Suture Type Recommendations
For deep fascial closure in emergency settings, use slowly absorbable monofilament sutures (such as PDS), and when available, choose antimicrobial-coated versions to reduce surgical site infections. For skin closure, absorbable monofilament sutures are equivalent to non-absorbable sutures in outcomes and eliminate the need for suture removal.
Deep Fascial/Subcutaneous Closure
Use absorbable monofilament sutures for fascial closure. The 2023 World Society of Emergency Surgery guidelines make a strong recommendation for monofilament materials based on significant data showing lower incisional hernia rates compared to braided sutures 1. Specifically:
- 0 or 2-0 polydioxanone (PDS II) for deep and superficial fascial layers 2
- Antimicrobial-coated sutures (typically triclosan-impregnated) are strongly recommended for clean, clean-contaminated, and contaminated fields when available, as high-quality RCTs demonstrate significantly lower surgical site infection rates 1
The monofilament structure reduces tissue drag and infection risk compared to braided materials, which have higher tissue friction and can harbor bacteria in their interstices 3.
Skin Closure
Absorbable monofilament sutures are recommended for skin closure as they provide equivalent clinical and aesthetic outcomes to non-absorbable sutures while eliminating the need for suture removal 4, 5. Specific recommendations:
- 4-0 or 5-0 PDS II for dermal sutures (when necessary) 2
- Poliglecaprone 25 (Monocryl) can serve as the sole suture material for both subcutaneous and epidermal closure, offering low tissue reactivity, clear appearance, and cost-effectiveness 6
- For superficial epidermal sutures when non-absorbable material is preferred: 6-0 or 7-0 polypropylene (Prolene) or nylon (Ethilon) 2
Meta-analysis of 19 RCTs involving 1,748 patients found no significant difference between absorbable and non-absorbable sutures regarding infections, cosmetic outcomes, scarring, or wound dehiscence 5. Intradermal absorbable sutures may provide superior cosmetic results, though longer follow-up studies are needed 5.
Patients with Nylon or Silk Allergies
For patients allergic to nylon, use:
- Polypropylene (Prolene) as the non-absorbable alternative for skin closure
- Absorbable synthetic polymers (PDS, poliglecaprone 25, polyglycolic acid) for all layers, as these undergo hydrolysis rather than enzymatic degradation and have minimal allergenic potential 3
For patients allergic to silk:
- Avoid all natural absorbable sutures derived from mammalian collagen
- Use synthetic absorbable monofilaments (PDS, poliglecaprone 25) or synthetic non-absorbable monofilaments (polypropylene, if nylon allergy is also present) 3
Key Principles
Monofilament over braided: Monofilament sutures have lower tissue resistance, reduced infection risk, and less tissue reaction compared to multifilament/braided sutures, which have higher friction and risk of suture sinus formation 3.
Smallest effective size: Choose the smallest suture diameter that provides adequate tensile strength to minimize tissue trauma and foreign material 3.
Avoid retention sutures routinely: The 2023 guidelines found insufficient evidence to recommend routine retention sutures, though they may be considered in very high-risk patients with severe malnutrition, immunocompromise, massive contamination, or previous fascial defects 1.