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Introduction to Sutures
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hello and welcome to a quick introduction to suture for surgical technology students i'm mark sowers so right from the start let's clarify something in medicine we like to use high class terms for everything all right we don't like to use the everyday terms we use high class terms fancy sounding terms so we're not talking about stitches here that's the everyday term we use the term sutures all right so suture is the high class term that we use in medicine so in other words
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got it okay now when it comes to suture there are many many types of suture many kinds of sutures all different sizes and varieties to choose from and different doctors are going to have different preferences for the type of suture that they like to use so i'm going to try to help organize this and make it a little bit understandable by categorizing some of the suture types into different sections so you can sort of see how they break down just a little bit now the first thing we should probably
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talk about is suture size now suture comes in all different sizes anywhere from really thick diameters to really tiny little diameters very thin threads that you can barely see so back in the day when suture sizes were just starting to get standardized they developed six standard suture sizes that they were going to use anywhere from just under half a millimeter thick to almost a full millimeter thick about three quarters of a millimeter thick so anywhere from point seven nine
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millimeters down to point four three millimeters six different sizes of those sutures and they realize that well if a doctor is asking for a 0.58 or a 0.65 that's going to get a little confusing so they decided to make it a little bit more simple they decided to say okay let's just call them size 1 2 3 4 5 and 6. that's going to make it easier for the people working in the or to say this is the size that i want they started size one is going to be the smallest size six is going to be the largest
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suture that we have and for years that worked just fine size one i need a size one i need a size six i need a size four whatever all right but what happened is surgeons started to realize that they wanted something a little bit smaller than a size one and manufacturers were getting better at making this stuff so they said okay we can make a suture that's smaller than say half a millimeter thick we can make it a little bit smaller than that but then they ran into trouble because
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what's smaller than a size one we don't want to go and change the whole system as we add new and new sutures so what's all smaller than a size one well okay we can call that a size zero all right so size zero be the next smallest suture well then they came up with an even smaller suture well what's going to be smaller than a size zero well we could go to like negative one but that's going to sound weird a size negative one what is that so how about we call it a double
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zero suture that's going to be smaller than a zero suture all right that works and then they came up with a smaller suture that's going to be a triple zero suture and a quadruple zero suture and you can see where this is going eventually to the point where nowadays we've got 11 zeros so zero zero zero zero zero zero zero zero zero zero zero suture well that's crazy now at this point so we've got to come up with a way of simplifying this as well and the way we do that is simply by counting the
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number of zeros so that suture with eleven zeros we're just going to call it an 11 0 suture 10 0 suture and all the way down to 2 2-0 suture now zero that's just gonna be one o so that's just zero and then of course the standard one two three four five and six so six being the largest down to zero and then all the way down to eleven o which is the smallest very very tiny suture that you're going to see so just how tiny are we talking well take a look at this this is a human hair
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running up and down the screen right there and you can see suture sizes compared to that human hair human hair is about the equivalent of a 7-0 suture it's about the same diameter all right but down to 11-0 suture which is really tiny that thing's about a third of the diameter of a human hair imagine very very tiny and very very hard to see especially with my old eyes it's really hard to see a suture that's a third of the size of a human hair so then imagine
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if they turn out the lights in the room because you're doing a laparoscopic or a microscopic surgery and all of a sudden it's dark in there well you're not going to see this tiny little suture at all so that's why having really good eyesight especially when working with these very tiny sutures is going to be very helpful so let's see if we can classify some of these types of sutures and sutures can generally be broken down into a couple of different types so the first way of
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breaking down or classifying suture would be whether it's absorbable or not so most suture is either absorbable or non-absorbable now what are we talking about here so absorbable suture is going to be broken down by the body the enzymes in the body are going to react with the suture material itself and eventually break it down and dissolve it so it eventually gets absorbed by the body so that suture is eventually going to go away over a couple of days usually
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a couple of weeks it'll get absorbed by the body non-absorbable suture on the other hand is not going to get absorbed by the body it's going to stay there it's going to stay there pretty much permanently so non-absorbable suture is really long-lasting so why do we have these two different types well for example if you're suturing the skin it's easy enough to come back a little bit later and have the suture removed but if you're suturing somewhere deeper in the
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body and you suture it closed you don't want to have to go in a couple weeks later open it back up to try to get those sutures out you want those sutures to sort of dissolve naturally so that's a good example of where you would use absorbable suture or maybe if you don't want the patient to have to come back into the doctor's office to have the sutures removed even if it's in the skin you can use absorbable sutures and they'll eventually sort of dissolve away on their own
