What is the recommended suture technique for wound closure in gynecology surgery, specifically the figure of eight (8) suture?

Figure-of-Eight Suture in Gynecologic Surgery

Primary Recommendation

The figure-of-eight suture technique is specifically indicated for hemostasis in gynecologic surgery, particularly for controlling bleeding from vascular pedicles or bleeding points, but is not recommended as a primary wound closure technique. The evidence-based guidelines prioritize continuous non-locking suturing techniques for fascial and skin closure in gynecologic procedures 1.

When to Use Figure-of-Eight Sutures

Hemostatic Applications

• Use figure-of-eight sutures for controlling active bleeding from vascular pedicles during hysterectomy or other gynecologic procedures where direct vessel ligation is needed 2
• Apply this technique when encountering bleeding from the uterine vessels, infundibulopelvic ligament, or other vascular structures requiring secure hemostasis 2
• The figure-of-eight configuration provides compression and secure vessel occlusion that simple interrupted sutures may not achieve 2

Recommended Closure Techniques for Gynecologic Surgery

Fascial Closure

For abdominal wall closure after laparotomy, use continuous non-locking "small bite" technique with slowly absorbable monofilament suture 1, 3:

• Place sutures approximately 5mm from wound edges 1, 3
• Space stitches 5mm apart 1, 3
• Maintain a suture-to-wound length ratio of 4:1 or higher to reduce incisional hernia risk 1, 3
• Use monofilament materials (poliglecaprone/Monocryl or polyglyconate/Maxon) as they cause less bacterial seeding 1, 3, 2

Rationale for Small Bite Technique

The small bite approach significantly reduces incisional hernias and wound complications compared to large bites (>10mm) because 1:

• Aponeurosis has limited regeneration capacity and cannot bridge large defects 1
• Large bites include fat and muscle, which compress under intra-abdominal pressure causing tissue devitalization 1
• Wound edge separation >10-12mm during early postoperative period strongly associates with incisional hernia development 1

Vaginal and Perineal Repair

Use continuous non-locking technique with monofilament absorbable sutures for all layers 1, 4:

• Anchor suture above the apex of vaginal epithelium 1, 4
• Close vaginal epithelium and muscularis continuously down to hymenal ring 1, 4
• Reapproximate bulbocavernosus muscles with crown stitch at perineal body 1, 4
• Close perineal skin with continuous non-locking subcuticular stitch 1, 4

Avoid locking sutures as they cause excessive tension leading to tissue edema and necrosis 1, 4.

Skin Closure

For midline vertical incisions in obese patients (BMI ≥30), subcuticular 4-0 monofilament suture is equivalent to staples for wound complications but provides superior cosmetic outcomes 5:

• No difference in wound complication rates (32-33%) between techniques 5
• Subcuticular suture results in better cosmetic scores, less scar darkness, and fewer skin marks 5
• BMI, postoperative glucose levels, and smoking are the actual predictors of wound complications, not closure method 5

Suture Material Selection

Optimal Choices

Prioritize slowly absorbable monofilament sutures for all gynecologic closures 1, 3, 2:

• Monofilament materials reduce bacterial seeding and infection risk compared to multifilament 1, 3
• Slowly absorbable sutures (vs rapidly absorbable) decrease incisional hernia rates with high-quality evidence 1
• Consider triclosan-coated sutures (Vicryl Plus) when available, as they reduce surgical site infections (OR 0.62,95% CI 0.44-0.88) 4

Avoid Catgut

Do not use catgut sutures as they are associated with more pain and higher resuturing rates compared to synthetic alternatives 3.

Special Considerations

Subcutaneous Closure in High-Risk Patients

In obese patients undergoing gynecologic malignancy surgery, prophylactic subcutaneous drainage plus subcuticular sutures significantly reduces wound separation compared to staples 6:

• Wound separation rate: 2.5% with drainage/subcuticular sutures vs 8.5% with staples (OR 7.34,95% CI 1.59-33.91) 6
• This technique is particularly protective in obese patients where zero wound separations occurred 6

Peritoneal Closure

Do not close the peritoneum during hysterectomy 2:

• Peritoneal closure provides no outcome benefit 2
• Non-closure reduces operative time 2
• No evidence supports peritoneal closure for preventing adhesions 2

Common Pitfalls to Avoid

• Never use figure-of-eight sutures for primary fascial or skin closure—reserve this technique exclusively for hemostasis 2
• Avoid interrupted sutures for fascial closure—continuous technique distributes tension more evenly and reduces complications 1
• Do not use large bite technique (>10mm)—this increases incisional hernia risk through tissue devitalization 1
• Never place overly tight sutures—this strangulates tissue and impairs healing 4, 2
• Avoid transcutaneous interrupted sutures on perineal skin—they damage superficial nerve endings causing pain 1, 4