CIS Lesson Plans provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.
For Online Grading (www.iahcsmm.org):
To activate a quiz:
Each lesson plan graded online with a passing score of 70% or higher is worth two points (contact hour). You can use these points toward either your re-certification of CRCST (12 points) or CIS (6 points).
Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the CIS Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions of the CIS Lesson Plans)
Surgeons have always been confronted with challenges as they considered the best method of closing their incisions. In early surgical history, suture selection included very few options; however, modern suture selection decisions relate to several factors, some of which are physician driven and others based on specific patient needs. Central Sterile Supply Department (CSSD) personnel must be familiar with the types of sutures and needles used in their facility. Then they can consistently provide requested items in their on-going efforts to provide excellent customer service to the patients, physicians, and surgical team members.
Suture materials are available in numerous sizes, packaging, and delivery styles. For example, common “ties” are suture material provided without a needle attached or included in the package that is used to ligate (tie off) smaller blood vessels not closed by electrosurgical cautery (burning). They are available packaged separately in lengths of 18” and 30” to accommodate the working depth of the procedure being performed. Note: typically surgeons prefer shorter sutures unless longer ones are required.
“Ties” are also available in several types of material pre-loaded onto a plastic reel (dispenser) which provides a continuous length of suture and reduces the need to hand-off sutures repeatedly. Alternately, “ties” of a required suture material may be requested with a specific and separate “free needle” (one with an ‘eye’ through which the chosen suture material is threaded). Then the surgeon can meet patient- specific needs when similar “swedged-on” sutures (those in which the suture is molded onto the needle as a continuous unit) are not available.
Most sutures are available in multiple sizes with a wide variety of needle types. For example, swedged-on needles can be “pop-off:” the slightest tug between the suture and the needle causes the needle to be immediately and permanently detached from the suture material. Use of pop-off sutures allows placement of an interrupted suture stitch which secures tissue approximation by knotting or tying off each individual suture. Sutures with “pop-off” needles are packaged with eight individual sutures and needles.
A second type of swedged-on needle provides a permanent attachment between the suture and the needle and allows the surgeon to place a continuous running or locking suture line. The needle is cut from the suture prior to securing the suture knot. This swedged-on needle is available in packages of one, three, or five individual sutures with needles. Note: the same suture material swedged-on to the same type of needle may be provided in packages of different suture lengths.
The majority of sutures including those just discussed have a needle swedged-on to only one end, and these are sometimes referred to as “single-arm” sutures. By contrast, “double-armed” sutures have a needle swedged-on to each end of the suture material. However, any suture request is presumed to be “single arm” unless a specific request for one that is “double- armed” is made.
The variety of sutures available can seem almost endless and confusing to people who are new to the surgical environment. However, every variation has a unique re-order/catalog number prominently displayed on each package and storage box of each suture. CSSD personnel should encourage the use of the specific suture number on all surgeon preference cards (electronic or manual) and with each individual suture request from the sterile core. Unfortunately, this is not the preferred method of suture requisition for the surgeons or surgical staff in many facilities. Gentle guidance from CSSD staff to include the identification number will help to best ensure superior service.
More About Sutures
Suture is produced from a wide variety of animal and synthetic materials. The simplest categories are “absorbable” and “non-absorbable.” Absorbable sutures will eventually dissolve, absorb into the tissue, and become non-identifiable. The speed at which this occurs is determined by the specific material, tissue condition, over-all patient health, and size of the suture utilized. Non-absorbable sutures are permanent fixtures in the body and, when properly tied or secured, will remain intact indefinitely.
Sutures can be made of monofilament (single strand) and braided (multiple strand) materials. Those made from chromic gut, plain gut, and stainless steel are monofilament. Nylon can be purchased as either a monofilament or braided suture. Silk and polymers (tiny molecules in long repeating chains) are used to make polyglycolic acid (PGA) sutures from multiple strands of material braided to form a single strand. Surgeons select the type of sutures they wish to use based on tissue condition, potential for wound infection, and the patient’s overall health.
Suture sizing is based on a scale where 0 (zero) is the common indicator. A size zero suture is the same thickness regardless of the type of material from which it is made. Note: the zero distinction does not relate to the material’s tensile strength (the stress it can bear without tearing apart). All other suture sizes are measured from zero. Suture materials thicker or heavier than zero are indicated by a number larger than zero and the larger the number, the thicker the suture material. When suture material is smaller than zero, the size is indicated by a number minus zero. Sutures are available from a size 10-0 (smallest size) to a 5 (largest size).
When verbalizing (talking about) suture sizes, they are referred to as number 1, 2, 3, 4 or 5 and 0 (zero or “oh!”), 2-(“oh!”) ……. 10-(oh!). Note: you will not hear anyone ask for a 1-0 (“oh!”) suture.
