Why is Ethibond Polyester Suture a Good Choice for Cardiovascular Surgery

There are several different suture materials used in precise and safe wound closure. Preferably, the choice of the suture material should be based on the biological interaction of the materials employed, the tissue configuration, and the biomechanical properties of the wound. An example of a suture that can be used in such cases is ETHIBOND suture. It belongs to the class of non absorbable sutures. It is a polyester suture that is composed of fibers of polyethylene terephthalate, which is a synthetic linear polyester resulting when glycol is reacted with a dibasic acid. The polyesters are long chains with a high molecular weight and aromatic rings that recur again and again as a vital part of the compound.  Examples of polyester sutures include Surgidac, TiCron made by Syneture Covidien and Ethibond Excel and Ethibond, made by Ethicon.

 These polyester sutures were the first man-made braided suture material made known to last for an indefinite period in tissues. Their acceptance in surgery was confined to a small section in the beginning because the suture had a high coefficient of friction. This used to get in the way of the passage through tissue and hampered the construction of a knot. However, with the increase in scientific technology, it was soon learned that these sutures could be coated with a lubricant. Thus, ETHIBOND sutures gained wide acceptance in surgery. This coating markedly reduced the suture’s coefficient of friction, thereby assisting in knot construction and passage through tissue. All TiCron polyester sutures are coated with silicone, while the surface lubricant for Surgidac is Polybutylene adipate. Due to some surgeons liking to tie sutures with a high coefficient of friction, Surgidac sutures are also obtainable without a surface coating.

 ETHIBOND Excel sutures are uniformly coated with polybutilate, a biologically non reactive and non absorbable compound that attaches itself to the braided polyester fiber strand. This was the first synthetic coating developed specifically as a surgical suture lubricant. The coating eases the passage of the braided strands through tissue and provides excellent pliability, handling qualities, and smooth tie down with each throw of the knot. Both the suture material and the coating are pharmacologically inactive. The sutures draw out negligible tissue reaction and retain their tensile strength in vivo for long periods of time. No significant change is known to occur in vivo. ETHIBOND Excel sutures are used primarily in cardiovascular surgery, for vessel anastomosis, and placement of prosthetic materials. Anastomosis is the joining together of two organs or vessels that are usually hollow, this is why any preferred brand of polyester suture will work beautifully in valve replacement procedures world wide.

 ETHIBOND Excel is available in two forms, green when dyed and white when not dyed. ETHIBOND Excel sutures are also available attached to TFE polymer felt pledgets. These are small flat absorbent pads used to medicate, drain, save a wound from harm or serve to put off possible tearing of adjacent friable tissue. They are used on a regular basis in valve replacement procedures. This is to prevent the annulus from tearing when the prosthetic valve is seated and the sutures are tied. They are also used in situations where extreme deformity, distortion, or tissue destruction occurred.

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Uses of Plain Gut Fast Absorbable Suture and How They Differ From Plain Gut Suture

Fast absorbing surgical gut suture is a strand of collagenous material prepared from the sub mucosal layers of the small intestine of healthy sheep, or from the layers of the small intestine of healthy cattle. Fast absorbing surgical gut sutures are sterile and elicit only a slight to minimal tissue reaction during absorption. Fast absorbing surgical gut sutures differ from U.S.P. minimum strength requirements by less than thirty percent. Fast absorbing surgical gut sutures are intended for dermal suturing only. They should be utilized only for external knot tying procedures.

 The results of implantation studies of fast absorbing surgical gut sutures in the skin of animals indicate that nearly all of its original strength is lost within approximately seven days of implantation. When surgical gut suture is placed in tissue, a moderate tissue inflammation occurs which is characteristic of the foreign body response to a substance. This is followed by a loss of tensile strength followed by a loss of suture mass, as the enzymatic digestive process dissolves the surgical gut. This process continues until the suture is completely absorbed. Many variable factors may affect the rate of absorption.  Data obtained from implantation studies in rats show that the absorption of these sutures is essentially complete by the twenty first to forty second post implantation day.

 Users should be familiar with surgical procedures and techniques involving gut suture before using fast absorbing surgical gut suture for wound closure, as the risk of wound dehiscence may vary with the site of application and the suture material used. The use of this suture may be inappropriate in elderly, malnourished, or debilitated patients, or in patients suffering from conditions which may delay wound healing. As this is an absorbing material, the use of supplemental non absorbable sutures should be considered by the surgeon in the closure of sites which may undergo expansion, stretching or distention or which may require additional support. As an absorbable suture, fast absorbable surgical gut may act transiently as a foreign body. Acceptable surgical practice should be followed in the management of contaminated or infected wounds.

