Sutures, Needles and Wound Closure Materials

This is Unit Twenty of Tech in Surgery Prep. Unit Nineteen ended with a surgeon accepting a correction from the scrub person. This unit turns to the materials that close what the surgeon opened: sutures, needles, staples and glue. Carry one idea through this lecture. The scrub person does not choose the suture, but is the last check before it reaches the surgeon's hand, so every package is read in full before it is opened. A worked example near the end shows a wrong size caught that way. No absorption times or strength figures are given here; the package and the preference card are the guide. By the end you will be able to classify sutures and read their sizes. To compare the common materials. To describe needles and read a package. And to explain ties, staples, glue, closure choices and needle counts.

Five entries on what suture does, the ways it is classified, and how its size is numbered.

Holding tissue until it heals.

TSC 476 What Sutures Do

Sutures hold tissue together until healing makes it strong enough alone, or permanently secure a structure or device. Closing an incision by suture, staples or glue lets it heal by primary intention, edges held together. The wrong suture or needle can cause breakdown or injury, so the choice is deliberate.

Temporary or lasting.

TSC 477 Absorbable and Nonabsorbable

Absorbable suture loses most of its strength within about two months and is then broken down by the body; examples include plain and chromic gut, polyglactin, polyglycolic acid and polydioxanone. Nonabsorbable suture keeps its strength far longer; examples include nylon, polypropylene, polyester, silk and steel. Nonabsorbable skin sutures are often removed after healing, while buried ones may stay for good. The choice follows the tissue and how long it needs support. Absorbable means temporary, not weak.

One strand or many.

TSC 478 Monofilament and Multifilament

Suture is a single strand, called monofilament, or many strands braided, called multifilament or braided. Both absorbable and nonabsorbable come in both forms, and braided sutures tend to handle and knot more easily. Ask which the surgeon wants; the card often says.

Natural or made.

TSC 479 Natural and Synthetic

Suture materials are natural, such as gut and silk, or synthetic, such as nylon, polypropylene and polyglactin. Gut comes from animal intestine, so allergic reaction is possible, and synthetics generally cause less tissue reaction. Allergies are checked before any natural material is opened.

A scale running two ways.

TSC 480 Suture Sizes

Suture size describes thickness, and the scale runs two ways from zero. Sizes above zero, such as one, two and three, get thicker as the number rises. Sizes below zero are written with zeros, such as two-zero, three-zero and four-zero, and get thinner as the zeros increase. Heavy sizes suit tough, high-tension tissue such as fascia; fine sizes suit delicate tissue and skin, and the finest serve eye and microsurgery. Read the whole size, zeros included, before opening: a three-zero and a three are very different sutures.

Four entries on how suture materials behave, and on the common materials compared with one another.

Three properties.

TSC 481 Strength, Reaction and Handling

Sutures differ in tensile strength, tissue reaction and handling, and a clinical chapter on sutures lists these among the main factors in choosing one. Silk, for example, is easy to handle and tie but more reactive; polypropylene is very inert. These are general comparisons, and the surgeon decides.

Suture that springs back.

TSC 482 Memory and Extra Knot Throws

Some monofilaments have memory, a tendency to spring back to their packaged shape. The clinical chapter describes nylon and polypropylene as needing extra knot throws because of memory and slipperiness. Handle monofilament gently and straighten it as the surgeon prefers, because kinks weaken it.

The absorbables, compared.

TSC 483 Common Absorbable Materials

The common absorbables are learned as comparisons. Plain gut is natural, short-lived and comparatively reactive. Chromic gut is treated to last longer and react less, though stiff. Polyglactin is synthetic, usually braided, and loses strength as it is absorbed. Polyglycolic acid is another braided synthetic, keeping strength somewhat longer than gut. Polydioxanone is a synthetic monofilament that lasts longer than the braided ones, with little reaction, though stiff. Exact absorption times vary by product, so the package and the card are the guide, not memory.

The nonabsorbables, compared.

TSC 484 Common Nonabsorbable Materials

Nylon is a strong synthetic monofilament with little inflammation. Polypropylene is a very inert monofilament, slippery and with memory, needing extra throws. Polyester, often braided, is strong and less slippery. Silk is natural and braided, easy to handle and tie but more reactive, and slowly loses strength over months. Steel is very strong and permanent, and cannot harbour infection. Nonabsorbable does not always mean removable, because many are buried and stay for life.

Seven entries on needles, the package that describes them, and how a needle is loaded.

Point, body, swage.

TSC 485 Parts of a Needle

A surgical needle has a point, a body, and a swage where the suture attaches. Needles are described by curve, length, wire diameter and point style. The needle holder grips the body, never the swage, because gripping the swage can loosen the suture.

Fractions of a circle.

TSC 486 Needle Curvature

Needles curve in fractions of a circle, such as a quarter, three-eighths or a half, or are straight. A half-circle needle takes a short, deep bite in a tight space; flatter curves take larger, shallower bites; straight needles serve some skin closure. Most general procedures use curved needles.

How the point meets tissue.

TSC 487 Needle Points

The point style decides how a needle passes through tissue. A taper point is round, spreading tissue rather than cutting, for softer tissue such as intestine and vessels. A conventional cutting needle is triangular, with its third edge inside the curve, for tough tissue such as skin. A reverse cutting needle has that edge outside the curve. A tapercut combines a short cutting tip with a taper body. Spatula needles are flat, mainly for eye surgery. A cutting needle can tear delicate tissue and a taper needle can bend in skin, so check the package matches the request.