Here is a recap of suture sizes:
Suture sizes 10-0, 9-0, and 8-0 require a microscope and the use of microscopic-style needle holders. Suture sizes 7-0, 6-0, and 5-0 usually require the surgeon to wear magnifying glasses and use microscopic needle holders. Sizes 4-0 and 3-0 do not require magnification to effectively place the suture, but a smaller or lighter weight needle holder is required. Sizes 2-0 through 5 sutures can be placed with standard Mayo-Hegar needle holders.Storage and arrangement of suture material will depend greatly on your facility and the surgical service lines it offers. You may find all general or commonly-used suture of a single material and/or type grouped together and arranged by size (such as 1-0, 2-0, 3-0, etc.). Manufacturers utilize a color code on the box and package for quick identification. Specialty sutures may be stored separately. For example, ophthalmic and cardiovascular sutures could be on separate racks or carriers. It is critical to know where and how sutures are stored so optimal service can be provided to the operating room team.
This suture rack groups sutures by suture material (color of box) and by size
(numeric). It also demonstrates top/back loading capability which facilitates proper
stock rotation: first-in; first-out.
Certified Instrument Specialist (CIS) Technicians recognize the need to know basic information about needle types and sizes so they can select the requested suture. Recall that each variation of suture material, suture size, needle type, and needle size has a unique re-order/catalog number. Needle size and type are noted on the dispensing box and on individual suture packets.
Needles can be tapered, cutting, trocar, or blunt. Some needles are straight and generally do not require use of a needle holder. The amount of desired needle curvature relates to the location and type of tissue that the needle is designed to approximate (close).
Tapered needles are curved and round-bodied and are of two basic types. One type is a small delicate needle used to suture bowel tissue, ligate larger blood vessels or other thin tissue, and they are often referred to as G.I. (gastrointestinal) needles. They may be used, for example, if a blood vessel is cut during surgery, and the surgeon must place a suture ligature to control bleeding. These G.I. needles are available in different sizes of the same shape, style and thicknesses and, for example, CSSD personnel may receive a STAT request for a “3-0 silk GI to OR #2”. This requisition would be for a single swedged-on, 3-0 silk suture on a delicate tapered needle. Alternate specialty needles vary in size, thickness and curvature depending upon the type of procedure for which they will be used: ophthalmology, plastic, and cardiovascular surgeries.
The second type of tapered needle is heavier and is used when the tissue being approximated is thicker or denser. It is often referred to as a G.C. (general closure) or Mayo needle. The G.C. needles also come in graduated sizes with needle size designations differing by brand of needle, and they are available attached to a variety of suture materials.
Figure 2 shows examples of gastrointestinal and general closure needles.
The needles on the left are for gastrointestinal use; those on the right are general
closure needles. Proper needle holder selection is required to avoid damage to
the needle holder and/or needle.
Cutting needles can be straight or curved, and they have a three point diamond-shaped tip that blends into a round body. Straight cutting needles, also referred to as Keith needles, are generally used for skin closure and do not require a needle holder. Cutting needles are available in numerous sizes, curvatures, and direction of cut. They are used in virtually every surgical specialty, each with their own unique needs that correspond to the tissue being sutured.
Trocar needles are very aggressive needles with a broader cutting edge. Tissue that is very fibrous and dense including strong connective tissues such as tendons and ligaments might require use of a trocar needle. These needles can be purchased in a variety of sizes and curvatures.
Blunt needles are large and curved and are used to approximate very fragile tissue. As the name implies, the tip is less pointed and more rounded to prevent additional tissue damage. Their primary uses are suturing the liver, pancreas, and kidneys.
This lesson has explored numerous details about suture materials that are of critical importance to CIS technicians. Surgeons requesting them have very specific needs, and careful attention to their requirements is necessary to ensure that the right sutures and needles are available for surgical procedures. Quality service will best be assured when CSSD personnel know suture basics then consistently apply this knowledge as suture materials are stored and issued for use in surgical suites.
Note: Surgical technology has provided several suture replacements. For example, internal tissue and skin can be approximated using staples made of surgical stainless steel or titanium, and clear-adhesives and fluid-proof sealants are also available. These alternatives greatly enhance tissue healing by reducing tissue reaction and the overall surgical and anesthesia time required for the procedure. Better patient outcomes are a positive result. These products will be more fully explored in a separate lesson.
Ethicon Wound Closure Manual . www.pilonidal.org
IAHCSMM acknowledges the assistance of the following two CSSD professionals who reviewed this quiz:
Lisa Huber, BA, CRCST, ACE, FCS
Sterile Processing Manager
Paula Vandiver, CRCST, CIS
Carla McDermott, RN, ACE, CRCST
Clinical Nurse III
South Florida Baptist Hospital
Plant City, Fl
Carla McDermott, RN, ACE, CRCST
Clinical Nurse III
South Florida Baptist Hospital
Plant City, Fl
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI