Introduction
Today's surgical teams face a critical decision with every closure: which method delivers optimal patient outcomes while balancing speed, infection risk, and cosmetic results?
Traditional metal staples offer undeniable speed advantages (saving approximately 5-7 minutes per closure), but research reveals concerning trade-offs. Studies show infection rates as high as 5.4% in certain procedures, alongside cosmetic complications like "railroad track" scarring.
Emerging bioabsorbable technologies now promise to combine stapler-like speed with superior healing outcomes. Understanding the trade-offs between conventional stapling and newer closure methods helps surgical teams make informed decisions for patient care.
This guide covers material science, clinical applications, infection data, removal protocols, and bioabsorbable alternatives that eliminate metal staples entirely.
TLDR: Key Takeaways
- Closure time drops by 5-7 minutes when using staples versus manual sutures
- Spine surgery infection rates: 5.4% with metal staples vs. 1.4% with absorbable sutures
- Removal required within 5-14 days based on location (face heals faster than trunk)
- Bioabsorbable subcuticular systems like SubQ It! close at stapler speed without removal or visible scars
What Are Surgical Staples?
Surgical staples are specialized medical fasteners designed to rapidly close skin wounds and connect internal tissue structures. The mechanism is straightforward: staple legs penetrate tissue layers and fold into a B-shaped configuration, securing wound edges in precise alignment.
Material composition directly affects performance and patient outcomes. External skin staples typically use stainless steel (316L grade) for strength and cost-effectiveness. Internal staplers prefer titanium and titanium alloys (Ti-6Al-4V) due to superior biocompatibility and reduced immune response. Titanium also produces minimal artifact on MRI and CT imaging—critical for post-operative monitoring.
Historical Development
Surgical stapling technology evolved through several key innovations:
- 1908: Hungarian surgeon Hümér Hültl developed the first stapling prototype for stomach surgery—an 8-pound device requiring two hours to assemble
- 1950s: Soviet scientists refined the technology at Moscow's Scientific Research Institute for Experimental Surgical Apparatus
- 1960s-70s: American surgeons Mark Ravitch and Felicien Steichen commercialized these designs through United States Surgical Corporation (now Covidien/Medtronic) and Ethicon
- Modern era: Disposable cartridge systems replaced reusable devices, making staplers standard in operating rooms worldwide
The original B-shaped staple formation introduced by Hültl remains the standard design, allowing tissue perfusion between staple legs.
Current adoption is widespread but specialty-specific. Gastrointestinal, thoracic, and bariatric procedures rely heavily on metal staplers, while adoption in orthopedics and obstetrics remains debated due to infection and cosmetic concerns. Modern alternatives—including bioabsorbable subcuticular closure systems—address these cosmetic and removal challenges by eliminating percutaneous metal entirely.
Types and Applications of Surgical Staples
Skin Staples for External Closure
Disposable skin staplers close external incisions across multiple surgical specialties. They excel in specific anatomical locations:
- Scalp wounds: Thick tissue tolerates staples well, with removal at 7-10 days
- Orthopedic incisions: Long linear wounds on extremities benefit from rapid closure
- Trunk incisions under moderate tension in abdominal surgery
- Thoracic procedures: Chest wall closures where speed reduces anesthesia time
Speed advantage: Research confirms staples save approximately 5-7 minutes compared to manual sutures, with closure rates of 22.5 cm/min versus 4.2 cm/min for sutures.
Internal Surgical Staplers
Beyond skin closure, internal staplers handle deep tissue work during organ procedures:
- Linear staplers place parallel staple rows for organ resection (lung, liver, bowel), often incorporating cutting blades to divide tissue simultaneously
- Circular staplers create end-to-end connections in colorectal and esophageal surgery by forming complete staple rings
- Hemostatic staplers compress tissue edges and seal blood vessels during application, reducing intraoperative bleeding
Specialty Applications
Laparoscopic staplers feature articulating mechanisms for minimally invasive procedures. In bariatric surgery—including gastric bypass and sleeve gastrectomy—proper staple height selection prevents leaks at connection points.
Guidelines emphasize matching cartridge color to tissue thickness to avoid tissue damage from overly tight staples or inadequate closure from loose application.
