Outpatient Surgery Magazine

With so many skin-closure options to choose from, how do you decide which to stock? To help you make sound purchasing decisions, we asked surgeons and administrators to walk us through how they choose among plain gut sutures, synthetic sutures, adhesive strips, staples, tissue adhesive glue and skin clips. As you'll see, you must consider a wide array of factors, from the incision type and operative site to the patient's safety and cosmetic needs to ease of application, physician preference, prevention of wound complications and affordability.

Some of this, that and the other
The first thing to keep in mind is that you'll likely need to stock some of each skin-closure option. "Each has situations that make it the most or the least desirable," says Mary Wilson, RN, BSN, CNOR, a clinical preceptor at West Virginia University Hospitals in Morgantown. "The effectiveness of the closure depends upon the specifics of the procedure such as location, patient age and type of surgery." Says a hospital surgical services director, "The surgeon makes his choice of what to use. If he requests something we don't have or haven't used before and it's considered essential for a good surgical outcome, we'll have it available for the surgery."

The second thing to consider is that wound-closure preferences vary from facility to facility. "They're all effective — it depends on what layer of tissue you're trying to close," says Michael S. Fitzgerald, RN, BA, clinical manager of surgical services at Holy Family Medical Center in Des Plaines, Ill. See "What's Your Preferred Method of Skin Closure?" on page 57 for a sampling of the responses we received when we asked our readers which skin-closure options are most and least effective.

The site of the incision
To a large extent, the type of case determines what you'll use to close the wound. "It depends on the area of closure," says an Iowa hospital OR supervisor. "If the surgeon does a good job of selecting the area, most options work well if correct application and selection has taken place."

"The thing about wound closure is that it's not necessarily the technique or the tools you use, but a combination of cleanliness of the wound, where it is and if you did a good job of bringing the layers together," says Andrew Schneider, MD, a plastic surgeon with Forsyth Plastic Surgical in Winston-Salem, N.C. "Anything we plastic surgeons can do that doesn't leave noticeable marks on the skin is real invaluable."

Look at how much tension the patient's skin around the surgical site will put on the wound, says Dr. Schneider. "For an eyelid it's almost nothing, but for a large wound, such as around a knee or stomach, the tension is significant. The larger the wound, the larger the suture you choose needs to be," he says. For a patient's eyelid, he recommends using a fine nylon non-absorbable suture, while a procedure on a tendon would call for a large non-absorbable suture.

It's also important to consider how much the skin moves around the surgical site, says John Rachel, MD, a plastic surgeon with Metropolitan MD in Chicago. "Certain areas heal better than others, and a wound around the eye or face will heal better than something on the patient's back or knee," he says. "Those wounds around a joint may get pushed or pulled, which can stretch them out."

Patients want to see the smallest scar possible, says Mr. Fitzgerald. "If the patient is not happy, then the physician will hear about it, and we as staff and managers in the operating room will hear about it from the physicians," he says. "We don't need to have sutures or similar products be an issue."

Keeping costs and inventory in check
Facility administrators like Lynda Simon, RN, manager of St. John's Clinic: Head & Neck Surgery in Springfield, Mo., are always working to keep enough of the appropriate sutures and other wound-closure options in stock without ordering too many. She keeps two boxes of the most popular options — one opened, the other closed. "When the spare box is opened, we order a new box," she says.

Since there will be occasions when a physician wants a specific item that you'll seldom use, Ms. Simon says it's important to find a way to fill special orders. "You should have a partnership with a hospital, another surgery center or your sales reps to get the items you'll only need once a year so you can order just one item instead of the whole box," she says.

Are staples the new standard?
Although sutures may be the first thing most people think of when wound closure is mentioned, staples are becoming much more popular in the outpatient setting. "Unless you're talking to somebody who's doing a plastic surgery closure, staples are the standard of care," says Mr. Fitzgerald.

That might be because stapler systems are easy to use. "You can simply open the package and start using them," says Matt Cooper, RN, CNOR, RNFA, nurse manger of surgery and central sterile at Covenant Medical Center in Waterloo, Iowa. "You don't have to have a specific needle holder and load them for right- or left-handed people. You also don't have to fight the needle through the correct tissue plains like you would with a subcuticular stitch."

The time frame for using synthetic sutures varies from physician to physician and by the size of the incision, says Mr. Cooper, while staples eliminate some of these problems. "I would estimate that it takes twice as long to suture as it does to put in staples, on average," he says.

Using a subcutaneous stapler can also be significantly quicker than using interrupted deep sutures, says Dr. Schneider. "It can shave 30 minutes to an hour off skin closure times when you're talking about a large wound, such as an abdominoplasty," he says. "I've had very good results with it, and I think the scars and final results are equivalent to any other technique out there."

Another benefit, says Mr. Fitzgerald, is that the staples barely leave a mark. "If you don't keep the staples in for too long by removing them after five to seven days, they tend not to leave any real scars behind," he says. "You may have little holes, but those tend to disappear quickly whereas sutures will leave ???railroad tracks.'" He says this could be caused by the way sutures stretch the patient's skin around the holes, while the staples simply hold it in place.

This is not to say that using staples is the ideal option. At Riverside Medical Center in Waupaca, Wis., Chief of Surgery Gary Edelman, MD, says he has heard many complaints from patients who experienced pain from these devices.

The sticky solutions
Adhesive strips have their advantages, says Mr. Fitzgerald, but if a physician is taking the time to make a subcuticular closure, he may prefer using surgical glue. "Adhesive strips hold the tissues together when used in conjunction with something else," he says. "Glue covers the wound's area, which can reduce the risk for infection."

