EP177 - Vicryl vs Monocryl for Wound Closure in Closed Hemorrhoidectomy: Association With Postoperative Anal Skin Tag Formation

Purpose/Background: Hemorrhoidectomy remains the gold-standard treatment for grade III & IV hemorrhoidal disease, providing durable symptom relief but often complicated by pain, wound dehiscence, and anal skin tag formation. These fibroepithelial tags may cause hygiene difficulties and dissatisfaction despite successful excision. Suture material influences wound healing, yet no study has directly compared Vicryl and Monocryl in this context. Braided and monofilament sutures differ in tensile strength, absorption, and tissue reactivity, which all influence postoperative remodeling. Understanding this relationship may guide evidence-based technique selection and enhance outcomes in hemorrhoidectomy. This study evaluates the relationship between suture type and postoperative skin tag formation following standardized closed (Ferguson) hemorrhoidectomy.

Methods/Interventions: A retrospective multicenter cohort included adults (≥18 years) undergoing closed (Ferguson) hemorrhoidectomy between January 2023 and January 2025 at two tertiary centers. Each center was represented by a board-certified colorectal surgeon using a standardized technique but different closure material: 2-0 Vicryl or 3-0 Monocryl. Inclusion criteria were grade III-IV hemorrhoids; exclusions were non-Ferguson techniques, concomitant anorectal procedures, prior perianal surgery, or < 4 week follow-up. Demographic (age, sex, BMI, parity), comorbidity (diabetes, hypertension, smoking, alcohol use), and operative variables were collected. The primary outcome was new anal or perianal skin tag formation within 4 weeks, defined as a fibroepithelial projection not present preoperatively. Analyses were performed in R using Fisher's exact and Mann-Whitney U tests. Relative risk (RR) with 95% confidence intervals (CI) was calculated for the primary endpoint, with significance at p < 0.05.

Results/Outcomes: A total of 113 patients were included (38 Monocryl, 75 Vicryl). At four weeks postoperatively, the incidence of new anal skin tags was significantly higher in the Monocryl group than in the Vicryl group (13/38 [34.2%] vs 3/75 [4.0%]; RR 8.55, 95% CI 2.59-28.2; p = 0.0029, Fisher's exact). Median age was 45.2 years in the Monocryl cohort and 54.6 years in the Vicryl cohort; females comprised 76% and 57%, respectively. Multivariable logistic regression identified suture type as the only independent predictor of skin tag formation (McFadden's R² = 0.25). No demographic or comorbidity variables were significant (all p > 0.05).

Conclusion/Discussion: In closed hemorrhoidectomy, Vicryl use resulted in significantly fewer skin tags than Monocryl (4% vs 34%; RR 8.55, 95% CI 2.59-28.2; p = 0.0029). Given the standardized technique and surgeon expertise, this difference is likely do to suture characteristics. Structural properties of each suture may explain this. Vicryl, a braided multifilament, offers greater tensile strength and sustained support during remodeling but may elicit more inflammation due to higher surface area and potential bacteria retention. Monocryl, a smooth monofilament, causes less tissue drag and bacterial adherence yet loses strength faster, allowing early wound separation and secondary granulation. Similar patterns have been noted in perineal/ episiotomy repair studies. Although limited by surgeon-suture confounding, this study highlights that suture selection may influence perianal wound remodeling. Prospective randomized studies are needed to confirm these findings and optimize closure strategies in hemorrhoidectomy.

Table 1. Skin Tag Outcomes and Risk Estimates by Suture Material
Incidence and relative risk of postoperative skin tag formation following closed (Ferguson) hemorrhoidectomy using Vicryl or Monocryl for wound closure.