ArticlePDF Available

From Ants to Staples: History and Ideas Concerning Suturing Techniques

While  performing  our  usual  surgical  tasks,  we  often
think that most of our routinely practiced surgical tech-
niques have been developed in the last 100 years. 
This idea stems from the knowledge that ether anaes-
thesia,  introduced  by  the  American  dentist  Morton  in
1846, and antisepsis, promoted by Lister in 1860, only
decades later allowed ‘greater surgical interventions (
However  various  aspects  of  surgery  have  a  much
longer history. Indeed, surgical practice has for centuries
been  focussed  around  three  basic  steps :  dieresis  (inci-
sion), exeresis (removal) and synthesis (suturing). In this
text, the evolution of the last one, namely suturing and its
various  forms  and  materials,  will  be  looked  at  more
closely (
Suture materials (
Looking at materials used for suturing throughout histo-
ry,  a  long  list  of  different  types  can  be  found :  gold
threads,  kangaroo’s  tendons,  black  horse’s  hair,  linen,
wire,  “cat  gut”,  cotton,  silk,  tantalum  and  many  more.
Recently, synthetic materials were added to that list, not
only having some typical suture characteristics, that have
been  wished  for  a  long  time,  but  also  avoiding  some
problems of the natural materials, used before.
One of the first written references in history to sutur-
ing materials is found in Egyptian literature (16th centu-
ry BC) in Edwin Smiths’s papyrus where the following
line  is  inscribed :  If thou examines a man having a
wound in the top of his eyebrow, draw together for him
the gash with stitching.’ (
Ancient populations in various continents were using
giant ants as “suturing devices” (
). These rather big and
still  existing  insects  (like  Oecophylla smaragdina and
Eciton burchelli) have powerful claws (Fig. 1). The ants,
held close to the wound, would strongly bite both edges
of the gap, drawing them close together. The “manipula-
tor”  of the  insect  would  then  decapitate  it,  leaving  the
head, with its bite, in place on the wound, thus maintain-
ing the edges close together (Fig. 2). The use of ant jaws
was equally mentioned in the  Samhita,  and  later  in  the
medieval Arabic medical literature (
Another  natural  way  of  treating  gaping  wounds  was
by using vegetable thorns or animal spikes, crossing both
Acta Chir Belg, 2012, 112, 395-402
From Ants to Staples : History and Ideas Concerning Suturing Techniques
J. Schiappa
, R. Van Hee
Staff  Surgeon,  Hospital  CUF  Infante  Santo,  Lisbon,  Portugal ; 
Emer.  Professor  of  Surgery  and  Medical  History,
niversity of Antwerp, Belgium.
Surgical history
Fig. 1
The giant ant Eciton burchelli, used for wound union (photo
G. Majno)  (From G.  Majno. The healing hand.  Harvard
University Press, 1991. Plate 7.2.).
(1)  It  is  indeed  noteworthy  to  acknowledge  that  most  practical
concepts,  related  with  these  discoveries,  date  from  even  later  years :
intubation and closed circuit anaesthesia date ‘only’from 1909 ; the use
of  surgical  gloves  in  surgical  practice  were  ‘only’  introduced  by
William Halsted in 1890 (see Lathan 2010) ; the first successful blood
transfusion ‘only’took place in 1914, when the Belgian doctor Albert
Hustin discovered the anticoagulant action of sodium citrate (see Dor
1993, pp. 78-81), etc. 
(2)  Several articles and books have been dedicated to the history of
suturing : see amongst  others Mackenzie 1973 ; Snyder  1976 ;  Black
1982 ;  Kuijjer  1998.  Some  articles  relate  specifically  to  suturing  of
particular  organ  systems  or  in  particular  regions,  e.g.  Picardi  2002 ;
Muffy et al. 2011.
(3)  For a specific history of suture materials, see Goldenberg 1959,
Teubner 1973, and others.
(4)  Case  10  of  the  Edwin  Smith  papyrus  (New York Academy  of
Medicine :  Rare  Book  Room).  See
egypt.html (consulted 30.06.12). For a recent discussion on the Edwin
Smith papyrus, see Sykes 2009. 
(5)  For an overview of the many actions and medicinal uses of ants,
see Lockhart 2000. 
(6)  See Haddad 2010 p. 54.
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 395
edges of the gap and, by using vegetable fibres around it
or  by  placing  them  as  a  figure  of  eight,  bringing  the
edges of the wound close together. Such techniques were
first used in Africa, around the 10
century BC.
Much later some metal devices, specifically designed
for this use were found, being used by the Greeks and by
the Mycenaean. These so called fibulae” were similar to
our actual safety pins and were placed in a similar way
as formerly described, to hold tissues together (Fig. 3).
The  use  of  prepared  animal  viscera,  treated  as  to
become threadlike usable fibres, was first mentioned by
Galen to treat gladiators cut tendons.
Galen  proposed  several  ways  of  suturing  to  obtain
wound  union (
).  In  peripheral  wounds  either  a  direct
suture  or  a  fibula  was  used (
).  In  abdominal  wounds
either  a  running  suture (
)  or  a  figure  8  -  double  layer
suture was applied (
) (Fig. 4).
As  suturing  material  Galen  proposed  silk  threads
which were imported from transalpine Gallia.
Catgut was used since the 15
century. Its name comes
from the fibres  used  as string chords  in  a specific con-
temporary  musical  instrument,  a  sort  of  pocket  violin
called  “kit” (
).  This  first  type  of  “catgut”  kept  being
used  in  the  same  form  until  the  19
century ;  by  then
intestinal  tissue  of  animals (
)  started  to  be  chemically
modified for surgical use.
Metallic wires were already mentioned during the late
Middle Ages.  One of the first  was  gold, used in hernia
surgery.  This so-called  golden thread suture was
intended  to  prevent  recurrence  after  hernia  sac  reduc-
tion (
396 J. Schiappa and R. Van Hee
In  the  20th  century,  cotton,  linen  and  silk  were
chemically prepared and started to be regularly used by
industrial preparation in large factories.
