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The effect of triclosan‐coated sutures on the incidence of surgical site

infection in laparoscopic sleeve gastrectomy, laparoscopic appendicectomy or
laparoscopic cholecystectomy:...

Article in International Wound Journal · September 2023

DOI: 10.1111/iwj.14387

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Misr University for Science & Technology Faculty of Medicine, Al-Azhar University
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DOI: 10.1111/iwj.14387

ORIGINAL ARTICLE

The effect of triclosan-coated sutures on the incidence of

surgical site infection in laparoscopic sleeve gastrectomy,
laparoscopic appendicectomy or laparoscopic
cholecystectomy: A multi-centre, double-blind,
randomized, intra-individual study

Moatasem A. Erfan 1 | El Ashraf M. Thabet 2 | Mahmoud A. Rageh 3 |

Sara M. Mohy 4 | Ibrahim El Wardany 1

1
Department of General Surgery, Faculty
of Medicine, Misr University for Science Abstract
and Technology (MUST), Giza, Egypt Surgical site infection (SSI) is a common cause of post-operative morbidity.
2
Department of General Surgery, Faculty According to the latest report announced by CDC, the SSI accounts for 20% of
of Medicine, Fayoum University, Fayoum,
healthcare-associated infection with a high risk of mortality up to twofold to
Egypt
3
Department of Dermatology, Faculty of
11-fold increase with high economic burden for the prolonged hospital stay.
Medicine, Al-Azhar University, Cairo, Port site infection (PSI) is a subgroup of SSI occurring at the ports of laparos-
Egypt copy. We tried to determine the efficacy of polyglactin 910 suture coated with
4
Department of Dermatology, Faculty of
triclosan in lowering the rate of PSI in some of the clean-contaminated wound
Medicine, Misr University for Science and
Technology (MUST), Giza, Egypt surgeries. This study included 480 individuals eligible for laparoscopic chole-
cystectomy, appendicectomy or sleeve operations. Polyglactin 910 sutures
Correspondence
coated with triclosan were used in one port site incision while polyglactin
Moatasem A. Erfan, Department of
General Surgery, Faculty of Medicine, 910 sutures were used in the other port sites incisions. In patients who under-
Misr University for Science and went laparoscopic cholecystectomy and appendicectomy, the incidence of PSI
Technology (MUST), Giza, Egypt.
Email: moatasem.erfan@must.edu.eg
was significantly lower in the triclosan-coated sutures. In sleeve gastrectomy
patients, although a lower number of triclosan-coated sutures developed PSI,
there was no statistically significant difference between triclosan and non-
triclosan-coated sutures. This study showed that using sutures coated with
antiseptics like triclosan has clinical benefits to prevent SSIs in most of the lap-
aroscopic surgeries.

KEYWORDS
antibacterial suture, laparoscopic appendicectomy, laparoscopic cholecystectomy,
laparoscopic sleeve gastrectomy, surgical site infection

Key Messages
• The authors investigated the effect of triclosan-coated sutures on the inci-
dence of surgical site infection in different laparoscopic surgeries.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Int Wound J. 2023;1–8. wileyonlinelibrary.com/journal/iwj 1

