What are the considerations for using non-absorbable (non-absorbing) sutures in a patient undergoing a gynecological procedure with a history of pelvic surgery or radiation therapy?

Non-Absorbable Sutures in Gynecological Procedures with Prior Pelvic Surgery or Radiation

Non-absorbable sutures should generally be avoided in gynecological procedures for patients with prior pelvic surgery or radiation therapy, as they increase the risk of suture exposure, chronic foreign body reaction, and infection in already compromised tissue. 1

Primary Recommendation: Use Delayed Absorbable Monofilament Sutures

For patients with history of pelvic surgery or radiation, select delayed absorbable monofilament sutures with longer absorption profiles (such as polydioxanone/PDS or polyglyconate/Maxon) rather than non-absorbable materials. 2 These provide:

• Extended tensile strength (90-180 days) for compromised tissue healing 2
• Elimination of permanent foreign body in radiation-damaged or scarred tissue 1
• Reduced risk of chronic suture exposure requiring surgical removal 3, 4
• Lower bacterial seeding potential compared to multifilament options 1, 5

Specific Tissue Considerations in Compromised Pelvic Tissue

Vaginal Tissue After Radiation

• Avoid non-absorbable sutures entirely due to radiation-induced fibrosis, stenosis, and vulvovaginal atrophy 1
• Use 3-0 or 4-0 delayed absorbable monofilament (poliglecaprone or polydioxanone) 5, 2
• Radiation causes long-term tissue changes including impaired healing and increased infection risk 1

Areas with Prior Adhesions

• Prior pelvic surgery creates adhesions that compromise blood supply and healing 1
• Select stronger delayed absorbable materials (Maxon or PDS) for areas under tension 2
• Non-absorbable sutures in adhesed tissue increase risk of chronic pain and bowel complications 1

Uterine/Cervical Closure

• Use delayed absorbable monofilament sutures exclusively for uterine closure in patients with prior radiation 2, 6
• Non-absorbable sutures in uterine compression techniques are inappropriate and should be avoided 7
• Continuous non-locking technique distributes tension evenly, critical in compromised tissue 5, 6

Evidence Against Non-Absorbable Sutures in This Population

Increased Exposure Risk

• Non-absorbable sutures show 9 exposures requiring excision (5 in clinic, 2 in operating room) versus 2 exposures with delayed absorbable (0 requiring excision) in mesh fixation studies 3
• Permanent suture exposure rate of 5.1% versus 7.0% for delayed absorbable in vaginal mesh procedures, though not statistically significant 4

Compromised Tissue Healing

• Radiation causes fibrosis and impaired vascularization, making permanent foreign material problematic 1
• Prior surgery creates scar tissue with reduced healing capacity 1
• Non-absorbable sutures create permanent inflammatory response in already compromised tissue 3

Need for Secondary Procedures

• Non-absorbable sutures require removal procedures, adding morbidity 8
• In one study, 0.52% VCD rate with non-absorbable (requiring removal at 90 days) versus 1.4% with absorbable 8
• The benefit of slightly lower dehiscence must be weighed against guaranteed second procedure for removal 8

Optimal Suturing Technique for Compromised Tissue

Use continuous non-locking technique for all layers to minimize tissue trauma and distribute tension: 5, 2, 6

• Reduces short-term pain and analgesic requirements 1, 5
• Decreases need for suture removal 1
• Avoids tissue strangulation from excessive tension 5, 2
• Never use locking sutures as they concentrate tension causing tissue edema and necrosis 5, 2, 6

Critical Pitfalls to Avoid

• Never use non-absorbable sutures for uterine compression techniques - documented inappropriate use with complications 7
• Avoid catgut entirely - causes more pain, higher resuturing rates, and inferior outcomes 1, 2
• Do not use overly tight sutures that strangulate tissue, especially critical in radiation-damaged tissue 5, 2
• Avoid rapidly absorbable sutures in compromised tissue - insufficient tensile strength duration 1
• Do not use multifilament sutures - increased bacterial seeding risk in already vulnerable tissue 1, 5

When Non-Absorbable Might Be Considered (Rare Exceptions)

The only scenario where non-absorbable sutures might be justified is in abdominal wall closure (not vaginal/pelvic tissue) following emergency laparotomy with contamination, where slowly absorbable sutures are still preferred but non-absorbable may be acceptable: 1

• Suture-to-wound length ratio of 4:1 or higher required 1
• Small bite technique (5mm from edge, 5mm between stitches) mandatory 1
• Even here, slowly absorbable monofilament is preferred over non-absorbable 1