxide

for 3 hrs
Chromic acid delays hydrolysis
Even so it is destroyed before many wounds
have healed

77

Atraumatic catgut

Made up of polyglycolic acid (Dexon)

Synthetic material
But completely absorbable

78

Reconstituted Collagen
The surgical catgut has the limitations of length of the intestinal material along with the
biological variations of thickness and character.
To overcome these disadvantages many other alternatives were searched for and one
of them is collagen.
Collagen is the major constituent of skin, tendon, ligament etc
It is partially soluble in acids and consists of 11 amino acids.
The acidic solution of collagen is prepared from hides or tendons which can be
extruded into a coagulating solution and resulting fibers are oriented by stretching.
Reconstituted collagen is produced mainly in the finer sizes for ophthalmic and
cuticular surgery.

79

Kangaroo Tendon
This absorbable material consists of the tail tendons of the Kangaroo.
The tendons, are preserved with naphthalene, and the strings are prepared in
three gauge sizes e.g. fine, medium and stout. With lengths from 30-40 cm.
They are processed and sterilized similar to that of catgut and used in hernia
repair and bone surgery.
It is absorbed slowly in the body and used to limited extent.

80

Ribbon gut
It is in the form of ribbon and is
usually about 12mm wide and 45cm
long.
Its use is limited and is prepared for
the repair of hernia and in the
closure of the kidney nephrotomy.
The material is prepared from bovine
oesophagus and is sterilised in the
same way as that of catgut.
81

Fascia Lata
This is obtained from ox fascia or prepared
from bovine thigh muscle.
It is used surgically for hernia repair and
similar cases.
It is supplied in the form of sterile strips
inches wide and 8 inches long and also in
sheets of 3 x 5 inches
82

Brocafil
This suture material was introduced by Dutch research workers.
It is prepared from animal sinew (A piece of tough fibrous tissue
uniting muscle to bone or bone to bone; a tendon or ligament.) by
maceration, in a special acid solution to disintegrate the tissue and
homogenization.
This does not damage the constituent fibrils of the tissue, and the
product is a viscous fluid containing these fibrils in suspension.
The fluid is squirted continuously into a basic liquid where it
solidifies as ribbons. The ribbons are then polished and sterilized.
Advantages:

1.
2.
3.
4.
5.
6.

Little contamination.
Exact and uniform gauging.
Threads may be as long as required.
Good tensile strength.
Ease of sterilisation and
Good absorption qualities.
83

Cargile Membrane.
This a thin sheet of pliable tissue obtained
from the appendix (blind gut) of the steer or
ox.
It is designed primarily to cover surfaces from
which the peritoneum has removed especially
when the adhesion of sterile membrane is less.
The membrane is available in sterile sheets of
4x6 inches and sometimes is used as a
packing or protective sheath and there is
limited use of this material.

84

Non absorbable sutures

Not absorbed by tissues

Used for suturing outer surface of the
body
Cheaper
Easy to handle
Smooth surface
Knot securely

85

Such sutures can cause stitch infection

or stitch sinus
Infection can be arrested by removal of
suture

86

SILK

It is an important non-absorbable surgical

suture which consists of the protein fibroin.
Silk strands are prepared from the filaments
of the cocoon spun by the silkworm of the
family Bombyx.
Natural form of the silk contains 25% of
natural gum and degummed silk fibres are
used commercially.
87

As the gum has been removed from the silk fibres it is

not serum proof or capillary proof i.e. spun yarn have
wick-like capillary properties that may allow the
contamination to be conveyed through the threads.

So to make them non-capillary they are treated with

proofing waxes or silicones. This minimizes the risk of
rise of tissue fluids to the surface and thus counter
passage inward of organisms from the surface.

