Vol. 20, No.

2 February 1998 V

CE Refereed Peer Review

Selecting Suture
FOCAL POINT Materials for Small
★ Suture materials should be
chosen with the goal of reducing
patient morbidity, not on the
Animal Surgery
basis of personal preference
or cost alone. Texas A&M University
Harry W. Boothe, Jr., DVM, MS
KEY FACTS
■ Poliglecaprone 25 has the
highest initial tensile strength
of absorbable suture materials,
N ew information about surgical sutures has made it possible for veteri-
narians to make better-informed decisions about the selection and use
of suture material. Also, veterinarians now have a broader range of
materials to choose from. Veterinary surgeons should base their choice of su-
ture material on the characteristics of the material and how it interacts with tis-
and surgical gut has the lowest.
sue, not just on personal preferences or cost. This article reviews the character-
■ Synthetic absorbable istics of suture materials and provides guidelines for choosing the suture
monofilament suture material that will minimize morbidity and maximize wound healing.
materials have advantages
over multifilament absorbable CHARACTERISTICS
materials. Several physical properties of suture material are important to surgeons (e.g.,
initial tensile strength, relative knot security, handling characteristics). Impor-
■ Ending knots of a continuous tant features of the suture–tissue interaction include tissue reactivity, rate of
pattern require at least loss of tensile strength, and degradation mechanism.
five throws to be secure
(polydioxanone requires Physical Properties
seven). Tensile Strength
Most suture materials are stronger fresh from the package than they will be
■ Excessively tight sutures increase after having been implanted in tissue. Size for size, poliglecaprone 25 has the
patient morbidity and decrease highest initial tensile strength of absorbable suture materials and surgical
wound strength. (chromic) gut has the lowest (Table I). Stainless steel is the strongest nonab-
sorbable suture material, whereas silk is the weakest (Table I).
■ Minimally reactive suture Sutures must be strong enough to withstand disruptive forces across a wound
materials, swaged needles, until the wound gains sufficient tensile strength. When choosing the type and
and smaller suture sizes are size of suture material to use in a wound, the surgeon must choose a material
preferable to more reactive whose physical properties closely match the mechanical properties of the tissue
materials, eyed needles, and being sutured (Figure 1). Mechanical properties of suture materials and their
larger suture sizes. relationship to those of tissue need further characterization for many species.
The mechanical properties of polypropylene and nylon (particularly elonga-
tion) are similar to those of skin.1
Table II presents guidelines for selecting the proper size of suture material.2
The properties of suture material (including the reliability of knots) improve as
Small Animal The Compendium February 1998

TABLE I
A Ranking of the Physical Characteristics of Suture Materials
Relative Knot Security
Effective Strength
Suture Material Initial Tensile Strength Ranking (%) Stiffness

Absorbable
Poliglecaprone 25 1 5 — 6
Polydioxanone 3 2 — 4
Polyglactin 910 4 4 — 1
Polyglycolic acid 5 3 66 5
Polyglyconate 2 1 — 3
Surgical gut 6 6 63 2
Nonabsorbable
Nylon 4 4 66 3
Polyester 2 6 51 5
Polymerized caprolactum 3 3 79 4
Polypropylene 5 2 89 2
Silk 6 5 57 6
Stainless steel 1 1 92 1

1 = highest, 6 = lowest.

