Sutures

Surgical suture materials are used in the closure of most wound types. The ideal suture
should allow the healing tissue to recover sufficiently to keep the wound closed together
once they are removed or absorbed.

Time for Suture

The time it takes for a tissue to no longer require support from sutures will vary depending on
tissue type:
Days: Muscle, subcutaneous tissue or skin
Weeks to Months: Fascia or tendon
Months to Never: Vascular prosthesis

Classification of Suture Materials

Broadly, sutures can be classified into absorbable or non-absorbable materials. They can be

further sub-classified into synthetic or natural sutures,
and monofilament or multifilament sutures.
The ideal suture is the smallest possible to produce uniform tensile strength, securely hold the
wound for the required time for healing, then be absorbed. It should be predictable, easy to
handle, produce minimal reaction, and knot securely.

Figure 1 – The different classifications and sub-classifications of suture materials.

The suture type chosen vary much depends on the clinical scenario. For example, as a rough
guide, a mass closure of a midline laparotomy may warrant use of PDS, a vascular
anastomosis will probably require prolene, a hand-sewn bowel anastomosis may need vicryl,
and securing a drain may need a silk suture.
Absorbable vs Non-Absorbable
Absorbable Sutures
Absorbable sutures are broken down by the body via enzymatic reactions or hydrolysis. The
time in which this absorption takes place varies between material, location of suture, and
patient factors.
Absorbable sutures are commonly used for deep tissues and tissues that heal rapidly; as a
result, they may be used in small bowel anastomosis, suturing in the urinary or biliary tracts,
or tying off small vessels near the skin.
For the more commonly used absorbable sutures, complete absorption times will vary:
Vicryl rapide = 42 days
Vicryl = 60 days
Monocryl = ~100 days
PDS = ~200 days
Non-Absorbable Sutures
Non-absorbable sutures are used to provide long-term tissue support, remaining walled-off by
the body’s inflammatory processes (until removed manually if required).
Uses include for tissues that heal slowly, such as fascia or tendons, closure of abdominal
wall, or vascular anastomoses.
Synthetic vs Natural
Suture materials can be further categorised by their raw origin:
Natural – made of natural fibres (e.g. silk or catgut). They are less frequently used, as they
tend to provoke a greater tissue reaction. However, suturing silk is still utilised regularly in
the securing of surgical drains.
Synthetic – comprised of man-made materials (e.g. PDS or nylon). They tend to be more
predictable than the natural sutures, particularly in their loss of tensile strength and
absorption.
Monofilament vs Multifilament
Suture materials can also be sub-classified by their structure:
Monofilament suture – a single stranded filament suture (e.g nylon, PDS*, or prolene). They
have a lower infection risk but also have a poor knot security and ease of handling.
Multifilament suture – made of several filaments that are twisted together (e.g braided silk or
vicryl). They handle easier and hold their shape for good knot security, yet can harbour
infections.
Suture Type Absorbable Non-absorbable Monofilament Multifilament

Vicryl ✓ ✓

PDS* ✓ ✓

Monocryl ✓ ✓

Nylon ✓ ✓

Prolene ✓ ✓

Silk ✓ ✓
Table 1 – Suture type and structure *PolyDioxanone Suture
Suture Size
The diameter of the suture will affect its handling properties and tensile strength. The larger
the size ascribed to the suture, the smaller the diameter is, for example a 7-0 suture is smaller
than a 4-0 suture.
When choosing suture size, the smallest size possible should be chosen, taking into account
the natural strength of the tissue.
 By TeachMeSeries Ltd (2020)

Figure 2 – Sutures come in a variety of sizes; the larger the number, the smaller the suture
Surgical Needles
The surgical needle allows the placement of the suture within the tissue, carrying the material
through with minimal residual trauma.
The ideal surgical needle should be rigid enough to resist distortion, yet flexible enough to
bend before breaking, be as slim as possible to minimise trauma, sharp enough to penetrate
tissue with minimal resistance, and be stable within a needle holder to permit accurate
placement.
Commonly, surgical needles are made from stainless steel. They are composed of:
The swaged end connects the needle to the suture
The needle body or shaft is the region grasped by the needle holder. Needle bodies can be
round, cutting, or reverse cutting:
Round bodied needles are used in friable tissue such as liver and kidney
Cutting needles are triangular in shape, and have 3 cutting edges to penetrate tough tissue
such as the skin and sternum, and have a cutting surface on the concave edge
Reverse cutting needles have a cutting surface on the convex edge, and are ideal for tough
tissue such as tendon or subcuticular sutures, and have reduced risk of cutting through tissue
The needle point acts to pierce the tissue, beginning at the maximal point of the body and
running to the end of the needle, and can be either sharp or blunt:
Blunt needles are used for abdominal wall closure, and in friable tissue, and can potentially
reduce the risk of blood borne virus infection from needlestick injuries.
Sharp needles pierce and spread tissues with minimal cutting, and are used in areas where
leakage must be prevented.
The needle shape vary in their curvature and are described as the proportion of a circle
completed – the ¼, ⅜, ½, and ⅝ are the most common curvatures used. Different curvatures
are required depending on the access to the area to suture.
 By TeachMeSeries Ltd (2020)

