8

Biomaterials, Suturing, and

Hemostasis

SUTURES AND SUTURE SELECTION

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Flexibility
Suture plays an important role in wound repair by providing The flexibility of a suture is determined by its torsional stiffness
hemostasis and support for healing tissue. Tissues have different and diameter, which influence its handling and use. Flexible
requirements for suture support, depending on the type of tissue sutures are indicated for ligating vessels or performing continuous
and anticipated duration of healing. Some tissues need support suture patterns. Less flexible sutures (e.g., wire) cannot be used
for only a few days (e.g., muscle, subcutaneous tissue, skin), to ligate small bleeders. Nylon and surgical gut are relatively stiff
whereas others require weeks (fascia) or months (tendon) to compared with silk suture; braided polyester sutures have
heal. Individual patient variation further affects suture choice. intermediate stiffness.
Healing of wounds may be delayed by infection, obesity, malnutri-
tion, neoplasia, drugs (e.g., steroids), and collagen disorders. In Surface Characteristics and Coating
rapidly healing tissue, a suture that will lose its tensile strength The surface characteristics of a suture influence the ease with
at a similar rate that the tissue gains strength, and that will which it is pulled through tissue (i.e., the amount of friction or
be absorbed by the tissue so that no foreign material remains “drag”) and the amount of trauma caused. Rough sutures
in the wound, is ideal. Minimally invasive surgical techniques cause more injury than smooth sutures. Smooth surfaces are
(see Chapter 14) put additional demands on the performance particularly important in delicate tissues, such as the eye. However,
of surgical sutures. Not only must good knot security be sutures with smooth surfaces also require greater tension to
maintained, but also the surface lubricant must ensure ease of ensure good apposition of tissues, and have less knot security.
manipulation, minimal tissue drag, and good biocompatibility Braided materials have more drag than monofilament sutures.
with minimal inflammatory responses. Subjective preferences, Braided materials are often coated to reduce capillarity (see
such as familiarity with the material and availability, need later discussion), but this also provides a smooth surface. Teflon,
also be taken into consideration when choosing a suture silicone, wax, paraffin-wax, and calcium stearate are used for
material. coating sutures.
Suture Characteristics Capillarity
The ideal suture is easy to handle, reacts minimally in tissue, Capillarity is the process by which fluid and bacteria are carried
inhibits bacterial growth, holds securely when knotted, resists into the interstices of multifilament fibers. Because neutrophils
shrinking in tissue, absorbs with minimal reaction after the tissue and macrophages are too large to enter the interstices of the
has healed, and is noncapillary, nonallergenic, noncarcinogenic, fiber, infection may persist, particularly in nonabsorbable sutures.
and nonferromagnetic; however, such a material does not exist. All braided materials (e.g., polyglycolic acid, silk) have degrees
Therefore surgeons must choose a suture that most closely of capillarity, whereas monofilament sutures are considered
approximates the ideal for a given procedure and tissue to be noncapillary. Coating reduces the capillarity of some sutures,
sutured. A wide variety of suture and needle combinations are but regardless, capillary suture materials should not be used in
available. contaminated or infected sites.
Suture Size Knot Tensile Strength
The smallest diameter suture that will adequately secure wounded Knot tensile strength is measured by the force in pounds that
tissue should be used to minimize trauma as the suture is the suture strand can withstand before it breaks when knotted
passed through the tissue, and to reduce the amount of foreign (Box 8.1). Sutures should be as strong as the normal tissue through
material left in the wound. There is no advantage to using a which they are being placed; however, the tensile strength of the
suture that is stronger than the tissue to be sutured. The most suture should not greatly exceed the tensile strength of the tissue.
commonly used standard for suture size is the United States
Pharmacopeia (USP), which denotes dimensions from fine to Relative Knot Security
coarse (with diameters in inches) according to a numeric scale, Relative knot security is the holding capacity of a suture expressed
with 12-0 being the smallest and 7 the largest. The USP as a percentage of its tensile strength. The knot-holding capacity
uses different standards for surgical gut and other materials of a suture material is the strength required to untie or break a
Copyright 2019. Mosby.

(Table 8.1). The smaller the suture size, the less tensile strength defined knot by loading the part of the suture that forms the
it has. Stainless steel wire is sized according to the metric or USP loop; the suture material’s tensile strength is the strength required
scale or by the Brown and Sharpe (B and S) wire gauge (see to break an untied fiber with a force applied in the direction of
Table 8.1). its length (see Box 8.1).

