Review Article Open Access J Surg

Volume 8 Issue 1 - February 2018

Copyright © All rights are reserved by Irami Araújo-Filho
DOI: 10.19080/OAJS.2018.08.555730

Surgical Sutures: The Necessary Update of

Current Knowledge
Irami Araújo-Neto1, Maria Helena Wanderley Costa Dantas2, Tarciso Bruno Montenegro Sampaio3, Amália
Cinthia Meneses do Rêgo4 and Irami Araújo-Filho5*
1
Undergraduate Student of the Medicine Course, Potiguar University (UnP)-Laureate International Universities- School of Health, Brazil
2
Undergraduate Student of Nutrition Course, Potiguar University (UnP)-Laureate International Universities - School of Health, Brazil
3
Adjunct Professor, Department of Biology, Potiguar University (UnP)-Laureate International Universities - School of Health, Brazil
4
Post Graduation Program in Biotechnology, Potiguar University (UnP)-Laureate International Universities - School of Health, Brazil
5
Full Professor of the Post Graduate Program in Biotechnology at Potiguar University-Laureate International Universities, Brazil
Received: January 11, 2018; Published: February 13, 2018
*Corresponding author: Irami Araújo Filho, Full Professor of the Post Graduate Program in Biotechnology at Potiguar University-Laureate
International Universities, Department of Surgery, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil,
Tel: ; Email:

Abstract

Objective: To describe the physical characteristicsandbiological of thewires ofmoresuture usedinsurgical practice daily andtheir
indications.

Methods: Review was conducted of literature through to search in the databases Pubmed, Embase, Web of Science and Scopus.

Results: Were described data on the qualities of the ideal suture, general classification and descriptive, criteria for use and the physical
and biological characteristics of absorbable sutures, wires, monofilaments and multifilamentary.

Conclusion: It was possible to synthesizethecurrent knowledgetherespectofstrands ofsuture,to be used by students of medicine, surgery
residents, surgeons and its subspecialties.

Keywords: Sutures; Sutures materials; Polymers; Suture; Absorbable effect; Non-absorbable effect suture; Biocompatible materials

Introduction
e. Arms andconstant resistance.
The suture thread began to be used for closing wounds
3.500 years before Christ in Egypt [1] and to this day the act of f. Coefficient of frictionfit.
stitch is still the most common method for rapprochement of
g. Ability to maintain the resistance until whenneeded.
the edges of the surgical wounds. The suture material selection
should be based on the biological properties of the tissues to be h. Absorption speed unaffected bybody fluids.
approximated, in the physical and biological characteristics of
i. Be easy to handle-easy knot andfirm.
yarns and wound conditions to be closed. Even with the current
advance of technology, it remains true that no suture has all the j. Appropriate elasticity
features that classify as the ideal wire.
k. Not be changed with thesterilization.
Qualities of the ideal suture
l. Have lowpenetration.
a. Appropriate resistance.
m. Non allergenic and non-mutagenic.
b. Minimaltissue reaction.
n. Be lowcost.
c. Do not degrade intotoxic products.
Objective
d. Not facilitate the infection and remain stable in
Describe the physical and biological characteristics of the
yourpresence.
sutures used in surgical practice daily and their indications.