Fig. 2
The  claws  of  the  ant,  approximating  the  edges  of  the  wound
(reference see supra).
(7) See de Moulin p. 19.
(8)  Ibidem p. 19.
(9)  Also called a furrier stitch, in view of the technique of suturing
used by the furrier craftsmen.
(10)  See de Moulin pp. 19-20.
(11)  We recently saw and heard for the first time a 21
century ver-
sion  of  the  same  instrument,  this  time  with  a  detachable  electronic
improvement added to it.
(12)  Usually sheep.
(13)  See Van Hee 2011 pp. 346-347.
Fig. 3
Fibula, as  used  in Roman times. a.  Closed instrument.
b. Several  fibulas  used  for  abdominal  wound  closure  (From
G. Majno. The healing hand. Harvard University Press, 1991.
Figures 9.21 & 9.22 p. 366).
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 396
From Ants to Staples 397
After  many  years  of  practice  it  was  realised  that
synthetic materials, like  polyglycolic  acid(
polyglactin (
),  polypropylene (
)  and  others,  guaran-
teed further use. They progressively were introduced and
applied as standardized suture materials.
The “Ideal Suturing Material”
During  all  these  times,  the  obvious  quest  for  an  “ideal
suturing material” was in the centre of scientific debate.
Everybody agreed that goals had to be matched that were
not easily obtained.
The  “ideal  suture”  should  be  usable  in  any  surgical
intervention,  be  flexible  and  easy  to  handle,  provoke
minimally  or  no  tissue  reaction,  have  strong  tension
force  during  the whole  healing  process,  be  totally
absorbed after having completed its function, be capable
of providing safe knots, keep uniform characteristics and
predictable behaviour without  shrinking, be easily  visi-
ble and moreover be cheap, easy to sterilise, and able to
keep  its  activity  during  storage.  This  list  of  necessary
characteristics for the “Ideal Suture” is long and difficult
to  fulfil. The  single Ideal Suture” is  therefore  still  far
away.  Depending  on  the  characteristics  and  surgeon’s
preferences of any particular suture, the main properties
of sutures relate to the qualities, cited in Table I.
With evolving  technology  some of these steps
towards the Ideal Suture have been overcome. From nat-
ural suture materials we moved to synthetic ones produc-
ing a more predictable and uniform behaviour. Different
types of  sutures have been  produced : monofilament or
multifilament,  threaded  or  braided,  absorbable  or  non
absorbable,  each  having  its  advantages  and  disadvan-
tages. Recently some suture materials even prove to have
their own antibacterial properties.
An actual classification of sutures is given in Table II.
Industrial sutures have many different diameters with
available  calibres  ranging  from  11/0  to  5,  the  smallest
diameter corresponding to the greater number of zeros ;
as a comparative example, the mean diameter of human
hair is equivalent to a 7/0 suture thread.
Referring  to  tensile strength,  it  is  necessary to
mention that strength is related to the period sutures keep
their  characteristics,  before  tissue  reaction  crumbles
them off, and the process  of absorption sets in.
Nevertheless there are few data regarding these process-
es in humans ; only animal testing has been performed,
providing figures usable as reference.
For now, despite many  improvements,  synthetic
sutures still present several problems in current practice,
including  handling  difficulty,  knot  insecurity  and  fric-
tion. Targeted solutions like special coating of materials
improve handling but often worsen knot safety.
Equally  nylon  sutures,  against  most  common  belief,
are not 100%  non-absorbable but gradually  loose
strength (15 to 20% per year) and can be expelled after
Summarizing, much still has to be done in the search
for an ideal suturing material”.
Suturing needles (
When humankind started to understand and use sutures,
the  need  for  needles  to  pass  those  suturing  materials
through body tissue immediately became evident. There
is evidence of their existence since many millennia BC.
Such  needles  were  made  of  different  origins :  starting
with bone fragments and natural vegetal “spikes”, sutur-
ing needles went into various types of metal composites,
maintained for many centuries.
(14) Also known as ‘Dexon’.
(15) Also known as ‘Vicryl’.
(16) Also known as ‘Prolene’.
(17) For an excellent overview on the history of needles, see Kirkup
Fig. 4
Galen  type  sutures :  a  running  suture  (I)  and  a  figure  8  –  double  layer  suture  (II).  (From  D.  de  Moulin.  A history of Surgery.
Dordrecht/Boston/Lancaster : Martinus Nijhoff, 1988. Figure 6, p. 20).
able I
1 Tensile strength
2 Induction of tissue reaction
3 Quality of knots
4 Quality of handling (flexibility, memory)
5 Sterilisation effects
6 Type of absorption
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 397
Important  needle  improvements  were  made  in  the
Renaissance period with a more standardized and even
industrial  production  of needles.  So  did  Cistercian
monks  in  Worcestershire  during  the  late  Middle  Ages
have a huge production of eyed needles till Henry VIII
closed  all  monasteries ;  the  monks  moved  to  Redditch
where  a  great  factory  producing  surgical  needles  still
exists (
Different types of needles were used in the course of
the  following  centuries.  So  did  Ambroise  Paré  (1510-
1590) design a  series  of  straight and curved needles of
different size (Fig. 5).
His handled needle in the 19
century was refined by
Jacques-Louis  Reverdin  (1842-1908) (
)  and  became
very popular for more than a hundred years (Fig. 6).
So-called atraumatic needles were produced since the
1920’s (
), when  it  was  found  that  a  strong  connection
between suture and needle could minimize tissue trauma.
Concurrently, different types of needle body and tip were
designed at the  same pace as  industrial production was
allowing  these  needles  to  be  put  into  use.  Moreover,
important developments took place, related to the alloys
used in the production of needles, importing their capac-
ity of resistance against bending, though allowing minute
bending before breaking.
