Annals of the Royal College of Surgeons of England
Sutures, incisions, and anastomoses
W G Everett Mch FRCS FRCSEd
Consultant Surgeon, Addenbrooke's Hospital, Cambridge
Summary
The properties of different types of suture
material are reviewed, with particular refer-
ence to the complications which may result
from their use. The aetiology, prevention,
diagnosis, and treatment of wound dehiscence
are discussed. The factors which are believed
to be important in performing successful
bowel anastomosis are considered.
Introduction
Suture materials are required, in practically
every surgical operation, for reconstruction of
incised or damaged tissues and for the liga-
tion of major blood vessels. Some of the com-
plications following surgery may be directly
attributable to the suture material itself. It is
therefore essential that every surgeon, what-
ever his specialty, should have a knowledge
of the properties and behaviour of different
sutures because the type of material he uses
will undoubtedly influence the results of his
surgery.
Properties of suture materials
There are four important properties common
to all suture materials: the intensity of the
inflammatory response which the particular
material evokes in the tissues; the behaviour
of the material in the presence of infection; its
durability; and its handling ability.
Inflammatory response All materials
induce a certain degree of inflammatory reac-
Postgraduate Lccture
(I974) vol 55
tion in the tissues in which they are implanted.
This is greatest in the case of plain catgut
and the reaction is diminished and delayed if
the catgut is treated with chromic salts.
Braided natural and synthetic materials cause
less tissue reaction than catgut, and the mono-
filamentous materials, which are almost inert,
cause the least reaction of all. There is thus
a spectrum of tissue reaction produced by the
various materials' ranging from the mono-
filamentous materials at one end of the scale
to plain catgut at the other (Fig. i). In gen-
eral, the thicker the material the greater is
the reaction produced2.
The degree of tissue reaction caused by
the sutures has two important consequences.
Firstly, an excessive tissue reaction will lead
to impairment of the strength of the tissues.
This decreases the holding power of the
stitches, which consequently tend to cut out.
In other words, materials which cause the
least tissue reaction generally produce the
strongest closure3'4. Secondly, there is some
evidence that infection is more likely to occur
in wounds sutured with materials which cause
excessive tissue reaction5.
There is therefore an apparent advantage
in using synthetic monofilamentous materials
of fine gauge which produce minimal tissue
reaction. Contrary to common belief, fine su-
tures are not more likely to cut through the
tissues than thick ones.
32 W G Everett

TISSUE REACTION MATER IAL

MONOFILAMENTOUS SYNTHETIC MATERIALS:
(Wire, Nylon, Polypropylene)
TWISTED OR BRAIDED NATURAL AND SYNTHETIC

*l
MATERIALS (cotton, linen, silks Dacron)
POLYGLYCOLIC ACID
CHROMIC CATGUT
PLAIN CATGUT

FIG. I Spectrum of tissue reaction produced by various suture

materials.
Behaviour of the material in the pre-
sence of infection It has been recog-
nized for many years that chronic discharging
sinuses are common in infected wounds where
these have been closed with braided materials.
Approximately 8o% of infected wounds de-
velop sinuses when silk suture material has
been used6'7. This figure probably applies to
all the braided materials, including synthetic
sutures. The infection persists until the offend-
ing suture material is extruded or removed,
and when this complication develops after
hemiorrhaphy the result can be quite dis-
astrous.
Because of this unfortunate experience with
silk, surgeons have been reluctant to use any
non-absorbable material in a contaminated
wound. What is not generally recognized is
that the incidence of sinus formation is low
in infected wounds closed with monofilamen-
tous materials, and is of the order of 6%7-9.
It is uncommon for sinuses to result from
suture materials buried in the abdominal
cavity. In this situation any of the braided
natural or synthetic materials can be used
safely, even in a contaminated field.
Durability of the suture material It
is essential that sutures should retain adequate
strength until the wound is firmly united. In
some situations, where there is little tension
on the tissues, suture support is necessary only
until they are united by fibrinous adhesion,
a process which takes less than 24 hours. In
other circumstances, such as after hemior-
raphy, indefinite support by the suture may
be desirable.
The absorption of Catgut is uncertain and
may be influenced by vascularity of the tis-
sues and infection. Polyglycolic acid is ab-
sorbed less rapidly than catgut10 but, even
so, it is doubtful if it retains adequate strength
to support an abdominal incision when heal-
ing is grossly impaired,
The durability of different non-absorbable
suture materials has been investigated by im-
planting sutures into animal tissues""2. It was
found that silk, linen thread, Teflon, and cot-
ton had no strength at all after 6 months,
and even multifilament nylon had lost 8o%
of its strength after a year. Monofilamentous
materials, on the other hand, showed only
minimal loss of strength. These, therefore, are
the materials of choice for operations such
as herniorraphy where the material forms an
integral part of the repair.

