1

Table of Contents
Design...................................................................................................................................... 4 Background ............................................................................................................................. 6 The Manufacturing Process......................................................................................................6 Quality Control......................................................................................................................... 7 Polyglactin 91 !utures......................................................................................................1" #au$e %andage...................................................................................................................... "&

W. O. W. Bandages................................................................................................................35
Co'(ression %andage........................................................................................................... "6 Tu%e %andage........................................................................................................................ "7 The )ole of MMPs in *ound Chronicity.............................................................................4" Collagen+%ased *ound Dressings......................................................................................4" Collagen, -ati.e .ersus Denatured....................................................................................44 Conclusion.......................................................................................................................... 4&

SURGICAL SUTURES

SURGICAL SUTURES
Definition

Surgical suture is a medical device used to hold body tissues together after an injury or surgery. They generally consist of a needle with an attached length of thread.

INTRODUCTION
The medical textile industry has diversified with new materials and innovative designs. Evolving polymer technology has yielded a wide range of applications of implantable medical textile devices or biotextiles. King has defined biotextiles as: structures composed of textile fibers designed for use in specific biological environments (e.g. surgical implants, biomass reactors , where their performance depends on their interactions with cells and biological fluids as measured in terms of their biocompatibility and biostability! ". #pplications of implantable biotextiles range from polymeric valves through woven or $nitted artificial ligaments to polymeric wound closure devices. Examples of implantable biotextiles include cardiac support devices %utures are the most common biotextile implantable devices due to their diverse usage in surgical procedures. They are used to achieve wound closure whenever tissue separation has occurred due to an incision, puncture, abrasion, or other in&ury.

Design
%utures are designed to meet many different needs. %utures for abdominal surgery, for example,

are different from sutures used in cataract surgery. %ince no one type of suture is ideal for every operation, surgeons and medical designers have come up with sutures with varying 'ualities. (ne may be more absorbable but less flexible, while another is exceedingly strong but perhaps somewhat difficult to $not. This gives surgeons many options. )esigners of a new suture have to ta$e into account many factors. The rate the suture degrades is important, not only along the length of the suture but at the $not. %ome sutures need to be elastic, so that they will stretch and not brea$. (thers need to hold tight. %uture manufacturers use specially designed machines to test and study sutures. *ew suture designs are also tested by sub&ecting them to chemical tests, such as soa$ing them in various solutions, and testing on animals.

ISTOR! O" SUTURES

The history of wound closure dates bac$ to +,,,-.,,, /.0., the origins of surgery". Early wound closure devices were made of natural materials such as flax, sil$, linen strips, and cotton1. These natural materials were lubricated in oil and wine prior to application so as to reduce tissue drag and create a cleaner wound closure procedure1. #nother early form of a wound closure techni'ue involved the use of the mandibles of soldier ants.. 2ith the development of synthetic polymers and fibers,synthetic sutures were introduced into the mar$et. These sutures allow for designers to engineer the polymer configuration, the fiber type and si3e, and the surface lubricant and4or coating for specific applications. Today, surgical sutures come in many forms: natural, synthetic, nonabsorbable, and absorbable. The application depends on the surgeon5s preference as well as the specific site and clinical techni'ue being performed. Through many millennia, various suture materials were used, debated, and remained largely unchanged. *eedles were made of bone or metals such as silver, copper, and aluminum bron3e wire. %utures were made of plant materials (flax, hemp and cotton or animal material (hair, tendons, arteries, muscle strips and nerves, sil$, catgut . #frican cultures used thorns, and others used ant sutures by coaxing insects to bite wound edges with their &aws and subse'uently twisting off the insects6 heads. The earliest reports of surgical suture date bac$ to .,,, /0 in ancient Egypt, and the oldest $nown suture is in a mummy from "",, /0. The first detailed description of a wound suture and the suture materials used in it is by the 7ndian sage and physician %ushruta, written in +,, /0E. The 8ree$ 9father of medicine9 :ippocrates described rudimentary suture techni'ues, as did the later ;oman #ulus 0ornelius 0elsus. The 1nd-century ;oman physician 8alen has been credited as the first to describe gut sutures or alternatively the ",th-century #ndalusian surgeon al<ahrawi. #l-<ahrawi reportedly discovered the dissolving nature of catgut when his lute6s strings were eaten by a mon$ey. The manufacturing process involved harvesting sheep intestines, the so called catgut suture, and was similar to that of strings for violins, guitar, and tennis rac'uets. =oseph >ister introduced great change in suturing techni'ue (as in all surgery when he endorsed the routine sterili3ation of all suture threads. :e first attempted sterili3ation with the "?@,s 9carbolic catgut,9 and chromic catgut followed two decades later. %terile catgut was finally achieved in "A,@ with iodine treatment.

The next great leap came in the twentieth century. The chemical industry drove production of the first synthetic thread in the early "A.,s, which exploded into production of numerous absorbable and non-absorbable synthetics. The first synthetic absorbable was based on polyvinyl alcohol in "A.". Bolyesters were developed in the "A+,s, and later the process of radiation sterili3ation was established for catgut and polyester. Bolyglycolic acid was discovered in the "A@,s and implemented in the "AC,s. Today, most sutures are made of synthetic polymer fibers. %il$ and gut sutures are the only materials still - though rarely - in use from ancient times. 8ut sutures are banned in =apan and Europe

Ba#$g%o&nd
# surgical suture is used to close the edges of a wound or incision and to repair damaged tissue. There are many $inds of sutures, with different properties suitable for various uses. %utures can be divided into two main groups: absorbable and non-absorbable. #n absorbable suture decomposes in the body. 7t degrades as a wound or incision heals. # non-absorbable suture resists the body6s attempt to dissolve it. *on-absorbable sutures may be removed by a surgeon after a surface incision has healed.

T'e (an&fa#t&%ing )%o#ess

The manufacturing of sutures for surgical use is not very different from the production of other synthetic textiles. The raw material is polymeri3ed, and the polymer extruded into fiber. The fiber is stretched and braided on machines similar to ones that might be found in a factory producing polyester thread for the garment industry. The manufacturing process typically occurs at three sites: one plant produces the suture textile, another produces the needles, and a third plant called the finishing plant attaches needles to the sutures, pac$ages, and sterili3es. *. The first step in suture manufacturing is to produce the raw polymer. 2or$ers measure the chemicals ma$ing up the polymer into a chemical reactor. 7n the reactor, the chemicals are combined (polymeri3ed , forced through a die, and discharged as tiny pellets. +. *ext wor$ers empty the pellets into an extrusion machine. The extruder has a no33le, loo$ing something li$e a shower head, pierced with many tiny holes. The machine melts the polymer, and the li'uid flows through the tiny holes, forming many individual filaments. 3. #fter extrusion, the filaments are stretched between two rollers. The filaments stretch to as much as five times their original length. ,. %ome sutures are produced as monofilaments. (thers are braided or twisted. To braid the suture, the extruded monofilament is wound onto bobbins, and the bobbins are loaded onto an automatic braiding machine. %uch a machine is typically of an old design that might also be used in the manufacture of textiles for fabric. The number of filaments braided together depends on the width of the suture made for the particular batch. # very fine suture might braid 1, filaments, a medium width hundreds, and a very thic$ suture might braid thousands of filaments. The braiding machine produces one continuous

strand of braided material. 7t wor$s very slowly, and typically the machine is set to run for as long as four wee$s at a time. The process is almost entirely automatic. 2or$ers in the plant inspect the e'uipment for brea$-downs and reload empty bobbins, but generally the process re'uires little man-power. 5. #fter braiding, the suture undergoes several stages of secondary processing. *on-braided sutures will also go through these steps after extrusion and initial stretching. 2or$ers load the material onto another machine that performs another stretching and pressing operation. Dnli$e the first stretching, this step might ta$e only a few minutes, and adds to the length of the material by only about 1,E. The suture passes over a hot plate, and any lumps, snags, or imperfections are ironed out. -. *ext, wor$ers pass the suture through an annealing oven. The annealing oven sub&ects the suture to high heat and tension, which actually orders the crystalline structure of the polymer fiber into a long chain. This step may ta$e several minutes or several hours, depending on the type of suture being made. .. #fter annealing, the suture may be coated. The coating material varies depending on what the suture is made of. The suture passes through a bath of coating material, which may be in solution or may be in a thic$, paste-li$e state called a sl&%%/. 0. #ll the ma&or manufacturing steps at the processing plant are complete at this point. *ow the 'uality assurance wor$ers test the batch of suture for various 'ualities. These wor$ers ma$e sure the suture conforms to the proper diameter, length, and strength, loo$ for physical defects, and chec$ the dissolvability of an absorbable suture in animal and testtube tests. 7f the batch passes all the tests, it is shipped to a finishing plant. 1. The surgical needles are made at another plant, and also shipped to the finishing plant. The needles are made of fine steel wire, and drilled lengthwise. 2or$ers at the finishing plant cut the suture into standard lengths. The length of suture is mechanically inserted into the hollow in the needle, and the needle is crimped onto the fiber. This process is called s2aging. *3. *ext, the suture and attached needle are inserted into a foil pac$et and sterili3ed. %terili3ation differs according to the suture material. %ome sutures are sterili3ed with gamma radiation. 7n this case, the sutures are pac$aged completely. The whole pac$age, typically a sealed foil pac$ inside a cardboard box, is set on a conveyor belt. The sealed pac$age passes under pencil-shaped lenses emitting gamma radiation. This $ills all microbes. The suture is now ready for shipment. %ome suture material cannot withstand gamma radiation, and it is sterili3ed in a different process. The suture and needles are pac$aged in a foil pac$, but the pac$ is left open. The pac$ages move into a gas chamber, which is then filled with ethylene oxide gas. Then the foil pac$s are sealed, inserted into boxes or other pac$aging, and readied for shipment.