In search for other alternative suturing techniques
After the more widespread use of surgical suturing, sur-
geons realised that bridging gaps in human tissues could
also  be  achieved  by  other  means.  Independently  the
French surgeon F.N. Denans in 1826 (
) and the Belgian
surgeon J.H.F. Henroz from Liège in the same year pub-
lished the results of their experiments on dogs, in which
for  the  first  time  they  used  a  mechanical  device  to
achieve  intestinal  anastomosis (
).  Technical  advances
and  confidence (
)  progressively  induced  better  results
in  suturing  and  anastomosing  different  portions  of  the
gastrointestinal  tract (
).  These  anastomotic  techniques
were how ever demanding and compelled surgical aware-
ness,  attention  and  expertise  without  which  complica-
tions would arise, such as stenosis, haemorrhage or leak-
age. To minimize these difficulties, technical errors and
398 J. Schiappa and R. Van Hee
complications, several new surgical devices were intro-
duced  to  ease  these  techniques  in  achieving  the  same
goals (
So the first mechanical devise using staples was intro-
duced in  1908 by Prof. Humer Hültl  (1868-1940) from
Hungary (
). This device placed two double rows of fine
(18) See Hayward 1961.
(19) See Farina-Perez 2010. 
(20) Atraumatic  needles  were  first  introduced  by  the  Company
Davis & Geck in 1922. See Nolan 1971 and Scannell 2005. 
(21) See Denans 1826.
(22) See Henroz 1826.
(23) Both were related to the introduction of anaesthesia and anti-
sepsis in the second half of the 19
(24) These techniques implied various expert approaches, which are
not discussed here.
(25) For an overview on this evolution, see Hardy 1990.
(26) See  Hültl  1909.  See  for  an  overview  of  non-mechanical  sta-
pling : Zeebregts et al. 2003.
Table II
Absorbable catgut, collagen, homopolymers and co-polymers
Non Absorbable silk, steel, nylons, polypropylene, cotton and linen
Biological catgut, silk, linen and cotton
Artificial steel, nylon and polypropylene
Monofilament nylon, steel, catgut, polypropylene
Braided silk, polyglycolic acid
Twisted cotton, linen
Coated silk, terylene
Non-coated steel, polypropylene, catgut
Fig. 5
Depiction  of  straight  and  curved  needles,  used  by Ambroise
Paré  (From  A. Paré.  Les Oeuvres.  13e  Edition.  Lyon :  Pierre
Valfray. p. 202).
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 398
From Ants to Staples 399
steel wire staples for distal gastric resection. The staples
were already closing in a B shape and were positioned in
a double staggered row, but the instrument weighed 4 kg
and took about two hours to be assembled and prepared
for use.
In  1924,  another  Hungarian  surgeon,  Aladar  Petz
(1888-1956) (
),  introduced  a  similar  instrument  for
gastro intestinal  anastomosis,  supposedly  more  effica-
cious but still weighing 3.5 kg !
In 1934, Dr. H. Friedrich, from Ulm in Germany, con-
structed a device with a replaceable, preloaded cartridge,
providing a real practical advantage, since time consum-
ing preparatory insertion of staples, placed manually one
by one, got prevented (
ecause of suture complications mentioned previous-
ly, the USSR during the 1940s started a systematic pro-
gram  of  developing  stapling  devices  at  the  Scientific
Institute for Experimental Surgical Apparatus and
Instruments.  From  this  research  work  originated  a  first
eries of staplers in 1952, meant for use in vascular sur-
gery and developed  by Alexander Shalinov from
Ukraine.  Afterwards  other  suturing  devices  were  con-
structed at the Institute, such as the PKS-25 and KTs-28
suturing  devices,  as  well  as  the  UKL-60  and  UO-40.
Although more  practical  and  lighter  in  weight  than  the
earlier types, these staplers were still executed in metal ;
they were reusable devices whose staplers had still to be
hand charged one by one, mostly by the surgeon himself.
Literature  references  about  these  staplers  appeared  in
1969 (
), when their type of construction had meanwhile
spread in the surgical world, so that many surgeons in the
West  had  already  tried  the  “Russian”  staplers.  New
developments occurred in the western world and led  to
the first staplers in the USA in 1967, inducing references
in western literature from 1968 onwards (
). Many other
Eastern and Western papers followed these first publica-
tions (
). Recent developments in stapling devices con-
sisted of disposable staple cartridges, preloaded with dif-
ferent sizes and patterns of staples.
Several companies started to produce staplers as dis-
posable devices, opening a gate for widespread use. Not
only  several  improvements  were  progressively  intro-
duced but also prices dropped and use became common.
After introduction of laparoscopic surgery, staplers were
also adopted with great success for endoscopic use, and
helped to introduce several new laparoscopic techniques.
Some of  them  would  even  be  very  difficult to perform
without the existence of endoscopic staplers.
The  “explosion”  of  laparoscopy  led  to  a  discussion
concerning  the  use  of  disposable (
),  reusable  or  “re-
posable” (
)  staplers,  trocars and  instruments.  Such
discussion  had  already  taken  place  in  connection  with
such staplers and other devices in open surgery.
(27) Also known as ‘von Petz’ in German literature. For a commen-
tary on his stapling device, see Olàh & Dézsi 2002.
(28) See Friedrich 1934.
(29) See Beiul 1969.
(30) See Steichen 1968.
(31) See Kalinina 1976 ; Chassin et al. 1978 ; Ravitch & Steichen
(32) Some  devices  even  only  exist  as  disposable.  Disposable
equipments are generally more expensive per procedure. However cost
calculations in different countries do not consider the many variables
like time and costs spent in cleaning, preparing and sterilizing reusable
instruments. On the other hand, in many hospitals extra costs of dispos-
able instruments are transferred to patients and is not accounted for.
(33) This  is  a  neologism  for  reusable  instruments  of  which  small
parts are to be thrown away after single use.
Fig. 6
The  handled  needle,  already  depicted  by  A.  Paré,  and  later
adapted by Jacques-Louis Reverdin (From A. Paré. Les Oeuvres.
13e Edition. Lyon : Pierre Valfray. p. 192).
