Tempowire surgical temporary heart pace wire has one-edge slipped insulation or diameter. It is fastened to myocardium with curved, round suture needle connected to ensure conductivity or fastened with a anchor by passing through the myocardium if it has anchor. The anchor is the stripped and winged piece of insulation close to the curved needle. The other end of the insulated wire is connected to the straight, sharp Keith needle that enables passage from inside to outside from the chest cavity wall to ensure conductivity. Keith needle is equipped with a special notch ensuring frangibility. The sharp part of the surgical needle is broken off from the notch, the part that remains attached to the wire forms the lead pin and connects to conventional pace or monitor equipment.

Tempowire Surgical Temporary Pace Wire Usage

Please check the custom sterile package before opening. If the package is damaged, do not use the pace wire. Please check the instructions regarding opening the sterile package in Figure 2 and 3. The content of the sterile package is sterile (see also Figure 2, indication statement 1). Carefully remove the products in the sterile package. The insulation color on the surgical pacing wire body can be used for identification purpose. Please check Figure 4 for atrial usage (indication statement 1).

Insert the curved needle through the myocardium (see Figure 4) in a direction so that the entry point of the surgical temporary pacing wire into the heart can subsequently align with the exit in the chest. This method might facilitate retraction of the temporary pace wire. It is important to properly position the electrode inside or on the myocardium (see also Figure 5).

Atrial Usage: Position the electrode inside the myocardium. This is ensure by slightly pulling the curved needle while pulling the wire inside the tissue.

Cut the wire removed from the myocardium and curved needle until the rest of it stays in the myocardium (see also Figure 6). During the high displacement risk period, the cutting procedure might not be applied immediately because the wire is cut after a short period. Discard the myocardial curved needle.

Hold the chest needle distally from the separation mark (see Figure 7) and insert it through the chest wall in a direction that will allow the pacing wire in the heart to align with the chest exit. Keep some part of the conductive wire inside the check to prevent any displacement due to patient movement. Using a needle driver for this procedure is recommended.

Break the chest needle from separation mark (see also Figure 8). Discard the chest needle.

Connect the wire connector pins to the external pulse generator, patient cable, or surgical cable, following the polarity below. Connect the pin to the negative pole (-). The neutral wires must be connected to the positive pole (+) of the external pulse generator.

When the surgical wire is no longer needed, carefully pull to remove the wire.

Surgical sutures which are also called the sutures are among the most preferred medical devices among other medical materials used for closing and sewing wounds (wound closure elements). Surgical sutures, whose discovery and usage date back 4000 years, have come a long way from the past to the present. With modern medicine, many different types of surgical sutures have been produced. Surgical sutures can be natural, synthetic, absorbable, unabsorbable, antibacterial, multifilament or monofilament options.

What Are Natural Surgical Sutures And What Are Their Types?

There are 2 different types when the surgical sutures are divided according to raw materials. These are natural surgical sutures and synthetic surgical sutures. The natural surgical sutures are divided into two categories. These are plant-based surgical sutures and animal product-based surgical sutures. The surgical sutures manufactured with these two raw materials from the nature can be categories as natural surgical sutures.

Plant-Based Surgical Sutures

Silk, which is the most widely used surgical suture today, is a sterile surgical suture consisting of non-absorbable organic polymer called fibroin. It is obtained from natural protein filaments derived from Bombyx Mori silkworm cocoon. (1, 2) Before the silk surgical suture is manufactured in the braided format, one of the 2 protein substances inside and the adhesive part are processed with wax and hum in the silk to be removed. This process gives a tighter knitting structure that significantly improves the quality of the braided and non-absorbable surgical suture produced from natural silk. After knitting, it is cooked and then coated with paraffin wax and silicone. (1, 2, 3)

Natural silk surgical sutures are the most preferred suture options around the world due to their softness, flexibility, thinness, ease of use and bonding properties. Due to its multi-filament (braided) structure, it has high capillary properties and requires very few nodes in terms of node safety. Surgical natural silk sutures are used for soft tissue closure or binding, including cardiovascular, ophthalmic and neurosurgery applications. (1.2)

