CE ONLINE
Technology Advancements:
NOT Yesterday’s Suture
A Continuing Education Activity
Sponsored By
Grant Funds Provided By
Welcome to
Technology Advancements:
NOT Yesterday’s Suture
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning
needs and objectives. At the end of the activity, you will be assessed on the
attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that
reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to reread the question and answer choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.
Pfiedler Enterprises will maintain a record of your continuing education credits
and provide verification, if necessary, for 7 years. Requests for certificates must
be submitted in writing by the learner.
If you have any questions, please call: 720-748-6144.
CONTACT INFORMATION:
© 2014
All rights reserved
Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
OVERVIEW
Preventing surgical site infections (SSIs) is a primary goal for all members of the
perioperative team; this is takes on greater significance in light of implementation of the
Affordable Care Act (ACA). Today, SSIs remain a major source of clinical complications and
therefore are associated with significant economic consequences. In this regard, effective
wound closure is essential for reducing the risk for SSIs and thus achieving optimal
surgical outcomes. The evolution of suture technology has paralleled developments in
the practice of surgery; this continues today as technological advancements in sutures,
specialty needles, and topical skin adhesives have resulted in exciting new options to
support contemporary surgical techniques and also offer distinct clinical and economic
benefits. This continuing education activity will present a review of technological advances
in suture, needle, and topical skin adhesive technology. The importance of effective wound
closure and the appropriate selection of sutures, tissue control devices, specialty needles,
and topical skin adhesives used for wound closure will be discussed. It will outline the
initiatives in the ACA that incentivize health care facilities to reduce SSIs and readmissions.
The differences between traditional sutures and selected advanced sutures, tissue control
devices, and specialty needles will be discussed. Advances in topical skin adhesives,
including their efficacy in preventing SSIs will be reviewed. The clinical and economic
benefits associated with the use of technologically advanced sutures and specialty needles
will be outlined.
OBJECTIVES
After completing this continuing nursing education activity, the participant should be able to:
1. Identify the initiatives outlined in the ACA related to SSIs and readmissions.
2. Differentiate between traditional sutures and technologically advanced sutures.
3. Discuss the science and technology behind advanced sutures, tissue control
devices, specialty needles, and topical skin adhesives.
4. Describe how technological advancements in sutures, tissue control devices, and
specialty needles improve clinical outcomes.
5. Discuss advances in topical skin adhesives and their role in preventing SSIs.
6. List the economic benefits of today’s advanced sutures and specialty needles in
light of the ACA.
INTENDED AUDIENCE
This continuing education activity is intended for perioperative registered nurses interested
in learning more about technological advancements in sutures, specialty needles, and
topical skin adhesives in order to improve clinical and economic outcomes.
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Credit/Credit Information
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hours.
Obtaining full credit for this offering depends upon attendance, regardless of circumstances,
from beginning to end. Licensees must provide their license numbers for record keeping
purposes.
The certificate of course completion issued at the conclusion of this course must be
retained in the participant’s records for at least four (4) years as proof of attendance.
IACET
Pfiedler Enterprises has been accredited as an Authorized Provider by the International
Association for Continuing Education and Training (IACET).
CEU Statements
• As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs
that qualify under the ANSI/IACET Standard.
• Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program.
Release and Expiration Date
This continuing education activity was planned and provided in accordance with accreditation
criteria. This material was originally produced in June 2014 and can no longer be used after
June 2016 without being updated; therefore, this continuing education activity expires June
2016.
DISCLAIMER
Accredited status as a provider refers only to continuing nursing education activities and
does not imply endorsement of any products.
SUPPORT
Funds to support this activity have been provided by Ethicon.
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Authors/Planning Committee/Reviewer
Elizabeth Deroian, BA, RN Program Manager/Planning Committee
Pfiedler Enterprises
Aurora, CO
Judith I. Pfister, MBA, RN
Program Manager/Planning Committee
Pfiedler Enterprises
Aurora, CO
Rose Moss, MN, RN, CNOR Nurse Consultant/Author
Moss Enterprises
Elizabeth, CO
Julia A. Kneedler, EdD, RN
Program Manager/Reviewer
Pfiedler Enterprises
Aurora, CO
Disclosure of Relationships with Commercial Entities for Those in a Position to
Control Content for this Activity
Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for
individuals who control content for an educational activity. Information below is provided to
the learner, so that a determination can be made if identified external interests or influences
pose potential bias in content, recommendations or conclusions. The intent is full disclosure
of those in a position to control content, with a goal of objectivity, balance and scientific rigor
in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process,
visit our website at: http://www. pfiedlerenterprises.com/disclosure
Disclosure includes relevant financial relationships with commercial interests related to
the subject matter that may be presented in this continuing education activity. “Relevant
financial relationships” are those in any amount, occurring within the past 12 months
that create a conflict of interest. A commercial interest is any entity producing, marketing,
reselling, or distributing health care goods or services consumed by, or used on, patients.
Activity Authors/ Planning Committee/Reviewer
Elizabeth Deroian, BA, RN
No conflict of interest
Rose Moss, MN, RN, CNOR
No conflict of interest
Judith I. Pfister, MBA, RN
Co-owner of company that receives grant funds from commercial entities
Julia A. Kneedler, EdD, RN
Co-owner of company that receives grant funds from commercial entities
5
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us at:
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Aurora, Colorado 80014
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http://www.pfiedlerenterprises.com
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INTRODUCTION
Infection prevention is a primary goal for all patients undergoing surgery: one of the
expected outcomes for surgical intervention is that the patient is free from signs and
symptoms of infection.1 Therefore, preventing surgical site infections (SSIs) is a primary
goal for all members of the perioperative team. However, despite awareness of the
problem and the advances that have been made in various infection prevention practices
(eg, surgical technique and antimicrobial prophylaxis), SSIs remain a substantial cause of
prolonged hospitalization, morbidity, and mortality.2
The Centers for Disease Control and Prevention (CDC) reports that in 2010, an estimated
16 million operative procedures were performed in the United States.3 On an annual
basis, SSIs are reported to be the most frequent health care-associated infection (HAI),
accounting for 36% of HAIs nationwide.4 The estimated 300,000 SSIs that occur annually
in the United States prolong hospitalization by 7 to10 days; in addition, the mortality rate
associated with SSIs is 3%, with approximately 75% of deaths being directly attributable
to the infection.5 A recently published meta-analysis of the costs and financial impact of
HAIs, in terms of attributable costs and lengths of stay on the United States health care
system, reported that SSIs were the third most costly HAI at $20,785.6 The total annual
costs for the five major infections (SSIs, central line-associated bloodstream infections,
catheter-associated urinary tract infections, ventilator-associated pneumonia, and
Clostridium difficile infections) were $9.8 billion (ranging from $8.3 to $11.5 billion), with
SSIs contributing the most to overall costs (33.7% of the total costs).
The economic impact of SSIs is especially significant in light of the 2010 Affordable Care
Act (ACA), which includes policies and other initiatives to help health care facilities and
providers improve the safety and quality of patient care and also reduce costs.
THE IMPACT OF POLICY CHANGES IN THE AFFORDABLE CARE ACT
(ACA) ON SSIs
Because the clinical and economic burdens associated with SSIs are significant, federal
initiatives are currently in place to incentivize hospitals and health care facilities to improve
the quality of care by reducing SSIs, other hospital-acquired conditions, and hospital
readmissions through limits on reimbursement, public reporting, and penalties.
Since 2008, the Centers for Medicare & Medicaid (CMS) has included SSI in its list of
hospital-acquired conditions (HACs) for which reimbursement will not be provided.7
Hospital-acquired conditions are defined by CMS as those that:
• Are high cost, high volume, or both;
• Result in the assignment of the case to a Medicare Severity Diagnosis Related
Group (MS-DRG) which has a higher payment when it present as a secondary
diagnosis; and
• Could reasonably have been prevented with the application of evidence-based
guidelines.
For discharges that occurred on or after October 1, 2008, hospitals no longer received
additional reimbursement for cases in which one of the selected conditions was not present
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on admission, ie, the case is paid as if the secondary diagnosis were not present. In
addition, as of 2014, hospitals must report their SSI rates to CDC’s National Healthcare
Safety Network (NHSN) to receive maximum reimbursement.8
In response to ongoing initiatives to improve the quality and safety of patient care, CMS
continues to update its rulings on payments to hospitals and health care providers based
on the quality of care, not just the quantity of the services they provide according to
provisions in the ACA.
On August 2, 2013, CMS issued a final rule that updated Medicare payment policies and
rates under the Inpatient Prospective Payment System (IPPS) in fiscal year (FY) 2014;
this rule will affect discharges that occurred on or after October 1, 2013.9 In addition to
setting the standards for payments for Medicare-covered inpatient services, the FY 2014
hospital payment rule describes the process for implementing a new HAC Reduction
Program, which will take effect in FY 2015. The ACA requires CMS to establish a program
for IPPS hospitals to improve patient safety by imposing financial penalties on those
hospitals that perform poorly in regards to HACs, ie, conditions that a patient did not have
upon admission to the hospital, but which developed during the course of his/her hospital
stay. Beginning in FY 2015 under the HAC Reduction Program, hospitals that rank in the
lowest-performing quartile of HACs will be paid 99% of what they otherwise would have
been paid, ie, they will be levied a 1% penalty.
