Wound Closure

Sutures, staples, and

adhesives

Some material taken from http://www.vetmed.auburn.edu/~hendera/guide/guide1.htm#outline

Historical Background Sutures

Sutures
Use of textiles goes back
at least 4000 years
Linen (earliest)
Other
Fe wire, Au, Ag, dried gut,
horse hair, strips of hide,
bark fibers, silk, and
tendon

Up until 1930, catgut and

silk

Stainless wire and

polymers (nylon, polyester,
polypropylene) during and
after WW II
1970s Dexron (polyglycolic
acid) and Vicryl (polyglactic
acid) resorbable
Controlled degradation

The Ideal Suture Material

Universal applicability only difference in diameter
Limp easy to handle, no kinks, coiling, twisting, or
levitating
Biocompatible
Inert
Strong
Frictionless surface to glide through tissue
High friction for secure knotting
Sterlizable without composition changes
Complete absorption, no residue, after healing is
complete no matter how long it takes

Suture Classification
Physical/Mechanical
Size (diameter)
Number of Filaments
Tensile strength and
elongation
Elastic modulus
Bending stiffness
Stress relaxation and creep
Capillarity
Swelling
Coefficient of friction

Handling
Pliability
Packaging
memory
Knot tie-down
Knot slippage
Tissue drag

Biocompatibility

Biodegradation

Inflammatory
reaction
Propensity toward
wound
infection,
thrombi
formation,
carcinogenicity,
and allergy

Tensile breaking
strength and mass
loss
Biocompatibility of
degradation
properties

Absorbability
Lose 50% of breaking strength within 60 days of
implanting
Monofilament, braided, or twisted
Natural or synthetic
Natural enzymatic attack
Synthetic hydrolysis
More stable mechanism

Rapidity commonly rated as percentage of

breaking strength breaking strength rate (BSR)
Can be modified in synthetic sutures

BSRs for Some Absorbable Sutures

Natural Fiber

Synthetic Fiber

BSR

Poly(glycolide-co-caprolactone)
(Monocryl)*
Poly(p-diaxonone) (PDS
II)*

Monofilament

Poly(glycolide cotrimethylene
carbonate) (Maxon)
+
Polyglactin 910 (Vicryl)*
Polyglactin 910 (Vicryl
Rapide)*
Polyglycolic acid
(Dexon)+

Braided

Twisted

Plain Surgical Gut

Light Surgical Gut
Medium Surgical Gut
Heavy Surgical Gut
BSR = Approximate days after placement when 50% of breaking strength remains.
*Ethicon Inc., +Davis & Geck Inc.

7
35
35

15
5
12
1
4
8
11

Nonabsorbable
Retain majority of breaking strength for
more than 60 days
Three classes
Class I silk, monofilament, and sheathed
Class II cotton and linen
Class III metallics

Classes I and III most common as Class II

are prone to contamination and infection

Common Nonabsorbable Sutures

Monofilament

Polypropylene (Prolene* & Surgilene+)

Nylon (Ethilon* & Dermalon+)

Braided

Polyester (Mersilene*)
Silk
Nylon (Surgilon* & Nurolon+)

Braided & Coated

Polyester & Polybuterate (Ethibond*)

Polyester & Silicone (Tichron+)
Polyester & Teflon (Tevdek#)
Silk & Beeswax

Multifilament Sheathed

Multistrand Nylon & Polyethylene Sheath (Supramid$)

*Ethicon Inc., +Davis & Geck Inc., #Deknatel Inc., $S. Jackson Inc.

Suture Sizes Two Systems

United States
Pharmacopia (USP)
Complex relationship
between diameter, tensile
strength, and knot security
Precise criteria vary with
suture class, natural or
synthetic, and absorbability
Whole numbers from 5 to
12-0
Allows comparison among
different types

European
Diameter in mm
Differences in tensile
strength of materials
make comparisons
difficult

Sutures function best

when their strength and
tissue strength are
similar.

Suture Sizes/Use
Examples of Suture Sizes for Use in Pet Animals
10-0 - 8-0

7-0 - 5-0

Microvascular
Corneal

Ophthalmic
Neural
Vascular

4-0 - 3-0

Skin & Subcutis

Bowel
Bladder

2-0 - 0

Abdominal Fascia
Stomach
Hernia

1-2

Rib Retention
Cutaneous Stents

Increase or decrease abdominal fascia and retention sutures appropriately based on weight & suture pattern

Tensile Strength of Sutures

Dependent upon
Material
Size/diameter
Condition

Wet
Dry
Knotted
Absorption of bodily fluids
Hydrophobic
Hydrophilic

Abuse
Heat history re-autoclaving

Knot Strength vs. Tensile

Strength
Strength of a knotted suture generally
significantly less than strength of a straight
yarn (~ 50%)
Knotting induces stresses in the suture
due to bending and twisting
As knotted suture pulled compressive
stress develops increasing residual stress
and lowering overall strength values

Sizes and Breaking Strengths of Dry 2-0 and 3-0 Sutures

Straight Pull

Dia. inches

3-0

2-0

No. 3-0

lbs.

