PRESENTATION
BROCHURE
Expanded edition
Veterinary suture handbook
José María Carbonell Tatay Julián Rodríguez Fernández
Veterinary suture handbook. Expanded edition
Expanded edition
Veterinary suture handbook
José María Carbonell Tatay Julián Rodríguez Fernández
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AUTHORS: José María Carbonell Tatay
and Julián Rodríguez Fernández.
FORMAT: 17 × 24 cm. NUMBER OF PAGES: 216 NUMBER OF IMAGES: 170. BINDING: Hardcover.
RETAIL PRICE
€70
This edition of the Veterinary suture handbook expands the contents
eBook included
of the previous edition with updated and more practical information. It includes basic aspects such as the different types of sutures, their characteristics and those of the instruments used, and the latest and most innovative materials. It also provides detailed descriptions of their use and advice on how to apply them to ensure the best results. In addition, the authors give greater relevance to the suturing of the different organs according to their characteristics and to new techniques, and a whole chapter is dedicated to eye surgery.
Veterinary suture handbook. Expanded edition
Presentation of the book With this new extended and improved edition of the Veterinary suture handbook, the aim of the authors is to provide more interesting and practical contents than in the previous edition and to broaden the reader’s knowledge. Therefore, some chapters that, because of their content, were not highly useful in daily clinical practice have been removed and new chapters with innovative material and techniques have been included. Sutures, surgical needles and the methods for suturing the different tissues have not undergone significant changes; classical suturing techniques remain the basis for suturing. However, the appearance of new materials opens a new door to veterinary surgeons to progress technically in their daily practice. The progress of science and new technologies is unstoppable and, in this expanded edition, the reader will find information about the new materials currently used, as well as about the different ways of applying them to ensure the most optimal results. An important section of this handbook is dedicated to surgical techniques, since a better knowledge of these is the basis to achieve better results. They are accompanied by a large number of illustrations and pictures that will help the reader to interpret and understand the techniques described. The importance of mechanical sutures should also be highlighted, as they are not only used for skin closure and are undoubtedly the immediate future of veterinary surgery. This book also includes a chapter in which the authors attempt to transmit ideas and key practical tips to suture the different tissues with the best possible results. Finally, laparoscopic sutures also occupy an important place in this handbook, as they are, without any doubt, increasingly used and must therefore be known by professionals, together with tissue adhesives, which are usually used for skin closure or in orthopaedic surgery for bone repair, and may even replace suture threads in the near future. This new edition of the Veterinary suture handbook is therefore an essential tool for both students and veterinary surgeons who wish to go deeper into the fascinating world of wound closure in veterinary medicine.
The authors José María Carbonell Tatay Dr Carbonell graduated in veterinary medicine from the University of Córdoba, Spain, in 1989. He founded the Taibaira Small Animal Veterinary Hospital in Teulada–Moraira (Alicante) in 1989 and is still the owner, manager, and currently the head of general surgery and traumatology. He is also a co-owner of the La Nao de Jávea veterinary practice in Alicante. He dedicates his time in the clinic exclusively to small animal surgery. In the field of hernia repair, Dr Carbonell has pioneered the use of surgical meshes and created the mesh– plug technique for use in animals. He has participated in seminars and courses, published articles in various national journals, and is a coauthor of Manual de suturas en veterinaria (Veterinary suture handbook) published by Editorial Servet (2007) and author of La pesca deportiva del atún rojo (Recreational tuna fishing) published by Tutor (2013). He currently focuses entirely on small animal clinical medicine, particularly on surgery.
Veterinary suture handbook. Expanded edition
Julián Rodríguez Fernández Dr Rodríguez graduated in veterinary medicine from the University of Zaragoza, Spain, in 1994. He works as a small animal veterinary surgeon at the La Nao de Jávea, of which he is co-owner, and Ambra de Pego veterinary practices in Alicante. He concentrates most of his time on surgery and collaborates in the application of the mesh–plug surgical technique for small animal hernia repairs. He has given lectures in seminars and courses and published articles in a variety of national journals. He is the author of the book Manual de suturas en Veterinaria (Veterinary suture handbook) published by Editorial Servet (2007).
Contributors José Mª Molleda Carbonell Lecturer at the Faculty of Veterinary Medicine of the University of Córdoba and graduate of the Latin American College of Veterinary Ophthalmologists (CLOVE).
