What is the preferred method for wound closure, sutures or staples?

Sutures vs. Staples for Wound Closure

For optimal wound closure with lowest risk of complications, sutures are recommended over staples due to their lower risk of wound dehiscence, surgical site infections, and better cosmetic outcomes.

Optimal Wound Closure Technique

Primary Recommendation

• Sutures are the preferred method for most wound closures 1, 2
• Specifically, subcuticular continuous sutures have demonstrated:
  • Lower rates of wound dehiscence
  • Reduced surgical site infections (SSIs)
  • Better cosmetic outcomes compared to staples 1

Suture Material Selection

1. Monofilament sutures are strongly recommended (Level 1A evidence) 3

   • Associated with significantly lower risk of incisional hernia
   • Provide better wound integrity

2. Slowly absorbable sutures are suggested for most closures 3

   • Lower incisional hernia rates compared to rapidly absorbable materials
   • May decrease post-operative pain compared to non-absorbable options 3

3. Antimicrobial-coated sutures are recommended for contaminated wounds 3, 1

   • Significantly lower rates of surgical site infections in clean-contaminated and contaminated fields

Suturing Technique

1. "Small bite" technique is recommended 3

   • Tissue stitch approximately 5mm from wound edges
   • Distance of approximately 5mm between stitches
   • Includes only aponeurosis (not fat or muscle)
   • Results in fewer incisional hernias and wound complications

2. Suture-to-wound length ratio should be at least 4:1 3

   • Critical for avoiding incisional hernia and wound complications
   • Should be documented at every wound closure

When to Consider Staples

While sutures are generally preferred, staples may be considered in specific situations:

1. Speed is critical - Stapling is significantly faster than suturing 4
2. Scalp wounds - Comparable outcomes to sutures with faster application 4
3. Reduced needlestick risk - Staples eliminate risk of accidental needlestick injury 4

Complications and Considerations

Sutures vs. Staples

• Wound dehiscence: Sutures have significantly lower risk (RR 3.35) 5
• Adverse events: Staples may increase risk (7.3% for staples vs. 3.5% for sutures) 2
• Postoperative pain: Staples may cause more pain (SMD 0.41) 2
• Cosmetic results: Sutures generally provide better cosmetic outcomes 2, 5

Special Considerations

• Contaminated wounds: Consider antimicrobial-coated sutures 3, 1
• High-tension areas: May require horizontal mattress sutures 1
• Impaired healing factors: Patients with diabetes, immunosuppression, malnutrition may require special consideration for suture technique and timing of removal 1

Post-Closure Care

• Optimal suture removal: 7-10 days after placement 1
• Wound hydration: Keep wound hydrated for proper healing 1
• Sun protection: Protect from sun exposure for at least 6 months 1
• Monitor for complications: Watch for signs of infection (erythema >5cm, purulent discharge) 1

Common Pitfalls to Avoid

1. Early staple removal can lead to wound dehiscence
2. Late staple removal can result in "railroad track" scarring
3. Ignoring signs of infection can lead to further complications
4. Using rapidly absorbable sutures for closures where wound strength is critical
5. Improper suture-to-wound length ratio increases risk of complications

By following these evidence-based recommendations, clinicians can optimize wound closure outcomes while minimizing complications such as infection, dehiscence, and poor cosmesis.