Such treatment also imparts required degree of

stiffness to improve the handling and tying properties,
to minimize the attachment of the tissue cells that would
cause pain on removal of suture and to lubricate the
implantation and removal of the silk.
88

Three forms are used in surgery

Twisted (Chinese)
Floss
Plaited or Braided silk

89

Twisted silk
Prepared from unbleached filaments which are spun
or twisted into single strands of various diameters
as specified in the USP or BPC.
It may be sold in natural colour or may be dyed with
non-toxic dye stuffs which should be approved by
FDA.
The surgical use of twisted silk has declined due to
increasing popularity of braided silk.

90

Floss silk

Prepared from coarser filaments on the

outer surface of the silkworm cocoon.

It is used in its spun glossy white form

mainly in the repair of hernia.

91

Braided or plaited silk

Most popular material and is used in

large scale in modern surgery.
Several twisted yarns are braided into a
compact structure which give the
required firmness and strength.

92

Dermal silk
These sutures consists of natural twisted
silk encased in an insoluble coating of
tanned gelatin or other protein.
This coating must withstand autoclave
without stripping and its purpose is to
prevent in growth of tissue cells which
would interfere with its removal after use
as skin or dermal suture.

93

Identification
test:

Silk + mercuric nitrate solution = brick red

colour
Silk + trinitrophenol = yellow colour

Sterilization:

Autoclaving, radiation or by ethylene oxide.

Autoclaving - losses some of its tensile
strength.

Uses:

Irritation

Used in many surgical operations and

particularly suited for ophthalmic and
neurosurgery.

They are well tolerated by body tissues

although they may cause significant tissue
reactions in some cases.
94

Cotton

These sutures are derived from cellulose and are

used to limited extent.
They are twisted from fiber staple, have
moderately high tensile strength and are stable to
heat sterilization.
Cotton sutures are uniform and have
reproducible strength and also they have good
handling properties.
They are used where the strength of the fiber is
to be maintained for longer period of time as the
cotton degrades slowly.

95

Linen

They consists of fibers made into twisted strands obtained from

flax.
The strand is prepared by spinning three cords together and the
size of the cords is dependent on the desired gauge of the thread.
It must be spun firmly and evenly and should be free from
fuzziness.
It may be dyed with any non-toxic dye and the majority of the
surgeons prefer off-white or ivory colour.
It is rendered as non-capillary and serum proof by some suitable
treatment same as that of braided silk.
It can be sterilized by autoclaving or ethylene oxide and use of
radiation sterilization causes considerable loss in its tensile
strength.
96

Polyamides or Nylon

It is the first modern synthetic fiber and is strong and water

resistant.
Its use came into picture during World War II when there was
shortage of the silk material
It is a synthetic polyamide formed from polymerization of an
acid and an amine.
Nylon 66 is formed by the combination of hexamethylene
diamine and adipic acid.
Nylon 6 is formed by the polymerization of caprolactum.
All the polyamides and suture materials are prepared by an
extrusion process and the size of the orifice on the extruder
head determines the size of the filament.

97

They are also available as multifilament fibers which are

braided into strands.
Monofilament is normally coloured with non-toxic dyes in
order to improve its visibility.
It may be sterilized by autoclaving or by ethylene oxide or by
irradiation treatment but it is incompatible with phenol and
other phenolic substances.
Monofilament nylon is used mainly in the suturing of skin
and for plastic surgery.
Braided nylon is buried in tissues and has the same limitations
as that of braided silk.
Polyamides mesh are used in hernia repair.
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Polyester

It is prepared by polymerizing ethylene glycol and

terephthalic acid and then they are braided or plaited into
suitable sizes.
The tensile strength of the braided polyester suture is superior
than that of the braided silk and nylon and twisted cotton.
They can be sterilized by autoclaving, ethylene oxide or by
radiation sterilization.
The polyester suture does not lose strength when they are in
contact with water and body fluids.
For this reason they are sutures of choice when there is
permanent reinforcement e.g. installation of artificial heart
valves.

99

They have excellent knot holding characteristics and

they are available in the natural colour or can be
dyed in order to improve its visibility.
Recently polyester fibers are coated or impregnated
with non-toxic lubricants such as PTEF or silicone
resins.
These sutures exhibits improved handling properties
and permits easier and more gentle passage through
skin.