Handling ability Any suture material
should, ideally, be easy to handle and form
a secure knot. For this reason the braided
materials are the most popular, but the con-
siderations already mentioned are of greater
importance when the material is used in
superficial tissues. The monofilamentous ma-
terials are more difficult to handle, but they
can be knotted securely using a double reef
knot squarely tied.
Unfortunately no single material possesses
all the characteristics one might desire. The
surgeon must therefore learn which is the
most appropriate suture material to use for
any given operative situation.
Incisions
The main consideration in making an abdo-
minal incision is that it should provide the
best possible access to the anticipated site of
disease. The type of incision used and the
siting of the incision should be planned accor-
dingly. This will be influenced by the personal
preference of the surgeon, the build of the
patient, and the confidence of the diagnosis.
DEEP
SUPERFICIAL
I
FIG. 2 Classification of wound dehiscence.
Sutures, incisions, and anastomoses 33
There are two important complications of
abdominal incisions wound disruption and
infection.
Wound disruption Aetiology Wound
disruptions can be classified as: (a) superficial,
(b) deep, and (c) complete (Fig. 2). Superficial
disruptions are usually the result of infection.
When the skin stitches are removed the super-
ficial layers part but the deep layers remain
intact. If the deep layers disrupt but the skin
layer heals, an incisional hernia develops. If
both superficial and deep layers part, a com-
plete disruption or burst abdomen results.
The exact point in time when wound dis-
ruption occurs after surgery is difficult to esti-
mate, and indeed it is often apparent only
when the skin sutures are removed and the
abdomen bursts. It is quite clear, however,
that in many instances the disruption has oc-
curred many days previously, as indicated by
the fact that the abdominal viscera are ad-
herent to the deep edges of the wound. It
seems probable that the majority of disrup-
tions develop within the first few days of
COMPLETE
I.t
34 W G Everett
surgery, when the disrupting forces such as
coughing, vomiting, and distension are great-
est. The violent muscular contractions induced
by pharyngeal and tracheal suction catheters
at the end of the operation may be a potent
cause of wound disruption. In this event the
disruption may occur even before the patient
leaves the theatre, although it will usually
remain undetected for several days.
In the healing wound two opposing forces
are involved. On the one hand there are
forces resulting in the rise of intra-abdominal
pressure, tending to cause disruption. Cough-
ing, vomiting, and abdominal distension are
commonly associated with a burst abdo-
men13"5. On the other hand the sutures and
the healing tissues of the wound tend to
resist these disrupting forces. The wound
gives way either because of failure of the
sutures or because of failure of the tissue
to hold them, leading to their cutting out.
In practice, tuntying of knots or break-
age of non-absorbable suture material is
an uncommon cause of disruption; but
dehiscence due to the premature absorption
of catgut is well recorded"''1 . The reliability
of any absorbable material is doubtful, par-
ticularly in the presence of infection. In pan-
FIG. 3 Abdominal wound showing closure of the deep layers.
These have been loosely approximated and the suture material
is clearly visible.
creatitis or in the presence of an intestinal
fistula catgut is rapidly absorbed9.
A small proportion of wound disruptions
are undoubtedly the result of the premature
absorption of catgut. For this reason non-
absorbable material should be used for gen-
eral closure. The majority of burst abdomens
and incisional hernias are not, however, due
to failure of the suture material but to the
sutures cutting out of the tissues.
Prevention Little can be done to over-
come the forces which tend to cause wound
disruption. The surgeon's efforts must there-
fore be directed towards suturing his wounds
so that they are sufficiently strong to resist
these forces. Absorbable materials should be
avoided because of their doubtful reliability.
The technique of suturing is important.
Large bites of tissue should be taken with each
stitch, and where the tissues are particularly
weak the needle should be placed as far as
'2 cm from the wound edge. There is a lot
to be said for all-layer closures in which all
the deep tissues are sutured as one layer"8. It
is important that the suturing is not tight,
otherwise cutting-out will occur from tissue
ischaemia. Suturing should be loose and just
produce apposition of the wound edges. When
 Sutures, incisions, and anastomoses 35
performed with the correct tension the suture lapse of the intestine through the wound re-
material should be clearly visible in the wound suture is mandatory and can be performed in
(Fig. 3). the manner already outlined by closing the
Although deep-tension sutures are still pop- deep tissues in a single layer.
ular, they have limited value and it is doubt- Infection The incidence of infection in
ful if their use diminishes the incidence of clean abdominal wounds is of the order
wound disruption. To be effective they should of 5/. Where the upper intestinal tract is
be placed at intervals of about 3 cm, other- opened this figure rises to approximately
wise bowel may herniate between them. De- IO%, and when pus is encountered or
hiscence may occur if they are removed the large bowel opened the infection rate is
before the I4th postoperative day. When tied over 15%.
too tight they tend to cut through the skin, Because so many abdominal wounds are
resulting in pain and unsightly scars. When contaminated by bowel organisms, surgeons
too loose they are ineffective. Because of these have in the past been reluctant to use non-
disadvantages it is preferable to suture the absorbable suture materials for general clo-
deep layers only, taking large bites of tissue sure. This fear was, as already mentioned,
and using non-absorbable material. based on the high incidence of chronic wound
Diagnosis and treatment Wound dehis- sinuses experienced with silk',7. If a mono-
cence should be suspected whenever sero-
sanguinous fluid drains from an abdominal
wound. If this ebbs and flows with respira-
tion or appears on coughing the diagnosis of
disruption is certain. This situation is often
best managed conservatively as the risk of re-
suture is not inconsiderable. Approximately
one-third of the patients who have a burst
abdomen repaired eventually end up with an
incisional hernia1920. While the skin sutures
hold, a conservative policy should be adopted
and the hernia dealt with at a later date, when
the chances of a successful repair are greater.
Tension should be taken off the suture line by
applying Elastoplast strapping across the
wound and the stitches left in place until it
is soundly healed.
Wound disruption is not always accom-
panied by leakage of serosanguinous fluid, be- FIG. 4 Grossly infected wound closed with
cause the deep layers of the wound may be monofilament nylon showing healing without
sealed by the underlying viscera. In these extrusion or removal of the suture material.
circumstances ileus or intestinal obstruction (a) Infected wound io days after surgery.
may result, and disruption should always be (b) The same wound 3 weeks later showing
suspected in the absence of other more ob- that the nylon has become incorporated in
vious causes of postoperative ileus. the healing granulation tissue. Reproduced by
When a burst abdomen occurs with pro- permission from Progress in Surgery'.
3(6 14J G Ererett