Animal-Based Surgical Sutures

This is an absorbable natural products called catgut which was named from a violin called “Kit” by the ancient Egyptians Arabs and it is referred as a surgical gut. During the production of this surgical suture which includes the submucous porous tissue of the sheep’s intestine or the serosa membrane of the cows, the parts of the connective tissue, which are cleaned with special care and whose oil is taken, are reconstituted, twisted and dried until the desired thickness is reached. (1, 4, 5)

In addition to the normal use of catgut sutures, it is treated with the necessary chrome salt solutions for the purpose of extending the absorption time. For this reason, the catgut surgical sutures are divided into normal catgut and chromium catgut in the medical field. (1,4,5)

What Are the Synthetic Surgical Sutures and Their Types?

Synthetic raw materials, which do not occur naturally and are created by human efforts, are used in the production of many medical devices in today’s health field. Synthetic raw materials, which provide many advantages especially in the production of surgical suture, have greatly contributed to the development of surgical sutures.

The types of synthetic surgical sutures used today are divided into different categories which are monofilament (straight) and multifilament (braided) as well as absorbable and non-absorbable. Synthetic surgical suture types with different chemical structures provide ease of use in many surgical branches, as well as low reaction and high strength in the tissue. (18,19)

Polyglycolic Acid (PGA) Surgical Sutures

This type which is a homo-polymer of glycolic acid, is the first synthetic, absorbable surgical suture and was first introduced in 1970. This type of suture with synthetic structure has delayed absorption and reduced tissue reaction compared to catgut sutures, as well as good tensile and better knot strength. Similar to chromic catgut, it shows absorption and polyester (PET)-like strength and knot safety.

Made from polyglycolic acid, these synthetic and absorbable surgical sutures have a multifilament structure and can also be coated with polycaprolactone, a synthetic coating to ensure smooth tissue transition and seamless knot bonding. (1,6,7)

Poly Glycolide Lactide Acid (PGLA) Surgical Sutures

Poly glycolide lactide acid (PGLA) which is another type of absorbable synthetic surgical suture is flexible, absorbable and poly [%90 glycolide + 10% lactide] (glycolic and lactide acid derivative), which can be absorbed when used in living organisms and does not cause excessive irritation in tissue. Striped variations of surgical sutures whose chemical structure is Poli Glycolide Lactide acid (PGLA) use Poli (Glycolide Lactide) (30/70) and calcium stearate as special coating agent. (20)

Poly Glycolide Caprolactone (PGCL) Surgical Sutures

Polyglycolidcocaprolacton PGCL, a synthetic type of surgical suture synthesized from caprolactone and found in a monofilament structure, provides high node safety in closing superficial wounds such as sterile surgical filament dental operations and does not cause excessive tissue irritation throughout absorption. (9)

Produced in two different colors, colorless and purple (violet), EO (ethylene oxide) sterilized and chemically manufactured from 75% Glycolide and 25% co-caprolactone, synthetic and absorbable PGCL surgical sutures provide 45%-70% tissue support in the first week and are completely absorbed by the body within 90-120 days. (8, 9)

Polydioxanone (PDO) Surgical Sutures

Manufactured from polydioxanone poly (p-dioxanone) polyesters, Polydioxanone (PDO) has a monofilament structure and is a type of synthetic sterile surgical suture. Polydioxanone polymer has a nonantigenic and nonpyrogenic structure. The empirical molecular formula of the polymer is (C₄H₆O₃)x and polydioxanone surgical sutures can cause light tissue reaction during absorption by the body. (10)

To ensure visibility in surgical operations, Polydioxanone (PDO) absorbable surgical sutures are purple (violet) colored and sterilized with EO (ethylene oxide) and used including ophthalmic applications and pediatric cardiovascular tissue where growth is expected to occur. Synthetic and absorbable PDO surgical sutures with chemical structure of 100% Polydioxanone provides 70% tissue support in 2 weeks and is fully absorbed by the body within 180-240 days. (10, 11)

Polypropylene (PP) Surgical Sutures

Manufactured from the stereoisomer of the isotactic crystal of polypropylene, the chemical structure of polypropylene (PP), a type of synthetic surgical suture with monofilament structure that is usually produced in blue or black to enhance its appearance during surgical intervention. Further, it is synthetic linear polyolefin, consisting of the stereoisomer of the isotactic crystal of polypropylene. (12)