Eva Mª Martín Suárez Lecturer at the Faculty of Veterinary Medicine of the University of Córdoba and graduate of the Latin American College of Veterinary Ophthalmologists (CLOVE).
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Chapter 9. Sutures in eye surgery
Communication services Website Online visualisation of the sample chapter. Presentation brochure in PDF format. Author’s CV. Sample chapter compatible with iPad.
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Expanded edition
Veterinary suture handbook
José María Carbonell Tatay Julián Rodríguez Fernández
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Table of contents 1. Sutures Definition Classification of suture materials
Polydioxanone Poly(trimethylene carbonate), PTMC Poliglecaprone 25 Glyconate
Origin
Surgical stainless steel
Behaviour
Silk
Structure
Linen
Advantages and disadvantages of each suture material
Nylon Polyester fibre sutures Polypropylene
2. Basic suture instruments Needle holders Types of needle holder
Dissecting forceps Types of forceps Types of scissors
3. Suture threads Characteristics Mechanical properties Biological properties
Description of the most common suture threads Catgut Polyglycolic acid (PGA)
Polyvinylidene difluoride (PVDF) Expanded polytetrafluoroethylene (PTFE)
4. Surgical needles Key design elements for surgical needles Rigidity Ductility Sharpness Stability in the needle holder
Surgical needle selection criteria Tissue type Surgical technique Needle anatomy
Parts of the needle
Low molecular weight polyglycolic acid
Swage
Polyglactin 910
Body
Low molecular weight polyglactin 910
Needle point
5. Key tips for successful sutures
The surgeon’s knot
6. Tissue repair
Instrument tie
Wound suturing Wound classification Clean wounds Clean–contaminated wounds
The deep tie Ligation around haemostatic clamps or vascular pedicle ligatures
8. Sutures in different tissues Skin
Contaminated wounds
Skin staples
Dirty or infected wounds
Simple stitches
Basic tips for wound closure Contaminated or potentially contaminated wounds Thread diameter selection
Apposition sutures Tension sutures
Subcutaneous tissue
In the urinary and biliary tracts
Fascial and aponeurotic tissues
In hernia repairs
Muscle tissues
In wild animals Subcutaneous sutures In asymmetrical wounds or cases with tissue loss
Vascular clips and ligatures Vascular clips Ligatures
7. Surgical knots The human factor in surgical knot security Surgical knot tying techniques The square knot
Gastrointestinal tract The stomach The small intestine The colon The rectum
Blood vessels Nerves Tendons The urinary tract Parenchymal organs Other sutures
9. Sutures in ophthalmology The appendages of the eye
12.Tissue adhesives Cyanoacrylate-based tissue adhesives
The eyelids and the orbicularis oculi muscle
Cyanoacrylates
The conjunctivae
Types of cyanoacrylates
The eyeball The cornea and sclera Socket
Adhesives in ophthalmology Synthetic adhesives Biological adhesives
10.Mechanical sutures Classification and description Circular staplers Linear staplers Linear cutter staplers Vascular clips Skin staplers
11.Sutures in laparoscopic surgery Manual suturing Instruments and handling
Suturing procedure Needle handling Knotting
Surgical applications Wound closure procedure Clinical toxicity
Biological adhesives or fibrin sealants
13.Regulatory control of suture characteristics 14.Sterile suture materials: manufacturing processes and current legislation Production process and quality control parameters
15.References
2
Basic suture instruments This chapter describes the different types of needle holders, forceps and scissors used when suturing. Although this is a descriptive chapter, the authors have provided a series of recommendations based on their own experience.
Needle holders A needle holder is a fundamental instrument for performing sutures. Figure 1 shows the different parts of a needle holder.
Finger rings
Serrated jaws
Joint
Shanks
Ratchet
Figure 1. Parts of a needle holder
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Veterinary suture handbook
Types of needle holder mayo–Hegar needle holders The Mayo–Hegar needle holder is the type most commonly used in veterinary surgery and we recommend it for those starting out in surgical practice. It is available in different sizes, but the most widely used is the 18 cm version (Fig. 5). The handles are fitted with finger rings and a three-toothed ratchet that can be used to apply different degrees of pressure to the jaws. The shanks are sterilised and longer than those of a Crile–Wood needle holder. Furthermore, they are connected with a box joint to stop them from becoming twisted on a ratcheted instrument. The tip of the jaws may be either cross-serrated or cross-serrated with a central groove designed for use with larger needles. Tungsten carbide inserts offer greater durability, reduce wear and therefore minimise the risk of cutting the suture.
