Transcript Document

November 16, 2009
A-B Tech
Kurt Prewitt
This promotional educational activity is brought to you by Ethicon, Inc. and is not certified for
continuing medical education.
1
SUTURES
SUTURE OVERVIEW
ABSORBABLE SUTURES
NON-ABSORBABLE SUTURES
SUTURE SELECTION BY TISSUE
2
SUTURES OVERVIEW
3
OBJECTIVES
1. Trace the evolution of sutures as a method of
ligating and approximating tissue
2. Aspects of wound healing
3. Differentiate among the types of sutures
SUTURES OVERVIEW
4
WHAT IS SUTURE?
Suture Definition
• The word “suture” describes any strand of
material used to ligate (tie) blood vessels or
approximate (sew) tissues
5
HISTORY OF SUTURES
A Timeline
50,000 BC Eyed needles are invented.
20,000 BC Bone needles are standard.
1600 BC One of the earliest known references to suture material. Sutures are
made from flax, hemp, bark fiber, hair, etc.
900 AD Used strings from a kit, a guitar-like musical instrument
1867-9 Joseph Lister proves that the body absorbs catgut sutures. However he
is most famous for demonstrating the need for antiseptic techniques for
sterilization of implanted sutures.
1918 George Merson begins the sale of eyeless needled sutures where one
strand of suture material is attached to the butt of the needle. This type
of swaged needle is still in use and is the standard today.
1947 Introduction of Nylon.
1972 First synthetic absorbable suture introduced.
2000 Distribution of gut material ends in many parts of Europe and Japan due
to Bovine Spongiform Encephalopathy (“Mad Cow Disease”)
SUTURES OVERVIEW
6
IDEAL SUTURE
1. Sterile
2. Easy to handle
3. Minimal tissue reaction/trauma
4. High tensile strength retention
5. Knot security
6. Absorbable
7. Useful in all tissues
SUTURES OVERVIEW
7
CRITICAL WOUND HEALING PERIOD
Skin
5-7 Days
Mucosa
5-7 Days
Subcutaneous
7-14 Days
Peritoneum
7-14 Days
Fascia
14-28 Days
0
Days
5
7
14
21
28
Tissue Healing Times
SUTURES OVERVIEW
8
SUTURE SIZING
Ethicon Suture Sizing
• Ranging from 7 to 11-0
• Size 7 is largest
• Size 11-0 is smallest
• Size 7-0 approximately
corresponds to the
thickness of human hair
SUTURES OVERVIEW
9
HISTORY OF INNOVATION
Dyed
MONOCRYL*
(poliglecaprone 25)
Suture
Coated VICRYL*
(polyglactin 910)
Suture
VICRYL*
(polyglactin 910)
Suture
PROLENE*
Polypropylene
Suture
MERSILENE*
Polyester Fiber
Suture
Nylon
Silk
and
Cat
Gut
1887
1947
1958
1969
MONOCRYL*
(poliglecaprone 25)
Suture
DERMABOND®
PDS* II
Topical
(polydioxanone)
Skin
Suture
Adhesive
High
Viscosity
ETHIGUARD* VICRYL RAPIDE*
Blunt
(polyglactin 910)
ETHIBOND
Point
Suture
EXCEL*
Needle
DERMABOND®
Polyester
Topical
Suture
Skin
Adhesive
1974
1976
1979
1989
1992
* Trademark
SUTURES OVERVIEW
PDS* Plus
Antibacterial
(polydioxanone)
Suture (May
Coated VICRYL* 2007 Launch)
Plus Antibacterial
(polyglactin 910)
Suture
10
1993
1995
1996
1998
2002
MONOCRYL* Plus
Antibacterial
(poliglecaprone 25)
Suture
2003
2006
2007
SUTURE CLASSIFICATIONS
• Absorbable / Non-Absorbable
• Natural / Synthetic
• Braided / Monofilament
• Antibacterial Sutures
SUTURES OVERVIEW
11
ABSORBABLE / NON-ABSORBABLE SUTURES
Absorbable Sutures
• Sutures that undergo degradation in tissues, losing their tensile
strength within 60 days
– Absorption Rate: Time required for a suture to be fully absorbed into the
tissue
– Tensile Strength In Vivo: Tension which a suture will withstand before it
breaks down inside the tissue
Non-Absorbable Sutures
• Sutures which are not digested by body enzymes or hydrolyzed in
body tissue
SUTURES OVERVIEW
12
NATURAL / SYNTHETIC SUTURES
Natural Sutures
• Sutures made of material that can be found in nature
– Absorption method (if absorbable): Enzymatic
Synthetic Sutures
• Sutures made of materials created by man
– Absorption Method (if absorbable): Hydrolysis –
breakdown in the presence of water or moisture
SUTURES OVERVIEW