filamentous material is used the incidence of may be damaged: (i) during mobilization of
wound sinus is small7 S. the splenic flexure; (2) in closure of the mesen-
Monofilament nylon can be used to close tery (which, in an anterior resection, is un-
the dirtiest abdominal wounds and, even if necessary); and (3) in the formation or closure
infection occurs, they will heal satisfactorily of a colostomy. For this reason, a colostomy
without sinus formation or extrusion of the
suture material9. This is illustrated in Figure
4, which shows a grossly infected wound in a
patient who had a large-bowel perforation.
The wound eventually healed by granulation
, ......
and none of the nylon was removed or
extruded.
Anastomoses
An intestinal anastomosis may be thought of
as a circumferential wound which has been
sutured in a contaminated field and, as with
abdominal wounds, the most significant com-
plication is disruption. I am going to discuss
mainly colonic anastomosis, although many of
my remarks apply to an anastomosis anywhere
in the gastrointestinal tract.
There are three fundamental considera-
tions: the blood supply to the bowel ends; b
the technique of suture; and the adherence
of surrounding structures.
Blood supply An adequate blood supply
is the first essential for any successful anasto-
mosis. Indeed, it is probable that when gross
leakage occurs from a suture line the blood
supply to the bowel ends has in most cases
been inadequate.
The colon receives its arterial supply from
vasa recti which originate from the marginal
artery. This is situated about 2.5 cm from the
mesenteric border of the bowel and is fed
by the major branches of the superior and FIG. 5 Preservation of blood supply to the
inferior mesenteric systems. colon. (a) The distal vasa recti have been
If, during resection of a carcinoma, the in- occluded in ligation of the marginal artery.
ferior mesenteric artery is ligated at its origin (b) The most distal vessel may be occluded
from the aorta, then the left colon is entirely by a stitch (at point X) thus impairing the
dependent on the marginal vessel for its blood blood supply to the antimesenteric border of
supply. Its careful preservation is absolutely the bowel. (c) The best blood supply is ob-
essential. There are three ways in which it tained by dividing the bowel obliquely.

