What is the recommended suture material and technique for approximating a large wound in a patient?

Approximation Suture for Large Wound

Recommended Suture Material and Technique

For large wound approximation, use a slowly absorbable monofilament suture (such as polydioxanone or polyglyconate) with a continuous "small bite" technique, placing stitches approximately 5 mm from wound edges and 5 mm apart, achieving a suture-to-wound length ratio of at least 4:1. 1

Suture Material Selection

Primary Recommendation: Monofilament

• Monofilament sutures are strongly recommended over multifilament sutures as they significantly decrease the incidence of incisional hernia in both elective and emergency settings 1
• Monofilament sutures have lower resistance when passed through tissues and reduced risk of suture sinus formation compared to multifilament options 2
• Multifilament sutures harbor bacteria within their braided structure, even after 70 days of implantation, increasing infection risk 3

Absorbability: Slowly Absorbable

• Choose slowly absorbable sutures over rapidly absorbable materials to maintain adequate tensile strength during the critical healing period 1
• Slowly absorbable sutures demonstrate lower incisional hernia rates compared to rapidly absorbable options 1
• Rapidly absorbable sutures lose tensile strength too quickly, particularly problematic in infected wounds where absorption is further delayed 3
• Absorbable sutures may decrease postoperative pain compared to non-absorbable options 1

Enhanced Option: Antimicrobial-Coated Sutures

• Strongly consider antimicrobial-coated sutures (typically triclosan-impregnated) when available, particularly for clean, clean-contaminated, and contaminated wounds 1
• Triclosan-coated sutures reduce surgical site infection risk (OR 0.62,95% CI 0.44–0.88) across multiple high-quality randomized controlled trials 1
• The benefit is consistent across different wound types and surgical procedures, including colorectal and mixed digestive surgeries 1

Suture Technique

Small Bite Technique (Preferred)

• Use the "small bite" technique with stitches approximately 5 mm from wound edges and 5 mm between stitches 1
• This technique includes only the aponeurosis/fascia, avoiding fat and muscle tissue 1
• Small bites prevent tissue compression and devitalization that occurs with large bites when combined with increased intra-abdominal pressure 1
• Wound edge separation greater than 10-12 mm during the early postoperative period strongly associates with incisional hernia development 1
• Evidence for small bite technique in emergency settings is limited, but large RCTs in elective settings demonstrate significantly lower incisional hernia and wound complication rates 1

Continuous vs. Interrupted Suturing

• Use continuous suturing technique as it takes less time than interrupted sutures with no difference in incisional hernia or dehiscence rates 1
• Continuous non-locking technique distributes tension evenly across the wound and reduces tissue edema 4

Suture-to-Wound Length Ratio

• Maintain a suture-to-wound length ratio (SL/WL) of at least 4:1 for continuous closure 1
• This ratio ensures adequate tissue approximation without excessive tension 1

Critical Pitfalls to Avoid

Tension Management

• Never place sutures under excessive tension as this strangulates tissue, impairs blood flow, and compromises healing 5, 4
• Excessive tension combined with large bites causes soft tissue compression, leading to wound edge separation and tissue devitalization 1

Material Selection Errors

• Avoid multifilament sutures as they harbor bacteria within their braided structure and increase infection risk 1, 5, 3
• Do not use rapidly absorbable sutures for large wounds requiring sustained support, as they lose tensile strength too quickly 5, 4
• Avoid catgut sutures as they are associated with more pain and higher risk of requiring resuturing 4

Technique Errors

• Do not use the "large bite" technique (>10 mm from wound edge and between stitches) as it includes fat and muscle, leading to tissue compression, devitalization, and increased hernia risk 1

Retention Sutures

• Routine use of retention sutures is not recommended as there is currently no high-quality evidence demonstrating they decrease wound dehiscence incidence 1
• The expert panel did not reach consensus (only 68% agreement) on avoiding retention sutures routinely 1
• Modern monofilament sutures with proper technique have eliminated the need for retention sutures in most practices 6

Specific Material Examples

Recommended Options

• Polydioxanone (PDS) - slowly absorbable monofilament 1
• Polyglyconate (Maxon) - slowly absorbable monofilament 4
• Poliglecaprone (MONOCRYL) - slowly absorbable monofilament 5, 4
• Monofilament polypropylene (Prolene) - non-absorbable monofilament for contaminated/dirty wounds 6

Enhanced Option

• Triclosan-coated polyglactin (VICRYL Plus) - antimicrobial-coated absorbable suture 4