Stapler suture or single button suture? A controlled clinical study on the comparison of both skin closure methods

In a controlled randomized clinical trial, skin closure with a skin-stapling technique was compared with interrupted sutures on 50 patients (26 sutured and 24 stapled). The two groups were similar in all important respects. The clinical side of the study was to compare 1) the cosmetic results, 2) the time taken to close the skin, and 3) advantages and disadvantages of the two techniques by a questionnaire completed by the clinical staff. The study suggested a cosmetic advantage for the stapling when the results at 6th postop. week were compared. The only significant difference was in cross hatching (22 out of 26 sutured wounds but none of the 24 stapled) which was predominantly visible in sutured wounds. A clear difference was found in operating time. Skin closure with interrupted sutures took 310s, compared with 122s for stapling (alpha = 0,001). Similarly time required to remove the closure material was less with the staples than with sutures. Staples are more expensive than sutures. However the advantage of the staples over the suture in avoiding cross hatching is significant as well as time saving.     

The influence of suture technique on early wound healing.

The burst strength, swelling, and microcirculatory dynamics were compared in model skin wounds closed by interrupted or continuous suturing techniques. Incised skin wounds of the midline abdomen and anteromedial and anterolateral knee of the pig were used. Microcirculatory kinetics were assessed by means of skin fluorescence following intravenous fluorescein at intervals of up to 12 days. The burst strength of wounds was measured at 12 days using an Instron Tensiometer. In wounds closed with an interrupted suture technique a 30 to 50% greater tensile strength, less edema and induration, and less impaired microcirculation at the wound margin was demonstrated in comparison to that observed in wounds closed with a continuous suture technique. The results support the use of interrupted rather than continuous suture technique for skin wound closure in instances where impaired healing can be anticipated due to disease or age, or where early stress on the healing wound is planned as in incisions about a moveable joint.     

Laser assisted fusion of the rat stomach: preliminary studies

The purpose of this study was (1) to determine whether rat gastrotomies could be securely closed without sutures by CO2 laser-induced tissue fusion alone and (2) to compare some characteristics (physical, biochemical, histological) of laser-fused gastrotomies with sutured gastrotomies. Following pentobarbital anesthesia a 1.5-cm longitudinal anterior gastrotomy was made in the forestomach of male Sprague-Dawley rats. This wound was closed using either a sutureless tissue weld created by a microscope-mounted CO2 laser (153 W/cm2) (Group I, N = 61) or with a running 6-O polypropylene suture (Group II, N = 58). Animals were sacrificed on Postoperative Days 1, 2, 4, 7, and 11 and the wounds were studied. Survival to scheduled sacrifice was 95% in Group I and 93% in Group II. Although bursting pressure of laser-fused gastrotomies was significantly lower than that of sutured controls on Postoperative Day 1, measurement on subsequent days showed comparable wound strength between the laser and suture groups. Wound hydroxyproline content was significantly higher on Postoperative Day 1 and lower on Postoperative Day 11 in the laser group. Histologic examination of the laser-fused wounds revealed less inflammation and earlier reepithelialization than the sutured wounds, giving the microscopic appearance of a "neater" healing wound. These results suggest that laser-induced fusion is a feasible method of gastrointestinal wound closure which may complement standard suture techniques.     

Two methods of skin closure in abdominal operations: a controlled clinical trial

Operative bacterial contamination of surgical wounds is common. The ability of the host to eradicate these bacteria and prevent subsequent wound infection is affected by a number of factors; one of these has been shown experimentally to be the presence of suture material in the subcutaneous tissues. In a prospective randomized controlled clinical trial in 341 abdominal operations we compared the primary infection rates after two methods of skin closure: either vertical mattress monofilament nylon sutures (182 patients) or steel clips which penetrated only the dermis (159 patients). All patients received a single dose of a cephalosporin intravenously at induction of anaesthesia and neither sutures nor drains were placed in the subcutaneous plane. The overall wound infection rate in the sutured wounds was 17.0 per cent, compared with 6.3 per cent in those closed by clips (X2 = 9.26, P less than 0.01). We conclude that skin closure with clips reduces the incidence of wound infection in patients in whom operative parietal contamination has occurred.     