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so usually you're going to see absorbable sutures used probably deeper in the body or in places where the doctor just doesn't want the patient to have to come back and have those sutures removed usually this is going to be used on soft tissue that heals rapidly so very soft tissue that has a lot of blood flow through it it's going to heal very quickly the suture doesn't have to hold it together for very long those are areas that you're going to use absorbable sutures but there are some
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cases where you might use a non-absorbable suture where it would be important to do so because you don't want that suture to absorb or dissolve too quickly so for example let's say you're suturing two arteries together in you're anastomosing these arteries that's the fancy term for putting them together all right so you're going to suture them together well these arteries are now under high blood pressure the blood's flowing through there it's high blood pressure
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you don't want these sutures to dissolve away too quickly before the blood vessel has a chance to heal because if the suture then dissolves and the blood vessel hasn't healed yet well then it's going to burst and that's going to create a lot of problems and you don't want that to happen so usually on blood vessels especially arteries you're going to use non-absorbable suture that's just going to stay there for a really long time hold those blood vessels together
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just in case another example where you might use non-absorbable sutures would be for tissues that don't necessarily have a whole lot of blood flow to them so they heal very slowly such as tendons tendons are a great example of this tendons ligaments things like that not very much blood flow in them they're very tough material and they heal very very slowly it takes weeks months even for these to heal and tendons and ligaments tend to have a lot of pressure put on there's a lot of stretching put
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on them so you don't want the suture to sort of dissolve away and have the tendon whatever a little bit has healed suddenly pull apart so you're going to use a non-absorbable suture that's going to hold that tendon together for a really really long time and one other case where you might use non-absorbable sutures even on skin you could do this if you have a patient let's say they're staying in the hospital for a long time and they're getting constant care and
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there's always going to be a doctor or nurse there to remove any sutures that might be there you can use up non-absorbable sutures then because they're fairly easy to take out so one way of classifying sutures is absorbable versus non-absorbable another way of classifying suture looks at the filament now what we mean by filament is we're looking at the thread itself what the thread itself is made up of all right so thread suture thread can be made up of a monofilament meaning a single strand of
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solid material think of a nice solid wire it's just a solid one strand material that's monofilament but sutures could also be made up of many very thin tiny filaments sort of woven or even braided together more like a rope rather than a wire so you have many tiny strands that are woven or braided together to create a multi-filament suture so you can imagine that monofilament versus multifilament sutures are going to have different properties that are going to make them more advantageous in
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different situations so let's take a look at some of the different properties between monofilament and multifilament sutures the first property is that monofilament sutures tend to have something called memory now memory means that it likes to retain its shape it doesn't bend or change its shape very well whatever shape it came in is the shape it's probably going to stay in it wants to stay in that shape here i'll give you an example this is monochrome suture monochrome suture
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so this is a monofilament suture and you can see how it's wavy here goes back and forth it's holding its shape that it had in the package so it doesn't just hang nice and neat it sort of waves back and forth if you can see that so this suture has memory it remembers the shape that it was in while it was in the package and that means you can't try to stretch it out and it sort of sprawlings back sprawling is a technical term it sort of springs back holding that shape that's
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sort of a feature of monofilament suture whereas this is vikral which is a popular suture you're going to see a lot of and notice it just sort of hangs there straight down it doesn't have a lot of memory yeah down here towards the bottom maybe a little bit but generally vicryl which is a multi-filament suture is just going to hang nice and smooth it's going to drape wherever you take it okay so it's going to act like a nice easy to use thread and this ease of use is one of
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the advantages of a multi-filament suture so while handling monofilament suture which has that memory which likes to spraying back into its original shape it can be a little challenging where it really comes into play is when you're trying to tie the knot you're trying to suture and tie that knot together and make that not hold so what happens is that suture that has memory doesn't tend to not as tightly as suture that doesn't have memory it tends to want to spring back to its original
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shape and the original shape was not in a knot so it wants to open that knot back up which makes these knots not quite as tight as they otherwise would and surgeons who use monofilament suture are usually going to throw several knots they're going to knot it and then they're going to knot it again and then knot it again and knot it again in order to make sure it really holds because monofilament doesn't tend to hold those knots quite as well as multi-filament suture does multi-filament suture
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because it doesn't care what shape you put it in it's going to knock nice and tight and it's going to hold that knot really good so that's one of the advantages of multi-filament over monofilament in this case it's held it's not better but when it comes to bacteria and bacteria is a bad thing when it comes to bacteria the monofilament is actually has the advantage so if we look at a close-up view of a monofilament suture here you can see that it's real smooth