Open Access J Surg 8(1): OAJS.MS.ID.555730 (2018) 001

 Open Access Journal of Surgery

Methods most intense inflammatory reaction among all suture, besides

presenting a time very short and unpredictable absorption.
Literature review was performed by searching in the
databases Pubmed, Embase, Web of Science and Scopus on The emergence of the synthetic absorbable was very
the topic, using the following keywords: sutures, sutures promising for several reasons:
materials, polymers, suture, absorbable effect, non-absorbable
a. Trigger inflammatory reactions significantly smaller
effect suture, biocompatible materials. Were described data
than natural absorbable
on the qualities of the ideal suture, general classification and
descriptive, criteria for use and the physical and biological b. Keep much of your resistance until the absorption
characteristics of absorbable sutures, wires, monofilaments and process begins and if complete
multifilamentary.
c. Are available withtimes ofabsorption
Results and Discussion short,mediumandlong,givingopportunitytothesurgeon
The suture can be classified according to several parameters choose the suitable wire for each case
that relate to your source material, structure and permanencein d. Quality mechanics of us isthe same for all the
the tissues. So, as the degradation that they suffer in vivo are wirestested synthetic absorbable [4-6]. The description of
classified into two broad categories as absorbable and non- each suture is made below.
absorbable sutures, both with wires that are manufactured from
natural fibersor synthetic materials. Although the natural fiber Absorbable
yarns have been used for a long time and to this day are with Catgut
good results, themost modern synthetic yarns are considered Yarn made from collagen extracted from the submucosa of
more suitable. Among other reasons, by the lower tissue reaction the small intestine of sheep or cattle intestinal serosa, is available
when compared to natural or organic yarn [2]. The sutures may in the form of catgut simple and catgut chrome. The simple
also be characterized by your physical setup. Those consisting loses half of strength after 5 to 7 days in the tissues and 100%
of a single filament are said monofilaments and the formed by after 3 to 4 weeks. The treatment with chrome wire extends
multiple fibers, braided or twisted, are called multifilamentary. absorption and increases your resistance to stress. The catgut
The nylon and the steel are examples of yarns available both as chrome loses 50% of the resistance in the 20 days 19 and 100%
monofilaments and multifilamentary. after 5 weeks in the tissues. It is a monofilament wire, absorbed
The general classification of the suture can be seen below, by the mechanism of enzymatic digestion, which causes tissue
where trade names have been added to some of them, with the significantly more intense reaction than the synthetic absorbable
sole purpose of facilitating the identification of the same. The [7]. Should be avoided in suturing of tendons and fasciae, since
decision of using absorbable, monofilament or multifilament, they are healing slowly, structures that are subjected to efforts
not absorbable depends of a series off actors. There is that and constant tensions. In addition, the time of absorption of
if you consider the time needed for the wound to heal, the catgut is unpredictable. Is contraindicated in bleeding duodenal
voltage supported by tissue during the healing process and the ulcers sutures or perforated, pancreaticojejunal anastomosis
issue of temporary or permanent need of the suture to ensure and biliary anastomosis, because it can be quickly disintegrated
mechanical support. Experimental studies have revealed that by the action of proteolytic enzymes [8].
the wires of suture in wounds of abdominal wall stopped to Polyglycolic Acid (Dexon)
engage mechanical support between the days 15 and 28 of the
postoperative period [3], and that only 41% of aponeurosis Multifilament yarn, braided synthetic absorbable by
regained your initial resistance 2 months after being sutured hydrolysis, in which is released the monomer glycolic acid soluble.
[4]. Both findings like these, as the complex dynamics of muscle It has been shown experimentally that the polyglycolic acid loses
structures and aponeurotic of the abdominal wall and your your strength after 28 days altogether in the tissues and is 100%
susceptibility to incisions hernias and event, have provoked absorbed within 60 days. As for postoperative adhesions, in the
discussion about the choice of the best suture thread beingused. form of gel can reduce the formation of pericardial adhesions
[9,10]. Clinical study showed that the closure of abdominal wall
The variations in the behavior of the different types of with Polyglycolic Acid resulted in 16% of infection, significantly
suture materials have been widely studied in vivo, in vitro, higher than the 7% of infection that occurred when the wounds
experimentally and clinically, each study emphasizing the were closed with absorbable monofilament synthetic [11].
qualities of each one of them. In general, the monofilaments are
appointed as more advantageous, because the multifilamentary Polyglactin 910 (Vicryl)
provide conditions for the development of infection, since Multifilament consists of 90% to 10% glycolic acid and lactic
bacterial colonies are formed in spaces between filaments acid. About 50% of the yarn is absorbed by hydrolysis after the
[5,6]. Absorbable natural yarns (catgut) are responsible for the 28th day after surgery and 100% after the 70th day [12]. When