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 399
Although  decisions  concerning  development  of  new
devices primarily cannot be based on prices or costs, it is
nevertheless mandatory to include  these factors in con-
sidering the advantages and disadvantages of the differ-
ent types of devices and instruments :
Disposable equipments can  give  a  sense  of  greater
safety and  confidence, guaranteeing efficacy and preci-
sion. They are delivered properly packed and sterile, pro-
viding less handling and reduced chance for contamina-
tion,  both  for  patients  and  for  personnel.  They  do  not
need handling and costs of reprocessing. Besides, some
only exist in this presentation. But they are more expen-
sive, imply a bigger effort on keeping stocks updated and
have a strong ecologic impact because of disposal.
Reusable equipments are  less  expensive  at  buying
time but imply reprocessing (cleaning, packing, inspec-
tion and sterilisation) ; maintenance and repair are equal-
ly important issues, as well as a certain risk of contami-
nation.  Technical  “outdating”  may  happen  during  the
normal  life  of  reusable  equipment,  resulting  in  biased
calculations of amortization.
Laparoscopy also  has  strong  impact  on  the  type  of
devices being constantly developed and commer-
cialised (
).  Laparoscopic  hand  suturing  is  a  difficult
technique,  so many  companies  tried  to  overcome  this
problem by introducing many devices to fulfil the task :
EndoStitch, Sew-Right, Suture Assistant, Quick Stitch, U-
clip and many  others are only  some examples showing
once  more  no  clear-cut  best  option  is  available (
Robotic assisted  suturing  may  be  a  possible  such  solu-
tion from the technical point of view (
), but is not the
right one in economical difficult times or in financially
precarious regions.
400 J. Schiappa and R. Van Hee
Non suturing types of approximation
Some “new technologies” for tissue approximation still
have to be mentioned here (
). It fact, devices for tissue
compression,  biological  glues,  laser  “welding”  and  the
use  of  growth  factors  are  not  new,  as  devices  of  tissue
compression  were  introduced  in  1826 (
)  (Fig.  7  &  8),
biological  glues  in  the  1960’s (
),  laser  “welding”  in
1985 (
) and growth factors in 1990 (
). The use of these
techniques, all with absence of suture material has some
potential (theoretical) benefit. Scar and healing will sup-
posedly be better as less changes in blood supply occur,
inflammatory reaction is reduced, no necrotic areas nor
foreign  body  reaction  appear,  while  infection  in  suture
tracts is absent. Anastomosis can be as sealed and conti-
nent  as  in  suture  approximation,  but  may  moreover  be
“malleable”  and  capable  of  following  “body  growth”.
(34) See Clarke 1972. For an overview, see Swain & Park 2004. For
an effect on suture strength, see Bariol et al. 2005.
(35) As  always whenever  there  is a  multitude  of solutions  for  the
same problem, none is an excellent choice.
(36) See Nio et al. 2004.
(37) They  are  very  much  in  the  centre  of  discussions,  especially
since the introduction of NOTES!
(38) See  Denans  1826  for  the  construction  of  rings,  and  Henroz
1826 for the development of articulated rings.
(39) See Lick et al. 1967. See also the historical introduction in the
article of Currie et al. 2001.
(40) See  for  introduction  of  the  technique  of  tissue  ‘welding’ in
vascular access, Okada et al. 1985. For use of the technique in nerve
coaptation, see Maragh et al. 1988.
(41) See Brantigan 1995, and Rohrich et al. 1999. For an overview
on the effect of growth factors, see Fuchs et al. 2012.
Fig. 7
Compressive device of Denans (See Denans 1826)
Fig. 8
Compressive device of Henroz (See Henroz 1826)
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 400
From Ants to Staples 401
Devices for tissue compression of which the most well-
known  was  Murphy’s  button (
),  introduced  in  clinical
practice  in  1892  (Fig.  9),  also  count  for  an  immediate
seal  closure  of  tissues  in  a  continuous  way,  having  an
immobile  anastomosis  without  distension  during  the
healing period and with no foreign bodies within tissues.
Biological Glues include  fibrin sealants(
)  and
cyanoacrylates (
). They can  also  be  complemented  by
collagen prostheses (
Laser tissue “welding” is based on the use of photo-
thermal  mechanisms  connecting  structural  proteins.  It
has been tested with oesophago-gastric anastomosis and
for closing skin (
Despite  all  claimed  advantages,  all  of  these  “new
technologies” still have to prove their efficacy and safe-
ty, before being used more widely in clinical practice. 
Time will show how these advances will perform. In
the future, other medico-historical texts will relate this!
Bariol  S.V.,  Stewart  G.D.  & Tolley  D.A.  Laparoscopic  suturing :
effect of instrument handling on suture strength. J. Endourol. 2005,
19 : 1127-1133.
Bass  L.S.  &  Treat  M.R.  Laser  tissue  welding :  a  comprehensive
review of current and future clinical applications. Lasers Surg Med
1995, 17 : 315-349.
Beiul A.E. [Ileotransverso-anastomosis and digestive disorders fol-
lowing resection of small intestine]. Khirurgiia (Moskou) 1969, 45 :
Black  J.J. A stitch  in  time-1.  The  history  of  sutures.  Nurs. Times
1982, 78 (15) : 619-623.
Brantigan  C.O.  The  history  of  understanding  the  role  of  growth
factors in wound healing. Wounds 1995, 8 : 78-96.
Chassin  J.L.,  Rifkind  K.M.,  Sussman  B.,  Kassel  B.,  Fingaret A.,
Drager S. & Chassin P.S. The stapled gastrointestinal tract anasto-
mosis :  incidence  of  postoperative  complications  compared  with
the sutured anastomosis. Ann.Surg. 1978, 188 : 689-696.
Clarke  H.C.  Laparoscopy  –  New  instruments  for  suturing  and
ligation. Fert.Steril. 1972, 23 : 274-277.
Currie L.J.,  Sharpe J.R.,  Martin  R. The use  of  fibrin glue  in skin
grafts  and  tissue-engineered  skin  replacements :  a  review.  Plast.
Reconstr. Surg. 2001, 108 : 1713-1726.
