นพ.สม ทธ สร อยมาด โรงพยาบาลวช ระภ เก ต

Transcription

1 นพ.สม ทธ สร อยมาด โรงพยาบาลวช ระภ เก ต

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3 Optimal suture qualities : 1. High uniform tensile strength, permitting use of finer sizes. 2. High tensile strength retention in vivo, holding the wound securely throughout the critical healing period, followed by rapid absorption. 3. Consistent uniform diameter. 4. Sterile. 5. Pliable for ease of handling and knot security. 6. Freedom from irritating substances or impurities for optimum tissue acceptance. 7. Predictable performance.

4 Factors that influence the surgeon s choice of materials: Wound closure experience during clinical training. Professional experience in the operating room. Knowledge of the healing characteristics of tissues and organs. Knowledge of the physical and biological characteristics of various suture materials. Patient factors (age, weight, overall health status, and the presence of infection).

5 Monofilament or multifilament, Braided or non braided Memory แนวโน มท จะร กษาสภาพเด ม ท าให ผ กเป นปมยาก คลาย ปมง าย Elasticity เม อถ กย ดแล ว กล บมาร กษาความยาวเด มได ด เหมาะท จะใช เย บเน อเย อท บวม Knot strength แรงท จะท าให เก ดการคลายปม Coefficient of friction ถ าส งก เย บผ านเน อเย อล าบาก และม การบาดเจ บต อเน อเย อมากกว า

6 Tensile strength แรงท ท าให suture ขาด ค ดต อพ นท หน าต ด ของ suture SIZE Tissue reaction Non absorbable or Absorbable

7 SIZE AND TENSILE STRENGTH Size denotes the diameter of the suture material. using the smallest diameter suture minimizes trauma also ensures that the minimum mass of foreign material is left in the body. Suture size is stated numerically; as the number of 0s in the suture size increases, the diameter of the strand decreases. For example, size 5 0, or 00000, is smaller in diameter than size 4 0, or The smaller the size, the less tensile strength the suture will have.

8 Knot tensile strength is measured by the force, in pounds, which the suture strand can withstand before it breaks when knotted. The accepted rule is that the tensile strength of the suture need never exceed the tensile strength of the tissue.

9 MONOFILAMENT VS. MULTIFILAMENT STRANDS Monofilament sutures are made of a single strand of material. Encounter less resistance as they pass through tissue than multifilament suture material. They also resist harboring organisms These characteristics make monofilament sutures well suited to vascular surgery. Monofilament sutures tie down easily. Extreme care must be taken when handling and tying these sutures. Crushing or crimping of this suture type can create a weak spot in the strand. This may result in suture breakage.

10 MONOFILAMENT VS. MULTIFILAMENT STRANDS Multifilament sutures consist of several filaments, or strands, twisted or braided together. This affords greater tensile strength, pliability, and flexibility. Multifilament sutures may also be coated to help them pass relatively smoothly through tissue and enhance handling characteristics. Coated multifilament sutures are well suited to intestinal procedures.

11 ABSORBABLE VS. NON ABSORBABLE SUTURES Sutures are classified according to their degradation properties. Sutures that undergo rapid degradation in tissues, losing their tensile strength within 60 days, are considered absorbable sutures. Sutures that generally maintain their tensile strength for longer than 60 days are non absorbable sutures.

12 Absorbable sutures may be used to hold wound edges in approximation temporarily, until they have healed sufficiently to withstand normal Stress These sutures are prepared either from the collagen of healthy mammals or from synthetic polymers. Some are absorbed rapidly, while others are treated or chemically structured to lengthen absorption time. They may also be impregnated or coated with agents that improve their handling properties, and colored

13 Absorbable sutures Natural absorbable sutures are digested by body enzymes which attack and break down the suture strand. Synthetic absorbable sutures are hydrolyzed a process by which water gradually penetrates the suture filaments, causing the breakdown of the suture's polymer chain. Compared to the enzymatic action of natural absorbables, hydrolyzation results in a lesser degree of tissue reaction following implantation.