 Adverse effects associated with the use of this fast absorbable surgical gut include wound dehiscence, variable rates of absorption over time (depending on such factors as the type of suture used, the presence of infection and the tissue site), failure to provide adequate wound support in closure of sites where expansion, stretching or distention occur, etc., unless additional support is supplied through the use of non-absorbable suture material, failure to provide adequate wound support in elderly, malnourished or debilitated patients or in patients suffering from cancer, anemia, obesity, diabetes, infection or other conditions which may delay wound healing, allergic response in patients with known sensitivities to collagen which may result in an immunological reaction resulting in inflammation, tissue granulation or fibrosis, wound suppuration and bleeding, as well as sinus formation, infection, moderate tissue inflammatory response characteristic of foreign body response, and calculi formation in urinary track when prolonged contact with salt solutions such as urine and bile occurs, and transitory local irritation at the wound site.

Fast absorbing surgical gut sutures are only available in sizes 5-0 (metric size 1.5) and 6-0 (metric size 1.0) both with a PC-1 cutting needle which is thirteen millimeters in diameter. They are made by Ethicon and their item code numbers are 1915G for 5-0 and 1916G for 6-0.

Vicryl Mesh Woven an Absorbable Mesh for Ventral Hernia Repair

How Does Vicryl Mesh Work?

The Vicryl mesh is a mesh created from two interlacing fibres of undyed Vicryl. It thus has the properties of Vicryl and is absorbable. It is different from a knitted mesh in that a knitted mesh is created from one continuous thread, in this case, made of Vicryl. A knitted mesh has some more flexibility than a woven mesh due to the redundancy of the fibres in the loops that are formed in the process.

Being completely absorbable, it is a contrast to the use of Polypropelene (Prolene) meshes that have been used for hernia repair since many years. Polypropelene meshes are composed of non-absorbable filaments of Polypropylene and remain in the tissue for extended periods of time. The concept of absorbable meshes being used to repair hernias was thought of when it was discovered that the actual strength of the hernia repair does not lie in the strength of the mesh, but rather in the fibrosis and hardening of connective tissue that occurs around the mesh. This property has been exploited in the use of absorbable Vicryl meshes since eventually the mesh is completely absorbed.

Advantages Of Using Vicryl Mesh Woven, Absorption Time And How Does It Compare?

The biggest advantage of using an absorbable Vicryl Mesh is in its property of being absorbable. This allows it to be used in situations where the abdominal defect cannot be completely closed and the bowel has a risk of being exposed. Covering the abdominal contents with a Vicryl mesh allows the bowel to be covered, and at the same time allows attempts to close the abdominal wall. Being absorbable, it is hydrolysed in the abdomen along with the development of fibrosis. Though adhesions do occur with the use of this mesh, the chances of developing enteric and enterocutaneous fistulas is very less; a phenomenon seen more commonly with Polypropylene meshes.

The other advantage of the mesh being absorbable is that the disadvantages of having the mesh remain permanently in the tissue are absent. These can be the presence of chronic pain, foreign body sensation and neuralgias. Once the Vicryl mesh is absorbed completely, which may take up to 70 days, these complications will not occur. However, there has been a concern of developing recurrent hernias since there is no prosthetic material present to act as buttress, but this has not been seen as yet.

Vicryl mesh carries the properties of Vicryl, with up to 75 % tensile strength remaining at 2 weeks and 25-30% at 4 weeks post implantation. The complete healing of tissue takes time and the patient must be advised to avoid straining and lifting of heavy weights for up to a year atleast.

Monocryl 4-0 Absorbable Suture a Great Suture For The Skin And Subcutaneous Tissue

Monocryl is a synthetic, absorbable monofilament suture material. It is available in dyed and undyed forms. Undyed Monocryl 4-0 suture is advantageous when subcuticular stitches are taken in a patient with light coloured skin, in order that the suture does not show through. Monocryl 4-0 suture is especially suited for the closure of skin after adequate closure of subcutaneous tissue and that forms a platform for the subcuticular skin closure with this particular suture size.

As compared to Vicryl, which is a multifilament suture, 4-0 Monocryl is a monofilament suture. Though this feature makes knotting a little more difficult, it also means that it can be used in tissues likely to be harbouring infection. The problem with multifilament sutures (braided) like Vicryl is that bacteria lodges into the crevices created by multifilament knots and have the potential to infect a wound.

As compared to a suture material like Catgut, 4-0 Monocryl incites a tissue reaction of much lower intensity. This allows for it to be used in the closure of skin. Suture materials causing significant tissue reactions, if used in the closure of skin, would have a high incidence of causing wound inflammation and tissue granulomas. Ultimately these would lead to a worse cosmetic outcome, and poor wound healing, along with increased risk of infection.