The ACA also established the Hospital Readmissions Reduction Program, which requires
CMS to reduce payments to hospitals with excess readmissions; this became effective for
discharges as of October 1, 2012.10 Readmission is defined by CMS as an admission to a
hospital within 30 days of a discharge from the same or another hospital.
In light of the significant clinical consequences of SSIs and their expanding economic
implications, the responsibility for reducing every patient’s risk for SSI through optimal
wound closure and healing is more important than ever. Excellent surgical technique,
which encompasses gentle handling of tissue, using suture material appropriately, and
effective management of the incision postoperatively, is commonly believed to reduce
the a patient’s risk for SSI.11 Today, technological advancements in sutures, needles, and
topical skin adhesive products can assist perioperative personnel in implementing effective
infection control strategies to prevent SSIs and realize clinical and economic benefits.
TRADITIONAL SUTURE MATERIALS AND SURGICAL NEEDLES
Historical Overview
The use of sutures dates back to the earliest human knowledge of the practice of
surgery.12 Throughout history, various types of materials have been used for closing
and suturing surgical wounds; these include the oldest suture materials, such as animal
tendons and hairs, as well as herbal fibers, which included linen, hemp, and various
species of grass. Since the Renaissance era and until 1940, there were significant
changes in regards to the types of suture materials used; these changes involved the use
of catgut, cotton, and surgical silk. In the 1940’s, the first synthetic suture materials – nylon
and polyester – were developed; soon thereafter, polyethylene and polypropylene sutures
8
were developed. In 1970, polyglycolic acid suture was introduced; during the 1970s,
polyglactine 910, an essential component of synthetic absorbable suture, became available.
Classifications/Characteristics of Traditional Suture Materials and Surgical Needles
In order to appreciate today’s technological advancements in sutures, specialty needles,
and topical skin adhesives, it is helpful to first review the classifications and characteristics
of traditional sutures and surgical needles.
Sutures
The three primary attributes of any suture material are its physical, handling, and tissue
reaction characteristics13:
• Physical characteristics. The physical characteristics of sutures can be measured or
visually determined according to the following properties:
○○ Physical configuration, ie, monofilament (single-stranded) or multifilament (multistranded) which contains numerous fibers that are twisted or braided into a single
thread.
○○ Capillary. This is the suture’s ability to transmit fluid along the strand.
○○ Diameter or size. Suture size is measured in millimeters and expressed in United
States Pharmacopeia (USP) sizes with zeros, ie, the smaller the diameter, the
more zeroes. Sizes range from #7 (largest) to 11-0 (smallest). Sutures in sizes
between 0 and 4-0 are typically used in general surgery. The surgeon will select
the finest suture possible for the tissue being closed. A smaller size (ie, finer
diameter) suture provides better handling qualities and small knots. In addition,
sutures of finer diameter facilitate improved suturing techniques.
○○ Tensile strength. This refers to the amount of weight (ie, breaking load) that is
required to break a suture (ie, breaking strength).
○○ Knot strength. This is defined as the strength required to cause a given type of
knot to slip, either partially or completely.
○○ Elasticity. Elasticity refers to the suture’s inherent ability to regain its original
length or form after it has been stretched.
○○ Memory. This refers to the capacity of a suture to return to its previous shape
after being re-formed, ie, as when tied. A high memory results in less knot
security.
• Handling characteristics. The handling characteristics of a suture material include
pliability, how easily the material bends and coefficient of friction, or how easily
a suture slides through tissue and can be tied. For example, a suture with a high
coefficient of friction has a tendency to drag through tissue; it is also more difficult
to tie because its knots do not set easily. Some sutures are coated to reduce their
coefficient of friction; this coating improves the way the suture pulls through tissue
on insertion and also reduces the force needed to remove the suture after the
wound has healed. A suture’s coefficient of friction should not be too low, since the
knots will be loosened too easily.
• Tissue-reaction characteristics. A suture is a foreign substance in the body;
therefore, all suture materials will cause some type of tissue reaction. A tissue
9
reaction begins when the tissue is injured upon insertion and continues as the
tissue reacts to the suture material itself. The tissue reaction to a suture material
begins with the infiltration of white blood cells into the affected area; next,
macrophages and fibroblasts arrive; by approximately the seventh day, fibrous
tissue with chronic inflammation is seen. This reaction will continue until the
suture is either absorbed or encapsulated.
Based on the body’s reaction to suture materials, ie, absorption or encapsulation, sutures
are classified as either absorbable or nonabsorbable14,15:
• Absorbable sutures. An absorbable surgical suture is defined as a sterile, flexible
strand developed from collagen derived from healthy mammals or prepared from
a synthetic polymer. It is capable of being absorbed by living mammalian tissue;
it may be treated to modify its resistance to absorption; it may be modified in
regards to its texture or body; it may be impregnated with a coating, softening, or
antimicrobial agent; and it may be colored with a color additive that is approved
by the United States Food and Drug Administration. As such, absorbable sutures
vary in their texture, structure, size, and color, according to their purpose. During
the healing process, absorbable sutures are either digested (through enzymatic
activity) or hydrolyzed (broken down through reaction with water in the tissue
fluid) and assimilated by the tissues. The various types of absorbable sutures
include surgical gut (either plain or chromic) and synthetic.
○○ Surgical gut. Surgical gut (ie, catgut), highly purified collagen, is prepared
from the submucosal layer of sheep intestine or the serosal layer of beef
intestine; it is processed by electronically spinning and polishing the strands
into various sizes. It can be remain plain, or it may be treated with a chromium
salt solution, ie, chromic sutures. Plain sutures may provoke a marked foreignbody response. The chromicizing process increases the suture’s resistance to
the digestive action of tissue enzymes, thus delaying absorption. In addition,
chromic gut sutures result in less tissue reaction than plain gut sutures.
○○ Synthetic absorbable sutures. To manufacture synthetic absorbable sutures,
specific polymers are extruded into the strands. The base material for these
sutures is a combination of lactic acid and glycolic acid polymers. Synthetic
absorbable sutures are prepared as either monofilament or multifilament
strands. Tissue reactions with this type of suture are mild; they are further
reduced when a monofilament strand is used. This type of suture is also
stronger than surgical gut; the tensile strength lasts longer (after approximately
seven days, 60% or more of the suture’s tensile strength remains). The
suture is absorbed through hydrolysis, which is responsible for the mild tissue
reaction; the suture is usually absorbed after 42 to 70 days. Polydioxanone
suture is generally absorbed after 90 to 180 days. Braided polymers have
similar handling characteristics to silk sutures; in addition, their higher
coefficient of friction results in good knot security. Monofilament or coated
sutures are smoother and slicker and therefore require additional throws for
improved knot security. Poly-4-hydroxybutyrate suture is a recently FDA10
approved monofilament absorbable suture based on recombinant DNA
technology. This suture is highly flexible and maneuverable, however, its use
may be limited in patients who are allergic to the cells or growth medium used
in its manufacture.
• Nonabsorbable sutures. Nonabsorbable sutures are strands of materials that are
not digested by tissue enzymes nor are they hydrolyzed by body fluids; they are
considered permanent sutures. Nonabsorbable sutures are used when the suture
strength must be retained for longer than a 2 to 3 week period of time; except
for wire sutures, they should not be used in the presence of infection, since the
suture itself could become the site of an infection, necessitating its removal. The
USP outlines the three following classes of nonabsorbable sutures:
○○ Class I Suture. This class includes suture composed of silk or synthetic fibers
(monofilament, with a twisted or braided construction).
○○ Class II Suture. This class includes suture composed of cotton or linen fibers
or coated natural or synthetic fibers, in which the coating contributes to the
thickness of the suture, but does not significantly affect its strength).
○○ Class III Suture. Suture that is composed of metal wire, either monofilament or
multifilament, is included in this class.
The strand of suture material may be uncoated or coated with a substance to decrease
capillary and friction when it is passed through tissue. There are various products used
for coatings, such as silicone, polytef, and other polymers. The fibers may be uncolored,
naturally colored, or impregnated with an appropriate dye.
Nonabsorbable sutures are encapsulated by the surrounding tissues during the wound
healing process. They are often used to suture skin and are removed before healing is
complete.
The most common types of nonabsorbable sutures are16,17:
○○ Silk. In the past, surgical silk was the most commonly used nonabsorbable
suture material. Silk suture is prepared from thread spun by the silkworm. After
the raw silk is processed (ie, the natural waxes and gum are removed; it is
manufactured into threads; and it is colored with a vegetable dye), the strands
are twisted or braided to form the suture, which gives it high tensile strength
and better handling qualities.