4&alit/ Cont%ol
%utures, as medical devices, are sub&ect to strict 'uality control. #ll the raw materials that arrive at the manufacturing plant are tested to ma$e sure they are what they are supposed to be. Each
7

batch of sutures is tested after the main manufacturing steps for a variety of physical characteristics such as diameter and strength. The suture industry has developed an array of sophisticated instruments for testing special suture characteristics such as $not security and tissue drag. Tests for diameter, length, and strength of the suture are also performed at the finishing plant. The finishing plant must also test how well the needle is attached to the suture. 8uidelines for suture 'uality control are laid down by the independent organi3ation Dnited %tates Bharmacopeia.

(AR5ET SI6E
%urgical sutures serve as a means of wound closure and tissue approximation. %utures bring together and maintain the tissue on each side of a wound until the natural healing process has provided a sufficient level of wound strengthF. 2hile other techni'ues for wound closure using, for example, clips, staples, or tissue adhesives have been developed in recent years, the suture continues to be the wound closure device of choice for most procedures. This is due to the extensive research and data that has been collected over time describing the exact behavior of suture materials and their tissue reactions invivo. 7n "AAA, there were F".. million inpatient and .".+ outpatient surgeries performed in the Dnited %tates. )uring these surgical procedures, sutures were the most common form of wound closure device. This number of interventions produced a mar$et si3e of G1", million worth of surgical sutures.

SUTURE (ATERIAL
%utures are made from both man-made and natural materials. *atural suture materials include sil$, linen, and catgut, which is actually the dried and treated intestine of a cow or sheep. %ynthetic sutures are made from a variety of textiles such as nylon or polyester, formulated specifically for surgical use. #bsorbable synthetic sutures are made from polyglycolic acid or other glycolide polymers. Host of the synthetic suture materials have proprietary names, such as )exon and Iicryl. The water-resistant material 8oretex has been used for surgical sutures, and other sutures are made from thin metal wire. Dsually, the suture material comprises

Bolyester %il$ *ylon %tainless steel wire

CLASSI"ICATION
%utures are also classified according to their form. %ome are monofilaments, that is, consisting of only one thread-li$e structure. (thers consist of several filaments braided or twisted together. %urgeons choose which type of suture to use depending on the operation. # monofilament has what is called low tissue drag, meaning it passes smoothly through tissue. /raided or twisted sutures may have higher tissue drag, but are easier to $not and have greater $not strength. /raided sutures are usually coated to improve tissue drag. (ther sutures may have a braided or twisted core within a smooth sleeve of extruded material. These are $nown as pseudomonofilaments. # suture can also be classified according to its diameter. 7n the Dnited %tates, suture diameter is represented on a scale descending from ", to ", and then descending again from "-, to "1-,.

T!)ES O" SUTURES

These sutures can further be classified as: #bsorbable suture: The absorbable ones get dissolved in the body on their own and do not re'uire removal.

*on absorbable suture: The non absorbable ones have to be removed after specified time. The type of suture is decided again by the location of the wound.
9

The internal layers are stitched by absorbable sutures and the upper or the s$in may be stitched by the non absorbable sutures. >ocal or general anesthesia has to be given to the patient as per the re'uirement before suturing.

"EATURES O" SUTURES

The body of suture is smooth. The body of the suture does not cause any capillary and repelling reaction. )ue to the softness of the suture, it will not tear at tissue. 7t is easy to $not and the $not tied is firm. The brea$ing strength of suture and $not are strong.

The sewing is made firm, which is best for the healing of the patient without ductility. )epending on the different human organs and operating location, different $inds and si3es of suture needles are chosen. The common features are that the body is smooth, the point type is sharp, and is painless to the human.

Abso%bable S&%gi#al S&t&%es

%utures can be divided into two types J those which are absorbable and will brea$ down harmlessly in the body over time without intervention, and those which are non-absorbable and must be manually removed if they are not left indefinitely. The type of suture used varies on the operation, with the ma&or criteria being the demands of the location and environment and depends on the discretion and professional experience of the %urgeons.

"eat&%es

The body of suture is smooth. The body of the suture does not cause any capillary and repelling reaction. )ue to the softness of the suture, it will not tear at tissue. 7t is easy to $not and the $not tied is firm. The brea$ing strength of suture and $not are strong. The sewing is made firm, which is best for the healing of the patient without ductility.

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11

Host popular surgical sutures:

B8# %utures Bolyglactin A", %utures 0atgut %utures Boliglecaprone %utures Bolydioxanone %utures

)GA S&t&%es
B8# is an ideal and time tested synthetic absorbable suture, widely used by surgeons all over the world. B8#6s superior features over catgut are predictable absorption, outstanding tensile strength, in-vivo inertness and excellent handling properties. Bolyglycolic #cid %uture is a synthetic, absorbable, sterile, surgical suture composed of ",,E glycolide, coated with polycaprolactone and calcium stearate. B8# sutures retain approximately C+E of B8# initial strength after two wee$s. #pproximately F+E of the B8# suture5s original tensile strength remains. Bolyglycolic #cid %uture has been found to be non-antigenic, nonpyrogenic and elicit only mild tissue reactivity during the absorption process. The absorption time for Bolyglycolic #cid (B8# is @, to A, days. #bsorption of bio-absorbable sutures occurs by hydrolysis K beginning with loss of tensile strength followed by loss of mass. B8# sutures are available in dyed (violet colour suture and also un-dyed versions from D%B si3es @-, to D%B si3e 1. B8# sutures are indicated for use in general soft tissue approximation including ophthalmic surgery. Bolyglycolic #cid %uture is not indicated for cardiovascular and neurological tissue approximation. B8# sutures have first launched in 7ndia by us under the /rand name Betcryl which provided the first %ynthetic #bsorbable %uture to the 7ndian mar$et apart from Iicryl sutures by Ethicon. Iicryl, being a Bolyglactin material is made from made from copolymer of A,E 8lycolide and ",E >-lactide but Betcryl sutures are ",,E glycolide. C'a%a#te%isti#s of )et#%/l )GA S&t&%es

Bolyglycolic #cid, better $nown as B8#, is composed of polymers of glycolide acids B8# surgical suture is coated to allow for easier passage through tissues with only minimal drag. Betcryl B8# sutures meet all the re'uirements established by the Dnited %tates Bharmacopoeia (D%B and the European Bharmacopoeia (EB for %ynthetic #bsorbable %urgical %utures. %mooth tie down # decreased tendency to irritate tissue 8reater tensile strength

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>onger absorption period

)ol/gla#tin 1*3 S&t&%es

Betcryl A", ( Bolyglactin A", or B8># suture is an absorbable, sterile, synthetic, braided suture. B8># sutures are indicated for soft tissue approximation and ligation. The suture5s tensile strength remains for approximately three to four wee$s in tissue. )ol/gla#tin A", %utures are composed of copolymers made from A,E glycolide and ",E >-lactide. Bolyglactin A", suture is an absorbable braided synthetic fibre. 7t is available as a plain (uncoated and coated suture. The coating is e'ual parts of a copolymer of lactide and glactide with calcium stearate. 0alcium sterate is a salt of calcium and stearic acid. This mixture forms an absorbable, adherent, nonfla$ing lubricant ideal for suture. #ll of these components are water repelling which slows tissue fluid penetration and absorption into the suture. 0linical trials have shown that after two wee$s, approximately C,E of Bolyglactin A", suture5s initial strength remained. Bolyglactin sutures are found to be non-antigenic and non-pyrogenic, eliciting only mild tissue reactivity during the absorption process. Bolyglactin A", sutures are available violet and colourless. C'a%a#te%isti#s )ol/gla#tin 1*3 S&t&%es7

Bolyglactin A", suture is coated in order to create a smoother synthetic absorbable suture that will pass through tissue readily. Easy tissue passage Brecise $not placement as compared with B8# sutures Bredictable absorption by simple hydrolytic mechanism # decreased tendency to irritate tissue 8reater tensile strength # longer absorption period

Catg&t S&t&%es
0atgut or gut suture is an absorbable suture usually manufactured from the intestine of sheep or goat. 0atgut sutures are composed of highly purified connective tissue derived from either beef or sheep intestines. The membrane is chemically treated and slender strands are woven together to form a suture. The grinding process creates a strand of uniform diameter. The suture strand is then further polished to achieve maximum smoothness, for reliability and strength. 0atgut sutures are available in the form of plain catgut or chromic catgut.

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Blain catgut is usually having shorter absorption periods and is absorbed more rapidly in infected areas. . The percentage of collagen in the catgut suture often determines the 'uality of the suture. :igher percentages of collagen allow for: superior tensile strength, longer absorption times, and lower reactions in vivo. Blain catgut is available in ivory colour. 0hromic catgut is treated with chromium salt solution to resist body en3ymes and slower the absorption process thus supporting the wound for longer periods. 0hromic gut is chromicised before it is spun into strands. This allows control over the amount of chromic content for an even absorption rate. The chromic content not only increases the tensile strength, but also reduces tissue irritation. C'a%a#te%isti#s of Catg&t C'%o8i# S&t&%es

#bsorption within @,-A, days for chromic sutures and @,-C, days for plain gut sutures. #llows for smooth passage through tissue. Bac$ed in 7B# to retain memory L increase pliability. Dniform chrome content provides re'uired wound support and absorption. 0atgut sutures are available from D.%.B %i3es +-, to 1 8eneral closure, (phthalmic, (rthopaedics, (bstetrics48ynaecology and 8astrointestinal Tract %urgery.

