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com

Surgical stapling provides

a quick and effective
alternative to manual
suturing in certain
circumstances, such as
for skin apposition

Suture materials
and patterns JACQUI NILES AND JOHN WILLIAMS

SUTURES are used either for apposing tissues or for ligation, and a variety of different types of suture
material is currently available. Suture selection should be based on knowledge of the physical and
biological properties of suture materials, an assessment of the healing rate of a particular tissue and local
conditions in the wound. The ideal properties of a suture material have yet to be fulfilled by any single
product on the market. The purpose of this article is to outline the properties of the available suture
materials and to give an indication of when and how to use them.
Jacqui Niles qualified
from the Royal CLASSIFICATION OF SUTURE MATERIALS
Veterinary College, 191 :I 41,71 f-Ill
London, in 1993. She Natural fibres* Synthetics
is a resident in small Suture materials are broadly clcassified as absorbable or Monofilament Multifilament
animal soft tissue
surgery at Liverpool non-absorbable. They can be further classified as syn-
Surgical gut Polydioxanone Polyglycolic acid
University and holds thetic or natural fibre and they may be multifilament or Plain (PDS; Ethicon) (Dexon; Davis & Geck)
the RCVS certificate in (PDS Il; Ethicon) (Dexon Il; Davis & Geck)
small animal surgery. monofilament, coated or uncoated. Chromic
Her special interests Polyglyconate Polyglactin 910
include all aspects of (Maxon; Davis & Geck) (Vicryl; Ethicon)
soft tissue surgery, (Vicryl Rapide; Ethicon)
especially the surgical ABSORBABLE SUTURES Poliglecaprone 25
management of (Monocryl; Ethicon)
portosystemic shunts
and chylothorax. All absorbable sutures Lindergco degradation in the tissue * All are multifilament but fused, so that they are essentially
and lose their tensile strength within 60 days. They are monofilament
absorbed by mieans of the body's defence system and all
will therefore produce so5ic tissuc rcaction. Absorbable
sutures are principally designed for use in closint Surgical gut
internal tissue layers or organs which do not require long Surgical gut (catgut) is prepared from the submucosa of
term support. There arc some exceptions to this - the sheep or cattle small intestine. After implantation, gut is
newer synthetic monofilaiment absorbables, such as absorbed by a combination of enzymatic degradation and
John Williams
polydioxanone (PDS 11) and polyglyconate (Maxon), phagocytosis; the rate of absorption is thus affected by
qualified from are designed to provide
p I :I :0 Y, Y-IltI
Cambridge University extended wound support. It is
in 1984. He holds the
certificate in important to remember that all Tensile strength Breaking strength per unit area
veterinary radiology, absorbable sutures will lose
and an FRCVS, and is their tensile strength before Knot security Related to surface frictional characteristics
a diplomate of the
European College of they are absorbed. Memory The property to unkink after loops have been formed during the
Veterinary Surgeons. There has been a trend development of a knot. Suture materials with a high memory
He is currently director (eg, polypropylene) tend to revert to their package shape
of small animal studies towards using absorbable
at Liverpool University sutures in infected surgical Chatter/tissue drag Lack of smoothness when sliding down a knot or friction while
and is an RCVS passing through tissue
Specialist in Small sites as they will rarely provide
Animal Surgery (Soft a nidus for further infection. Tissue reaction Tissues respond to the implantation of sutures as they do to other
Tissue). His clinical foreign material. Sutures can evoke an acute or chronic inflammatory
interests lie in However, enzymatic process- response
portosystemic shunts, es may, in fact, increase the
and reconstructive degradation process and make Capillarity and Tendency to wick, allowing fluid and infection to move along the
and cardiorespiratory resistance to infection suture
surgery. the suture unreliable.