As the benefits of glues become better understood, Dr. Rachel says they're becoming more popular. "In the beginning, when glues first became available, we thought they would replace stitches, but that hasn't happened," he says. "Instead, using glue in combination with a subcuticular stitch lets us eliminate the running stitch, and it could be very effective at closing a wound if the deeper layers are treated appropriately." By placing subcutaneous sutures under a layer of glue, Mr. Fitzgerald says a physician can create a solid seal that barely leaves a scar.

But in practice, some facilities have found glue difficult to use. "We used glue on a few plastic surgery cases, and the process of mixing the adhesive was lengthy and had too many steps," says Laura Langan, RN, the vice president of patient care services at Wayne (N.J.) Surgical Center. "The application was messy, and surgeons did not like the suture line when the healing was complete." However, she says one bonding agent proved to be an exception in this situation. One of her surgeons uses it exclusively because it's so easy to apply.

The high price of surgical glues can also pose a problem for your case costs, particularly for patients who are paying for their own care and for surgeons who use glue for everything, says Ms. Simon. "We had one surgeon who would ask for a vial [of an expensive adhesive] whenever he got a paper cut, and we couldn't allow that," she says, "so we started locking it up with the narcotic agents. A surgeon now has to ask for the key and tell us why he needs it."

New ways of closing wounds
While staples and adhesives continue to gain in popularity, manufacturers are working on newer skin-closure options. "The products may not be perfect now, but there have been large advances in the past five to 10 years, and as research and development continues there will be very nice options for surgeons that will keep patients happy and allow us to close wounds more efficiently than we currently can," says Dr. Rachel.

One relatively new type of suture that both Dr. Schneider and Dr. Rachel say they're interested in are the self-retaining systems, or barbed sutures. These have hook-like barbs to hold the patient's skin in place without knots, which Dr. Rachel says helps to distribute the tension and reduce pressure on the wound.

Skin clips are another recent addition to the market, but Dr. Rachel says the usefulness of these is generally limited to the scalp and hairline. "It's an effective way to reduce closure time because you can close a large area for scalp reduction quickly and also decrease the risk of alopecia since there's no strangulation of hair follicles," he says. "The clip can be an upper-closure used for the top part of the skin, but not the deeper tissues. If a clip is used alone to close a wound with no deeper sutures, the tension can be significant."

Whatever advances are made in skin closure, Dr. Schneider says they'll still have to meet the same criteria as the existing options. "The tried-and-true techniques really haven't changed much," says Dr. Schneider. "The major principles and the need to approximate skin will always be there. The newer techniques are just ways of achieving that."

What's Your Preferred Method of Skin Closure?

By the Numbers, Your Preference to Close

Which of these skin-closure options are in use at your facility?*

Adhesive strips

92.6%

Synthetic sutures

88.9%

Tissue adhesive glue

85.2%

Staples

81.5%

Plain gut sutures

66.7%

Skin clips

37.0%

Zippers

0.0%

SOURCE: Outpatient Surgery Magazine Reader Survey, August 2008, n=28
* Respondents were prompted to check all skin-closure options that applied.

• The manager of a Milwaukee ASC rates suture as the most effective way to close a wound, skin staples as the fastest and skin glue as the most expensive.
• Laura Langan, RN, the vice president of patient care services at Wayne (N.J.) Surgical Center, favors staples for their ease of use and clean lines, but considers glue to be difficult both to apply and remove.
• Matt Cooper, RN, CNOR, RNFA, nurse manger of surgery and central sterile at Covenant Medical Center in Waterloo, Iowa, says staples are most convenient. Using synthetic sutures, he says, takes more time.
• Use suture for incisions larger than 0.5cm and use closure strips for incisions 0.5cm or less, says a physician assistant at an ASC in Boise, Idaho. Using glue makes it difficult to get wound edges to line up, but the wounds do heal pretty well, he adds.
• Tissue adhesive glue is the most effective option "because it protects the incision from moisture such as sweat and water," says Mandi Strode, RN, the clinical lead at LeBonheur East Surgery Center in Memphis, Tenn., specializing exclusively in kids. Adhesive strips, she says, are less effective "because they easily come off when the skin becomes moist."
• Some synthetic absorbable sutures "tend to spit or cause suture abscesses, especially if placed superficially," says Lawrence E. Ruf, MD, a plastic surgeon from Savannah, Ga.
• "Staples work very well on the skin and tend to leave a better scar if utilized correctly. The holes left behind seem to disappear better than heavy nylon suture," says Michael Fitzgerald, RN, BA, clinical manager of surgical services at Holy Family Medical Center in Des Plaines, Ill.
• The clinical projects manager at a Washington state hospital says that subcutaneous absorbable sutures with adhesive strips provide good approximation until the skin closes, but that plain gut gets absorbed too quickly.
• Synthetic sutures provide cosmetic closure with little pain, says Gary Edelman, MD, FACS, chief of surgery at Theda Care Physicians in Waupaca, Wisc. He says many patients complain of pain from staples, and adhesive strips can cause tape burns if cut too long.
• "Occasionally, if the patient is not careful, skin glue will pull apart but we always have subcutaneous sutures," says a hospital OR manager. "I've seen skin sutures pull out if adequate sub-Q sutures have not been used."
• Synthetic sutures hold together well after procedures while tissue adhesive glue doesn't hold together well where movement is involved, says a clinical manager at an ASC in Tyler, Texas.
• Adhesive strips are most cost effective, and tissue glue takes too long to dry and is very expensive, says Martha Andres, BSRN, director of nursing at Advanced Fertility Care in Scottsdale, Ariz.