The tensile strength of Monocryl 4-0 suture is at fifty to sixty percent at one week and twenty to thirty percent at two weeks after suture placement. This is slightly lower than Vicryl which maintains a tensile strength of approximately sixty percent at two weeks. Therefore; Monocryl 4-0 is absorbed completely by ninety to one hundred and twenty days. The properties of Monocryl coincide well with the closure of skin and the time required for skin wounds to heal.

A good tip to keep in mind when using Monocryl 4-0 sutures is that this suture has considerable memory. It is more pliable than synthetic non absorbable (permanent) sutures, but needs to have the memory removed prior to initiation of closure of skin. The techniques of using 4-0  Monocryl to close skin include options to leave the terminal knots inside the dermis for a seamless closure, or creating the knots outside, requiring removal after a period of ten to fourteen days. The most important thing to get a good closure of skin when selecting a 4-0 strand in size; is to have an entry perpendicular to the plane of the dermis and to try and go as deep in the dermis as possible to keep the tissue reaction furthest away from the skin surface.

Monocryl 4-0 absorbable sutures on a nineteen millimetre PS-2 reverse cutting needle which is three eights of a circle is used a lot in plastic and cosmetic surgery. Usually most absorbable sutures come in different lengths, although not all of the suture material available comes in every suture size and every suture needle combination. The Ethicon item code on this particular suture/needle combo is Y426H and it is twenty seven inches long (seventy centimetres).

What are Antibacterial Vicryl Sutures Made of and What are Their Absorbable Suture Properties

Synthetic absorbable sutures offer the strength needed for a wide range of applications, from abdominal and chest wound closure to ophthalmic and plastic surgery. Once such example is the Antibacterial Vicryl Suture, which is a synthetic, absorbable, sterile, surgical suture. It is a copolymer made from ninety percent glycolide and ten percent L-lactide. Coated Vicryl Plus Antibacterial Suture is coated with a mixture composed of equal parts of a copolymer of glycolide and lactide (polyglactin 370) and calcium stearate. Coated Vicryl Plus Antibacterial suture contains IRGACARE MP, which is one of the purest forms of the broad spectrum antibacterial agent triclosan.

 Coated Vicryl Plus Antibacterial suture offers protection against bacterial colonization of the suture. In vivostudies demonstrate that Coated Vicryl PlusAntibacterial suture has a zone of inhibition that is effective against the disease causing organisms that most often cause surgical site infection  Staphylococcus aureus, methicillin resistant Staphylococcus aureus, Staphylococcus epidermidis, methicillin resistant staphylococcus epidermidis. In vivostudies demonstrate that Vicryl Plus Antibacterial suture has no adverse effect on normal wound healing. Coated Vicryl PlusAntibacterial suture performs and handles the same and has the same dependable construction as Coated Vicryl suture. In vivo testing by surgeons demonstrates the same excellence in performance and handling.

 The suture is available in the market in two forms: When it is not dyed (naturally in a beige hue) and when it is dyed. The dyed form comes in violet color. Coated Vicryl  Plussuture is indicated for use in general soft tissue approximation and or ligation requiring medium support, except for ophthalmic, cardiovascular and neurological tissues. Frequent uses include general closure, bowel, orthopedic, and plastic surgery. Coated Vicryl PlusAntibacterial suture retains approximately seventy five percent of the original tensile strength at two weeks post implantation. At three weeks, approximately fifty percent of the original strength is retained. At four weeks, approximately twenty five percent of the original strength is retained. All of the original tensile strength is lost by five weeks post implantation. Absorption of Coated Vicryl Plus Antibacterial Suture is fundamentally complete between fifty six and seventy days.

 Some of the major factors which can affect tensile strength loss and absorption rates are the type of suture, infection, and tissue sites. Plain gut generally absorbs more rapidly than chromic gut. Surgical gut is absorbed more rapidly in infected tissue than in non infected tissue. Surgical gut will absorb more rapidly in tissues where increased levels of enzymes are present, as in the secretions exhibited in the stomach, cervix and vagina. Physicians should consider the in vivo performance when selecting a suture for use in patients. . As with any foreign body, prolonged contact of any suture with salt solutions, such as those found in the urinary tracts may result in calculus formation.

 Antibacterial Vicryl suture is only being made by Ethicon Inc. at this time. All Ethicon product codes related to Antibacterial  Vicryls begin with the prefix VCP.

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Monocryl Suture and its Absorbable Suture Characteristics

Absorbable suture materials are those that are broken down. The special characteristic of absorbable sutures is that they lose most of their tensile strength within sixty days after placement. These materials are broken down by hydrolysis but not by enzymes. Water penetrates the suture filaments and causes breakdown of the polymer chain. As a result, synthetic absorbable tends to evoke less tissue reaction than plain or chromic gut. They are used primarily as buried sutures to close the dermis and subcutaneous tissue and reduce wound tension. Today there are many synthetic absorbable suture materials made from polymers. One example of this is Monocryl suture which was manufactured by a company called Ethicon and that was also a part of the Johnson and Johnson Company. It was first introduced in the year 1993.

