Most Effective Suture Technique in Gynecology Surgery
The continuous non-locking subcuticular suture technique using monofilament absorbable sutures is the most effective approach in gynecologic surgery, as it reduces pain, wound complications, and analgesic requirements while improving patient satisfaction and cosmetic outcomes. 1, 2
Optimal Suturing Technique
Continuous Non-Locking Method
Use continuous non-locking sutures for all layers of gynecologic repair rather than interrupted sutures, as this technique distributes tension more evenly across the suture line and prevents tissue strangulation. 1, 2
For perineal and vaginal repairs: Continuous suturing reduces pain for up to 10 days postpartum (RR 0.76; 95% CI 0.66-0.88), decreases analgesic use (RR 0.70; 95% CI 0.59-0.84), and reduces need for suture removal (RR 0.56; 95% CI 0.32-0.98) compared to interrupted techniques. 1
For abdominal wall closure: Use the "small bite" technique with sutures placed approximately 5mm from wound edges and 5mm apart, maintaining a suture-to-wound length ratio of 4:1 or higher. 2
Avoid locking sutures as they cause excessive tension leading to tissue edema and necrosis. 1, 2
Specific Technical Steps for Vaginal/Perineal Repair
Anchor the suture above the apex of the vaginal epithelium laceration 1, 2
Close vaginal epithelium and muscularis using continuous non-locking suture down to the hymenal ring 1, 2
Reapproximate bulbocavernosus muscles with a crown stitch at the perineal body 1, 2
Close perineal body musculature with continuous technique 1, 2
Close perineal skin with continuous non-locking subcuticular stitch from inferior margin to hymen, avoiding transcutaneous sutures that damage superficial nerve endings 1, 2
Optimal Suture Material Selection
Monofilament absorbable synthetic sutures (poliglecaprone/Monocryl or polyglyconate/Maxon) are superior to multifilament options because they cause less bacterial seeding and reduce infection risk. 1, 3, 2
Rapidly-absorbing synthetic sutures like polyglactin 910 eliminate the need for postpartum suture removal, though they cost more than standard synthetic sutures. 1
Consider triclosan-coated Vicryl (Vicryl Plus) when available, as it reduces surgical site infections (OR 0.62; 95% CI 0.44-0.88) compared to standard Vicryl. 3
Never use catgut sutures as they are associated with more pain and higher risk of requiring resuturing. 4
Comparison with Alternative Closure Methods
Continuous vs. Interrupted Sutures
Continuous subcuticular sutures reduce superficial wound dehiscence (RR 0.08; 95% CI 0.02-0.35) compared to interrupted transcutaneous sutures, with no difference in surgical site infection rates or hospital stay. 1
Subcuticular Sutures vs. Staples
Subcuticular sutures are superior to staples in gynecologic surgery, with probably lower wound complications (RR 0.79; 95% CI 0.64-0.98) and higher patient satisfaction scores. 1, 5
- One study in gynecologic malignancy surgery found subcuticular sutures with prophylactic subcutaneous drainage reduced wound separation compared to staples (3/120 vs 17/201, P = 0.033), with particular benefit in obese patients. 6
Tissue Adhesives
Tissue adhesives (cyanoacrylate/Dermabond) are acceptable alternatives for port site closure in minimally invasive gynecologic surgery, with significantly shorter closure time (5.4 vs 24.9 minutes, P < 0.0005) and comparable or superior cosmetic outcomes. 7
- However, subcuticular sutures may achieve higher patient satisfaction in some contexts. 5
Critical Pitfalls to Avoid
Never use figure-of-eight sutures for primary wound closure—reserve this technique exclusively for hemostasis of vascular pedicles. 2
Avoid large bite technique (>10mm) as this increases incisional hernia risk through tissue devitalization. 2
Do not place overly tight sutures that strangulate wound edges and impair healing. 1, 2
Avoid transcutaneous interrupted sutures on perineal skin as they damage superficial nerve endings causing pain. 1, 2
Do not close the peritoneum during hysterectomy—it provides no outcome benefit and only increases operative time. 2
Special Considerations for High-Risk Patients
In obese patients undergoing gynecologic surgery, consider prophylactic subcutaneous drainage combined with subcuticular sutures, as this combination significantly reduces wound separation risk (OR 7.34 for staples vs. sutures; 95% CI 1.59-33.91). 6
For cesarean delivery in obese women, interrupted subcuticular sutures may reduce wound complications compared to continuous technique, though this contradicts general recommendations and requires individual surgical judgment. 8
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