diameter increases.3 However, larger-diameter sutures (there are two throws in a square knot) needed to tie a
cause greater tissue reaction.3 The size of material cho- secure knot depends on the suture material and the su-
sen usually represents a compromise between maximal ture pattern5 (Table III). To make a secure knot in an
mechanical support and minimal tissue reactivity. 3
interrupted suture pattern takes at least three throws
Sometimes, the need for mechanical support (e.g., when polyglactin 910, polyglycolic acid, surgical gut, or
for body-wall closure or tension sutures) is more critical polypropylene suture material is used but at least four
than the need to minimize tissue reaction. When one is throws when polydioxanone or nylon is used. When
closing a body wall with a continuous pattern of starting a continuous pattern using polydioxanone, sur-
polypropylene suture, a suture diameter one size larger gical gut, or nylon, the surgeon should add one throw
than that usually selected is recommended.4 In other more than would be needed for an interrupted pattern.
situations (e.g., closure of The ending knots of a con-
visceral wounds or subcuta- tinuous pattern tend to be
neous tissue), the need to the least secure and require
minimize tissue reaction at least five throws—or more
predominates. if polyglactin 910, nylon, or
Because larger-diameter polydioxanone is used 5
suture materials provide (Table III).
more-secure knots, a veteri- For some suture materials
narian may be tempted to that were developed recently
use excessively large suture (e.g., poliglecaprone 25 and
materials routinely. Howev- polyglyconate) or that have
er, veterinarians should re- been used frequently in vet-
sist this temptation because erinary patients (e.g., poly-
the larger materials cause ex- Figure 1—Relationship between loss of tensile strength by se- merized caprolactum and
cessive tissue reaction. lected absorbable sutures and gain in strength of various tis- stainless steel), the number
sues as a result of healing (From Bucknall TE, Ellis H: of throws necessary to create
Wound Healing for Surgeons. London, Baillière Tindall, 1984, secure knots has not been
Knot Security
pp 77, 81. Modified with permission.)
The number of throws evaluated. The knot security

MECHANICAL SUPPORT ■ TISSUE REACTION ■ ENDING KNOTS

The Compendium February 1998 Small Animal

of many suture materials TABLE II tures.8 Silk is so easy to han-

has been evaluated qualita- Guide for Selecting Suture dle that suture materials
tively. 6,7 All sutures lose Size for Small Animal Surgerya with excellent pliability are
strength when knotted; described as “handling like
many lose at least a third of Tissue or Use Recommended Size
silk.” Poliglecaprone 25, a
their initial tensile strength7 Skin 4-0 to 2-0 recently marketed absor-
(Table I). Relative knot se- Subcutaneous tissue 4-0 to 3-0 bable suture material, has
curity expresses knot-hold- Muscle 3-0 to 2-0 the least stiffness (greatest
ing capacity as a percentage Fascia 3-0 to 0 pliability) of the absorbable
of initial tensile strength Viscera 5-0 to 3-0 sutures9 (Table I). Although
(Table I). The effective Ligation of small vessels 4-0 to 3-0 handling characteristics
strength of the suture mate- Ligation of large vessels 2-0 to 1 may be the decisive factor
rial depends on both the Tension sutures 2-0 to 1 in the choice of suture ma-
initial tensile strength and terial for some surgical pro-
aData from Grier RL: Surgical sutures—Part II: Indications
the relative knot security cedures, a suture material
(see Effective Strength of for different suture materials and comparable costs. Iowa should never be chosen sole-
State Univ Vet 34:89–92, 1972.
Suture Materials). ly on the basis of its handling
characteristics.
Handling Characteristics
The handling characteristics of suture materials are Suture–Tissue Interaction
an important consideration. Stiffer (i.e., less pliable) su- Suture materials influence patient morbidity primari-
ture materials are more difficult to handle.8 When us- ly through their interaction with tissue. Many factors
ing a stiff suture material, the surgeon must take partic- affect this interaction, including the amount (diameter
ular care to ensure that the knots are secure. and length) of suture material in the wound as well as
In general, monofilament sutures are stiffer than mul- the placement technique. The impact of sutures on the
tifilament sutures of the same composition, Also, larger- wound is an important consideration in the selection of
diameter sutures are stiffer than smaller-diameter su- a suture material. Although much is known about the
influence of sutures as foreign material in
wounds, little is known about their effect
TABLE III
on the wound microenvironment. 10 Tis-
Number of Throws Needed to Create a Secure Knota
sue–suture interactions are complex, involv-
Continuous Pattern ing humoral and cellular factors.11
Interrupted
Sutures alter the healing process in con-
Suture Material Pattern Start End
taminated or infected wounds. The pres-
Absorbable ence of any suture in tissue increases the tis-
Poliglecaprone 25 — — — sue’s susceptibility to infection. Thus, the
Polydioxanone 4 5 7 veterinarian should avoid placing suture in
Polyglactin 910 3 3 6 a contaminated wound unless it is essential
Polyglycolic acid 3 3 5 for positioning tissue.12
Polyglyconate — — — Both the physical construction (monofil-
Surgical gut 3 4 5 ament versus multifilament) and the chemi-
Nonabsorbable cal composition of the suture material affect
Nylon 4 5 6 whether a contaminated wound will be-
Polyester — — — come infected.13–15 Monofilament sutures
Polymerized caprolactum — — — withstand contamination better than multi-
Polypropylene 3 3 5 filament sutures. The number of sutures in
Silk — — — the wound also influences whether a con-
Stainless steel — N/Ab N/Ab taminated wound will become infected. Su-
ture size and length should be minimized in
a
For many suture materials, the number of throws needed to create a secure any wound but particularly in a contami-
knot has not been established. nated wound.
bNot applicable: Stainless steel should not be used in a continuous suture

