PART 1 | BASIC PRINCIPLES

Wound closure 89

point, 3 cm below the left subcostal margin in the mid-

clavicular line. Adequate lighting and good assistance Summary box 7.4
with retraction are essential. Types of wound healing
11 In obese patients with scars from previous surgery an opti- ●● Primary intention
cal blunt trocar can be used to enter the peritoneal cavity
Clean wound
under vision. ●● Secondary intention
Healthy granulation tissue
WOUND CLOSURE Overexuberant granulation tissue
Infected sloughy wound
The suturing of any incision or wound needs to take into con-
Black eschar
sideration the site and tissues involved, and the technique for
●● Tertiary intention
closure should be chosen accordingly. There is no ideal wound
Delayed closure
closure technique that would be appropriate for all situations,
Skin grafting
and the ideal suture has yet to be produced, although many
of the desired characteristics are listed in Summary box 7.3.
Therefore, the correct choice of suture technique and suture When choosing suture materials, there are certain specific
material is vital, but will never compensate for inadequate requirements depending on the tissues to be sutured; for
operative technique, and, for any wound to heal well, there example, vascular anastomoses require smooth, non-absorbable,
must be a good blood supply and no tension on the closure. non-elastic material, while biliary anastomoses require an
Clean uninfected wounds with a good blood supply heal by absorbable material that will not promote tissue reaction or
primary intention and therefore closure simply requires accu- stone formation. When using absorbable material, the time
rate apposition of the wound edges. However, if a wound is left for which wound support is required and maintained will vary
open, it heals by secondary intention through the formation according to the tissues in which it is inserted. Furthermore,
of granulation tissue, which is tissue composed of capillaries, certain tissues require wound support for longer than others, for
fibroblasts and inflammatory cells. Wound contraction and example muscular aponeuroses compared with subcutaneous
epithelialisation assist in ultimate healing, but the process tissues. It is therefore crucial for the surgeon to select the suture
may take several weeks or months. Delayed primary closure, material and suture technique that will most effectively achieve
or tertiary intention, is utilised when there is a high probabil- the desired objective for each wound closure or anastomosis.
ity of the wound being infected. The wound is left open for a
few days and, provided any infective process has resolved, the
wound is closed to heal by primary intention. Skin grafting is Suture materials
another form of tertiary intention healing. History
Sutures are best made of soft thread, not too hard twisted
that it may sit easier on the tissue, nor are too few nor too
many of either of them to be put in.
Summary box 7.3 Aurelius Cornelius Celsus, 25bc–ad50

Suture material: desired characteristsics Multiple examples of early surgery abound, with East African
●● Easy to handle tribes ligating blood vessels with tendon strips, and closing
●● Predictable behaviour in tissues wounds with acacia thorns pushed through the wound with
●● Predictable tensile strength strips of vegetable matter wound round these in a figure of
●● Sterile eight. A South American method of wound closure involved
●● Glides through tissues easily using large black ants to bite the wound together with their
●● Secure knotting ability pincers or jaws acting like skin clips, and then the ant’s body
●● Inexpensive was twisted off leaving the head in place keeping the wound
●● Minimal tissue reaction apposed. By 1000bc, Indian surgeons were using horsehair,
●● Non-capillary cotton and leather sutures while, in Roman times, linen
●● Non-allergenic and silk and metal clips, called fibulae, were commonly used
●● Non-carcinogenic to close gladiatorial wounds. By the end of the nineteenth
●● Non-electrolytic century, developments in the textile industry led to major
●● Non-shrinkage advances, and both silk and catgut became popular as suture
materials. Lister believed that catgut soaked in chromic acid

Aurelius Cornelius Celsus, Roman physician, 25bc–ad50.

Joseph Lister (Lord Lister), Professor of Surgery in Glasgow, Edinburgh and King’s College Hospital, London and Vice President of Royal College of Surgeons of
England, 1827–1912.
Alexis Carrel, 1873–1944, surgeon from Lyons in France, worked at the Rockefeller Institute for Medical Research in New York, NY, USA. He received the Nobel
Prize for Physiology or Medicine in 1912 ‘in recognition for his works on vascular suture and the transplantation of blood vessels and organs’.
Gladiatorswere so called because they fought with a Roman sword called a ‘gladius’.