Olsen–Hegar needle holders The Olsen–Hegar needle holder is designed to be two instruments in one: needle holder and scissors (Fig. 6). It measures 14–16 cm. The handles feature finger rings and a twotoothed ratchet. The shanks, which are connected with a screw joint, are flatter and thicker than in Mayo–Hegar needle holders. The scissor portion of the jaws is closer to the joint than the cross-serrated tip that holds the needle.
Close-up of the jaws showing the crossserrated surface.
Figure 5. mayo–Hegar needle holder.
Figure 6. Olsen–Hegar needle holder. 16
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BASIC SUTURE INSTRUMENTS
2
While scissors and a needle holder in a single instrument may appear to be a convenient advantage, we do not recommend Olsen–Hegar needle holders as the first choice of instrument. The presence of scissors so close to where the needle is held increases the risk of cutting or breaking the suture, if the surgeon is not familiar with its use.
Crile–Wood needle holders The Crile–Wood needle holder is very similar to the Mayo–Hegar instrument, but smaller and with slimmer shanks (Fig. 7).
Mathieu needle holders The main difference between Mathieu needle holders and those described above is that they do not have finger rings, but they do feature a three-toothed ratchet (Fig. 8). The ratchet is secured by squeezing the handle. More pressure must be applied to the handle in order to release the ratchet (some specialists call them “automatic”). The shanks are connected with a box joint and various inserts are available for the jaws. Mathieu needle holders are very comfortable to use. However, they are less durable and not just due to wear on the jaws, but also because of the opening and closing mechanism.
Castroviejo needle holders Castroviejo needle holders are commonly used in ophthalmology. They are very delicate and feature a ratchet lock so that they can be held in a pencil grip holder.
Close-up of the jaw showing the central groove which provides a better grip on the needle.
Figure 7. Crile–Wood needle holder.
Figure 8. Mathieu needle holder. 17
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Polyglycolic acid (PGA) This is the simplest of all linear (unbranched) aliphatic polyesters. PGA was used to develop the first fully absorbable synthetic suture. PGA is a polymer formed from either glycolic or hydroxyacetic acid. It is sold as a multifilament suture coated with an absorbable copolymer which reduces its capillarity and the amount of trauma caused when it passes through tissues, thus improving its handling and tensile strength (Fig. 2). PGA is degraded in the body through chemical hydrolysis and, unlike polyglactin 910, its tensile strength is higher in an acidic environment than in alkaline conditions. It generally causes minimal tissue reaction, although occasionally there may be some intolerance. It maintains at least half of its tensile strength for 15 days and is fully absorbed after 120 days. Polyglycolic acid sutures are available in braided threads dyed green or violet, but the smallest sizes are produced from undyed fibres, a wide variety of diameters and lengths, and with or without needles. In general, this suture material is suitable for the gastrointestinal tract, urinary tract, subcutaneous tissue, oral cavity, aponeuroses and fasciae, as well as in gynaecological surgery, muscle repair and closure (except for hernias or ruptures), and for ligating blood vessels.
Figure 2. Braided polylactic and polyglycolic acid suture thread. This suture is dyed violet.
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SUTURE THREADS
3
Low molecular weight polyglycolic acid This synthetic suture material is comprises a low molecular weight polymer of glycolic acid. It is manufactured as a multifilament suture with an absorbable coating that minimises the capillarity and reduces the amount of trauma caused when it passes through tissues. The body degrades low molecular weight PGA sutures by chemical hydrolysis and, unlike polyglactin 910, its tensile strength is higher in acidic pHs compared to alkaline conditions. It causes minimal tissue reaction. It retains at least half of its tensile strength for 7 days and is fully absorbed after 42 days. Low molecular weight polyglycolic acid sutures are available in either colourless or green braided threads (Fig. 3), a wide range of sizes and lengths, and with or without needles. They are used in gynaecological surgery, in subcutaneous tissue, oral cavity, ophthalmology, and for ligatures.
Figure 3. Colourless polyglycolic acid derivative.
