What type of suture material is recommended for gynaecological procedures, considering factors such as absorbability (e.g. mono (monofilament) vs multi (multifilament)) and patient history of pelvic surgery or radiation therapy?

Recommended Suture Material for Gynecological Procedures

For gynecological procedures, use monofilament absorbable synthetic sutures such as poliglecaprone (Monocryl) as the primary choice, as they minimize infection risk through reduced bacterial seeding compared to multifilament options. 1, 2

Monofilament vs Multifilament Selection

Monofilament Sutures (Preferred)

• Monofilament absorbable sutures are the first-line choice for gynecological tissue repair because they cause less bacterial seeding and have demonstrably lower infection risk compared to multifilament alternatives 1, 2
• Specific monofilament options include:
  • Poliglecaprone (Monocryl): Primary recommendation for vaginal, perineal, and uterine closure with excellent handling properties and minimal tissue resistance 1, 2, 3
  • Polyglyconate (Maxon): Alternative option that elicits lower chronic inflammation and retains tensile strength longer during critical wound healing 4, 5
  • Polydioxanone (PDS): Another monofilament option with lower inflammatory response, though with less tensile strength than Maxon during early healing 4

Multifilament Sutures (Secondary Option)

• Multifilament sutures like polyglactin 910 (Vicryl) are acceptable alternatives but carry higher infection risk due to bacterial harboring in the interstices of the braided structure 6, 3
• Triclosan-coated Vicryl (Vicryl Plus) reduces surgical site infections by 38% (OR 0.62,95% CI 0.44-0.88) compared to standard Vicryl, making it preferable if multifilament sutures are selected 1
• Multifilament sutures provide higher tensile strength and flexibility but create greater tissue friction during passage 6

Specific Suture Sizes and Techniques

For Vaginal and Perineal Repair

• Use 3-0 or 4-0 delayed absorbable monofilament sutures 7
• Apply continuous non-locking technique for all layers to reduce pain, decrease analgesic requirements, and lower suture removal needs 1
• Avoid locking sutures as they create excessive tension leading to tissue edema and necrosis 1

For Uterine Closure (Hysterectomy/Cesarean)

• Use delayed absorbable monofilament sutures, preferably poliglecaprone 2
• Employ continuous non-locking technique to distribute tension evenly and reduce short-term pain 2
• Consider two-layer closure for cesarean sections to potentially reduce future uterine rupture risk 2

For Anal Sphincter Repair (OASIS)

• Use 3-0 delayed absorbable sutures (polyglactin or poliglecaprone) for internal anal sphincter repair 7
• Apply either mattress or interrupted end-to-end technique 7

Special Considerations for High-Risk Patients

Patients with Prior Pelvic Surgery or Radiation

• Select stronger monofilament suture materials with longer absorption profiles (Maxon or PDS) for areas under tension or with compromised healing 2, 4
• These materials retain a larger percentage of tensile strength during extended postoperative periods while maintaining low inflammatory response 4
• Avoid catgut entirely as it causes more pain, higher resuturing rates, and inferior outcomes 1, 8

Critical Pitfalls to Avoid

• Never use multifilament sutures without considering antimicrobial coating in contaminated fields or high-risk patients, as the braided structure potentiates infection 6, 3
• Avoid overly tight sutures that strangulate tissue and impair healing regardless of suture type 1, 2
• Do not use catgut or chromic catgut as they are obsolete with documented inferior outcomes 1, 9
• Never use locking continuous sutures as they concentrate tension and cause tissue necrosis 1