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
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
, R. Van Hee
Staff Surgeon, Hospital CUF Infante Santo, Lisbon, Portugal ;
Emer. Professor of Surgery and Medical History,
niversity of Antwerp, Belgium.
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 www.trauma.org/archive/history/
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
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 gladiator’s 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-
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.
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
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.
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 (
), 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
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).
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
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
), 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
So the first mechanical devise using staples was intro-
duced in 1908 by Prof. Humer Hültl (1868-1940) from
). 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.
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
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
In 1924, another Hungarian surgeon, Aladar Petz
), 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
), 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-
). 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-
) 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.
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-
). 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
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
) 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.
Compressive device of Denans (See Denans 1826)
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 (
). 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!
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2610 Antwerpen-Wilrijk, Belgium
E-mail : email@example.com
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