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Polyglactin 910 Polyglactin 910 is a synthetic, multifilament suture material (Fig. 4). The thread is coated with an equal mixture of lactic and glycolic acid copolymers plus calcium stearate. This combination of coating agents produces an absorbable lubricant. Polyglactin 910’s maximum tensile strength coincides with the body’s natural pH. Fourteen days after insertion, polyglactin 910 retains approximately 65 % of its tensile strength. There is minimal absorption up to day 40, yet it is practically fully absorbed between days 56 and 70, depending on the size used. Lactic and glycolic acids are easily eliminated by the body, mainly in urine. Its effectiveness and safety has not been established in neural and cardiovascular tissues. Polyglactin 910 sutures are available in violet, braided threads, although the smallest sizes are made from undyed fibres, a wide variety of sizes and lengths, and with or without needles. In general, they can be used for the gastrointestinal tract, urinary tract, subcutaneous tissue, oral cavity, aponeuroses and fasciae, as well as in gynaecological surgery, muscle repair and closure (except for hernias or ruptures), and for ligating blood vessels.
Figure 4. braided polyglactin 910 suture thread, dyed violet.
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SUTURE THREADS
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Low molecular weight polyglactin 910 Low molecular weight polyglactin 910 (Fig. 5) is a synthetic, multifilament copolymer of glycolide (90 %) and lactide (10 %), coated with a 50 % mix of polyglactin 370 (35 % glycolide and 65 % lactide) and calcium stearate. This combination produces a more absorbable lubricant. The material has maximum tensile strength at physiological pH. Seven days after insertion, low molecular weight polyglactin 910 retains approximately 30 % of its tensile strength. It provides wound support for 10–12 days and is absorbed after 42 days. It causes very little tissue reaction and its degradation products are easily eliminated by the body, mainly in urine. This type of suture is available in braided threads dyed violet, or as undyed fibres, and with a wide variety of lengths and needles. Low molecular weight polyglactin 910 is used in gynaecological surgery, for subcutaneous tissue, in the oral cavity, in ophthalmology and for ligatures.
Figure 5. braided, white, low molecular weight polyglactin 910 thread.
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a
b
Figure 4. (a) Vascular clip applicator for use in laparoscopic surgery. (b) Detailed view of the applicator tip.
Advantages and disadvantages of vascular clips over ligatures Advantages
Disadvantages
• Clips can be applied more quickly.
• They loosen more readily than ligatures, in other words they are less secure.
• They are easy to apply in locations that prove inaccessible for ligatures.
• Clips are foreign bodies that stay in the wound (potentially with negative consequences). • Clips can interfere with subsequent X-rays.
Nowadays, some of these disadvantages have been resolved with the development of clips made from absorbable synthetic materials such as polydioxanone. Figures 5a–5f show the procedure for fitting a vascular clip.
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TISSUE REPAIR
a
b
c
d
e
f
6
Figure 5. Application of vascular clips to mesenteric blood vessels.
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Ligatures The most common method of achieving haemostasis is to apply a ligature (Fig. 6), that is, the use of sutures and surgical knots to attain effective blood vessel occlusions.
Figure 6. Haemostatic control by applying vascular ligatures. 86
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The publishing strength of Grupo AsĂs Editorial Servet, a division of Grupo AsĂs, has become one of the reference publishing companies in the veterinary sector worldwide. More than 15 years of experience in the publishing of contents about veterinary medicine guarantees the quality of its work. With a wide national and international distribution, the books in its catalogue are present in many different countries and have been translated into nine languages to date: English, French, Portuguese, German, Italian, Turkish, Japanese, Russian and Chinese. Its identifying characteristic is a large multidisciplinary team formed by doctors and graduates in Veterinary Medicine and Fine Arts, and specialised designers with a great knowledge of the sector in which they work. Every book is subject to thorough technical and linguistic reviews and analyses, which allow the creation of works with a unique design and excellent contents. Servet works with the most renowned national and international authors to include the topics most demanded by veterinary surgeons in its catalogue. In addition to its own works, Servet also prepares books for companies and the main multinational companies in the sector are among its clients.
Servet (División de Grupo Asís Biomedia S.L.) Centro Empresarial El Trovador, planta 8, oficina I Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza (España) Tel.: +34 976 461 480 • Fax: +34 976 423 000 • www.grupoasis.com