Put away the Swingline and dust off the sewing kit – staples associated with more post-op wound complications than subcutaneous closure after Cesarean delivery

Being a Family Physician who formerly had C-Section privileges, I welcomed the use of closure with staples. They seemed faster (true), sterile, non-wicking in wound closure, and, I thought, better. Well, at the University of Alabama, Figueroa and others recently performed a randomized study of wound closure by staple versus subcutaneous closure in unplanned C-section deliveries. The primary endpoint was wound disruption or infection by 4 to 6 weeks postpartum. 393 women were randomized to the two closure techniques.  Of note, 99% received intraoperative antibiotics. Women with prior C-sections were included.

Regardless of maternal BMI, women in the staples closure group were more likely to suffer complications (14.5% versus 5.9%, RR = 2.5, P=.008, 95% CI 1.2-5.0). Operative time was longer in the suture closure group by a median time of 58 versus 48 minutes. Pain scores at 72-96 hours and 6 weeks, cosmesis scores, and patient satisfaction scores did not differ. Most of the difference was accounted for by wound disruption (both longer in length and deeper) in the staple group.

Well, I doubt that I will be returning any time soon to the delivery OR, but it will be interesting to see if practices will change as a result of this study. Of additional interest, there is a cost to the added OR time in the suture group, but this might be offset by the added cost of the complications, the staples and staple removal kits, and the time needed to remove the staples. Residents with some experience were allowed to participate and one might think (as I have observed) that they would be handier with a stapler than subcuticular closure. Yet the results stand.

I wonder if these findings would extend to other surgical procedures and would they still stand in the absence of intraoperative antibiotics?

Marshall Kubota, MD

Figueroa D et al., “Surgical staples compared with subcuticular suture for skin closure after cesarean delivery:  A randomized controlled trial.” Obstet Gynecol 2013 Jan; 121:33.

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