Most Effective Suture Technique in Hysterectomy
For vaginal cuff closure during hysterectomy, use a continuous running non-locking technique with absorbable monofilament suture (such as poliglecaprone or Vicryl), which reduces operative time, distributes tension evenly, and minimizes complications compared to interrupted suturing methods.
Optimal Suture Material
- Monofilament absorbable synthetic sutures are strongly preferred for vaginal cuff closure, as they minimize infection risk through reduced bacterial seeding and cause less tissue reaction 1
- Poliglecaprone or polyglactin 910 (Vicryl) are the recommended suture materials 1
- Consider triclosan-coated Vicryl (Vicryl Plus) when available, as it demonstrates reduced surgical site infection rates (OR 0.62,95% CI 0.44-0.88) 1
- Avoid multifilament sutures due to higher bacterial seeding and infection risk 1
Recommended Suturing Technique
Continuous non-locking running suture is the technique of choice for the following evidence-based reasons:
- Continuous suturing distributes tension more evenly across the entire suture line, preventing tissue strangulation 2
- Non-locking technique prevents excessive tension that leads to tissue edema and necrosis 2, 1
- This approach reduces postoperative pain and analgesic requirements 2, 1
- Continuous techniques decrease the need for suture removal 2, 1
Specific Technical Approaches by Hysterectomy Type
For Total Laparoscopic Hysterectomy (TLH):
- Two-layer running suture technique is safe and effective for vaginal cuff closure 3
- Barbed suture with running technique significantly reduces vaginal cuff suturing time (SMD = -0.96,95% CI 1.26-0.70; p <0.001) without increasing complications 4
- Barbed suture shows comparable rates of vaginal cuff dehiscence (RD = -0.01,95% CI 0.02-0.00) and bleeding compared to conventional suture 4
For Robotic-Assisted Single-Site Hysterectomy:
- Barbed suture with straightened needle in running fashion from posterior to anterior vaginal cuff demonstrates safety and efficiency, with mean closure time of 12.0 minutes and no dehiscence complications 5
For Abdominal Hysterectomy:
- Two separate running and interlocking absorbable monofilament sutures keep the vagina closed throughout closure, avoiding blood loss and spillage 6
- This technique resulted in only 2.6% cuff cellulitis, 3.1% granulation tissue, and zero postoperative bleeding in 77 consecutive cases 6
Critical Technical Pitfalls to Avoid
- Never use locking continuous sutures - they create excessive tension causing tissue edema and necrosis 2, 1
- Avoid interrupted figure-of-eight sutures - while commonly used, they show no advantage over continuous techniques and may increase operative time 3
- Do not use overly tight sutures that can strangulate tissue and impair healing 1
- Avoid transcutaneous interrupted sutures as they damage superficial nerve endings and increase pain 2
Surgical Approach Considerations
When choosing the hysterectomy approach itself, vaginal hysterectomy (VH) should be performed in preference to abdominal hysterectomy (AH) when possible, as it results in shorter hospital stay (WMD 1.0 day), faster return to normal activities (WMD 9.5 days), and fewer infections (OR 0.42) 7. Laparoscopic hysterectomy (LH) may be appropriate when VH is not feasible, though it increases operating time and requires greater surgical expertise 7.
Essential Perioperative Measures
- Ensure adequate anesthesia (regional or general preferred) 2
- Perform surgical-site vaginal preparation with povidone-iodine or chlorhexidine gluconate 2
- Administer prophylactic antibiotics: first-generation cephalosporin (cefazolin 2g) or second-generation cephalosporin (cefoxitin 2g) 2
- Count all surgical instruments, sponges, and sutures pre- and postoperatively 2, 1
High-Risk Patient Factors
Be particularly vigilant in patients with diabetes, cigarette smoking history, or pelvic adhesions, as these factors significantly increase complication risks including vaginal cuff dehiscence 3.