Suture Material Selection by Surgical Site
Primary Recommendation
Use slowly absorbable monofilament sutures (such as PDS or Maxon) with triclosan coating for fascial closure in abdominal surgery, and continuous subcuticular absorbable sutures (4-0 poliglecaprone or polyglactin) for skin closure. 1, 2
Fascial Closure (Abdominal Wall/Deep Tissue)
Material Selection
Monofilament sutures are strongly preferred over multifilament sutures (Grade 1A recommendation) because they significantly reduce incisional hernia rates in both elective and emergency settings 1, 2
Choose slowly absorbable monofilament materials (such as polydioxanone or polyglyconate) that maintain 50-75% tensile strength after 1 week, providing sustained wound support during the critical healing period 1, 3, 2
Add antimicrobial coating (triclosan-impregnated) when available (Grade 1B recommendation) for clean, clean-contaminated, and contaminated fields, as this reduces surgical site infections with an odds ratio of 0.67 (95% CI 0.46-0.98) 1, 3, 2
Technique Considerations
Use the "small bite" technique: Take 5mm bites from the wound edge with 5mm spacing between stitches, incorporating only the aponeurosis 1, 2
Avoid large bites that include fat and muscle tissue, as these lead to tissue devitalization, wound edge separation, and increased infection risk 2
Do not use retention sutures routinely, as there is insufficient evidence supporting their benefit in preventing wound dehiscence 1, 2
Skin Closure
Material and Technique Selection
Continuous subcuticular sutures are superior to interrupted sutures or staples for reducing superficial wound dehiscence (RR 0.08; 95% CI 0.02 to 0.35) 1, 2
Use 4-0 poliglecaprone or 4-0 polyglactin for continuous subcuticular closure, as these materials retain adequate tensile strength (50-75% after 1 week) to prevent dehiscence during the healing phase 1
In hepato-pancreato-biliary surgery specifically, continuous subcuticular sutures reduce SSI to 1.8% compared to 10.0% with stapling (P < 0.01) 1
Avoiding Common Pitfalls
Do not pull continuous sutures too tightly, as this strangulates wound edges and compromises healing 1, 4
Avoid tissue adhesives alone in high-tension areas, as they have 3.35 times higher risk of dehiscence compared to sutures (95% CI 1.53 to 7.33), with a number needed to treat of 43 to prevent one dehiscence 1, 4
Do not add adhesive steri-strips routinely, as they provide no significant improvement in cosmetic outcomes (patient assessment scores 14.0 vs 14.7, P = 0.39) or scar width (both 1.1mm, P = 0.89) 1, 4
Site-Specific Applications
Obstetric/Gynecologic Surgery
Use Normal Vicryl (polyglactin 910) for cesarean delivery uterine incisions and abdominal wall closure where longer tensile strength is required 3
Triclosan-coated Vicryl significantly reduces SSI in abdominal fascial closure (OR 0.67,95% CI 0.46-0.98) 3
Emergency Laparotomy
Apply the same monofilament, slowly absorbable, antimicrobial-coated suture principles as in elective surgery, though evidence quality is lower in emergency settings 1, 2
The small bite technique is suggested for emergency midline laparotomy, though future prospective studies are needed to confirm effectiveness 1
Key Evidence Considerations
The strongest evidence comes from the 2023 World Society of Emergency Surgery guidelines 1 and 2020 WSES position paper 1, which provide Grade 1A recommendations for monofilament sutures and Grade 1B for antimicrobial coating. The Cochrane review data 1 supports continuous subcuticular technique superiority, though most trials involved pediatric appendectomy patients, limiting generalizability. The single-institution Japanese HPB study 1 showing dramatic SSI reduction with continuous subcuticular sutures is promising but requires validation in multicenter RCTs.