pattern. Because of their monofilament construc-

tion, polydioxanone, polyglyconate, and

RELATIVE KNOT SECURITY ■ PLIABILITY ■ CONTAMINATED WOUNDS

Small Animal The Compendium February 1998

poliglecaprone 25 are the and tissue reactivity by a

preferred absorbable su- Effective Strength of Suture Materials factor of approximately
ture materials for use in 1.5.
The effective strength of a suture material depends
contaminated wounds. How tightly the suture
Polypropylene and mono- on both the initial tensile strength and the relative should be tied depends
filament nylon are the knot security. The materials listed here are in de- on the intended use. Li-
superior nonabsorbable scending order according to effective strength: gatures are tied tightly
suture materials for a con- to strangulate vessels.
taminated wound.13 1. Stainless steel 7. Nylon Sutures to approximate
2. Polymerized caprolactum 8. Polyglactin 910 wounds should be tied
Tissue Reactivity 3. Polypropylene 9. Polyglycolic acid just tightly enough to
Tissue reactivity is un- 4. Polyglyconate 10. Polyester provide tissue contact
desirable, particularly without strangulation.
5. Poliglecaprone 25 11. Silk
when the sutures are Excessively tight suture
placed near the body sur- 6. Polydioxanone 12. Surgical gut lines increase patient mor-
face. Increased tissue reac- bidity and reduce short-
tivity probably leads to increased morbidity (e.g., an and long-term strength in fascial wounds.17
intensified or prolonged inflammatory phase of wound
healing or enhanced patient awareness of the wound Tensile Strength Loss
and subsequent self-mutilation). Sutures of natural ori- Although many nonabsorbable suture materials lose
gin tend to be more reactive than those of synthetic strength over time in tissue, such loss of tensile strength
origin. is usually clinically insignificant. However, absorbable
Surgical gut stimulates the greatest tissue reactions; materials lose strength dramatically as they are ab-
silk, polymerized caprolactum, and polyester are the sorbed.
most reactive nonabsorbable suture materials (Table When choosing an absorbable material, the veterinar-
IV). Although some surgeons like to use surgical gut ian should select one that loses strength at a rate that is
when strong adhesions are desired at the surgical site appropriate for the healing characteristics of the tissue
(e.g., perineal herniorrhaphy), surgical gut did not en- being sutured. Materials that lose tensile strength rapid-
hance adhesion formation in dogs.16
Tissue reactivity is minimized by use of TABLE IV
inert monofilament materials.11 Sutures that Characteristics of Suture–Tissue Interaction
stimulate minimal tissue reactivity (e.g., Rate of Tensile
polypropylene, nylon, stainless steel, poly- Tissue Reactivity Strength Loss Degradation
dioxanone, polyglyconate, polyglactin 910, Suture Material (Rank) (Rank) Pattern
polyglycolic acid, or poliglecaprone 25) are
preferable to more-reactive sutures (e.g., Absorbable
surgical gut, silk, polymerized caprolactum, Poliglecaprone 25 2 2 Hydrolysis
or polyester). Because of excessive reactivity, Polydioxanone 6 6 Hydrolysis
surgical gut has largely been replaced by Polyglactin 910 4 4 Hydrolysis
synthetic absorbable sutures. Polyglycolic acid 3 3 Hydrolysis
Inflammatory reactions to sutures are Polyglyconate 5 5 Hydrolysis
most pronounced near knots.3 Knots have Surgical gut 1 1 Foreign body
the highest density of foreign material, and Nonabsorbable
they cause the greatest mechanical trauma Nylon 5 2 Hydrolysis
in tissue.3 Knot size or volume (which de- Polyester 3 N/A NA
pends on suture size and number of throws) Polymerized caprolactum 2 N/A NA
affects tissue reactivity. Suture size has the Polypropylene 6 N/A NA
major influence on knot volume and tissue Silk 1 1 Foreign body
reactivity. An increase of two suture sizes re- Stainless steel 4 N/A NA
sults in more than a four- to sixfold increase
in knot volume and more than a two- to 1 = highest (i.e., most tissue reaction or fastest loss of tensile strength); 6 = low-
3 est (i.e., least tissue reaction or slowest loss of tensile strength); N/A = not ap-
threefold increase in tissue reactivity. Add- plicable.
ing two extra throws increases knot volume