)oligle#a9%one S&t&%es
Boliglecaprone suture is a fast absorbing suture made of a synthetic absorbable monofilament composed of glycolide and epsilon-caprolactone copolymer (usually called B80> sutures . 7t comes both dyed (violet and un-dyed (clear , and is a monofilament suture. Ethicon are the original inventors of B80> sutures which are available under the brand name Honocryl sutures. Boliglecaprone suture has a low tissue reactivity, maintains high tensile strength, but B80> suture loses about F,E of its Tensile %trength within C to "F days and loses about +, to @,E tensile strength by . to F wee$s, and the suture is completely hydroly3ed by . to F months. Brogressive loss of tensile strength and eventual absorption of B80> sutures occurs by means of hydrolysis. Boliglecaprone 1+ copolymer has been found to be non-antigenic, non-pyrogenic and elicits only a slight tissue reaction during absorption. Boliglecaprone sutures are contraindicated for use in cardiovascular and neurologic tissues, and for usage in ophthalmic and microsurgery. Boliglecaprone sutures are rarely used for percutaneous s$in closure, and are not used in areas of high tension. . The use of Boliglecaprone suture may be inappropriate in elderly, malnourished, or debilitated patients, or in patients suffering from conditions that may delay wound healing. C'a%a#te%isti#s of )oligle#a9%one +5 s&t&%es7

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Iery high tensile strength initially Dsed for soft-tissue approximation and ligation. Excellent $not security and high pliability Iery low incidence of infection and trauma %mooth tissue passage as it is monofilament ;eliable absorption :igh in vivo strength retention

)ol/dio:anone S&t&%es
Bolydioxanone suture (B)( or B)% sutures or poly-p-dioxanone is a colourless, crystalline, biodegradable polymer. Bolydioxanone suture is an absorbable, sterile, surgical suture composed of the polyester, poly (p-dioxanone . Bolydioxanone suture has been found to be non-antigenic, non-pyrogenic, and elicits only minimal tissue reactivity during the absorption process. Bolydioxanone is a poly (ether-ester characteri3ed by a glass transition temperature in the range of M", and , N0 and a crystallinity of about ++E. /ecause of the presence of an ether oxygen group into the bac$bone of the polymer chain, materials prepared with polydioxanone li$e sutures are provided with a good flexibility. Oor the production of sutures, polydioxanone is generally extruded into fibres, however care should be ta$en to process the polymer to the lowest possible temperature, in order to avoid its spontaneous de-polymeri3ation bac$ to the monomer. The sutures prepared with this material typically lose half of their mechanical strength in about three wee$s and complete degradation ta$es place in a time frame of around six months. C'a%a#te%isti#s of )ol/dio:anone S&t&%es7

/est suited for use in general orthopaedic surgery, paediatric cardiovascular surgery, general, sub cuticular and fascia closure. Hinimal tissue reaction. )oes not support infection. #bsorbed slowly over a period of @ to C months, thus it provides wound support for longer periods. Bolydioxanone sutures retain approximately ?,E of initial Tensile strength after "F days of surgery. %mooth, pliable and minimal memory. )yed )ar$ /lue coloured for easy identification during %urgery.

Non;abso%bable s&%gi#al s&t&%es

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*on absorbable sutures are made of materials which are not metaboli3ed by the body, and are used therefore either on s$in wound closure, where the sutures can be removed after a few wee$s, or in some inner tissues in which absorbable sutures are not ade'uate. This is the case, for example, in the heart and in blood vessels, whose rhythmic movement re'uires a suture which stays longer than three wee$s, to give the wound enough time to close. (ther organs, li$e the bladder, contain fluids which ma$e absorbable sutures disappear in only a few days, too early for the wound to heal. 7nflammation caused by the foreign protein in some absorbable sutures can amplify scarring, so if other types of suture are less antigenic (i.e., do not provo$e as much of an immune response it would represent a way to reduce scarring. There are several materials used for non absorbable sutures. The most common is a natural fibre, sil$, which undergoes a special manufacturing process to ma$e it ade'uate for its use in surgery. (ther non-absorbable sutures are made of artificial fibres, li$e polypropylene, polyester or nylonK these may or may not have coatings to enhance their performance characteristics. Oinally, stainless steel wires are commonly used in orthopaedic surgery and for sternal closure in cardiac surgery. #ll nonabsorbable sutures are manufactured $eeping in mind several fundamental characteristics, such as follows:

Dniform diameter Dniform si3e %terility Bliability for ease of handling Knot security Dniform tensile strength Oreedom from irritants or impurities

Oollowing is the list of *on-#bsorbable %utures: ". %il$ %utures J /lac$ /raided suture 1. Bolypropylene sutures- monofilament suture .. *ylon suture or Bolyamide sutures- monofilament suture F. Bolyester sutures- coated and braided suture +. Boly vinylidene fluoride sutures- monofilament sutures

)ol/9%o9/lene S&t&%e
Bolypropylene suture is a non-absorbable, sterile surgical suture composed of an isotactic crystalline stereoisomer of polypropylene or synthetic linear polyolefin. Bolypropylene suture is

16

commonly used in both human and veterinary medicine for s$in closure, 0ardiovascular, (phthalmic, 8eneral 0losure, (rthopedics, Blastic and Hicrosurgeries, soft tissue approximation and, or ligation. #s it is a monofilament suture, it does not support bacterial growth. 7t is not affected by blood, or wea$ened by tissue en3ymes. 7t offers prolonged tensile strength even in infected areas as it is not degraded over time. This suture is $nown for low tissue drag, easy handling and good strength. Bolypropylene sutures are normally available in blue colour, allowing for easy identification and better visibility against s$in when operating. C'a%a#te%isti#s of )ol/9%o9/lene s&t&%e7

Bolypropylene suture is a non-absorbable

".

%mooth texture, resulting in minimal tissue trauma. :igh plasticity and difficulty of use compared to standard nylon sutures. Dniform diameter with high tensile strength resists brea$age :ighly visible in the wound Basses through tissue easily.

Coated < B%aided Sil$ S&t&%es

These braided sil$ sutures are specially treated with silicone or wax to give strength and smoothen the surface. #ll these sutures conform to the D%B standards and they are not used in biliary and urinary tract surgery. 2idely used as ligature they have moderate tissue reaction and are also used for other applications li$e s$in, opthalmic, 87 tract, etc. )OL!)RO)!LENE ERNIA (ES "OR ERNIA RE)AIR

2e are manufacturers of Bolypropylene Hesh for :ernia repair under the brand name )olphin Hesh. (ur %urgical meshes are available in popular si3es of 1xF, .x@, @x@ and "1x"1 inches. To facilitate the %urgeons convenience, )olphin mesh is made available in two types, namely BH and B% types. BH type mesh is thinner, smoother and more flexible. 2hereas B% mesh is %trong, thic$er and normal flexibility. )olphin :ernia mesh is also $nown as surgical mesh or

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polypropylene mesh for hernia repair. :ernia Heshes need to be strong and sturdy to withstand the pressure, but they also need to be thin and flexible. :ernia Hesh is used in both tension-free and laparoscopic tension-free hernia repairs.

)ol/9%o9/lene (es' fo%

e%nia Re9ai%

)olphin Heshes are ultrasonically cleaned and pac$ed in internationally acceptable standard pouches, with E( sterile proof. Ourther all edges of mesh are sealed to avoid post surgical inconvenience. )olphin :ernia meshes are thermally annealed to prevent fabric curling and increase softness. )olphin :ernia Heshes are provided with very :igh /ursting %trength, Elasticity and tested for /io-compatibility after implantation. Ourther the )olphin :ernia Heshes are made available to medical fraternity at reasonable prices. "eat&%es7 %urgical meshes are thermally annealed to prevent fabric curling P Iariety of surgical meshes available to satisfy surgeons6 needs P (ur surgical hernia meshes offer ideal flexibility and strength for hernia repairs P 7deal porosity for high visibility L coloni3ation. P :igh strength L burst resistance for permanent support. P 2e offer our )olphin :ernia Hesh under (EH label at competitive prices

e%nia (es' )RO)ERTIES

DOL) IN (ES )( T!)E )S T!)E .@, F1,

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TE*%7>E %T;E*8T: -0;(%% Qin *ewtonsR ->(*8

11, 11,

/;E#K7*8 E>(*8#T7(* E - 0;(%% - >(*8 HD>>E* /D;%T Q*ewtonsR T:70K*E%% Oabric weight Qgms4m1R Oabric count QdtexR Honofilament )iameter Bore si3e

"1, "+, .@, ,.+"mm @+ "?@ ,."+mm ,.?+mm

"1, "C, C,, ,.Cmm "1, "?@ ,."+mm ,.?+mm

Needles fo% s&%gi#al s&t&%es7;

T%a&8ati# needles are needles with holes or eyes which are supplied to the hospital separate from their suture thread. The suture must be threaded on site, as is done when sewing at home. At%a&8ati# needles 2it' s&t&%es comprise an eyeless needle attached to a specific length of suture thread. The suture manufacturer swages the suture thread to the eyeless atraumatic needle at the factory. There are several advantages to having the needle pre-mounted on the suture. The doctor or the nurse or odp does not have to spend time threading the suture on the needle. Hore importantly, the suture end of a swaged needle is smaller than the needle body. 7n traumatic needles with eyes, the thread comes out of the needle6s hole on both sides. 2hen passing through the tissues, this type of suture rips the tissue to a certain extent, thus the name traumatic. *early all modern sutures feature swaged atraumatic needles. There are several shapes of surgical needles, including:

straight half curved or s$i "4F circle .4? circle

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"41 circle +4? circle compound curve

*eedles may also be classified by their point geometryK examples include:

taper (needle body is round and tapers smoothly to a point cutting (needle body is triangular and has a sharpened cutting edge on the inside reverse cutting (cutting edge on the outside trocar point or tapercut (needle body is round and tapered, but ends in a small triangular cutting point blunt points for sewing friable tissues side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side for eye surgery

Oinally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp straight tug. These 9pop-offs9 are commonly used for interrupted sutures, where each suture is only passed once and then tied.

S&t&%e 9la#e8ent
# needle holder is used to grasp the needle at the distal portion of the body, one half to three 'uarters of the distance from the tip of the needle, depending on the surgeon6s preference. The needle holder is tightened by s'uee3ing it until the first ratchet catches. The needle holder should not be tightened excessively because damage to both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular to the needle holder.

The needle is placed vertically and longitudinally perpendicular to the needle holder.

7ncorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the s$in, and4or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth finger into the loops and by placing the index finger on the fulcrum of the needle holder to provide stability. #lternatively, the needle holder may be held in the palm to increase dexterity.

20

The needle holder is held through the loops between the thumb and the fourth finger, and the index finger rests on the fulcrum of the instrument.

The needle holder is held in the palm, allowing greater dexterity.

The tissue must be stabili3ed to allow suture placement. )epending on the surgeon6s preference, toothed or untoothed forceps or s$in hoo$s may be used to gently grasp the tissue. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis. Oorceps are necessary for grasping the needle as it exits the tissue after a pass. Brior to removing the needle holder, grasping and stabili3ing the needle is important. This maneuver decreases the ris$ of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the bac$, where large needle bites are necessary for proper tissue approximation. The needle should always penetrate the s$in at a A,N angle, which minimi3es the si3e of the entry wound and promotes eversion of the s$in edges. The needle should be inserted "-. mm from the wound edge, depending on s$in thic$ness. The depth and angle of the suture depends on the particular suturing techni'ue. 7n general, the 1 sides of the suture should become mirror images, and the needle should also exit the s$in perpendicular to the s$in surface.

5not t/ing
(nce the suture is satisfactorily placed, it must be secured with a $not. The instrument tie is used most commonly in cutaneous surgery. The s'uare $not is traditionally used. Oirst, the tip of the needle holder is rotated cloc$wise around the long end of the suture material for 1 complete turns. The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, such that the 1 ends of the suture material are situated on opposite sides of the suture line. The needle holder is rotated countercloc$wise once around the long end of the suture. The short end is grasped with the needle holder tip, and the short end is pulled through the loop again.

21

The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. %ometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increases with increased wound edema. )epending on the surgeon6s preference, "-1 additional throws may be added. Broperly s'uaring successive ties is important. That is, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny $not, which tends to slip and is inherently wea$er than a properly s'uared $not. 2hen the desired number of throws is completed, the suture material may be cut (if interrupted stitches are used , or the next suture may be placed.

Knot tying.

Diffe%ent S&t&%e Te#'ni=&es

Si89le Inte%%&9ted S&t&%es
Te#'ni=&e

The most commonly used and versatile suture in cutaneous surgery is the simple interrupted suture.F This suture is placed by inserting the needle perpendicular to the epidermis, traversing the epidermis and the full thic$ness of the dermis, and exiting perpendicular to the epidermis on the opposite side of the wound. The 1 sides of the stitch should be symmetrically placed in terms of depth and width. 7n general, the suture should have a flas$-shaped configuration, that is, the stitch should be wider at its base (dermal side than at its superficial portion (epidermal side . 7f the stitch encompasses a greater volume of tissue at the base than at its apex, the resulting compression at the base forces the tissue upward and promotes eversion of the wound edges. This maneuver decreases the li$elihood of creating a depressed scar as the wound retracts during healing.

22

Simple interrupted suture placement. Bottom right image shows a flask shaped stitch, which maximi!es eversion.

7n general, tissue bites should be evenly placed so that the wound edges meet at the same level to minimi3e the possibility of mismatched wound-edge heights (ie, stepping . :owever, the si3e of the bite ta$en from the 1 sides of the wound can be deliberately varied by modifying the distance of the needle insertion site from the wound edge, the distance of the needle exit site from the wound edge, and the depth of the bite ta$en. The use of differently si3ed needle bites on each side of the wound can correct preexisting asymmetry in edge thic$ness or height. %mall bites can be used to precisely coapt wound edges. >arge bites can be used to reduce wound tension. Broper tension is important to ensure precise wound approximation while preventing tissue strangulation.

"ine of interrupted sutures.

Uses
0ompared with running sutures, interrupted sutures are easy to place, have greater tensile strength, and have less potential for causing wound edema and impaired cutaneous circulation. 7nterrupted sutures also allow the surgeon to ma$e ad&ustments as needed to properly align wound edges as the wound is sutured. )isadvantages of interrupted sutures include the length of time re'uired for their placement and the greater ris$ of crosshatched mar$s (i.e. train trac$s across the suture line. The ris$ of crosshatching can be minimi3ed by removing sutures early to prevent the development of suture trac$s.

R&nning S&t&%es Si89le %&nning s&t&%es Te#'ni=&e

23

The simple running suture is an uninterrupted series of simple interrupted sutures. The suture is started by placing a simple interrupted stitch, which is tied but not cut. # series of simple sutures are placed in succession without tying or cutting the suture material after each pass. %utures should be evenly spaced, and tension should be evenly distributed along the suture line. The line of stitches is completed by tying a $not after the last pass at the end of the suture line. The $not is tied between the tail end of the suture material where it exits the wound and the loop of the last suture placed.

#unning suture line.

Uses
;unning sutures are useful for long wounds in which wound tension has been minimi3ed with properly placed deep sutures and in which approximation of the wound edges is good. This type of suture may also be used to secure a split- or full-thic$ness s$in graft. Theoretically, less scarring occurs with running sutures compared with interrupted sutures because fewer $nots are made with simple running suturesK however, the number of needle insertions remains the same. #dvantages of the simple running suture include 'uic$er placement and more rapid reapproximation of wound edges, compared with simple interrupted sutures. )isadvantages include possible crosshatching, the ris$ of dehiscence if the suture material ruptures, difficulty in ma$ing fine ad&ustments along the suture line, and puc$ering of the suture line when the stitches are placed in thin s$in.

R&nning lo#$ed s&t&%es Te#'ni=&e

The simple running suture may be loc$ed or left unloc$ed. The first $not of a running loc$ed suture is tied as in a traditional running suture and may be loc$ed by passing the needle through the loop preceding it as each stitch is placed. This suture is also $nown as the baseball stitch because of the final appearance of the running loc$ed suture line.

#unning locked suture.

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Uses
>oc$ed sutures have increased tensile strengthK therefore, they are useful in wounds under moderate tension or in those re'uiring additional hemostasis because of oo3ing from the s$in edges. ;unning loc$ed sutures have an increased ris$ of impairing the microcirculation surrounding the wound, and they can cause tissue strangulation if placed too tightly. Therefore, this type of suture should be used only in areas with good vasculari3ation. 7n particular, the running loc$ed suture may be useful on the scalp or in the postauricular sulcus, especially when additional hemostasis is needed.

(att%ess S&t&%es >e%ti#al 8att%ess s&t&%es Te#'ni=&e

The vertical mattress suture is a variation of the simple interrupted suture. 7t consists of a simple interrupted stitch placed wide and deep into the wound edge and a second more superficial interrupted stitch placed closer to the wound edge and in the opposite direction. The width of the stitch should be increased in proportion to the amount of tension on the wound. That is, the higher the tension, the wider the stitch.

$ertical mattress suture.

Uses
# vertical mattress suture is especially useful in maximi3ing wound eversion, reducing dead space, and minimi3ing tension across the wound. (ne of the disadvantages of this suture is crosshatching. The ris$ of crosshatching is greater because of increased tension across the wound and the F entry and exit points of the stitch in the s$in. The recommended time for removal of this suture is +-C days (before formation of epithelial suture trac$s is complete to reduce the ris$ of scarring. 7f the suture must be left in place longer, bolsters may be placed between the suture and the s$in to minimi3e contact. The use of bolsters minimi3es strangulation of the tissues when the wound swells in response to postoperative edema. Blacing each stitch precisely and ta$ing symmetric bites is especially important with this suture.

25

alf;b&%ied ?e%ti#al 8att%ess s&t&%es Te#'ni=&e

The half-buried vertical mattress suture is a modification of the vertical mattress suture and eliminates 1 of the F entry points, thereby reducing scarring. The half-buried vertical mattress suture is placed in the same manner as the vertical mattress suture, except that the needle penetrates the s$in to the level of the deep part of the dermis on one side of the wound, ta$es a bite in the deep part of the dermis on the opposite side of the wound without exiting the s$in, crosses bac$ to the original side of the wound, and exits the s$in. Entry and exit points therefore are $ept on one side of the wound.

Uses
The half-buried vertical mattress is used in cosmetically important areas such as the face.

)&lle/ s&t&%es Te#'ni=&e

The pulley suture is a modification of the vertical mattress suture. 2hen pulley sutures are used, a vertical mattress suture is placed, the $not is left untied, and the suture is looped through the external loop on the other side of the incision and pulled across. #t this point, the $not is tied. This new loop functions as a pulley, directing tension away from the other strands.

%ulley stitch, type &.

Uses
The pulley suture facilitates greater stretching of the wound edges and is used when additional wound closure strength is desired.

"a%;nea% nea%;fa% 8odified ?e%ti#al 8att%ess s&t&%es Te#'ni=&e

#nother stitch that serves the same function as the pulley suture is the far-near near-far modification of the vertical mattress suture. The first loop is placed approximately F-@ mm from the wound edge on the far side and approximately 1 mm from the wound edge on the near side. The suture crosses the suture line and reenters the s$in on the original side at 1 mm from the

26

wound edge on the near side. The loop is completed, and the suture exits the s$in on the opposite side F-@ mm away from the wound edge on the far side. This placement creates a pulley effect.

'ar near near far pulley stitch.

Uses
The pulley suture is useful when tissue expansion is desired, and it may be used intraoperatively for this purpose. The suture is also useful when beginning the closure of a wound that is under significant tension. /y placing pulley stitches first, the wound edges can be approximated, thereby facilitating the placement of buried sutures. 2hen wound closure is complete, the pulley stitches may be either left in place or removed if wound tension has been ade'uately distributed after placement of the buried and surface sutures.

o%i@ontal 8att%ess s&t&%e Te#'ni=&e

The hori3ontal mattress suture is placed by entering the s$in + mm to " cm from the wound edge. The suture is passed deep in the dermis to the opposite side of the suture line and exits the s$in e'uidistant from the wound edge (in effect, a deep simple interrupted stitch . The needle reenters the s$in on the same side of the suture line + mm to " cm lateral of the exit point. The stitch is passed deep to the opposite side of the wound where it exits the s$in and the $not is tied.