01_07-B&L27_Pt1_Ch07.indd 89 25/10/2017 07:46

 PART 1 | BASIC PRINCIPLES
90 CHAPTER 7  Basic surgical skills and anastomoses
(a form of tanning) prevented early dissolution in body flu-
ids and tissues, while Moynihan felt that chromic catgut was
ideal as it could be sterilised, was non-irritant to tissues, kept
its strength until its work was done and then disappeared.
However, catgut is no longer in use as it causes an inflamma-
tory cellular reaction with release of proteases and may also
carry the risk of prion transmission if of bovine origin.
Suture characteristics
There are five characteristics of any suture material that need
to be considered:
1 Physical structure. Suture material may be monofilament
or multifilament. Monofilament suture material is smooth
and tends to slide through tissues easily without any saw-
ing action, but is more difficult to knot effectively. Such
material can be easily damaged by gripping it with needle
holder or forceps and this can lead to fracture of the suture
material. Multifilament or braided sutures are much easier
to knot, but have a surface area of several thousand times
that of monofilament sutures and thus have a capillary
action and interstices where bacteria may lodge and be
responsible for persistent infection or sinuses. In order to
overcome some of these problems, certain materials are
produced as a braided suture, which is coated with silicone
in order to make it smooth.
2 Strength. The strength of a suture material depends upon
its constituent material, its thickness and how it is hand­
led in the tissues. Suture material thickness is classified
according to its diameter in tenths of a millimetre (Table
7.1), although the figure assigned is also dependent upon
the nature of the material, e.g. absorbable material and
non-absorbable material, such as polypropylene, may dif-
fer in their designations. The tensile strength of a suture
can be expressed as the force required to break it when
pulling the two ends apart, but is only a useful approxi-
mation as to its strength in the tissues, because what mat-
ters is the material’s in vivo strength. Absorbable sutures
show a decay of this strength with the passage of time and
although a material may last in the tissues for the stated
period in the manufacturer’s product profile, its tensile
strength cannot be relied on in vivo for this entire period.
TABLE 7.1  Size of suture material.
Metric (EurPh) Range of diameter (mm)
1 0.100–0.149
1.5 0.150–0.199
2 0.200–0.249
3 0.300–0.349
3.5 0.350–0.399
4 0.400–0.499
5 0.500–0.599
Berkley George Andrew Moynihan (Lord Moynihan of Leeds), 1865–1936, Professor of Clinical Surgery, University of Leeds, Leeds, UK. Moynihan felt that
English surgeons knew little about the work of their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929
became the Moynihan Chirurgical Club. It still exists today. He took a leading part in founding the British Journal of Surgery in 1913 and became the first chair-
man of the editorial committee until his death.
01_07-B&L27_Pt1_Ch07.indd 90
Materials, such as catgut (no longer in use in the UK),
have a tensile strength that lasts only about a week, while
PDS will remain strong in the tissues for several weeks.
However, even non-absorbable sutures do not necessar-
ily maintain their strength indefinitely, and may degrade
with time. Those non-absorbable materials of synthetic
origin, such as polypropylene, probably retain their ten-
sile strength indefinitely and do not change in mass in the
tissues, although it is still possible for them to fracture.
Non-absorbable materials of biological origin, such as silk,
will definitely fragment with time and lose their strength,
and such materials should never be used in vascular anas-
tomoses for fear of late fistula formation.
3 Tensile behaviour. Suture materials behave differently
depending upon their deformability and flexibility. Some
may be ‘elastic’, where the material will return to its orig-
inal length once any tension is released, while others
may be ‘plastic’, in which case this phenomenon does
not occur. Sutures may be deformable, in that a circu-
lar cross-section may be converted to an oval shape, or
they may be more rigid and have the somewhat irritat-
ing capacity to kink and coil. Many synthetic materials
demonstrate ‘memory’, so that they keep curling up in the
shape they adopted within the packaging. A sharp but
gentle pull on the suture material helps to diminish this
memory, but the more memory a suture material has, the
lower is the knot security. Therefore, knotting technique
also plays a significant role in any suture line’s tensile
strength and it is important to recognise that sutures lose
50% of their strength at the knot.
4 Absorbability. Suture materials may be non-absorbable
(Table 7.2) or absorbable (Table 7.3) and this property must
be taken into consideration when choosing suture mater­
ials for specific wound closures or anastomoses. Sutures for
use in the biliary or urinary tract need to be absorbable in
order to minimise the risk of stone production. However,
a vascular anastomosis requires a non-absorbable material
and it is wise to avoid braided material because platelet
adherence may predispose to distal embolisation. Non-
absorbable materials tend to be preferred where persistent
strength is required and, as an artificial graft or prosthesis
never heals fully or integrates into a host artery, persistent
monofilament suture materials, such as polypropylene, are
almost universally used.
5 Biological behaviour. The biological behaviour of suture
material within the tissues depends upon the constituent
raw material. Biological or natural sutures, such as catgut,
USP (‘old’)
are proteolysed, but this involves a process that is not
5–0 entirely predictable and can cause local irritation, and
4–0 such materials are therefore seldom used. Synthetic poly-
3–0
2–0
mers are hydrolysed and their disappearance in the tissues
0 is more predictable. However, the presence of pus, urine or
1 faeces influences the final result and renders the outcome
2 more unpredictable. There is also some evidence that, in
25/10/2017 07:46
 PART 1 | BASIC PRINCIPLES
Wound closure 91

