Background: Skin approximation is a very important step in a surgical operation. The quality of skin approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications. Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation). The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation) had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction. Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.

1. SURGERY | ORIGINAL RESEARCH
COMPARISON BETWEEN SUTURING AND STAPLE
APPROXIMATION OF SKIN IN ABDOMINAL INCISIONS.
(STUDY OF 150 CASES)
Ketan Vagholkar∗,1, Shantanu Chandrashekhar∗ and Suvarna Vagholkar∗
∗Department of Surgery, D.Y.Patil University school of Medicine, Navi Mumbai-400706. MS. India
ABSTRACT Background: Skin approximation is a very important step in a surgical operation. The quality of skin
approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complica-
tions. Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare
traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound
complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients
are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation).
The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation)
had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction.
Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.
KEYWORDS Skin suturing, stapling, complications, scarring
Introduction
Suturing with sutures has withstood the test of time. A vari-
ety of suture materials have been used with variable results.
Braided suture materials were replaced with monofilament ma-
terial leading to improvement in surgical outcomes. However,
surgical site infections continue to be the main problem. The
advent of staples has revolutionized skin closure. Staples enable
approximation without penetration of the skin. It is, therefore,
necessary to evaluate the superiority of staples over traditional
suturing techniques. [1]
Aim
To compare the surgical outcomes in suture approximated skin
closure versus staple approximation in abdominal surgical inci-
Copyright © 2021 by the Bulgarian Association of Young Surgeons
DOI:10.5455/IJMRCR.suturing-and-staple-approximation-skin-abdominal-incisions
First Received: January 19, 2021
Accepted: February 18, 2021
Associate Editor: Ivan Inkov (BG);
1
Department of Surgery, D.Y.Patil University school of Medicine, Navi Mumbai-400706.
MS. India, Email: kvagholkar@yahoo.com
sions.
Objectives
1. To compare duration of closure required for suture and
staple closure.
2. To compare the effects on wound healing concerning surgi-
cal site infections, pain, and scarring.
3. To compare patient satisfaction concerning cosmetic out-
come between the two techniques.
Inclusion criteria
All patients undergoing elective abdominal surgical procedures.
Exclusion criteria
Patients undergoing redo surgery
Patients with comorbidities
Patients with age less than 18 years
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):31-36

2. Materials and methods
One hundred fifty consecutive patients undergoing elective ab-
dominal surgical procedures, in a single surgical unit, of a ter-
tiary care hospital, over one year from January 2018 to December
2018, were included in the study. The study protocol was ap-
proved by the institutional ethics committee prior to commenc-
ing the study. Written informed consent was obtained before the
surgical procedure. Patients were randomised into two groups.
Randomisation was done by picking up a draw at the time of ob-
taining consent for surgery. A detailed proforma was completed,
which included demographic data and indications for surgery.
Group A constituted the control group who underwent skin
closure by suture technique, and group B underwent approxi-
mation of skin by staples. Skin suturing was done by vertical
mattress sutures with 2-0 ethilon. Skins staples were applied
after accurate approximation and eversion of the skin edges.
Check-dressing was done after 48 hours. Both suture and staple
removal was done on the 10th postoperative day. Results were
tabulated and analysed statistically using SPSS software.
Results
There were 75 patients in group A who underwent suture closure
and 75 patients in group B who underwent staple closure.
There were 30 females in group A and 29 females in group B
whereas there were 45 males in group A and 46 males in group
B. (Table 1)
The mean age of patients in group A was 48.29±11.72 years
and the mean age of patients in group B was 46.29±11.49 years.
(Table 2)
The mean time required for closure in group A was
422.75±129.12 seconds whereas the mean time required for clo-
sure in group B was 68.03±23.90 seconds. (Table 2) All four
types of surgical wounds were included in the study. Sixty-
four were clean surgical wounds, out of which sutures and 25
approximated 39 by staples. Fifty-eight patients were clean-
contaminated surgical wounds, out of which 24 were approxi-
mated with sutures and 34 with staples. Twenty-seven patients
were contaminated surgical wounds, with 12 patients approxi-
mated by sutures and 15 patients by staples. One patient had a
dirty wound who underwent staple approximation. (Table 3)
Eighteen patients developed wound complications. All 18
patients belonged to group A. Six patients had redness in the
wound during the first check-dressing. Six patients developed a
discharge, and six patients developed dehiscence. (Table 4)
Thirty-five patients in group B had no pain, 20 patients had
mild pain, whereas 75 patients in group A had moderate pain.
