SUTURE AND LIGATURE

The history of
sutures is
largely a
reflection in
miniature of
the major
phases in the
history of
surgery itself.
The earliest
known text on
surgery is
found in the
Edwin Smith
papyrus (circa
3000 E.C.)
where it is
recorded that
the ancient
Egyptians
were already aware of the importance of approximating the
INTRODUCTION: edges of a created wound. For this purpose they used strips
of linen cloth. In India about this time- dried animal
intestines were being used as ligatures while in China silk
threads were employed for the same purpose.
Even the origin of modern skin clips is hallowed
·in antiquity. In surgery Susruta (1500 B.C.)
records the use of ligatures

for tying umbilical cord and Celsus in the first

century A.D. describes the ligatures of ancient
origin. Galen (A.D. 200) used silk and hemp
cords as ligatures and also recommended the use
of animal gut.About the year 1000 B.C. giant ant
or beetle were used, in India, to clip wound
margins together these were the original skin
clips. By the sixth century B.C. several materials
had been modified and adapted for use as sutures,
including cotton, silk, animal tendons, strips of
leather and horse hair. Hippocrates (500 B.C.)
stressed the importance of closing wounds and he
further advocated the ligation of bleeding vessels.
Galen, whose teachings were destined to
nbjbj

KIRAN C R (Pharm.D 1st Year)

dominate the practice of surgery, for the next fifteen 1908, Lister demonstrated that by soaking catgut, in
centuries, also ligated arteries and makes special this carbolic solution it could be left
mention of catgut:"Select from those materials that ,in the tissues and the wound closed. He first used
substance which is least putrescible, such as very plain catgut ligatures[1] but after extensive research
,thin catgut which rots easily and quickly falls from he developed chromic catgut.
the vessels."In the thirteen century A.D. there was The history of this work applied to surgical
reawakening of interest in the techniques of wound sutures and ligatures during the past seventy years is
suture and vessel ligation.Theodoric (1205 - 1296 too large a subject for this chapter but the
A.D.) and Mundinus (1275 - 1326 A.D.) both wrote investigations by a host of dedicated workers into
extensively on the subject. Ambroise Pare (1510 hundreds of different procedures has led to the
- 1590) whose extensive experience of war wounds highly efficient methods being employed today. A
was unparalleled, advocated the cleaning and ligature is a thread used to constrict and seal off a
dra;nage of wounds and the arrest of bleeding by blood vessel, vein or artery hence to ligate. The
ligature rather than cauterising with boiling tar or thread is a suture when it is used to stitch together
hot irons as was then customary. the edges of various tissues, e.g. skin, fascia, muscle,
John Hunter and his students favoured the tendon, peritoneum, etc. Hence a needle is always
ligation of arteries. Lembert dsscribed the technique used for a suture (sewing) but not for ligature.The
of successful suture of the intestine by apposition of advances in organic chemistry, in the physical
serosa to serosa. At this time ligatures were sciences and in engineering technology which
generally non absorbable and, of course, non- characterize the last decades have led to the
sterile.The introduction of antisepsis by Lister introduction of an array of new suture materials
revolutionized surgical technique. In particularly metallic wires and the synthetic non-
absorbable fibres.