Advantages of Surgical Staples Over Sutures
Operating room efficiency improves measurably with staples. Meta-analysis data shows mean closure time differences of 5.84 minutes favoring staples in orthopedic procedures.
This translates to reduced anesthesia exposure and increased surgical throughput.
Beyond speed, stapling techniques offer distinct clinical advantages:
- Reduced tissue handling: Mechanical stapling minimizes the number of times surgeons manipulate wound edges compared to multiple needle passes required for suturing, reducing tissue trauma and cellular damage at the incision site
- Consistent tension distribution: Mechanical deployment provides uniform compression across all staple points, whereas hand-tied sutures introduce variability based on surgeon technique, fatigue, and individual knot-tying tension
- Simplified training: Standardized stapling devices require less technical skill development than mastering various suturing techniques and knot-tying methods
Limitations and Risks of Surgical Staples
While metal staples offer speed advantages, clinical evidence reveals several limitations that impact patient outcomes and healthcare costs.
Infection risk varies significantly by procedure type. A comprehensive systematic review of 42 randomized controlled trials involving 11,067 patients found overall wound infection rates of 6.75% with staples versus 4.90% with sutures—a risk ratio of 1.20.
The difference is more pronounced in high-risk surgical contexts:
- Posterior lumbar spine surgery shows deep surgical site infection rates of 5.4% with metal staples compared to 1.4% with absorbable sutures—a nearly fourfold increase
- Orthopedic and spinal procedures demonstrate the highest differential infection risk
- Contaminated or high-tension closures amplify staple-associated complications
Cosmetic outcomes consistently favor suture-based closures. Staples create characteristic "railroad track" scarring—cross-hatching marks left by staple legs, particularly when left in place too long or placed under tension.
Cesarean section studies demonstrate significantly better patient and observer scar assessment scores with subcuticular sutures versus staples. This cosmetic disadvantage matters most in visible areas and procedures where patient satisfaction depends heavily on aesthetic results.
Removal requirements create downstream costs and patient discomfort. Follow-up appointments for staple extraction add healthcare system expenses while causing patient anxiety. The removal process, though brief, produces a pinching sensation that patients find uncomfortable.
Alternatives to Traditional Surgical Staples
Absorbable Subcuticular Sutures
Running subcuticular suture techniques using materials like poliglecaprone 25 (Monocryl) or polyglycolic acid (Vicryl) offer superior outcomes in specific contexts.
These polymers provide tensile strength during critical healing phases and are absorbed naturally by the body, eliminating removal procedures.
Meta-analysis of cesarean sections involving 3,112 patients showed wound complications occurred 51% less frequently with sutures compared to staples, with 71% lower risk of wound separation.
Bioabsorbable Subcuticular Closure Systems
For surgeons seeking stapler-speed deployment without metal staples, bioabsorbable subcuticular systems offer an alternative approach.
SubQ It! uses bioabsorbable dermal fasteners made from PLGA (polylactic-co-glycolic acid) inserted subcutaneously via retractable surgical needles. The system combines the efficiency of staplers with the cosmetic benefits of subcuticular closure.
Key differentiators:
- External skin is never pierced—fasteners deploy entirely beneath the dermis
- Maintains 80% strength for 21 days before natural absorption
- Eliminates removal procedures and associated costs
- FDA-cleared for abdominal, thoracic, gynecologic, orthopedic, and plastic surgery
- Available in SU-10 (10 fasteners, up to 10 cm) and SU-25 (25 fasteners, up to 25 cm) models
The subcutaneous placement eliminates "train track" scarring while matching stapler deployment speed—approximately 7 seconds per fastener.
Tissue Adhesives and Surgical Glues
Cyanoacrylate-based adhesives provide needle-free closure for low-tension superficial wounds. These are particularly useful in pediatric facial lacerations where avoiding injection pain is valuable.
Limitations are significant:
- Not suitable for high-tension areas or wounds requiring layered closure
- Contraindicated on mucosal surfaces, infected wounds, and joints (unless immobilized)
- Comparable cosmetic outcomes to sutures only in short-term follow-up (<1 month)
Best Practices for Staple Application
Patient Selection Criteria
Successful staple closure begins with identifying appropriate candidates. Evaluate these factors before proceeding:
- Adequate skin thickness (thin, fragile skin may tear during application)
- Low-to-moderate wound tension (high tension increases wound separation risk)
- No active infection or significant contamination
- Appropriate anatomical location (avoid cosmetically sensitive areas)
- No history of keloid formation or hypertrophic scarring
Bioabsorbable stapling systems offer advantages over traditional metal staples for patients requiring post-operative imaging, as they eliminate MRI artifacts and the need for removal appointments.