14 Absorbable sutures During the first stage of the absorption process, tensile strength diminishes in a gradual, almost linear fashion. This occurs over the first several weeks post implantation. The second stage often follows with considerable overlap, characterized by loss of suture mass.

15 Absorbable sutures Both stages exhibit leukocytic cellular responses which serve to remove cellular debris and suture material from the line of tissue approximation. The loss of tensile strength and the rate of absorption are separate phenomena. A suture can lose tensile strength rapidly and yet be absorbed slowly. or it can maintain adequate tensile strength through wound healing, followed by rapid absorption. In any case, the strand is eventually completely dissolved, leaving no detectable traces in tissue.

16 Absorbable sutures inherent limitations If a patient has a fever, infection, or protein deficiency, the suture absorption process may accelerate, causing too rapid a decline in tensile strength. if the sutures become wet or moist during handling, prior to being implanted in tissue, the absorption process may begin prematurely.

17 Non absorbable sutures not digested by body enzymes or hydrolyzed in body tissue. They are made from a variety of non biodegradable materials encapsulated or walled off by the body s fibroblasts. Non absorbable sutures ordinarily remain where they are buried within the tissues. When used for skin closure, they must be removed postoperatively.

18 applications: Exterior skin closure, to be removed after sufficient healing has occurred. Within the body cavity, where they will remain permanently encapsulated in tissue. Patient history of reaction to absorbable sutures, keloidal tendency, or possible tissue hypertrophy. Prosthesis attachment

19 SPECIFIC SUTURING MATERIALS Absorbable Sutures Surgical Gut plain or chromic. Both types consist of processed strands of highly purified collagen. The percentage of collagen in the suture determines its tensile strength and its ability to be absorbed by the body without adverse reaction. Non collagenous material can cause a reaction ranging from irritation to rejection of the suture.

20 Plain surgical gut is rapidly absorbed. Tensile strength is maintained for only 7 to 10 days Absorption is complete within 70 days. The surgeon may choose plain gut for use in tissues which heal rapidly and require minimal support (suturing subcutaneous fatty tissue). Plain surgical gut can also be specially heat treated to accelerate tensile strength loss and absorption. This fast absorbing surgical gut is used primarily for epidermal suturing where sutures are required for only 5 to 7 days.

21 Chromic gut treated with a chromium salt solution to resist body enzymes, prolonging absorption time over 90 days. The process alters the coloration of the surgical gut from yellowish tan to brown. Chromic gut sutures minimize tissue irritation, causing less reaction than plain surgical gut Tensile strength may be retained for 10 to 14 days, with some measurable strength remaining for up to 21 days.

22 COATED VICRYL* RAPIDE POLYGLACTIN 910) SUTURE Coated VICRYL RAPIDE suture is the fastest absorbing synthetic suture exhibits characteristics that model the performance of surgical gut suture. However, being a synthetic material. Elicits a lower tissue reaction than chromic gut suture. indicated only for use in superficial soft tissue approximation of the skin and mucosa short term wound support (7 to 10 days) retain approximately 50% of the original tensile strength at 5 days post implantation. All of the original tensile strength is lost by approximately 10 to 14 days. Absorption is essentially complete by 42 days.

23 MONOCRYL (POLIGLECAPRONE 25) SUTURE This monofilament suture features superior pliability for easy handling and tying. it is virtually inert in tissue and absorbs predictably. procedures which require high initial tensile strength diminishing over 2 weeks postoperatively. These include subcuticular closure and soft tissue approximations and ligations. with the exception of neural, cardiovascular, ophthalmic, and microsurgical applications.

24 MONOCRYL At 7 days, undyed MONOCRYL suture retains approximately 50% to 60% of its original strength, And approximately 20% to 30% at 14 days post implantation. All of the original tensile strength of undyed suture is lost by 21 days. Absorption is essentially complete at 91 to 119 days. Dyed MONOCRYL suture retains 60% to 70% of its original strength at 7 days, reduced to 30% to 40% at 14 days.