2 ERFAN ET AL.
• Using sutures coated with antiseptics like triclosan has clinical benefits to
prevent surgical site infections in most of the laparoscopic surgeries.
1 | INTRODUCTION
Surgical site infection (SSI) is a common and serious
cause of morbidity after surgery. Port site infection (PSI)
is a kind of SSI that occurs at laparoscopic ports. The
incidence of SSI in the United States is around 2.8%.1 The
SSI rate ranged from 1.5% to 20% due to variations in data
collection techniques, monitoring criteria and the broad
variance in the surgical procedures evaluated. It was
established that the SSI rate needs to be clarified and was
likely underreported previously.2
In 1964, the US National Research Council group cre-
ated a method of categorization for operating wounds
based on the degree of microbial contamination, with four
classes: clean, clean-contaminated, contaminated and
unclean wounds. Clean wounds are elective operations
with no entry of tracts. In contrast, a clean-contaminated
wound is a surgical wound with controlled entry into the
gastrointestinal, respiratory, genital or uninfected urinary
tract with minimal contamination.3
The definition of SSI proposed by Horan and
colleagues and adopted by the CDC is the most commonly
recognized in the United States and Europe. It is an infec-
tion that occurs within 30 days after surgery. Collection,
inflammatory indications (i.e., pain, soreness, oedema or
redness), dehiscence and culture are all symptoms that
indicate an anatomical plane has been affected.4
Laparoscopic surgery, often known as minimally
invasive surgery, was initially introduced at the end of
the previous century and quickly became the surgical
treatment of choice for various operations.5 Nowadays,
the gold standard therapy for symptomatic gallbladder
stones is laparoscopic cholecystectomy.6 Also, laparo-
scopic appendicectomy has gained popularity after being
described by Kurt Semm in 1982.7 Since 1991, when the
first laparoscopic sleeve gastrectomy was carried out, it
has become one of the most famous bariatric surgeries.8
PSI is a subtype of SSI occurring at the laparoscopic
ports. PSI has three varieties; superficial PSI occurs
within 30 days after surgery and affects only the skin
and subcutaneous tissues, with at least one purulent dis-
charge or organism isolated from the superficial inci-
sion. Deep PSI occurs after 30 days following surgery
and includes deep soft tissues (fascia and muscles) deep
to the incision with purulent drainage, dehiscence of
the deep incision, and an abscess. In the third type of
PSI, the infection occurs in any organ or space, not the
incision.9–12
In this study, we tried to determine the efficacy of poly-
glactin 910 suture coated with triclosan in lowering the
PSI rate in some clean-contaminated wound surgeries.
2 | METHODS
This randomized, controlled, double-blind, intra-
individualized, multi-centre study was conducted at our
affiliated university hospitals on 480 individuals eligible for
laparoscopic cholecystectomy, appendicectomy or sleeve
operations between February 2020 and February 2023. The
ethical review committee approved the study. The purpose
of this study was clearly explained to all patients and then
informed consent was obtained. The study was done follow-
ing the declaration of Helsinki and was approved by The
Local Ethical Committee (Approval No. 2020/0004).
Exclusion criteria included patients younger than
18 years old, presence of immunodeficiency disorders,
patients receiving anti-cancer or immunosuppressive ther-
apy, patients with an established preoperative infection,
refusal to participate or participating in another study.
A detailed medical history was taken in all cases. All
patients underwent a preoperative clinical examination, a
complete blood count (CBC) and other routine pre-
anaesthetic evaluations.
A standard three-, four-, or five-port technique was
used (Figure 1). Polyglactin 910 sutures coated with triclo-
san (Vicryl Plus, Ethicon Inc, Somerville, NJ) were utilized
in one port site incision, while polyglactin 910 sutures
(Vicryl) were used in the other port site incisions.
The blinding process depended upon two teams: the
assessing physician's team and the operation team
(the surgeons who did the operations, the assistant and
the nurses). Only the operation team knew about the
type of suture material used for every port.
After the surgery, the operating surgeon indicated the
types of sutures used in each operation on a chart sealed
in an envelope that was opened by the research team at
the last follow-up visit.
Experienced surgeons performed all operations. No
prophylactic systemic antibiotics were used. After sur-
gery, patients were followed up daily during their stay at
the hospital by a trained physician (assessor). After dis-
charge, patients were requested to return to the outpa-
tient clinic every week until the end of 30 days, and
then telephone follow-up was done once per month for
another 5 months.
ERFAN ET AL. 3

F I G U R E 1 Demonstration of port sites for each operation. E, Epigastric port; L, left lumbar port; P, pelvic port; R, right lumbar port; S,
subcostal port; U, umbilical port.

