Suture Materials and Suturing Techniques

BULE HORA UNIVERSITY
College of Agriculture and Veterinary Science
Department of Veterinary Medicine
Veterinary General surgery and Anesthesiology

Lecture Note
Prepared by:
Dr. Zerihun Mulatu (DVM, MVSc, Assist. Professor of

Veterinary Surgery)
Bule Hora, Ethiopia

Friday, April 19, 2024 Bule Hora University 1
Suture Materials
Definitions:
 Suture material is an artificial fibre used to keep wound
together until they hold sufficiently well by themselves by

natural fibre (collagen) which is synthesized and woven
into a stronger scar
 Suture is a stitch/series of Stiches made to secure
apposition of the edges of a surgical/traumatic wound

(Wilkins)
 Any strand of material utilized to ligate blood vessels or
approximate tissues (Silverstein L.H 1999)

Uses of suture materials
 To bring the edges of a wound in close approximation
 To retain the medicated plug for dressing in deep wound or

cavity
 To close any accidental opening
 To reduce the size of a natural opening
 To keep the lips of a deep open wound in contact to check

recurrent hemorrhage.

Objectives of Suturing
 The aims of wound closure include :
 Obliteration of dead space,
 Even distribution of tension along deep suture lines
 Maintenance of tensile strength across the wound until
tissue tensile strength is adequate.
 Suture plays an important role in wound repair by providing
hemostasis and support to the healing tissue.
 The primary function of suture materials is to hold tissues in
a position until the wound can withstand outside stresses.

Gaol of Suturing
 Suturing is performed to
 Provide an adequate tension
 Maintain hemostasis
 Permit primary intention healing
 Provide support for tissue margins
 Reduce postoperative pain
 Prevent bone exposure
 Permit proper flap position

Qualities of an ideal suture material
 Remain intact until tissue union occur
 Minimum tissue reaction
 Non-capillary in action
 Uniform thickness
 Knotable (retain secured knots)
 Smooth surface (to reduce friction)
 Sufficient tensile and functional strength
 Easily sterilizable

Cont’d…
 Be cheap and readily available
 Be easy to handle - Minimum memory
 Non allergic, non electrolytic and non carcinogènic
 Biologically inactive

Suture size
 All suture materials are available in a variety of sizes. There
are currently 2 standards used to describe the size of suture
material:
 The USP and
 The European Pharmacopoeia.
 The USP is the more commonly used system in the world.
 The USP standard uses a combination of two numerals- a 0

and a number other than 0 (such as 2-0 or 2/0).
 The higher the first number, the smaller the suture diameter.
Cont’d…
 These numbers representing diameter ranging in descending
order from 10 to 1 and then 1-0 to 12-0,
 10 being the largest and
 12-0 being the smallest at a diameter than a human hair.
 The smaller the size of the suture the milder would often be the
inflammatory process due to reduced foreign body reaction.

Principles of Suture Selection
The selection of suture material by a surgeon must be based
on a sound knowledge of:
 Healing characteristics of the tissues to be approximated
 The physical and biological properties of the suture materials
 The condition of the wound to be closed
 The probable post-operative course of the patient
 The tissue to be repaired
 The tensile strength of suture materials
 Knot-holding characteristics of suture materials
 The reaction of surrounding tissue to the suture materials

Cont’d
Rate of healing of tissue
 When a wound has reached maximal strength, sutures are
no longer needed
 Tissues the ordinary heal slowly such as skin, fascia and
tendons should usually closed with non absorbable sutures
 Tissue that heal rapidly such as peritoneum, liver, small
intestine, muscles, stomach, colon and bladder may be
closed with absorbable sutures
 Suture should be stronger than the sutured tissue to
implant more bacteria than necessary
Cont’d
Tissue Contamination
 Avoid multifilament(simaagoo foohaa qabdu) sutures as
bacteria can linger with them and may convert a
contaminated wound into an infected one
 Use monofilament absorbable or non absorbable sutures in
potentially contaminated tissues
 Monofilament(simaagoo foohaa hin qabne)polypropylene is
ideal

