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

Sutures vs Staples for Wound Closure

Primary Recommendation

Use sutures as the first-line method for most surgical wound closures, as they significantly reduce wound dehiscence risk and provide superior mechanical support for wound integrity. 1

Evidence-Based Decision Framework

When Sutures Are Mandatory

• High-tension wounds require sutures because tissue adhesives and alternative methods fail where mechanical forces are significant 1
• Contaminated or infection-prone wounds should be closed with triclosan-coated antimicrobial sutures, which reduce surgical site infection risk (OR 0.72; 95% CI 0.59-0.88) 1
• Abdominal wall closures and emergency laparotomies require proper suture technique with appropriate ratios and materials, not tissue adhesives alone 1

Optimal Suture Technique

• Use continuous subcuticular sutures rather than interrupted sutures, as they significantly reduce superficial wound dehiscence (RR 0.08; 95% CI 0.02-0.35) 2, 1
• Maintain a suture-to-wound length ratio of at least 4:1 to minimize incisional hernia and wound complications 1
• Choose slowly absorbable monofilament sutures (such as 4-0 poliglecaprone or 4-0 polyglactin) that retain 50-75% tensile strength after 1 week 2, 1
• Apply the "small bite" technique with 5mm spacing from wound edge and between stitches to include only the aponeurosis and ensure proper tension distribution 1

Sutures vs Staples Comparison

While the question asks about staples, the evidence shows:

• Staples may reduce wound closure time by approximately 5.56 minutes per wound (95% CI 0.05-11.07) 3
• Staples are associated with significantly more postoperative pain compared to sutures in multiple studies 3, 4
• Wound infection rates are controversial: one meta-analysis showed fewer infections with staples (OR 2.06; 95% CI 1.20-3.51) 3, but another found insufficient evidence of difference 4
• Cosmetic outcomes and patient satisfaction show no significant differences between methods 3, 4

Critical Pitfalls to Avoid

• Never use rapidly absorbable sutures for fascial closure, as they increase incisional hernia rates compared to slowly absorbable materials 1
• Avoid including adipose tissue or foreign material (like hair) in the suture line, as this significantly increases dehiscence, infection, and incisional hernia risk 1
• Do not apply continuous tightly pulled sutures that can strangulate wound edges and compromise healing 5
• Avoid tissue adhesives in high-tension areas, as they have a 3.35-fold higher risk of dehiscence compared to sutures (95% CI 1.53-7.33), requiring treatment of 43 patients with sutures instead of glue to prevent one additional dehiscence 1, 6

Post-Closure Monitoring

• Monitor for wound dehiscence particularly in the first 7-10 days, as this is the critical period when suture strength matters most 1, 5
• Watch for signs of infection including increasing pain, redness, swelling, or discharge regardless of closure method 1, 7
• Recognize that pain disproportionate to injury severity may suggest deeper complications requiring evaluation 7

Special Considerations

• Adding adhesive strips (steri-strips) to buried sutures does not significantly improve outcomes or reduce scar width (mean 1.1mm for both methods, P=0.89) and cannot be recommended 2, 5
• For contaminated fields, triclosan-coated sutures provide consistent infection risk reduction and should be preferentially selected 1, 5