Figure 3 – The parts of a surgical needle

Key Points
Suture materials can be classified in a variety of ways
Choice of suture material is dependent on numerous factors, such as tissue type, infection
risk, and personal preferences
The surgical needle allows for the correct positioning of the suture material within a tissue
The surgical suture is used to hold body tissues together after injury or surgery. Sutures (or
stitches) are typically applied using a needle with an attached piece of thread and are secured
with surgical knots.
Suturing a wound is an important surgical skill to learn and become competent in. Wound
suturing and closure is important in order to:
Reduce dead space
Support and strengthen wounds until healing
Approximation of skin edges to reduce scaring
Reduce the risk of bleeding and wound infection
In this article, we shall look at three types of suture – the interrupted suture, the continuous
suture, and the mattress suture
Interrupted Suture
The interrupted suture is the most commonly used technique in wound closure. Its name is
derived from the fact that the individual stitches are not connected.
Sutures performed with this technique have the advantage of being easy to place and have
a high tensile strength. In addition, individual sutures can be removed (e.g in cases of
infection) without jeopardising the closure.
However, they require a relatively long time to be placed and, as each suture requires its own
knot, are at a greater risk of inducing infection.
Procedure
Start in the middle of the wound, place sutures at 1cm intervals until wound is approximated
without tension.
For each suture, grasp and evert the skin edge (gently with the non-dominant hand).
Pronate the dominant hand so that the needle will pierce perpendicular to the skin and drive
the needle through the skin by supinating the hand before picking up the needle (2/3 from the
tip) with the needle holders. A no touch needle technique is important, reducing sharps injury
and infection risk
Finish by carefully gathering the thread to create a long thread (with needle) and short thread,
before performing a hand or instrument tie.
Repeat with separate sutures to close the wound.
Continuous Suture
In the continuous suture, the stitches are connected along the wound. This technique tends to
be faster, particularly for long wounds. However, the wound is at greater risk of dehiscence if
the suture material breaks.
Procedure
Start at the wound edge and work along the wound (traditionally this is done working
towards yourself).
For each suture, grasp and evert the skin edge (gently with the non-dominant hand).
Pronate the dominant hand so that the needle will pierce perpendicular to the skin and drive
the needle through the skin by supinating the hand (using the curve of the needle) before
picking up the needle (2/3 from the tip) with the needle holders. A no touch needle technique
is important, reducing sharps injury and infection risk.
Place each suture as above, at 1cm intervals, until wound is approximated without tension.
Carry this on along the wound.
Finish by carefully gathering the thread to create a long thread (with needle) and short thread
before performing a hand tie or instrument tie.
Note: care should be taken to apply the correct amount of tension to the suture material – if
too much the skin becomes strangulated, if too little the wound edges may not be opposed
correctly.
Mattress Suture
The mattress sutures, both horizontal and vertical, are one of the most commonly used
methods for skin closure. Mattress sutures are used, especially when skin edges, must
be closed under tension, as they achieve good skin eversion (which aids wound healing and
produces less prominent scaring).
This type of suture tends to be performed using non-absorbable suture material, with the
sutures removed 10-14 days on average after wound closure (however, typically less than this
for closures on the head and neck).
Procedure
Grasp the wound edge with the forceps.
Drive the needle through the skin, using the needle holder, around 4-8mm away from the
wound edge, passing the suture deep through the dermis.
Pick up the needle with the forceps at the wound edge, before reloading the needle onto the
needle holder.
Grasp the opposing wound edge with the forceps, drive the needle deep through the other side
of the wound, piercing the skin to re-emerge around 4-8mm away from the wound on the
opposite side.
Backwards load your needle in your needle holder.
Grasp the second wound edge again with the forceps and drive the needle through the skin, in
vertical alignment with the other puncture site, around 1-2mm away from the wound edge.
This near placement should occur at a shallow depth and should pass though the upper
dermis.
Pick up the needle with the forceps at the wound edge, before reloading the needle onto the
needle holder.
Grasp the opposing wound edge with the forceps, drive the needle deep through the other side
of the wound (also in the upper dermis layer), piercing the skin to re-emerge around 1-2mm
away from the wound on the opposite side (also in vertical alignment with the other puncture
site).
Gently pull the suture to achieve the desired skin tension, as the wound edges close.
Finish by performing a hand tie or instrument tie.