Silk suture is soft, handles well, and forms secure knots. However, due to
the capillary of untreated silk, body fluids may transmit infection along the
length of a suture strand; for this reason, surgical silk is treated to eliminate
its capillary properties and enable it to resist the absorption of moisture and
body fluids, but still should not be used in an infected wound. Silk suture
causes a greater degree of tissue reaction in comparison to other commonly
used nonabsorbable sutures. Silk suture should be used dry, because it is
weakened by moisture. Its tensile strength decreases after 90 to 120 days;
the suture is generally absorbed within 2 years. Therefore, silk is not a true
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nonabsorbable material, but is classified as such because it remains in tissue
for so long.
○○ Nylon. Surgical nylon suture is made from a synthetic polyamide polymer; it
is available in monofilament and multifilament (braided) forms. Monofilament
nylon suture is a smooth material that is noncapillary and handles easily;
however, because of its poor knot security, it does require additional throws
for knot security. Multifilament nylon is relatively inert in tissue and has a high
tensile strength; it is braided very tightly and treated for noncapillary. Nylon
sutures handle like silk, but with less tissue reaction. Nylon suture loses 15%
to 20% of its tensile strength every year in tissue and will not provide indefinite
support.
○○ Polyester. Polyester suture is made from polyethylene terephthalate fibers
that are available in fine filaments that are braided together into various suture
sizes to provide good handling properties. Polyester suture is available in
two forms: a nontreated polyester fiber suture and a polyester fiber suture
that has been impregnated with polybutylate, a synthetic coating that is a
surgical lubricant to facilitate smooth passage of the suture through tissue.
Polybutester is a special type of polyester suture that has many of the
advantages of polyester and polypropylene; because it is monofilament, it
induces very little tissue reaction. Polyester suture has several advantages
over other nonabsorbable, braided sutures, including that it is not absorbed in
tissue fluid, has greater tensile strength, and offers maximal visibility.
○○ Polypropylene. Polypropylene suture is a polymer, which is either clear or
pigmented; it allows little or no saturation. It is a smooth monofilament suture
that does not weaken in tissues, is easy to handle, holds knots securely,
and causes very little tissue reaction. Because it is extremely inert in tissue,
polypropylene may be used in the presence of infection.
○○ Stainless steel wire. Surgical stainless steel wire sutures are made from
strong, flexible, uniform steel alloy; they are designed to be compatible with
stainless steel implants and prostheses; and are known for their strength,
inert properties, and low tissue reaction. Stainless steel sutures are available
as either monofilament or multifilament wire; both types can be held securely
in place by twisting or knotting the suture. The major disadvantages of
surgical stainless steel is related to handling, eg, suturing technique is very
challenging, gloves can be punctured, barbs on the end of steel can traumatize
surrounding tissue, and it can pull or tear out of tissue.
Based on these characteristics, the surgeon selects the type of suture material that is
best suited to maintain tensile strength and promote healing.18 Additional considerations
in the choice of suture material include the condition and age of the patient; the presence
of infection; and the type of tissue to be sutured.19
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Surgical Needles20,21
A surgical needle transports the suture material through tissue during a procedure
with as little tissue trauma as possible. Surgical needles are made from stainless steel
or carbon steel; they are available in various sizes, shapes, point design, and wire
diameter. Needles must be strong enough to penetrate tissue without bending, breaking
or deforming; ductile; and capable of withstanding the stress imposed by tough tissues.
Stainless steel is generally the most popular metal for needles because it provides
these three characteristics and is noncorrosive. A new Tungsten-rhenium alloy has been
applied to needle designs; this ultra-high-strength alloy provides more strength and bend
resistance than conventional stainless steel needles.22
The three basic parts of a surgical needle are:
• Eye. The eye of a needle is located at the end, where the suture is attached. The
three types of needle eyes are closed eyed, in which the needle must be threaded
with the strand of suture and thus two strands of suture must be pulled through
the tissue; French eye or split, in which the suture is placed or snapped through a
spring; and swaged, in which the needle is permanently attached to one or both
ends of the suture material. The swaged needle is most commonly used.
• Body or shaft. The body of the needle can be round, triangular, or flattened; they
may also be straight or curved. The curve of a needle is described as part of
an imaginary circle (ie, ¼ circle, ½ circle); as the radius of this imaginary circle
increases, the size of the needle also increases. The body of a round needle
gradually tapers to a point.
• Point. The point of a needle is the end that first penetrates the tissue being
sutured. The design of the point differs according to the type and density of the
tissue to be penetrated; the three basic point designs are taper, blunt, and cutting.
Taper needles, generally called “round” needles, cause minimal tissue trauma and
leave a smaller hole in the tissue; they must be used on delicate tissue that they
can easily penetrate (eg, kidney or bowel). A blunt needle does not have a sharp
point; this type of needle essentially dissects the tissue as it is pushed through,
resulting in less trauma than a conventional sharp, pointed needle. Blunt protectpoint needles are being recommended as an alternative to taper point needles to
reduce the risk for exposure to bloodborne pathogens due to percutaneous injury.
Other types of points available for use in various tissues include:
○○ Cutting taper – reverse cutting tip with tapered shaft.
○○ Penetrating point – a tapered body with a finely sharpened point; provides
optimal penetration with less tissue trauma.
○○ Protect-point – a tapered body with a blunted point; no cutting edge.
○○ Regular cutting – triangular point with cutting edge on inner curvature.
○○ Reverse cutting – triangular point with cutting edge on outer curvature.
○○ Spatula side cutting – two cutting edges in horizontal plane.
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The Role of Sutures in Effective Wound Healing and SSIs
Before discussing today’s advanced sutures, needles, and other wound closure
devices, it is important to review the role of sutures in effective wound healing and the
development of SSIs.
Every type of tissue, whether skin, fascia, or organ has its own specialized function
as well as needs. When selecting a wound closure device, it is critical that the specific
healing requirements for the type of tissue being repaired are taken into consideration.
Although there are differences in tissue healing profiles and types of wound closure
devices, in order to promote optimal patient outcomes, every wound closure device
should provide strength and support to maintain tissue integrity; address the risk factors
for infection, which can delay healing and cause excess scarring23,24; and minimize tissue
trauma.25 The specific considerations in effective healing for skin and fascia, and organs
are briefly outlined below.
• Skin. The skin is the body’s largest organ and is vital to sustaining life. When the
skin is compromised, such as through an incision, it is important to return skin to
its original function and appearance. Therefore, secure skin closure is an integral
step in nearly every surgical procedure. If the closure device does not provide the
strength and support required by the skin tissue, the wound edges may separate,
providing a potential pathway for bacterial contamination, which can lead to
infection and suboptimal cosmesis.26,27 To create an environment that facilitates
healing of the skin tissue, sutures should:
○○ Provide the support necessary to maintain wound-edge approximation during
the critical healing period (5 to 7 days after surgery);
○○ Protect against colonization of the suture by organisms commonly associated
with SSIs28,29; and
○○ Pass smoothly through skin to minimize tissue trauma.
Appropriate support of the skin tissue helps maintain the integrity of the wound closure
and minimize scarring, taking into consideration that:
○○ During skin approximation, it is important to prevent the formation of skin gaps
and to keep skin edges everted.
○○ Uneven skin edges may have an adverse impact on cosmetic outcomes.
○○ Poor skin approximation can provide an entry point for bacteria to enter the
wound, potentially leading to an infection, since for most SSIs, the source of
pathogens is the endogenous flora of the patient’s skin, mucous membranes,
or hollow viscera.30
○○ Until the skin tissue regains sufficient strength, the sutures must provide the
support the tissue requires to maintain its integrity.
• Fascia. The fascia is a layer of specialized, avascular connective tissue that holds
anatomical structures together. When the fascia damaged, it regains strength
gradually; however, fascial healing is a slow process and may be delayed under
certain circumstances:
○○ At 14 to 28 days, the fascia is self-supportive but still weak31,32;
14
○○ Even at 2 months, it still has less than half its original strength33,34;
○○ Many surgical procedures are performed on patients with preexisting
conditions that may delay healing35,36,37,38;
○○ Fascia heals even slower in patients with comorbidities – such as diabetes – or
who are otherwise debilitated (ie patients with poor nutrition, cancer, acquired
immunodeficiency syndrome [AIDS])39,40; and
○○ Healing may also be delayed by infection, a common complication in
abdominal surgery.41,42,43,44
Until the fascial tissue regains sufficient strength, the sutures must provide the
support the tissue needs to maintain its integrity.45,46 For these reasons, it is
vital to effectively support the fascia while it is compromised in order to prevent
complications such as hernias and dehiscence.47,48 By providing the fascia with
the support it needs as it slowly heals, the risks for wound dehiscence and
surgical site infections can be addressed and, thus, patients are given a better
chance of healing without complications and returning to their daily lives as soon
as possible.49,50
• Organ. Although an organ is often viewed as a single entity that performs a
distinct bodily function, organs typically consist of several types of tissues. For
example, the heart primarily consists of muscle tissues to pump blood, but it also
contains many other types of tissues, such as the fibrous tissue in the valves and
specialized cells that maintain its rhythm. Additionally, the close link between the
heart and the vascular system increases the number of tissues associated with
this organ. When a complicated structure such as the heart requires repair, it is
essential to consider the specific needs of the tissue within the organ. As another
example regarding the heart, to avoid complications during coronary artery
bypass graft (CABG) procedures, the surgeon needs suture needles that are
sharp enough to penetrate calcified tissue, even after multiple passes.51,52 On the
other hand, while operating on diseased valve annuli, it is important to securely
repair the damage, without harming the delicate valve tissue.53
The selection of wound closure device is determined by the tissue-specific
healing times (see Figure 1).