60
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 CHAPTER 8 Biomaterials, Suturing, and Hemostasis 60.e1

ABSTRACT KEYWORDS
When choosing a suture material, the surgeon must be knowledge- knot security
able about the healing properties of the particular tissue, the tensile strength
wound healing capability of the patient, and the characteristics absorbable
of suitable suture materials (particularly tissue reactivity, tensile nonabsorbable
strength, knot security, and rate of absorption). The type of monofilament
suture to be used depends on the procedure being performed multifilament
and the tissue in which it will be placed. The suture material interrupted
chosen must retain its strength until the wound heals sufficiently. continuous
Other methods for hemostasis and tissue apposition include, cyanoacrylate
but are not limited to, energy-based devices and tissue adhesives energy-based hemostasis
(e.g., cyanoacrylates).

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 CHAPTER 8 Biomaterials, Suturing, and Hemostasis 61

TABLE 8.1 Suture Sizes BOX 8.1 Terminology Used to Describe

Synthetic Brown and
Suture Characteristics
Suture Sharpe • Absorbability. Progressive loss of mass and/or volume of suture material;
Materials Surgical Wire Metric Actual Size does not correlate with initial tensile strength.
(USP) Gut (USP) Gauge Gauge (mm) • Breaking strength. Limit of tensile strength at which suture failure occurs.
• Capillarity. Extent to which absorbed fluid is transferred along the suture.
10-0 0.2 0.02 • Elasticity. Measure of the ability of the material to regain its original
9-0 0.3 0.03 form and length after deformation.
• Fluid absorption. Ability to take up fluid after immersion.
8-0 0.4 0.04
• Knot-pull tensile strength. Breaking strength of knotted suture material
7-0 8-0 41 0.5 0.05 (10%–40% weaker after deformation by knot placement).
6-0 7-0 38–40 0.7 0.07 • Knot strength. Amount of force necessary to cause a knot to slip
(related to the coefficient of static friction and plasticity of a given
5-0 6-0 35 1 0.1 material).
4-0 5-0 32–34 1.5 0.15 • Memory. Inherent capability of suture to return to or maintain its
3-0 4-0 30 2 0.2 original gross shape (related to elasticity, plasticity, and diameter).
• Plasticity. Measure of the ability to deform without breaking and to
2-0 3-0 28 3 0.3 maintain a new form after relief of the deforming force.
0 2-0 26 3.5 0.35 • Pliability. Ease of handling of suture material; ability to adjust knot
tension and to secure knots (related to suture material, filament type,
1 0 25 4 0.4
and diameter).
2 1 24 5 0.5 • Straight-pull tensile strength. Linear breaking strength of suture
3,4 2 22 6 0.6 material.
• Suture pullout value. The application of force to a loop of suture
5 3 20 7 0.7
located where tissue failure occurs, which measures the strength of
6 4 19 8 0.8 a particular tissue; variable depending on anatomic site and histologic
7 18 9 0.9 composition (fat, 0.2 kg; muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg).
• Tensile strength. Measure of the ability of a material or tissue to resist
USP, United States Pharmacopeia. deformation and breakage.
• Wound breaking strength. Limit of tensile strength of a healing wound
at which separation of the wound edges occurs.

Specific Suturing Materials From Lai SY, Becker DG. Sutures and needles, e-medicine. Topic. 2004;38.

