Recommended Suture Technique for High-Risk Surgical Site Infection Cases
For surgical procedures with high risk of surgical site infection, use antimicrobial-coated (triclosan-impregnated) slowly absorbable monofilament sutures with a continuous "small bite" technique, maintaining a suture-to-wound length ratio of at least 4:1. 1
Suture Material Selection
Antimicrobial-coated sutures are mandatory for high SSI-risk cases, as they significantly reduce surgical site infections with an odds ratio of 0.72 (95% CI 0.59-0.88) across clean, clean-contaminated, and contaminated surgical fields. 1 Recent high-quality RCTs in emergency settings demonstrate consistently lower SSI rates when triclosan-impregnated sutures are used for fascial closure. 1
Material Characteristics
Slowly absorbable monofilament sutures (such as 4-0 poliglecaprone or 4-0 polyglactin) are strongly recommended, as they retain 50-75% of their original tensile strength after 1 week in situ, providing extended wound support during the critical healing period. 1, 2
Monofilament configuration is superior to multifilament, with significantly lower incisional hernia rates in both elective and emergency settings (Grade 1A recommendation with 96.8% expert consensus). 1
Avoid rapidly absorbable sutures, as they lose tensile strength too quickly and increase incisional hernia rates compared to slowly absorbable materials. 1, 2
Suture Technique
Small Bite Technique
The "small bite" technique significantly reduces both incisional hernia and wound complications compared to traditional large bite closure, with odds ratios of 0.39 (95% CI 0.21-0.71) for incisional hernia and 0.68 (95% CI 0.51-0.91) for SSI. 1, 3
Technical specifications:
- Place stitches 5mm from the wound edge 1, 2
- Maintain 5mm intervals between stitches 1, 2
- Include only the aponeurosis (no muscle or adipose tissue) 1, 2
- This distributes tension evenly and minimizes tissue trauma 1
Continuous vs. Interrupted Suturing
Continuous suturing is preferred because it takes less operative time while achieving equivalent outcomes for incisional hernia and dehiscence compared to interrupted sutures. 1 For fascial closure specifically, no difference exists in complication rates between techniques, making continuous suturing the pragmatic choice in time-sensitive situations. 1
For skin closure, continuous subcuticular sutures dramatically reduce superficial wound dehiscence by 92% (RR 0.08; 95% CI 0.02-0.35) compared to interrupted transcutaneous sutures. 1, 2, 4
Critical Suture-to-Wound Length Ratio
Maintain a minimum 4:1 suture-to-wound length ratio for all midline abdominal wall closures, as this is essential for preventing incisional hernia and wound complications (Grade 1B recommendation). 1, 2 This ratio is more important than whether you use continuous or interrupted technique. 2
Layered Closure Approach
Peritoneum
Do NOT close the peritoneum separately during abdominal wall closure (Grade 1B recommendation against this practice). 1 Separate peritoneal closure provides no benefit and wastes operative time. 1
Fascia
Mass closure is recommended over layered closure because it achieves equivalent outcomes for incisional hernia and wound complications while being significantly faster—a critical consideration in emergency or high-risk settings. 1
Skin
Use continuous subcuticular technique with slowly absorbable monofilament sutures rather than interrupted transcutaneous non-absorbable sutures that require removal at 7-9 days. 1, 2, 4 The absorbable subcuticular approach eliminates the need for suture removal and provides continued wound support beyond the first week. 1, 2
Common Pitfalls to Avoid
Never include adipose tissue or muscle in fascial sutures, as this significantly increases dehiscence, infection, and incisional hernia risk. 2 The small bite technique specifically avoids this by including only aponeurosis. 1, 2
Avoid pulling continuous sutures too tightly, as this strangulates wound edges, causes tissue ischemia, and compromises healing. 2, 5
Do not use multifilament sutures, as they carry higher incisional hernia rates compared to monofilament materials. 1
Never use tissue adhesives alone in high-tension wounds or contaminated fields, as they have a 3.35 times higher risk of wound breakdown (RR 3.35; 95% CI 1.53-7.33) compared to sutures. 2, 5
Avoid non-absorbable transcutaneous interrupted sutures for skin closure when absorbable subcuticular continuous sutures are available, as the latter dramatically reduce dehiscence without requiring removal. 1, 2, 4
Adjunctive Measures for SSI Prevention
Beyond suture technique, implement these evidence-based strategies to further reduce SSI risk:
Chlorhexidine gluconate plus alcohol-based skin preparation reduces SSI from 6.5% to 4.0% compared to povidone-iodine plus alcohol. 6
Avoid razors for hair removal (use clippers instead), as razors increase SSI from 2.5% to 4.4%. 6
Maintain normothermia (body temperature >36°C) with active warming, reducing SSI from 13% to 4.7%. 6
Perioperative glycemic control (glucose <150 mg/dL) reduces SSI from 16% to 9.4%. 6
Consider povidone-iodine wound irrigation in clean, clean-contaminated, and contaminated fields, though avoid antibiotic irrigation. 1
Retention Sutures
No consensus exists on routine retention suture use, as the expert panel achieved only 68% agreement (below the 80% threshold for guideline inclusion). 1 However, consider retention sutures selectively for patients with increased incision tension, severe malnutrition, immunocompromise, previous fascial defects, or massive abdominal contamination. 1