15
Figure
Figure 11 –– Minimum
MinimumWound
Woundhealing
HealingTimes*
Times*
*Note:
These
minimum
healing
timestimes
are for
patients
without
medical
complications.
*Note:
These
minimum
healing
arehealthy
for healthy
patients
without
medical
complications.
There are both patient (ie, uncontrollable) and procedural (ie, controllable) factors that may potentially
54,55:
increaseThere
the riskare
forboth
postoperative
as describedand
below
patient (ie,SSI,
uncontrollable)
procedural
(ie, controllable) factors that
 Examples
of uncontrollable
the patient’s SSI,
age and
other characteristics
may potentially
increase thefactors
risk forare
postoperative
as described
below54,55: and
comorbidities, such as diabetes, cigarette smoking, systemic steroid use, obesity (ie, over 20%
• Examples of uncontrollable factors are the patient’s age and other characteristics
of ideal body weight), poor nutritional status, remote site infections or colonization, and prior
and comorbidities, such as diabetes, cigarette smoking, systemic steroid use,
contamination of the wound.
obesity (ie, over 20% of ideal body weight), poor nutritional status, remote site
 Controllable factors include endogenous bacteria; exogenous bacteria from perioperative
infections
or colonization,
prior contamination
of the
wound. equipment, and
personnel
(especially
members of and
the surgical
team); surgical
instruments,
•
Controllable
factors
include
endogenous
bacteria;
exogenous
from
tools brought to the sterile field during a procedure; the OR environmentbacteria
(including
the air); and
personnel
(especially members of the surgical team); surgical
bacterialperioperative
colonization of
the suture.
instruments, equipment, and tools brought to the sterile field during a procedure;
OR environment
(including the
air); andsome
bacterial
colonization
of the
suture.
Effective wound the
closure
provides an opportunity
to address
of these
controllable
factors,
including bacterial colonization of the suture and entry of bacteria into the wound after surgery.56,57 Any
Effective
wound
closure
provides
opportunity
to address
some
of these
foreign body,
including
suture
material,
mayanpromote
inflammation
at the
surgical
sitecontrollable
and therefore
factors,
including
bacterial
colonization
of
the
suture
and
entry
of
bacteria
into the wound58 As
increase the potential for SSI development after otherwise minimal levels of tissue contamination.
Any foreign
body,
including suture material, may promote inflammation
a result, after
suturesurgery.
is both56,57
a route
and a site
of infection.
at the surgical
siteofand
therefore
increase the
potential
for SSI
development
after59 While
 Suture
as a route
infection.
Percutaneous
sutures
create
a conduit
for bacteria.
58
preoperative
antimicrobial
preparations
can greatly
amount
of bacteria
on the
otherwise minimal
levels ofskin
tissue
contamination.
As areduce
result,the
suture
is both
a route and
surface
the skin, these products do not eliminate all of the bacteria, especially those bacteria
a site ofofinfection.
that •reside
in the
layers
of the stratum
corneum sutures
or liningcreate
the hair
follicles for
and pores.60
Suture
aslower
a route
of infection.
Percutaneous
a conduit
Figure 2bacteria.
depicts 59
theWhile
number
of bacteriaantimicrobial
remaining onskin
the preparations
surface of thecan
skingreatly
and inreduce
the deeper
preoperative
layers before
topicalofantiseptic
and of
immediately
afterwards.
the amount
bacteria application
on the surface
the skin, these
products do not eliminate
all of the bacteria, especially those bacteria that reside in the lower layers of
Figure 2 – Bacteria on the Skin Surface and in Deeper Layers:60Before and Immediately
the stratum corneum or lining the hair follicles and pores. Figure 2 depicts the
Following Antiseptic Application
number of bacteria remaining on the surface of the skin and in the deeper layers
before topical antiseptic application and immediately afterwards.
Before Antiseptic
Application
Immediately following
Antiseptic Application
16
that reside in the lower layers of the stratum corneum or lining the hair follicles and pores.
Figure 2 depicts the number of bacteria remaining on the surface of the skin and in the de
layers before topical antiseptic application and immediately afterwards.
Figure 2 – Bacteria
the SkinonSurface
and
in Deeper
Before
andBefore and Immediat
Figure 2 on
– Bacteria
the Skin
Surface
and Layers:
in Deeper
Layers:
Antiseptic
Application
ImmediatelyFollowing
Following
Antiseptic
Application
Before Antiseptic
Application
Immediately following
Antiseptic Application
Until the epidermis heals (within 24 to 48 hours after surgery), bacteria can enter
the wound from the patient’s skin or the environment.61
• Suture as a site for infection. Microbial contamination of the surgical site is a
prerequisite for a surgical site infection; furthermore, the risk of SSI increases
with the dose of bacterial contamination and the virulence of the bacteria.62 In this
regard, SSI risk can be conceptualized by the following relationship:
Dose of bacterial contamination x virulence (resistance)
_____________________________________________
Resistance of the host (patient)
=
Risk of SSI
Foreign materials, such as sutures, reduce the number of bacteria required
to cause an infection.63 Quantitatively, it has been shown that the typical
bacterial concentration required for a surgical site infection to develop is105
microorganisms per gram of tissue; however, the dose of contaminating
microorganisms required to produce an infection may be much lower when
foreign material is present at the site (eg, 100 staphylococci per gram of tissue
introduced by silk sutures).
Percutaneous sutures create a conduit for bacteria to enter the wound. As with all
foreign bodies, when sutures are implanted, they are rapidly coated with tissue
protein; this creates sites for bacterial colonization, which can lead to biofilm
formation (see Figure 3).64,65,66 Biofilm formation increases the difficulty in treating
an infection.67
17
bodies, when sutures are implanted, they are rapidly coated with tissue protein; this creates
sites for bacterial colonization, which can lead to biofilm formation (see Figure 3).64,65,66 Biofilm
formation increases the difficulty in treating an infection.67
3 – Colonization
of Suture
by Bacteria
Figure 3Figure
– Colonization
of Suture
by Bacteria
Colonization of a Suture Knot
Colonization of Braided Suture
important totonote
thatthat
thethe
mostmost
vulnerable
time fortime
bacterial
colonization
of a wound is
ItItisis important
note
vulnerable
for bacterial
colonization
ofthe
48 hours after wound closure. Until the epithelial barrier is complete (usually within 48
afirst
wound
is the first 48 hours after wound closure. Until the epithelial barrier is
hours), wounds are dependent on the wound closure device to maintain the integrity of the
complete
within
48 bacterial
hours), contamination.
wounds are dependent
wound
closure
68 Bacteria inon
thethe
wound
may delay
wound and(usually
also protect
it from
device
to
maintain
the
integrity
of
the
wound
and
also
protect
it
from
bacterial
healing and also result in poor cosmesis and/or hypertrophic scarring.
contamination.68 Bacteria in the wound may delay healing and also result in poor
TEChNOlOGY
IN SUTURES,
cosmesisADVANCEMENTS
and/or hypertrophic
scarring.TISSUE CONTROL DEVICES, SPECIALTY
NEEDLES, AND TOPICAl SKIN ADhESIVES
TECHNOLOGY
ADVANCEMENTS
IN SUTURES,
CONTROL
Today, technological advancements
in sutures, tissue
control devices,TISSUE
specialty needles,
and topical
skin
adhesives
have
led
to
the
development
of
exciting
new
options
to
support
contemporary
surgical
DEVICES, SPECIALTY NEEDLES, AND TOPICAL SKIN ADHESIVES
techniques
and that also
provide distinct in
clinical
and economic
benefitsdevices,
by reducing
the risk needles,
for SSI.
Today,
technological
advancements
sutures,
tissue control
specialty
Advanced antibacterial sutures, knotless tissue control devices, specialty cardiovascular needles, and
and
topical
skin adhesives
have
to the
development
of exciting
options below.
to
topical
skin adhesives,
including
theirled
related
clinical
and economic
benefits. new
are described
support contemporary surgical techniques and that also provide distinct clinical and
economic benefits by reducing the risk for SSI. Advanced antibacterial sutures, knotless
tissue control devices, specialty cardiovascular needles, and topical skin adhesives,
including their related clinical and economic benefits are described below.
Antibacterial Sutures
As noted above, suture selection provides an opportunity to address one of the known
Antibacterial Sutures
risk
factor for SSI: bacterial colonization of the suture.69,70 As seen Figure 4, bacteria (the
As noted above, suture selection provides an opportunity to address one of the known risk factor for
darkened
area)
will grow
in all
areas
petriFigure
dish 4,
except
for(the
a zone
of inhibition
on and
69,70of
SSI: bacterial
colonization
of the
suture.