Suture materials may be classified according to their behavior in

tissue (absorbable or nonabsorbable), their structure (monofilament
or multifilament), or their origin (synthetic, organic, or metallic) referring to a young cat led to the use of the term catgut. Surgical
(Fig. 8.1 and Table 8.2). Two major mechanisms of absorption gut is made from the submucosa of sheep intestine or the serosa
result in the degradation of absorbable sutures. Sutures of organic of bovine intestine, and is approximately 90% collagen. It is
origin, such as surgical gut, are gradually digested by tissue enzymes broken down by phagocytosis and, in contrast with other suture
and phagocytized, whereas sutures manufactured from synthetic materials, elicits a notable inflammatory reaction. Plain surgical
polymers are principally broken down by hydrolysis. Nonabsorb- gut loses strength rapidly after tissue implantation. “Tanning”
able sutures are ultimately encapsulated or walled off by fibrous (cross-linking of collagen fibers), which occurs by exposure to
tissue. chrome or aldehyde, slows absorption. Surgical gut is available
Monofilament sutures are made of a single strand of material as plain, medium chromic, or chromic; increased tanning generally
and therefore have less tissue drag than multifilament sutures implies prolonged strength and reduced tissue reaction. Surgical
and do not have interstices that may harbor bacteria or fluid. gut is rapidly removed from infected sites or areas where it is
Care should be used in handling monofilament sutures because exposed to digestive enzymes, and is quickly degraded in catabolic
nicking or damaging the material with forceps or needle holders patients. The knots may loosen when wet.
may weaken the suture and predispose it to breakage. Multifila- Synthetic absorbable materials. Synthetic absorbable materials
ment sutures consist of several strands of suture that are twisted (see Table 8.2) are generally broken down by hydrolysis and
or braided together. Multifilament sutures generally are more cause minimal tissue reaction. The time to loss of strength and
pliable and flexible than monofilament sutures. They may be to absorption is fairly constant in different tissue. Infection or
coated to reduce tissue drag and enhance handling characteristics exposure to digestive enzymes does not significantly influence
(see previous discussion). the rate of absorption of most synthetic absorbable sutures.
Polyglactin 910 and polyglycolic acid are more rapidly hydrolyzed
Absorbable Suture Materials in alkaline environments but are relatively stable in contaminated
Absorbable suture materials lose most of their tensile strength wounds. Polyglycolic acid, polyglactin 910, and poliglecaprone
within 60 days and eventually disappear from the tissue implanta- 25 may be rapidly degraded in infected urine; polydioxanone,
tion site because they have been phagocytized or hydrolyzed polyglyconate, and glycomer 631 are acceptable for use in sterile
(see Fig. 8.1 and Table 8.2). The time to loss of strength and for bladders and those infected with E. coli. However, use of any
complete absorption varies among suture materials. suture that is degraded via hydrolysis may be at risk for accelerated
Organic absorbable materials. Catgut (surgical gut) is the most degradation when the bladder is infected with Proteus spp. (see
common nonsynthetic absorbable suture material. The word also p. 696) as all common monofilament absorbable sutures
catgut is derived from the term kitgut or kitstring (the string have been shown to degrade within 7 days in P. mirabilis-
used on a kit, or fiddle). Misinterpretation of the word kit as inoculated urine.

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 62 PART ONE General Surgical Principles

Suture

Absorbable Non-
absorbable

Short Medium Long Natural Synthetic

Term Term Term

Natural Synthetic Braided Monofilament Braided Monofilament Silk Braided Monofilament

Catgut Vicryl Vicryl Monocryl Maxon Nurolon Ethilon

Rapide Braided Dexon PDS II Ethibond Flexon
Caprosyn Dexon Biosyn Supramid Prolene
Polysorb Braunamid Dermalon
Mersilene Surgilene
Dacron Fluorofil
TiCron
Surgilon

FIG. 8.1 Characteristics of sutures used in veterinary medicine.

