What type of suture material and antibiotic regimen is recommended for a patient requiring suturing, considering potential allergies and impaired renal or liver function?

Suture Material and Antibiotic Selection for Wound Closure

Use slowly absorbable monofilament sutures (such as poliglecaprone or polydioxanone) for fascial and deep tissue closure, and strongly consider antimicrobial-coated (triclosan-impregnated) sutures when available to reduce surgical site infections. 1, 2, 3

Optimal Suture Material Selection

For Fascial/Deep Tissue Closure

• Monofilament sutures are strongly recommended over multifilament sutures (Grade 1A, high certainty of evidence) as they significantly decrease the incidence of incisional hernia in both emergency and elective settings 1, 3
• Slowly absorbable monofilament sutures (such as polydioxanone/PDS or poliglecaprone) maintain adequate tensile strength during the critical healing period and are superior to rapidly absorbable options 1, 3
• Monofilament sutures cause less bacterial seeding, have lower infection risk, and create less tissue friction compared to multifilament options 2, 4

For Vaginal/Perineal Repair

• Use monofilament absorbable synthetic sutures like poliglecaprone (3-0 or 4-0) as they minimize infection risk, reduce short-term pain, and decrease analgesic requirements 1, 2
• Rapidly-absorbing synthetic sutures like polyglactin 910 eliminate the need for suture removal 2

For Skin Closure

• Use continuous non-locking subcuticular technique with monofilament absorbable sutures to reduce pain and avoid nerve ending damage 1, 2
• Alternatively, consider leaving skin unsutured or using skin adhesive to reduce pain and dyspareunia in perineal repairs 1

Antimicrobial-Coated Sutures

Antimicrobial-coated sutures (typically triclosan-impregnated like Vicryl Plus) are strongly recommended (Grade 1B) for fascial closure in clean, clean-contaminated, and contaminated surgical fields 1, 3

Evidence Supporting Antimicrobial Sutures

• Significantly reduce surgical site infection rates with risk ratio of 0.67 (95% CI 0.48-0.94) in digestive surgery 1
• Meta-analysis shows OR 0.72 (95% CI 0.59-0.88) for SSI reduction in randomized controlled trials 1
• Triclosan-coated Vicryl demonstrates superior outcomes compared to standard Vicryl with OR 0.62 (95% CI 0.44-0.88) 1, 2
• Benefits are consistent across different wound types (clean, clean-contaminated, contaminated) and procedure types (colorectal, cardiovascular, head and neck) 1

Antibiotic Prophylaxis

For Obstetric Anal Sphincter Injuries (OASIS)

Administer preoperative antibiotics before OASIS repair as they significantly reduce postpartum wound complications 1

• Use second- or third-generation cephalosporin as first-line agent 1
• For penicillin allergy: use metronidazole with consideration of adding gentamicin or clindamycin to provide adequate coverage for both vaginal and bowel flora 1
• Evidence shows antibiotic administration reduces purulent discharge (17.2% vs 4.1%, P=0.04) and any wound complication (24.1% vs 8.2%, P=0.04) 1

For Emergency Laparotomy

• Antimicrobial-coated sutures are recommended when available, which may reduce the need for additional systemic antibiotics specifically for wound closure 1
• The use of antimicrobial sutures shows benefit even when prophylactic antibiotics are administered (RR 0.79,95% CI 0.63-0.99) 1

Suturing Technique Recommendations

Small Bite Technique

• Use the "small bite" technique for midline laparotomy closure: include only aponeurosis, approximately 5mm from wound edge with 5mm between stitches 1, 3
• This technique results in lower incidence of incisional hernias and wound complications 1, 3

Continuous vs Interrupted Sutures

• Use continuous non-locking technique for all layers as it reduces pain, decreases analgesic use, and lowers need for suture removal 1, 2
• Continuous suturing reduces superficial wound dehiscence compared to interrupted sutures 3

Suture-to-Wound Length Ratio

• Maintain a suture-to-wound length ratio of at least 4:1 for continuous closure of midline abdominal wall incisions 1

Critical Pitfalls to Avoid

Material Selection Errors

• Avoid multifilament sutures (like silk) as they show greater microbial adherence, stronger inflammatory reaction, and poorest soft tissue healing 4
• Avoid catgut or glycerol-impregnated catgut due to inferior outcomes 2
• Do not use rapidly absorbable sutures for fascial closure as they lose tensile strength too quickly 1

Technique Errors

• Never use overly tight or locking continuous sutures as they cause excessive tension leading to tissue edema, necrosis, and impaired healing 2
• Avoid the large bite technique as it includes fat and muscle tissue, leading to tissue devitalization and infection 3
• Do not use transcutaneous interrupted sutures on perineal skin as they damage superficial nerve endings 2
• Avoid retention sutures for routine closures as there is insufficient evidence supporting their benefit 1, 3

Special Considerations for Patient Factors

Renal/Hepatic Impairment

• Suture material selection does not require adjustment for renal or hepatic impairment as sutures undergo local tissue degradation (hydrolysis for synthetic absorbable sutures) rather than systemic metabolism 5
• Antibiotic dosing should be adjusted according to standard renal/hepatic dosing protocols for the specific agent chosen 1

Allergy Considerations

• For iodine allergy during surgical site preparation, use chlorhexidine gluconate instead of povidone-iodine 1
• For penicillin/cephalosporin allergy in OASIS repair, use metronidazole with gentamicin or clindamycin 1

Contaminated/Infected Wounds

• Infection does not significantly influence the tensile strength reduction of sutures over time, even for absorbable materials 5
• Antimicrobial-coated sutures remain effective in contaminated fields and should be prioritized 1