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MONOFILAMENT / BRAIDED SUTURES
Monofilament
• A single strand of material
– Less resistance as it passes through tissue
– Resists bacterial harboring compared to braided
Braided
• Multifilament sutures that consist of several filaments or strands,
twisted or braided together
– Greater tensile strength
– Pliability and flexibility
SUTURES OVERVIEW
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ANTIBACTERIAL SUTURES
Properties of Antibacterial Sutures
– Biocompatibility
– Effectiveness against S.Aureus and S.Epidermidis
(most common for device infections) among other bacteria1-3
– Ability to withstand manufacturing process
o Heat, humidity, solvent, sterilization, etc
o Mass production
– Will not negatively alter suture properties
– Ability to maintain antibacterial activity on the suture for a
clinically relevant duration
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87.
2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.
3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
SUTURES OVERVIEW
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CDC SURGICAL WOUND CATEGORIES1
Class I
Clean
Uninfected wound in which no inflammation is
encountered and respiratory, alimentary, genital, or
uninfected urinary tract is not entered.
Class II
Clean-contaminated
Operative wound in which respiratory, alimentary, genital,
or urinary tracts are entered under controlled conditions
and without unusual contamination.
Class III
Contaminated
Open, fresh, accidental wounds.
Class IV
Dirty-infected
Old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infection or perforated
viscera.
1. CDC=Centers for Disease Control and Prevention. Mangram AJ et al. Am J Infect Control. 1999;27:97-134.
SUTURES OVERVIEW
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COMPLICATIONS IN WOUND HEALING
•
Infection (including SSIs)
•
Wound Disruption
–
–
Deshiscence – Splitting open of the wound due to
o
Too much tension placed on the wound
o
Improper suturing technique
o
Inappropriate suture materials
o
Weakened tissue
Evisceration – Protrusion of the bowel through the
separated edges of the abdominal wound closure
SUTURES OVERVIEW
17
PLUS ANTIBATERIAL SUTURES
• Coated polyglactin 910 sutures with triclosan exhibit
antibacterial activity on the suture in vitro against methicillinsensitive and -resistant S aureus and S epidermidis
compared with untreated controls1
• Antibacterial activity endures on the suture despite
extended exposure to aqueous environment1
• Suture diameter, knotting, or passage through tissues
does not diminish antibacterial activity of triclosan-coated
sutures1
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3(suppl):S79-S87.
SUTURES OVERVIEW
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IRGACARE® MP
IRGACARE® MP, the antibacterial component of Ethicon
Plus Sutures, is effective on the suture against the
pathogens most commonly associated with SSIs1
• Staphylococcus aureus
• Staphylococcus epidermidis
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Methicillin-resistant Stapylococcus aureus (MRSE)
• Escherichia coli †
• Klebsiella pneumoniae †
1. Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial
adherence to surgical sutures J Am Coll Surg. 2006;203:481-489.
† Only for MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture
and PDS* Plus Antibacterial (polydioxanone) Suture
* Trademark
SUTURES OVERVIEW
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ZONE OF INHIBITION
PLUS Antibacterial Sutures kill bacteria on the suture and
inhibit bacterial colonization of the suture1-3
Zone of Inhibition – Areas of inhibited bacterial growth for Plus Antibaterial Sutures
MONOCRYL* Plus Antibacterial
(poliglecaprone 25) Suture
Coated VICRYL* Plus
Antibacterial (polyglactin
910) Suture
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87.