Monofilament absorbable materials. Polydioxanone (PDS comprised of glycolide and lactide. This suture is indicated for
II) and polyglyconate (Maxon) are classic monofilament sutures use in soft tissue approximation of the skin and mucosa, when
that retain their tensile strength longer than multifilament sutures, only 7 to 10 days of wound support is required, as it retains the
with complete absorption occurring in 6 months. Poliglecaprone majority of its tensile strength until approximately 5 days.
25 (Monocryl) and Glycomer 631 (Biosyn) are monofilament Complete absorption of Velosorb takes 40 to 50 days.
rapidly absorbable synthetic materials that are pliable, lack stiffness,
and have good handling characteristics. These sutures have good Nonabsorbable Suture Materials
initial tensile strength that deteriorates in 2 to 3 weeks following Organic nonabsorbable materials. Silk is the most common
implantation, and are completely absorbed by 120 days. organic nonabsorbable suture material used. It is a braided
Polyglytone 6211 (Caprosyn) is a relatively new, rapidly multifilament suture made by a special type of silkworm, and
absorbable monofilament suture. It is a synthetic polyester of is marketed as uncoated or coated. Silk has excellent handling
glycolide, caprolactone, trimethylene carbonate, and lactide. characteristics and is often used in cardiovascular procedures;
Absorption of this material is essentially complete in 56 days, however, it does not maintain significant tensile strength after
which is thought to lead to less wound complications and tissue 6 months and is therefore contraindicated for use in vascular
reactions. This suture retains up to 30% knot strength at 10 days grafts. It should also be avoided in contaminated sites; one silk
postimplantation and has excellent handling characteristics; suture may reduce the number of bacteria required to induce
however, its rapid absorption also limits its application. infection in a wound from 106 to 103.
Multifilament absorbable materials. Polyglycolic acid (Dexon) Synthetic nonabsorbable materials. Synthetic nonabsorbable
is braided from filaments extracted from glycolic acid and is available suture materials (see Table 8.2) are marketed as braided multifila-
in both coated and uncoated forms. Polyglactin 910 (Vicryl) is a ment threads (e.g., polyester or coated caprolactam) or monofila-
multifilament suture made of a copolymer of lactide and glycolide ment threads (e.g., polypropylene, polyamide, or polybutester).
with polyglactin 370. It is coated with calcium stearate, and its rate These sutures are typically strong and induce minimal tissue
of loss of tensile strength is similar to that of polyglycolic acid. reaction. Nonabsorbable suture materials with an inner core
Vicryl Rapide is a rapidly absorbed, synthetic braided suture that and an outer sheath (e.g., Supramid) should not be buried in
has an initial strength that is comparable to nylon and gut. However, tissue because it may predispose to infection and fistulation.
the tensile strength declines to 50% in 5 to 6 days, and it is completely The outer sheath frequently is broken, which allows bacteria to
absorbed in 42 days. This suture is indicated for superficial closure reside underneath it.