Cont’d
Cosmetic result
 Where cosmetic results are important, close and prolonged
apposition of wound and avoidance of irritants will produce
the best result:
 Use the smallest inert monofilament suture materials such
as poly amide, nylon or polypropylene
 Avoid skin suture and close subcuticularly whenever
possible
 Under certain circumstance, to secure close apposition of
skin edges, skin close tape may be used
Suture’s Characteristics
 Physical configuration
 Tensile strength
 Knot strength
 Elasticity
 Plasticity
 Memory

Classification of Suture Materials
 According to fate: 1. Absorbable
2. Non-absorbable
 According to source: 1. Natural
2. Synthetic
 According to structure: 1. Monofilament
2. Multifilament
 According to coating፡ 1. Coated
2. Uncoated
 According to tissue 1. Reactive
reaction፡
2. Not reactive

Cont’d

Natural VS Synthetic suture
Natural Synthetic:
Monofilament/multifilament Monofilament/multifilament
Relatively low TS High TS
Induce high tissue reaction Induce low tissue reaction
High coefficient of friction Low coefficient of friction
Good knot holding ability Knot holding is difficult
Used on rapid healing tissue Used for slow healing tissue

Absorbable Suture Materials
 Designed to rapid degradation in tissues
 Losing their tensile strength within 60 days
 Used for short term immobilization of wound edge
 Used for temporary support is required
 Natural absorbable sutures-digested by body enzymes
 Synthetic absorbable suture-breakdown by hydrolyzed

a process
 Hydrolyzation results in a lesser degree of tissue reaction
Absorbable Suture Materials
Inherent limitations
1. Patient has: fever, infection or protein deficiency
 Accelerate suture absorption process
 Decline tensile strength of suture
2. Sutures become wet or moist during handling
 Absorption process may begin prematurely
3. Absorbed more rapidly in tissues with:

 high vascularity and increased digestive enzymes (e.g.
stomach or urinary bladder)
Natural absorbable suture
Surgical gut
Two types: plain or chromic cat gut
Consist of processed strands of highly purified collagen
Percentage of collagen in the suture determines:

 Its tensile strength
 Its ability to be absorbed by the body without adverse
reaction
Non collagenous material can cause a reaction ranging
from irritation to
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rejection of the suture
Bule Hora University 20
Surgical gut

A tough thin cord made from the treated and stretched sub-mucosa of
sheep intestine or serosal of bovine intestine.
Commonly used to suture the inner structure of the body such as:
wall of the organ
Rectal sheath
Muscles
Subcutaneous tissue
Peritoneum
Intestinal anastomosis
Plain surgical gut

Rapidly absorbed
Tensile strength is maintained for only 7 to 10 days
Absorption is complete within 70 days
Used in rapid healing tissue and required minimal support
such as:
 Suturing of subcutaneous fatty suture
 epidermal suturing

Chromic surgical gut

 Treated with a chromium salt solution to:
 Resist body enzymes
 Prolonging absorption time over 90 days
 Minimize tissue irritation
 The process alters the coloration of the surgical gut
from yellowish‐tan to brown
 Causing less reaction than plain surgical gut
 Tensile strength may be retained for 10 to 14 days
Based on the degree of chromatization:

Collagen suture
Natural, absorbable, monofilament
Obtained by homogenous dispersion of pure collagen fibrils
from the flexor tendon of cattle
Absorption-56 days
TS-10% after 10 days
Used in ophthalmic surgery
Disadvantage: premature absorption

Kangaroo tendon
 It is obtained from the tendon of tail of kangaroo
 It is used for suturing join capsule, hernial rings
 It is very expensive so they are rarely used.
Fascia- lata
 Fascia-lata is obtained from best cattle.
 It is prepared in strips so that it support weakened fascia.