(ori!ontal mattress suture.

Uses
27

The hori3ontal mattress suture is useful for wounds under high tension because it provides strength and wound eversion. This suture may also be used as a stay stitch to temporarily approximate wound edges, allowing placement of simple interrupted or subcuticular stitches. The temporary stitches are removed after the tension is evenly distributed across the wound. :ori3ontal mattress sutures may be left in place for a few days if wound tension persists after placement of the remaining stitches. 7n areas of extremely high tension at ris$ for dehiscence, hori3ontal mattress sutures may be left in place even after removal of the superficial s$in sutures. :owever, they have a high ris$ of producing suture mar$s if left in place for longer than C days. :ori3ontal mattress sutures may be placed prior to a proposed excision as a s$in expansion techni'ue to reduce tension. 7mproved eversion may be achieved with this stitch in wounds without significant tension by using small bites and a fine suture. 7n addition to the ris$ of suture mar$s, hori3ontal sutures have a high ris$ of tissue strangulation and wound edge necrosis if tied too tightly. Ta$ing generous bites, using bolsters, and cinching the suture only as tightly as necessary to approximate the wound edges may decrease the ris$, as does removing the sutures as early as possible. Blacing sutures at a greater distance from the wound edge facilitates their removal.

B&%ied S&t&%es alf;b&%ied 'o%i@ontal s&t&%es o% ti9 stit#'es Te#'ni=&e

The half-buried hori3ontal suture or tip stitch begins on the side of the wound on which the flap is to be attached. The suture is passed through the dermis of the wound edge to the dermis of the flap tip. The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, and reenters the s$in to which the flap is to be attached. The needle is directed perpendicularly and exits the s$inK then, the $not is tied.

Tip stitch.

28

Uses
The half-buried hori3ontal suture or tip stitch is used primarily to position the corners and tips of flaps and to perform H-plasties and I-S closures.

Abso%bable b&%ied s&t&%es

#bsorbable buried sutures are used as part of a layered closure in wounds under moderate-tohigh tension. /uried sutures provide support to the wound and reduce tension on the wound edges, allowing better epidermal approximation of the wound. They are also used to eliminate dead space, or they are used as anchor sutures to fix the overlying tissue to the underlying structures.

De%8al;s&bde%8al s&t&%es Te#'ni=&e

The suture is placed by inserting the needle parallel to the epidermis at the &unction of the dermis and the subcutis. The needle curves upward and exits in the papillary dermis, again parallel to the epidermis. The needle is inserted parallel to the epidermis in the papillary dermis on the opposing edge of the wound, curves down through the reticular dermis, and exits at the base of the wound at the interface between the dermis and the subcutis and parallel to the epidermis. The $not is tied at the base of the wound to minimi3e the possibility of tissue reaction and extrusion of the $not. 7f the suture is placed more superficially in the dermis at 1-F mm from the wound edge, eversion is increased.

Uses
# buried dermal-subdermal suture maximi3es wound eversion. 7t is placed so that the suture is more superficial away from the wound edge.

B&%ied 'o%i@ontal 8att%ess s&t&%e Te#'ni=&e

The buried hori3ontal mattress suture is a purse-string suture. The suture must be placed in the mid-to-deep part of the dermis to prevent the s$in from tearing. 7f tied too tightly, the suture may strangulate the approximated tissue.

Uses
The buried hori3ontal mattress suture is used to eliminate dead space, reduce the si3e of a defect, or reduce tension across wounds.

>a%iations of R&nning S&t&%es R&nning 'o%i@ontal 8att%ess s&t&%es Te#'ni=&e

29

# simple suture is placed, and the $not is tied but not cut. # continuous series of hori3ontal mattress sutures is placed, with the final loop tied to the free end of the suture material.

Uses
The running hori3ontal mattress suture is used for s$in eversion. 7t is useful in areas with a high tendency for inversion, such as the nec$. 7t can also be useful for reducing the spread of facial scars. 7f the sutures are tied too tightly, tissue strangulation is a ris$.

R&nning s&b#&ti#&la% s&t&%es Te#'ni=&e

The running subcuticular suture is a buried form of the running hori3ontal mattress suture. 7t is placed by ta$ing hori3ontal bites through the papillary dermis on alternating sides of the wound. *o suture mar$s are visible, and the suture may be left in place for several wee$s.

Subcuticular stitch. The skin surface remains intact along the length of the suture line.

Uses
The running subcuticular suture is valuable in areas in which the tension is minimal, the dead space has been eliminated, and the best possible cosmetic result is desired. /ecause the epidermis is penetrated only at the beginning and end of the suture line, the subcuticular suture effectively eliminates the ris$ of crosshatching. The suture does not provide significant wound strength, although it does precisely approximate the wound edges. Therefore, the running subcuticular suture is best reserved for wounds in which the tension has been eliminated with deep sutures, and the wound edges are of approximately e'ual thic$nesses.

R&nning s&b#&taneo&s s&t&%es Te#'ni=&e

The running subcutaneous suture begins with a simple interrupted subcutaneous suture, which is tied but not cut. The suture is looped through the subcutaneous tissue by successively passing through the opposite sides of the wound. The $not is tied at the opposite end of the wound by $notting the long end of the suture material to the loop of the last pass that was placed.

Uses
The running subcutaneous suture is used to close the deep portion of surgical defects under moderate tension. 7t is used in place of buried dermal sutures in large wounds when a 'uic$
30

closure is desired. )isadvantages of running subcutaneous sutures include the ris$ of suture brea$age and the formation of dead space beneath the s$in surface.

S&t&%e Re8o?al and Alte%nati?e (et'ods of Wo&nd Clos&%e S&t&%e %e8o?al

%utures should be removed within "-1 wee$s of their placement, depending on the anatomic location. Brompt removal reduces the ris$ of suture mar$s, infection, and tissue reaction. The average wound usually achieves approximately ?E of its expected tensile strength "-1 wee$s after surgery. To prevent dehiscence and spread of the scar, sutures should not be removed too soon. #s a general rule, the greater the tension across a wound, the longer the sutures should remain in place. #s a guide, on the face, sutures should be removed in +-C daysK on the nec$, C daysK on the scalp, ", daysK on the trun$ and upper extremities, ",-"F daysK and on the lower extremities, "F1" days. %utures in wounds under greater tension may need to be left in place slightly longer. /uried sutures, which are placed with absorbable suture material, are left in place because they dissolve. Broper suture removal techni'ue is important to maintain good results after sutures are properly selected and executed. %utures should be gently elevated with forceps, and one side of the suture should be cut. Then, the suture is gently grasped by the $not and gently pulled toward the wound or suture line until the suture material is completely removed. 7f the suture is pulled away from the suture line, the wound edges may separate. %teri-%trips may be applied with a tissue adhesive to provide continued supplemental wound support after the sutures are removed.

Alte%nati?e 8et'ods of 2o&nd #los&%e Ste%i;St%i9s

2ound closure tapes, or %teri-%trips, are reinforced microporous surgical adhesive tape. %teri%trips are used to provide extra support to a suture line, either when running subcuticular sutures are used or after sutures are removed. 2ound closure tapes may reduce spreading of the scar if they are $ept in place for several wee$s after suture removal. (ften, they are used with a tissue adhesive. These tapes are rarely used for primary wound closure.

Sta9les
%tainless steel staples are fre'uently used in wounds under high tension, including wounds on the scalp and trun$. #dvantages of staples include 'uic$ placement, minimal tissue reaction, low ris$ of infection, and strong wound closure. )isadvantages include less precise wound edge alignment and cost.

Tiss&e ad'esi?e
%uperglues that contain acrylates may be applied to superficial wounds to bloc$ pinpoint s$in hemorrhages and to precisely coapt wound edges. The usefulness of rapidly polymeri3ing

31

plastics is limited because of the difficulty in handling the adhesive and the potential for tissue toxicity and inflammation. The use of tissue adhesives in dermatologic surgery is still evolving. #s new and improved products are developed, the use of adhesives for s$in closure may increase. 8reenhill and (6;egan reported on the use of *-butyl 1-cyanoacrylate (7ndermil for closure of parotid wounds and its relationship to $eloid and hypertrophic scar formation versus using sutures. Their results indicated a simpler techni'ue and a comparable result. 7n a related area, Tsui and 8ogolews$i report on the use of microporous biodegradable polyurethane membranes, which may be useful for coverage of s$in wounds, among other things.

Ba%bed s&t&%es
# barbed suture has been developed and is being evaluated for its efficacy in cutaneous surgery. The proposed advantage of such a suture is the avoidance of suture $nots. %uture $nots theoretically may be a nidus for infection, are tedious to place, may place ischemic demands on tissue, and may extrude following surgery. # randomi3ed controlled trial comparing a barbed suture with conventional closure using .-, polydioxanone suture suggests that a barbed suture has a safety and cosmesis profile similar to the conventional suture when used to close cesarean delivery wounds. #dditional studies are li$ely needed before the barbed suture is accepted for widespread use.

32

BANDAGES

33

Bandages
# bandage is a piece of material used either to support a medical device such as a dressing or splint, or on its own to provide support to the body. /andages are available in a wide range of types, from generic cloth strips, to specialised shaped bandages designed for a specific limb or part of the body, although bandages can often be improvised as the situation demands, using clothing, blan$ets or other material. 7n common speech, the word 9bandage9 is often used to mean a dressing, which is used directly on a wound, whereas a bandage is technically only used to support a dressing, and not directly on a wound.

