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From Ants to Staples: History and Ideas Concerning Suturing Techniques

Article  in  Acta chirurgica Belgica · September 2012

DOI: 10.1080/00015458.2012.11680861 · Source: PubMed

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schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 395

Surgical history

Acta Chir Belg, 2012, 112, 395-402

From Ants to Staples : History and Ideas Concerning Suturing Techniques

J. Schiappa1, R. Van Hee2
Staff  Surgeon,  Hospital  CUF  Infante  Santo,  Lisbon,  Portugal ;  2Emer.  Professor  of  Surgery  and  Medical  History,
1

University of Antwerp, Belgium.

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 (1).
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 (2).

Suture materials (3) Fig. 1

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.’ (4).
Ancient populations in various continents were using
giant ants as “suturing devices” (5). 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 (6).
Another  natural  way  of  treating  gaping  wounds  was
by using vegetable thorns or animal spikes, crossing both
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
c  oncepts,  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 396

396 J. Schiappa and R. Van Hee

Fig. 2
The  claws  of  the  ant,  approximating  the  edges  of  the  wound
(reference see supra).

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 10th 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 b
Galen to treat gladiator’s cut tendons.
Fig. 3
Galen  proposed  several  ways  of  suturing  to  obtain
Fibula,  as  used  in  Roman  times.  a.  Closed  instrument.
wound  union (7).  In  peripheral  wounds  either  a  direct b. Several  fibulas  used  for  abdominal  wound  closure  (From
suture  or  a  fibula  was  used (8).  In  abdominal  wounds G. Majno. The healing hand. Harvard University Press, 1991.
either  a  running  suture (9)  or  a  figure  8  -  double  layer Figures 9.21 & 9.22 p. 366).
suture was applied (10) (Fig. 4).
As  suturing  material  Galen  proposed  silk  threads
In  the  20th  century,  cotton,  linen  and  silk  were
which were imported from transalpine Gallia.
c  hemically prepared and started to be regularly used by
Catgut was used since the 15th century. Its name comes
industrial preparation in large factories.
from  the  fibres  used  as  string  chords  in  a  specific  con-
temporary  musical  instrument,  a  sort  of  pocket  violin
called  “kit” (11).  This  first  type  of  “catgut”  kept  being
(7) See de Moulin p. 19.
used  in  the  same  form  until  the  19th century ;  by  then (8)  Ibidem p. 19.
intestinal  tissue  of  animals (12)  started  to  be  chemically (9)  Also called a furrier stitch, in view of the technique of suturing
modified for surgical use. used by the furrier craftsmen.
Metallic wires were already mentioned during the late (10)  See de Moulin pp. 19-20.
(11)  We recently saw and heard for the first time a 21st century ver-
Middle Ages.  One  of  the  first  was  gold,  used  in  hernia
sion  of  the  same  instrument,  this  time  with  a  detachable  electronic
surgery.  This  so-called  ‘golden thread suture’  was improvement added to it.
intended  to  prevent  recurrence  after  hernia  sac  reduc- (12)  Usually sheep.
tion (13). (13)  See Van Hee 2011 pp. 346-347.
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 397
From Ants to Staples
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).
After  many  years  of  practice  it  was  realised  that
 synthetic  materials,  like  polyglycolic  acid (14),
polyglactin (15),  polypropylene (16)  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
397
Table 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
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
fragmentation.
Summarizing, much still has to be done in the search
for an “ideal suturing material”.
Suturing needles (17)
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
1986.
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 398

