Prevention of Incisional Surgical Site Infection Using a Subcuticular Absorbable Suture in Elective Surgery for Gastrointestinal Cancer

This study examined whether subcuticular absorbable sutures actually reduce incisional SSI in patients undergoing surgery for gastrointestinal (GI) cancer. Surgical site infection (SSI) is still a source of major complications in digestive tract surgery. Reportedly, incisional SSI can be reduced using subcuticular suturing. We performed subcuticular suturing using a 4-0 absorbable monofilament in patients undergoing elective surgery for GI cancer beginning in 2008. Using an interrupted technique, sutures were placed 1.5-2.0cm from the edge of the wound, with everted subcuticular sutures created at intervals of 1.5-2.0cm. The control group consisted of cases in which the common subcutaneous suture method using clip. One hundred cases were examined in the subcuticular group. The incidence of SSI was 0% in the subcuticular suture group, compared with 13.9% in the control group; this difference was significant. Incisional SSI can be prevented using the devised subcuticular absorbable sutures in patients undergoing elective surgery for GI cancer.Key words: Surgical site infection, Subcuticular suture, Absorbable monofilament, Gastrointestinal cancer surgerySurgical site infection (SSI) is still a source of major complications in digestive tract surgery. The Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance System (NNIS) risk adjustment index is an internationally recognized method of stratifying the risk of SSI according to three major factors.¹ First, the American Society of Anesthesiologists'' score reflects the patient''s state of health before surgery.² Second, the wound classification reflects the degree of wound contamination. And third, the duration of the operation reflects the technical aspects of surgery. The infection rate increases with an increasing risk index score.^1,3 Excellent surgical technique is widely believed to reduce the risk of SSI.^4–7 In the case of wound closure, such techniques include the maintenance of effective hemostasis while preserving an adequate blood supply, preventing hypothermia, gently handling the tissues, avoiding inadvertent entries into a hollow viscus, removing devitalized (e.g., necrotic or charred) tissues, the appropriate use of drains and suture materials, the eradication of dead space, and the appropriate postoperative management of incisions. Hematoma at the site of a surgical wound is a relatively common complication in elective surgical procedures. In most cases, the hematoma is caused by incomplete preoperative hemostasis, and not the omission of a subcutaneous fat layer suture.^1,8 According to current knowledge, seroma formation is caused by the ultrafiltration of blood serum, lymphatic secretion, the fibrinolytic activity of plasmin (causing the decay of fibrin complexes in the surrounding injured vessels), and tissue exudate formed during early inflammation reactions.^3,9,10 A large dead space also appears to contribute to the formation or a seroma.³ According to some authors, the presence of suturing material (as extraneous material) in tissues can also increase the risk of surgical site infections.^11–13Subcuticular suturing was recently reported to reduce incisional SSI.^14–16 Subcuticular sutures are thought to enable a maintained blood supply and to eradicate dead space in the subcutaneous environment. Therefore, we investigated whether the devised subcuticular suturing actually reduces incisional SSI, compared with the common subcutaneous sutures with clip, in patients undergoing elective surgery for gastrointestinal cancer.