the gut, cancer cells may accumulate at sites where sutures

persist, possibly giving rise to local recurrence. For this
reason, synthetic materials that have a greater predictabil-
ity and elicit minimal tissue reaction may have an import-
ant non-carcinogenic property.

Barbed sutures
Recently, novel suture materials have helped surgeons to
reduce or eradicate the need for knot tying in some situations,
such as laparoscopic surgery. These sutures have unidirectional
or bidirectional barbs that secure the suture in the tissues.

Suture techniques
There are four frequently used suture techniques.
1 Interrupted sutures. Interrupted sutures require the
­needle to be inserted at right angles to the incision and
Figure 7.11  Interrupted suture technique. Reproduced with permis-
then to pass through both aspects of the suture line and sion from Royal College of Surgeons of England. The intercollegiate
exit again at right angles (Figure 7.11). It is important for basic surgical skills course participants handbook, edns 1–4. London:
the needle to be rotated through the tissues rather than to RCS.
be dragged through, to avoid unnecessarily enlarging the
needle hole. As a guide, the distance from the entry point
of the needle to the edge of the wound should be approx-
imately the same as the depth of the tissue being sutured,
and each successive suture should be placed at twice this X
distance apart (Figure 7.12). Each suture should reach
into the depths of the wound and be placed at right angles X
to the axis of the wound. In linear wounds, it is sometimes
easier to insert the middle suture first and then to com- X
plete the closure by successively inserting sutures, halving
the remaining deficits in the wound length.
2X
2 Continuous sutures. For a continuous suture, the first
suture is inserted in an identical manner to an interrupted
suture, but the rest of the sutures are inserted in a continu- Figure 7.12  The siting of sutures. As a rule of thumb, the distance of
insertion from the edge of the wound should correspond to the thick-
ous manner until the far end of the wound is reached (Fig- ness of the tissue being sutured (X). Each successive suture should be
ure 7.13). Each throw of the continuous suture should be placed at twice this distance apart (2X). Reproduced with permission
inserted at right angles to the wound, and this will mean from Royal College of Surgeons of England. The intercollegiate basic
that the externally observed suture material will usually surgical skills course participants handbook, edns 1–4. London: RCS.
lie diagonal to the axis of the wound. It is important to
have an assistant who will follow the suture, keeping it
at the same tension in order to avoid either purse string-
Title: Bailey & Love’s Short Practice of Surgery, 26th Ed ISBN: 9781444121278 Proof Stage: 1
ing the wound by too much tension, or leaving the suture
material too slack. There is www.cactusdesign.co.uk
more danger of producing too
much tension by using too little suture length than there
is of leaving the suture line too lax. Postoperative oedema
will often take up any slack in the suture material. At the
far end of the wound, this suture line should be secured
either by using an Aberdeen knot or by tying the free end
to the loop of the last suture to be inserted.
3 Mattress sutures. Mattress sutures may be either verti- Figure 7.13  Continuous suture technique. Reproduced with permis-
cal or horizontal and tend to be used to produce either sion from Royal College of Surgeons of England. The intercollegiate
eversion or inversion of a wound edge (Figure 7.14). The basic surgical skills course participants handbook, edns 1–4. London:
initial suture is inserted as for an interrupted suture, but RCS.
then the needle moves either horizontally or vertically,
and traverses both edges of the wound once again. Such
sutures are very useful in producing accurate approxima-
tion of wound edges, especially when the edges to be anas-
tomosed are irregular in depth or disposition.

Title: Bailey & Love’s Short Practice of Surgery, 26th Ed ISBN: 9781444121278 Proof

www.cactusdesign.co.uk
01_07-B&L27_Pt1_Ch07.indd 91 25/10/2017 07:47