Asaseen
bacteria
darkened
area) will grow
in
around
suture.
all areasan
of aantibacterial
petri dish except
for a zone of inhibition on and around an antibacterial suture.
Figure
Bacterial
Growth
in Petri
Dish:
Prior to Incubation
After 24 Hours
Figure 44––Bacterial
Growth
in Petri
Dish: Prior
to Incubation
and After 24and
Hours
Prior to incubation
Zone of inhibition around an antibacterial suture at
24 hours
Today, a range of sutures impregnated with triclosan, a broad-spectrum antibacterial agent, are
available to meet the needs of skin and fascial tissue repair, as described below.
18
 Antibacterial poliglecaprone 25 suture is a monofilament
synthetic, absorbable suture
Today, a range of sutures impregnated with triclosan, a broad-spectrum antibacterial
agent, are available to meet the needs of skin and fascial tissue repair, as described
Prior to incubation
Zone of inhibition around an antibacterial suture at
below.
24 hours
• Antibacterial poliglecaprone 25 suture is a monofilament synthetic, absorbable
Today, asuture
range of
sutures impregnated
withtype
triclosan,
a broad-spectrum
antibacterial
containing
triclosan. This
of suture
is used for subcuticular
skinagent, are
availableclosure,
to meet because:
the needs of skin and fascial tissue repair, as described below.
 Antibacterial poliglecaprone 25 suture is a monofilament synthetic, absorbable suture
○○ It has high initial breaking strength to maintain wound approximation during
containing triclosan. This type of suture is used for subcuticular
skin closure, because:
the critical first few days (ie, 5 to 7 days) of skin healing.71 Compared with
o It has high initial breaking strength to maintain wound approximation during the critical first
other
synthetic
absorbable
material,
this suturewith
hasother
the highest
initial
71 Compared
synthetic
absorbable
few days
(ie, 5 to
7 days) ofsuture
skin healing.
breaking
strength
to
maintain
wound
edge
approximation
during
those
criticalwound
suture material, this suture has the highest initial breaking strength to maintain
first
postoperatively,
skinfirst
needs
most support (see
edgedays
approximation
duringwhen
thosethe
critical
daysthepostoperatively,
whenFigure
the skin needs
5).
the most support (see Figure 5).
FigureFigure
5 – Breaking
Strength
of Antibacterial
Poliglecaprone
Suture
in in Postoperative
5 – Breaking
Strength
of Antibacterial
Poliglecaprone
Suture
Postoperative
Days Days
o○○ ItIt has
has been shown in vitro
vitro to
to kill
killbacteria
bacteriaand
andinhibit
inhibitbacterial
bacterialcolonization
colonizationofofthe suture.
o the
Thesuture.
monofilament design and polymer properties minimize drag force and elicit only a
72,73,74
slightmonofilament
tissue reaction
duringand
absorption.
○○ The
design
polymer properties minimize drag force and
elicit only a slight tissue reaction during absorption.72,73,74
• Antibacterial polydioxanone monofilament synthetic absorbable suture is
prepared from the polyester poly (p-dioxanone) and also contains triclosan. This
type of suture is particularly useful where the combination of an absorbable suture
and extended wound support (up to six weeks) is desirable.
Antibacterial polydioxanone sutures are specifically designed for secure fascial
closure. As discussed above, since the fascia heals slowly, fascial closure
presents unique clinical challenges, such as the risk of dehiscence and infection.
However, choosing the appropriate material for fascial closure can help address
known risk factors for these complications.75,76 To create an environment that
facilitates healing of the fascial tissue, a suture should:
19
discussed above, since the fascia heals slowly, fascial closure presents unique clinical
challenges, such as the risk of dehiscence and infection. However, choosing the appropriate
material for fascial closure can help address known risk factors for these complications.75,76 To
○○ Provide that
the strength
supportofthe
resist
abdominal
pressure
create an environment
facilitatestohealing
thefascia
fascialand
tissue,
a suture
should:
o Provide thethrough
strengththe
to critical
supporthealing
the fascia
and(14
resist
abdominal
pressure
through
the 77,78;
period
to 28
days after
surgery)
and beyond
77,78
critical healing
period
(14 tocolonization
28 days after
and
○○ Protect
against
of surgery)
the suture
bybeyond
organisms; commonly associated
79,80
o Protect against
colonization
of
the
suture
by
organisms
commonly
associated with
with SSIs ; and
SSIs79,80; and
○○ Pass smoothly through fascia to minimize tissue trauma.
o Pass smoothly through fascia to minimize tissue trauma.
Antibacterial polydioxanone monofilament synthetic absorbable suture are specifically
Antibacterial
monofilament
absorbable
are specifically
designedpolydioxanone
for secure fascial
closure in synthetic
multiple patient
typessuture
because:
designed for secure fascial closure in multiple patient types because:
○○ They retain 60% of its original strength for 6 weeks, providing support to the
o They retain 60% of its original strength for 6 weeks, providing support to the fascia as it
fascia as it slowly heals;
slowly heals;
○
○
Their monofilament
polymerminimize
properties
minimize
drag
force
and
o Their monofilament
design anddesign
polymerand
properties
drag
force and
elicit
only
a
81
elicit
only
a
slight
tissue
reaction
during
absorption
;
and
81
slight tissue reaction during absorption ; and
○○ They
shown
vitro to kill
and inhibit
bacterial colonization
o They have
been have
shownbeen
in vitro
to killinbacteria
andbacteria
inhibit bacterial
colonization
of the
suture. Figure
6 shows
difference
in adherence
of MRSA
to non-triclosan
treated
of the
suture.the
Figure
6 shows
the difference
in adherence
of MRSA
to nonsutures andtriclosan
suturestreated
treated sutures
with triclosan.
and sutures treated with triclosan.
Figure 6 – Difference
Difference of
of MRSA
MRSAAdherence:
Adherence:Non-Triclosan
Non-TriclosanTreated
TreatedSutures
Sutures(left)
(left)and
and
Triclosan Treated Sutures
Sutures (right)
(right)
MRSA adheres to non-triclosan-treated suture
(magnification 5,400 times)

Only a few MRSA (arrows) adhere to triclosantreated suture (magnification 5,260 times)
• Antibacterial
polyglactin
suture isabsorbable
a syntheticsurgical
absorbable
surgical
suture
Antibacterial
polyglactin 910
suture is910
a synthetic
suture
composed
of a
copolymer made
from 90%
glycolide and
10%from
L-lactide
and also contains
composed
of a copolymer
made
90% glycolide
and 10%triclosan.
L-lactideThis
and type
also
of suture also
provides
multipleThis
benefits,
including:
contains
triclosan.
type of
suture also provides multiple benefits, including:
o A predictable
breaking strength
retention
to provide
for 14
to 28 for
days
○○ A predictable
breaking
strengthprofile
retention
profilesupport
to provide
support
14while
to 28
tissues healdays
(seewhile
Figure
7);
tissues heal (see Figure 7);
20
7 – Breaking
Strength
of Antibacterial
Polyglactin
910 Suture
Figure Figure
7 – Breaking
Strength
of Antibacterial
Polyglactin
910 Suture
in in Postoperative
Days
Postoperative Days
○○ In vitro ability to kill bacteria and inhibit bacterial colonization of the suture; and
o In vitro ability to kill bacteria and inhibit bacterial colonization of the suture; and
and polymer
polymer properties
propertiesthat
thatminimize
minimizedrag
dragforce
forceand
andelicit
elicit
only
o○○ Suture
Suture coating
coating and
only
a slight
atissue
slightreaction
tissue reaction
during absorption.
during absorption.
Theuse
useofofantibacterial
antibacterialsutures
sutures
offers
several
distinct
clinical
economic
benefits,
The
offers
several
distinct
clinical
andand
economic
benefits,
including fewer
including
fewer SSIs,inwith
reductions
in and
health
care costs
andofimproved
quality82ofIn life
forsutures
vitro,
SSIs,
with reductions
health
care costs
improved
quality
life for patients.
82
In vitro,
sutureshave
with antibacterial
the ability
to
patients.
with
antibacterial
protection
demonstratedprotection
the ability have
to kill demonstrated
bacteria and inhibit
bacterial
kill bacteriaofand
inhibitpathogens
bacterial commonly
colonization
of variouswith
pathogens
associated
colonization
various
associated
SSIs; thecommonly
results of several
research
studies
are outlined
below.
with SSIs;
the results
of several research studies are outlined below.
 In a study conducted by Rothenburger et al a tricolan-coated polyglactin suture was evaluated
• inInvitro
a study
conducted
by Rothenburger
al a tricolan-coated
polyglactin Staphylococcus
for its
ability to inhibit
the growth ofetwild-type
and methicillin-resistant
suture (MRSA)
was evaluated
in vitro for its epidermidis.
ability to inhibit
theresults
growthdemonstrated
of wild-type that the
83 The
aureus
and Staphylococcus
and methicillin-resistant
Staphylococcus
(MRSA)
triclosan-coated
polyglactin
suture inhibitedaureus
the growth
of theand
testStaphylococcus
organisms consistently over
83
The
results demonstrated
the triclosan-coated
polyglactin
aepidermidis.
range of suture
diameters
and treatment that
conditions.