should always be sited to the right of the
middle colic vessels.
There is virtually no anastomosis between
the tributaries of the vasa recti in the long
axis of the bowel. Therefore preservation of
these vessels, supplying the cut end of the
bowel, is most important. To prevent these
most distal vessels being damaged by inclusion
in a ligature (Fig. 5a) the marginal artery
should be tied 2.5 cm distal to the point at
which the bowel is to be transected. If the
bowel is divided straight across, then the vas-
cularity of the antimesenteric border may be
jeopardized by a stitch which occludes the
most distal of the vasa recti (Fig. 5b). It is
therefore wise to transect the colon obliquely,
because this wvill provide the best blood supply
to the bowel end (Fig. 5c).
It is absolutely essential to check that the
blood supply is adequate before the anasto-
mosis is started. If there is the slightest doubt
about this, then the bowel should be cut back
until there is brisk bleeding.
Technique of anastomosis Halstead in
I887 demonstrated that only one layer of the
bowel had any significant strength, and this
was the submucosal layer21. It is in fact this
layer which is used to make catgut. Halstead
pointed out that any stitch placed in the bowel
wall should pick up this layer; and he de-
monstrated that leakage occurred when the
mucosa and seromuscular layer only were
sutured.
Conventionally, anastomoses are performed
in two layers, using an inner layer of continu-
ous catgut through all the coats of the bowel
wall and an outer seromuscular layer (which
should pick up the submucosa). For the colon,
where the blood supply is precarious, inter-
rupted non-absorbable sutures are preferable
for the seromuscular layer.
There has been much experimental work
on the relative merits of different techniques
of anastomosis-narnely, one-layer or two-
Sutures, incisions, and anastomoses 37
layer, inversion or eversion-and the results
are extremely confusing. The accurate placing
of the sutures is probably more important
than whether the anastomosis is performed
in one or two layers or whether it is inverted
or everted.
A controlled trial of a one-layer compared
with a two-layer technique for anastomoses
of the left colon has been performed. The
integrity of the anastomosis was assessed radio-
logically by a barium enema on the I oth
postoperative day. It was found that there
was no significant difference between the two
groups when the anastomosis was performed
above the pelvic peritoneum. For anasto-
moses performed below the pelvic peritoneum
leakage occurred more frequently when a two-
layer technique was used, and this probably
reflects the difficulty of using this technique
low in the pelvis, where a one-layer closure
is relatively easier.
The type of suture material used for anasto-
mosis has received little attention. In theory,
suture materials causing the least tissue reac-
tion should be less likely to cut out and result
in stronger anastomoses. In an experimental
study anastomoses performed with non-ab-
sorbable materials were found to be signi-
ficantly stronger than those in which catgut
was used9',2. It would therefore seem advis-
able to use a non-absorbable material for
oesophageal and large-bowel anastomoses
where there is a significant incidence of
dehiscence.
Non-absorbable sutures should not be used
for gastric anastomoses, where they may cause
stomal ulceration, nor for techniques applied
to the actual biliary tract or genitourinary
system, where they may form calculi.
Adherence of surrounding structures
When experimental anastomoses are carefully
examined it is found that, almost invariably,
leakage of a minor nature has developed
 38 W G Everett
around the suture line22. This is usually
sealed off by the adherence of surrounding
fat or bowel so that it is of no consequence.
If this sealing-off effect is prevented in an
experimental situation by surrounding the
anastomosis with a membrane of polyethylene,
major leakage and peritonitis result23'24. A
similar effect can be produced by placing a
drainage tube in contact with the anasto-
mosis25.
It is clear that minor leakage from an
anastomosis is very common and that more
widespread breakdown and peritonitis are
prevented by the adherence of surrounding
structures. It is perhaps significant that the
highest incidence of anastomotic breakdown
occurs in the chest following oesophagojejunal
anastomosis and in the pelvis following low
anterior resection of the rectum. In both these
situations physical contact of surrounding vis-
cera with the suture line may be prevented.
Conclusion
As in all surgery, whether suturing an ab-
dominal incision or fashioning an anastomosis,
good results are achieved only by careful
attention to many points of technical detail.
I have attempted to outline some of those
which I consider to be of greatest significance.
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