UEMB 2323 Materials in Biomedical Engineering

Group Assignment: Surgical Sutures

Group: 3
Lecturer: Mr. Chong Yu Zheng
Date of submission: 23/8/2019

Name Student ID
Wong Yi Jie 1703758
Ng Yee Shuang 1703398
Tan Wei Tien 1700723
Toh Keat Hong 1702417
INTRODUCTION

What are surgical sutures?

Sutures are sterile surgical threads that are used to repair cuts (lacerations), or to close
incisions from surgery. It is use to hold skin, internal organs, blood vessel and other tissues
after injury, incision or surgery.

There are various kinds of sutures. Each sutures have their unique properties for their
intended uses. Usually, sutures can be classified based on their degradation properties or
material structures.

Classifications of Sutures based on degradation properties

 Absorbable Sutures
- Such sutures will degrade harmlessly in the body over time without intervention
(Dolphin Sutures, n.d.).
- Life span of absorbable suture lasts from 10 days to 8 weeks. In most cases, 3 weeks
is sufficient for the wound to close firmly.
- According to Jill Seladi-Schulman (2018), absorbable sutures do not requires surgeon
to remove them, because enzymes found in body tissues will naturally digest them.
- Main advantages of absorbable sutures is that no foreign material will be left inside
the body since it will degrade on its own. Therefore, it is suitable for internal wounds,
as it is harder and riskier for surgeons to remove the sutures.
- It is also suitable for patient that cannot return for suture removal (Southern
Anesthesia & Surgical, n.d.).

 Non-absorbable sutures
- According to Dolphin Sutures (n.d.), these sutures must be manually removed if they
are not left indefinitely.
- It is commonly used for external wounds. Although not common, non-absorbable
sutures are occasionally used internally when absorbable sutures will not sufficiently
hold the wound closure area, especially in higher pressure areas (Southern Anesthesia
& Surgical, n.d.).
- Non-absorbable sutures typically has less scarring compared to absorbable sutures.
Therefore, it is usually preferred by patient that can return for suture removal.
 Absorbable sutures Non-absorbable sutures
Life span - 10 days to 8 weeks - Last longer than typical
absorbable sutures,
usually years
Need of No Yes
removal
Advantages - No foreign materials left - Less scaring on the skin
inside body surfaces
- Ideal for internal wounds - Can sustain higher
pressure

Table 1: Comparison between absorbable and non-absorbable sutures.

Classifications of Sutures based on material structures

 Monofilament sutures
- Monofilament suture is a single stranded filament suture (Jones, 2019).
- It has lower infection risk, and elicit lower tissue reaction compared to
multifilament suture. This is because it has a smooth surface, and will not support
bacterial growth.
- According to Dolphin Sutures (n.d.), monofilament suture also provides better
passage through tissues since it is thin and smooth. Dr Juleena states that the
smooth surface of suture has low frictional coefficient, thus creating less friction
compared to multifilament suture.

Figure 1: Structure of Monofilament Suture

 Multifilament(Braided) Sutures
- According to Jones (2019), multifilament or braided suture is made of several
filaments that are twisted together.
- It provides better knot security, yet has chance to harbor infections (Dolphin
Sutures, n.d.). The irregular surface caused by the knots can potentially carry
pathogens inside human body (Dr Juleena, 2017).
- It is also less stiff, and have a higher coefficient of friction compared to
monofilament suture due to its braided structure.

Figure 2: Structure of Multifilament (Braided) Suture

 Barb Sutures
- Barb sutures are monofilament sutures that have barbs/projections on the surface.
- It has the advantages of penetrating the tissues and holding them without the
needs for knots. (Dolphin Sutures, n.d.). This is because the barbs on the suture
can penetrate through the tissue, and lock them into place.

Figure 3: Structure of Barb Suture

 Monofilament Multifilament Barb sutures
sutures (Braided) sutures

Structure - A single stranded - Make of several - Monofilament

filament suture filaments that are sutures that have
twisted together barbs on the
surface
Advantages - lower infection - Provides better knot - Can penetrate the
risk security tissues and hold
- provides better them without the
passage through needs for knots
tissues
Disadvantages - Tends to be stiffer - Can harbor bacteria
than
multifilament
sutures

Table 2: Comparison between sutures with different structure types.