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it's just one strand of suture there and it's real smooth surface now bacteria really likes little nooks and crannies little places to hide from the immune system and monofilament suture doesn't really have this it's so smooth that the immune system can get to any bacteria that might happen to form on there whereas multi-filament suture because of all those tiny little threads woven and braided together well there's lots of little nooks and crannies in there for
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that bacteria to hide in and the immune the immune system can't get in there to get it so what happens is multifilament suture shouldn't be used in areas of infection because that infection can tend to very quickly grow in that suture the immune system can't clean it out and then it's going to tend to follow that suture all the way along that suture line and the bacteria are going to follow it all the way along that wound infecting now the entire wound because
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they're protected by that multifilament suture one other advantage of monofilament over multi-filament is that because it's so smooth it tends to just glide through the material so let's say you're suturing a very tiny little blood vessel a very soft very delicate blood vessel and you take your monofilament suture and it's just going to pull right through and you can pull that suture through the little hole that you've created and it's just going to glide right through there not causing any
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damage to the tissue of that blood vessel whereas a multi-filament suture tends to be rougher it has all these little edges and little nooks and crannies on it so as you're pulling it through that very delicate tissue it's going to tend to catch and drag on that it's going to tear it a little bit it's going to create a little bit larger opening and when we're talking about blood vessels we want that opening around that suture to be nice and tight so usually when we're talking about
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blood vessels we're going to use a monofilament suture because it's not going to drag it's not going to create friction as it pulls through that tissue so those are two different ways of classifying suture we can classify it whether it's absorbable or non-absorbable we can classify it whether it's monofilament or multifilament and those two different types of classifications can sort of mix and match one isn't linked to the other in any way so we can make a grid here of
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the different combinations that we could have we have absorbable monofilament suture and here's a couple of examples monocryl pds plane gut chromic gut we're going to get to what these are in a minute those are absorbable monofilament sutures whereas you can also have non-absorbable monofilament sutures those would be say proline gore-tex surgical steel yeah stainless steel they make suture out of thin threads of stainless steel or ethelon which is sort of a nylon like your nylons that you
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would wear kind of stretchy suture there so ethelon is a non-absorbable monofilament suture but then you can also have absorbable multifilament sutures and a good example of this would be vicryl viral is a real popular suture you're going to hear about that one a lot so vicroal or vicryl rapid is going to be a mo absorbable multifilament suture and then if you want a non-absorbable multifilament suture you can use something like ethybond or silk so again there are many many different
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types and names of sutures out there these are just some of the more popular ones some of the more common ones that you're going to see in the hospitals so we're just going to cover a few of these just to give you a little introduction to some of the more popular more common suture that's out there one of the original types of suture sutures that was used hundreds thousands of years ago is gut suture this is suture it's called gut because it's made out of you know guts it's made out of
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sheep or beef intestines and they cut them into very thin strips and this thin strip is then used to suture wounds together so this plain gut or sometimes called cat gut don't worry it's not actually made out of cat guts you think of it more as a shortened cattle gut so cat gut or in this case just plain gut suture is made from beef or sheep intestines and put into a single thread so cat gut or plain gut suture intestine suture is absorbable now some manufacturers actually start out by
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taking several different threads of this gut tissue and sort of winding them together but then they grind them and smooth them out so it becomes very smooth and very monofilament like so gut suture is generally considered monofilament and again it is absorbable and this suture is going to be used in areas with lots of really good blood flow that's going to heal very very quickly often use the digestive system especially the upper digestive system think the mouth the
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tongue the lips things like that or even places like a circumcision that again has a lot of blood flow it's going to heal very rapidly plain gut suture is often used in these areas now because of the natural fibers we don't want them to dry out this suture is actually packaged in a little alcohol mix so when you open it up the suture itself is moist it's wet and it's alcohol-based so it has a fairly strong odor or smell to it so you're definitely going to notice when you're using a gut suture
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now plain gut suture happens to dissolve or absorb very rapidly usually in just a few days it can break down and start to break off but if you want it to last maybe a little bit longer you want it to hold a little bit longer what the manufacturers do is they treat this with chromic salts so now you have chromic gut suture and because of these chromium salts that are mixed in with the alcohol that treats this suture it's still going to be wet it's still going to have an
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odor but because of the chromium salt it's going to last a little bit longer so maybe it'll last a few weeks rather than just a few days but then new modern manufacturing techniques have allowed us to use certain different types of plastics to make our suture so a mono krill is a type of plastic absorbable monofilament suture it has very similar properties to the chromic gut suture it's just synthetic okay it's a plastic type of suture it's good for use for