100

Polyolefin fibers
2 main types are used:
1. Polypropylene
2. Pronova

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Polypropylene fibers

Polypropylene sutures compared to

monofilament nylon have more secure
knots and low order tissue reactivity.
As they are smooth they slip through tissue
easily and they may be removed easily
when necessary.
They have found wide application in
cardiovascular and other surgical
specialties.
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Pronova

It is Polytetrafluoroethylene (PTFE) suture

It is blend of polyvinylidene fluoride and

hexafluoropropylene.
This suture is resistant to damage and may be
useful in robotic surgery.

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Metallic Wires
Silver

It is one of the oldest material which is used relatively

to less extent in the form of wire or foil and other
forms.

Silver is available readily and have some antiseptic

action but in some tissues they have irritating action.

The choice of metal wires depends on irritation

controlling parameter.
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Stainless Steel Wire

Stainless steel has replaced the wires made

from silver, tantalum, phosphor bronze, etc.

They are resistant to attack by body fluids and

behaves as an inert material in tissues.

It is supplied in three forms- monofilament,

twisted and plaited or braided.
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In all three cases wire is prepared from

austenitic chromium-nickel stainless steel and
is fully annealed.
The austenitic steel are non-magnetic and
capable of being hardened by gold working.
They are sterilized by dry heat, autoclaving,
ethylene oxide or radiation but when the heat
treatment is used the wire should be fully
degreased.
It is mainly used in orthopaedic work, in the
repair of the sternum after chest surgery, also in
plastic surgery and in repair of tendons.

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Suture clips:

They are used for long skin wound and used particularly in
research work on animals where they are less irritating in the
skin surface than sutures.

Wire Staples:

They are usually prepared from stainless steel and are used in
orthopaedic, cardiovascular and arterial work.

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Category

Absorbable sutures

Non-absorbable sutures

Removal process from

body

Not needed

Needed

In vivo degradation

Occurs and the formed products

are absorbed
Hydrolysis or proteolytic enzymes

Does not occur

10 days to 8 weeks
High

May extend from weeks to

years
Low

Scarring tendency

High

Low

Surface treatment

Chromicising

Coating with wax or silicon

Applications

Suturing internal wounds

Suturing surface or skin

wounds or in cases where
absorbable sutures cannot
stand the stress eg. Suturing
organs like heart, bladder etc

Examples

Catgut (collagen), chromicised

catgut, polyglycolic acid
derivatives

Nylon, steel, polypropylene

Mechanism of
degradation
Time it remains in the
body
Chances of infection

Not applicable

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Type of catgut
Absorbable

Non-absorbable

1.
2.
3.

Advantages
They are digested and absorbed by tissues
They are useful for suturing internal wounds
No foreign left in the body

1.
2.
3.
4.
5.
6.
7.

Permanent wound support

Used for suturing surface wounds
Easier to handle
Less irritation
Smoother surface
Knots securely
Cheap

1.
2.

Foreign bodies left in body

Surgical removal can be costly and
inconvenient

Handling and knotting is easy

Economic

1.
2.

Tissue reactions observed

Route of degradation is by enzymatic
degradation by proteolytic enzymes
thus unpredictable
Residence time is short

Biological/ natural 1.
sutures
2.

1.
2.
3.

3.
Synthetic

1.
2.
3.
4.

Monofilamentous
sutures

Multifilamentous/
braided

Less immune response ie inert

More tensile strength
Smoother surface
If absorbable, breakdown is by hydrolysis
and doesnt depend on proteolytic enzymes
Smooth surface
Less tissue trauma
Bo bacterial harbours
No capillarity

1.
2.
3.

Greater tensile strength

Soft and pliable
Good handling and knotting

Disadvantages
Short residence time
Expensive
Higher incidence of immune response
and irritation

1.

Difficult to handle monofilamentous

synthetic sutures

1.
2.

Handling and knotting is difficult

Knots or ends may get buried

1. Bacterial harbours present at

junctions of braids
2. Capillarity observed
3. Tissue trauma observed
109