308 In Practice * J U N E 1 999

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**SLlloll
-ml1 I0 0o ~ I 'Memory' of three different
absorbable suture materials:
Catgut Absorption time (top) polyglactin 910
(Vicryl) - low memory;
Plain untreated 10 days (middle) poliglecaprone 25
Mild chromicisation 14 days
(Monocryl) - higher memory
than polyglactin but still
Medium chromicisation 21 days easy to handle;
(bottom) polydioxanone
Prolonged chromicisation 40 days (PDS II) - high memory,
hence knots must be tied
carefully
vascularity and infection. There is always a mild to
severe inflammatory response to surgical gut and more
so in cats than in dogs. Large diameter gut can act as a
nidus for infection when placed in contaminated sites.
Because phagocytosis is important in its absorption,
gut tends to lose its tensile strength rapidly and in a non-
predictable fashion. Chromicisation reduces soft tissue implantation. PDS is very strong and causes little tissue
reaction to the gut - thus, chromic gut maintains its ten- reaction and less tissue drag than multifilament suture
sile strength for longer than plain gut. materials. Improvements have been made in its handling
Catgut handles well as a material in moderate gauges characteristics (PDS II), but care is required when tying
but knots which may be secure when dry have a tenden- knots because of its high memory.
cy to swell and untie when wet. It is therefore important
always to place at least three throws on a knot (see tables Polyglyconate
on page 316). Catgut also has a tendency to fracture Polyglyconate (Maxon) is a monofilament suture materi-
when knots are tied. al with similar tensile strength to PDS. It also loses its
strength in a similar fashion: ie, 19 per cent after 14
Polyglycolic acid days, 41 per cent after 28 days and 70 per cent after 42
Polyglycolic acid (PGA; Dexon, Dexon II) is a braided days. It is absorbed by macrophages between six and
multifilament suture which is absorbed by hydrolysis. seven months after implantation.
Dexon II has a polycaprolate coating which improves
its handling characteristics, particularly when wet.
Although initially very strong, PGA rapidly loses its
strength (ie, 33 per cent loss in seven days and 80 per Tissue reaction elicited by a variety of
cent within 14 days), particularly in an alkaline environ- different absorbable suture materials.
Pictures reproduced, with permission, from
ment. It is completely absorbed within 120 days and Ethicon
associated with a markedly reduced inflammatory
response compared with catgut. PGA is well tolerated in
both clean and infected wounds. Its disadvantages
include its tendency to drag through tissue and, possibly,
poorer knot security in comparison with catgut.

Polyglactin 910
Polyglactin 910, day 14. There is minimal
Polyglactin 910 (Vicryl), a braided suture which is coat- tissue reaction around the suture
ed to improve its handling and knotting characteristics, is
more resistant to hydrolysis than PGA. Vicryl loses 50
per cent of its strength by about two weeks and is totally
absorbed within 60 to 90 days. Polyglactin sutures are
well tolerated in many different wound conditions, have
an excellent size to strength ratio, are relatively easy to
handle, stable in contaminated wounds and elicit mini-
mal tissue reaction.
Changes to the manufacturing process produce Vicryl
Rapide, a braided material which provides approximate-
Chromic catgut, day 7. The suture is
ly 66 per cent of the initial tensile strength of coated surrounded Chromic catgut, day 28. There is continued
by a wide zone of active tissue active cellular tissue reaction
Vicryl. It loses 50 per cent of its strength by five days reaction
post-implantation and all tensile strength is lost between
10 and 14 days. Absorption by hydrolysis is essentially
complete within 42 days. When used in the skin, Vicryl
Rapide typically falls off in seven to 10 days or can be
wiped off, thus negating the need for suture removal.

Polydioxanone
Polydioxanone (PDS) is a monofilament suture that, like
PGA and polyglactin 910, is degraded by hydrolysis, but
at a slower rate. It loses 26 per cent of its tensile strength
after 14 days, 50 per cent after 28 days and 86 per cent
after 56 days. Absorption is complete at 182 days after
Polydioxanone, day 7. The area of tissue
reaction is minimal
I
Polydioxanone, day 28. The suture is
surrounded by a narrow mature zone of
tissue reaction

In Practice * J UNE 1999 3311

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is inferior to many other suture materials in strength and

knot security. Silk should not be used in the lining
epithelium of hollow viscera and should be avoided in
contaminated wounds.