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approximating or bringing together soft tissues again has a lot of blood flow to it's going to heal very rapidly and again because it's monofilament it's going to have memory it's going to sprawling back and it's going to be a little bit harder to tie a knot in another type of suture is pds suture or pds2 in this case so pds just defines the type of chemical the type of plastic that makes it up so different types of plastic different polymers make up different types of sutures and pds is
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one of those types of sutures now one of the neat things about the suture packaging is that it will often tell you what you need to know about it here it says monofilament and here it says absorbable so pds is a monofilament absorbable suture and you can find that right on the packaging one very popular type of suture is called proline now proline is monofilament so it has a really good memory but it's non-absorbable it's going to last a long time in fact surgeons like to talk about patients
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that they had a long time ago they did a surgery on that patient they put in some proline 10 years later the patient comes back for a different surgery surgeon opens them up and sure enough there's this bright blue monofilament suture still sitting there just like it was the day it was put in even 10 years later it hasn't broken down so proline is a very long lasting it's a bright blue suture that's a way to remember that one now proline has many uses you're going to
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see it used a lot of places but because it's non-absorbable one of the good uses for it is to hold surgical mesh in place let's say you're repairing a hernia you got to put some mesh in there to cover up the opening to make sure that things don't protrude where they're not supposed to and you're going to suture that in place using proline which is going to stay there for a long time and really hold that mesh in place for a long time that's a good example of using
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proline inside the body another example would be because it's monofilament and non-absorbable it's really used very often on vascular procedures on procedures on blood vessels so you're going to suture the blood vessel closed and because it's nice and smooth it's not going to tear the tissue and because it's non-absorbable it's going to stay there and hold that blood vessel closed for a very long time now one of the most commonly used types of sutures that you're going to see is
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called a vicryl vicryl is used in lots and lots of places get used to vicryl you're going to see this everywhere and because vikro is so popular people who write test questions like to ask a lot of questions about it so one of the things they like to ask is okay it's made up of plastic it's made up of a type of plastic a polymer well what exactly is it made up of so knowing that vicryl is made up of polyglactin 910 i know that's kind of a mouthful polyglactin 910 knowing that that is the
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polymer the type of plastic that makes a vicryl is really going to help you out i'm telling you memorize that one right now polygalactin 910 is another name for vicryl suture now vicryl suture is absorbable and it is multifilament so it doesn't have that memory you can tie a nice tight knot with it and it will absorb eventually so a good use for this is say for example if you're doing an abdominal surgery and you're closing up the abdomen well you you start by suturing
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down deeper in the belly in the abdomen area you're going to suture the fascia and some of the peritoneum together you're going to use an absorbable suture because that's going to heal fairly quickly but you don't want it to be there 10 years later you want it to sort of absorb into the body so that's a good use general soft tissue approximation approximation means bringing it together so general soft tissue approximation for is a good use for vicryl suture
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now vicro suture is usually dyed purple so if you see purple suture it's usually going to be vital suture but vicryl is also available undyed meaning it doesn't have that purple in it so in that case it's usually a white suture so another very common type of suture is silk now silk is a natural suture it's made out of silk from you know silk worms that create silk and they take all these little threads that the silkworm has created and of course they clean them up
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you know but they'll wind them and braid them together so this is a braided suture it is multifilament they'll wind it up into this nice thin thread and then they'll usually dye it black so that's how you can tell silk sutures dyed black so this is a multi-filament non-absorbable suture because silk is going to last a long time even in the body it's going to last a long time so silk is multifilament because of all those tiny little silk threads and non-absorbable it's going to last a long
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time another common use for silk suture is to attach drains now usually we put a little tube a little drain into a wound to let that soda drain out any fluid that builds up in that wound it's going to drain out through this little tube that's a drain and then we're going to suture that into place temporarily with silk suture which is going to hold it there until you know once the wound stops draining then we can take all that out now there's a couple of things to
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remember about silk suture number one is that it is multi-filament and because it's multifilament and it doesn't absorb it doesn't break down it's just there for a long time that means you never want to use it in the presence of an infection if you've got an infection it's going to get into that silk suture and because it's around forever it's just going to follow that suture all the way through that wound and it's going to create a lot of problems so never use silk suture in the
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presence of an infection and silk suture tends to cause inflammation of the skin so you probably don't want to use silk suture in skin at least leaving it there for a long time because it is going to cause inflammation in skin tissue so that's just a few of the many many types of sutures out there and you're going to hear about many more of these but these are some of the more common ones that you'll hear about so just sort of a quick introduction to those so