Application Technique Essentials
Proper staple placement directly impacts healing outcomes and cosmetic results. Follow these critical steps:
Wound edge preparation:
- Evert wound edges using forceps or manual manipulation before firing
- Position edges to turn outward, not inward (inversion compromises healing)
- Ensure dermis-to-dermis contact for optimal tissue apposition
Stapler positioning:
- Hold device perpendicular to skin surface
- Align center mark with wound midline
- Maintain consistent angle throughout closure
Spacing and closure:
- Place fasteners 5-10 mm apart for adequate approximation
- Allow sufficient spacing for drainage and swelling
- Fire device smoothly without hesitation
For subcuticular bioabsorbable systems like SubQ It!, the external skin surface remains unpierced, reducing scarring and eliminating removal-related discomfort.
Clinical Contraindications
Avoid staple closure in these situations:
- High-precision cosmetic areas (face, neck, hands, anterior chest)
- Wounds under excessive tension or crossing major joints
- Areas with compromised tissue quality or blood supply
- Patients with documented allergies to device materials
Bioabsorbable stapling systems expand the range of suitable applications compared to metal alternatives, particularly for patients concerned about scarring or those unable to return for staple removal.
Staple Removal Process and Timeline
Traditional metal staples require timely removal to prevent embedding and minimize scarring. Understanding these timelines helps illustrate why bioabsorbable alternatives have gained traction in modern surgical practice.
Authoritative guidelines recommend these removal schedules for conventional metal staples:
| Body Location | Removal Timeline | Rationale |
|---|---|---|
| Face | 3-5 days | Minimize scarring; rarely used here |
| Scalp | 7-10 days | Thick tissue; good blood supply |
| Neck | 5-7 days | Balance healing with cosmetic concerns |
| Trunk/Upper Extremities | 7-10 days | Standard healing timeline |
| Lower Extremities | 8-14 days | Slower healing; higher tension |
The removal procedure requires a follow-up visit and specialized tools:
- Staple remover deforms metal into M-shape to disengage from tissue
- Patients typically experience brief pinching sensations
- Anxiety about removal often exceeds actual discomfort
- Requires scheduling, travel, and clinical time for patients
Eliminating the removal step entirely: Bioabsorbable closure systems like SubQ It! address these concerns by placing fasteners subcutaneously where they're absorbed naturally during healing. This eliminates removal appointments, patient discomfort, and the risk of premature or delayed staple extraction that can compromise wound healing.
Frequently Asked Questions
How long do staples for skin closure need to stay in?
Removal timing depends on wound location and healing factors. Face and neck staples come out in 5-7 days, trunk and upper extremities in 7-10 days, and lower extremities in 8-14 days depending on tension and healing progress.
Is it painful to have skin staples removed?
Most patients report brief pinching sensations during removal, with pain scores typically under 3/10. The procedure takes only seconds per staple.
What are the main advantages of using staples instead of sutures?
Staples save 5-7 minutes of operating room time, reduce tissue handling through fewer passes, and provide consistent mechanical tension across the wound compared to variable hand-tied suture tension.
Can surgical staples cause infections?
Yes, infection risk varies by procedure type. Overall rates show 6.75% with staples versus 4.90% with sutures, with higher disparities in specific contexts like spine surgery where staples show 5.4% infection rates compared to 1.4% for absorbable sutures.
Are surgical staples safe for MRI scans?
Titanium staples are MRI-safe with minimal artifact, making them suitable for patients requiring post-operative imaging. Stainless steel staples may cause significant imaging interference and are sometimes contraindicated when immediate MRI is needed.
What are the alternatives to traditional metal staples?
Absorbable subcuticular sutures (Monocryl, Vicryl), bioabsorbable fastener systems like SubQ It! that combine stapler speed with no removal required, and tissue adhesives for low-tension wounds.