A revolutionary advance in skin closure compared to current methods

Six pigs were used to evaluate the influence of three separate modalities on contaminated wounds. Full-thickness skin wounds on the abdomen were contaminated with 10(4) or 10(5) Staphylococcus aureus and then closed with one of three methods. The three closure modalities included (1) a new absorbable staple (Insorb) placed in the subcuticular tissue, (2) a braided Vicryl suture, and (3) percutaneous metal staples. Any foreign body material implanted in tissue increases the risk of infection at that site. Wound closure always involves the use of a foreign body. Historically, sutures have been the primary material used to close tissue. The newer synthetic sutures are significangly more biodegradable and cause less infection than sutures composed of protein, such as silk and catgut. Metal staples are also associated with a low risk of infection. Recently, Incisive Surgical, Inc. (Plymouth, Minnesota) has developed an absorbable polymer staple specifically for subcuticular skin closure. The purpose of this study was to compare the new Insorb staple to both an absorbable polymer suture and a metal staple. Wound infection was assessed 7 days after closure by clinical signs and quantitative bacterial swabs. The results demonstrated that wounds closed with Insorb staples had the lowest incidence (33%) of infection, followed by percutaneous metal staples (44%). All wounds (100%) closed with Vicryl suture became infected. The incidence of wound infection directly correlated with the level of quantitative bacterial count at analysis. The Insorb staple was associated with significantly reduced closure time, less inflammation and infection, and better aesthetic result compared to Vicryl. Compared to metal staples, the Insorb subcuticular staplers demonstrated comparable closure time without the need for later staple removal. In conclusion, the closure of contaminated wounds with the Insorb staples is a superior choice to Vicryl suture because they have a significantly (p = 0.009) lower incidence of infection. The Insorb staple is a revolutionary advance in subcuticular skin stapling.     

Comparative study of leg wound skin closure in coronary artery bypass graft operations.

A prospective randomised study of four different methods of leg wound skin closure after removal of the long saphenous vein was carried out in 113 patients undergoing coronary artery bypass grafting. These methods were: (1) continuous nylon vertical mattress suture (27 patients); (2) continuous subcuticular absorbable (Dexon) suture (29 patients); (3) metal skin staples (Autosuture) (27 patients); and (4) adhesive sutureless skin closure ("Op-site") (30 patients). All wounds were examined by two independent observers at five, 10, and 45 days after operation. At five days, inflammation, extent of oedema, discharge, and infection were assessed. At 10 days attention was paid to the state of wound healing and at 45 days to the final cosmetic appearance. The use of continuous subcuticular suture resulted in significantly less discharge than did the use of metal staples, nylon vertical mattress suture, or Op-site. The incidence of established wound infection was 4.5% overall, with no infection in the wounds closed with Dexon. Assessment of the healing process showed subcuticular Dexon to be more effective than metal staples or vertical mattress nylon suture. The final cosmetic result showed continuous subcuticular suture to be superior to nylon vertical mattress suture and skin staples but as effective as Op-site sutureless skin closure.     

Hypertrophic scarring: Dexon suture in a randomized trial.

In a randomized prospective trial of three methods of skin suture an increased incidence of hypertrophic scarring in paramedian and inguinal wounds has been found to be associated with the use of 2/0 Dexon suture subcuticularly. However, the variance associated with the type of suture was less than that associated with the sex of the patient. The patient's opinion of the appearance of the scar was the same for all three suture methods used in skin closure.     

Staples or sutures for chest and leg wounds following cardiovascular surgery

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question asked was whether the use of skin sutures or skin staples for chest and leg wounds in patients following cardiovascular surgery reduces the incidence of wound infections. Altogether 119 abstracts were found using the reported search, of which five randomized controlled trials, represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We concluded in the five randomized controlled trials in cardiovascular surgery that compared staples with suture closure, three out of five found that the complication rate was lower with sutures and the other two found no difference. With regard to cosmesis, two of the five studies found sutures to be superior and the remaining papers found no difference. We conclude that sutured skin closure for leg and chest wounds is superior to stapled closure.     

小腿开放性骨折伤口处理

目的 报道开放性小腿骨折伤口闭合的处理经验。方法 清创和处理骨折后，直接缝合伤口时应无张力，否则行关系和缝合，创面有软组织，可游离植皮。套状４撕脱皮肤可修得成中厚皮片行原位缝合。理宜延期Ⅰ期闭合。对骨质外露，宜采用筋膜皮瓣，肌（皮）瓣。感染创口需炎症控制后行伤口闭合。结果 新鲜创口２８例伤口闭合。仅皮片原位缝合出现７例坏死，经第二次手术创口闭合。６３例感染创面经抗炎、植皮和组织瓣方法闭合。结论 伤     

Transforming growth factor-β2 (TGF-β2) reverses the inhibitory effects of fibrin sealant on cutaneous wound repair in the pig