Data were analysed using Statistical Program for T A B L E 1 Description of demographic data and risk factors in
Social Science (SPSS) version 24. Quantitative data were all studied patients.
expressed as mean ± SD. Qualitative data were expressed Studied patients (N = 480)
as frequency and percentage. p Value was considered sig-
Age (years) Mean ± SD 42.2 ± 12.2
nificant if <0.05.
Min–Max 18–77
Sex Male 260 54.2%
3 | R E SUL T S Female 220 45.8%
2
BMI (kg/m ) Mean ± SD 35.9 ± 9.4
This study included 480 patients (260 males and Min–Max 19–60
220 females). Their age ranged between 18 and 77 years,
Risk factors DM 148 30.8%
with a mean of 35.9 ± 9.4 years. All studied patients'
Hypertension 128 26.7%
mean body mass index (BMI) was 35.9 ± 9.4 kg/m2.
There were 148 diabetic patients (30.8%), 128 hypertensive Smoking 176 36.7%
patients (26.7%) and 176 smokers (36.7%) in the studied Abbreviations: BMI, body mass index; DM, diabetes mellitus.
patients (Table 1).
The American Society of Anesthesiologists Classifica-
tion (ASA)13 was applied, and there were 248 patients there was a statistically significant ( p-value = 0.015)
(51.7%) of class I and 232 patients (48.3%) of class II in increased percentage of infection in non-triclosan sutures
the studied patients. Regarding the type of operation per- (16 sutures, 4.9%) when compared with triclosan-coated
formed in the studied patients, there were 164 patients sutures (1 suture, 0.6%). In sleeve gastrectomy patients,
(34.2%) subjected to appendicectomy, 232 patients (48.3%) although a lower number of triclosan-coated sutures
subjected to cholecystectomy, and 84 patients (17.5%) sub- developed PSI, there was no statistically significant differ-
jected to sleeve gastrectomy. Regarding post-operative hos- ence ( p-value = 0.142) between triclosan and non-
pital stay, 344 patients (71.7%) stayed for 1 day, and triclosan-coated sutures (Tables 3–5 and Figures 2 and 3).
136 (28.3%) stayed for 2 days (Table 2).
In patients who underwent laparoscopic cholecystec-
tomy, a highly statistically significant ( p-value < 0.001) 4 | DISCUSSION
increased percentage of infection was found in non-
triclosan sutures (32 sutures, 6.9%) when compared with The current study showed that despite no antibiotic pro-
triclosan-coated sutures (2 sutures, 0.9%). Similarly, in phylaxis, the incidence of PSI was significantly lower in
patients who underwent laparoscopic appendicectomy, the polyglactin 910 suture coated with triclosan-treated
4 ERFAN ET AL.

ports than in the ports treated by polyglactin 910 suture. control and sterilization techniques that could differ from
This impact of using triclosan-coated sutures was evident place to place. The incidence of PSI in our study is higher
in different operations. Therefore, using sutures coated than that reported in other studies. However, most of the
with antiseptics like triclosan has clinical benefits for studies used prophylactic antibiotics, which were not
patients. All cases of PSI were of the superficial type used in our current research.
because all operations were laparoscopically carried out. To the best of our knowledge, no published study
In addition, the duration of the post-operative stay was compared the impact of using triclosan-coated polyglac-
comparable between all patients. tin sutures to uncoated polyglactin sutures in laparo-
The incidence of PSI is quite variable from one study scopic surgeries of different types. However, we found
to another.14–16 Differences among the studies can be one study by Granados-Romero and colleagues,17 who
attributed to differences in the population, infection studied 200 laparoscopic operations. They used polyglac-
tin 910 versus polyglactin 910 coated with chlorhexidine.
The incidence of infection was significantly lower in the
TABLE 2 Description of clinical data in all studied patients.
coated suture group compared with polyglactin 910. Also,
Studied they used prophylactic antibiotics, and all their cases
patients were emergency, which is quite different from the cur-
(N = 480) rent study.
ASA Class I 248 51.7% The World Health Organization (WHO) has released
Class II 232 48.3% the first global recommendations for preventing SSI.
Operation Appendicectomy 164 34.2% These guidelines cover a variety of methods for reducing
SSI. Because the evidence in the reviewed literature is of
Cholecystectomy 232 48.3%
moderate quality, the authors' panel recommends the
Sleeve gastrectomy 84 17.5%
routine use of triclosan-coated sutures in surgical opera-
Amount of Mild (5–10 mL) 320 66.6% tions, regardless of the recommended surgery.18
blood loss Moderate (11–20 mL) 80 16.7% The suggested recommendation is primarily based on
Severe (>20 mL) 80 16.7% Wu and colleagues' meta-analysis.19 The quality of the
Duration of surgery 30 min 164 34.2% included randomized controlled trials was moderate to
low, and several studies were funded by industry.
40 min 232 48.3%
Another flaw in this meta-analysis was that it included
60 min 84 17.5%
diverse types of surgery (for example, breast, vascular,
Post-operative 1 day 344 71.7% orthopaedic and colorectal surgery), all of which had sig-
hospital stay 2 days 136 28.3% nificantly varied SSI rates. Even emergency surgery
Abbreviations: ASA, The American Society of Anesthesiologists was compared with elective surgery and open versus la-
Classification. paroscopic surgery, despite the fact that one of the