(Table 5)
The duration of hospital stay in group A was 4.80±0.89 days,
whereas the hospital stays in group B was 3.21±0.79 days. (Table
2)
Wounds healed with a fine scar in 67 patients in group B and
39 patients in group A, whereas eight patients in group B and 28
patients in group A had an average scar. A poor scar was seen
in 9 patients belonging to group A. (Table 6)
Patient satisfaction was good in 61 patients of group B and
16 patients in group A whereas it was average in 14 patients in
group B and 25 patients in group A. Poor satisfaction was seen
in 34 patients from group A. (Table 7)
Discussion
Conventional skin suturing has certain inherent disadvantages.
The needle has to pass through the intact skin on either of the
wound edges. In case of mattress suturing, four such punctures
have to be made. During suturing, the epidermis and dermis
are breached. Commensal organisms in the skin are carried
along the track into the wound’s depths, thereby causing an
increased chance of wound infection.[1,2] Wound infection in-
variably starts in the subcutaneous tissues, thereby giving rise
to localised infection signs. This may be redness, oedema, dis-
charge and finally, wound breakdown. Braided suture materials
such as silk have a higher chance of causing infection due to the
wick effect. Excessive tension on the wound edges also threat-
ens the blood supply, thereby increasing the chances of wound
infection. Once infection sets in, the chances of a bad scar are
extremely high, leading to a poor cosmetic outcome. Skin sta-
ples is an innovative method for approximating the skin. [2] The
material is inert, causing the least tissue reaction. As there is no
skin penetration, the chances of wound infection are reduced
considerably, thereby giving rise to a fine scar.
In the present study, group A patients underwent skin ap-
proximation by suturing, whereas group B staples were used.
The mean age of patients in group A was 48.29 years and 46.29
years in group B. Staples can be used safely in all age groups,
especially for closure of laparotomy wounds. [2]
Thirty females in group A were sutured, and 29 females in
whom skin were approximated with staples. In contrast, there
were 45 males in group A, and 46 males in group B. Cosmesis
is a very important criteria for judging the outcome of skin
closure irrespective of the sex of the patient. [3] The surgeon
has to ensure that the cosmetic outcome is the best. This can be
achieved by taking all necessary precautions to prevent infection,
followed by an accurate approximation of the skin edges.
Closure of the laparotomy wound is a very important fac-
tor in deciding the surgical outcome. If the surgery duration
is prolonged, then there is a high possibility of a breach in the
aseptic technique of closure, thereby leading to a higher inci-
dence of complications. [4] Approximating the skin with the
traditional suturing technique increases the time duration re-
quired for the skin closure. This may also lead to a breach in
the aseptic technique due to fatigue. Staple approximation is a
very good alternative. In the present study, the mean duration of
closure with staples was 68.03 seconds than 422.75 seconds for
suturing techniques. It was also observed that the incidence of
complication in group B patients was nil as compared to group
A patients. Limiting the time for closure also helps in reduc-
ing the anaesthesia time, which may positively impact surgical
outcomes. [4]
Staples can be used for all surgical wounds; clean, clean-
contaminated, contaminated and dirty. [5] Staples confer a dis-
tinct advantage of not penetrating the epidermis and thereby
reducing the chances of surgical site infections. In the present
study, none of the patients across all four categories of surgi-
cal wounds developed complications in group B, whereas 18
patients in group A developed would complications which in-
cluded redness, discharge and even dehiscence. This was found
to be statistically significant. (p<0.05) Therefore staples should
be safely used in all types of surgical wounds
Pain is a common accompaniment of a surgical procedure.
Many times post-operative pain may be related to the method
used for approximating the skin. [5, 6] Suturing involves cre-
ation of multiple punctures and increased tension during ap-
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):31-36

3. Table 1 Comparison of the study groups based on gender
Gender Group Total
Staples (B) Suture (A)
Female 29 30 59
38.7% 40.0% 39.3%
Male 46 45 91
61.3% 60.0% 60.7%
Total 75 75 150
100.0% 100.0% 100.0%
P value = 1.0
Gender distribution was comparable in both groups, with male predominance was seen in
both groups (60.7% vs 39.3%; p-1.0)
Table 2 Mean comparison of the study groups based on age, time of closure and hospital stay
Variables Group N Mean SD p- value
Age (years) Staples (B) 75 46.29 11.49 0.293
Suture (A) 75 48.29 11.72
Time for
Closure (sec)
Staples (B) 75 68.03 23.90 <0.01
Suture (A) 75 422.75 129.12
Hospital Stay
(Days)
Staples (B) 75 3.21 0.79 <0.01
Suture (A) 75 4.80 0.89
The mean age of subjects in the staple and suture group was 46.29 and 48.29 years,
respectively (p-0.293). Time for closure was significantly less in the staple group
than the suture group (68.03 vs 422.75 sec; p<0.01). Mean hospital stay was also
shorter in patients of staple group (3.21 vs 4.80 days; p<0.01).
