What type of suture, monofilament or multifilament, is recommended for a patient with a history of pelvic surgery or radiation therapy undergoing a gynecological procedure?

Monofilament Suture is Strongly Recommended for Gynecological Procedures in Patients with Prior Pelvic Surgery or Radiation

For patients with a history of pelvic surgery or radiation therapy undergoing gynecological procedures, monofilament absorbable sutures—specifically stronger materials with longer absorption profiles such as polyglyconate (Maxon) or polydioxanone (PDS)—should be selected for areas under tension or with compromised healing. 1

Primary Recommendation: Monofilament Over Multifilament

Monofilament sutures are the first-line choice for all gynecological tissue repair because they cause significantly less bacterial seeding and have demonstrably lower infection risk compared to multifilament alternatives. 1 This recommendation is supported by high-quality evidence showing monofilament sutures are associated with significantly lower risk of incisional hernia than multifilament sutures in both elective and emergency settings. 2

Key Advantages of Monofilament Sutures:

• Reduced infection risk: Monofilament sutures eliminate bacterial seeding through interstices that occur with braided/multifilament constructions 3, 4
• Lower erosion rates: Studies demonstrate 3.7% mesh/suture exposure with permanent braided sutures versus 0% with delayed absorbable monofilament (PDS) in pelvic reconstructive surgery 5
• Superior tissue passage: Monofilament sutures display minimal resistance during passage through tissue, reducing trauma 3
• Decreased hernia formation: Strong evidence supports lower incisional hernia rates with monofilament materials 2

Specific Material Selection for Compromised Tissue

For patients with prior pelvic surgery or radiation—where tissue healing is compromised—stronger monofilament suture materials with longer absorption profiles are essential. 1 The recommended options include:

First-Line Choices:

• Polyglyconate (Maxon): Provides extended strength retention with complete absorption between 180-210 days; superior handling properties compared to multifilament alternatives 6
• Polydioxanone (PDS): Maintains approximately 70% tensile strength at 2 weeks, with complete absorption by 180-210 days 3, 5

Standard Gynecological Procedures:

• Poliglecaprone (Monocryl): Primary recommendation for vaginal, perineal, and uterine closure in non-compromised tissue, providing 20-30% breaking strength retention at 2 weeks with complete absorption by 91-119 days 1, 3

Suture Technique Considerations

Regardless of material choice, continuous non-locking technique should be applied for all layers to reduce pain, decrease analgesic requirements, and lower suture removal needs. 1, 7 This is critical because:

• Locking sutures create excessive tension leading to tissue edema and necrosis 2, 1, 7
• Non-locking continuous sutures distribute tension evenly and reduce short-term pain 1
• For perineal skin specifically, continuous non-locking subcutaneous suturing avoids damage to nerve endings on the skin surface 2, 7

Why Multifilament Sutures Should Be Avoided

The evidence against multifilament sutures in this population is compelling:

• Increased bacterial adherence: Confocal microscopy demonstrates significantly more bacterial adherence to braided sutures than monofilament 4
• Higher infection rates: Braided constructions allow bacterial seeding through interstices of the braid structure 3
• Greater tissue drag: Multifilament sutures cause more tissue trauma during passage 3, 6
• Increased erosion risk: Permanent braided sutures show 3.7% erosion rates versus 0% with monofilament in pelvic surgery 5

Additional Considerations for Compromised Tissue

When operating on patients with prior radiation or multiple surgeries:

• Use 2-0 or 3-0 gauge for fascial and vaginal vault closure to provide adequate tensile strength 1, 5
• Consider antimicrobial-coated monofilament sutures (triclosan-coated) when available, as they reduce surgical site infection rates with an odds ratio of 0.62 7
• Avoid overly tight sutures that strangulate tissue and impair healing, regardless of suture type 1, 7

Critical Pitfalls to Avoid

• Never use catgut sutures: Associated with more pain, higher resuturing rates, and inferior outcomes 1, 7
• Never use locking continuous sutures: They concentrate tension and cause tissue necrosis 1, 7
• Avoid permanent braided sutures: Risk of erosion requiring invasive removal, particularly in compromised tissue 8, 5
• Do not use standard rapid-absorbing sutures in compromised tissue: Insufficient strength retention during critical healing period 1