The antibacterial
effect was robust and
did
not diminish
to 7 days.
suture
inhibitedfor
theupgrowth
of the test organisms consistently over a range of
suture diameters and treatment conditions. The antibacterial effect was robust
 Edmiston
et al
assessed
adherence and the antibacterial activity of a triclosan-coated
and did not
diminish
for bacterial
up to 7 days.
polyglactin braided suture against selected Gram-positive and Gram-negative clinical isolates
Staphylococcus
and Escherichia
in culture media.
• (MRSA,
Edmiston
et al assessedepidermidis,
bacterial adherence
and thecoli)
antibacterial
activity84ofThe results
demonstrated
substantial
reductions
in both
Gram-positive
and Gram-negative
a triclosan-coated
polyglactin
braided
suture
against selected
Gram-positivebacterial
adherence
on the triclosan-coated
sutures
compared
with noncoated
suture, which was
and Gram-negative
clinical isolates
(MRSA,
Staphylococcus
epidermidis,
associated
with
decreased
microbial
viability.
The
authors
concluded
that,
because bacterial
84
and Escherichia coli) in culture media. The results demonstrated substantial
contamination
of
suture
material
within
a
surgical
wound
may
increase
the
virulence
reductions in both Gram-positive and Gram-negative bacterial adherence
on the of a SSI,
treating the suture with triclosan offers an effective strategy for decreasing perioperative
triclosan-coated sutures compared with noncoated suture, which was associated
surgical morbidity.
with decreased microbial viability. The authors concluded that, because bacterial
of suture
material
within
surgical et
wound
may increase
the of
 Acontamination
prospective clinical
study
conducted
byaRozzelle,
al evaluated
the incidence
virulence
of
a
SSI,
treating
the
suture
with
triclosan
offers
an
effective
strategy
for
cerebrospinal fluid (CSF) shunt infections after shunt procedures using either antimicrobial
decreasing
perioperative
surgical
morbidity.
85
sutures or conventional sutures. The results of this study demonstrated that the infection rate
was significantly reduced in the antimicrobial suture group (4.3%) compared to the control
• group
A prospective
(21%). clinical study conducted by Rozzelle, et al evaluated the incidence
of cerebrospinal fluid (CSF) shunt infections after shunt procedures using
 Ming, et al evaluated the efficacy of polydioxanone suture with and without triclosan against
gram-positive and gram-negative bacteria (Staphylococcus aureus, MRSA, Staphylococcus
21
epidermidis, methicillin-resistant Staphylococcus
epidermidis, Klebsiella pneumoniae, and
either antimicrobial sutures or conventional sutures.85 The results of this study
demonstrated that the infection rate was significantly reduced in the antimicrobial
suture group (4.3%) compared to the control group (21%).
• Ming, et al evaluated the efficacy of polydioxanone suture with and without
triclosan against gram-positive and gram-negative bacteria (Staphylococcus
aureus, MRSA, Staphylococcus epidermidis, methicillin-resistant Staphylococcus
epidermidis, Klebsiella pneumoniae, and Escherichia coli) by a zone of inhibition
assay.86 The results of this study demonstrated that polydioxanone suture with
triclosan demonstrated activity against all test organisms in vitro; furthermore,
Escherichia
coli) activity
by a zone
inhibition until
assay.
The results
of this
study
the antibacterial
wasofmaintained
the86sutures
dissolved
after
17 demonstrated t
to 23 days when
testedwith
against
Escherichia
coli andactivity
Staphylococcus
aureus,
polydioxanone
suture
triclosan
demonstrated
against all
test organisms in vi
respectively.the
Theantibacterial
results in animal
models
a 99.9%
reduction
in
furthermore,
activity
was demonstrated
maintained until
the sutures
dissolved
after 17
Staphylococcus
and
a 90% reduction
in Escherichia
coli compared
to the
days
when testedaureus
against
Escherichia
coli and
Staphylococcus
aureus, respectively.
The
controls.
results
in animal models demonstrated a 99.9% reduction in Staphylococcus aureus and
90% reduction in Escherichia coli compared to the controls.
• In regards to cost savings, Fleck, et al evaluated the use of triclosan-coated
closure
of the
sternal
notingthe
that
most
SSIs are related sutures for t
 Insutures
regardsfortothe
cost
savings,
Fleck,
et incision,
al evaluated
use
of triclosan-coated
87
to
the
incision
site.
In
this
study,
479
patients
underwent
a
cardiac
closure of the sternal incision, noting that most SSIs are related tosurgical
the incision site.87 In t
procedure;
of theseunderwent
patients, 103
were closed
with procedure;
triclosan-coated
suture
study,
479 patients
a cardiac
surgical
of these
patients, 103 were
material and the remaining 376 patients had their incision closed with noncoated
with
triclosan-coated suture material and the remaining 376 patients had their incision cl
sutures. The results demonstrated that 24 patients (all from the conventional
with noncoated sutures. The results demonstrated that 24 patients (all from the conventi
suture group) had superficial or deep sternal wound infections, with an estimated
suture group) had superficial or deep sternal wound infections, with an estimated cost pe
cost per patient of $11,200). In the group whose incisions were closed with
patient of $11,200). In the group whose incisions were closed with triclosan-coated sutur
triclosan-coated suture, no wound infection or dehiscence was observed during
wound infection or dehiscence was observed during their hospital stay and follow-up visi
their hospital stay and follow-up visits.
Knotless
Tissue
Knotless
TissueControl
ControlDevices
Devices
Knotless
tissue
technologicaladvancement
advancementin in
sutures and wou
Knotless
tissuecontrol
controldevices
devicesrepresent
represent another
another technological
sutures
closure
devices.
Thisdevices.
type of device
consists
of aconsists
uniqueofanchor
design,
a suture
and wound
closure
This type
of device
a unique
anchorwith
design,
with needle on
enda or
a surgical
one
and aneedle
loop ononthe
the abarbs
allow
tissue
suture
needleneedle
on eachonend
or end
a surgical
oneother;
end and
loop on
thefor
other;
the approxim
without
need
to tie surgical
knots without
(see Figure
8). to tie surgical knots (see Figure 8).
barbsthe
allow
for tissue
approximation
the need
Figure
8 – Knotless Tissue Control Device
Figure 8 – Knotless Tissue Control Device
With significantly more points of fixation (ie, anchors (or “barbs”) spaced 1 mm apart) along the s
than traditional sutures, knotless tissue control devices provide surgeons with more consistent te
control over every pass; they also combine the
22 strength and security of interrupted closure with m
88,89,90
With significantly more points of fixation (ie, anchors [or “barbs”] spaced 1 mm apart)
along the suture than traditional sutures, knotless tissue control devices provide
surgeons with more consistent tension control over every pass; they also combine
the strength and security of interrupted closure with more efficiency than continuous
closure.88,89,90 The unique anchor designs provide multiple points of fixation along the
suture, allowing tension on the suture to be maintained during closure. Because there
is no need for an assistant to follow the suture, closure is more efficient than continuous
suturing with traditional sutures. Knotless tissue control devices can close wounds
substantially faster than using an interrupted technique with the combination of equal
strength and security.91,92,93,94
As noted above, the selection of wound closure device is determined by the tissuespecific healing times. Knotless tissue control devices are available in short-term, longterm, and nonabsorbable polymers in various sizes and lengths, with multiple needle
types, to address the needs of multiple procedures, including open, laparoscopic, and
robotic and also to provide the appropriate support for wound closure, including95:
• Spiral PGA-PCL knotless tissue control device. This is a synthetic absorbable
monofilament suture, with a surgical needle on each end, prepared from a
copolymer of glycolide and e-caprolactone. It provides strength and support to
maintain tension for 1 to 2 weeks and absorbs in 90 to 120 days.
• Spiral PDO (dyed polyester, poly [p-dioxanone]) knotless tissue control device
also has a surgical needle on each end. It provides strength and support to
maintain tension for 4 to 6 weeks and absorbs in 120 to 180 days.
• Spiral polypropylene knotless tissue control device. This type of device has a
surgical needle on one end and a loop at the opposite end; it is designed to
anchor with the closed loop at one end and the unidirectional barbed section on
the other end. It provides permanent strength and support to maintain tension.
The clinical and economic benefits of knotless tissue control devices across multiple
surgical specialties have also been reported in the literature, as outlined below.
• Eickmann and Quane conducted a retrospective data review of 178 patients
who had total knee arthroplasty procedures.96 For 88 of these procedures,
conventional absorbable sutures were used for interrupted closure of the
retinacular and subcutaneous layers and for running closure of the subcuticular
layer; for 90 procedures, bidirectional barbed absorbable sutures were used
for running closure of the retinacular and subcutaneous layers. The results
demonstrated that the procedures performed with the barbed sutures were
significantly faster than those performed with conventional sutures (average times
of 74.3 minutes and 85.8 minutes, respectively) with no adverse clinical effects.