Tensile strength of 2-cm, full-thickness, surgically incised porcine skin wounds sealed with fibrin sealant was enhanced compared to conventionally sutured wounds at 6 hours postwounding, but was significantly reduced after 3 days. Supplementation of fibrin sealant with transforming growth factor-beta2 (TGF-beta2) reversed the inhibitory effects of fibrin sealant on tensile strength at 3 days, and enhanced tensile strength at 7 days compared to suture or fibrin sealant alone. By 14 days, the tensile strengths of all wounds were similar, although wounds treated with fibrin sealant supplemented with TGF-beta2 showed a small, but statistically significant, improvement in wound strength compared to wounds treated with fibrin sealant alone. Histological assessment at day 7 revealed significant remnants of fibrin sealant at the wound site following fibrin sealant treatment alone, while wounds treated with fibrin sealant supplemented with TGF-beta2 or suture exhibited fibroblast infiltration and extracellular matrix deposition. At day 7, TGF-beta was immunolocalized in the base and margins of only wounds treated with fibrin sealant supplemented with TGF-beta2. A significant increase in matrix metalloproteinase-9 activity was found in fibrin sealant-treated wounds at day 7 as compared to sutured wounds. Addition of TGF-beta to the fibrin sealant suppressed the up-regulation of matrix metalloproteinase-9 in these wounds. These results suggest that fibrin sealant supplemented with TGF-beta may provide superior wound healing as compared to fibrin sealant alone.     

Experimental wound healing: increased breaking strength and collagen synthetic activity in abdominal fascial wounds healing with secondary closure of the skin

Delayed primary closure or secondary closure of skin and subcutaneous fat in contaminated laparotomy incisions virtually eliminates the risk of wound abscess in clinical practice. Incisional hernias rarely develop in these wounds. This experimental study offers a possible explanation. Longitudinal incisions in the linea alba of female Wistar rats healed under skin incisions which were either sutured ('closed' subgroup) or left to close by secondary intention ('open' subgroup). Postoperative breaking strengths and collagen contents (measured as hydroxyproline) were studied at intervals of 3-120 days. Measurable strength developed by 5 days, at which time 'open' subgroup wounds were found to be weaker and to have less collagen. At all other times, however, 'open' subgroup wounds were stronger, a property which could be ascribed at earlier, but not at later, periods (42 or 120 days), to a higher content and concentration of collagen. At 3 days the rate of collagen production was significantly (P less than 0.025) lower in 'open' than in 'closed' subgroup wounds but the converse was true at 6 and 9 days (P less than 0.025), thus accounting for the changes in biomechanical properties. It is suggested that initially the stimulus for collagen synthesis is greater in the 'open' wounds and this leads to the development of a collagenous structure which is better adapted to resist tensile forces.     

Usefulness of galea suturing method for scalp closure]

A method for scalp closure to prevent alopecia along a suture line is described. Only the galea is sutured. By tacking a sufficient width of the galea on both sides with an absorbable suture material, the sutured wound forms a ridge. The outer layer is then closed with skin staples to keep the blood circulation undisturbed. This procedure contrasts with the traditional method in which the galea is sutured with the overlying subcutaneous tissue and consequently the hair follicles are strangled. By adopting the method of suturing the galea, development of alopecia along a suture line has been effectively prevented and scarring has become less conspicuous.     

Comparison of laser-welded and sutured arteriotomies

We compared the histologic features, tensile strength, and collagen synthesis of laser-welded and sutured arteriotomies. Four bilateral canine femoral or carotid arteries, 2 cm long, were studied at one through four weeks postoperatively, with one vessel (control) closed with interrupted 6-0 polypropylene sutures and the contralateral vessel (experimental) welded with an argon laser (0.5 W [1417 J/cm2], four-minute exposure per 1-cm length of incision). Histologic examination revealed that laser-welded arteriotomies had less inflammatory reaction, more normal collagen and elastin reorientation, and similar endothelial continuity when compared with the control, sutured wounds. The tensile strength of the one- and two-week laser-welded specimens was less than that of sutured wounds and became approximately equal to sutured repairs at three and four weeks. There were no significant differences in the rate of collagen synthesis. There was no evidence of abnormal healing in the laser-welded specimens, suggesting that argon laser welding may be an alternative to suture repair of arteriotomies.     