2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.
3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
* Trademark
SUTURES OVERVIEW
20
PDS* Plus Antibacterial
(polydioxanone) Suture
PLUS ANTIBACTERIAL SUTURES
• In vitro testing (petri dish) has shown Plus Antibacterial
Sutures create a zone of inhibition around the suture in
which certain bacteria are unable to grow1-3
• IRGACARE® MP in the Plus Sutures creates a zone of
inhibition which lasts in vitro for:
Coated VICRYL* Plus Antibacterial
(polyglactin 910) Suture
Minimum of 7 days for S.Aureus
MONOCRYL* Plus Antibacterial
(poliglecaprone 25) Suture
31 days for S.Aureus
21 days for E.Coli
PDS* Plus Antibacterial
(polydioxanone) Suture
23 days for S.Aureus
17 days for E.Coli
1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87.
2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207.
3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
* Trademark
SUTURES OVERVIEW
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ABSORBABLE SUTURES
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ABSORBABLE SUTURE TYPES
Natural Absorbable
Synthetic Absorbable
Natural
Synthetic
Monofilament
Virtual
Monofilament
Short /
Medium
Long
Short
ShortMedium
Medium
PDS* II (polydioxanone)
Suture, PDS* Plus
Antibacterial
(polydioxanone) Suture
Fast
Absorbing
Gut
Plain
Gut
Chromic
Gut
MONOCRYL* (poliglecaprone
25) Suture, MONOCRYL* Plus
Antibacterial (poliglecaprone
25) Suture
* Trademark
ABSORBABLE SUTURES
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Braided
Short
Medium
VICRYL RAPIDE*
(polyglactin 910)
Suture
Coated VICRYL* (polyglactin
910) Suture, Coated VICRYL*
Plus Antibacterial (polyglactin
910) Suture
NATURAL ABSORBABLE SUTURES
Ethicon Gut Sutures1
• Submucosal or serosal layer of animal intestine
• 97-98% pure collagen
• Clean and purified
• Strands twisted for controlled diameter
• Packaged wet to maintain pliability
• Spun and polished into virtual monofilament
strands
1. Wound Closure Manual, page 13
ABSORBABLE SUTURES
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NATURAL ABSORBABLE SUTURES
Plain gut
• TRU-GAUGING process1
– Eliminates high and low spots
– Greater surface smoothness
– No fraying of the suture
– Better knot security
– Uniform diameter across entire length
– Uniform high tensile strength
– Wound support for approximately 2 weeks
1. Wound Closure Manual, page 13,14
ABSORBABLE SUTURES
25
NATURAL ABSORBABLE SUTURES
Chromic gut
– TRU-GAUGING process1
– TRU-CHROMICIZING process1
o Entire cross-section of strand is
evenly chromicized
o Minimizes tissue irritation
Chromic Gut
o Less reaction
– Wound support for approximately 4 weeks2
Fast-absorbing gut
– Plain surgical gut is heat treated to accelerate tensile strength
loss and absorption1
– Wound support for approximately 1 week
1.
2.
