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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5183_Библиотеки_им_академика_М_И_Перельмана.pdf
78 A. Petzold and F. Wilhelm
ab
cd
Fig. 5.18 Micro-colibri forceps, extra fine, surgical (image courtesy of Geuder AG)
Fig. 5.19 Examples of the use of colibri forceps. (a)
Fixation of the eyeball during the creation of a scleral-corneal tunnel. (b) Fixation of the eyeball with
5.5 Instruments for pars plana
counterpressure during paracentesis. (c) Fixation and
presentation of the conjunctiva. (d) Conjunctival suture
5.5.1 Holding Instruments
vitrectomy
Examples of blunt instruments:
Special requirements must be met for instruments used in vitreous and retinal surgical procedures. They must be able to be introduced
intraocularly through correspondingly small
scleral openings and be longer than those used
in the anterior segment to manipulate the posterior pole. Scissors and forceps for vitrectomy
are therefore generally tube-guided (Fig. 5.20).
Since a detailed treatment of these operations is
not the concern of an introduction for beginners
in ophthalmic surgery, reference is made here to
the book “Vitreoretinal Surgery: Strategies and
Tactics” by F. Kuhn.
• Needle holder
• Razor blade holder
• Artery clamps
• Towel clamps
• Dieffenbach clamps
• Position hooks
• Fixation rings
Needle holders (Figs. 5.21 and 5.22) are
mainly used in eyelid and strabismus surgery.
In addition to the various sizes, one can choose
between straight and curved designs for the
Instruments for vitreous
and retinal surgery
795 Instrument Knowledge
tube-guided
very delicate
0.5-0.9 mm
Vitreoretinal
scissors angled
Fig. 5.20 Examples of instruments frequently used in
vitreous/retinal surgery
Fig. 5.22 Needle holder according to Castroviejo, fine jaw, with lock (image courtesy of Geuder AG)
Vitreoretinal
scissors straight
jaw geometry. In ophthalmology, needle holders with a spring mechanism are generally used,
optionally with or without a lock. When sewing
with very fine threads, needle holders without a
lock and with a curved tip have proven effective
(Chap. 10).
5.5.2 Spreading Instruments
Examples of spreading instruments:
• Eyelid speculums
• Eyelid retractors
Vitreoretinal
forceps
Membrane
peeler
Fig. 5.21 Needle holders of various sizes, with and
without lock
• Wound spreaders
• Wound hooks
Eyelid speculums (Figs. 5.23, 5.24, 5.25 and
5.26) are available in different sizes for use in
infants, young children, and adults. The valves
are fenestrated or closed and are manufactured in various shapes. In addition to the eyelid speculums with a simple spring mechanism,
there are also adjustable ones that are either selfretaining or can be fixed with a locking screw.
To remove excess fluid from the surgical area,
eyelid specula with integrated suction can be
used if necessary.
80 A. Petzold and F. Wilhelm
Fig. 5.23 Selection of commonly used models: Eyelid
speculum according to Weiss (adjustable, with locking
screw, open valves), Eyelid speculum according to Cook
(adjustable, with locking screw, closed valves), Eyelid
speculum according to Barraquer (fenestrated)
Fig. 5.24 Eyelid speculum according to Barraquer (fenestrated) (image courtesy of Geuder AG)
Fig. 5.25 Eyelid speculum according to Weiss (adjustable, with locking screw, closed valves) (image courtesy of
Geuder AG)
Fig. 5.26 Eyelid speculum according to Cook (adjustable, with locking screw, closed valves) (image courtesy of
Geuder AG)
Fig. 5.27 The specification of the cannula tube’s gauge
is given in Gauge
5.5.3 Suction and Irrigation Instruments
815 Instrument Knowledge
Examples of suction and irrigation instruments:
• Irrigation cannulas for tear ducts
• Suction-irrigation handpieces
The specification of the cannula tube’s gauge is
given in “G” (Gauge). The higher the gauge value,
the smaller the outer diameter of the cannula. The
corresponding outer diameters of the cannulas in
millimeters and the color coding are standardized
in EN ISO 6009 and EN ISO 9626 (Fig. 5.27).
5.5.4 Measuring and Marking Instruments
Examples of instruments for measuring and
marking:
Compasses
•
• Measuring spatulas
• Rulers
• Measuring rings
• Depth gauges
• Keratometers
• Markers as positioning and suturing aids for
the cornea
5.5.5 Sterilization Containers
The assembly of surgical instruments is done
according to the individual preferences of the
surgeon. If different procedures are performed,
Fig. 5.28 Instruments on a surgical tray for cataract
operations
it is advisable to acquire various surgical trays
(e.g., cataract tray, lid tray, glaucoma tray, etc.).
