Choice of suture
Objective 1. Review the evidence base for suture materials in the handsewn anastomosis
The ideal suture material would:
- be easy to handle
- tie without fraying
- be easy to sterilise
- elicit little inflammation
- maintain its strength during the lag phase of healing
Unfortunately, no available suture materials fulfil all of these criteria, however certain suture materials have properties which would be more or less desirable for use in a handsewn ileocolic anastomosis.
Overall, there is limited high-quality evidence to support suture selection in ileocolic anastomoses, much of which comes from historical pre-clinical or animal studies. Therefore, a Delphi consensus process was again used to support discussion around technical considerations in handsewn anastomoses.
A synopsis of a paper related to the experimental evidence for suture selection is available below:
Experimental evidence for suture materials in colonic surgery
Choosing a multifilament (braided) or monofilament suture:
- Greater tissue trauma
- Increased risk of infection, although the clinical significance of this is uncertain
Related paper: Mid-term absorbable monofilament is safe and effective for gastrointestinal anastomosis (PROMEGAT)
- More adherent
- Easier to tie and secure knots
In the Delphi consensus process, surgeons agreed that either use of monofilament or multifilament sutures are both acceptable
If you are using a multifilament suture, you therefore should take additional care to injury the tissue of the bowel.
If you are using a monofilament suture, you should take additional care to secure and check your knots.
Choosing an absorbable or non-absorbable suture:
In the Delphi consensus, surgeons agreed that absorbable sutures are preferable to non-absorbable sutures for handsewn anastomoses.
The preferred suture gauge was 3-0 or 4-0.
Absorbable sutures have specific benefits:
- Reduced rate of bacterial colonisation and infection
- Less intermediate-term inflammation
- Absence of foreign body
- Despite absorption, no loss of bursting strength of gastric or colonic wall after 7-14 days in rat models (i.e. maintain strength during lag phase of anastomotic healing)
Related paper: The effect of new monofilament absorbable sutures on the healing of musculoaponeurotic incisions, gastrotomies, and colonic anastomoses
Related paper: Collagen deposition and mechanical strength of colon anastomoses and skin incisional wounds of rats
- In pre-clinical studies, absorbable sutures seem to demonstrate more early tissue reaction than non-absorbable sutures.
- The inflammatory response is highest for silk versus intermediate for polypropylene – this lead to a greater chance of anatomic stricturing with silk in a rat model
- Gastrointestinal contents may increase the rate of absorption of absorbable sutures
Related paper: End-to-end oesophageal anastomosis: an experimental study in the rat
Related paper: Effect of Different Absorbable Sutures on Healing of Gastrointestinal Anastomoses