Poliglecaprone 25
(Monocryl) in rapid dispense
packaging
Poliglecaprone 25
Poliglecaprone 25 (Monocryl) is a relatively new
monofilament suture that is prepared from a copolymer
of glycolide and E-caprolactone. Dyed and undyed
forms are available. Progressive loss of tensile strength
and eventual absorption occurs by means of hydrolysis,
with the dyed form losing all its original strength by 21
days post-implantation and the undyed form by 28 days.
Poliglecaprone elicits a minimal inflammatory reaction
in tissues, is easy to handle (having lower memory than
the other monofilament synthetic absorbables) and has
good knot security.
Nylon
Nylon is available as both a monofilament (Ethilon,
Dermalon) and multifilament (Surgilon, Supramid)
suture material. It causes minimal tissue reaction and,
when used in veterinary work, is regarded as permanent
(although it loses 30 per cent of its original tensile
strength by two years as a result of slow hydrolysis).
The main disadvantages of nylon are its poor
handling characteristics and knot security. The braided
forms handle and knot better but suffer from inherent
capillarity. Nylon should not be used within serosa or
synovial cavities because buried sharp ends may cause
irritation.
Polyester
Polyester (Mersilene) is a braided multifilament suture
material available in plain and coated forms. It is
extremely strong and offers prolonged support for slow
healing tissues. It has poor knot security and causes the
most tissue reaction of any of the synthetic suture
materials.

NON-ABSORBABLE SUTURES
Non-absorbable suture materials are not degraded during
the healing process although they do become encapsulat-
ed with fibrous tissue and remain permanently within the
tissue unless they are extruded or removed. They are
designed for use where prolonged mechanical support is
required until sufficient healing has occurred to maintain
tissue apposition.
Non-reactive non-absorbables can be buried within
tissues or organs to support slow healing tissues. They
do not need to be removed as they are generally well
tolerated by the body.
Silk
Silk is available as a braided multifilament suture mater-
ial (Mersilk), which may be coated to decrease its natur-
al capillarity. Although classified as a non-absorbable, it
slowly loses tensile strength and is absorbed within
approximately two years of implantation.
Silk is inexpensive and has excellent handling charac-
teristics. However, it causes marked tissue reaction and
Polypropylene
Polypropylene (Prolene) is a monofilament suture that
has a lower tensile strength than nylon. It retains its
strength on implantation, is not weakened by tissue
enzymes and is the least thrombogenic suture. It is there-
fore frequently used in vascular surgery. Its disadvan-
tages are its high memory and poor knot holding ability.
Polybutester
Polybutester (Novafil) is a special type of polyester
suture which possesses many of the advantages of both
polypropylene and polyester. It has good tensile strength
and knot security.
Stainless steel
Stainless steel is available as a monofilament or multifil-
ament suture. It is biologically inert, non-capillary and
has the highest tensile strength of all the suture materi-
als. Its main use is in tendon and ligament repair.
The disadvantages of stainless steel include its
tendency to cut tissues, its poor handling characteristics
(especially in knot tying) and relatively poor ability to
withstand repeated bending without breaking.

OTHER OPTIONS FOR TISSUE APPOSITION/

*
iI]0wl il-4*1 AFVi LGATION
Natural fibres* Synthetics
Monofilament Multifilament Tissue adhesives
Silk Nylon 66 and nylon 6 Polyester Tissue adhesives have been used experimentally and
(Mersilk; Ethicon) (Ethilon; Ethicon) (Mersilene; Ethicon) clinically in the management of comeal lacerations, in
(Dermalon; Davis & Geck) the control of haemorrhage from the cut surface of
Linen Nylon
Polypropylene (Surgilon; Davis & Geck) parenchymatous organs, and for cutaneous skin incisions
(Prolene; Ethicon) (Supramid; Bayer) and skin grafts. The cyanoacrylates have been used most
Polybutester Stainless steel extensively. Tissue toxicity can be a problem, as can
(Novafil; Davis & Geck) granuloma formation, wound infections when used in
Stainless steel contaminated sites, delayed healing if the wound edges
are separated, and poor adhesion on excessively moist
*
All are multifilament
surfaces.

312 In Practice * J U N E 1 999

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Skin stapler being used to

close a wound on the distal
limb of a dog

Use of skin staples to

allow rapid closure of a
large wound on the trunk
of a dog

Surgical stapling that are less than 11 mm in diameter.