The instruments are then stored in appropriately labeled, sterilizable containers, where they
are fixed by silicone nubs, stored, and sterilized
in one or more sieve trays (Chap. 1).
For a smooth and safe operation process, the
instruments should always be stored on the trays
in the same manner. Especially in larger surgical
facilities, photographic documentation is useful
as a guideline for uniform procedures and for
training personnel (Fig. 5.28).
References and Further Reading
1. Blaskovics-Kettesy (1970) Eingriffe am Auge,
Ferdinand. Enke, Stuttgart
2. DIN-Taschenbuch 100/1, Medizinische Instrumente
1, Grundnormen, Schneidende Intrumente, HNOInstrumente und Wiederaufbereitung, 5th edn. Beuth
3. Kaboth B (1943) Lehrbuch der Instrumentenkunde
für die Operationspraxis. Walter de DeGruyter &Co,
Berlin
4. Kuhn F (2016) Vitreoretinal surgery: strategies and
tactics. Springer, Berlin
5. Medizinprodukte-EU-Anpassungsgesetz –
MPEUAnpG. https://www.bundesgesundheitsmin-
isterium.de/fileadmin/Dateien/3_Downloads/
Gesetze_und_Verordnungen/GuV/M/Anpassung_
des_Medizinprodukterechts.pdf
6. Neue EU-Verordnungen. https://www.bundesge-
sundheitsministerium.de/themen/gesundheitswesen/
medizinprodukte/neue-eu-verordnungen.html
82 A. Petzold and F. Wilhelm
7. Normgerechte Darstellung der CE-Kennzeichnung.
https://upload.wikimedia.org/wikipedia/commons/
thumb/f/ff/CE_with_grid.svg/440px-CE_with_grid.
svg.png
8. Osterloh F (2024) drohen Engpässe. Dtsch Ärztblatt
118(22):1094–1095, 4.Juni 2021
9. Verordnung (EU) 2020/561 des europäischen
Parlaments und des Rates vom 23. April 2020 zur
Änderung der Verordnung (EU) 2017/745 über
Medizinprodukte hinsichtlich des Geltungsbeginns
einiger ihrer Bestimmungen: https://eur-lex.europa.
eu/legal-content/DE/TXT/PDF/?uri=CELEX:3202
0R0561&from=EN%20_blank. Zugriffsdatum Mai
2021
10. Was sind Medizinprodukte? https://www.bundesge-
sundheitsministerium.de/themen/gesundheitswesen/
medizinprodukte/definition-und-wirtschaftlichebedeutung.html
Suture Material
Erik Chankiewitz and Martin Knorrn
Contents
6.1 Suture ....................................................... 83
6.2 Needle ....................................................... 85
6.3 Packaging and Coding .......................................... 86
6
Healing requires contact! Traumatic or surgically created interfaces should come into
contact with each other using suitable suture
material, because only then will a “restitutio ad
integrum” – a complete healingresult. The healing of wounds is a highly complex cascade
in the interplay of cell biological mechanisms
such as inflammatory reactions, debridement,
cell migration, and fibroblast activity. A wound
is considered healed when it withstands all
natural mechanical stresses and no inflammation is present. In the eye, a satisfactory result
is always associated with the physical-optical,
mechanical, or biological function. For example, a single corneal suture can completely seal
a corneal incision and bring about healing, but
make vision imperfect due to suture-induced
astigmatism. A poorly treated eyelid wound can
lead to an ectropion and have serious effects on
E. Chankiewitz ()
Augenklinik, Städtisches Klinikum Braunschweig
gGmbH, Braunschweig, Germany
e-mail: erik@chankiewitz.de
M. Knorrn
Augenzentrum am Johannisplatz, Leipzig, Germany
the corneal surface, up to blindness. The correct
choice of suture material, as well as the proper
handling of it, is particularly important for the
treatment of wounds on the eye.
6.1 Suture
The surgical suture material to be used must meet
high-quality standards to ensure controlled healing. Nowadays, suture material is used exclusively as a strictly certified medical product.