of mucosa, gingival closure, and periocular skin closure.
Polysorb sutures are composed of Lactomer glycolide/lactide
copolymer, which is a synthetic polyester composed of glycolide
and lactide (derived from glycolic and lactic acids). Polysorb NOTE Nylon cable ties are not recommended to be implanted in
the body (e.g., used to ligate ovarian pedicles), as toxic substances
maintains 80% of its tensile strength at 2 weeks and 30% at 3 are released during degradation, and may result in abscess or tumor
weeks, with absorption ranging from 56 to 70 days. Velosorb formation.
Fast sutures are composed of absorbable synthetic polyester

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 CHAPTER 8 Biomaterials, Suturing, and Hemostasis 63

TABLE 8.2 Characteristics of Suture Materials Commonly Used in Veterinary Medicine

Reduction in Complete Relative
Generic Suture Tensile Absorption Knot Tissue
Name Trade Name Manufacturer Characteristics Strengtha (Days) Securityb Reactionc
Chromic — — Absorbable 33% at 7 days 60 — (wet) +++
surgical gut Multifilament
(catgut)
Polyglactin Vicryl and Vicryl Plus Ethicon Absorbable 25% at 14 days 56–70 ++ +
910 Multifilament 50% at 21 days ++ +
Vicryl Rapide Ethicon Absorbable 50% at 5 days 42 ++ +
Multifilament 100% at 14 days
Polyglycolic Dexon “S” (uncoated) Medtronic Absorbable 35% at 14 days 60–90 ++ +
acid Dexon II (coated) Multifilament 65% at 21 days
Glycolide/ Polysorb Medtronic Absorbable 20% at 14 days 60 +++ —
lactide Multifilament 70% at 21 days
polymer
Polydioxanone PDS II Ethicon Absorbable 14% at 14 days 180 ++ +
Monofilament 31% at 42 days
Polyglyconate Maxon Medtronic Absorbable 30% at 14 days 180 ++ +
Monofilament 45% at 21 days
Poliglecaprone Monocryl Ethicon Absorbable 40%–50% at 7 days 90–120 ++ +
25 Monofilament 70%–80% at 14 days
Glycomer 631 Biosyn Medtronic Absorbable 25% at 14 days 90–110 ++ +
Monofilament 60% at 21 days
Polyglytone Caprosyn Medtronic Absorbable 40%–50% at 5 days 56 +++ +
6211 Monofilament 70%–80% at 10 days
Silk Perma-Hand Ethicon Nonabsorbable 30% at 14 days > 2 years — +++
Medtronic Multifilament 50% at 1 year
Polyester Mersilene (uncoated) Ethicon Nonabsorbable — ++
Ethibond (coated) Ethicon Multifilament
Dacron (uncoated) Medtronic
Ticron (coated) Medtronic
Polyamide Ethilon (monofilament) Ethicon Nonabsorbable 30% at 2 years + —
(Nylon) Nurolon (multifilament) Ethicon Monofilament or (monofilament)
Dermalon Medtronic multifilament 75% at 180 days
(monofilament) Medtronic (multifilament)
Surgilon (multifilament)
Polypropylene Prolene Ethicon Nonabsorbable +++ —
Surgilene Medtronic Monofilament
Fluorofil Mallinckrodt
Veterinary
Polybutester Novafil Medtronic Nonabsorbable ++ —
Monofilament
Polymerized Supramid S. Jackson Nonabsorbable ++ ++ (if coating
caprolactam Braunamid B. Braun Multifilament breaks)
Vetcassette II Melsungen Ag
Mallinckrodt
Veterinary
Stainless steel Flexon (multifilament) Medtronic Nonabsorbable +++ —
wire Ethicon Monofilament or
Multifilament
a
Values given are approximate. Actual loss of tensile strength may vary depending on suture and tissue.
b
(−), Poor (<60%); (+), fair (60%–70%); (++), good (70%–85%); (+++), excellent (>85%).
c
(−), Minimal to none; (+), mild; (++), moderate; (+++), severe.