Wound Closure Manual, page 13,14
Chromic Gut Product Insert
ABSORBABLE SUTURES
26
SYNTHETIC ABSORBABLE SUTURES
VICRYL RAPIDE*
(polyglactin 910) Suture
• Short-term wound support1
– 7-10 days
– Rapid strength loss
– Absorption complete in just 42 days
• For mucosa and superficial closure of skin
• Convenient for the patients
– No return visit necessary for suture removal
1. Wound Closure Manual, page 14
* Trademark
ABSORBABLE SUTURES
27
SYNTHETIC ABSORBABLE SUTURES
VICRYL RAPIDE*
(polyglactin 910) Suture
• Initial strength comparable to that
of Nylon and Gut
• Fastest-absorbing synthetic suture
• Elicits lower tissue reaction than chromic gut suture
1. Wound Closure Manual, page 14; Product Inserts of VICRYL RAPIDE*
(polyglactin 910) Suture, ETHILON* Nylon Suture and Chromic Gut
* Trademark
ABSORBABLE SUTURES
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ANTIBACTERIAL SUTURES
• Wound support for approximately 14 days
• Consistent handling and performance
– Significantly less tissue drag than chromic gut
sutures and braided synthetic absorbable sutures
– Excellent knot security
1. Wound Closure Manual, page 14; MONOCRYL Plus Suture Product Insert
* Trademark
ABSORBABLE SUTURES
29
ANTIBACTERIAL SUTURES
Reliable Strength
• Consistent absorption rate with a predictable decrease in
tensile strength over time
• Stronger than gut suture initially and through the critical
wound-healing period
• Offers protection for subcuticular closure and soft tissue
approximation
1. Wound Closure Manual, page 13,14; MONOCRYL Plus Suture Product
Insert, Chromic Gut Product Insert
* Trademark
ABSORBABLE SUTURES
30
ANTIBACTERIAL SUTURES
Excellent handling and performance
– Knot security and knot snug-down
– First-throw holding security
– Smooth passage with minimal tissue drag
– Virtually no package memory
* Trademark
ABSORBABLE SUTURES
31
ANTIBACTERIAL SUTURES
Exceptional strength
– Wound support for approximately 4 weeks
– Offers protection and strength for general tissue
approximation
1. Product Inserts for Coated VICRYL Plus Suture, MONOCRYL Plus Suture, Chromic Gut and Plain Gut
* Trademark
ABSORBABLE SUTURES
32
ANTIBACTERIAL SUTURES
• Extended monofilament wound support for
approximately 42 days
• Offers protection and strength for slow-healing tissue
– Fascia closure, Orthopedic surgery
– Blood vessel anastomoses
– Diabetic, cancer and obese patients
1. Wound Closure Manual page 20,21; PDS Plus Suture Product Insert
* Trademark
ABSORBABLE SUTURES
33
ANTIBACTERIAL SUTURES
PDS Plus Sutures offer surgeons:
– Low out-of-package memory
– Smooth passage through tissue
– Low bending stiffness for more pliability and easier
handling
PDS Plus Suture stays stronger, longer†
†
Compared to Maxon™ or Biosyn™: Data from Maxon™, Biosyn™ and PDS* Plus Suture product inserts
* Trademark
ABSORBABLE SUTURES
34
NON-ABSORBABLE SUTURES
35
NON-ABSORBABLE SUTURE TYPES
Natural
Monofilament
Braided
Surgical
Stainless
Steel
PERMA-HAND*
Silk Suture
Synthetic
Monofilament
ETHILON*
Nylon
Suture
PRONOVA* Poly
(Hexafluoropropylene
- VDF) Suture
PROLENE*
Polypropylene Suture
* Trademark
NON-ABSORBABLE SUTURES
36
Braided
NUROLON*
Nylon
Suture
MERSILENE*
Polyester
Fiber Suture
ETHIBOND EXCEL*
Polyester Suture
SILK - BRAIDED
PERMA-HAND*
Silk Suture1
• Wax proofed
– Improves surface quality
– Reduces bacterial harboring
– Reduces capillarity
• Braided
– Excellent handling and knotting characteristics
• Used in a wide variety of surgical procedures
1. Wound Closure Manual, page 16
* Trademark
NON-ABSORBABLE SUTURES
37
STEEL - MONOFILAMENT
Surgical Stainless Steel Suture1
• High tensile strength
• Reliable and ductile alloy
− Made of 316L stainless steel
− Optimal compatibility with stainless steel implants
• Low tissue reactivity
• Multistrand packaging
− Eliminates kinking and bending of strands
− 2 or 4 strands per pack
1. Wound Closure Manual, page 16
NON-ABSORBABLE SUTURES
38
NYLON - MONOFILAMENT
ETHILON*
Nylon Suture1
• Well suited for skin and retention
closure
• Finer sizes used in ophthalmic and