Cargile membrane
 Is a sterile membrane made from the peritoneum of the ox.
 Used in abdominal surgery to interpose between raw

surfaces and thus prevent the formation of adhesions.
 It also used to envelop freshly sutured nerves or tendons,
and to protect wounds

Synthetic absorbable suture
Glycolic Acid Homopolymer (Maxon)

Polyglycolic Acid
Polymer of glycolic acid
Has greater pull & TS than surgical gut
Synthetic, absorbable, braided
Absorption-hydrolysis with minimal tissue reaction
Braided and so catch itself
Knot tying and passage through tissue difficult
Doesn’t tolerate
Bulewound
Friday, April 19, 2024 infection & not percutaneous suture
Hora University 28
Glycolic Acid (Maxon)
Polyglyconate
Synthetic, absorbable, monofilament
Polyglycolic acid and trimethylene carbonate
TS-14-21 days (Dexon)
Absorption-hydrolysis in 180 days
Used for slow healing tissue
Smooth, uniformly absorbed
Antibacterial agent

Polydioxanone (PDS II)
Synthetic, absorbable, monofilament
Polyester derivative poly P dioxanone
TS-14-42 days
Absorption-hydrolysis in 6 months
Pass in tissue easily
Significant memory-compromises the ease of knot-
tying and knot security
Minimal tissue reaction
For wounds under tension and contaminated wounds
April
Friday, So19,used
2024 onlyBuledeeper than subcuticular layer
Hora University 30
Polyglactin 910 (Vicryl)
Polyglactic Acid
Coated and uncoated
Synthetic, monofilament/multifilament
Lactide has hydrophobic quality delayed loss of TS
TS-14-21 days
Absorption- hydrolysis within 56-70 days
Minimal tissue reactivity and used in infected tissue
Available in purple and undyed
Coated with polyglactin 370 and calcium stearate which allow
easy passage through tissue as well as easier knot placement
On skin wound associated with delayed absorption as well as
increased inflammation
Non-absorbable suture materials
Suture materials are not absorbed by the body tissue
Retains its tensile strength more than 60 days
Commonly used in skin suturing
Encapsulated by fibrous tissue = used in internal organs
Used for long term immobilization tissue
Suitably resistant to the action of living mammalian tissue
Treated for capillarity (the passage of tissue fluid along
the strand permitting infection)

Natural non-absorbable suture
Surgical silk:
Braided or twisted
TS-loss after 1 year
Derived from silk worms larvae to form its cocoon
After braiding, the strand are dyed, stretched and
impregnated with mixture of wax and silicone
Dry suture is stronger than wet silk suture
Use: plastic surgery, ophthalmic and general surgeries,
ligating body tissue
Advantage:
superior handling quality
high elasticity
good knot security
black dyed for easy visibility
Disadvantage:
bacteria and fluid collection (Wick effect)
high potential for infection
severe inflammatory reaction
Surgical Cotton:
Natural, non absorbable, multifilament
Braided/twisted filaments
From stable Egyptian cotton fibers
Good knot security
Not good in contaminated & infected wound
Severe inflammatory reaction
Rarely used now days
Use: most body
tissue for ligating & suturing
Linen:
Natural, non absorbable, multifilament
Braided/twisted filaments
Made from stable flax fibers
Poor tensile strength & not for suturing under tension
Severe inflammatory reaction
Use: ligation of superficial vessels
Muscular suturing without stress
Synthetic non-absorbable suture
Nylon-braided (Surgilon, Nurilon):

Synthetic, non absorbable
Inert polyamide polymer
Braided and sealed with silicon coating
Excellent handling quality
Excellent knot security
Greater tensile strength than silk
No inflammatory reaction
Nylon-Monofilament (Dermalon, Ethilon):

Uncoated but inert and non irritating to the tissue
High TS and low tissue reactivity
Memory & return to original linear shape over time
Moistened nylon monofilament are more easily
handled and are packed wet
Use: skin closure, retention, plastic, ophthalmic and
microsurgeryBule Hora University
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Polyester-Braided:
Uncoated-MERSILENE* polyester fiber suture
Coated-ETHIONOND* excel polyester suture
Multifilament fibers of polyester
Excellent TS which is maintained indefinitely
Uncoated is rougher and stiffer than coated
Coated provided: low infection rate, secure knotting, smooth
removal, low reactivity, easy passage through tissue
More expensive
In deeper layer,
Friday, April 19, 2024 may
Bule Hora last indefinitely
University 39
GOR-TEX:
Synthetic, non absorbable, monofilament
From expanded polytetrafluoroethylene (Eptfe)
Extremely low tissue reaction
Good knot security
High TS and ease of handling
Use: - all types of tissue approximation
- Cardiovascular surgery
Monocryl:
Synthetic, non absorbable, monofilament
Poliglecaprone 25; copolymer of glycolide and
caprolactone
Hydrolysis-90-120 days
Tissue reaction-minimal
Good knot strength
Used for soft tissue closure
Most pliable material ever made
Polybutester (Novofil):
New, synthetic, non absorbable, monofilament
Made of polyglycol trephthate and polybutylene terphthalate
and considered as a modified polyester suture
No significan memory compare to plolypropylene and nylon
Good knot security, high TS, minimal tissue reaction
Unique feature: their ability to elongate or strength with
increasing wound edema
When edema subscribe, suture resume orginal shape
So ideal sutureBule
forHoralaceration
University
secondary to blunt trauma 42
Polyethylene (Prolene):
Polymer of polypropylene
Inert and TS for 2 years
Holds knot better than other synthetic suture
Advantage: minimal tissue reaction and used in
infected & contaminated wound
Use: Skin closure, general, plastic, cardiovascular &
ophthalmic surgery
Polyamide:
Minimal tissue reaction
High tensile strength
Smooth
Flexible
Less irritating to tissues
Use: skin sutures