De  Moulin D.  A history of surgery, with emphasis on the
Netherlands. Dordrecht/Boston/Lancaster :  Martinus  Nijhoff
Publishers, 1988.
Denans  F.N.  Nouveau  procédé  pour  la  guérison  des  plaies  des
intestins. Recueil de la Société Royale de Médecine de Marseille.
Séance  du  24  février  1826,  rédigé  par  Mr.  P.  Roux.  Marseille :
Archard, 1827, vol.1 : 127-131. 
Dor  P.  Les  membres  marquants  à  Bruxelles.  In :  R.  Van  Hee  &
P. Mendes  da  Costa  (Eds.) :  Société Royale Belge de Chirurgie.
1893-1993. Koninklijk Belgisch Genootschap voor Heelkunde.
Wetteren : Universa Press, 1993, pp.57- 89.
Farina-Perez L.A.  Jacques-Louis Reverdin (1842-1929) :  the
surgeon and the needle. Arch. Esp. Urol. 2010, 63 : 269-274.
Friedrich  H.  Ein neuer Magen-Darm Nähtapparat.  Zentralblatt
Chir. 1934, 61 : 504-506. 
Fuchs  T.F.,  Surke  C.,  Stange  R.,  Quandte  S.,  Wildemann  B.,
Raschke  M.J.,  Schmidmaier  G.  Local  delivery  of  growth  factors
using coated suture material. The Scientific World Journal. Article
ID 109216 (8 pp.) 
Goldenberg  I.S.  Catgut,  silk,  and  silver.  The  story  of  surgical
sutures. Surgery 1959, 46 (5) : 908-912.
Haddad F.S. Suturing methods and material with special emphasis
on the jaws of giant ants (an old-new surgical instrument). J. Med.
Liban 2010, 58 (1) : 53-56.
Hardy  K.J.  Non-suture  anastomosis :  the  historical  development.
Aust. N. Z. J. Surg. 1990, 60 : 625-633.
Hayward L. Surgical needles, ancient and modern. Transactions of
the British Surgical Technicians 1961, 8 : 18.
Henroz  J.H.F.  Dissertatio inauguralis critica de methodis ad
servanda intestina divisa adhibitis, in qua nova sanationis
methodus proponitur. In Universitate  Leodiense  Publico Examini.
Thesis, submitted June 14
, 1826.
Hültl  H.  II.Kongress  der  Ungarischen  Gesellschaft  für  Chirurgie,
Budapest, Mai 1908. Pester Med.-Chir. Presse 1909, 45 : 108-110
& 121-122.
Jakob H.,  Campbell  C.D., Stemberger  A., Wriedt-Lübbe I.,
Blümel G.,  Replogle  R.L.  Combined  application  of  heterologous
collagen and fibrin sealant for liver injuries. J. Surg. Res. 1984, 36 :
Kalinina  T.V.  [Use  of  the  KC-28  Stapler.].  Khirurgiia (Moskou),
1976, March (3) : 137-141.
Kirkup  J.  The  history  and  evolution  of  surgical  instruments.  V.
Needles  and  their  penetrating  derivatives.  Ann. Royal Coll. Surg.
Engl. 1986, 68 : 29-33.
Kuijjer P.J. Geschiedenis van het genezen : de wondhechting. Ned.
Tijdschr. v. Geneesk. 1998, 142 : 473-479.
Lathan  S.R.  Caroline  Hampton  Halsted :  the  first  to  use  rubber
gloves in the operating room. Proc. Bayl. Univ. Med. Cent. 2010,
23 : 389-392.
Lick  R.F.,  Brückner  W.,  Dietrich  K.F.  Zum  nahtlosen  Wund -
verschluss  durch  Kleben.  Histomorphologische  Befunde.  Mediz.
Klinik 1967, 62 : 321-323.
Lockhart G.J. Ants, and other great medicines. Unpublished, 2000.
Made  available  online  by  A.L.  Jacobson  in  2007.  Consulted  on
internet, April 20
, 2012.
Mackenzie  D. The  history  of  sutures.  Med. Hist.  1973,  17 :  158-
Maragh H., Hawn R. & Gould J. Is laser nerve repair comparable to
microsuture coaptation ? J. Reconstr Microsurg. 1988, 4 : 189-195.
(42) See Murphy 1892.
(43) Introduced since 1940. For an overview, see Sierra 1993.
(44) Introduced since 1960. See Shantha et al. 1989.
(45) See Jakob et al. 1984.
(46) For a comprehensive review on laser tissue welding, see Bass
& Treat, 1995. For extensive laboratory work on laser nerve welding,
see the various articles by Menovsky & Beek, e.g. 2001 & 2003.
Fig. 9
Murphy button, as depicted in his original article of 1892 (See
Murphy 1892).
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 401
Menofsky T. & Beek J. Laser, fibrin glue, or suture repair of peri -
pheral nerves : a comparative functional, histological, and morpho-
metric study in the rat sciatic nerve. J. Neurosurg. 2001, 95 : 694-
Menofsky T. & Beek J. Carbon dioxide laser-assisted nerve repair :
effect  of  solder  and  suture  material  on  nerve  regeneration  in  rat
sciatic nerve. Microsurgery 2003, 23 : 109-116.
Muffy T.M. , Tizzano A.P. & Walters M.D. The history and evolu-
tion  of  sutures  in  pelvic  surgery.  J. Royal Soc. Med. 2011,  104 :
Murphy J. Cholecysto-intestinal, gastro-intestinal, entero-intestinal
anastomosis,  and approximation  without  sutures.  Medical Record
1892, 42 : 665-676.
Nolan S.P. The Eureka needle. Surgery 1971, 69 : 788-791.
Nio  D.,  Balm  R.,  Maartense  S.,  Guijt  M.,  Bemelman  W.A.  The
efficacy of robot-assisted versus conventional laparoscopic vascu-
lar anastomosis in an experimental model. Eur. J. Vasc. Endovasc.
Surg. 2004, 27 : 283-286.
Okada  M.,  Shimizu  K.,  Ikuta  H.,  Horii  H.  &  Nakamura  K.  An
alternative method of vascular anastomosis by laser : experimental
and clinical study. Lasers Surg Med. 1987, 7 : 240-248.