Metallic sutures. Stainless steel is the metallic suture most standard for judging knot security and tissue reaction to suture
commonly used and is available as a monofilament or multifila- materials.
ment twisted wire. Surgical steel is strong and inert with minimal Antimicrobial-coated sutures. Triclosan-impregnated suture
tissue reaction, but knot ends evoke an inflammatory reaction. is available in certain monofilament (PDS Plus, Monocryl Plus)
Stainless steel has a tendency to cut tissue and may fragment and multifilament (Vicryl Plus) absorbable sutures. These sutures
and migrate. It is stable in contaminated wounds and is the create an in vitro zone of inhibition against Staphylococcus aureus,

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 64 PART ONE General Surgical Principles

deformation a needle can withstand before becoming permanently

deformed is called surgical yield. Ductility is the needle’s resistance
to breaking under a specified amount of bending. The sharpness
of a needle is related to the angle of the point (see p. 65) and
the taper ratio of the needle. The sharpest needles have a long,
thin, tapered point with smooth cutting edges. Most surgical
needles are made from stainless steel wire because it is strong,
corrosion free, and does not harbor bacteria.
The three basic components of a needle are the attachment
end (i.e., swaged or eyed end), the body, and the point
(Fig. 8.3A). Eyed needles must be threaded, and because a double
strand of suture is pulled through the tissue, a larger hole is created
than when swaged suture material is used. Eyed needles may be
closed (i.e., round, oblong, or square) or French (i.e., with a slit
from the inside of the eye to the end of the needle for ease of
threading) (see Fig. 8.3B). Eyed needles are threaded from the
FIG. 8.2 Barbed suture material with unidirectional barbs notched
inside curvature and are uncommonly used in surgical practice.
into the strand.
With swaged sutures, the needle and suture are a continuous unit,
which minimizes tissue trauma and increases ease of use.
The needle body comes in a variety of shapes (see Fig. 8.3C);
Staphylococcus epidermidis, and Escherichia coli and are used to the tissue type and depth and the size of the wound determine
decrease rates of surgical site infection. Systematic reviews and the appropriate needle shape. Straight (Keith) needles are generally
meta-analyses in the human literature have failed to find evidence used in accessible places where the needle can be manipulated
demonstrating the protective effect of triclosan-impregnated directly with the fingers (e.g., placement of purse-string sutures
sutures on the occurrence of surgical site infections.1,2 In the in the anus). Curved needles are manipulated with needle holders.
veterinary literature, a retrospective cohort study did not find The depth and diameter of a wound are important when selecting
additional benefit for using triclosan-impregnated suture for the most appropriate curved needle. One-fourth circle needles
wound closure following tibial plateau leveling osteotomy in are primarily used in ophthalmic procedures. Three-eighths
dogs.3 However, in vitro comparison of impregnated versus and one-half circle needles are the most commonly used surgical
nonimpregnated suture for adherence of methicillin-resistant needles in veterinary medicine. Three-eighths circle needles are
Staphylococcus pseudointermedius found PDS Plus to have sig- more easily manipulated than one-half circle needles because
nificantly less adherence than PDS II, Monocryl, Vicryl, and they require less pronation and supination of the wrist. However,
Stratafix Spiral PDO.4 because of the larger arc of manipulation required, they are
Knotless barbed suture. Barbed suture material (e.g., V-Loc, awkward to use in deep or inaccessible locations. A one-half
Stratafix, Quill) has unidirectional barbs placed in a helical circle or five-eighths circle needle, despite requiring more prona-
fashion around the suture strand (Fig. 8.2). These barbs allow tion and supination of the wrist, is easier to use in confined
the suture to become lodged in the tissue, creating multiple locations.
anchor points to distribute tension along the suture line. These The needle point (i.e., cutting, taper, reverse cutting, or side
sutures are also knotless as there is a preconstructed loop on cutting) (see Fig. 8.3D) affects the sharpness of a needle and the
the end to allow initial anchor of the suture line. Due to the type of tissue in which the needle can be used. Cutting needles
unidirectional movement and anchoring of the suture through generally have two or three opposing cutting edges and are
the tissue, there is no need for an end knot. Bidirectional barbs designed for use in tissues that are difficult to penetrate, such
with double-swaged needles are also available on certain knot- as skin. With conventional cutting needles, the third cutting edge
less suture materials (i.e., Quill, Statafix). Multiple experimental is on the inside (i.e., concave) curvature of the needle. The location
biomechanical studies have demonstrated similar tensile strength of the inside cutting edge may promote more “cut out” of tissue
to standard monofilament suture material in a variety of tissues because it cuts toward the edges of the wound or incision. Reverse
and procedures.5–7 However, for tendon repair, smooth mono- cutting needles have a third cutting edge on the outer (i.e., convex)
filament sutures were consistently stronger and were associated curvature of the needle; this makes them stronger than similarly
with less gap formation than knotless barbed suture.8,9 Barbed sized conventional cutting needles and reduces the amount of
monofilament suture (Stratofix Spiral PDO) has also been shown tissue cut out. Side cutting needles (i.e., spatula needles) are flat
to have a comparable bacterial adherence profile of methicillin- on the top and bottom and are generally used for ophthalmic
resistant S. pseudintermedius to nonbarbed monofilament procedures. Taper needles (i.e., round needles) have a sharp tip
suture.4 that pierces and spreads tissues without cutting them. They are
generally used in easily penetrated tissues, such as the intestine,
Surgical Needles subcutaneous tissue, or fascia. Tapercut needles, which are a
A variety of needle shapes and sizes are available; selection of a combination of a reverse cutting edge tip and a taperpoint body,
needle depends on the type of tissue to be sutured (e.g., penetrabil- are generally used for suturing dense, tough fibrous tissue, such
ity, density, elasticity, and thickness), topography of the wound as a tendon, and for some cardiovascular procedures, such as
(e.g., deep or narrow), and characteristics of the needle (i.e., vascular grafts. Bluntpoint needles have a rounded, blunt point
type of eye, length, and diameter). Needle strength, ductility, that can dissect through friable tissue without cutting. They are
and sharpness are important factors in determining the handling occasionally used for suturing soft, parenchymal organs, such
characteristics and use of a needle. The amount of angular as the liver or kidney.

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 CHAPTER 8 Biomaterials, Suturing, and Hemostasis 65

Closed Straight
Needle
point
French
Swaged 1/4 5/8
end
1/2
Needle
body 3/8

A B C

1. Taperpoint 2. Tapercut 3. Regular cutting

Body Body Body

Point Point Point

4. Reverse cutting 5. Spatula point 6. Blunt point

Body Body Body

D Point Point Point

FIG. 8.3 (A) Basic components of a needle. (B) Types of eyed needles. (C) Shapes and sizes of
needle bodies. (D) Detail of needle points.