Table 3 Comparison of the study groups based on the type of wound
Type of wound Group Total
Staples (B) Suture (A)
Clean 25 39 64
33.3% 52.0% 42.7%
Clean and
Contaminated
34 24 58
45.3% 32.0% 38.7%
Contaminated 15 12 27
20.0% 16.0% 18.0%
Dirty 1 0 1
1.3% 0.0% 0.7%
Total 75 75 150
100.0% 100.0% 100.0%
P value = 0.106
In most of the cases of both groups, the clean or clean and contaminated wound was
achieved. No difference was observed between both groups concerning the type of wound
achieved (p-0.106)
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):31-36

4. Table 4 Comparison of the study groups based on Condition of wound
Condition of Wound Group Total p-value
Staples (B) Suture (A)
Redness 0 6 6 0.028
0.00% 8.00% 4.00%
Discharge 0 6 6 0.028
0.00% 8.00% 4.00%
Dehiscence 0 6 6 0.028
0.00% 8.00% 4.00%
In most of the cases of both groups, the clean or clean and contaminated wound was
achieved. No difference was observed between both groups concerning the type of wound
achieved (p-0.106)
Table 5 Comparison of the study groups based on post-operative pain
Post-op pain (VAS) Group Total
Staples (B) Suture (A)
No Pain 55 0 55
73.3% 0.0% 36.7%
Mild 20 0 20
26.7% 0.0% 13.3%
Moderate 0 75 75
0.0% 100.0% 50.0%
Total 75 75 150
100.0% 100.0% 100.0%
P value < 0.01
Most of the cases of staple group felt no pain (73.3%) or mild pain after the skin wound
closure as compared to moderate pain felt by all the subjects of suture group (p<0.05).
Table 6 Comparison of the study groups based on the appearance of scar
Appearance of Scar Group Total
Staples (B) Suture (A)
Good 67 39 106
89.3% 52.0% 70.7%
Average 8 28 36
10.7% 37.3% 24.0%
Poor 0 8 8
0.0% 10.7% 5.3%
Total 75 75 150
100.0% 100.0% 100.0%
P value < 0.01
The cosmetic appearance of the scar was subjectively assessed as good in 89.3% patients of
staple group as compared to 52% in suture group while poor appearance reported in 10.7%
cases of suture group compared to none in staple group (p<0.01).
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):31-36

5. Table 7 Comparison of the study groups based on patient satisfaction
Patient’s Satisfaction Group Total
Staples (B) Suture (A)
Good 61 16 77
81.3% 21.3% 51.3%
Average 14 25 39
18.7% 33.3% 26.0%
Poor 0 34 34
0.0% 45.3% 22.7%
Total 75 75 150
100.0% 100.0% 100.0%
P value < 0.01
Patient satisfaction was reported as good by 81.3% of the staple group as compared to 21.3%
in suture group while 45.3% cases of suture group reported poor satisfaction compared to
none in staple group (p<0.01).
proximation causing more pain. In the present study, group
A patients experienced more pain as compared to group B pa-
tients, which was found to be statistically significant, thereby
conferring added advantage to the staple technique (p<0.05).
In the present study, 67 patients in group B had an excellent
hairline scar compared to 39 patients in group A who had a
good scar.[7,8] Multiple puncture marks of suturing lead to an
unsatisfying scar. As skin staples only approximated the skin,
this limits the scar to a single line making it more satisfying to
the patient. [9, 10, 11]
Duration of hospital stay is significantly reduced by the use
of staples for skin approximation. [12] In the present study,
the mean duration of hospital stay in group B was 3.21 days,
whereas group A was 4.8 days. A shorter duration of stay is
attributable to fewer wound complications as compared to the
suture techniques.[13] Complications such as redness, discharge,
or dehiscence have to be managed during a stay in hospital,
causing a prolonged stay. The overall level of satisfaction is
very good with staple approximation as compared to suture
approximation.[14,15] This is by virtue of less pain, least wound
complications and an excellent scar. Sixty-one patients in group
B expressed good satisfaction compared to only 16 patients in
group A which was a significant observation. Limitations of
the study were small sample size, exclusion of paediatric group
patients as well as emergency surgical operations. The strength
of the study was proving the distinct advantage of staple ap-
proximation of the skin in abdominal surgery.
Conclusion
Staple approximation of the skin has distinct advantages over
suture approximation. Shorter operating time, lesser pain, very
few wound complications and excellent surgical outcomes by
way of a fine scar leading to better patient satisfaction render a
staple approximation of the skin the most recommended closure
method.
Funding
This study received no fund
Conflict of interest
The authors declared that this project was done independently
without any conflict of interest.
References
1. Pickford IR, Brennan SS, Evans M, Pollock AV. Two meth-
ods of skin closure in abdominal operations: a controlled
clinical trial. Br J Surg. 1983 Apr; 70(4):226-8. doi:
10.1002/bjs.1800700414. PMID: 6338996.