398 J. Schiappa and R. Van Hee

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

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 (18).
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 19th century was refined by
Jacques-Louis  Reverdin  (1842-1908) (19)  and  became
very popular for more than a hundred years (Fig. 6).
So-called atraumatic needles were produced since the
1920’s (20),  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 Fig. 5
designed at the same pace as industrial production was Depiction  of  straight  and  curved  needles,  used  by  Ambroise
Paré  (From A. Paré.  Les Oeuvres.  13e  Edition.  Lyon :  Pierre
allowing  these  needles  to  be  put  into  use.  Moreover, Valfray. p. 202).
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 complications, several new surgical devices were intro-
bending before breaking. duced  to  ease  these  techniques  in  achieving  the  same
goals (25).
In search for other alternative suturing techniques So the first mechanical devise using staples was intro-
After the more widespread use of surgical suturing, sur- duced in 1908 by Prof. Humer Hültl (1868-1940) from
geons realised that bridging gaps in human tissues could Hungary (26). This device placed two double rows of fine
also  be  achieved  by  other  means.  Independently  the
French surgeon F.N. Denans in 1826 (21) and the Belgian
surgeon J.H.F. Henroz from Liège in the same year pub- (18) See Hayward 1961.
lished the results of their experiments on dogs, in which (19) See Farina-Perez 2010. 
for  the  first  time  they  used  a  mechanical  device  to (20) Atraumatic  needles  were  first  introduced  by  the  Company
Davis & Geck in 1922. See Nolan 1971 and Scannell 2005. 
achieve  intestinal  anastomosis (22).  Technical  advances (21) See Denans 1826.
and  confidence (23)  progressively  induced  better  results (22) See Henroz 1826.
in  suturing  and  anastomosing  different  portions  of  the (23) Both were related to the introduction of anaesthesia and anti-
gastrointestinal  tract (24).  These  anastomotic  techniques sepsis in the second half of the 19th century.
were how ever demanding and compelled surgical aware- (24) These techniques implied various expert approaches, which are
not discussed here.
ness,  attention  and  expertise  without  which  complica- (25) For an overview on this evolution, see Hardy 1990.
tions would arise, such as stenosis, haemorrhage or leak- (26) See  Hültl  1909.  See  for  an  overview  of  non-mechanical  sta-
age. To  minimize these difficulties, technical errors and pling : Zeebregts et al. 2003.
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 399
From Ants to Staples
ferent sizes and patterns of staples.
posable devices, opening a gate for widespread use. Not
duced but also prices dropped and use became common.
After introduction of laparoscopic surgery, staplers were
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).
 
such staplers and other devices in open surgery.
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) (27),  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 (28).
399
Because 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
series 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 (29), 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 (30). Many other
Eastern and Western papers followed these first publica-
tions (31). Recent developments in stapling devices con-
sisted of disposable staple cartridges, preloaded with dif-
Several companies started to produce staplers as dis-
only  several  improvements  were  progressively  intro-
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 (32),  reusable  or  “re-
 posable” (33)  staplers,  trocars  and  instruments.  Such
discussion  had  already  taken  place  in  connection  with
(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
1979. 
(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.
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 400
400
Fig. 7
Compressive device of Denans (See Denans 1826)
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 (34).  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 (35).
Robotic  assisted  suturing  may  be  a  possible  such  solu-
tion from the technical point of view (36), but is not the
right one in economical difficult times or in financially
precarious regions.
J. Schiappa and R. Van Hee
Fig. 8
Compressive device of Henroz (See Henroz 1826)
Non suturing types of approximation
Some “new technologies” for tissue approximation still
have to be mentioned here (37). 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 (38)  (Fig.  7  &  8),
biological  glues  in  the  1960’s (39),  laser  “welding”  in
1985 (40) and growth factors in 1990 (41). 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.
schiappa(Surg.Hist.)_Opmaak 1 4/10/12 14:41 Pagina 401
From Ants to Staples
Fig. 9
Murphy button, as depicted in his original article of 1892 (See
Murphy 1892).
Devices for tissue compression of which the most well-
known  was  Murphy’s  button (42),  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 (43)  and
cyanoacrylates (44). They  can  also  be  complemented  by
collagen prostheses (45).  Budapest, Mai 1908. Pester Med.-Chir. Presse 1909, 45 : 108-110
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 (46).  – Kalinina  T.V.  [Use  of  the  KC-28  Stapler.].  Khirurgiia (Moskou),
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.  Engl. 1986, 68 : 29-33.
Time will show how these advances will perform. In
the future, other medico-historical texts will relate this!
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R. Van Hee, M.D., Ph.D.
Flamingolaan 4
2610 Antwerpen-Wilrijk, Belgium
E-mail : bob.van.hee@skynet.be