TABLE 3 Correlation between suture types and studied data in patients who underwent laparoscopic cholecystectomy.

Cholecystectomy sutures

Triclosan (N = 232) Non-triclosan (N = 464) Test p-Value

Site U 84 36.2% 148 31.9% χ = 57.3
2
<0.001 HS
E 112 48.3% 120 25.9%
S 36 15.5% 196 42.2%
Pain No 84 36.2% 168 36.2% χ 2 = 0.0 1.0 NS
Yes 148 63.8% 296 63.8%
Infection No 230 99.1% 432 93.1% χ 2 = 12.1 <0.001 HS
Yes 2 0.9% 32 6.9%
Redness No 217 93.5% 394 84.9% χ 2 = 10.7 0.001 S
Yes 15 6.5% 70 15.1%
Note: HS (pink-coloured cells): p-value <0.001 is considered highly significant; NS: p-value >0.05 is considered non-significant; S (green-coloured cells): p-value
<0.05 is considered significant.
Abbreviations: E, epigastric port; S, subcostal port; U, umbilical port.
ERFAN ET AL. 5

TABLE 4 Correlation between suture types and studied data in patients who underwent laparoscopic appendicectomy.

Appendicectomy sutures

Triclosan (N = 164) Non-triclosan (N = 328) Test p-Value

Site U 56 34.1% 108 32.9% χ = 37.2
2
<0.001 HS
P 28 17.1% 136 41.5%
R 80 48.8% 84 25.6%
Pain No 32 19.5% 64 19.5% χ 2 = 0.0 1.0 NS
Yes 132 80.5% 264 80.5%
Infection No 163 99.4% 312 95.1% χ 2 = 5.9 0.015 S
Yes 1 0.6% 16 4.9%
Redness No 136 82.9% 272 82.9% χ 2 = 0.0 1.0 NS
Yes 28 17.1% 56 17.1%
Note: HS (pink-coloured cells): p-value <0.001 is considered highly significant; NS: p-value >0.05 is considered non-significant; S (green-coloured cells): p-value
<0.05 is considered significant.
Abbreviations: P, pelvic port; R, right lumbar port; U, umbilical port.

TABLE 5 Correlation between suture types and studied data in patients who underwent laparoscopic sleeve gastrectomy.

Sleeve gastrectomy sutures

Triclosan (N = 84) Non-triclosan (N = 252) Test p-Value

Site E 56 66.7% 28 11.1% χ = 108.4
2
<0.001 HS
L 4 4.8% 80 31.7%
U 8 9.5% 76 30.2%
R 16 19% 68 27%
Pain No 72 85.7% 212 85.5% χ 2 = 0.003 0.959 NS
Yes 12 14.3% 36 14.5%
Infection No 83 98.8% 240 95.2% χ 2 = 2.16 0.142 NS
Yes 1 1.2% 12 4.8%
Redness No 44 52.4% 129 51.8% χ 2 = 0.008 0.927 NS
Yes 40 47.6% 120 48.2%
Note: HS (pink-coloured cells): p-value <0.001 is considered highly significant; NS: p-value >0.05 is considered non-significant.
Abbreviations: E, epigastric port; L, left lumbar port; R, right lumbar port; U, umbilical port.

