What is the preferred method for wound closure, glue or sutures (surgical threads), in patients with various medical histories and wound types?

Sutures Are Superior to Tissue Adhesives for Wound Closure

Sutures should be your first-line method for wound closure in nearly all clinical scenarios, as tissue adhesives carry an unacceptably high risk of wound breakdown with a 3.35-fold increased risk of dehiscence compared to sutures. 1, 2

The Evidence Against Tissue Adhesives

The data is clear and concerning:

• Tissue adhesives result in wound breakdown 3.35 times more frequently than sutures (95% CI 1.53-7.33), meaning you would need to treat 43 patients with sutures instead of glue to prevent one additional dehiscence 1, 2
• This finding comes from a Cochrane systematic review of 10 trials with 736 participants, representing the highest quality evidence available 2
• The American College of Surgeons explicitly recommends sutures as first-line for most wound closures, particularly when wound integrity and mechanical support are critical 1

When Sutures Are Mandatory

Certain clinical situations absolutely require sutures:

• High-tension wounds - Tissue adhesives fail catastrophically in areas where mechanical forces are significant, such as joints, areas of movement, or wounds under tension 1
• Contaminated or infection-prone wounds - Use triclosan-coated antimicrobial sutures, which reduce surgical site infection risk (OR 0.72; 95% CI 0.59-0.88) 1
• Deep tissue closure - Adhesives cannot provide the structural support needed for fascial or deep tissue layers 1

Optimal Suture Technique for Best Outcomes

When using sutures (which should be nearly always), follow this evidence-based approach:

For Skin Closure:

• Use continuous subcuticular sutures with slowly absorbable monofilament material (4-0 poliglecaprone or polyglactin) 1
• This technique reduces superficial wound dehiscence by 92% (RR 0.08; 95% CI 0.02-0.35) compared to interrupted sutures 1
• The dramatic reduction occurs because absorbable material provides prolonged support without requiring removal at 7-9 days 1

For Fascial/Deep Closure:

• Maintain a suture-to-wound length ratio of at least 4:1 to minimize incisional hernia and wound complications 1
• Use the "small bite" technique: place stitches 5mm from the wound edge and 5mm between stitches, including only the aponeurosis 1
• Choose slowly absorbable monofilament sutures that retain 50-75% tensile strength after 1 week 1

For High-Risk Scenarios:

• Use triclosan-coated sutures for contaminated wounds or abdominal/colorectal surgery (OR 0.67; 95% CI 0.46-0.98 for SSI reduction) 1, 3

Critical Pitfalls to Avoid

• Never use tissue adhesives alone in emergency laparotomy or abdominal wall closures - these require proper suture technique 1
• Never use rapidly absorbable sutures for fascial closure - they increase incisional hernia rates compared to slowly absorbable materials 1, 3
• Don't remove non-absorbable sutures before 7-9 days for most surgical wounds, as premature removal causes dehiscence 1
• Avoid pulling continuous sutures too tightly - this strangulates wound edges and causes ischemia 1

The Limited Role of Tissue Adhesives

While tissue adhesives may have a role as adjuncts in very specific, low-tension scenarios, the evidence does not support their use as a primary closure method:

• No evidence shows tissue adhesives reduce infection rates compared to sutures 2
• Patient and operator satisfaction show no significant differences 2
• The only potential advantage is slightly faster application time, which is clinically insignificant given the dehiscence risk 2

Clinical Algorithm

For any surgical wound closure:

1. Default to sutures unless you have a compelling reason not to 1
2. Assess wound tension - if any tension exists, sutures are mandatory 1
3. Assess contamination risk - if contaminated/dirty, use triclosan-coated sutures 1, 3
4. Choose technique:
   • Skin: continuous subcuticular with slowly absorbable monofilament 1
   • Fascia: continuous or interrupted with 4:1 ratio and slowly absorbable material 1
5. Monitor for dehiscence in first 7-10 days regardless of method chosen 1