Stapling provides a quick and effective alternative to
manual suturing in certain circumstances (eg, for gastro-
intestinal anastomosis, skin apposition and pulmonary,
cardiovascular and hepatic resections). Many stapling
instruments place a staggered double row of stainless
steel staples, each staple having a 'B' configuration.
Skin staples, however, are rectangular-shaped and placed
in a single row.
The advantages of surgical stapling include improved
efficiency, consistency of application and haemostatic
security, and ease of use in areas of difficult accessi-
bility. Care should be taken to ensure that the amount
of tissue to be stapled is not excessive. The stapled area
should be carefully inspected to check that there has
been no mechanical failure of the stapling device.
Ligating clips
Ligating clips can be used for a variety of surgical
procedures, including neutering, splenectomy and
intestinal resection. They are quick and easy to apply,
and are particularly useful in areas of limited accessi-
bility. They are, however, limited to use on vessels
Both metallic and absorbable clips are available.
Metallic clips (tantalum, stainless steel and titanium) are
widely used, V-shaped and produce minimal reaction in
tissues. Absorbable clips (polyglactin 910 and PDS)
have an integral locking mechanism to prevent reopen-
ing; this adds to the bulk of the clip.
SUTURE SELECTION
Suture selection involves the choice of both the appro-
priate type (see table below) and size of suture material.
Use of too large a suture results in excessive foreign
material in the wound and needlessly alters the architec-
ture of the sutured tissue.
Sutures are usually gauged using the metric system
which measures suture diameter in multiples of 0 1 mm
(ie, 3 metric = 0 3 mm diameter). The older USP
system also still persists, in which sutures are graded in
increasing diameter from the finest 0000000000 (usually
written '10-0') up to 0, then 1, 2, 3 on up to a maximum
of 7.

~ -ul
=~~~~~ COMEW;s,, Ik;1 Fre;{z I;&eX;S,]-iI
S

Skin Monofilament - nylon or polypropylene. Avoid

sutures that are capillary or reactive

Subcutis Synthetic absorbables

Fascia Synthetic non-absorbables
Muscle Synthetic absorbables or non-absorbables
Hollow viscus Synthetic absorbables. Avoid multifilament
non-absorbables
Tendon Nylon or stainless steel. Polydioxanone and
polyglyconate may also be effective
Blood vessel Polypropylene
Nerve Nylon or polypropylene
Ligating clip applicator

In Practice * J U N E 1 9 9 9 313
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A ide y of swaged-on ( edles are available

s i i
for th sure materials derid Thi mnai;n advantages
arett:litum-a is. casdhnring the suture
threuhtets,adtea ovnett s,ec uro-
ee with a new, sarned. If an eyed nee
iSC .sased, the,.sut.re,should nee Xe knte or. tied to theES
D :

M. tf km 414m 0\
: this il rult ote tauma.

KNOTS mise vascular supply, enhance infection and delay heal-

The surgical suture has three components:
* The loop - the suture material within the apposed or
ligated tissue;
* The knot - composed of a number of throvws (a throw is
the wrapping of two strands of suture around each other);
e The ears - the cut ends of the suture, which guard
against the loop untying due to knot slippagee.
The basic surgical knot is a square knoxt, formed by
two throws in which the ear and the loop come out on
the same side of the knot (see below). It can be either
hand tied or instrument tied. (When tying, itt is important
to avoid creating a granny knot which is weaker.)
Occasionally, when suturing elastic tissue oir tissue under
tension, the two free strands of the suture are passed
around each other twice before the knot is closed, to
produce the so-called 'surgeon's knot'. The advantage of
this in such situations is that it reduces th e risk of the
first throw unwrapping before a second thr4ow is placed.
The disadvantage of the surgeon's knot is tiiat it is bulky
and uneven and may damage monofilament materials.
Though knots should be snug, they shoulld not be tied
so that the suture loop is shortened, as this may compro-
Square knot Granny knot
ing. It may also be uncomfortable for the patient and
lead to self-trauma. There will almost invariably be a
degree of inflammation and oedema and this should be
allowed for by the suture loop; the suture should lie flat
on the tissue but, if lifted, there should be a gap between
the suture loop and the tissue. The aim when suturing
soft tissues is to achieve gentle apposition of the wound
edges. Once tied, knots should be placed on one side of
the incision so as to minimise interference with healing.
Knot security
The knot is the weakest part of the suture. Knot failure
can lead to a variety of surgical disasters, such as evis-
ceration or exsanguination.
If overloaded, sutures may break or unravel at the
knot. The breaking strength of a suture loop is equal to
the sum of the breaking strength of the straight strand and
the knotted strand. To overcome the risk of suture break-
down, it is important to place enough sutures of slightly
greater strength than the holding power of the tissue.
If only two throws are used the majority of knots will
slip - this is a particular problem with monofilament
materials, such as polypropylene, which have a high
memory as there is a tendency for knots to unravel. The
minimum number of throws required for a snug knot is
shown in the table below. If continuous suture patterns
are used (eg, simple continuous or Ford interlocking), it
is essential that the knots are tied with extra throws for
additional security (see bottom table).