Synthetic non-absorbable sutures
Dermal suture
Twisted silk fibers encased
Non absorbable, synthetic
The coating prevents in growth of tissue cells
Removed after skin closure
Particularly strong
Primarily used in plastic surgery

Synthetic non-absorbable sutures
Stainless steel
Monofilament/multifilament forms
Have high tensile strength,
Easily sterilized
Relatively inexpensive
Minimal tissue reaction
Stable in contaminated wound
Use: = retention sutures
= skin closure
= tendon repair
Monofilament VS Multifilament
Monofilament Multifilament
Advantage: Advantage:
Thinner, Smooth & strong Stretch
Less tissue trauma Thicker
No bacterial harbors Soft & pliable
No capillary Good handling &
Disadvantage: knotting
Poor handling & knotting Disadvantage:
Not stretch Bacterial harbors
Any nick or crimp in the Capillary action
material lead to breakage High tissue trauma

Knots Tying
Principles of knot tying:

Knot should be simple & secure
All knots placed to one side of the incision
Knot must be as small as possible
Sutures ends should be cut as short as possible
Avoid knot tying friction b/n strands and sawing
Avoid application of crushing instrument
Avoiding excessive tension
Sutured knots
SK Has 3 components:
 Loop: created by knot
 Knot: itself which composed
of a number of tight throws
 Ears: which are cut ends of
the suture

Types of surgical knots
1. Simple Knot:
 It is half-bitch and primary
step in square knot
 It is seldom used alone
 Not used due to slip of
suture

2. Granny knot:
Granny knot Square knot
The slipknot is similar to a square knot in
that it is made with two overhand knots
But both knots are made in the same
direction
One overhand knot is made so that the loop
forms over the jaws of the needle holder
and is then tightened
A second overhand knot is then made so
that the loop goes in the same direction
over the needle holder
Friday, April 19, 2024 and is tightened
3. Square knot:
This suture knot is made by tying two overhand
knots
Each knot done in opposite directions
For example, the first loop is made by making a
loop over the jaws of the needle holder
The second knot is subsequently made by
forming a loop under the jaws of the needle
holder
This knot is easy to tie, but may loosen when a
synthetic or monofilament suture material is
Friday,used
April 19, 2024 Bule Hora University 52
4. Surgeon’s knot:
The surgeon’s knot is a modified square knot in
which the first overhand knot is doubled
Two loops of the suture are formed over the jaws
of the needle holder and tightened
The last loop is formed under the jaws of the
needle holder in a direction opposite from the first
loops
This is the standard suture knot used in
conjunction with the mattress technique of
suturing
Suture Techniques/Patterns
Suture Patterns
 Many types of suture patterns available to close the incisions and
wounds encountered daily in veterinary practice
 Selecting the appropriate type of pattern is important to achieve:
 Uncomplicated wound healing
 Good cosmetic appearance
 Factors that assist in the selection of the appropriate pattern
 Species of animals
 Individual patient
 Personal preference
Suture patterns are categorized as:
1. Effect on the edges of the incision
2. Appositional, inverting or everting
2. Continuous or interrupted

Suture patterns are categorized as:
1. Effect on the edges of the incision
2. Appositional, inverting or everting
2. Continuous or interrupted