Materials Involved

 Absorbable
1) Polyglactin
- Synthetic multifilament suture
- Can retain its strength for up to 3 weeks
- Can be broken down by enzymes, instead of phagocytosis
- Suitable for repairing hand or facial laceration
- However, according to Spano SJ and Dimock B (2014), it is not suitable for
cardiovascular or neurological procedure, due to the nature of multifilament suture
of harboring pathogens

2) Catgut
- Natural monofilament suture
- Made by twisting together strands of purified collagen taken from serosal or
submucosal layer of small intestine from healthy ruminants (David B, 2006)
- Absorption is complete in 60 to 70 days, and can retain its full tensile strength for
at least 7 days in-vivo (Dolphin Sutures, n.d.).
- Can be naturally digested by proteolytic enzymes
- Suitable for rapidly healing tissue and internal structures that cannot be re-
accessed for suture removal, due to its ability to retain its full tensile strength
during the first few days of healing

3) Polyglycolic acid
- Synthetic multifilament suture
- Can be broken down by enzymes
- Have better knot security
- Have outstanding tensile strength and in-vivo inertness (Dolphin Sutures, n.d.)
- Stronger than catgut suture

 Non-absorbable
1) Stainless steel
- Synthetic monofilament suture
- Strongest suture available commercially (Dolphin Sutures, n.d.)
 - Ductile (Properties of Stainless Steel, n.d.)
- Great knot security compared to most other commercially available non-
absorbable sutures (Dolphin Sutures, n.d.)
- Little tissue reaction, therefore will not harbor pathogen

2) Polypropylene
- Synthetic monofilament suture
- Will not lose tensile strength over time (Adel, 2014)
- Inert, very little tissue reaction
- High plasticity (Adel, 2014)

3) Silk
- Natural multifilament suture
- Smooth flow through tissue while maintaining optimal knot security
- However, it has poor microbe-resistance, and some patients have allergies to silk
(Stoelting, n.d.)

Absorbable sutures Non-absorbable sutures

Polyglactin (vicryl) Stainless steel
Catgut Polypropylene
Polyglycolic acid Silk

Table 3: Examples of materials used for sutures, according to its degradation properties.
 Biocompatibility, Toxity and Degradation

Sutures must non-toxic and hypoallergenic to avoid adverse reactions in the body (Dolphin
Sutures, n.d.). Therefore, most sutures has little to none toxicity if used for their intended
function.

There is no doubt on the efficacy of the materials below as a biomaterial, especially

surgical sutures. However, this does not eliminates the biocompatibility issues and toxicity of
the materials themselves. The table below discuss the biocompatibility, toxicity and the
degradation of the materials.

Materials Biocompatibility Toxicity Degradation

Polyglactin - Since it is used in - Non-toxic and non- - Biodegradable

closure of cutaneous carcinogenic /absorbable
wound of skins - However, may evoke mild - Can be broken
surface, wound is tissue response down by enzymes
exposed to air - Decay Schedule:
- It draws moisture - 75% at 2 weeks
from healing tissue to - 50% at 3 weeks
skin, allowing - 25% at 4 weeks
pathogens to migrate
into wound
- This leads to high
risk of contamination
- Thus, it is not
suitable for
cardiovascular or
neurological
procedure (Spano &
Dimock, 2014)
- To decrease risk of
contamination, the
surface of surgical
line can be treated
with triclosan
Catgut - Since it can retain its - May cause inflammation - Biodegradable
full tensile strength at /absorbable
least for 7 days in- - If treated with
vivo, it is suitable for chromic acid salts,
rapidly healing tissue the full tensile
(David B, 2006) strength in-vivo
- All guts harvested to can be increased to
manufacture catgut around 18 to 21
sutures are from days (David B,
certified BSE-free 2006)
herds
- However, it is banned
in certain countries
due to the concerns
that they could
transmit mad-cow
disease.
Polyglycolic - Have high in-vivo - Minimal systemic toxicity - Biodegradable
acid inertness - May cause inflammatory /absorbable
- Due to its outstanding and may cause foreign - Can be broken
tensile strength, it is body reactions down by enzymes
recommended used in - The reactions are initiated
orthopaedic surgeries by a pH decrease in
(Dolphin Sutures, surrounding tissue, which
n.d.) results from accumulation
of lactic acid and glycolic
acid during degradation
(Anson J. Tsugawa, 2012)
Stainless steel - Corrosion resistant - Metallic suspension may - Non-biodegradable
- However, may cause tissue vacuolation, /non-absorbable
corrode if in oxygen cell degeneration and - Corrosion resistant
depleted area multinucleated cell
formation
 - May impair
spermatogenesis (Pereira,
Silva, Tracana, and
Carvalho, 1994)
Polypropylene - May cause allergic - Bad for reproductive - Non-biodegradable
reactions to people system /non-absorbable
exposed to it - It can mimic the female - Relatively Inert in-
hormone estrogen, vivo
- May cause problem with - Will not lose
fertility and conceiving tensile strength
(Robinson, 2017) over time (Adel,
2014)