• Einarsson et al conducted a retrospective analysis of 138 consecutive
laparoscopic myomectomies to compare perioperative outcomes using a
bidirectional barbed suture versus conventional smooth suture.97 The results
demonstrated that the use of bidirectional barbed suture significantly shorten the
average length of the procedure (118 minutes in this group versus 162 minutes
23
in the conventional suture group) and reduced the length of hospital stay (0.58
days versus 0.97 days). There were no significant differences observed between
the two groups in regards to incidence of perioperative complications, estimated
blood loss, and number or weight of myomas removed during surgery. The
authors concluded that the use of bidirectional barbed suture seemed to facilitate
closure of the hysterotomy site in laparoscopic myomectomy.
• Warner and Gutkowski evaluated a progressive tension suture technique
modification using a barbed suture to plicate the abdominoplasty flap to the
underlying abdominal wall to determine if the benefits of this technique can
be achieved in a shorter operating time.98 The placement of the suture was
performed with a running suture technique to provide progressive tension,
which results in minimal tension along the incision line. Data from 58 patients
undergoing abdominoplasty using this technique were examined, including time
to insert the sutures and complications such as seroma, hematoma, and skin
necrosis. The results demonstrated a marked decrease in the time necessary
to perform the modified progressive tension suture technique using barbed
sutures compared to previously published data. The authors’ average time was
nine minutes to complete plication of the entire abdominal flap. They concluded
that the use of barbed sutures to perform progressive tension suture closure
in abdominoplasty is a safe and effective method to substantially decrease
operating time while retaining all the benefits of the original progressive tension
suture technique.
Specialty Cardiovascular (CV) Needles
Ongoing technological advancements have also lead to the development of an innovative
specialty needle developed from a tungsten-rhenium alloy and novel coating for use in
CV procedures (see Figure 9).
Figure 9 – Specialty Cardiovascular Needle
24
This type of needle incorporates the latest technological advances in CV needle
technology with the same polypropylene sutures that have been used for over 40 years;
moreover, polypropylene suture has99:
• Been used in over 100 million people worldwide and in 8 out of 10 CABG
procedures;
• High tensile strength and “stretch before break” breaking resistance engineered
into every strand; and
• Uniform suture diameter, which avoids weak spots.
Patients undergoing CABG procedures are typically older with comorbidities; as a result,
surgeons may encounter challenging situations during surgery, such as calcified and
friable vessels.100,101,102 To avoid complications in these challenging situations, needles
should be:
• Stronger and more bend resistant for more precise needle placement, since
encountering calcified vessels can bend, break, or dull standard stainless steel
needles.103
• Sharp enough to penetrate calcified tissue, even after multiple passes, since
needle dulling can increase the penetration force required and cause tenting and
tissue trauma, which may slow healing of the vessel anastomoses.104,105
• Smaller and thinner to minimize tissue trauma and bleeding in small, friable
vessels.106
A specialty CV needle is designed to meet these challenges, thereby providing several
key clinical benefits for today’s cardiovascular interventions, such as:
• Increased strength and bend resistance. Current stainless steel alloys cannot
be strengthened without sacrificing the ductility of the needle. Therefore, an
ultra-high-strength tungsten-rhenium alloy makes this type of needle up to 38%
stronger and 121% more bend resistant than conventional stainless steel suture
needles, without compromising ductility.107,108
• Maximum penetration consistency. A unique multilayer silicon coating facilitates
superior penetration and also helps to maintain the durability of the tip over
multiple passes and also through unexpected calcium deposits.109
• Easier handling and arming in various positions due to advanced needle
geometry and non-magnetic properties.110
Topical Skin Adhesives
Technological advancements in wound closure devices have also led to the development
of innovative topical skin adhesives. As discussed, secure skin closure is an integral
step of nearly every surgical procedure; moreover, if the closure device does not provide
the strength and support required by the skin tissue, the wound edges may separate,
providing a potential pathway for bacterial contamination, which can lead to infection,
suboptimal cosmesis, and decreased patient satisfaction.111,112
Today, an advanced topical skin adhesive formulation, used to hold the approximated
skin edges of a surgical incision wound closed, has been shown to provide excellent
25
strength and microbial protection versus other topical skin adhesives.113 This formulation
consists of:
• A highly purified 2-octylcyanoacrylate monomer, which, after polymerization is
stronger, more flexible, and less brittle than other cyanoacrylates.114
• A chemical initiator in the applicator tip to ensure consistent, reliable
polymerization times.115
 A highly
purified 2-octylcyanoacrylate
monomer,
after polymerization
is116
stronger, more
• Additives
to enhance strength,
flexibility,which,
and adherence
to the skin.
flexible, and less brittle than other cyanoacrylates.114
 AThis
chemical
in the helps
applicator
tip to
ensureby
consistent,
reliable
polymerization
uniqueinitiator
formulation
protect
patients
maintaining
wound
integrity.117,118times.
The 115
116
 Additives
to enhance
and adherence
to the
plasticizers
increase strength,
flexibility flexibility,
and 3-dimensional
strength
forskin.
secure wound closure and
improved patient comfort; an initiator enables consistent setting time across varying
This unique
formulation
protect
119 patients by maintaining wound integrity.117,118 The plasticizers
conditions
and helps
skin types.
increase flexibility and 3-dimensional strength for secure wound closure and improved patient comfort;
119 excellent
an initiator
enables consistent
time across
varyingclinical
conditions
and skin
types.
Advanced
topical skinsetting
adhesives
offer several
benefits;
in this
regard,
Advanced
topical skin
offerwith
several
clinical
benefits;
in this
regard,
outcomes can
outcomes
canadhesives
be achieved
the use
of an
advanced
topical
skinexcellent
adhesive:
be achieved •withProvides
the use oftheanstrength
advanced
skin
adhesive:
to topical
maintain
skin
edges so that they remain approximated
 Providesand
thelevel.
strength
to maintain
edges
that they
remain approximated
and level.
When
used in skin
addition
to so
suture,
an advanced
topical skin adhesive
When used
in
addition
to
suture,
an
advanced
topical
skin
adhesive
has
been
shown
ex vivo to
has been shown ex vivo to add 75% more strength 120
to wound closure than sutures
add 75%alone.
more120strength to wound closure than sutures alone.
• Distributes
tension
entire adding
incision,
addingstrength
uniformtostrength
to the
 Distributes
tension along
thealong
entirethe
incision,
uniform
the incision
and
incision
and preventing
the formation
skin
when
the skin
is stressed.
preventing
the formation
of skin gaps
when the of
skin
is gaps
stressed.
Figure
10 shows
the
Figure
10 shows
the difference
between
closed
with
sutures
difference
between
an incision
closed with
suturesan
andincision
one closed
with
sutures
andand
an one
closed
with
and an
topical
adhesive.
The figure
shows (on
advanced
topical
skinsutures
adhesive.
Theadvanced
figure shows
thatskin
in the
incision closed
with sutures
the incision
left), closed
skin gaps
at aand
force
the left),that
skiningaps
form at aclosed
force ofwith
182sutures
mmHg;(on
thethe
incision
withform
sutures
an
advanced
skin
(on the
right)with
maintains
a force
of 320
of topical
182 mm
Hg;adhesive
the incision
closed
suturesskin
andapproximation
an advanced at
topical
skin
mm Hg.121
adhesive (on the right) maintains skin approximation at a force of 320 mm Hg.121
Figure
Incision
Closed
with
Sutures
andand
an an
Figure10
10––Incision
IncisionClosed
Closedwith
withSutures
Sutures(left);
(left);
Incision
Closed
with
Sutures
122
122
Advanced
AdvancedTopical
TopicalSkin
SkinAdhesive
Adhesive(right)
(right)

Creates
a strong,aflexible
preventtobacteria
entering
incisionthe
until
the
• Creates
strong,barrier
flexibletobarrier
preventfrom
bacteria
fromthe
entering
incision
epidermis
hasthe
fully
healed. Providing
an effective
microbial
barrier is microbial
a key factor
in preventing
until
epidermis
has fully healed.
Providing
an effective
barrier
is
SSIs. In avitro
have demonstrated
thatexperiments
octylcyanoacrylate
tissue adhesive
keyexperiments
factor in preventing
SSIs. In vitro
have demonstrated
thatprovides
a barrieroctylcyanoacrylate
to microbial penetration
many of provides
the organisms
(eg,to
Staphylococcus epidermidis,
tissuebyadhesive
a barrier
microbial penetration by
Staphylococcus aureus, Escherichia coli, Enterococcus faecium, Pseudomonas aeruginosa)
many
the with
organisms
(eg, Staphylococcus
epidermidis,
Staphylococcus
aureus,
123,124
responsible
forofSSIs
95% confidence
of 99% efficacy
for 72 hours.