Olàh  A.  &  Dézsi  C.A.  Aladar  Petz  (1888-1956)  and  his  world-
renowned  invention :  the  gastric  stapler.  Digestive Surgery 2002,
19 : 393-399. 
Picardi  N.  Storia  della  sutura  con  dispositive  meccanici  nella
chirurgia  dell’apparato  digerente.  Ann. Ital. Chir.  2002,  73 :  1-
Ravitch  M.M.  &  Steichen  F.M. A stapling  instrument  for  end-to-
end inverting  anastomosis in  the  gastrointestinal tract.  Ann. Surg.
1979, 189 : 791-796.
Rohrich  R.J.,  Trott  S.A.,  Love  M.,  Beran  S.J.,  Orenstein  H.H.
Mersilene  suture  as  a  vehicle  for  delivery  of  growth  factors  in
tendon repair. Plast.Reconstr. Surg. 1999, 104 : 1713-1717.
Scannell J.W. The Davis and Geck Company Records, compiled by
James W. Scannell in 2005 (
402 J. Schiappa and R. Van Hee
Sierra  D.H.  Fibrin  sealant  adhesive  systems :  a  review  of  their
chemistry, material properties and clinical applications. J. Biomater.
Appl. 1993, 7 : 309-352.
Shantha K.L., Thennarasu S., Krishnamurti N. Developments and
applications  of  cyanoacrylate  adhesives.  J. Adhesion Science &
Technology 1989, 3 : 237-260.
Snyder  C.C.  On  the  history  of  the  suture.  Plast. Reconstr. Surg.
1976, 58 (4) : 401-406.
Steichen  F.  M.  The  use  of  staples  in  anatomical  side-to-side  and
functional  and-toend  enteroanastomosis.  Surgery 1968,  64 :  948-
Swain P. & Park P.O. Endoscopic suturing. Best Pract. Res. Clin.
Gastroenterol. 2004, 18 : 37-47.
Sykes P. The Edwin Smith Papyrus (ca.16
century BC). Ann. Plast.
Surg. 2009, 62(1) : 3-4.
Teubner  E.  History  of  ligation  and  suture  materials.  Med. Welt
1973, 24 (22) : 946-950.
Van Hee R. The evolution of Surgery in the Low Countries during
the sixteenth century. Sartoniana 2002, 15 : 97-153.
Van Hee R. Inguinal Hernia Repair in the 16th century. Acta Chir.
Belg. 2011, 111 : 342-350.
Van  Hee R.  De  evolutie  van  de  Heelkunde  tijdens  de laatste  100
jaar. In : Société Royale Belge de Chirurgie. 1893-1993. Koninklijk
Belgisch Genootschap voor Heelkunde.  Eds.  R.  Van  Hee  &
P. Mendes da Costa. Wetteren : Universa, 1993, pp. 11-42.
Zeebregts  C.J.,  Heijmen  R.H., van den  Dungen  J.J.  & van
Schilfgaarde R. Non-suture methods of vascular anastomosis. Brit.
J. Surg. 2003, 90 : 261-271.
R. Van Hee, M.D., Ph.D.
Flamingolaan 4
2610 Antwerpen-Wilrijk, Belgium
E-mail :
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 402
... Closing a wound using ant mandibles of large black ants is described as one of the first suturing techniques [48][49][50][51][52][53][54]. The insects family Formicidae of the order Hymenoptera is the main source of insects in direct bio-clamp applications. ...
... The insects family Formicidae of the order Hymenoptera is the main source of insects in direct bio-clamp applications. The clinician lets multiple ants bite the wound edges and pull them together [48,49,[51][52][53]. Afterward, the ants' bodies are twisted off or cut off, leaving the head with the mandibles to maintain the edges close together [48,49,[51][52][53]. ...
... The clinician lets multiple ants bite the wound edges and pull them together [48,49,[51][52][53]. Afterward, the ants' bodies are twisted off or cut off, leaving the head with the mandibles to maintain the edges close together [48,49,[51][52][53]. Supplementary file S3 contains a timeline of the reported use of ants as a suturing technique. ...
Full-text available
Insects are important agents in ecosystems. Their diverseness and developed coping mechanisms also make them interesting for direct application and as a source of inspiration in medical engineering. We summarized the main contribution of insects in biomedical applications. Medical centers in North America, the United Kingdom, and Europe use fly larvae for maggot therapy to remove necrotic tissue, decrease infection risk, and improve wound healing. Ant mandibles are used as a suturing technique by African tribes and as sources of inspiration for surgical clamps. Both the mosquito fascicle and the wasp ovipositor are sources of inspiration for the design of medical needles. Herein, a new research field called “entomomedical engineering,” is proposed. We define entomomedical engineering as the branch of engineering that uses insects either directly or as a source of inspiration to design and develop medical treatments or instruments. In addition, we want to emphasize the importance of preserving insects because of their function in the ecosystem, medicine, and medical engineering.
... Around 1000 BC, in Africa, thorns or animal spikes were used to pierce the two edges of a wound that was then closed together with the help of vegetable fibers [173]. Such techniques have been probably used all around the Continent, but not many examples of such an ingenuous application of natural materials survived until today [174]. ...
... The manipulator of the insect would then decapitate it, leaving the head, with its bite, in place on the wound, thus maintaining the edges close together. It is surprising that the same surgical technique has developed independently in India [13], Africa [173] and South America [196]. ...
Full-text available
This review focuses on the characteristics and applications of biomaterials through the ages, ranging from the prehistoric times to the beginning of the era of modern medicine, which has been arbitrarily set to the middle of the 19th century, when aseptic procedures, antiseptic substances and modern anaesthetics were developed. After a brief discussion on the definition of “biomaterial” from an historical point of view and a short introduction on the general history of surgery and dentistry, each material or class of materials will be presented with references listed in chronological order and, where possible, with their real, scientifically demonstrated effects on biological tissues. Particular attention has been given to references that are nowadays considered spurious or affected by translation errors or other kinds of biases. This article is protected by copyright. All rights reserved.
