What is the best suture to use for closing the uterus during a cesarean section (CS)?

Best Suture for Uterine Closure During Cesarean Section

Use delayed absorbable monofilament sutures (such as poliglecaprone/Monocryl) for uterine closure during cesarean delivery, as these materials cause less bacterial seeding and reduce infection risk compared to multifilament options. 1, 2

Primary Suture Material Recommendation

The Enhanced Recovery After Surgery (ERAS) Society guidelines explicitly state that delayed absorbable monofilament sutures are the preferred choice for uterine closure. 1 The most commonly described options include:

• Poliglecaprone (Monocryl) - Primary recommendation 1, 2
• Polyglactin 910 (Vicryl) - Acceptable alternative 1, 2
• Chromic catgut - Acceptable alternative 1

The key distinction is that monofilament sutures demonstrate superior performance over multifilament materials by reducing bacterial seeding and infection risk. 2

Why Monofilament Over Multifilament

Monofilament sutures are structurally superior because their smooth surface prevents bacterial colonization in the interstices that exist in braided multifilament materials. 3, 2 While a 2022 randomized trial found no significant difference in cesarean scar defect rates between monofilament (polyglytone) and multifilament (Vicryl Plus) at 6 months postoperatively (18.4% vs 23.4%, P=0.31), this study did not assess infection outcomes, which remain the primary concern driving the monofilament recommendation. 4

Closure Technique: Single vs Two-Layer

Close the uterine hysterotomy in two layers, as this approach may be associated with lower rates of uterine rupture in subsequent pregnancies. 1, 2

The evidence here requires nuance:

• Non-randomized observational data suggest higher uterine rupture rates with single-layer closure in women attempting vaginal birth after cesarean. 1
• The most recent Cochrane review found no significant difference in outcomes between one- or two-layer closure. 1
• Despite equivocal evidence, the ERAS Society recommends two-layer closure given the potential catastrophic consequences of uterine rupture (maternal and fetal mortality), even though the recommendation grade is weak. 1

Emerging Alternative: Barbed Sutures

Barbed sutures (such as STRATAFIX Spiral PDO) represent a newer option that may offer operational advantages. A 2019 randomized trial demonstrated that barbed sutures reduced uterine closure time compared to conventional Vicryl (224±46 vs 343±75 seconds, p<0.001) and required fewer additional hemostatic sutures (2 vs 12 patients, p=0.009). 5 However, this study used different closure techniques between groups (both layers continuous with barbed vs first layer continuous/second layer interrupted with Vicryl), making it difficult to isolate the suture material effect from technique. 5 Given the lack of long-term safety data on uterine rupture rates and abnormal placentation with barbed sutures, conventional delayed absorbable monofilament sutures remain the standard recommendation. 1, 2

Critical Pitfalls to Avoid

• Never use overly tight sutures - This strangulates tissue and impairs healing. 3, 2
• Avoid locking continuous sutures - These create excessive tension leading to tissue edema and necrosis. 6
• Do not use figure-of-eight sutures for primary uterine closure - Reserve this technique exclusively for hemostasis of specific bleeding points, not for wound closure. 3
• Consider triclosan-coated sutures (Vicryl Plus) when available - These reduce surgical site infections (OR 0.62,95% CI 0.44-0.88) without compromising other outcomes. 3, 6

Additional Surgical Considerations

Do not close the peritoneum during cesarean delivery. 1, 2 Peritoneal closure provides no outcome benefit, does not prevent adhesions, and only increases operative time. 1, 2

Use blunt expansion rather than sharp extension of the transverse uterine hysterotomy to reduce surgical blood loss. 1