34

T/9es of Bandages
" 8au3e bandages 1 0ompression bandages . Triangular bandages F Tube bandages + 0ollegan bandages @ #lginate /andages

)au!e bandage
The most common type of bandage is the gau3e bandage, a simple woven strip of material, or a woven strip of material with a Telfa absorbant barrier to prevent adhering to wounds, which can come in any number of widths and lengths. # gau3e bandage can be used for almost any bandage application, including holding a dressing in place. E:a89les

C&%it/A Ga&@e S9onges

%urgical mesh efficiently controls bleeding, fluid suppuration :ighly absorbent mesh allows wounds to drain naturally Edges are folded inK no loose threads *on-sterile

W. O. W. Bandages
",,E cotton, /B %tandard 2hite paper banded 4 roll and blue craft paper 4 do3en Thread 0ount per s'. 7nch: 1F T 1,, 1? T "?, 1? T 1F, ., T 1, 2idth: ", 1, ., F L @ inch >ength: F, +, @, ", yds

35

Thread 0ount per s'. 7nch: .1 T .?, F. T 1C (/. B. 2idth: +, C, ",, "1, "+ L 1, cmK >ength: F, +, @, ", m

*ompression bandage
The term 6compression bandage6 describes a wide variety of bandages with many different applications.%hort stretch compression bandages are good for protecting wounds on one6s hands, especially on one6s fingers. S'o%t st%et#' #o89%ession bandages are applied to a limb (usually for treatment of lymphedema or venous ulcers . This type of bandage that is capable of shortening around the limb after application and is therefore not exerting ever-increasing pressure during inactivity. This dynamic is called resting pressure and is considered safe and comfortable for long-term treatment. 0onversely, the stability of the bandage creates a very high resistance to stretch when pressure is applied through internal muscle contraction and &oint movement. This force is called wor$ing pressure. Long st%et#' #o89%ession bandages have long stretch properties, meaning their high compressive power can be easily ad&usted. :owever, they also have a very high resting pressure and must be removed at night or if the patient is in a resting position. E:a89les

BSN;BOBST Co?e%letA Ad'esi?e D%essings

%pecial flexible fabric allows 0overletU to move and conform to body curves #dhesive mass provides firm and even adherence, yet is easy to remove, helps limit s$in irritation and scab removal %imple, peel open pac$age #vailable in ". shapes and si3es

which

(ed#o S'ee% S9ots

0ircular shape, perfect for the smallest scrapes and cuts %terile pad won6t stic$ to wound %emi-transparentK blends with s$in

36

T%iang&la% bandage
#lso $nown as a cravat bandage, a triangular bandage is a piece of cloth cut into a right-angled triangle. 7t can be used fully unrolled as a sling, folded as a normal bandage, or for speciali3ed applications, as on the head. (ne advantage of this type of /andage is that it can be ma$eshift and made from a fabric scrap or a piece of a t-shirt. The /oy %couts populari3ed use of this bandage in many of their first aid lessons. They carry a cravat bandage with their uniform in the form of a nec$erchief. E:a89les

W%ist B%a#e CE A99%o?ed

%uitable for bone surgery operation, orthoraedic gypsum, healthy sports matreial for slim figure and so on. Dnder the tenet of 9ta$e people and sincerity as bases, abide by professional ethics, always ta$e demotic health as its duty9, we are determined to ma$e our company become the high 'uality and efficient company.

Tube bandage
# tube bandage is applied using an applicator, and is woven in a continuous circle. 7t is used to hold dressings or splints on to limbs, or to provide support to sprains and strains, and it stops the bleeding. E:a89les

3(C Ste%i;St%i9sC S$in Clos&%es

Hicroporous, non-woven rayon-bac$ed material permits s$in ventilation, but is reinforced with filaments for strength to provide wound support and assist in increasing tensile strength of wound, permitting early staple4suture removal :ypoallergenic adhesive Dse results in greater resistance to infection than sutures or staples alone #llows for finer wound edge approximation %trips are pac$aged singly in boxes of "? or .,K + to an envelope in 1+,-ct. boxesK . to an envelope in "+,-ct. boxes

Le&$ost%i9C Ad'esi?e S$in Clos&%es

37

V %terile wound closure with programmed elasticity! maintains precise tissue approximation during and following edema V #ir and exudate permeable, speeding healing V :ypoallergenic adhesive minimi3es ris$ of reaction

(an&fa#t&%ing )%o#ess
The manufacturing process has different stages, through which material passes and changed into bandages

Cotton Wool )%o#essing Lines

The processing of cotton wool starts from cotton wastes and low grade cottons, which are cleaned, bleached and dryed, after carded and transformed in finished products. # cotton wool processing line gives the possibility to obtain bleached cotton in bales. This cotton can be sold to companies speciali3ed in finishing and pac$aging, or can be exported with an added value in respect to the raw cotton. 7n this way it is also possible to obtain a saving on transport costs, which are calculated on a higher value product. Oinished products of a cotton wool processing line, destined to the sanitary and cosmetic use

Ga&@e Bandage (an&fa#t&%ing

(EDICAL is a special crochet machine for the production of cotton gau3es and elastic bandages in the re'uested width, with already-made selvedges. #s no longitudinal cutting is re'uested, there are no more floating threads (very dangerous for health and cotton gau3es have a good strength in both directions.

38

The total width of the machine is ?, cm. 8au3es and bandages are produced in the re'uested width from min. + cm up to ., cm. 7t is also possible to produce gau3es of ?, cm, in certain conditions. Hedical machines are fed from yarns on cones. The cone creel is included in the machine. #t exit, gau3es and bandages are rolled on big bobbins (around ., cm of diameter , or can be collected into a container in loose form. HE)70#> machines prouduce cotton gau3es starting from bleached cotton yarns. These yarns can be easily found on the mar$et. 0ompanies which want to start this production are not obliged to afford big investments to install costly bleaching and drying e'uipment. The big versatility of this machine allows to produce a large variety of rigid and elastic bandages, by using yarns of different nature: cotton, wool, polyester, nylon, lycra, rubber threads.

Ad'esi?e bandage 8an&fa#t&%ing

;(T(B>#%TE; #0 is used for the production and single-wrapping of adhesive first aid bandages of various sizes and shapes with island or continuous pad, round or
square edges and hot perforation

;(T(B>#%TE; #0 has a production capacity up to 1,,, pieces4min (based on si3e"AxC1 mm . The production speed can vary according to the 'uality of raw materials. Brecision, simplicity and versatility are the characteristics of ;(T(B>#%TE; #0 machines. ;(T(B>#%TE; #0 machines are completely controlled by electronics. #ll modules and raw material feeding groups are driven each by a separate brushless motor. The complete operating cycle is controlled and synchroni3ed by a B0, specially programmed for the production of adhesive bandages.
39

#ccording to the 'uality of raw materials, it is sufficient to select the proper programme to get the correct and complete set up of the machine, including the tension of raw materials. *o manual regulation is re'uested on this machine, which is self-regulating. ;(T(B>#%TE; #0 machines can produce with all $inds of adhesive substrates, such as: plastic, nonwoven, fabric, as well as all new materials re'uested by the medical mar$ets. #lso pre-printed substrates can be used, as this machine is able to center the print. The modular construction of machines allows easy and 'uic$ change of si3e and setting, for a better efficiency. Berforators, die-cutters, counter-rollers and all rotary parts of ;(T(B>#%TE; #0 machines are made in our factory with absolute precision, using top 'uality materials. ;(T(B>#%TE; machines are fed from raw materials in reels ext. diameter +,, mm for adhesive substrates and F,, mm for all other materials. ;eel width depends on bandage si3e to be produced.

;aw materials are:

adhesive substrates: BE, BI0, BD, nonwoven, non stretchable cloth, pre-print substratesK absorbent pad: nonwovenK release papers: single-face silicone paper, embossed filmK wrapping papers: cold sealable paper.

;(T(B>#%TE; #0 can produce all usual formats and si3es of adhesive first aid bandages and many others on client re'uest.

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Collegan and Collegan based 2o&nd d%essings

Abst%a#t
0ollagen is a $ey component of a healing wound. 7n this review, a general description of the wound healing process is provided focusing on collagen5s uni'ue role. The mode of action (Ho# of collagen-based dressings is also addressed. )ue to a number of potential stimuli (local tissue ischemia, bioburden, necrotic tissue, repeated trauma, etc. , wounds can stall in the inflammatory phase contributing to the chronicity of the wound. (ne $ey component of chronic wounds is an elevated level of matrix metalloproteinases (HHBs . #t elevated levels, HHBs not only degrade nonviable collagen but also viable collagen. 7n addition, fibroblasts in a chronic wound may not secrete tissue inhibitors of HHBs (T7HBs at an ade'uate level to control the activity of HHBs. These events prevent the formation of the scaffold needed for cell migration and ultimately prevent the formation of the extracellular matrix (E0H and granulation tissue. 0ollagen based wound dressings are uni'uely suited to address the issue of elevated levels of HHBs by acting as a Wsacrificial substrate5 in the wound. 7t has also been demonstrated that collagen brea$down products are chemotactic for a variety of cell types re'uired for the formation of granulation tissue. 7n addition, collagen based dressings have the ability to absorb wound exudates and maintain a moist wound environment.