... In Chinese medicine, approximately 300 insect species are used to produce 1700 conventional medications [39,40]. Ants are famous medicinal species, their mandibles are used in surgery to staple wounds and ant-generated substances accelerate wound healing [41]. However, Drosophila melanogaster is the most common insect studied over the last few years. ...
Full-text available
Functional antimicrobial peptides (AMPs) are an important class of effector molecules of innate host immune defense against pathogen invasion. Inability of microorganisms to develop resistance against the majority of AMPs has made them alternatives to antibiotics, contributing to the development of a new generation of antimicrobials. Due to extensive biodiversity, insects are one of the most abundant sources of novel AMPs. Notably, black soldier fly insect (BSF; Hermetia illucens (Diptera: Stratiomyidae)) feeds on decaying substrates and displays a supernormal capacity to survive under adverse conditions in the presence of abundant microorganisms, therefore, BSF is one of the most promising sources for identification of AMPs. However, discovery, functional investigation, and drug development to replace antibiotics with AMPs from Hermetia illucens remain in a preliminary stage. In this review, we provide general information on currently verified AMPs of Hermetia illucens, describe their potential medical value, discuss the mechanism of their synthesis and interactions, and consider the development of bacterial resistance to AMPs in comparison with antibiotics, aiming to provide a candidate for substitution of antibiotics in livestock farming or, to some extent, for blocking the horizontal transfer of resistance genes in the environment, which is beneficial to human and animal welfare.
... Giant ants would hold the wound together with their claws and then the surgeon of the time would separate the ant's body, leaving the claws in site. This would allow the skin to heal protecting the patient from possible infections [1]. ...
Full-text available
... Around 300 insect species are used to produce 1,700 traditional Chinese medicaments (Ratcliffe et al., 2011). Among insect species known in ancient time medicine are ants, whose jaws were used in a surgery as staples for stitching wounds (Schiappa and Van Hee, 2012). Additionally, some ants produce substances that promote wound healing. ...
Full-text available
The aim of the study was to evaluate the effect of full-fat insect meals fed “on top” to broiler chickens on their growth performance and gastrointestinal tract (GIT) microbiota composition. A total of 1,850 one-day-old Ross 308 females were used in a set of four independent experiments. The insects Gryllodes sigillatus, Shelfordella lateralis, Gryllus assimilis (imago and nimfa stages), Tenebrio molitor, and Hermetia illucens were applied in amounts that varied from 0.05 to 0.20%. The application of insect meals to the diets of broilers did not affect their growth performance in experiments 1 and 2. However, the additions of T. molitor and H. illucens stimulated feed intake for the 14-35 d period and the entire 35 d of experiment 3. Moreover, with S. lateralis supplementation, BWG (10-21 and 1-21 d), FI (1-10 and 1-21 d), and FCR (1-21 d) improved in experiment 4. The addition of insects reduced the pH value of digesta in the crop and in the caeca. Supplementation with H. illucens caused the most significant effect on the microbiota populations in the crop, ileum, and caeca (experiment 3). However, at the higher levels of S. lateralis addition to the diets of broilers, the counts of selected microbiota in the crop and ileum increased (experiment 4). Based on the results, the application of the insect meals as a feed additive can improve bird growth performance and may affect the composition of GIT microbiota as a result of the antimicrobial peptide and chitin contents of the insect meals.
As one of the oldest materials used by human, many evidences show that ropes are closely related to human evolution. Due to perishability, few ropes remain intact after thousands of years. Even if there are few intact ropes found, most of them are collected in museums. Therefore, ropes may be “the most remarkable invention of human.” One piece of fiber is of no use. But when these fibers are spun into yarns, yarns are twisted into strands, and strands are woven into ropes, such a trivial thing will become strong and flexible, creating unlimited possibilities.
Full-text available
Los aprendices de cirugía en cualquiera de sus divisiones precisan un conjunto de conocimientos básicos de los aspectos teórico-prácticos que rigen el quehacer quirúrgico. Aunque muchas de estas habilidades son las mismas que usaban sus predecesores del siglo XX, los aprendices de hoy deben mantenerse al tanto de las tecnologías que cambian y avanzan rápidamente. El presente trabajo tiene como objetivo facilitar el aprendizaje más rápido requerido en un programa quirúrgico moderno, con capítulos concisos sobre las principales técnicas y destrezas que deben dominarse en los primeros años de entrenamiento. Está dirigido tanto a estudiantes de medicina, residentes de las distintas áreas quirúrgicas en sus primeros años de residencia, adjuntos jóvenes, al equipo de enfermería, y al público en general interesado en conocer algunos de los principios básicos que rigen las habilidades técnicas quirúrgicas, y su relación con el manejo del paciente en torno al perioperatorio. El desarrollo del libro se ha estructurado en 17 capítulos. Cada autor ha presentado una gran cantidad de valiosa información, a partir de su experiencia, que resume el abordaje más oportuno aceptado al momento de publicación del presente libro. También es una colaboración entre los variados
Background. Surgical stapling devices are known for their reliability and convenience. A letter to health care professionals published by the US Food and Drug Administration in March 2019 highlighted the increasing number of adverse events associated with surgical staplers. Driven by a case of stapler malfunction during an elective laparoscopic sleeve gastrectomy, we performed a literature review to investigate the incidence of primary stapler malfunction. We also discuss the common types and an approach to its management. Methods. PubMed, MEDLINE, and EMBASE databases were searched for articles discussing surgical stapler malfunction. Twelve studies were selected that described the incidence and/or consequences of primary stapler malfunction. A narrative synthesis was performed. Results. From observational studies, the incidence ranged from 0.022% to 2.3%. A prospective survey reported that 86% of laparoscopic surgeons either had personal experience with or knew of surgeons who experienced stapler malfunction, implying a higher incidence. Underreporting has been an issue as manufacturers can get exemptions from public reporting. Significantly, higher malfunctions have been reported after exemptions were lifted. The most common types of stapler malfunction are stapler misfire and stapler locking. Major morbidity and mortality have been reported. Conclusion. Surgeons are increasingly reliant on technological innovations. Stapling failure occurs and it is imperative to be aware of this. Given the high volume of stapler use, a high percentage of surgeons are likely to encounter this problem in their career. It is important to have an approach to the prevention and management of this potentially catastrophic complication.