Number of throws
Chromic gut 3
Polyglactin 910 3
Polyglycolic acid 3
Polypropylene 3
Poliglecaprone 25 4
Surgeon's knot 4
Polydioxanone
(above) Surgical knots. (below left) Basic surgical or square knot. (below right) Surgeon's Monofilament nylon 4
knot, consisting of a double throw initially, followed by a single throw

Start Finish

Chromic gut 4 5
Polyglactin 910 3 6
Polyglycolic acid 3 5
Polypropylene 3 5
Polydioxanone 5 7
Monofilament nylon 6

316 In Practice * J UNE 1 999

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CHOICE OF SUTURE PATTERN Gastrointestinal tract

Skin
Like many other tissues, skin heals most rapidly when
repaired with appositional patterns which allow epider-
mis to heal directly across to epidermis. Hence patterns
such as simple interrupted, continuous intradermal (sub-
cuticular), simple continuous and Ford interlocking are
appropriate, while everting or inverting patterns delay
repair. The aim shouldl he to gently appose the skin
edges. with no overlapping or gaping of the wound
edges. In the case of simple interrupted sutures, the indi-
vidual sutures should be placed squarely across the
wound. at least 5 mm t'rom the wound edge and at anl
interval of 5 mm to produce maximum wound strength;
sutures placed closer- thani this only add to the amount ot'
foreign material present in the tissues.
Despite a tendency in the past to use inverting suture
patterns (eg. Cushing. Lembert. Halsted or Connell) for
the repair of gastrointestinal structures, a more rational
approach achieves appositional reconstruction of the
intestinal wall using simple interrupted or simple contin-
uous patterns. In the intestine, the suture-retaining layer
of the wall has been shown to be the submucosa and a
suture pattern which includes this layer should be used.
Synthetic absorbables are most frequently selected for
this purpose because of their comparatively long reten-
tion of tensile strength and reduced tissue response.
Repair- of the oesophagus should also be based on appo-
sitional patterns which include the submucosa, although
a second layer through the outer adventitia or muscle
may be used. In the past, two-layer invertinT patterns
weere used for repair of the bladder, but recent studies
have shown that single or double layer appositional
sutures provide equal resistance to bursting of the viscus
and may allow more rapid healing.

Laparotomy incisions
Suture patterns selected for the repair- of laparotomies
should make use of the suture-retaining layer, which is
the tough linea alba oI the external rectus fascia away
fi-om the midline. Closure of the peritoneum or rectus
and oblique muscle layers is unnecessar-y and may
contribute to ischaemia in these layers and, possibly.
increase the risk of abdominal adhesions. Synthetic
absorbables are preferred to natural absorbables and
retain sufficient tensile strength for per-miianent materials
(monofilament nylon or polypropylene) not to offer any
significant advantage here.