KNOT SIZE ■ KNOT VOLUME ■ SUTURE TIGHTNESS

The Compendium February 1998 Small Animal

ly (e.g., surgical gut and less steel is minimally reac-

poliglecaprone 25) should tive and has excellent knot
be reserved for use in wounds security; but it is stiff and
that regain tensile strength subject to breaking when
quickly (Figure 1). Absor- used in a continuous pat-
bable suture materials that tern. Polypropylene with
lose tensile strength more fluorescent pigment has
slowly (e.g., polydioxanone properties similar to those of
and polyglyconate) are ap- polypropylene, and it is easy
propriate to use in body to visualize in ambient or
walls because fascia heals black light.22
slowly. Subcutaneous tissue should
The site of implantation be closed with small amounts
may affect the behavior of Figure 2—Stainless steel has excellent knot security, produces of small-diameter, minimal-
sutures. Urine weakens minimal tissue reaction, and is appropriate for an interrupted ly reactive absorbable mate-
polyglactin 910 and poly- pattern to close skin. rial. Synthetic absorbable
glycolic acid.18 Surgical gut materials, particularly poly-
loses tensile strength quicker where there is increased glyconate or polydioxanone, seem most appropriate for
inflammation or proteolytic enzymes. 19 In general, subcutaneous tissue.
monofilament absorbable sutures tend to maintain ten-
sile strength longer than do multifilament absorbable Viscera
sutures. Surgical gut loses tensile strength quicker, Visceral wounds heal relatively quickly, usually at-
whereas polydioxanone loses strength slower than other taining full tensile strength by 21 days after surgery
absorbable suture materials20,21 (Table IV). (Figure 1). Because of its rapid healing, the gastroin-
The tissue response to sutures depends on the testinal tract is well suited to the use of absorbable su-
amount of suture placed in the wound and the tech- ture materials. Synthetic absorbable sutures, especially
nique of suture placement. Multifilament sutures have polydioxanone and polyglyconate, are recommended
greater surface area than monofilament sutures have, so because of their minimal reactivity. Relatively small-di-
multifilament sutures tend to stimulate more tissue re- ameter sutures (3-0 to 5-0) and swaged needles are rec-
sponse.19 The suture pattern affects the amount of su- ommended for gastrointestinal surgery.
ture implanted in a wound. Continuous patterns usual- Closure of various canine viscera has been evaluated
ly have fewer knots than do interrupted patterns and recently. Sutures recommended for closing the urinary
probably result in less suture material in the wound. bladder include polydioxanone and polyglyconate—in
The technique of suture placement also affects tissue part because they maintain tensile strength when in
response. Excessively traumatic tissue handling, use of contact with urine.18 Contact with urine may cause pre-
eyed (nonswaged) needles, and excessively tight sutures mature absorption of polyglactin 910 and polyglycolic
all enhance tissue reaction. acid. Although sutures used to close urinary bladder in-
cisions do not usually come into contact with urine,
SUTURE FOR SPECIFIC TISSUE the use of monofilament synthetic absorbable suture
Skin and Subcutaneous Tissue materials (e.g., polydioxanone or polyglyconate) to
Recent information can help the veterinary surgeon close a cystotomy incision seems appropriate. Tracheal
select an appropriate suture material for a specific tis- closure with polydioxanone resulted in minimal tissue
sue. Veterinarians frequently use polymerized caprolac- reaction.23 In general, suture material used to close vis-
tum, polypropylene, nylon, stainless steel (Figure 2), or ceral incisions should be absorbable and minimally re-
polypropylene with fluorescent pigment to close skin. active.
Polymerized caprolactum, which is a coated multifila-
ment, has good handling and knotting characteristics Body Wall
but stimulates the greatest reaction in skin.22 Polypropy- Body walls require prolonged suture support because
lene is minimally reactive and has excellent knot securi- fascia heals relatively slowly.17 Although the abdominal
ty; like nylon, it has mechanical properties similar to walls of many small animals have been closed success-
those of skin. Monofilament nylon is also minimally re- fully with surgical gut, synthetic absorbable materials
active; but it has lower knot security than does stainless (particularly polydioxanone or polyglyconate) are pre-
steel, polypropylene, or polymerized caprolactum. Stain- ferred because of their prolonged maintenance of ten-