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we've talked about the suture the thread itself but now let's talk about the needles that come on the ends of those threads and just like there are many many different types of suture threads there are many many different types of needles that can come on the ends of these suture threads now we're not going to cover all of these but i will tell you some of the general classifications of needles it comes sort of four different major types and there are many other types but four different major
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ones that you're going to see and one type of needle is the taper point needle now think of this as a sewing needle it's a round needle it's got a round sort of diameter to it and then it tapers down to a nice sharp point so a round needle that tapers to a point that's going to be a taper point suture needle now different from that is you can have still a round needle but it's sort of a softer blunter point it's not a real sharp point it's got a blunt point so
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this is going to be a blunt point needle and the reason you would have this is if you're going to very soft or very delicate tissue you want it to sort of pull through nice and gently you don't want to cut through that and it's going to cause it to tear so a blunt point needle you'll use through very soft very friable tissue there's another word you're going to hear friable tissue means it's very soft it pulls apart very easily and in those cases you're going to use a blunt point needle now the
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opposite of that if you have some really tough tissue let's say some fascia which is kind of like gristle it's real tough or even skin in many cases can be tough you're going to use something called a cutting needle now instead of say the sewing needle which is nice and round and easy to hold a cutting needle happens to be in more of a shape of a triangle and it's got along the shaft of the needle it's got these three points these three edges that are really sharp
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all the way along the needle itself so as you throw it through the tissue it's going to cut through that tissue because it's going to be really tough tissue so it's going to easily cut through it allowing you to pull that needle through there so these three sharp edges along the shaft of that needle make this a cutting needle and a conventional needle has one of those blades on the inside curve of that needle now what they've realized is that having a blade on the inside curve might
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be a bad thing because it tends to make this tissue tear in the direction that the thread's eventually going to be pulling so then they created a reverse cutting needle which is going to have that third sharp side on the outside of the curve which means the thread is going to be pulling inward but that tear is going to go outward so it's going to help to hold that thread that suture in place a little bit better so a conventional cutting needle and a reverse cutting needle would be the
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other two types of needles that you're going to see so there are four main types again there are many others they're curved real tight curves and there are straight needles and lots of different things that you can learn about but these are the four main types of needles that you'll see out there now if all of this sounds really confusing i do have some good news for you the good news is that most suture packaging comes with really good labeling on it so you can find what you're looking for
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just by reading the label and that's pretty cool for example here we've got some ethelon suture and it's got all kinds of information on it notice the biggest thing that it says is the gauge it's 5-0 suture so it's kind of a small suture a 5-0 suture that's the size of the diameter of the suture thread itself it tells you the type of suture it says ethelon on it and it tells you the type of plastic that makes up ethon in this case it says polyamide six so that's the
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type of plastic the type of polymer that makes up the suture that's the material that the suture is made out of it tells you about the needle in this case we have a reverse cutting needle it shows you the size and the length of the needle and needles come in different codes so you can identify them quickly in this case it's a ps2 needle that's a very specific type of needle you're going to be learning more about that as you go along in your course work the image of the needle shows only a single
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needle so there is only one needle in this suture sometimes you can find suture that has a needle on each end of the suture so there's going to be a picture of two needles on there that'll tell you how many needles are attached to the suture it also shows the suture length so the length of the suture string itself in this case it's 18 inches long it says 18 inches here so it's about 18 inches long you can have suture that's shorter you can have suture that's a much longer maybe three
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feet 36 inches long so different lengths to the suture is going to be indicated here and probably the most important thing the expiration date you always want to check the expiration date of your suture before you use it and the expiration date is going to be printed on every single package of suture so that's just a quick introduction to suture that's used during surgery there is a lot of information here there's a lot more to learn you're not going to learn all of it during your coursework
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most of it you're going to sort of pick up as you go through the clinical sites and even after you graduate you're going to be learning much much more as you start to use these different types of suture different types of needles over and over you're going to start to get a feel for it you're not going to know everything all at once don't worry about that just try to do your best understand the main categories of suture the main categories of needles and you're
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probably going to be okay and you sort of build from there so good luck on your studies of suture
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