Characteristics of suture[2] Absorbable suture

1. It should have no delaying effects in the course Absorbable sutures and ligatures are absorbed by the
of healing; tissues in which they are implanted and the time
2. It should retain its tensile strength unimpaired for taken for complete disappearance is dependent on a
an indefinite period; number of factors, which will be treated more fully
3. It should be inert in the tissues. later in this chapter. Absorbable materials are catgut
4. It should cause minimal tissue injury or tissue (non-boilalable and boilable), reconstituted collagen,
reaction (ie, non electrolytic, non capillary, non synthetic absorbable polymers, kangaroo tendon,
allergenic, non carcinogenic) ribbon gut and fascia lata.
5. It should have favorable absorption profile.
6. It should have all-purpose (composed of  Natural absorbable materials
material that can be used in any surgical procedure) 1. Surgical catgut
property. Sterilized surgical catgut consists of a strand
prepared from collagen derived from healthy
Classification[3-8] mammals purified and sterilized. The most widely
Sutures and ligatures are classified as absorbable used source is the sub mucosa of the small intestine
and non-absorbable, depending on the materials on from sheep or lambs and to a lesser extent, the serosa
which they are made. sheep beef cattle. The
length of ovine intestine is about 20 m and it is 5. Fascia lata
desirable in the preparation of surgical catgut that This may be excised from the patient, or prepared
the diameter of the intestine should not be more than from bovine thigh muscle, cleaned and sterilized. It
18 mm. A number of factors are important in the is supplied in lengths of about 30 cm × 6 mm wide
selection of suitable intestinal material. Generally and is used surgically for hernia repair, urethral
the younger the animal the smaller it is intestine and slings, etc.
less likely to be affected by feed. A number of  Synthetic absorbable material
manufacturers of catgut use only the first 8 m of 1. Plain surgical gut
intestine measured from the duodenum. In the Surgical gut is made from the intestinal sub mucosa
slaughterhouse the gut is removed from the animal tissue of sheep. These casings are split into ribbons,
by the gut pullers and is first of all cleaned to which are cleaned chemically as well as
remove faecal matter after which it is inspected, mechanically and matched by computers to meet the
measured and the preserved either in a frozen state most exacting demands for diameter and tensile
or salted. strength. Then an exclusive electronic spinning
2. Reconstituted collagen process creates a strand that is virtually a
Collagen is available from a large number of monofilament for dependable strength and holding
sources. It is the major constituent of skin, tendon, power. Finally the strand is polished to size to an
ligament, etc. It is partially soluble in acids. The accuracy of five thousand of a millimeter to produce
basic process has been to obtain an acidic solution an extremely smooth, highly uniform suture.
of collagen prepared from hides or tendons which Surgical Gut draws through delicate tissue without
can be extruded into a coagulation solution and the sawing, ties down securely and holds uniformly and
resulting fibers oriented by stretching. The filaments predictably, until the wound regains tensile strength.
can then either be spun or rolled to make up the 2. Chromic surgical gut suture
necessary sizes of strand required. Reconstituted Chromic gut is made from the intestinal sub mucosal
collagen is produced mainly in the finer sizes 0.5, 1 tissue of sheep. These casing are split into ribbons
and 2 for ophthalmic and cuticular surgery. which are cleaned chemically as well as
3. Kangaroo tendon mechanically and matched by computers in order to
This absorbable material consists of the tail tendons meet the most exacting demands for diameter and
of the wallaby. The tendons, which were usually tensile strength. Then an exclusive electronic
preserved with naphthalene, were prepared and spinning process creates a strand that is virtually a
graded into various sizes e.g. fine, medium, and monofilament for dependable strength and holding
stout. Lengths were 30-40 cm. They were sterilized power. Finally the strand is polished to size to an
as for catgut and their main use was for hernia accuracy of five thousand of a millimeter to produce
repair and bone surgery. an extremely smooth, highly uniform suture.
4. Ribbon gut Surgical gut draws through delicate tissue without
Ribbon gut is in the form of ribbon approximately ties down securely and holds uniformly and
12 mm wide and usually about 45 cm long. Its use is predictably until the wounds regains tensile strength.
limited but is preferred by some surgeons for the 3. Coated vicryl (Polyglactin 910)
repair of large ventral hernia and in the closure of Available as a braided suture in distinct violet as well
the kidney after nephrology. The material is as undyed colures coated vicryl (Polyglactin 910) is
prepared from bovine esophagus and is sterilized in now the most widely used coated braided synthetic
the same way as catgut. absorbable suture. The