Evaluation of the long-term outcome of wounds closed with ”Indermil” adhesive

”Indermil” is a new formulation of n-Butyl-2- Cyanoacrylate used for securing skin grafts and surface wound closure. We report a prospective randomized trial, comparing the use of ”Indermil” adhesive with suture in wound closure. A total of 30 patients underwent 37 procedures for the removal of benign skin lesions under local anaesthesia. ”Indermil” was used in the skin closure in 18 procedures and sutures were used in 19 procedures. Scar quality, patient satisfaction and complications were recorded at a period between 8 and 18 months (median 12.2) following the procedure. The study showed no difference between the two groups in terms of scar quality and patient satisfaction. We conclude that long term outcome of wounds closed with ”Indermil” are no different from sutured wounds. Received: 16 November 1999 / Accepted: 8 February 2000     

Evaluation of peritoneal closure at laparotomy.

Laparotomy closure was performed in rats with and without peritoneal suture. Both paramedian and midline incisions were used. The incidence of adhesions to the parietal peritoneum was significantly higher when the peritoneum was sutured, more so with catgut. The peritoneal surface reperitonealized in 7 days when peritoneum was not sutured. The tensile and bursting strength was studied on the 7th and 14th day, and was found to be similar in both midline and paramedian incisions whether or not the peritoneum had been sutured. The same results were obtained whether continuous or interrupted sutures of the muscle sheath with monofilament nylon was used. We believe that the peritoneum should not be sutured at laparotomy closure and that a midline incision with rectus sheath closure using monofilament nylon should be used as it is less time-consuming and provides sufficient strength to the abdomen.     

Octyl-2-Cyanoacrylate Liquid Bandage as a Wound Dressing in Facial Excisional Surgery: Results of an Uncontrolled Pilot Study

BACKGROUND: Although cyanoacrylate tissue adhesives are frequently used in the closure of cutaneous lacerations and excisions, only a few reports comment on their usefulness as a dressing over sutured wounds. A new formulation of octyl-2-cyanoacrylate (Liquid Bandage; BAND-AID, Johnson & Johnson) is used as an occlusive protective film over minor cuts and scrapes. OBJECTIVE: An uncontrolled pilot study to assess the safety, efficacy, and cost of Liquid Bandage as an occlusive dressing over sutured facial excisions. METHODS: Patients undergoing excision of facial neoplasms were recruited. After conventional layered repair, Liquid Bandage was applied. On suture removal, the wounds were photographed and evaluated by three dermatologists, who assigned an overall outcome rating. The average cost of Liquid Bandage and routine wound care materials was calculated based on prices from three different pharmacies. RESULTS: Of the 18 wounds available at follow-up, 17 were assigned an overall outcome rating of good or excellent by at least one of the evaluators. Eleven wounds received an excellent rating from at least two of the evaluators. One case of distal flap necrosis occurred. Liquid Bandage proved to be less expensive than routine postsurgical wound care materials. CONCLUSIONS: Liquid Bandage dressing is safe and effective over sutured facial excisions.     

The Donati stitch revisited: favorable cosmetic results in a randomized clinical trial

BACKGROUND: Literature on the cosmetic results of various surgical methods to close the skin is scarce. We sought to compare the cosmetic results of two different surgical techniques of skin closure after lower midline laparotomy. MATERIALS AND METHODS: A randomized clinical trial compared a running nylon skin suture to interrupted Donati stitches in 58 patients undergoing gynecological surgery. Scar hypertrophy, scar width, scar color, the presence of cross-hatching marks, and a total scar score were assessed in all patients at 2 weeks, 6 months, and 12 months postoperatively. RESULTS: On average closing the wounds with Donati stitches took 5 min longer than using a running suture (P > 0.001). The Donati sutures caused significantly less cross-hatching at 2 weeks and 6 months postoperatively. At 1 year, the scar color following Donati closure was also significantly less pronounced than in the running suture arm. The total scar score was significantly better in the Donati arm at each of the three time periods of assessment. The difference at 6 months was equal to the difference at 1 year. CONCLUSIONS: Closing the skin of lower midline laparotomy wounds with Donati stitches resulted in a cosmetically better scar. Scar cosmetics of lower midline laparotomies could be improved by using interrupted Donati stitches instead of a running suture. The difference was significant at 2 weeks, 6 months, and 12 months postoperatively, but the magnitude of the difference was the same at 6 and at 12 months.     

Cutaneous closure after cardiac operations: a controlled, randomized, prospective comparison of intradermal versus staple closures.