Depending on the area of application and
task, the suture material must temporarily or
permanently take over the mechanical bridging
function to replace the lost tissue integrity. This
determines the choice of the right suture and
requires knowledge of its physical and biological
properties. Sutures made from organic materials
have been largely replaced by synthetic ones.
In ophthalmic surgery, sutures made of polyglactin, polydioxanone, polypropylene, polyester, and polyamide are predominantly used. Silk,
as a material of organic origin, is still used. Steel
wire is mentioned here only for completeness
and is no longer really used in the eye.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_6
83
84 E. Chankiewitz and M. Knorrn
Properties such as sterilizability, compatibility, high tensile strength, secure knot stability,
good knot run, good tissue glide, and the smallest possible capillarity are prerequisites for use
in surgery. Additionally, good visibility when
handling under the microscope is a particular
challenge in ophthalmology.
The properties of the suture can also be influenced by the type of processing. Thus, the suture
structure can be fundamentally distinguished as
monofilament and polyfilament.
A monofilament suture, consisting of only
one filament, is characterized by a smooth surface with low capillarity, without a sawing
effect, with good tissue passage, good knot glide
properties, but poorer knotting ability and easier
tissue passage (Fig. 6.1). A disadvantage is often
the stiffness in handling and the poor knotting
ability, which requires some practice and experience for secure knot placement. Examples of
available and often used monofilament sutures
are made from materials such as polyamide,
polypropylene, and PVDF (polyvinylidene
fluoride).
A polyfilament—or also referred to as “multifilament”—suture consists of a braided suture
structure, similar to a rope (Fig. 6.2). The filaments are intertwined, twisted, or both. This
results in very high tensile strength, optimal
flexibility, and secure knot stability, while tissue passage is more traumatic due to the surface
texture compared to the monofilament suture.
Typical examples of polyfilament sutures are
those made from silk and polyglycolic acid.
Another classification of suture material
describes the absorption property. A fundamental distinction is made between absorbable
and non-absorbable. A material is considered
absorbable if it can be completely broken down.
The absorbable thread gradually loses its tensile
strength in the process. The absorption time is,
by definition, the time in which the thread loses
50% of its knot tensile strength and should not
be confused with complete material breakdown.
The breakdown occurs enzymatically in animal
materials into protein chains and amino acids or
hydrolytically in synthetic materials into lactic
acid (lactate), glycolic acid (glycolate), water,
and carbon dioxide. Non-absorbable materials remain almost unchanged in the tissue.
Depending on the material properties, they are
incorporated into the scar tissue and remain or
must be removed after sufficient wound adaptation. For example, suture removal in the eyelid area can occur after five to ten days. Even
longer-lasting non-absorbable threads can
undergo changes due to degradation by light and
fluid, but complete breakdown does not occur.
A suture function exists only as long as the
tensile strength is present. Therefore, “a loose
thread is without function and should always be
removed or replaced.” In the same proportion as
the tensile strength decreases, the strength of the
wound should increase.
The half-life of an absorbable thread is
understood to be the time in which the tensile
strength has decreased to half of the original tensile strength.
Fig. 6.1 Monofilament suture
Fig. 6.2 Braided polyfilament suture
856 Suture Material
Table 6.1 Comparison of the different specifications for
the thread thickness of the suture material
USP PH.Eur.
metric mm range
11–0 0.1 0.010–0.019
10–0 0.2 0.020–0.029
9–0 0.3 0.030–0.039
8–0 0.4 0.040–0.049
7–0 0.5 0.050–0.059
6–0 0.7 0.070–0.079
5–0 1 0.100–0.149
4–0 1.5 0.150–0.199
3–0 2 0.200–0.249
2–0 2.5 0.250–0.299
1–0 3 0.300–0.349
0 3.5 0.350–0.399
1 4 0.400–0.499
2 5 0.500–0.599
3+4 6 0.600–0.699
5 7 0.700–0.799
6 8 0.800–0.899
7 9 0.900–0.999
8 10 1.000–1.099
The suture thickness (see Table 6.1) is defined
by the American and European compendiums
of standards for the quality of pharmaceuticals,
medical devices, and individual medical products.
While the American designation is largely used
in everyday surgical practice (USP: United States
Pharmacopeia), the underlying metric specification forms the basis of the European designation
(Ph.Eur.: European Pharmacopeia). The following
table lists the two designations for suture thickness
with the corresponding millimeter specifications.
6.2 Needle
In modern ophthalmic surgery, only atraumatic
needles, i.e., needles that are firmly connected
to the thread at the end in a sleeve (thus armed),
are used. There are threads with one needle (single-armed) or with two needles (double-armed).