How to cite this article: I Araújo-Neto, Maria H W C D, Tarciso B M S, et al. Surgical Sutures: The Necessary Update of Current Knowledge. Open Access
002
J Surg. 2018; 8(1): 555730. DOI: 10.19080/OAJS.2018.08.555730
 Open Access Journal of Surgery

compared with the polidioxanona (PDS) in intradermal suture Nonabsorbable Sutures

on the presence of erythema, induration, hypertrophic scarring
Cotton, linen and silk
and infection, there was no significant difference [13]. Used in
experimental rabbits, pyeloplasty, proved to be the most suitable Are multifilamentares of natural fibers, yarns have high
wire compared to other natural and synthetic resorbable wires resistance, are easy to handle and provide firm mechanical node.
[14]. Suture materials interact with immunocompetent cells and His great virtue is the low cost, reason by which still today are
may affect host immunity. In experimental work was studied the widely used in many hospitals. For being multifilamentary of
influence of soluble factors of multiple sutures on the function of high capillarity, leverage infection more than monofilamentares
macrophages. It was found that your capacity for phagocytosis, wires nonabsorbable sutures. The intense inflammatory reaction
adherence, lysozyme and production of tumor necrosis factor causing decreases tissue resistance to infection and multifilament
was significantly more affected by polyglactin, in comparison structure retains the bacteria in your intimacy. This facilitates
with the other wires [15]. wall infection, fistula formation and the elimination of through
points of operative wounds. This way, these wires should be
Polydioxanone (PDS) avoided in wound suture that present bacterial contamination.
Monofilament yarn produced from the polymerization of Silk, in particular, exerts a considerable inhibitory effect on the
paradioxanone. Of violet color, absorbed by hydrolysis, your functions of macrophages, harming mostly the adhesion of these
time of absorption is more extended than polyglactin. Study cells [15].
in rats showed that the polidioxanone was present in vascular
Polyester (Dacron, Mersilene)
anastomoses after 120 days, suggesting that this material is safe
invascular sutures [16]. On average, the absorption of the wire Manufactured through polymerization resulting
starts after 90 days and ends after 180 days. Anastomosis and ester ethylene glycol combination with terephthalic acid,
micro anastomosis performed showed that the polidioxanone multifilament, braided, is of high resistance. By be a wire of
provoked little inflammatory reaction when compared with high coefficient of friction, the handling is not of more easy, that
othermaterials of suture [17,18]. Study in vitro showed that the makes your limited use. The us present unfavorable mechanical
wires of suture release factors influencing behavior considerably qualities, which made trying to improve quality coating your
immunotoxic macrophages and that these effects may have surface with teflon, silicone and polybutilate, targeting also
important clinical implications. One of the wires tested in the decrease yourcapillarity. Polyester induces a significantly higher
study, the polidioxanone and steel were the materials that have tissue reaction ofthe polypropylene in abdominal wound closure,
less inhibition of macrophage functions [15]. with increased risk of infection [22]. The addition of inert
materials and waterproof cover polyester filaments did not alter
Poliglecaprone (Monocril) significantly the tissue inflammatory response, did not decrease
Absorbable, monofilament is a copolymer of epsilon- the incidence of infection in contaminated wounds sewn up with
caprolactone and glycoside. Laboratory tests have shown that this thread. Therefore, should be avoided in wounds with these
shows excellent ease of handling, minimal resistance during characteristics.
passage through the tissues and resisting proper tension.
Polyamide (Nylon)
The time of complete absorption between 90 and 120 days of
deployment in the tissues, with minimal tissue reaction [19]. Available as monofilament and multifilament, braided nylon
causes little tissue reaction, can be used and is well tolerated
Polyglyconate (Maxon) in infected tissues in presentation monofilament. Is a low-cost,
Slow absorption monofilament, features high resistance. easy to handle, but we can dispose very easily. This requires the
Randomized clinical study showed that polyglyconate, even used surgeon to make multiple nodes at each point of a suture, doing
with smaller diameter than the polyglycolic acid, retained high with that bacteria proliferate in the recesses of these nodes. Had
strength tension postoperatively, when employed in the closure once as chemically inert material, nylon decomposes over time in
of abdominal wall [20]. When it comes to sutured, presented 1-6-hexanediamine and adipic acid, so that after 6 months in the
infection rate significantly lower (7%) on laparotomies lock, tissue loses almost entirely your resistance to tension [23]. This
when compared with polyglycolic acid (16%). Displays the node loss is resistance by chemical degradation and not by physical
mechanically more secure than poliglecaprone and poliglactin phenomena as exhaustion of matter or undone the knots.
[21]. Study conducted in rabbits, in which the femoral artery
Proteolytic enzymes cause hydrolysis to attacking the amide
anastomoses were carried out under normal stress and
group of the polymer, resulting in 1-6-hexanediamine and adipic
increased showed, optical microscopy and electronics, that
acid. In vitro study indicateda probable antibacterial action of
polyglyconate wire keeps the voltage resistance until complete
these degradation products of nylon, able to reduce the number
healing of anastomosis. The tissue reaction proved to be minimal
of colonies of Staphylococcus aureusa concentrations varied
and the complete absorption was followed by total regeneration
[3]. However, when the wire was deployed in the subcutaneous
of the vascular wall, demonstrating that the cord is suitable for
tissue of rats for a prolonged period, their supposed degradation
this type of fabric [21-23].
products did not show any antibacterial action [24].