OBJECTIVE: To determine the difference in wound complication and infection rates between suture and staple closure techniques applied to clean incisions in coronary bypass patients. BACKGROUND: The true incidence of postoperative wound complications, and their correlation with closure techniques, has been obscured by study designs incorporating small numbers, retrospective short follow-up, uncontrolled host factors, and narrowly defined complications. METHODS: Sternal and leg wounds were studied prospectively, each patient serving as his or her own control. Two hundred forty-two patients with sternal and saphenous vein harvest wounds had half of each wound closed with staples and the other half with intradermal sutures (484 sternal and 516 leg segments). Wound complications were defined as drainage, erythema, separation, necrosis, seroma, or infection. Infections were identified in the subset having purulent drainage, antibiotic therapy, or debridement. Wounds were examined at discharge, at 1 week after discharge, and at 3 to 4 weeks after operation. Patient preferences for closure type were assessed 3 to 4 weeks after operation. RESULTS: Neither leg nor sternal wounds had a statistically significant difference in infection rate according to closure method (leg sutured = 9.3% vs. leg stapled = 8.9%; p = 0.99, and sternal sutured = 0.4% vs. sternal stapled = 2.5%; p = 0.128). There was, however, a greater complication rate in stapled segments (leg stapled = 46.9% vs. leg sutured = 32.6%; p = 0.001, and sternal stapled = 14.9% vs. sternal sutured = 3.7%; p = 0.00005). Sutures were favored over staples among patients who expressed a preference (sternal = 75.6%, leg = 74.6%). CONCLUSIONS: With the host factors controlled by pairing staples and sutures in each patient, we demonstrated a similar incidence of infection but a significantly lower incidence of total wound complications with intradermal suture closure than with staple closure.     

Small tissue bites and wound strength: an experimental study

HYPOTHESIS: Placing stitches close to the cut wound edge does not produce low wound bursting strength in midline laparotomy incisions closed with a suture length:wound length ratio of 4. DESIGN: Experimental study in rats. METHODS: Midline incisions were closed with a running suture in 51 Sprague-Dawley rats. A suture length:wound length ratio of 4 was used and stitches were placed at a distance of 3, 6, or 10 mm from the wound edge. Wound bursting strength was studied immediately after and 4 days after wound closure. RESULTS: Immediately after wound closure, bursting pressure was higher with stitches placed 10 mm from the wound edge than those at a distance of 3 mm. After 4 days, bursting pressure and bursting volume were lower with stitches placed 10 mm from the wound edge than those at a distance of 3 or 6 mm. The abdominal wall ruptured outside the suture line in 14 of 17 wounds closed with 21 stitches, in 11 of 17 wounds closed with 16 stitches, and in 6 of 17 wounds closed with 11 stitches (P=.02). CONCLUSIONS: Four days after closure of midline laparotomy incisions using a suture length-wound length ratio of 4, wound bursting strength is higher with stitches placed 3 to 6 mm from the wound edge than those at a distance of 10 mm. Wound bursting strength increases with the number of stitches used.     

Frequency of Use of Suturing and Repair Techniques Preferred by Dermatologic Surgeons

BACKGROUND: There are many closure techniques and suture types available to cutaneous surgeons. Evidence-based data are not available regarding the frequency of use of these techniques by experienced practitioners. OBJECTIVE: To quantify, by anatomic site, the frequency of use of common closure techniques and suture types by cutaneous surgeons. METHOD: A prospective survey of the members of the Association of Academic Dermatologic Surgeons that used length-calibrated visual-analog scales to elicit the frequency of use of specific suture techniques. RESULTS: A response rate of 60% (61/101) indicated reliability of the received data. Epidermal layers were closed most often, in descending order, by simple interrupted sutures (38-50%), simple running sutures (37-42%), and vertical mattress sutures (3-8%), with subcuticular sutures used more often on the trunk and extremities (28%). The most commonly used superficial sutures were nylon (51%) and polypropylene (44%), and the most common absorbable suture was polyglactin 910 (73%). Bilayered closures, undermining, and electrocoagulation were used, on average, in 90% or more sutured repairs. The median diameters (defined as longest extent along any axis) of most final wound defects were 1.1 to 2.0 cm (56%) or 2.1 to 3.0 cm (37%). Fifty-four percent of wounds were repaired by primary closure, 20% with local flaps, and 10% with skin grafting, with the remaining 15% left to heal by second intent (10%) or referred for repair (5%). Experience-related differences were detected in defect size and closure technique: defects less than 2 cm in diameter were seen by less experienced surgeons, and defects greater than 2 cm by more experienced surgeons (Wilcoxon's rank-sum test: p=.02). But more experienced surgeons were less likely to use bilayered closures (r=-0.28, p=.036) and undermining (r=-0.28, p=.035). CONCLUSIONS: There is widespread consensus among cutaneous surgeons regarding optimal suture selection and closure technique by anatomic location. More experienced surgeons tend to repair larger defects but, possibly because of their increased confidence and skill, rely on less complicated repairs.