What types of sutures are used for different surgical procedures and when are absorbable (e.g. Vicryl, Monocryl) versus non-absorbable (e.g. Nylon, Prolene) sutures preferred?

Suture Selection Guide

For emergency laparotomy and most surgical closures, use slowly absorbable monofilament sutures (such as Monocryl or PDS) with a continuous "small bite" technique and maintain a 4:1 suture-to-wound length ratio to minimize incisional hernia and wound complications. 1

Absorbable vs Non-Absorbable Sutures

When to Use Absorbable Sutures

• Absorbable sutures are preferred for fascial closure in emergency and elective laparotomy because they reduce postoperative pain compared to non-absorbable options, though evidence shows no significant difference in incisional hernia or surgical site infection rates between the two 1
• Slowly absorbable synthetic sutures (e.g., Vicryl, Monocryl, PDS, Maxon) are strongly recommended over rapidly absorbable materials with high-quality evidence showing lower incisional hernia rates 1, 2
• Avoid catgut sutures entirely—they cause more pain and require resuturing more frequently than synthetic alternatives 2, 3

When to Use Non-Absorbable Sutures

• Non-absorbable sutures (e.g., Nylon, Prolene, silk) are appropriate for skin closure requiring removal and situations where permanent tensile strength is needed 4, 5
• Polypropylene (Prolene) maintains consistent tensile strength over time in both clean and contaminated conditions 6
• Non-absorbable sutures typically cause inflammatory reactions that lead to fibrous encapsulation; excessive reaction can cause chronic inflammation or suture extrusion 5

Monofilament vs Multifilament Sutures

Monofilament Advantages

• Monofilament sutures (Monocryl, PDS, Prolene, Nylon) cause less bacterial seeding and lower tissue resistance during passage 2, 3, 5
• Particularly beneficial for hand lacerations and high-mobility areas where infection risk is elevated 3
• Lower friction reduces tissue trauma during placement 5

Multifilament Considerations

• Multifilament sutures (Vicryl, silk) provide higher tensile strength and flexibility but increase tissue friction 5
• Braided materials pose higher risks of suture sinus formation and infection 5
• For cesarean subcuticular closure, 4-0 Vicryl and 4-0 Monocryl show comparable surgical site infection rates (6.1% vs 5.1%, p=0.58), making either acceptable based on surgeon preference 7

Specific Suture Applications by Procedure

Abdominal Wall Closure (Emergency/Elective Laparotomy)

• Use slowly absorbable monofilament sutures with continuous running technique 1, 2
• Maintain suture-to-wound length ratio ≥4:1 (Jenkins Rule) to significantly reduce incisional hernia and wound complications 1, 2
• Apply "small bite" technique: 5mm from wound edge, 5mm between stitches, including only aponeurosis to prevent tissue devitalization and wound edge separation 1, 2, 3
• Avoid "large bite" technique (>10mm spacing) as it includes fat and muscle, leading to tissue compression, damage, and increased hernia risk 1

Hand and Finger Lacerations

• Use 4-0 or 5-0 monofilament absorbable sutures to reduce bacterial seeding while eliminating painful suture removal 3
• Leave sutures in place 10-14 days (12-14 days for thumb webbing) due to high mobility and tension 3
• Avoid locking sutures—they cause excessive tension leading to tissue edema and necrosis 3
• Consider subcuticular closure for final layer to minimize scarring 3

Cesarean Skin Closure

• Either 4-0 Vicryl or 4-0 Monocryl for subcuticular closure are acceptable with equivalent wound complication rates 7
• Subcuticular suture closure is superior to staples for reducing wound complications 7

Enhanced Suture Materials

Triclosan-Coated Sutures

• Triclosan-coated sutures significantly reduce surgical site infection prevalence compared to non-coated sutures (Grade of Recommendation 1B) 2
• Consider for contaminated or high-risk cases 2

Critical Technical Points

Suture Sizing

• Use the smallest suture size that accomplishes the purpose to minimize tissue trauma and foreign material 5
• Tensile strength is limited by suture size—balance between adequate strength and minimal tissue reaction 5

Contaminated Fields

• Tensile strength reduction over time does not differ significantly between clean and contaminated conditions for silk, Prolene, Vicryl, or PDS 6
• Silk shows significantly more severe macroscopic inflammation under contaminated conditions (p=0.03), while monofilament and synthetic multifilament sutures show no significant difference 6

Common Pitfalls to Avoid

• Never use rapidly absorbable sutures for fascial closure—they significantly increase incisional hernia rates 1
• Avoid catgut in all circumstances—synthetic alternatives are superior 2, 3
• Do not use suture-to-wound ratios <4:1—this dramatically increases hernia and wound complication risk 1, 2
• Avoid locking continuous sutures in hand lacerations—causes tissue necrosis 3