braided construction ensures that handling and during the critical wound healing period, yet, be absorbed rapidly
knotting are excellent and the unique lubricant after the suture has excellent handling characteristic and its
coating remains effectively bonded to the material distinctive violet colour is highly visible in thewound. Coated
throughout its use, ensuring smooth passage through vicryl is also available in undyed form, especially for cuticular
tissue and easy knot tie down. The unique molecular and plastic surgery.
structure of coated vicryl allows it to retain strength 4. Monocryl (Poliglecaprone 25)
It is monofilament synthetic absorbable suture.
Available as a golden colour  Non-absorbable suture
monofilament.Monocryl (Poliglecaprone 25) is a Non-absorbable sutures and ligatures are not
monofilament, synthetic absorbable suture. A absorbed by tissue and unless they are on the surface,
copolymer of 75% glycoside and 25% caprolactone, remain in the body after the wound has healed.
Monocryl is undyed, presenting as a natural 1. Silk
golden coloured Silk consists of strands prepared from filaments of
monofilament.Monocryl is the most pliable the cocoon spun by the silk worm of the Bombyx
synthetic absorbable monofilament suture ever, has family before it enters the chrysalis stage. Three
virtually no memory when dispensed and its forms are used in surgery- twisted (sometimes
exceptionally smooth surface ensure tissue glidde known as Chinese twist). Floss and plaited or
when passed through tissue. This added to the fact braided silk. DSilk in its natural state contains up to
that it elicts only minimal tissue reaction makes this 25 percent of natural gum and strands prepared from
suture an ideal choice for plastic and cosmetic unbleached, un discharged. Twisted silk suture
surgery and for Gastrointestinal surgery. material is prepared from unbleached, un discharged
5. PDS II filaments spun in multiples to the British
It is monofilament synthetic absorbable suture. Pharmaceutical Codex range of diameters and may
Available as a distinct violet Suture.PDS II suture is be dyed with non-toxic dyestuffs. The surgical use of
a monofilament synthetic absorbable suture made of twisted silk has very much declined in favor of the
polydioxanone.PDS II has the characteristic of braided type.Floss silk is prepared from the coarser
extremely high initial tensile strength, coupled with filaments on the outer surface of the silkworm
extended wound support. Also being a cocoon and is used in its spun glossy white form
monofilament handling is extremely easy and mainly in the repair of hernia. Its use is diminishing
knotting is secure. Passage through tissue is smooth, fast as the plastic polymer meshes gain in popularity.
eliminating tissue drag. It is indicated for use in Plaited or braided silk is the material in large-scale
areas such as closure of fascia and sheath, in use in modern surgery. It is prepared from discharged
pediatric cardiovascular surgery, in the gastro silk and the range of sizes is dependent on the
intestinal tract, in obstretrics/gynaecology, in number of strands braded together. As the gum has
orthopedic surgery and for sub cuticular closure. been removed it is not serum proof or non capillary
and for most surgical purposes it therefore treated
with proofing waxes or silicones.
2. Linen
Linen sutures consist of selected fibers made into a
twisted strand from flax (Linum usitatissinum). The
strand is normally prepared by spinning three cords
together, the size of the cords being chosen to
produce the ultimate desired gauge of thread. For
surgical use it must be firmly and evenly spun and
free from fuzziness. Linen may be dyed with any
non- toxic dyestuff but although a certain amount of
black thread is used the majority of surgeons
prefer off-white or ivory colour. It is extensively has the further advantages of being minimally
used in many surgical techniques and frequently irritating to tissue and remarkably smooth and easy
needs to be non capillary and serum proof by to handle. The smoothness of suture makes it suitable
treatment with suitable proofing agents similarly to for closing skin and sub cuticular layers. Its high
braided silk. degree of elasticity contributes to its great strength in
3. Polyamides[9] the fine sizes, enabling the plastic surgeon; the micro
In the U.K. these polymers are better known by the surgeon and the ophthalmologist to tie secure knots.
word Nylon but as this is a registered trademark in 6. Mersilene Braided and Monofilament
certain European countries, it is likely that the word Polyester
polyamide will be used in the future. These Mersilene suture is made from fine filaments of pure
compounds are formed from the polymerization of polyester, an extremely strong synthetic material. It