Anastomotic leak rates in colorectal surgery remain persistently high despite increased awareness of contributing factors, low threshold for proximal fecal diversion, and modern technologies to better assess bowel perfusion. Leak rates for low colorectal anastomoses range 3–30% with risk factors including malnutrition, smoking, immunosuppression, prior radiation therapy, obesity, and male gender. Technical factors such as tension on the anastomosis and adequacy of the blood supply also play a critical role in the occurrence of leaks. This chapter will review intraoperative strategies to assess the integrity of colorectal anastomoses, reduce the risk of anastomotic leaks, and salvage a failed anastomosis and ischemic colonic conduit. Reconstructive techniques to salvage intraoperative and postoperative anastomotic leaks will also be reviewed.
Full-text available
The optimization of healing processes in a wide range of tissues represents a central point for surgical research. One approach is to stimulate healing processes with growth factors. These substances have a short half-life and therefore it seems useful to administer these substances locally rather than systemically. One possible method of local delivery is to incorporate growth factors into a bioabsorbable poly (D, L-lactide) suspension (PDLLA) and coat suture material. The aim of the present study was to establish a procedure for the local delivery of growth factors using coated suture material. Sutures coated with growth factors were tested in an animal model. Anastomoses of the colon were created in a rat model using monofilament sutures. These were either untreated or coated with PDLLA coating alone or coated with PDLLA incorporating insulin-like growth factor-I (IGF-I). The anastomoses were subjected to biomechanical, histological, and immunohistochemical examination. After 3 days the treated groups showed a significantly greater capacity to withstand biomechanical stress than the control groups. This finding was supported by the results of the histomorphometric. The results of the study indicate that it is possible to deliver bioactive growth factors locally using PDLLA coated suture material. Healing processes can thus be stimulated locally without subjecting the whole organism to potentially damaging high systemic doses.
Full-text available
The purpose of the study is to review the history and innovations of sutures used in pelvic surgery. Based on a review of the literature using electronic- and hand-searched databases we identified appropriate articles and gynaecology surgical textbooks regarding suture for wound closure. The first documented uses of suture are explored and then the article focuses on the use of knotted materials in pelvic surgery. The development of suture of natural materials is followed chronologically until the present time where synthetic suture is implanted during countless surgeries every day. This millennial history of suture contains an appreciation of the early work of Susruta, Celsus, Paré and Lister, including a survey of some significant developments of suture methods over the last 100 years. Most surgeons know little about the history and science of sutures. A retrospective view of suture is critical to the appreciation of the current work and development of this common tool.
During the first half of the twentieth century researchers focused their attention on the cellular events of wound healing. At that time Carrel made the observation that plasma rather than serum was required for successful tissue culture. He also identified tissue extracts which would stimulate wound healing. His research was cut short by the First World War, when he had to return to more fundamental areas of wound research, where he also made major contributions important to this day. Carrel's search for a factor which would stimulate wound healing was continued by other physicians until in 1954 Dunphy's studies failed to find such a factor. At the same time another line of research was developing. Basic scientists discovered mitogens and growth factors and gave them names based on what now seem whimsical ideas of what they did. Epidermal growth factor, for example, was discovered as urogastrone, so named because it was found in the urine of pregnant women and it inhibited gastric secretion. In the 1970's it became clear that the mitogens sought by Carrel were growth factors found in platelets, and that wound healing was perpetuated by similar factors produced by macrophages. Knighton reported a series of patients whose chronic wounds were healed by good wound care coupled with a complex mixture of these growth factors. Since then attempts have been made to induce healing using single recombinant factors. These attempts have been largely unsuccessful. It is now clear that growth factors work like the coagulation cascade. Individual factors work with eachother and in sequence creating a biochemical symphony. At present we know some of the instruments of the orchestra but do not know when each should play or how many of each are required.
—Various developments in the synthesis of alkyl 2-cyanoacrylates, their analytical and test methods, adhesive compositions for different applications including those in the medical field, handling and storage, and health and safety hazards are reviewed.
Biographical and bibliographical review of Jaques-MLouis Reverdin and his contributions to surgery Jaques-Louis Reverdin (1842-1929), born in Geneva, completed his medical studies in Paris, where he practised in several well-known hospitals such as La Pitié (with Goselin), Saint Louis (with Guérin), Lariboisiére, and Necker (with Guyon). In 1869 he published and presented in several meetings, a pioneering experience of successful free skin graft procedure, that is still performed in some cases and constitutes the first organ transplantation. In 1870 he presented his doctoral thesis "Etude sur l'uréthrotomie interne" with the expeience of his master Guyon (63 operations), gaining the Civiale prize and the bronze medal of the Paris Faculty of Medicine. He returned back to Geneva in 1872 to begin a long surgical practice and Faculty teaching, and he made seminal contributions to the knowledge of thyroid diseases, in particular on the clinical presentation of function deficiency following exeresis of the thyroid gland ( postoperative myxoedema). His contributions paralleled that made by Theodor Kocher in Bern, the surgeon that received in solitary the Nobel prize for these studies in 1909. With Jean6hyphen;Louis Prevost and Constant Picot, they founded the "Revue medicale de la Suisse romande", the most important Swiss medical journal of the 20th century. He is remembered in the field of Urology for a special needle designed to pass through a suture in a time were catgut and silk were the most employed sutures to control organ pedicles. Reverdin, that pertains to the glorious epoch were surgery -performed under anaesthesia and with the antisepsis postulates of Lister and Pasteur-, reached most of his goals, is remembered for the first human transplant (skin grafting), and, fortunately, one of the several surgical instrument he designed, the Reverdin needle, had a revival in current laparoscopic surgery.