Should I document when no visible suture remains after a procedure?

Documentation of Complete Resection After Endoscopic Procedures

Yes, you should document when no visible suture or residual tissue remains after a procedure, particularly following endoscopic resections, as this documentation is critical for assessing completeness of resection and guiding surveillance strategies.

Why Documentation is Essential

Prevents Missed Incomplete Resections

The British Society of Gastroenterology/Association of Coloproctologists strongly recommends careful post-procedure inspection of the resection site with photographic documentation of completeness of resection 1. This recommendation exists because:

• Incomplete resection is far more common than previously recognized, even among experienced endoscopists 1
• The CARE study demonstrated that 23.3% of 10-20 mm lesions felt to be completely resected were actually incompletely resected, despite the endoscopist believing complete resection had occurred 1
• A 2014 study found histological evidence of recurrence in 7% of large non-pedunculated colorectal polyps where complete resection was believed to have occurred both initially and at follow-up 1

Enables Future Identification of Resection Sites

The American Society for Gastrointestinal Endoscopy (ASGE) specifically recommends photo documentation in the area of a tattoo post-endoscopic resection because it enables identification of a scar site where no residual tissue is present 1. This is crucial for:

• Distinguishing between scar tissue and recurrent lesions at surveillance endoscopy
• Confirming the absence of perforation at the resection site 1
• Guiding future therapeutic decisions if recurrence is suspected

What to Document Specifically

For Endoscopic Resections

Document the following elements with photographic evidence:

• Complete absence of visible residual adenomatous tissue after meticulous inspection 1
• Appearance of the post-resection mucosal defect, including assessment for perforation risk 1
• Relationship to any tattoo markers placed for future identification 1
• Whether adjuvant thermal ablation was applied to margins where no endoscopically visible adenoma remains 1

Critical Distinction: Visible vs. Microscopic Disease

The US Multi-Society Task Force strongly recommends against using ablative techniques (such as argon plasma coagulation or snare tip soft coagulation) on endoscopically visible residual tissue, as this is associated with increased recurrence risk 1. However, they conditionally suggest adjuvant thermal ablation of post-EMR margins only when no endoscopically visible adenoma remains despite meticulous inspection 1.

This makes documentation of "no visible residual tissue" particularly important, as it:

• Justifies the decision to use adjuvant thermal ablation if applied
• Establishes baseline for surveillance endoscopy
• Provides medicolegal protection regarding completeness of resection

Common Pitfalls to Avoid

Don't Rely on Clinical Impression Alone

Even experienced endoscopists significantly underestimate incomplete resection rates 1. Photographic documentation provides:

• Objective evidence for quality assurance review
• Baseline comparison for surveillance procedures
• Teaching material for training purposes

Don't Confuse Suture Removal with Resection Completeness

While the question mentions sutures, the evidence primarily addresses endoscopic resections where tissue removal completeness is the key concern. For surgical procedures with skin closure:

• Non-absorbable sutures require timely removal to prevent complications and optimize cosmetic results 2
• Documentation should note suture removal and wound healing status 2
• However, this is distinct from documenting complete tissue resection in endoscopic procedures

Documentation Improves Patient Outcomes

Proper documentation of complete resection directly impacts morbidity and mortality by:

• Reducing recurrence rates through early identification of incomplete resections requiring re-treatment 1
• Preventing progression to invasive cancer in cases of incompletely resected colorectal lesions 1
• Optimizing surveillance intervals based on documented completeness of resection 1

The evidence consistently demonstrates that what appears complete to the endoscopist often is not, making objective photographic documentation essential for patient safety and optimal outcomes.