Collegan
Broteins are natural polymers and ma$e up almost "+E of the human body. The building bloc$s of all proteins are amino acids. 0ollagen is the ma&or protein of the extracellular matrix (E0H and is the most abundant protein found in mammals, comprising 1+E of the total protein and C,E to ?,E of s$in (dry weight . 0ollagen acts as a structural scaffold in tissues. The central feature of all collagen molecules is their stiff, triple-stranded helical structure." Types 7, 77, and 777 are the main types of collagen found in connective tissue and constitute A,E of all collagen in the body. Ounction of collagen in wound healing. Breviously, collagens were thought to function only as a structural supportK however, it is now evident that collagen and collagen-derived fragments control many cellular functions, including cell shape and differentiation, 1,. migration, F and synthesis of a number of proteins. + Oindings suggest that cell contact with precise extracellular matrix molecules influence cell behavior by regulating the 'uantity and 'uality of matrix deposition. Type 7 collagen is the most abundant structural component of the dermal matrixK migrating $eratinocytes li$ely interact with this protein. 0ollagenase (via formation of gelatin
41

may aid in dissociating $eratinocytes from collagen-rich matrix and thereby promote efficient migration over the dermal and provisional matrices. 0ellular functions are regulated by the E0H. The information provided by E0H macromolecules is processed and transduced into the cells by speciali3ed cell surface receptors. + Evidence demonstrates that the receptors play a ma&or function in contraction of wounds, @,C migration of epithelial cells, ? collagen deposition, A and induction of matrix-degrading collagenase. #lthough $eratinocytes will adhere to denatured collagen (gelatin , collagenase production is not turned on in response to this substrate. ", Keratinocytes have been $nown to recogni3e and migrate on Type 7 collagen substratum, resulting in enhanced collagenase production. "" 0ollagen plays a $ey role in each phase of wound healing. :emostasis (duration X minutes . Blatelets aggregate around exposed collagen. Blatelets then secrete factors, which interact with and stimulate the intrinsic clotting cascade, which strengthens the platelet aggregate into a stable hemostatic plug.! /lood platelets also release Ya-granules, which release a variety of growth factors (8Os and cyto$ines, such as platelet derived 8O (B)8O , insulin-li$e 8O (78O-" , epidermal 8O (E8O , and transforming 8O-beta (T8O-b , "1 which call! a variety of inflammatory cells (neutrophils, eosinophils, and monocytes to the wound site and initiate the inflammatory phase. 7nflammation (duration X days . Broteolytic en3ymes are secreted by inflammatory cells that migrate to wound sites, notably neutrophils, eosinophils, and macrophages. The action of proteolytic en3ymes on the macromolecular constituents of the E0H (such as collagen gives rise to many peptides (protein fragments during wound healing. These degradation products have a chemotactic effect in the recruitment of other cells, such as mononuclear cells, additional neutrophils, and macrophages. #ctivated macrophages secrete T*O-a, which among other things, induces macrophages to produce 7>-"b. 7>-"bZ is mitogenic for fibroblast and up-regulates matrix metalloproteinase (HHB expression. T*O-Y and 7>-"bZ are $ey pro-inflammatory cyto$ines, which directly influence deposition of collagen in the wound by inducing synthesis of collagen via fibroblasts and down regulation of tissue inhibitors of matrix metalloproteinases (T7HBs . "1 7nflammatory cells also secrete growth factors including T8O-b, T8O-b, b:/-E8O, and bO8O. "1 These 8Os continue to stimulate migration of fibroblasts, epithelial cells and vascular endothelial cells into the wound. #s a result, the cellularity of the wound increases. This begins the proliferative phase. Broliferation (duration X wee$s . 0leavage products resulting from collagen degradation stimulate fibroblast proliferation. Oibroblasts secrete a variety of 8Os (78O-", bO8O, T8O-b, B)8O, and K8O , "1 which guide the formation of the E0H. The collagen cleavage products also stimulate vascular endothelial cell proliferation. These cells secrete a variety of 8Os (IE8O, ZO8O, B)8O , "1 which promote angiogenesis. 2ith a vasculari3ed E0H, granulation is achieved. 0ollagen cleavage products also stimulate $eratinocyte migration and proliferation. Keratinocytes secrete a variety of 8Os and cyto$ines, such as T8O-b, T8O-b, and 7>-". "1 #s $eratinocytes migrate from the edge of the wound across the newly formed granulation tissue, reepitheli3ation is achieved. ;emodeling (duration X " year [ . # balance is reached between the synthesis of new components of the scar matrix and their degradation by HHBs, such as collagenase, gelatinase,

42

and stromelysin. Oibroblasts are the ma&or cell type that synthesi3es collagen, elastin, and proteoglycans. They are also the ma&or source of HHBs and T7HBs. 7n addition, they secrete lysyl oxidase, which cross-lin$s components of the E0H. #ngiogenesis ceases and the density of capillaries in the wound site decreases as the scar matures. The result is the creation of a stronger scar, though the s$in only regains almost C+E of its original tensile strength.

T'e Role of (()s in Wo&nd C'%oni#it/

2ound bed preparation (2/B can be described as the management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. ".,"F The F basic aspects of 2/B can be represented by the acronym: T7HE. T X tissue (nonviable or deficient K 7 X infection or inflammationK H X moisture controlK E X epidermal margin. "+ Oocusing on the E! in T7HE, collagen dressings possess properties, which lend themselves to creating a wound environment favorable to the migration of cells from the epidermal margin across granulation tissue, encouraging wound closure. )ue to a number of potential stimuli (local tissue ischemia, bioburden, necrotic tissue, repeated trauma, etc. , the wound has stalled in the inflammatory phase contributing to the chronicity of the wound. #s a result of the aforementioned pro-inflammatory stimuli, the wound is overstimulated and inflammatory cells, such as macrophages, are present in higher numbers and are more active than they typically would be in an acute wound. 7n addition, the cells, such as fibroblasts and endothelial cells, are senescent and unable to function properly as they would in an acute wound. 2ith the overabundance of macrophages, there is an overabundance of $ey pro-inflammatory cyto$ines, such as T*O-b and 7>-"b, secreted by the macrophages. These pro-inflammatory cyto$ines signal the fibroblasts to secrete HHBs, but due to the overabundance of pro-inflammatory cyto$ines the fibroblasts secrete elevated levels of HHBs. #t this level, HHBs not only degrade nonviable collagen, but also viable collagen laid down by the fibroblasts themselves. #dditionally, the fibroblasts are unable to secrete tissue inhibitors of HHBs (T7HBs at an ade'uate level to control the activity of the HHBs. These events prevent the formation of the scaffold needed for cell migration and ultimately prevent the formation of the E0H. 7n addition, cells in a chronic wound tend to be senescent, thus unable to communicate with other cells and unable to function properly. (ne result of this is a lac$ of endothelial cell activity slowing the formation of blood vessels. 2ithout an ade'uate blood supply, tissue can die and as a result, there is an increase in wound si3e. #ll of the aforementioned phenomena impede the formation of viable granulation tissue and thus inhibit re-epitheliali3ation (ie, wound closure . "1 (ne of the $ey contributors to wound chronicity is an overabundance (and4or activity of HHBs in the woundK the ability to inhibit or deactivate a number of excess HHBs may help create an environment more conducive to the formation of granulation tissue, and eventual wound closure.

Collagen;based Wo&nd D%essings

There are a number of different collagen dressings available, which employ a variety of carriers4combining agents such as gels, pastes, polymers, oxidi3ed regenerated cellulose ((;0 , and ethylene diamine tetraacetic acid (E)T# . The collagen within these products tends to be derived from bovine, porcine, e'uine, or avian sources, which is purified in order to render it nonantigenic. The collagen in a given collagen dressing can vary in concentration and type. 0ertain collagen dressings are comprised of Type 7 (native collagenK whereas, other collagen
43

dressings contain denatured collagen as well. # given collagen dressing may contain ingredients, such as alginates and cellulose derivatives that can enhance absorbency, flexibility, and comfort, and help maintain a moist wound environment. 0ollagen dressings have a variety of pore si3es and surface areas, as well. #ll of these attributes are meant to enhance the wound management aspects of the dressings. Hany collagen dressings contain an antimicrobial agent to control pathogens within the wound. 0ollagen dressings typically re'uire a secondary dressing (see #ppendix 7 for a summary of currently available collagen-based wound dressings . Hode of action (Ho# . ;esearch has shown that some collagen-based dressings produce a significant increase in the fibroblast productionK have a hydrophilic property that may be important in encouraging fibroblast permeationK enhance the deposition of oriented, organi3ed collagen fibers by attracting fibroblasts and causing a directed migration of cellsK aid in the upta$e and bioavailability of fibronectinK help preserve leu$ocytes, macrophages, fibroblasts, and epithelial cellsK and assist in the maintenance of the chemical and thermostatic microenvironment of the wound. "@J1, The Ho# of several collagen dressings includes the inhibition or deactivation excess HHBs. #s mentioned, excess HHBs are a $ey contributor to wound chronicity.

Collagen7 Nati?e ?e%s&s Denat&%ed

7n addition to the various sources of collagen (bovine, porcine, etc. , collagen dressings can also contain different types of collagen. These types of collagens may result in uni'ue activity in the wound bed as they have different substrate specificity. Oor example, Type 7 (native collagen attracts HHB-". " )enatured collagen (gelatin attracts HHB-1 and HHB-A. ",1" 8elatin also attracts stromelysin and matrilysin.1" These HHBs (among others are found in excess in chronic wounds and contribute to a wound5s chronicity (see #ppendix 77 for a brea$down of collagen source4type per collagen dressing . /iochemistry of collagen types. 2hen a migrating cell (such as a $eratinocyte encounters Type 7 collagen, the cell secretes HHBs in order to denature the Type 7 collagen to gelatin. # critical reason for this is that once Type 7 collagen is converted into gelatin, many active sites (;8) se'uences are made accessible to the cells. ;8) (#rg-8ly-#sp se'uences are attachment sites and are chemotactic for a variety of cells responsible for creating granulation tissue. Thus, a collagen dressing containing gelatin could provide enhanced signaling to the cells responsible for creating granulation tissue. # collagen-dressing containing only Type 7 collagen re'uires HHB-" to initially convert collagen to gelatin, so cells in the wound must first release HHB-" to change the Type 7 collagen into gelatin to get this benefit. Bore si3e and surface area. Bore si3e of collagen dressings is important to allow cells to enter the dressing and concentrate therein. 7n addition, surface area plays a role in managing exudate. Typically the larger the surface area, the more exudate is absorbed.

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Con#l&sion
Breviously, collagens were thought to function only as structural supportK however, collagen and collagen-derived fragments control many cellular functions, including cell shape and differentiation, migration, and synthesis of a number of proteins. 0ollagen also plays a critical role in all phases of wound healing (hemostasis, inflammation, proliferation, and remodelling . 7t is also clear that while much of the Ho# of the various collagen dressings is similar, there are $ey differences as well.