Silk - Poor microbe- - The decomposed by- - Non-biodegradable

resistance products from silk may /non-absorbable
- Some patients have trigger different level of
allergies to silk immune response and
diseases (Katarzyna
Lundmark, 2005)

Table 3: Biocompatibility, Toxicity and Degradation of different sutures’ material.

State-of-the-art

The usage of polymeric biomaterials in sutures for biomedical applications has been increased.
This is because polymeric material shows excellent physical and chemical properties which
assuring the suture quality. Polymers are highly flexible, which provide a suture material with
excellent physical and mechanical properties. Polymers also possess the ability as carriers for
drugs, stem cells, proteins, peptides, antibodies, DNA, nanoparticles, and so forth, to the
desired site which can enhance the therapeutic potential of sutures.

 Knotless barbed sutures

Barbed sutures are getting popular in recent years. According to a recent randomized
controlled study, using knotless barbed sutures to close the uterine incision after caesarean
delivery reduced operating time and blood loss. Dr David Paleg said that on average, knotless
barbed sutures were 1 minute and 43 seconds faster. Total operative time with barbed sutures
are shorter and did not even reach statistical significance. However, barbed sutures also require
fewer haemostatic sutures. Barbed sutures are usually made of monofilament with barbs
created by the addition of tiny diagonal cuts made just partway through the suture material.
(Oakes, 2018). According to Oakes, when the suture is pulled through with the angle of the
barbs, it pulls smoothly, but pulling back against the barb angle causes the barbs to protrude
and catch against tissue, preventing slippage and eliminating the need for knots. In fact, the
monofilament has been partially cut to create the barbs which can reduce the tensile strength.

 Antimicrobial sutures
Patients who have undergone sutures are likely to expose themselves to surgical site
infections as sutures are found as niche by bacteria such as Escherichia coli, Staphylococcus
aureus, and enterococci that are common in wound site. The formation of microbial biofilms
may lead to chronic infections which might need prolonged treatment. Braided sutures consist
of several small threads braided together have higher tensile strength than monofilament
sutures. However, they would facilitate bacterial adherence which affect the wound healing
process adversely. Hence, researchers have come up with antibacterial sutures coated with
antibiotics or other antimicrobial drugs (Gokarneshan, 2018). It was proposed that it can
prevent the microbe’s adherence effectively.
 Triclosan coated sutures
Recently, triclosan coated sutures have been widely used in sutures. Triclosan is an
antibacterial substance which can reduce bacteria growth by inhibiting fatty acid synthesis.
(Bergstrom et. al., 2013). However, when comparing it to nanoparticles, sutures coated with
silver nanoparticles have shown better antibacterial activity without much altering in tensile
strength.

 Force Fiber Fusion Suture

Force Fiber Fusion Suture was introduced in 2017. It was prepared from ultra-high
molecular weight polyethylene (UHMWPE). It is braided using a proprietary, continuous
process that creates seamless transitions between each segment. According to Teleflex Medical
OEM, Force Fiber Fusion Suture is softer, more pliable and has a lower knot profile compared
to other similar sutures. Besides, it is strong, durable and lubricious. With Force Fiber Fusion
Suture, tissue strangulation and a “cutting effect” in applications where tissue pull-through may
be a concern may be reduced

Conclusion

In conclusion, surgical sutures are generally categorised into absorbable sutures and non-
absorbable sutures. Absorbable sutures are usually used for internal surgeries, while non-
absorbable sutures are commonly used for external surgeries.

Besides, the two main structure of sutures are monofilament, multifilament and barb
suture. Monofilament sutures are single-stranded, while multifilament sutures are in braided
shape. Monofilament provides better passage through tissue, and has less tendency of causing
tissue reaction. On the other hand, multifilament suture tends to provide better knot security.

A surgeon must have a deep understanding on types of sutures to be used in different

scenario. Different surgical cases requires specific properties of sutures. If applied in incorrect
uses, sutures might causes allergies and inflammation.
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