2. Cochetti G, Abraha I, Randolph J, Montedori A, Boni A,
Arezzo A, Mazza E, Rossi De Vermandois JA, Cirocchi R,
Mearini E. Surgical wound closure by staples or sutures?:
Systematic review. Medicine (Baltimore). 2020 Jun 19;
99(25):e20573. doi: 10.1097/MD.0000000000020573. PMID:
32569183; PMCID: PMC7310845.
3. Krishnan RJ, Crawford EJ, Syed I, Kim P, Rampersaud
YR, Martin J. Is the Risk of Infection Lower with Su-
tures than with Staples for Skin Closure After Orthopaedic
Surgery? A Meta-analysis of Randomized Trials. Clin
Orthop Relat Res. 2019 May; 477(5):922-937. doi:
10.1097/CORR.0000000000000690. PMID: 30958392; PM-
CID: PMC6494321.
4. Stillman RM, Bella FJ, Seligman SJ. Skin wound closure.
The effect of various wound closure methods on suscepti-
bility to infection. Arch Surg. 1980 May; 115(5):674-5. doi:
10.1001/archsurg.1980.01380050094024. PMID: 6246851.
5. Stillman RM, Bella FJ, Seligman SJ. Skin wound closure.
The effect of various wound closure methods on suscepti-
bility to infection. Arch Surg. 1980 May; 115(5):674-5. doi:
10.1001/archsurg.1980.01380050094024. PMID: 6246851.
6. Stillman RM, Bella FJ, Seligman SJ. Skin wound closure.
The effect of various wound closure methods on suscepti-
bility to infection. Arch Surg. 1980 May; 115(5):674-5. doi:
10.1001/archsurg.1980.01380050094024. PMID: 6246851.
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):31-36

6. 7. Shetty AA, Kumar VS, Morgan-Hough C, Georgeu GA,
James KD, Nicholl JE. Comparing wound complication
rates following closure of hip wounds with metallic skin sta-
ples or subcuticular vicryl suture: a prospective randomised
trial. J Orthop Surg (Hong Kong). 2004 Dec; 12(2):191-3.
doi: 10.1177/230949900401200210. PMID: 15621905.
8. Shetty AA, Kumar VS, Morgan-Hough C, Georgeu GA,
James KD, Nicholl JE. Comparing wound complication
rates following closure of hip wounds with metallic skin sta-
ples or subcuticular vicryl suture: a prospective randomised
trial. J Orthop Surg (Hong Kong). 2004 Dec; 12(2):191-3.
doi: 10.1177/230949900401200210. PMID: 15621905.
9. Shetty AA, Kumar VS, Morgan-Hough C, Georgeu GA,
James KD, Nicholl JE. Comparing wound complication
rates following closure of hip wounds with metallic skin sta-
ples or subcuticular vicryl suture: a prospective randomised
trial. J Orthop Surg (Hong Kong). 2004 Dec; 12(2):191-3.
doi: 10.1177/230949900401200210. PMID: 15621905.
10. Krishnan R, MacNeil SD, Malvankar-Mehta MS. Compar-
ing sutures versus staples for skin closure after orthopaedic
surgery: systematic review and meta-analysis. BMJ Open.
2016 Jan 20; 6(1):e009257. doi: 10.1136/bmjopen-2015-
009257. PMID: 26792213; PMCID: PMC4735308.
11. Stockley I, Elson RA. Skin closure using staples and nylon
sutures: a comparison of results. Ann R Coll Surg Engl. 1987
Mar; 69(2):76-8. PMID: 3566131; PMCID: PMC2498348.
12. Stockley I, Elson RA. Skin closure using staples and nylon
sutures: a comparison of results. Ann R Coll Surg Engl. 1987
Mar; 69(2):76-8. PMID: 3566131; PMCID: PMC2498348.
13. Hlubek R, Walder P, Káňa J, Salounová D. Použití kovových
klipů při sutuře kůže u totální endoprotézy kolene [Metal
staples versus conventional suture for wound closure in
total knee arthroplasty]. Acta Chir Orthop Traumatol Cech.
2014; 81(3):233-7. Czech. PMID: 24945393.
14. Selvadurai D, Wildin C, Treharne G, Choksy SA, Heywood
MM, Nicholson ML. Randomised trial of subcuticular su-
ture versus metal clips for wound closure after thyroid
and parathyroid surgery. Ann R Coll Surg Engl. 1997 Jul;
79(4):303-6. PMID: 9244079; PMCID: PMC2502834.
15. Gatt D, Quick CR, Owen-Smith MS. Staples for wound
closure: a controlled trial. Ann R Coll Surg Engl. 1985 Sep;
67(5):318-20. PMID: 3901864; PMCID: PMC2499561.
Ketan Vagholkar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):31-36