When using an interrupted pattern, numerous suture materials

Suture Selection for Different Tissue Types are adequate; however, suture that is rapidly removed (e.g.,
Considerations for suture selection include the length of time the surgical gut) should be avoided in catabolic (i.e., hypoalbumin-
suture will be required to help strengthen the wound or tissue, emic and malnourished) patients. When a continuous suture
the risk of infection, the effect of the suture material on wound pattern is used, a standard absorbable or nonabsorbable monofila-
healing, and the dimension and strength of the suture required. ment suture with good knot security should be used (e.g.,
polypropylene, polybutester, polydioxanone, polyglyconate).
Skin One size larger suture than would normally be used is preferred
Monofilament sutures should be used in skin to prevent wicking for a continuous suture pattern. The knots should be tied
or capillary transport of bacteria to deeper tissue. Synthetic carefully, and three or four square knots (six or eight throws)
monofilament nonabsorbable sutures (e.g., nylon, polypropylene) should be placed. Standard absorbable suture (e.g., polydioxanone
generally have good relative knot security and are relatively or polyglyconate) may be preferable to prevent large amounts
noncapillary. Polymerized caprolactam (Supramid, Vetafil) has of foreign material from remaining permanently in the
good handling characteristics, but it is braided and should not incision.
be buried in deeper tissue. Absorbable sutures (e.g., polydioxa-
none, polyconate) may be used in skin, but they should ultimately Muscle and Tendon
be removed because absorption requires contact with body fluids. Muscle has poor holding power and is difficult to suture. Absorb-
Subcutaneous sutures are used to obliterate dead space and reduce able or nonabsorbable suture material may be used. Sutures
tension on skin edges; multifilament or monofilament absorbable placed parallel to the muscle fibers are likely to pull out, so
suture material is preferred. consideration should be given to the type of suture pattern chosen
(see p. 68). Suture material used for tendon repair should be
Abdominal Closure strong, nonabsorbable, and minimally reactive. Suturing with a
The rectus fascia may be closed with either an interrupted or a taper or taper-cut needle is generally less traumatic to these
continuous suture pattern; however, most surgeons routinely tissues. The largest suture that will pass without trauma through
close the rectus fascia with a simple continuous suture pattern. the tendon should be used.

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 66 PART ONE General Surgical Principles

tissue is unpredictable. Synthetic monofilament nylon and

Parenchymal Organs polypropylene sutures may elicit less infection in contaminated
Parenchymal organs, such as the liver, spleen, and kidneys, are tissue than metallic sutures.
generally sutured with absorbable monofilament sutures, as
multifilament sutures tend to cut through this type of tissue Vessels and Vascular Anastomoses
because of the increased drag. Vessels should be ligated with absorbable suture material. Vascular
anastomoses are typically performed with monofilament non-
Hollow Viscus Organs absorbable suture material such as polypropylene. Nonabsorbable
Absorbable monofilament sutures are generally recommended suture should also be used for vascular grafts. Arterial anastomoses
in hollow viscus organs, such as the trachea, gastrointestinal may be performed in an end-end (Fig. 8.4A) or end-side fashion
tract, or bladder, to prevent tissue retention of foreign material (see Fig. 8.4B). Arteriotomies may be closed using a vertical
once the wound is healed. In addition, nonabsorbable suture (Fig. 8.5A) or transverse (see Fig. 8.5B) method.
may be calculogenic when placed in the urinary bladder or Reduction of blood loss from a vascular anastomosis (e.g.,
gallbladder and may be extruded into the lumen when implanted when a polytetrafluoroethylene g raft i s u sed) c an b e a ffected b y
in intestine. Polyglycolic acid suture rapidly dissolves when suture choice, even when a technically perfect anastomosis has
incubated in sterile urine (6 days) or infected urine (3 days). been performed, as bleeding may occur from the needle holes.
Sutures having a needle-to-suture ratio of 2 : 1 or 3 : 1 are associ-
Infected or Contaminated Wounds ated with more bleeding than when the needle-to-suture diameter
If possible, sutures should be avoided in highly contaminated ratio is 1 : 1, which allows the suture to completely fill t he g raft
or infected wounds because even the least-reactive nonabsorbable needle hole.
sutures elicit some degree of infection in tissue contaminated
with either Escherichia coli or Staphylococcus aureus. Multifilament
nonabsorbable sutures (e.g., silk or polyester) should not be
used in infected tissue because they potentiate infection and
may fistulate. Absorbable suture material is preferred; however,
surgical gut should be avoided because its absorption in infected

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