Use insight when selecting sutures


Gone are the days when the practitioner turns to the suture material cabinet and only has a couple of choices for suture materials.

Gone are the days when the practitioner turns to the suture material cabinet and only has a couple of choices for suture materials.

Specialization in the medical field has driven companies to make a wide variety of suture materials.

While the surgeon has many options, the choices can sometimes be confusing and expensive. My goal is to shed light on the different types of suture material and on how to select the appropriate type of suture material for particular situations.

Suture basics

In most cases suture material can be separated into four main categories: absorbable or non-absorbable and monofilament or multifilament (braided).

(Table 1 provides a partial listing of more common suture materials, their respective categories and manufacturers.)

Table 1: Partial listing of common Suture Types

Most suture materials can be purchased with a swedged on needle. While many people frown upon the expense of suture packets with swedged on needles, the advantages far outweigh the added cost. Swedged on needles generally produce less tissue trauma when passing the needles through the tissue by reducing the amount of suture material (the suture is not doubled) and by having sharper needles (single use).

Absorbable sutures, when buried beneath the skin's surface, are absorbed by the body. (See Table 2.) Most absorbable sutures begin to absorb shortly after suture placement and are usually organized into categories based on how long they maintain their tensile strength.

Table 2: Suture Characteristics: Absorbable versus Non-absorbable

Suture materials that maintain their strength for relatively longer periods of time (21 days or longer) include Maxon, Dexon, Polysorb, Vicryl and PDS. Suture materials that do not maintain their strength for 21 days include Biosyn, Monocryl, and chromic gut. Most newer suture materials are made of synthetic materials, giving them more consistent absorption times through the process of hydrolysis. Only gut is made from a naturally occurring material (the submucosal layer of sheep small intestine).

Absorbable sutures are inherently more inflammatory in the short term, but less inflammatory in the long term than non-absorbable suture materials because they are no longer present in the wound.

In general, absorbable sutures should be used when the suture will be buried. Absorbable suture can be used in the skin in areas that suture removal would be difficult as long as the client knows that the suture may last for 60 days or longer.

Non-absorbable suture materials can be less inflammatory than absorbable suture materials, but in some cases cause a much more severe inflammatory response (silk is an example of a very inflammatory suture material). (See Table 2 Suture Characteristics: Absorbable versus Non-absorbable).

Table 3: Suture Characteristics: Monofilament versus Multifilament

Non-absorbable sutures are often used in the skin, or buried in areas where the suture must maintain strength beyond that normally achievable with absorbable suture material. If non-absorbable suture is required for holding strength beyond the typical absorption time, monofilament non-absorbable sutures should be used to minimize the inflammatory response.

Monofilament sutures tend to be less reactive, and cause less of an inflammatory response than braided sutures (see Table 3). Monofilament suture materials generally have more memory than multifilament, and the handling characteristics are generally considered poorer than when using a multifilament suture material.

Multifilament suture material has been proposed to increase the chance of wicking bacteria and other contaminants over what occurs with a monofilament suture material.

Photo 1: Skin incision closed with surgical skin staples just prior to staple removal.

When performing skin or intestinal surgery, use a monofilament suture material to reduce chances of wicking bacteria into the depths of the wound.

The choice between monofilament and multifilament is usually based on surgeon's preference. (My preference is a monofilament in most surgical instances.)

Surgical staples

Surgical staples are available in stainless steel and titanium. They are very inert, and have been suggested to reduce surgical time. Staples are available as ligature clips, automated stapling devices used in gastrointestinal, urogenital, and thoracic surgery, and for skin closure. Recently, techniques have been described to use one of the stapling devices (LDS, US Surgical) to ligate the vasculature in castrations. Surgical staples can often reduce surgical time, but tend to be more expensive than other suture materials (Photos 1 and 2, p. 1E).

Photo 2: Formed with a GIA 90 from US Surgical at the time of surgery and six months following surgery.

Knot geometry and suture size

Knot geometry is very important in the volume of suture material that is buried in a wound. The larger the suture, the greater the volume. The more suture throws, the greater the volume. In one study, using a multifilament suture, increasing the suture size from 4-0 to 2-0 resulted in a four- to six-fold increase in knot volume and three- to four-fold increase in tissue reactivity. Consequently, using a surgeon's throw adds more foreign material to the wound. More foreign material will lead to a greater inflammatory response.

Photo 3: Cruciate pattern sutures in the supraorbital skin using Maxon suture material.

In general, the surgeon should use the smallest size of suture possible, with the least amount of throws possible and only use a surgeon's throw when necessary.

Specific suture uses


I recommend use of a monofilament suture material in the skin such as nylon or Maxon (Photos 3 and 4). A cutting needle should be used to reduce the trauma of forcing a taper point needle through the skin. Skin staples are beneficial to reduce surgical time. (Photo 1) Skin staples are particularly useful in treating lacerations of show horses where use of a local anesthetic may be disallowed. With a twitch and a skin stapler, the skin edges can be apposed without the use of local anesthetic.

Photo 4: Simple interrupted sutures in the sub-ischial region of a horse after en-bloc penile resection using Maxon suture material.

Gastrointestinal system. The appropriate choice of suture material in the gastrointestinal tract is very important. If the wrong suture is chosen, and the suture absorbs prior to healing of the bowel wall, the anastomosis can break down, leading to peritonitis. Chromic gut is very quickly absorbed in gastric or intestinal juices making it a poor choice for bowel closure, especially if the suture penetrates the lumen of the bowel.

The newer synthetic sutures are much better choices for bowel closure and have more consistent absorption characteristics. Multifilament suture materials have less memory and many consider them to have better handling characteristics. However, they are more likely to allow wicking of bacteria from the lumen of the bowel to the serosal surface and peritoneal cavity.

Photo 5: Handsewn two-layer end-to-end anastomosis using absorbable monofilament suture material.

Monofilament suture materials tend to be less reactive thereby causing less inflammatory response, perhaps leading to better anastomotic healing. (Photo 5) It is important to use only as much suture material as necessary to reduce the amount of inflammation. Stapling devices have been designed for bowel closure, and have been reported to reduce the amount of surgical time and contamination. (See Photo 2)

Urogenital system. The structures in the urogenital system tend to heal very quickly. Consequently it is not as critical to have the suture maintain its strength as long as it is necessary in other structures.

Sutures like Biosyn or Monocryl can minimize the likelihood of leaving a nidus for stone formation in the bladder. Highly reactive suture materials such as chromic gut are not the best choice for bladder surgery. If possible the lumen of the bladder should not be penetrated to reduce the possibility of stone formation. (Photo 6) Staples have been associated with stone formation, and probably should not be used in the bladder.

Photo 6: Bladder closure after traumatic rupture using Monocryl suture material.

The uterus also heals very quickly, and adds the concept of involution after cesarean. It is important to use a suture pattern that minimizes the amount of suture present on the peritoneal surface of the uterus. The uterus is a good area to use a rapidly dissolving suture material such as Biosyn, Monocryl or chromic gut.

Body wall. Closure of the body wall will differ according to the approach and consequently the tissue layers that are incised. It is important that the holding layer (for example the linea alba in a ventral midline approach) be closed with suture that will maintain strength long enough to allow the tissue to heal before absorption is complete. Many newer synthetic absorbable suture materials are very good choices for suturing the holding layer of the body wall and may reduce the possibility of suture sinus formation under the skin.

Table 4: Common Suture Uses


While the choice of suture materials is still up to the surgeon, certainly some materials are better suited for certain indications than others. Table 4 lists many of the readily available suture materials along with suggested uses.

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