Polypropylene sutures that used in general soft tissue closure and binding, including cardiovascular, ophthalmic and neurosurgery applications, are often used in general surgery, soft tissue approximation and ligation, fascia stitching, patch detection and skin closure (both individually and subcuticular). It is used in almost all surgical areas, including cardiovascular, orthopedic, eye, microsurgery and neurological surgery. It is the type of surgical suture used in the vascular suturing the anastomoses due to its slippery and elastic structure. (13, 14)

Polyamide (PA) Surgical Sutures

Non-absorbable and sterile Polyamide (PA) surgical sutures which are the first synthetic surgical strand are manufactured in two different type as monofilament and multifilament consisting of long-chain chains of aliphatic polymer chemically known as nylon 6 or nylon 6.6 come in black or blue color to increase visibility in the tissue. (1, 15)

Known for its high tensile strength, excellent elastic properties and minimal tissue reaction, polyamide (PA) non-absorbable surgical sutures are used in general soft tissue closure and binding, including cardiovascular, ophthalmic and neurosurgery applications. (1, 15)

Polyvinyl Difluoride (PVDF) Surgical Sutures

Known as polyvinyl fluoride or polyvinyl difluoride (PVDF), it is a non-reactive thermoplastic produced by polymerization of vinylene difluoride. Sterile, non-absorbable PVDF surgical sutures consisting of polyvinyl difluoride polymer has monofilament structure and dyed blue and black to increase visibility. (16, 17)

In addition to its strong and flexible structure, the surgical suture sterilized with EO (ethylene oxide) is resistant to infection. It is successfully used in infected or contaminated wounds to minimize or eliminate subsequent sinus formation and excretion of the suture. (16, 17)

Polytetrafluoroethylene (PTFE) Surgical Sutures

Non-absorbable, monofilament and synthetic surgical sutures made of 100% Polytetrafluoroethylene are produced from high density 100% polytetrafluoroethylene by pulling to maintain integrity and tensile strength, as well as to produce a structure with a minimum pore size and volume.

Polytetrafluoroethylene (PTFE) surgical sutures are often preferred in cardiovascular surgery, dental treatment and eye surgery, show excellent biocompatibility, provide high knot strength and have an extremely low friction coefficient. (21, 22)

Polyester (PET) Surgical Sutures

Polyester (PET) surgical sutures made of long-chain linear polyester, with high molecular weight and composed of Polysyl Poly (ethylene terephthalate) are multifilament and synthetic surgical sutures. The surgical suture with Polyester (PET) comes with either coated or uncoated silicone elastomer form. The coating material, which has high adhesive strength in the tissue, is not reactive and is sterilized with EO (Ethylene oxide).

The non-absorbable coating provides permanent tissue support and acts as a lubricant. This property enables the synthetic structure to easily pass from the tissue as well as ease-of-use. Polyester (PET) synthetic non-absorbable surgical sutures are often used to seal and bind general soft tissues, including cardiovascular, ophthalmic and neurosurgery applications. (23)

Wound is the damaged anatomic integrity of a tissue due to any trauma. Applying the necessary treatment to stop the bleeding and to connect the damaged tissue date back to thousands of years ago. The development of surgical sutures in line with the developments of surgery in the history of medicine led the sutures to pass through different phases. In ancient ages, the deep wounds were sutured with plant materials such as linen, cotton, silk and animal tissues such as animal gut or skin, horse – pig hair, tendon and nerve to prevent bleeding and infection for wound healing. (2)

This surgical material called sutures in the modern medical literature has significantly developed from the old ages and still continues to develop with various research. The name suture for natural or synthetic materials comes from Latin and this term was first used by Hippocrates in 400 BC. (4) Today, synthetic materials are often preferred as a suture raw material. However, raw materials from organic polymers such as silk and catguts manufactured from animal mucosa are actively used for surgical suture manufactured for certain scenario.

First Period – The Oldest Surgical Document of The World: Edwin Smith Papyrus

Edwin Smith Surgical Papyrus which was discovered as a piece of a coursebook in ancient Egypt is recorded as the oldest surgical document. When this historical document in Egyptian hieroglyphs was investigated, it was found that the word structure dated to 1600 BC but the content dated to older times around 3000-2500 BC. This document mentioned methods to close the wounds with sutures and preventing the infection for the sutured wound. The cranial sutures (the fibrous tissue that connects the scalp bones) in this surgical document contain the first known explanations about the brain surface and cerebrospinal fluid. (9, 10)

The oldest and well-preserved sutures on the human body was found on a mummy of the 21st Egyptian Dynasty (around 1100 BC). The sutures were on the belly, knee and elbow of the mummy. (3) Societies from different cultures in the ancient period used such as horsehair, gut, dry tendon or hair, or gold and silver wires as suture material. (2,4,10)

Hippocrates who was one of the best surgeons of all times mentioned using sutures to close the veins and tissues. Roman Galen, one of the best physicians of the period after Hippocrates, mentioned flax, silk and catgut for suturing wounds in his book named ‘De Method Medendi’.

Second Period – Adolescence of Medicine

There were important developments in surgery which became an occupation in the 18th century. This period from 1860s to 1930-50 was marked as the adolescence of medicine. The surgical methods developed in this period but the pain and ache during and after the surgery halted this advancement in the surgical field. For this reason, the pain issue was solved with surgical anaesthesia in 1840 which was considered as one of the greatest inventions of human history. But the infection problem required a long time to solve which was the 19th century when the modern surgery was born. Due to post-op infections, the sutures didn’t last and the patients mostly died from sepsis. (4,7,8)

Third Period – Modern Surgery

Anti-sepsis and asepsis technique developed in the second half of the 19th century which shaped the modern surgical methods in current form were considered as an important stage to eliminate the postop infection problem. The term anti-sepsis first used in 1750 by John Pringle which is defined as removing the pathogen microorganisms from the surgical operation area and “antiseptic surgical” method developed by Joseph Lister for the surgery led to important developments in wound treatment and suture material. (3,4,9)

From the beginning of the modern surgery until today which is referred as the third period, surgical sutures significantly developed. Further, R&D studies to create the ideal suture materials are ongoing. Boz Medical that has an important role in medical textile manufacturing in Turkey has the success and right product to be the first medical textile manufacturing firm in 1960s. The same success is visible for surgical suture manufacturing.

Bibliography

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(2) Atıcı T., Atıcı E., Şahin N., “Geçmişten günümüze cerrahi dikiş ipliklerinin tarihsel gelişimi”. Ulusal Cerrahi Dergisi 2010; 26(4): 233-242

(3) Black JJ. A stitch in time-1. The history of sutures. Nurs Times 1982; 78: 619-623.

(4) Snyder CC. Sütürün tarihi üzerine. Plast Reconstruct Surg 1976; 58: 401- [DOI: 10.1097 / 00006534-197610000- 00001]

(5) Trier WC. Considerations in the choice of surgical needles. Surg Gynecol Obstet. 1979;149:84-94.

(6) Köhle Ü, Demir CY. Oftalmik Cerrahide Sütür Materyalleri. İnönü Üniversitesi Tıp Fakültesi Dergisi. 2003;10:217-21

(7) Dereli, T . “SÜTÜR MALZEMELERİ VE SÜTÜR TEKNİKLERİ”. Güncel Dermatoloji Dergisi 1 (2016 ): 24-33

(8) Edwin Smith Surgical Papyrus 1600 B.C. Page 38. The Medical Book: From Witch Doctors to Robot Surgeons, 250 Milestones in the History of Medicine. 2012

(9) Özdoğan, Mustafa. Edwin Smith Cerrahi Papirüs MÖ 1600 – En eski cerrahi belge “https://www.drozdogan.com/edwin-smith-cerrahi-papirus-mc-1600-en-eski-cerrahi-belge/ 15.02.2021”

(10) Feldmsn RP, Goodrich JT. The Edwin Smith sutgical papyrus. Child’s Nerv Syst 1999; 15: 281-284. [DOI:10.1007/s003810050395]

(11) Tarhan, Ömer Rıdvan. Cerrahinin Tarihçesi “https://www.drozdogan.com/edwin-smith-cerrahi-papirus-mc-1600-en-eski-cerrahi-belge/ 15.02.2021”