microsurgery procedures
• May be clear, or dyed green or black for better visibility
• Specific codes (sizes 3-0 to 6-0) are “pliabilized.” Pliabilization
– Includes pre-moistening the suture to make it more pliable
– Enhances handling and knot tying characteristics to approximate
that of braided sutures
1. Wound Closure Manual, page 17
* Trademark
NON-ABSORBABLE SUTURES
39
NYLON - BRAIDED
NUROLON*
NYLON SUTURE1
• Handles like silk
• Stronger than silk
• Better knot tie-down than silk
• Lower tissue reactivity
• Less fragmentation
• Ideal silk replacement in neurosurgery
1. Wound Closure Manual, page 17
* Trademark
NON-ABSORBABLE SUTURES
40
POLYESTER - BRAIDED
MERSILENE*
Polyester Fiber Suture1
Polyester
– Permanent wound support
Braided
– Good handling characteristics
– Provide precise and consistent suture tension
Synthetic
– Less tissue reaction
1. Wound Closure Manual, page 18
* Trademark
NON-ABSORBABLE SUTURES
41
POLYESTER - BRAIDED
• Polyester: permanent wound support
• Minimal tissue reaction; suture material and
coating are pharmacologically inactive1
• A central core and 16 outer carriers
– Tighter, compact and stronger braid
• Excellent handling properties (suppleness
and pliability)
• Polybutylate coating
– Smooth knot tie-down
– High knot and tensile strength
1. Wound Closure Manual page 18
* Trademark
NON-ABSORBABLE SUTURES
42
POLYESTER - BRAIDED
Many options available1:
• Specialized CV Needles
• Single or Multi-strand
• D-Specials
• Pledgets – Soft and hard, 2 sizes
• In green & white for ease of use
• Available in many suture sizes & lengths used in CV
and Ortho procedures
1. ETHIBOND EXCEL Suture Product Insert
* Trademark
NON-ABSORBABLE SUTURES
43
POLYESTER - BRAIDED
Improvements in ETHIBOND
EXCEL Suture
• Tight, compact braid
– Results in stronger suture
– Avoids suture bunching
• Effective coating levels
– Less “slippery” suture
– Excellent knot security
• Packaging
– Fast, reliable suture delivery
– Clear package and box graphics
1. CPC-2007-0160 and AST-2008-0046 ETHIBOND EXCEL Suture reports
* Trademark
NON-ABSORBABLE SUTURES
44
POLYPROPYLENE - MONOFILAMENT
• Minimal tissue reaction
• Polypropylene: Inert, reliable, strong, smooth, secure
− Will not fatigue with normal flexing
− Exceptionally smooth surface avoids snagging vessel adventitia
• Plastic knot deformity - When knotted, deforms and flattens to
provide excellent knot security2
• Controlled linear elongation - Excellent pliability2
1.
2.
Wound Closure Manual page 18
CPC-2006-0445 and CPC-2008-0046 PROLENE Suture Reports
* Trademark
NON-ABSORBABLE SUTURES
45
POLYPROPYLENE - MONOFILAMENT
• Laser scanning process for sizes
5-0, 6-0 and 7-0
– More consistent diameter and improved
tensile strength
• Sizes 8/0 and smaller are hand inspected
* Trademark
NON-ABSORBABLE SUTURES
46
POLYPROPYLENE - MONOFILAMENT
Packaging
•
Unique RELAY* Suture Delivery System
•
Straight pack delivers the suture virtually memory-free
Many options available1
•
Available in a variety of sizes and lengths used in different specialties
•
Specialized Cardiovascular needles
•
Single or multi-strand
•
E-Packs and D-Specials
1. Prolene Package Insert
* Trademark
NON-ABSORBABLE SUTURES
47
PRONOVA - MONOFILAMENT
PRONOVA*
Poly (hexafluoropropylene-VDF) Suture1
• Offers excellent strength
• Less memory than polypropylene
• Exceptional strength for delicate tissues
• Monofilament, more resistant to bacterial colonization
• Strong resistance to handling damage and fraying
• Excellent handling and tying characteristics
• Excellent resistance to repetitive stress fatigue such as to those
imposed by heart and vessels
1. Wound Closure Manual page 18
* Trademark
NON-ABSORBABLE SUTURES
48
SUTURE SELECTION BY TISSUE TYPE
49
SUTURE SELECTION
Joint Capsule (knee, hip, shoulder)
Recommended Suture†
Needle Options††
OS-4, OS-6, OS-8, CT-1, CTX, MO-4
Tissue Characteristics
Ligamentous sac surrounding the articular cavity of the joint; consists of
vascular, very dense, fibrous tissue. Heals in approximately 3 weeks.
† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options
available with each recommended suture
* Trademark
SUTURE SELECTION
50
SUTURE SELECTION
Epidermis, Oral (facial)/Vaginal Mucosa, Perineal Skin
Recommended Suture
VICRYL RAPIDE*
(polyglactin 910) Suture
Needle Options†
PC-1, PC-3, P-1, P-3, PS-2
Tissue Characteristics
Superficial layer of skin; dense and tough, but thin. It is usually supported by
dermal closure.
† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options
available with each recommended suture
* Trademark
SUTURE SELECTION
51
SUTURE SELECTION
Peritoneum
Recommended Suture†
Needle Options††
SH, CT-1
Tissue Characteristics
Thin, membranous lining of the abdominal cavity. Very little fibrosis. Heals
quickly. Closure is optional, based on surgeon preference.
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options
available with each recommended suture
* Trademark
SUTURE SELECTION
52
SUTURE SELECTION
Dermis / Subcuticular
Recommended Suture†
Needle Options††
PC-5, PS-2, PS-1, PS#, PSL, PSLX#
Tissue Characteristics
Deep, vascular, subcuticular layer; 3 times thicker than epidermis; consists of
dense connective tissue. Regains tensile strength slowly. Most of the stress
placed upon the healing wound is absorbed by fascia. Sutures need only be strong
enough to withstand natural skin tension and hold wound edges in apposition.
† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture
# Available on ETHILON* Nylon Suture which may also used for subcuticular closure
* Trademark
SUTURE SELECTION
53
SUTURE SELECTION
Abdominal Fascia
Recommended Suture†
Needle Options††
CT-1, CT, CTX, TP-1, XLH
Tissue Characteristics
Fibrous, sheath-like, connective tissue covering muscle.
Strongest tissue in abdominal wall; regains 25% - 40% of original strength
in 1 month; 55% - 65% in 3 months; 70% -80% in 9 months.
Never regains full original strength.
† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
54
SUTURE SELECTION
Urinary Bladder
Recommended Suture†
Needle Options††
RB-1, SH-1, SH
Tissue Characteristics
Very vascular, dense, tough, muscular membranous sac.
Composed of multiple layers.
Heals quickly, achieving 75% to 90% of original strength in 2 weeks.
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options
available with each recommended suture
* Trademark
SUTURE SELECTION
55
SUTURE SELECTION
Colon
Recommended Suture†
Needle Options††
SH, SHB
Tissue Characteristics
Wall varies in consistency and density; relatively soft and rubbery, with little
dense, fibrous support.
Heals rapidly, achieving 50% to 60% of original strength in 1 month.
† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
56
SUTURE SELECTION
Ureter
Recommended Suture†
Needle Options††
TF, RB-1, SH-1
Tissue Characteristics
Narrow tube with vulnerable blood supply.
Easy to manipulate and penetrate, unless fibrous or hardened.
Achieves normal healing in 7 days.
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options
available with each recommended suture
* Trademark
SUTURE SELECTION
57
SUTURE SELECTION
Ligament
Recommended Suture†
Needle Options††
PS-4, PS-2, OS-4, MO-6, CT-2, CT-1
Tissue Characteristics
Very dense, longitudinally arrayed, collagenous tissue.
Achieves 50% to 70% of original strength in 12 months.
† PDS II Suture may also be used in place of PDS Plus Suture
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
58
SUTURE SELECTION
Subcutaneous (fat) / Superficial Fascia
Recommended Suture†
Needle Options††
SH, CT-1
Tissue Characteristics
Soft, friable, poorly vascularized tissue; fat does not hold sutures well.