Effect on the edges of the incision

 Refers to how the suture pattern approximates the
edges of the wound
 The goal of tissue closure is usually to anatomically
appose the wound edges
This results in the most rapid healing and return of
wound strength
1. Appositional:
Designed to bring the
tissues in direct apposition
Anatomically opposes the
edges of the incision
Results in the fastest healing
 Gives most cosmetic result

2. Inverting:
 Turns incision edges inward,
away from surgeon
 May be desirable when closing
hollow organs
 better “seal” against fluid leakage
 minimizes exposed suture and
subsequent adhesions
 decreases the size of a hollow organ’s
lumen (avoid if already small)
 Avoid in skin as delays healing

3. Everting:
 Turns incision edges
outwards, towards surgeon
 Results in delayed healing
 Rarely indicated
 Used in skin suture

Types of Interrupted Suture Pattern
1. Interrupted suture pattern
Each suture is a separate and independent
entity
Sutures can be individually positioned
and tightened as needed: more anatomic
closure possible
Places more foreign material (suture) in
the tissues when used in deeper layers
Allows adjustment of tension throughout
the suture line
Types of Interrupted Suture Pattern
Advantage:
Failure of one knot is often inconsequential
It is easy to apply and accurate
Infection occurs at any point not affect other side
Disadvantage:
More time needed to tie individual knots
Requires more quantity of suture materials
Increased amount of foreign material in the wound
Types of interrupted suture pattern
A. Simple interrupted suture

 Used when excessive tension isn't
expected
 Appositional types of suture pattern
 Allows adjustment of suture tension
 Secure anatomical closure
Advantage:
 Failure of one knot is inconsequential
 Easy to apply
Disadvantage:
 Minimal holding power against stress
 Time consuming
 Requires more quantity of suture
materials
Use:
 Skin, subcutaneous tissue, fascia,
vessels, nerve, gastrointestinal and
urinary tract

B. Cruciate/cross matters suture
Appositional types of suture pattern
Faster closure than simple interrupted
Resists tension and prevents eversion
Stronger closure than simple interrupted
Preferred if the skin edges are under
tension
Used for closure of hole made by larger
hypodermic needle
Suture is commenced by inserting

the needle from one side to the next
as simple interrupted suture
A second throw is made in the same
way parallel to the first throw
Now suture ends on opposite sides
of wound
Form ‘X’ while finishing the suture
C. Interrupted horizontal mattress
 Appositional to everting suture pattern
 Depending on tightness of throws
 Can strangulate blood
 Used where relative speed is desired
 Used as a tension suture
Advantages:
 Involves a small amount of suture material
 Rapidly applied
 A tension type of
suture is obtained
Disadvantage:
 Difficulty of applying it in skin
without causing excessive aversion
Use:
 Closure in areas of high tension or
occasionally used in closure of flat
tendons or muscle with minimal
fascia vessels at wound edges

4. Interrupted vertical mattress
 Appositional to everting suture pattern
 Stronger in tissues under tension than
horizontal mattress
 Less likely to occlude small vessels at
wound edges
 Preferable in large lacerated wound
Advantage:
 Stronger tension than horizontal mattress
Disadvantage:
 Requires large amount of suture material
 More time consuming
Use: closure in areas of high tension (some
situations of skin closure)

5. Far-far-near-near and far-near-near-far
 Appositional to everting suture pattern
 Variations of vertical mattress
 Can provide necessary tension for wound
approximation without direct tension to
wound edge
 Use closure under tension such as:
 skin
 subcutaneous
 fascial
Types of continuous suture pattern
2. Continuous Sutures
Knots only at beginning and end of pattern
Providing air & water tight closure
Less precise control of suture tension and
wound approximation
 tension is adjusted after each bite as
difficult to adjust at the end
If one knot fails or the suture strand breaks:
 knots must be properly tied
 avoid kinking or grasping the suture with
instruments (handle the ends)