Refe%en#es
". =effrey =. Hetalloproteinases and tissue turnover. 2(D*)%. "AA+KC(%uppl # :".#J11#. 1. Hontesano ;, (rci >, Iasselli B. 7n vitro rapid organi3ation of endothelial cells into capillaryli$e networ$s is promoted by collagen matrices. = 0ell /iol. "A?.KAC(+ Bt " :"@F?J"@+1. .. Hadri =#, Harx H. Hatrix composition, organi3ation, and soluble factors: modulators of microvascular cell differentiation in vitro. Kidney 7nt. "AA1KF"(. :+@,J+@+. F. #lbini #, #delmann-8rill /0. 0ollagenolytic cleavage products of collagen Type 7 as chemoattractants for human dermal fibroblasts. Eur. = 0ell /iol. "A?+K.@(" :",FJ",C. +. :ynes ;(. 7ntegrins: versatility, modulation, and signaling in cell adhesion. 0ell. "AA1K@A(" :""J1+. @. Klein 0E, )ressel ), %teinmayer T, et al. 7ntegrin alpha 1 beta " is upregulated in fibroblasts and highly aggressive melanoma cells in three-dimensional collagen lattices and mediates the reorgani3ation of collage 7 fibrils. = 0ells /iol. "AA"K""+(+ :"F1CJ"F.@. C. %chiro =#, 0han /H, ;oswit 2T, et al. 7ntegrin alpha 1 beta " (I>#-1 mediates reorgani3ation and contraction of collagen matrices by human cells. 0ell. "AA"K@C(1 :F,.JF",. ?. %charffetter-Kochane$ K, Klein 0E, :einen 8, et al. Higration of human $eratinocyte cell line (:a0aT to interstitial collagen Type 7 is mediated by the alpha 1 beta "-integrin receptor. = 7nvest )ermatol. "AA1KA?(" :.J"". A. Krieg T. 0ollagen in the :ealing 2ound. 2(D*)%. "AA+KC(%uppl # :+#J"1#. ",. %ubdec$ /), Bar$s 20, 2elgus :8, Bentland #B. 0ollagen-stimulated induction of $eratinocyte collagenase is mediated via tyrosine $inase and protein $inase 0 activities. = /iol 0hem. "AAFK1@A(FC :.,,11J.,,1A. "". Betersen H=, 2oodley )T, %tric$lin 8B, (5Keefe E=. Enhanced synthesis of collagenase by human $eratinocytes cultured on Type 7 or Type 7I collagen. = 7nvest )ermatol. "AA,KAF(. :.F"J.F@. "1. %chult3 8, Hast /. Holecular analysis of the environment of healing and chronic wounds: cyto$ines, proteases and growth factors. 2(D*)%. "AA?K",(@ suppl :"OJAO. ".. %ibbald ;8, 2illiamson ), (rsted :>, et al. Breparing the wound bed\debridement, bacterial balance, and moisture balance. (stomy 2ound Hanage. 1,,,KF@("" "FJ.+. "F. Oalanga I. 0lassifications for wound bed preparation and stimulation of chronic wounds. 2ound ;epair ;egen. 1,,,K?(+ :.FCJ.+1. "+. %chult3 8%, %ibbald ;8, Oalanga I, et al. 2ound bed preparation: a systematic approach to wound management. 2ound ;epair ;egen. 1,,.K""(%uppl " :"J1?. "@. )oillon 0=, %ilver O:. 0ollagen-based wound dressing: effects of hyaluronic acid and fibronectin on wound healing. /iomaterials. "A?@KC(" :.J?. "C. )oillon 0=, %ilver O:, (lson ;H, Kamath 0S, /erg ;#. Oibroblast and epidermal cell-Type
45

7 collagen interactions: cell culture and human studies. %canning Hicrosc. "A??K1(1 :A?+JAA1. "?. /urton =>, Etherington )=, Beachey ;). 0ollagen sponge for leg ulcers. /r = )ermatol. "AC?KAA(@ :@?"J@?+. "A. )oillon 0=, 2hyne 0O, /erg ;#, (lson ;H, %ilver O:. Oibroblast-collagen sponge interactions and spatial deposition of newly synthesi3ed collagen fibers in vitro and in vivo. %can Electron Hicrosc. "A?FK(Bt . :".".J".1,. 1,. Balmieri /. :eterologous collagen in wound healing: a clinical study. 7nt = Tissue ;eact. "AA1K"F(%uppl :1"J1+. 1". Bar$s 20. The production, role, and regulation of matrix metalloproteinases in the healing epidermis. 2(D*)%. "AA+KC(%uppl # :1.J.C. 11. Hignatti B, ;if$in )/, 2elgus :8, Bar$s 20. Broteinases and tissue remodeling. 7n: 0lar$ ;#O, ed. The Holecular and 0ellular /iology of 2ound ;epair. 1nd ed. *ew Sor$, *S: Blenum BressK "AA@:F1CJFCF.

Alginate D%essing
Des#%i9tion
#lgisite H sheets may be applied to exuding lesions including leg ulcers, pressure areas, donor sites, and most other granulating wounds but for deeper cavity wounds and sinuses, the rope pac$ing form is generally preferred. The dressing also appears to be of value as an ad&unct to the systemic treatment of infected or malodorous wounds and for the management of painful wounds when removal of other more traditional dressings causes unacceptable levels of pain or trauma. Broduct *ame: Algisite (

0lassification *ame: Cal#i&8 Alginate )%i8a%/ Wo&nd D%essing Hanufacturer: S8it' < Ne9'e2 ealt'#a%e Ltd

Cont%a;indi#ations
#lthough there are no $nown contra-indications to the use of #lgisite H, the dressing will be of little value if applied to wounds that are very dry, or covered with hard blac$ necrotic tissue.

(et'od of &se
#n #lgisite H dressing, chosen to be slightly larger than the area of the wound, is placed in intimate contact with the wound base. #ny overlap may be cut away or folded bac$ over the wound surface before the application of a sterile secondary dressing held in place with surgical tape or a bandage as appropriate. The nature of the secondary dressing will be governed by the

46

condition of the wound. 7f large 'uantities of exudate are anticipated, a simple absorbent dressing pad may be re'uiredK but as the wound heals and less exudate is produced, a thinner pad bearing a plastic film of low adherence may help to conserve moisture and prevent the wound drying out too 'uic$ly. )eeper cavity wounds or sinuses may be dressed with #lgisite H rope, which should be placed gently in position but not pac$ed in too tightly. /ecause of the needling process used in its construction, the dressing has significant wet strength, which means that it can be easily removed from a wound in one piece, a process that may be facilitated by irrigation with sterile normal saline. This may be accomplished without causing either damage to the wound or pain to the patient. # small percentage of patients experience a mild ]drawing6 or ]burning6 sensation immediately after the application of an alginate dressing to a dry wound bed. This sensation, which is usually transient, is thought to be due to the hydrophilic nature of the dressing causing temporary localised drying of the surface of the wound. This discomfort may generally be prevented by moistening the surface of the wound with a small 'uantity of sterile normal saline prior to the application of the dressing.

"%e=&en#/ of C'ange
The interval between dressing changes will depend entirely upon the state of the wound and the nature of the secondary dressing. #lgisite H applied to heavily exuding or sloughy wounds may need replacing daily initially, but as healing progresses and the amount of exudate decreases, the interval between changes may be extended to up to C days in some circumstances. #t this stage a change to an alternative dressing such as a film product should be considered to conserve moisture.

Wa%nings
2ounds that show signs of clinical infection may be dressed with #lgisite H but the dressing should be changed daily and the use of systemic antibiotic therapy considered.

)%esentation
The dressings are presented individually pac$ed in peel pouches, sterilised by ethylene oxide.

Sto%age
Si@es
#lgisite H is available in a range of si3es as follows. #n$le circumference (0olour 0ode +cm x +cm

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",cm x ",cm "+cm x 1,cm 1g x .,cm rope

Refe%en#es
". Thomas, %., 1,,,, #lginate dressings in surgery and wound management - part ": =ournal of 2ound 0are, v. A, p. +@-@,. 1. Thomas, %., 1,,,, #lginate dressings in surgery and wound management - part 1: =ournal of 2ound 0are, v. A, p. ""+-""A. .. Thomas, %., 1,,,, #lginate dressings in surgery and wound management - part .: F.Timmons =. #lginates and hydrofibre dressings. Brof *urse "AAAK"F(C :FA@-A, +,", +,..

BandagesD (an&fa#t&%e%s /ei&ing %tronger ;ich 7mp.L Exp. 0o. >td 0hina 2en3hou Times 0o.,>td. 0hina Oran$ :ealthcare 0o. >td 0hina %hanghai (riland 8roup Hedical Broducts Hanufactory 0hina 7deal Hedical 7ndustries 0o., >td.Q0hinaR 2en3hou 0aremed Hedical Technology 0o., >td.Q0hinaR 0hang3hou (person 7mp. L Exp. 0o., >td.Q0hinaR Sang3hou 8oldenwell Hedical )evices OactoryQ0hinaR %u3hou %unmed 0o., >td.Q0hinaR *ingbo Oirst 7mp. L Exp. 0o., >td.Q0hinaR <he&iang Kanglidi Hedical #rticles 0o., >td.Q0hinaR %u3hou 7ndustrial Bar$ 2inwin 74E 0o., >td.Q0hinaR
48

 :ospital L :omecare 7mp. L Exp. 0o., >td. *an&ingQ0hinaR Song$ang /angli Hedical Broducts 0o., >td.Q0hinaR #n&i %unlight Hedical Broducts 0o., >td.Q0hinaR ^ingdao /ondex Trade %ervice 0o., >td.Q0hinaR %ainty 7nternational 8roup =iangsu Sang3hou %umex 7mp. L Exp. 0o., >td.Q0hinaR *an&ing Bhyto-%pring 7mp. L Exp. 0o., >td.Q0hinaR Sancheng )iling Hedical 7nstrument 0o., >td.Q0hinaR Refe%en#e7
:and boo$ of technical textiles by #.; :orroc$s %.0 #nand

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