The most important requirements for surgical
needles are absolute rust resistance, high bending strength, high fracture strength, good piercing and cutting ability, optimal penetration, and
secure fit in the needle holder.
In addition to the mentioned properties of the
material, there are form-specific features for the
needle cross-section, arc length, and needle curvature, as well as the needle tip, depending on
the area of application.
Most commonly, needles are used in 5/8, 1/2,
3/8, and 1/4 circles (Fig. 6.3). The choice of
length is determined by the spatial possibilities,
the tissue load, and to some extent the preferences of the surgeon.
The following will discuss the more commonly used needles.
The cutting needle
(Fig. 6.4a) has a dis-
tinctly sharp tip with long cutting edges that are
perpendicular to the direction of insertion. After
the long round body follows a secure shaft for
holding the needle. Very firm tissue, such as the
epidermis, can be sutured with minimal trauma.
The cutting needle with micro tip
(Fig. 6.4b) has a shorter, sharp tip that is flat to
the direction of insertion. Firm and loose tissue, such as eyelid skin or conjunctiva, can be
sutured with maximum tissue preservation.
The pointed round-bodied needle(Fig. 6.4c)
has a round tip and thus no cutting edge. The
puncture is microscopically always a crater-like
tear. It is suitable for loose tissue of all types.
The spatula needle (Fig. 6.4d) is a small
needle and has a sharp tip with a long cutting
edge. The puncture is atraumatic, i.e., without
tearing the tissue, and allows for secure and precise guidance without high penetration pressure.
It is suitable for firmer tissue in the eye, such as
the cornea and sclera.
The blunt round-bodied needle (Fig. 6.4e)
has no tip. A puncture is not possible (or very
traumatic) and is only suitable for looping eye
muscles or vascular ligatures, for example, in
temporal artery biopsy.
The straight needle (Fig. 6.4f) is thin and
without curvature. It has a slightly rounded tip.
The puncture is traumatic. Its application in the
eye involves guiding the long needle across the
entire width of the anterior chamber to adapt iris
tissue or to suture secondary intraocular lenses.
The so-called skin needle
(Fig. 6.4g) is a
long, thin needle with a slight bend at the end
and a slightly rounded tip. The puncture is traumatic. Its application in the eye also involves
86 E. Chankiewitz and M. Knorrn
ab c
String
Needle point
Needle
radius
Circle length
Needle body
Fig. 6.3 Circle length and needle structure
de f
Reinforcement
zone
Needle
diameter
g
Fig. 6.4 (a–g) (a) Cutting needle. (b) Cutting needle with micro tip. (c) Round-bodied needle. (d) Spatula needle. (e)
Blunt round-bodied needle. (f) Straight needle. (g) Skin needle
guiding the needle through the anterior chamber
when suturing iris tissue or secondary lenses.
identified. The other properties mentioned above
are clearly marked on the packaging (Fig. 6.5).
The following table (Table 6.2) is intended
6.3 Packaging and Coding
Safe and quick handling in the operating room
is an important prerequisite for a complicationfree, successful procedure. Based on the color
coding, the suture material can be immediately
to provide a recommendation for selecting the
appropriate suture material for each procedure.
The given recommendations can only serve as
a guideline for choosing the appropriate suture
material. Ultimately, the decision is made based
on the individual experiences of the surgeon
and the specific conditions in the surgical area.
Needle type
Thread thickness
Order number
Thread length
876 Suture Material
Disposable
product
Batch number
Clearly structured:
CE codes and barcodes
Fig. 6.5 Packaging labels using the example of an original package from the company Ethicon
Table 6.2 Recommendations for the selection of suture material
Anterior Segment Indication Material
Strabismus Polyglactin 6/0
Eyelid and Plastic Surgery Blepharoplasty Polypropylene 7/0
Retinal Detachment Surgery Scleral Buckling and
Sterilization type
Conjunctiva Polyglactin 7/0–8/0
Glaucoma Polyglactin 10/0
Cornea Polyamide 10/0
Iris Suture Polypropylene 10/0
IOL Lens Fixation Polypropylene 10/0
Chalazion Polyglactin 6/0–7/0
Levator Resection/
-Folding
Cerclage Suturing
Expiry day
Polyamide 10/0
Polyglactin 6/0–7/0
Polypropylene 7/0
Suturamid 4/0
Strength