Suture joined to needle.

TSC 488 Swaged Needles

Most needles are swaged, with the suture permanently attached during manufacture. A swaged needle pulls a single strand, leaving a smaller tract than an old eyed needle with a doubled strand. The swage is the weakest point of the joint, so it is never gripped or bent.

Needles with blunt tips.

TSC 489 Blunt-Tip Suture Needles

Blunt-tip suture needles have rounded points and are used, where suitable, to reduce needlesticks. Federal workplace guidance lists them among the suite's engineering controls, with safer sharps devices and a neutral zone. They do not suit every tissue, and the surgeon decides when to use them.

Reading before opening.

TSC 490 Reading a Suture Package

A suture package carries everything needed to confirm it before opening. Read the material and whether it is absorbable; the size, with its zeros; monofilament or braided, and colour; the needle's point and curve; the number of needles, verified when opened because needles are counted by the number marked; and the expiration date and an intact, dry package. Opening the wrong suture wastes it, and a wrong one at closure delays the case. Read it fully, compare it with the request, and say it aloud as you pass it if your surgeon prefers.

Loading the needle.

TSC 491 Loading the Needle Holder

A needle is loaded in the needle holder's jaws at a right angle, about a third of the way back from the swage. The grip is firm but gentle, and the loaded holder is passed ready for use. Loading at the swage risks pulling off the suture and lets the needle turn.

Eight entries on ties, staples and glue, how closure is chosen, and needle counts, then two worked examples. The opening idea is paid off at the last.

Suture without a needle.

TSC 492 Ties and Free Ties

A tie is a length of suture without a needle, used to tie off a vessel or structure. A free tie is handed to the surgeon directly or carried on the tip of a clamp, such as a right angle, to pass around a vessel. When a right angle is asked for, have a tie ready.

Tying off a vessel.

TSC 493 Ligatures and Suture Ligatures

A ligature is a suture tied around a vessel to stop bleeding, often after it has been clamped. Small vessels can seal themselves, but larger ones usually need surgical control, with clamps holding them while they are tied or sealed. Have the next tie ready when vessels are clamped in sequence.

Closing skin with staples.

TSC 494 Skin Staples

Skin staplers close skin quickly with metal staples, as an alternative to suture. Wounds are commonly closed with sutures, staples or glue, and staples often reflect cosmetic outcome and surgeon preference. Staplers fall under the count or tracking process the facility sets, like any device.

Glue for the skin.

TSC 495 Surgical Skin Glue

Surgical skin glue is a sterile adhesive that closes skin edges in place of suture or staples, letting the wound heal by primary intention. The surgeon chooses it for suitable wounds. It needs a dry, well-aligned edge, so it is applied only when the surgeon is ready.

How closure is chosen.

TSC 496 Choosing Closure for the Tissue

The surgeon chooses suture, needle and method to fit the tissue and purpose. First the purpose: holding tissue until healed, or permanent fixation. Then the tissue: tough fascia needs strong suture and often a cutting or heavy needle, while bowel or vessels need fine suture and a taper needle. Then the material's properties, the size, and for skin, suture, staples or glue. The scrub person does not choose, but understanding why lets them anticipate the next request and notice a package that does not match the layer.

Every needle accounted for.

TSC 497 Needle Counts and Sharps

Suture needles are sharps, counted by the number marked on each package and kept contained throughout. They are verified when opened, kept in a counter, on a needle holder or in the package, and never left loose. Many needles moving back and forth make counts error-prone, so every used needle goes straight into the counter.

Sutures for each layer.

TSC 498 Preparing Closure for an Abdomen

A worked example, constructed for this course, follows Sam preparing to close an abdomen from the card, layer by layer, reading each package with the circulator. For fascia, a heavy absorbable monofilament on a large curved needle. For the subcutaneous layer, a finer absorbable braided suture on a taper needle. For skin, the surgeon chooses staples today. Sam loads the fascial suture in a long holder, a third back from the swage, and puts each returned needle straight into the counter. The closing count is done before the fascia closes. Sam passes each layer's needs a step ahead: Mayo scissors to cut, the next suture, then the stapler. The card and surgeon chose; Sam's reading and anticipation removed the pauses.

A three that should be three-zero.

TSC 499 The Wrong Suture Opened

A worked example, constructed for this course, pays off the opening idea. During a hernia repair, the surgeon asks for a suture in a particular size. The busy circulator holds out a package of the same material. Sam reads it before it is opened: size three, not three-zero, a much heavier suture. Sam says the size aloud and points out the difference. The circulator agrees, returns it unopened, and opens the right one, which Sam reads in full and says aloud as it is passed. Later the department separates sizes on the shelf. Reading before opening made this a near miss, and the scrub person is the last check before a suture reaches the surgeon's hand.

Look at what you can now do. You can classify suture as absorbable or not, single or braided, natural or synthetic, and read sizes in both directions from zero. You can compare strength, reaction, handling and memory, and the common absorbable and nonabsorbable materials, as comparisons rather than numbers. You can describe a needle's parts, curve, point and swage, read a suture package in full, and load a needle holder correctly. And you can explain ties, ligatures, staples and glue, how the surgeon chooses closure, and why every needle goes straight into the counter. Unit Twenty-One turns to staplers, implants, drains and catheters.