the reaction product of an acids and an amine. All is specially processed to render it non capillary. A
the polyamides and suture materials are produced by special process to produce a tight, smooth, uniform
an extrusion process, the size of the orifice on the strand braids it. The tensile strength of mersiline
extruder head determining the size of the filament. suture is considerably higher than that of natural
The bulk of the material used in surgery is produced non- absorbable sutures. It is not weakened by
in the form of monofilament. Its main use is in skin wetting. It has excellent handling characteristics,
suturing although it is sometimes used internally. draws easily through tissue and knots hold securely
Polyamide mesh finds a use in hernia repair.Finer with standard synthetic knotting technique.
filament of polyamide is braided together to form 7. Polybutylate coated braided polyester suture It is
braided nylon on nonabsorbable surgical sutures. available as a highly visible green or white coated
4. Polyester braided suture. Suture is made of fine filaments of
This suture material is usually prepared in the polyester fiber, braided by a special process to
plainted or braided form and consists of filaments produce a firm suture that remains soft and pliable.
prepared by polymerizing the ester formed by a For added lubricity and smoothness, the suture is
combination of ethylene glycol and terephthalic coated with a highly adherent, biologically inert
acid. In its commercial form it is known under the Polybutylate. The unique process gives suture a
trademarks Terylene (I.C.I.) and Dacron (Dupont). number of advantages. Flaking is virtually
The number of filaments in the braid determines the eliminated and the suture is smooth to plave and tie
size of the completed strand.The polymer has a down making it an excellent choice for
softening temperature of not less than 255 degree cardiovascular and ophthalmic work. Knots hold
and may be sterilized by autoclaving, ethylene oxide securely when standard synthetic technique is used.
or radiation treatments, in order to improve its Suture is virtually non reactive and will retain its strength in
visibility in tissue it is often dyed or pigmented with tissue.
non- toxic materials. 8. Monofilament stainless steel suture Available
5. Monofilament Polyamide as sterile monofilament eyeless needled
The suture use in this product is an extremely sutures.Surgical stainless steel is made from
strong, very pliable surgical nylon produced by a premium grade steel, formulated specifically
special, closely controlled extrusion and polishing for surgical use. This grade of surgical stainless steel
process that assures uniformity throughout its must undergo many more quality control steps than
length. It has high in-vivo tensile strength, does not ordinary commercial
support bacterial growth and
steel. Surgical steel is the strongest suture material silk. Natural silk is composed of approximately 70 %
that makes. It offers the ultimate in knot security. As protein fibers and 30% extraneous material or gum.
a inert material it will elicit virtually no tissue A specially developed degumming process removes
reaction. extraneous material amounting to 30% of the original
9. Prolene mono filament polypropylene volume of raw silk. This process is essential for a
It is available as a bright blue monofilament suture. compact braid whilst ensuring that the filaments
Prolene polypropylene[10] suture is made from a retain their natural body and elasticity. These
polymer of propylene, which is extruded by the filaments are then tightly braided at a slow controlled
special ethicon a very strong, smooth, uniform rate and electronically inspected during the
suture. The unique combination of qualities in the processing.
suture material itself makes prolene suture one of
the most versatile non- remarkable smoothness CONCLUSION:
remarkable smoothness absorbable sutures
available. It makes it desirable as a cosmetic suture. Proper designing of sutures make it possible to
The same quality is valuable in cardiovascular sharply reduce the percentage of postoperative
work. It is un wetted by blood, un weakened by complications and correspondingly to reduce the
tissue enzymes, offers prolonged tensile strength number of repeated operations. The ideal suture
even in infected areas. prolene suture is pliable, ties material would be a perfect union of easy
securely and handles well because of its controlled sterilization, adequate tensile strength, handling ease,
elongation. absence of foreign body reaction, and complete
10. Perma-hand tissue absorption. Simultaneously, the time for
It is available as a black braided suture. Perma hand treating surgical patients will be shortened and
surgical silk begins as a filament of natural expenses for treatment will be reduced.

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