Simple interrupted sutures

of polyglactin 910 (Vicryl)
being used following
resection of a urethral
prolapse
r) .
. > w
.
''\ vi-

.s
-:

4
i,\ Fm
r ff'

N- {
W i S
Ei lAt--
r:-r

SA
:-

.
X
4
0';
X-
; s ,,
{ X -.
S w -'
* '
Ford interlocking suture
pattern for rapid
Skin closure on a cat's limb using a combination of simple appositional closure of
interrupted sutures and tension-relieving sutures a laparotomy wound

318 In Practice * JUNE 1999

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Suture patterns
* INTERRUPTED. Each suture has a separate knot. Appositional sutures (a-f)
Sutures are easily inserted and removed and tension
may be readily adjusted. Failure of one suture is
inconsequential
* CONTINUOUS. These patterns comprise a row of
sutures with a knot present only at each end. They
are quick to insert and provide even tension along
the incision with a minimum amount of suture
placed in the tissue. They are an acceptable alterna- (a) Simple interrupted (b) Gambee
tive to simple interrupted sutures, especially for
long wounds (eg, closure of a midline laparotomy
incision). Suture breakage, however, may lead to
disruption of the entire line of closure
* MATTRESS. These are tension patterns, allowing
faster closure than a simple pattern, but tend to
interfere with healing due to incorporation of tissue
on each side of the wound and potential vascular
compromise
- Horizontal mattress patterns cause eversion of the
wound edges. Sutures may be difficult to remove due
to burying in the skin
- Vertical mattress patterns involve the placement of
sutures at a distance from the wound margin. These
sutures have less tendency to reduce circulation at
the wound edges than horizontal mattress sutures, (e) Continuous
and can be used together with simple interrupted intradermal
or subcuticular
sutures for skin apposition
* APPOSITIONAL. Sutures bring wound edges together
* INVERTING. Sutures turn wound edges inwards Tension sutures (g-k)
S EVERTING. Sutures turn wound edges outwards
* PURSE STRING. Sutures are used to close a circular
defect or reduce the size of an orifice

(g) Vertical mattress

(h) Horizontal mattress (i) Continuous

horizontal mattress

(j) Far-far-near-near (k) Far-near-near-far

Inverting sutures (I-o)

(n) Cushing
Penetrates the submucosa
but not the lumen.
Provides less inversion than
(I) Lembert (m) Haisted Lembert
Can be used in interrupted A variation of Lembert
or continuous patterns
(o) Connell
Similar to Cushing except penetrates
bowel lumen

In Practice C JUNE 1999 319

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Contaminated and infected wounds

The overriding concern when dealing with contaminated
or infected wounds is the risk of bacterial adherence
within the suture material. Braided or multifilament
materials are notoriously prone to the persistence of
bacteria within the interstices of the fibres, where they
are resistant to removal by the macrophages. In the pres-
ence of contamination or established sepsis, the surgeon
is therefore wise to choose either a monofilament materi-
al, which is more resistant to bacterial adherence, or an
absorbable material, which will be removed from the
wound together with any associated bacteria. It should
be noted, however, that other factors may influence the
persistence of bacteria in a suture material; in particular,
the size of the knot and amount of suture material
required when using monofilament materials may be
responsible for the formation of sinuses.

Closure of the linea alba with a simple continuous suture of

polydioxanone (PDS 11) SUTURE REMOVAL

Sutures are generally removed after seven to 10 days,

The choice of a simple or continuous pattern for even though at this time the skin bursting strength is
laparotomy repair is still somewhat controversial, with only 10 to 20 per cent of normal. Such early suture
concern about the risk of dehiscence swaying some removal minimises the inflammatory and infectious
surgeons' choice towards an interrupted pattern. processes which are encouraged by sutures. There are
Nevertheless, with modern synthetic absorbable materi- rarely any problems with wound dehiscence as most of
als and an adequate number of throws at each end of the the stresses are taken up by the underlying fascia. If
suture (a minimum of six for monofilament materials), a tension appears to be a problem, it may be better to leave
simple continuous pattern is perfectly safe. Furthermore, the sutures in place for 14 to 21 days. Where tension
significantly less suture material is left in the wound and sutures have been interspersed between appositional
the tissue response is minimised. sutures, they are usually removed after three to five days.

...........................................................................................................................................................................................................................................................................

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Suture materials and patterns

Jacqui Niles and John Williams

In Practice 1999 21: 308-320

doi: 10.1136/inpract.21.6.308

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http://inpractice.bmj.com/content/21/6/308

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