URINE ■ NONSWAGED NEEDLES ■ TISSUE HANDLING

Small Animal The Compendium February 1998

sile strength (Figure 1). As surgeons to select the type

an alternative, synthetic and size of suture material
nonabsorbable materials and the suture pattern that
(e.g., polypropylene, mono- is appropriate for each
filament nylon, or monofil- wound and that will maxi-
ament stainless steel) can be mize the patient’s well-
used. Stainless-steel fascial being. The goal is to pro-
staples have compared fa- vide secure wound closure
vorably with a simple con- while minimizing morbidi-
tinuous pattern of poly- ty. For example, the surgeon
propylene suture material in may have to use a smaller-
closing the body wall of diameter material (which is
dogs.24 Removing such sta- harder to handle and pro-
ples at a subsequent laparo- Figure 3—Relatively large purchases (8 mm) should be taken vides a somewhat less-secure
tomy may be more difficult in the external fascial sheath during closure of the body wall. closure) in order to reduce
than removing sutures. Synthetic absorbable or nonabsorbable suture materials are the likelihood that a con-
Body walls should be closed recommended. taminated wound will be-
with sutures that are tied come infected.
just tightly enough to appose the wound edges. Tissue The type and size of suture material chosen should
purchases should be approximately 8 mm wide—larger be appropriate for the task. It is important to place su-
than those used in other tissues25 (Figure 3). tures of the appropriate composition, size, and tight-
ness. In general, it is better to use a material that causes
SOURCES OF SUTURE MATERIAL minimal tissue reaction. Surgeons should avoid using
The packaging of suture materials affects cost and excessively large sutures and should try to minimize tis-
ease of use. Bulk sources (e.g., suture cassette) are less sue trauma during suture placement.
expensive than prepackaged suture. Although bulk
sources are cheaper, they have disadvantages. First, they
require the use of eyed needles, which produce more About the Author
tissue trauma and are less efficient to use than swaged Dr. Boothe is affiliated with the Department of Small
needles.26 A member of the surgical team must thread Animal Medicine and Surgery, College of Veterinary
the needle, and the needle can separate from the suture Medicine, Texas A&M University, College Station, Texas.
during use. Second, bulk sources of suture probably He is a Diplomate of the American College of Veterinary
carry a greater risk of contamination than does pre- Surgeons.
packaged suture. Third, only selected suture materials
are available in bulk sources (e.g., surgical gut, poly-
merized caprolactum, stainless steel, and polypropylene
with fluorescent pigment). The risk of contamination REFERENCES
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of the suture. suture materials and comparable costs. Iowa State Univ Vet
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BULK SUTURE ■ SWAGED NEEDLES ■ SUTURE SIZE

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