Knotted Pull

No. 2-0

psi.

lbs.

No. 3-0

psi.

lbs.

No. 2-0

psi.

lbs.

psi.

Surgical
Gut
Dexon
Vicryl
PDS II
Maxon

0.0125
0.0100
0.100
-

0.0160
0.0127
0.0130
0.0130
0.0153

6.7
6.1
-

54600
77800
-

9.8
9.6
11.5
14.8

48000
75900
80000
80000

3.8
3.9
5.0
-

30900
49700
-

5.7
6.4
7.9
10.8

28000
50300
50000
58000

Silk
Cotton
Polyprop
ylene
Nylon
Polyeste
r

0.104
0.0103
0.0097

0.0131
0.0128
0.0123
0.0131
0.0131

5.3
4.0
8.5

62400
48000
115000

8.2
5.5
7.6
9
14.5

60900
40200
63000
67000
107600

3.4
2.7
3.8
4.3
3.7

40000
32400
50100

4.8
3.5
5.5
6.5
6.8

35600
27200
46000
48000
50400

Coating Materials
Facilitate handling
Ease of passing through tissue
Ease in sliding knots down
But can result in poor knot security

Nonabsorbable coatings

Beeswax
Silicone
Paraffin wax
Poly(tetrafluoroethylene)

Absorbable
Must be absorbable like the suture
Water soluble
Water insoluble break down by hydrolysis

Problems Associated with Surgical

Sutures
Time-consuming nature of secure knot tying
Need for knot security under all conditions
with all sutures
Risk of suture breakage during surgery
Loss of control due to needle slippage or
rotation within the needle holder
Postsurgical slippage of the knotted suture
Early or pathologically induced degradation
of absorbable suture

Ligating Clips
Essentially clips to
replace sutures when
occluding (closing) the
lumen (central canal) of
a vessel or tubular
organ
Blood vessels
Gynecological &
urological (GU)
procedures

Metallic or polymeric

Requirements
Nontoxic and
biocompatible
Absence of allergic and
immunogenic effects
Tolerated by wide range
of tissue types
High strength and low
solubility
Finite longevity
Secure

Metallic Clips

First Cushing neurosurgery clip,

1910
Ag wire formed in the shape of
a U and closed around blood
vessel
Tantulum (1940)
Tubule ligation
Others
Co-Cr
Titanium
Stainless Steel
Memory metal Ni-Ti
alloy

Desirable properties in metallic

clips
High strength
Malleability & ductility can
make fine wire
Capacity for work-hardening
Corrosion resistance
Some problems
Allergic reaction
Radio-opaque can cause
problems with CT, X-ray, and
MRI examinations

Polymeric Clips
Absorbable and nonabsorbable
Viscoelastic
Creep
Stress-relaxation

Surgical Stapling
Introduced in the late
1970s
Used widely in human
and veterinary
medicine

Gynecological
Cardiovascular
Gastrointestinal
Esophageal
Pulmonary

Staples originally
stainless but now Ti
and polymeric used
Polymeric 2 parts
U-shaped fastener
Figure 8 retainer

Surgical Staples

Staple

Staple Gun

Staple Remover

Staples & Clips vs. Sutures

Speed
Convenience
Reduced infection rate
Lower cost
If done properly, no cosmetic difference

Before Curing

Tissue Adhesives
After Curing

Sterilizable
Easy in preparation
Viscous liquid or liquid
possible for spray
Nontoxic
Rapidly curable under
wet physiological
conditions (pH 7.3, 37C,
1 atm)
Reasonable cost

Strongly bondable to
tissues
Biostable union until
wound healing
Tough and pliable
Resorbable after wound
healing
Nontoxic
Nonobstructive to wound
healing or promoting
wound healing

Natural Tissue Fibrin Glue

First reported in 1940
Mimics blood clot major component
fibrin network
Excellent tissue adhesive but insufficient
in amount for larger wounds
Nontoxic if human protein sources are
used to obtain fibrin

Synthetic Systems:
Poly-Alkyl-2-Cyanoacrylates
Discovered in 1951
Crazy Glue
H2C=CCO2R

CN
R = alkyl group
CH3 (methyl)
H3CCH2 (ethyl)

Release small amount of

formaldehyde when curing
amount lessens with
length of alkyl chain

Characteristics of Currently Available Adhesive

Systems
Fibrin Glue
Cyanoacrylate
Handling

Excellent

Poor

Set time

Medium

Short

Poor

Good

Pliability

Excellent

Poor

Toxicity

Low

Medium

Resorbability

Good

Poor

Cell infiltration

Excellent

Poor

Tissue bonding

Other Experimental Systems

Gelatin-based adhesives
Mimic coagulation but without fibrin

Polyurethane (-HNOCO-) based adhesives

Capped with isocyanate to rapidly gel upon
exposure to water
More flexible than current cyanoacrylate
adhesives

Collagen-based adhesives