Suture Selection Guide for Surgical Procedures
Primary Recommendation for Fascial/Abdominal Closure
Use slowly absorbable monofilament sutures (such as 4-0 poliglecaprone or polyglactin) with a continuous "small bite" technique, maintaining a suture-to-wound length ratio of at least 4:1. 1
Fascial Closure Technique Specifications
- Small bite technique: Place stitches 5mm from the wound edge and 5mm between stitches, including only the aponeurosis (not fat or muscle) 1
- Suture-to-wound ratio: Document and maintain a 4:1 ratio or higher to reduce incisional hernia and wound complications 1
- Material choice: Slowly absorbable monofilament sutures retain 50-75% tensile strength after 1 week, providing extended wound support 1, 2
- Avoid rapidly absorbable sutures: These significantly increase incisional hernia rates compared to slowly absorbable materials 1
Why Monofilament Over Multifilament
- Monofilament sutures reduce bacterial seeding and infection risk compared to braided multifilament materials 2, 3
- No significant difference exists between monofilament and multifilament for incisional hernia rates when proper technique is used, but infection risk favors monofilament 1
Skin Closure Recommendations
Use continuous subcuticular sutures with slowly absorbable monofilament material (4-0 poliglecaprone or polyglactin) for optimal outcomes. 1, 2
Evidence for Continuous vs Interrupted Technique
- Continuous subcuticular sutures reduce superficial wound dehiscence by 92% (RR 0.08; 95% CI 0.02-0.35) compared to interrupted sutures 1, 2
- No difference in surgical site infection rates between techniques (RR 0.73; 95% CI 0.40-1.33) 1
- Continuous technique requires less operative time and eliminates need for suture removal 2
- The dramatic reduction in dehiscence occurs because absorbable continuous sutures provide prolonged support without requiring removal at 7-9 days 1, 2
When to Use Interrupted Sutures
- High-tension wounds where individual stitch adjustment is needed 2
- Contaminated wounds where selective stitch removal may be necessary 4
- Facial wounds requiring precise edge approximation: use 5-0 or 6-0 monofilament non-absorbable sutures, remove at 5-7 days 4
Antimicrobial-Coated Sutures
Use triclosan-coated sutures for abdominal and colorectal surgery to reduce surgical site infections. 1
Specific Evidence by Suture Type
- Triclosan-coated Vicryl: Significantly reduces SSI (OR 0.67; 95% CI 0.46-0.98) across all wound classes 1
- Triclosan-coated PDS: No significant effect on SSI rates (OR 0.85; 95% CI 0.61-1.17) 1
- Overall SSI reduction with triclosan-coated sutures: OR 0.72 (95% CI 0.59-0.88) 1
When Antimicrobial Coating Provides Benefit
- Clean-contaminated wounds (RR 0.66; 95% CI 0.44-0.98) 1
- Colorectal surgeries (RR 0.69; 95% CI 0.49-0.98) 1
- Abdominal surgeries with prophylactic antibiotics (RR 0.79; 95% CI 0.63-0.99) 1
- Emergency laparotomies including contaminated/dirty wounds 1
Where Antimicrobial Coating Shows No Benefit
Tissue Adhesives vs Sutures
Sutures are mandatory for most wound closures; tissue adhesives carry unacceptable dehiscence risk. 2
Critical Evidence Against Tissue Adhesives
- Tissue adhesives have 3.35 times higher risk of wound breakdown (RR 3.35; 95% CI 1.53-7.33) 1, 2
- Number needed to harm: treating 43 patients with adhesives instead of sutures causes one additional dehiscence 2
- No difference in infection rates, patient satisfaction, or cost between methods 1
Absolute Contraindications for Tissue Adhesives
- High-tension wounds 2
- Emergency laparotomy or abdominal wall closures 2
- Contaminated or infection-prone wounds 2
- Any wound requiring mechanical support for healing 2
Limited Acceptable Use
- Low-tension superficial lacerations where speed is prioritized over reliability 1
- Adjunct to sutures in select cases, never as sole closure method 2
Suture Removal Timing
Remove non-absorbable sutures at specific intervals based on anatomic location to prevent both premature dehiscence and excessive scarring. 4
Location-Specific Timing
- Facial wounds: 5-7 days 4
- Scalp and trunk: 7-9 days 1, 4
- Extremities: 10-14 days (longer for lower extremities) 4
- High-tension areas: Consider delayed removal or use absorbable sutures instead 4
Common Pitfalls to Avoid
Technical Errors
- Never include fat or muscle in fascial closure: This causes tissue compression, devitalization, and increased hernia risk 1
- Avoid pulling continuous sutures too tightly: This strangulates wound edges and causes ischemia 1, 2
- Don't use large bite technique (>10mm from edge): This significantly increases incisional hernia rates compared to small bite technique 1
Material Selection Errors
- Never use rapidly absorbable sutures for fascial closure: These lose tensile strength too quickly 1
- Avoid multifilament sutures in contaminated fields: Braided material harbors bacteria 2, 3
- Don't use tissue adhesives for abdominal or high-tension closures: Unacceptable dehiscence rates 2
Postoperative Management Errors
- Don't routinely add adhesive steri-strips after suturing: No evidence of benefit for cosmetic outcomes or scar width 1, 4
- Avoid premature suture removal: Removing before 7-9 days (non-facial) causes dehiscence 1, 4
- Don't leave any retained suture material in infected wounds: This significantly increases infection risk 4
Special Populations and Scenarios
Emergency Surgery
- Use slowly absorbable monofilament sutures with 4:1 ratio 1
- Consider triclosan-coated sutures for contaminated/dirty wounds 1
- Small bite continuous technique still applies 1
Pediatric Patients
- Same principles apply: continuous subcuticular technique reduces dehiscence 1
- Absorbable sutures eliminate need for traumatic removal 1, 2
- Triclosan-coated sutures show similar SSI reduction as in adults 1