How to cite this article: I Araújo-Neto, Maria H W C D, Tarciso B M S, et al. Surgical Sutures: The Necessary Update of Current Knowledge. Open Access
003
J Surg. 2018; 8(1): 555730. DOI: 10.19080/OAJS.2018.08.555730
 Open Access Journal of Surgery

Polypropylene (Prolene, Surgilene) [31]. The steel wire is high resistant and difficult to handle by
the scant flexibility.
Monofilament wire, available in blue color, biologically inert
even in the presence of infection. Is easy to handle, the node It is often used in sutures in mass of the abdominal wall,
is firm, has proper elasticity and wide chemical resistance to insternal closure, in the department of orthopedic surgery and
acids, alkalis and enzymes. Its resistance to tension remained in the hernia repair. Edlich et al. [26,32] conducted extensive
unchanged in tests conducted after several years of deployment collective review of literature showed the reliable performance
in the tissues. Polypropylene has great tensile strength, although of sutures of stainless steel monofilament under the following
it can easily be fractured by the needles, as often occurs with techniques of wound closure: sternal fixation, abdominal wound
the monofilamentares. Highresistance, combined with the closure, inguinal hernia repair and closing skin wounds. Steel
appropriate elasticity, makes him a suitable wire for vascular multifilament yarn has been used with good results in various
anastomosis, anastomosis of tendons and suture of abdominal types of suture of different organs.
wall [25,26].
McDonald et al. demonstrated that this wire ensured a
Polytetrafluoroethylene (PTFE) secure attachment to a tendon, when compared to the Ethibond
Is a non-absorbable monofilament wire, tested with good and Supramid sutures, showing minimum elongation of the
results in plastic surgery. In a comparative study with 10 other multifilament and stainless steel better retention capacity of the
sutures, it was verified that the PTFE caused the less tissue node, resulting in a higher ultimate tensile strength in repairs of
reaction, making him considered the wire of choice for facial tendons [27,33].
plastic surgery, where the critical functional and aesthetic Conclusion
results [27].
In conclusion, the existing knowledge of sutures and
Polybutester (Novafil) their biophysical chemistry characteristics contributes to
Monofilament non-absorbable synthetic which offers the surgeons decide the proper use of these during surgical
elasticity, flexibility and resistance to the voltage that the sensitive synthesis, contributing to best postoperative results, avoiding
of the other of the same category. The degree of elongation at rejections, infections and other complications inherent to the
break time and safety of us are similar to those found in other operative procedure, favoring a speedy recovery of the patient
sutures Nonabsorbable sutures, synthetic monofilamentares with therapeutic costs reduction.
[28]. These features make it potentially beneficial for closure
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How to cite this article: I Araújo-Neto, Maria H W C D, Tarciso B M S, et al. Surgical Sutures: The Necessary Update of Current Knowledge. Open Access
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J Surg. 2018; 8(1): 555730. DOI: 10.19080/OAJS.2018.08.555730
 Open Access Journal of Surgery

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How to cite this article: I Araújo-Neto, Maria H W C D, Tarciso B M S, et al. Surgical Sutures: The Necessary Update of Current Knowledge. Open Access
005
J Surg. 2018; 8(1): 555730. DOI: 10.19080/OAJS.2018.08.555730