The goal of “suturing the fat” is to approximate the superficial fascia
(Scarpa’s fascia) which is located in the upper 1/3 of the fatty layer.
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
59
SUTURE SELECTION
Small Intestine
Recommended Suture†
Needle Options††
RB-1, SH-1, SH
Tissue Characteristics
Wall varies in consistency and density; relatively soft and rubbery, with little
dense, fibrous support.
Heals very rapidly, reaching maximum strength in approximately 14 days.
† Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
60
SUTURE SELECTION
Uterus
Recommended Suture†
Needle Options††
MO-4, MO-2, CT-1, CT, CTX
Tissue Characteristics
Very vascular, tough and muscular.
† Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Vagina
Recommended Suture†
VICRYL RAPIDE*
(polyglactin 910) Suture
Needle Options††
V-34, CP-1, CT-1, SH
Tissue Characteristics
Extremely thick, tough and vascular.
Heals completely in 10 days.
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Tendon
Recommended Suture†
Needle Options††
OS-4, MO-6, CT-2, CT-1
Tissue Characteristics
Very dense, longitudinally arrayed, collagenous tissue.
† PRONOVA* Poly (hexafluoropropylene-VDF) Suture and NUROLON* Nylon Suture may also be
used to suture tendon to bone. PDS II Suture may also be used in place of PDS Plus Suture
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all
needle options available with each recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Stomach
Recommended Suture†
Needle Options††
SH, SHB
Tissue Characteristics
Relatively soft and rubbery, with little dense, fibrous support. Submucosa /
mucosa is especially thick and vascular.
Heals quickly, achieving maximum strength within 21 days.
† Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Nerves, Dura Mater
Recommended Suture
NUROLON*
NYLON SUTURE
Needle Options††
TF, RB-1
Tissue Characteristics
Dura mater tears easily and cannot withstand excessive tension.
In nerve repair, the strength of sutures is less of a consideration than the
degree of inflammatory and fibroplastic tissue reaction.
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Eye, Ocular Muscles
Recommended Suture
Coated VICRYL*
(polyglactin 910)
Suture
Needle Options††
CS140-6, CS160-6, CS90-6, CSB-6, TG140-8
Tissue Characteristics
Cornea is avascular, therefore heals slowly and requires sutures to remain in
place for at least 21 days. Ocular muscles, conjunctiva and the sclera have
good blood supply and require suture support only for about 7 days.
† PDS II Suture may also be used in place of PDS Plus Suture
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Vessels and Anastomosis
Recommended Suture†
PRONOVA* Poly
(hexafluoropropylene-VDF)
Suture
Needle Options††
BV-1, BV130-5, BV175-6, BV175-7, BV175-8, CC, CC-1
Tissue Characteristics
The outermost tunica adventitia is fibrous connective tissue. The innermost tunica
intima is the thinnest. Excessive tissue reaction may lead to decreased luminal
diameter or thrombus formation. Hence inert synthetics are material of choice.
† PDS Plus Suture and PERMA-HAND Silk Suture may be used to permit future growth in patients such as pediatric patients
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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SUTURE SELECTION
Vascular Prostheses and Heart Valves
Recommended Suture
Needle Options††
V-5, V-7
Tissue Characteristics
Strong, dense and fibrous. Adapted to be highly resistant to fatigue. Since there
is constant movement of the suture line, the sutures must retain their original
physical characteristics and strength throughout the life of patient
†† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each
recommended suture
* Trademark
SUTURE SELECTION
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BEST PRACTICE IN WOUND CLOSURE
Surface: DERMABOND® Topical Skin Adhesive
Dermis: MONOCRYL* Plus Antibacterial
(poliglecaprone 25) Suture
SubQ-Fat: Coated VICRYL* Plus Antibacterial
(polyglactin 910) Suture
Fascia/Muscle: ETHIGUARD* Blunt Point
Needle with Coated VICRYL Plus or PDS* Plus
Antibacterial (polydioxanone) Suture
* Trademark
SUTURE SELECTION
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Thank you
EP-0063-09-10/11
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