F I G U R E 2 A case of laparoscopic sleeve gastrectomy showing a triclosan-coated suture port (red arrow) and non-coated vicryl suture
ports (blue arrows). (A) Intra-operative (Day 0); (B) 2 weeks post-operative (Day 14); (C) 1-month post-operative (Day 30).
6 ERFAN ET AL.
F I G U R E 3 A case of laparoscopic sleeve gastrectomy showing a triclosan-coated suture port (red arrow) and non-coated vicryl suture
ports (blue arrows). (A) Intra-operative (Day 0); (B) 2 weeks post-operative (Day 14); (C) 1-month post-operative (Day 30).
well-documented advantages of laparoscopic surgery is
the low rate of SSI and the inverse association between
SSI and mortality.20–22
In addition, Henriksen's meta-analysis evaluated sev-
eral forms of surgery, including elective open colorectal
surgery, elective midline laparotomy, open appendicec-
tomy and even faecal peritonitis laparotomies.20,23 Other
meta-analyses pooled all available randomized controlled
trials without categorizing the risk by wound class, kind
of operation, or organ or apparatus implicated.19,20,24–29
Different studies have been conducted and demon-
strated the superiority of triclosan. In vitro, preclinical stud-
ies have demonstrated that coated polyglactin 910 sutures
effectively inhibit the growth of Staphylococcus aureus,
Staphylococcus epidermidis, methicillin-resistant Staphylo-
coccus aureus (MRSA) and methicillin-resistant Staphylo-
coccus epidermidis (MRSE).30
Triclosan has been used effectively for over 30 years
in humans. The safety of triclosan has been well
established. It was found to be non-toxic, non-irritating,
non-carcinogenic, non-teratogenic and non-pyrogenic
chemically.31 No differences were observed in breaking
strength and absorption rates between the two sutures,
coated and uncoated polyglactin 910.32
In vivo, animal testing demonstrated no significant
differences between polyglactin 910 sutures coated with
triclosan and polyglactin 910 sutures in wound healing.
In addition, it demonstrated no significant difference in
bursting strength between polyglactin 910 suture coated
with triclosan and polyglactin 910 suture.33 Other studies
confirmed no statistically significant differences in han-
dling or wound healing characteristics between both
sutures.34
Triclosan is effective against pathogens commonly
associated with SSIs. Concerning resistance, triclosan
has been used for several years with no significant
reduction in efficacy. It has been proven to be an effec-
tive antiseptic with a favourable safety profile.35 In
addition, there was no statistically significant associa-
tion between triclosan mean inhibitory concentrations
and antibiotic susceptibility.36
5 | CONCLUSIONS
This study can support the beneficial effects of using
triclosan-coated polyglactin sutures in laparoscopic oper-
ations. The design of this study (a double-blind, random-
ized, intra-individual study) ameliorates the selection
bias and limits the variables that may affect the proce-
dure's outcome.
C O N F L I C T O F I N T E R E S T S T A TE M E N T
The authors declare no conflicts of interest.
DA TA AVAI LA BI LI TY S T ATE ME NT
The data that support the findings of this study are
available on request from the corresponding author.
The data are not publicly available due to privacy or eth-
ical restrictions.
ORCID
Moatasem A. Erfan https://orcid.org/0009-0003-2998-
8147
Mahmoud A. Rageh https://orcid.org/0000-0001-6212-
9748
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How to cite this article: Erfan MA, Thabet EAM,
Rageh MA, Mohy SM, El Wardany I. The effect of
triclosan-coated sutures on the incidence of
surgical site infection in laparoscopic sleeve
gastrectomy, laparoscopic appendicectomy or
laparoscopic cholecystectomy: A multi-centre,
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Int Wound J. 2023;1‐8. doi:10.1111/iwj.14387

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