What are the clinical guidelines for suture (surgical stitch) placement?

From the Guidelines

Clinical guidelines for sutures strongly recommend using monofilament sutures due to their association with a significantly lower risk of incisional hernia compared to multifilament sutures in both elective and emergency settings. When it comes to the technique, the 'small bite' technique is suggested for the closure of midline laparotomy, as it has been shown to reduce the risk of incisional hernias and wound complications in elective settings 1. Although the evidence for the 'small bite' technique in emergency settings is limited, it is still recommended due to its potential benefits.

For emergency laparotomy closures, the use of antibiotic-coated sutures is recommended when available, as they have been shown to significantly reduce the rate of surgical site infections in high-quality RCTs and systematic reviews 1. However, the use of retention sutures is not routinely recommended, except in cases of high-risk patients, such as those with increased tension in the incision, severe malnutrition, immunocompromised status, previous fascial defects, or massive abdominal contamination.

Key considerations for suture selection and technique include:

• Using monofilament sutures for their lower risk of incisional hernia
• Employing the 'small bite' technique for midline laparotomy closure
• Utilizing antibiotic-coated sutures when available to reduce surgical site infections
• Reserving retention sutures for high-risk patients
• Proper wound preparation, including irrigation, debridement, and hemostasis
• Appropriate use of local anesthesia and post-closure wound care

These guidelines aim to optimize wound healing, minimize scarring, and reduce the risk of infection and wound dehiscence by matching suture strength and absorption characteristics to specific wound requirements 1.

From the Research

Clinical Guidelines for Sutures

• The selection of optimal suture materials is crucial to minimize ischaemia, excess wound tension, and tissue injury, and to maximize wound healing and scar aesthetics 2.
• Suture materials should have predictable tensile strength, good handling, secure knot-tying properties, and could be enhanced with an antibacterial agent to resist infection 2.
• The smallest suture size that will accomplish the purpose should be chosen to minimize tissue trauma and foreign material within tissues 2.
• Monofilament suture has lower resistance when passed through tissues, whereas multifilament sutures possesses higher tensile strength and flexibility but greater tissue friction and pose risks of suture sinus and infection 2.

Suture Materials

• Natural absorbable sutures derived from mammalian collagen undergo enzymatic degradation, whereas synthetic polymers undergo hydrolysis 2.
• Collagen or polymer structures in the suture can be modified to control absorption time 2.
• Nonabsorbable sutures typically cause an inflammatory reaction that eventually encapsulates by fibrous tissue formation, and excess reaction leads to chronic inflammation, suboptimal scarring, or suture extrusion 2.
• Irradiated polyglactin 910 is a rapidly absorbed suture material suitable for closure of wounds where rapid suture absorption is desirable, particularly for wounds in the scalp, scrotum, and perineum 3.

Suturing Techniques

• The selection of the most proper suture material remains challenging for clinicians, and the choice of material depends on various factors such as wound tension, desire for wound edge eversion/inversion, desired hemostasis, repair type, and patient's ability to care for the wound and return for suture removal 4, 5.
• Subcuticular sutures may be preferable to simple interrupted sutures for superficial wound closure, and there may also be a role for skin staples in dermatological surgery, particularly on the scalp 6.
• Absorbable superficial sutures may be a preferred alternative to nonabsorbable sutures by both patients and surgeons 6.

Considerations for Suture Selection

• Wound location, skin integrity, and patient satisfaction are important factors to consider when choosing a wound closure material and suturing technique 5, 6.
• The use of barbed sutures and modern skin adhesives can eliminate the need for skin sutures, improve scar aesthetics, and increase efficiency of closure 2.
• Further high-quality research is required to support the use of particular suture materials and suturing techniques in dermatological surgery 6.