25 COATED VICRYL (POLYGLACTIN 910) SUTURE This material fills the need for a smoother synthetic absorbable suture that will pass through tissue readily with minimal drag. facilitate ease of handling, smooth tie down and excellent knot security with or without needles. At 2 weeks, approximately 75% of the tensile strength remains. Approximately 50% of tensile strength is retained at 3 weeks for sizes 6 0 and larger. Absorption is complete between 56 and 70 days.

26 NON ABSORBABLE SUTURES SURGICAL SILK Superior handling characteristics. Silk filaments can be twisted or braided, providing the best handling qualities. classified as a non absorbable suture, long term in vivo studies have shown that it loses most or all of its tensile strength in about 1 year cannot be detected in tissue after 2 years. Thus, it behaves in reality as a very slowly absorbing suture.

27 ETHILON NYLON SUTURE noncapillary single or monofilament strands characterized by high tensile strength and extremely low tissue reactivity. They degrade in vivo at rate of approximately 15% to 20% per year by hydrolysis. monofilament nylon sutures have a tendency to return to their original straight extruded state (a property known as "memory"). Therefore, more throws in the knot are required to securely hold monofilament than braided nylon sutures. used in ophthalmology and micro surgery procedures in very fine sizes. For this reason, sizes 9 0 and 10 0 have an intensified black dye for high visibility.

28 NUROLON NYLON SUTURE This suture is composed of filaments of nylon that have been tightly braided into a multifilament strand. sutures look, feel, and handle like silk. However, sutures have more strength and elicit less tissue reaction than silk. Braided nylon may be used in all tissues where multifilament non absorbable sutures are acceptable. Braided nylon sutures generally lose 15% to 20% of their tensile strength per year in tissue by hydrolyzation.

29 PROLENE POLYPROPYLENE SUTURE Widely used in general, cardiovascular, plastic, and orthopaedic surgery, PROLENE sutures do not adhere to tissue and are therefore efficacious as a pull out suture. relatively biologically inert, offering proven strength, reliability and versatility. recommended for use where minimal suture reaction is desired, such as in contaminated and infected wounds to minimize later sinus formation and suture extrusion. They are available clear or dyed blue.

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34 ABSORBABLE SUTURES: BASIC RAW MATERIALS

35 NON ABSORBABLE SUTURES: RAW MATERIALS

36 Instruments: Size of suture material Size originally scaled from 0 3 As technology advanced and sutures became smaller, extra 0s were added Scale now ranges from 3 (largest) to 12/0 (smallest) Size Uses 7/0 and smaller Ophthalmology, microsurgery 6/0 Face, blood vessels 5/0 Face, neck, blood vessels 4/0 Mucosa, neck, hands, limbs, tendons, blood vessels 3/0 Limbs, trunk, gut blood vessels 2/0 Trunk, fascia, viscera, blood vessels 0 and larger Abdominal wall, fascia, drain sites, arterial lines, orthopaedics

37 6 0 Face 5 0 Chin Low tension/detail 4 0 Large laceration Moderate tension 3 0 Significant tension Choosing Your Suture

38 Instruments: Suture material summary Non-absorbable Natural Synthetic Mersilk Braided Monofilament Nurolon Ethibond Ethilon Prolene Absorbable Short term Medium term Long term Natural Synthetic Braided Monofilament Braided Monofilament Catgut Vicryl rapide Braided vicryl Monocryl Panacryl PDS II

39 Instruments: Needle (I) The main types of needle include: Tapered Gradually taper to the point and cross section reveals a round, smooth shaft Used for tissue that is easy to penetrate, such as bowel or blood vessels Cutting Triangular tip with the apex forming a cutting surface Used for tough tissue, such as skin (use of a tapered needle with skin causes excess trauma because of difficulty in penetration) Reverse cutting needle Similar to a conventional cutting needle except the cutting edge faces down instead of up This may decrease the likelihood of sutures pulling through soft tissue

40 Instruments: Needle (II) Most sutures with the suture material swaged onto the base of the needle Shapes vary from a quarter circle to five eighths of a circle, depending on how confined the operating field is Choice of needle should alter the tissue to be sutured as little as possible and is dependent on: The tissue being sutured (when in doubt about selection of a taper point or cutting needle, choose the taper for everything except skin sutures) Ease of access to the tissue Individual preference