# The Clinical and Economic Value of Triclosan-Coated Surgical Sutures in Abdominal Surgery
## 1 Introduction  
A surgical site infection (SSI) is defined as an infection that occurs within 30 days of surgery if no implant is left in place or within 90 days if an implant is left in place [1]. According to the World Health Organization (WHO) definition, SSIs may involve skin and subcutaneous tissue (superficial incisional), the deep soft tissue of the incision such as fascia or muscle (deep incisional), and/or any part of the body other than the incision that was opened or manipulated during an operation (organ/space) [1].  
Despite established preventive measures [2], SSI remains the most frequent complication following abdominal surgery--defined as any surgical procedure on the abdominal cavity followed by abdominal wall closure--with an incidence rate of 10%-20% in contaminated and dirty surgery [3]. SSI is not only a surgical complication that affects the length of stay, it also has a significant impact on the patient's perceived quality of life. Moreover, SSI is an important risk factor for readmission, reintervention, and the development of incisional hernia [4, 5], resulting in increased healthcare-related costs [6]. Postoperative infectious complications also negatively affect long-term outcomes [7, 8].  
The pathogenesis of SSI is multifactorial. The main patient-related risk factors for SSIs include active smoking, impaired nutritional status, obesity, immune deficits, and diabetes, while surgery-related risk factors include the degree of field contamination, the duration of surgery, hypothermia in the operating room, and the colonization of bacterial biofilm on sutures [9; 10; 11; 12; 13]. To help reduce the risk of SSI, sutures coated with antimicrobial materials have been introduced in clinical practice. The most common antibacterial agent that is used to coat sutures is triclosan, which offers broad-spectrum bactericidal action against Gram-positive and Gram-negative bacteria [14]. In both in vitro and in vivo studies, microorganisms that are responsible for SSIs were prevented from binding to and colonizing triclosan-coated sutures (TCS), with the action lasting roughly 30 days from the implantation of these sutures [15; 16].  
Guidelines, including those issued by the US Center for Disease Control (CDC), WHO, the American College of Surgeons (ACS), and National Institute for Health and clinical Excellence (NICE), recommend the use of TCS for the prevention of SSIs [16; 17; 18; 19].  
Several randomized clinical trials have investigated the efficacy of TCS in reducing SSI following abdominal surgery; some have established a positive effect of TCS, whereas others have failed to demonstrate statistically significant differences versus conventional absorbable sutures (CS) [20; 21; 22; 23; 24; 25; 26; 27]. Recent meta-analyses reported a significant effect, or at least a positive trend, in favor of TCS over CS in reducing SSI rates following abdominal surgery [28; 29]. The partial disagreement between the meta-analyses results is likely attributable to differences in the number of studies included, the degree of field contamination (CDC classification of the wounds), the heterogeneity of surgical procedures considered, and the inclusion of trials with low-level evidence, all of which introduced uncertainty in the overall interpretation of results.  
The purpose of this study was to critically analyze and appraise the latest available evidence on the role of TCS on SSI prevention in a more homogeneous population represented by patients undergoing abdominal surgery. A literature review of meta-analyses that considered TCS in abdominal surgery was conducted, and a cost analysis was subsequently performed to investigate the economic impact of TCS to provide a more comprehensive representation of the value of this technology in clinical practice.