Types of continuous suture pattern
Advantages:
 Less foreign material in wound
 Potentially better airtight or watertight seal
 Ease to application
 Minimal use of suture material
 Minimal amount of knots
 Ease to removal
 More complete tissue apposition
Disadvantages:
 Failure of knot may lead to disruption of suture
line
 Less precise control of wound approximation
and tension Bule Hora University
Friday, April 19, 2024 72
Types of Continuous Sutures pattern
1. Simple continuous suture
Faster than interrupted suture pattern
Promotes suture economy
Provides a more air tight or fluid tight seal
More difficult to adjust tension
Can fail completely if knot is weak or
inadequate
A first bite is placed across the incision
Used in tissues that require minimal
holding but maximal tissue apposition
 Use: skin, subcutaneous tissue, fascia,
vessels, nerve, gastrointestinal and urinary
tract
Types of Continuous Sutures
2. Continuous lock-suture
Modification of simple continuous
suture
Provides better apposition of the
wound edges
Prevent the diagonal crossing of
wound edges
Greater stability of partial failure
More difficult to remove

3. Continuous intradermal
suture
Intradermal or horizontal
mattress suture
Provides suture economy
Provides good skin
apposition
Weaker than skin sutures
No suture to remove
3. Purse- string suture
 It is placed in a circle around an opening
 The suture is tied when the circumference of the circle is
finished
 The suture alternates above and below with on interval of
1 cm
 The suture do not penetrate the mucosa
 It is important to over sew an opening that evacuates gas
to the GIT
 After correction of rectal prolapse to narrow the lumen of
hollow organs
Types of Suture Pattern for Hallow Organs
1. Cushing suture
 It is continuous suturing
 The bites are parallel to the
wound edge
 It penetrates the serosa,
muscularis and submucosa
 But does not pass through the
mucous membrane
 It does not enter the lumen of the
viscous
2. Connell suture
 Connell resembles the Cushing suture
 But the suture material penetrates all
the layers of the gut wall
 Once outside the serosal surface, the
needle and the suture cross the
incision and reinserted in the serosa of
the opposite side at a point that
corresponds to the preceding exit site
 Directions of Connell and Cushing
suture are the same
 Both sutures invert the tissues
3. Lembert suture
 It is continuous suturing
 The bites are made at right angle to
wound edge
 It penetrates serosa, muscularis and
submucosa but does not pass through
mucosa
 Interrupted Lembert is also used in
large animal surgery
4. Jobber’s suture
 It is like Lembert suture but penetrates
all layers
 The chances of contamination are more

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BULE HORA UNIVERSITY

College of Agriculture and Veterinary Science

Department of Veterinary Medicine

Veterinary General surgery and Anesthesiology

Dr. Zerihun Mulatu (DVM, MVSc, Assist. Professor of

Bule Hora, Ethiopia

together until they hold sufficiently well by themselves by

apposition of the edges of a surgical/traumatic wound

approximate tissues (Silverstein L.H 1999)

 To retain the medicated plug for dressing in deep wound or

 To reduce the size of a natural opening

 To keep the lips of a deep open wound in contact to check

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 Minimum tissue reaction

 Knotable (retain secured knots)

 Smooth surface (to reduce friction)

 Sufficient tensile and functional strength

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 Be easy to handle - Minimum memory

 Non allergic, non electrolytic and non carcinogènic

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 The USP standard uses a combination of two numerals- a 0

Friday, April 19, 2024 Bule Hora University 9

 The physical and biological properties of the suture materials

 The condition of the wound to be closed

 The probable post-operative course of the patient

 The tissue to be repaired

 The tensile strength of suture materials

 Knot-holding characteristics of suture materials

 The reaction of surrounding tissue to the suture materials

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 Designed to rapid degradation in tissues

 Losing their tensile strength within 60 days

 Used for short term immobilization of wound edge

 Used for temporary support is required

 Natural absorbable sutures-digested by body enzymes

 Synthetic absorbable suture-breakdown by hydrolyzed

3. Absorbed more rapidly in tissues with:

Two types: plain or chromic cat gut

Consist of processed strands of highly purified collagen

Percentage of collagen in the suture determines:

 Its ability to be absorbed by the body without adverse

Non collagenous material can cause a reaction ranging

sheep intestine or serosal of bovine intestine.

Plain surgical gut

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Chromic surgical gut

Based on the degree of chromatization:

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 It is used for suturing join capsule, hernial rings

 It is very expensive so they are rarely used.

 It is prepared in strips so that it support weakened fascia.