It is generally used for soft-tissue approximation and ligation. Monocryl sutures are composed of a compound known as poliglecaprone 25. This is a copolymer of glycolide and epsilon-caprolactone. A polymer means that it has recurring large molecules made from smaller molecules of the same kind. It is a monofilament material, but is very pliable in spite of this. It also has excellent pliability and provides easy handling and good knot security.  Monocryl suturecomes dyed with gentian violet which makes it easier to see in surgery. It also comes undyed which is the preferred option for plastic surgery use since it’s not visibly seen in the healing process of the scars.

There are many advantages of using Monocryl suture. The dyed form of Monocryl retains sixty to seventy percent of its strength in the first week and thirty to forty percent in the second week, while the colored form of Monocryl retains fifty to sixty percent of its strength in the first week and twenty to thirty percent in the second week. These statistics show that it has a very high rate of absorption. It is essentially completely hydrolyzed by ninety to one hundred and twenty days. Monocryl has low tissue reactivity, maintains high tensile strength, and has a half-life of seven to fourteen days. When taken out of the package, it has a high degree of memory, or coil. One other benefit of monocryl sutures is that it is slippery, making it easier to pass than a braided suture. It has a consistency close to the nylon suture material. It is rarely used for percutaneous skin closure, and is not used in areas of especially high tension. One example of this is fascia.

Poliglecaprone is most useful as a buried suture in wounds in which prolonged dermal support is not essential. Similar to other monofilament sutures, poliglecaprone has minimal tissue drag and reactivity. The cost of poliglecaprone is comparable to that of polydioxanone. An antibacterial form of poliglecaprone is now available. The antibacterial agent is triclosan, which has been shown to inhibit colonization of the suture by methicillin-sensitive and methicillin-resistant S aureusand S epidermidis, Escherichia coli, and Klebsiella pneumoniae, even after direct in vivo challenge with bacteria. The tensile strength and absorption profile are not affected, however, and are similar to that of untreated poliglecaprone.

The Generalities and Differences Between Vicryl Suture, Vicryl Rapide Suture, and Antibacterial Sutures

Dermatologic wounds can be closed by a range of methods. Although the skill and method of the surgeon are of utmost importance, the choice of wound closure materials also matters a lot. The rationale of these materials is to assist the wound closure until a wound is strong enough to withstand daily tensile forces and to enhance wound healing when the wound is most susceptible. Stitches are one of the ways of giving strength to a wound until the body’s tissues are strong enough to take over. Absorbable stitches are used if the wounds are expected to heal within a week or two, for example subcutaneous tissues.

Vicryl sutures were first introduced in 1974. They were the second synthetic absorbable suture materials available. Like polyglycolic acid, polyglactin is braided and has similar handling and knot security properties. Vicryl is sometimes coated with another form of a compound called Polyglactin 370. This assists in knot tying and lessens tissue drag; however, this coating also reduces knot security and may cause surgeons to use more throws. Among the absorbable suture materials, Vicryl absorbable suture is a multifilament material.

There are many advantages of using Vicryl suture. The first tensile strength of polyglactin is a little greater than that of polyglycolic acid and is absorbed at a much faster rate. One of the special characteristics of Vicryl absorbable suture is that it retains sixty percent of its tensile strength at day fourteen after implantation and only eight percent of its original strength at day twenty eight. It is totally hydrolyzed in about sixty to ninety days. Tissue reactivity with polyglactin is small. Although used first and foremost as a buried suture, polyglactin has been used for percutaneous closures without unfavorable outcomes. This was coupled with cost savings. Polyglactin is accessible as an undyed or violet suture.

Two additional Polyglactin 910 sutures have been developed by Ethicon. Vicryl RAPIDE Suture which is composed of Polyglactin 910 that has been ionized with gamma rays to increase its rate of absorption. This product is useful as a buried suture in a wound needing restricted dermal support; it is wholly absorbed in thirty five days. The newest material is an antibacterial suture which is essentially Vicryl suture with additional antibacterial properties. The antibacterial agent used to coat the suture is known as triclosan.The Antibacterial Coated Vicryl provides decreased drag through tissue. For this reason, coated Vicryl sutures are used by some surgeons for the interior layer of bowel anastomosis; which is the joining together of two organs, usually hollow. Biocompatibility and implantation studies have shown this to be nontoxic and nonirritating. Managing, wound healing and absorption characteristics are of a similar standard as the Vicryl RAPIDE.

Few pediatric patients treated with the Vicryl antibacterial suture had pain on the first day after operation in comparison to those treated with the original Vicryl suture. This demonstrated a ratio of sixty-eight to eighty-nine percent. This suture may be helpful in wounds where there is a higher risk of infection.

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