Inhibits bacterial growth. Adhesive topical skin26adhesives have also demonstrated in vitro
Escherichia coli, Enterococcus faecium, Pseudomonas aeruginosa) responsible
for SSIs with 95% confidence of 99% efficacy for 72 hours.123,124
• Inhibits bacterial growth. Adhesive topical skin adhesives have also demonstrated
in vitro inhibition of gram-positive bacteria (eg, MRSA and MRSE) and gramTable
1 – Percent
Inoculum
negative
bacteria Inhibition
(Escherichia in
coli),
as outlinedCount
in Tableafter
1.125 10 Minutes of Contact T
Advanced Topical Skin Adhesive126
Table 1 – Percent Inhibition in Inoculum Count after 10 Minutes of Contact Time
with Advanced Topical Skin Adhesive126
Organism
MRSA
Organism
MRSE
MRSA
Escherichia
MRSE coli
Escherichia coli
Percent Inhibition
99.999
Percent Inhibition
99.999 99.99
99.99 99.99
99.99
The use of advanced topical skin adhesives for effective wound closure also offers severa
Theinuse
of advanced
topical skin
for effective wound closure also offers
benefits
regards
to reducing
the adhesives
risk for SSIs.
several economic benefits in regards to reducing the risk for SSIs.
 A retrospective analysis of over 155,000 Cesarean section procedures compared
• A retrospective analysis of over 155,000 Cesarean section procedures
postoperative
clinical
and economic
outcomes
using a topical
compared the
postoperative
clinical and
economic outcomes
using a skin
topicaladhesive (2-oc
cyanoacrylate)
versus
conventional
skin
closure
methods
(suture,
staples, topical
skin adhesive (2-octyl cyanoacrylate) versus conventional skin closure methods
adhesive,
staples
plus
skin
women
(suture,and
staples,
topical
skintopical
adhesive,
andadhesive)
staples plusintopical
skinundergoing
adhesive) total abdo
127
127 The results
in women undergoing
total abdominal
hysterectomy.
The results
thispatients
study in whom
of this study
demonstrated
thatofthe
hysterectomy.
demonstrated
that the
patients
whom
an advanced
topical skin
adhesive
was on averag
topical
skin adhesive
was
usedinhad
lower
hospitalization
costs
by $500
used
had
lower
hospitalization
costs
by
$500
on
average
and
decreased
use
decreased use of nonprophylactic antibiotic after Day 4 compared to of
patients clos
nonprophylactic antibiotic after Day 4 compared to patients closed with sutures or
sutures
or staples (see Figure 11).
staples (see Figure 11).
Figure
11 –11
Total
Hospitalization
Costs of Costs
Cesarean
Patients
Closed
with
Figure
– Total
Hospitalization
ofSection
Cesarean
Section
Patients
Closed
Sutures,
Staples,
and
Topical
Skin
Adhesive
Sutures, Staples, and Topical Skin Adhesive
This authors of this study concluded
27 that 2-octyl cyanoacrylate appears to be a sa
This authors of this study concluded that 2-octyl cyanoacrylate appears to be a
safe and cost-effective alternative to topical sutures, as in this study there were
less favorable outcomes in the patients who received staples for wound closure.
• Because of its performance as a microbial barrier to exogenous bacteria, a
retrospective study of 1,300 CABG patients, assessed the effectiveness of 2-octyl
cyanoacrylate used as an add-on measure in the closure of sternotomy incision
wounds by comparing postoperative infection rates and length of hospital stays
before and after this change in procedure.128 For the control group (ie, without
the topical skin adhesive) the infection rate was 4.9%; this rate was reduced to
2.1% after the systematic use of the topical skin adhesive. Superficial and deep
infection rates decreased from 4.3% and 0.6% to 2.1% and 0%, respectively. The
lengths of postoperative hospital stay were also significantly reduced, decreasing
from a median of 13 days to 9 days (see Figure 12).
Figure 12 – Length of Stay (Days) in CABG Patients with Sternotomy Incision
Wounds Closed Without and With a Topical Skin Adhesive
The microbial barrier effectiveness of topical skin adhesives in reducing the risk for
SSI across multiple surgical specialties has also been documented in the literature, as
outlined below.
• An assessment of the overall results and safety of cyanoacrylate glue applied
after the surgical wound had been closed with subcuticular vicryl suture
in patients undergoing primary total hip replacement demonstrated that
this technique provided an immediate water tight seal in a sterile operative
environment and thus provides a barrier to microorganisms; it provides good
tensile strength, aesthetic value, as well as patient satisfaction.129
28
• A medical record review of 200 patients undergoing anterior cervical discectomy,
microlumbar discectomy, or lumbar laminectomy demonstrated that 2-octyl
cyanoacrylate is safe to use in neurosurgery patients undergoing these types of
procedures, with only 1 patient in 200 having a proven infection.130 In addition,
patients are able to shower and do not have sutures or staples to remove;
therefore, patient responses are overwhelmingly positive.
• The results of a review of children undergoing their first shunt insertion, for whom
wound closure in one group was performed with an octyl cyanoacrylate tissue
adhesive used for the final layer closure of the skin, demonstrated that with the
use of the tissue adhesive, the wound dehiscence rate was reduced from 24%
to 2% and the infection rate was reduced from 17% to 0%.131 The authors of
this study concluded that this minimal change in surgical technique substantially
affects the shunt infection rate due to the elimination of the “wick-effect” along
filaments used to close the skin; furthermore, the adhesive itself has a bactericidal
effect.
SUMMARY
One of the expected outcomes for every surgical patient is that he/she is free from the
signs and symptoms of infection. The development of an SSI results in unnecessary
discomfort, increased lengths of stay, and additional health care costs. Today, federal
initiatives outlined in the ACA increase the economic pressures on health care facilities
and personnel and thus incentivize them to develop and implement appropriate infection
prevention strategies. In regards to wound closure devices, any foreign body, including
suture material, may promote inflammation at the surgical site, thereby increasing the
potential for development of a surgical site infection. Effective wound closure provides
an opportunity to address known risk factors for SSI: bacterial colonization of the suture
and entry of bacteria into the wound after surgery. Technological advancements in
antimicrobial sutures, knotless tissue control devices, specialty CV needles, and topical
skin adhesives have resulted in exciting new options to support contemporary surgical
techniques and also offer distinct clinical and economic benefits to help perioperative
personnel meet their infection prevention goals. Through knowledge and effective
use of today’s advanced wound closure devices, perioperative personnel can realize
both clinical and economic benefits by protecting surgical wounds from bacterial
contamination, creating a healing environment that fosters optimal cosmesis, increasing
patient satisfaction, and reducing lengths of hospital stay as well as health care costs.
29
GLOSSARY
Absorbable Suture
A sterile, flexible strand developed from collagen
derived from healthy mammals or prepared from a
synthetic polymer; it is capable of being absorbed
by living mammalian tissue and may be treated
to modify its resistance to absorption, modified in
its texture or body, impregnated with a coating,
softening, or antimicrobial agent, and colored with
a color additive that is approved by the U.S. Food
and Drug Administration.
Biofilm
A thin coating that contains biologically active
organisms, capable of growing in vivo, that
coat the surface of structures (eg, implanted or
indwelling devices); it contains both viable and
nonviable microorganisms that adhere to the
surfaces and become trapped within a matrix of
organic matter (eg, proteins and carbohydrates)
which prevents antimicrobial agents from reaching
the cells.
Capillary
A suture’s ability to transmit fluid along the strand.
Cyanoacrylate
The generic name for cyanoacrylate-based fastacting adhesives such as methyl-2-cyanoacrylate,
ethyl 2-cyanoacrylate, and n-butyl-cyanoacrylate.
2-octyl cyanoacrylate is medical-grade glue,
which was developed to be non-toxic and less
irritating to skin tissue.
Ductile
In regards to metal, capable of being bent or
pulled into various shapes.
Elasticity
A suture’s inherent ability to regain its original
length or form after it has been stretched.
Endogenous
A source from the patient (eg, skin); caused by
factors within the body or arising from internal
structural or functional causes.
Exogenous
From a source other than the patient (eg, the
environment, personnel, equipment).
30
Knot Strength
The strength required to cause a given type of
knot to slip, either partially or completely.
Memory
The capacity of a suture to return to its previous
shape after being re-formed, ie, as when tied; a
high memory results in less knot security.
Microbial Barrier
An attribute that prevents the ingress of
microorganisms.
Microorganism
An organism that is too small to be seen with the
naked eye and requires a microscope. Bacteria,
viruses, fungi, and protozoa are generally called
microorganisms.
Monofilament
Single stranded suture material.
Nonabsorbable Suture
Suture materials that are not digested by tissue
enzymes nor are they hydrolyzed by body fluids;
they are considered permanent sutures.
Pathogen
A microorganism that causes disease.
Skin
The outer protective covering of the body; it
is composed of the outer epidermis and inner
epidermis, containing hair, sweat glands, nerve
endings, and capillaries.
Surgical Site Infection (SSI)
An infection at the site of a surgical incision;
the infection may be superficial, deep, or it may
extend to organs.
Surgical Site Infection Risk
Measure of the likelihood that a patient will
develop an SSI.
Tensile Strength Resistance to a pulling force; it refers to the
amount of weight (ie, breaking load) that is
required to break a suture (ie, breaking strength).
Ultifilament
Multistranded suture material.
31
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