Introduction
The choice between subcuticular sutures and surgical staples in gastrointestinal surgery directly affects surgical efficiency, patient outcomes, cosmetic results, and total healthcare costs. In GI procedures where wounds are often classified as clean-contaminated (Class II), this decision carries significant weight.
Wound complications rank among the most common surgical morbidities, with patients experiencing surgical site infections facing a 2.2 times higher risk of death compared to those without infections.
With staples currently used in 79% of abdominal skin closures, understanding the comparative benefits and limitations of each method is essential for surgical teams and healthcare administrators. Both clinical outcomes and operational efficiency depend on making the right closure choice.
TL;DR
- Superior cosmetic results and patient comfort: subcuticular sutures eliminate removal procedures
- 5-8 minutes faster closure with staples, but follow-up removal visits required
- Infection rates show no significant difference between methods
- Sutures prove more cost-effective when factoring in removal visit expenses
- Bioabsorbable subcuticular closure systems now deliver staple speed with suture-quality cosmetic outcomes
Subcuticular Sutures vs Staples: Quick Comparison Table
When evaluating closure methods for GI surgery, surgeons weigh multiple factors beyond closure time alone. This comparison synthesizes clinical evidence on cosmetic outcomes, patient comfort, and total costs.
| Aspect | Subcuticular Sutures | Surgical Staples |
|---|---|---|
| Closure Time | 5-10 minutes for standard abdominal incision | 1-2 minutes for standard abdominal incision |
| Cosmetic Outcome | Superior; 16.7% hypertrophic scarring at 6 months | More visible scarring; 21.6% hypertrophic scarring at 6 months |
| Patient Comfort | No removal required; minimal anxiety | Painful removal; patient discomfort during wear |
| Removal Requirement | None (absorbable) or single visit (non-absorbable) | Required at 7-14 days post-op |
| Material Cost | Comparable to staples | Comparable to sutures |
| Total Cost | Lower when including no removal visits | Higher with removal visit overhead ($225-$250) |
| Wound Complications | 8.4% at 30 days | 11.5% at 30 days (not statistically significant) |
| Best Use Cases | Clean wounds, cosmetic priority, uncertain follow-up | Emergency surgery, long incisions, reliable follow-up |
Note: The optimal choice depends on wound classification, patient risk factors (diabetes, obesity, immunosuppression), cosmetic priorities, and institutional resources rather than a universal "best" method.
Current practice shows staples dominate at 79% of abdominal closures, though evidence increasingly supports individualized selection.
What Are Subcuticular Sutures?
Subcuticular suturing is a technique that places suture material beneath the epidermis, creating wound closure without piercing the external skin surface.
The sutures run through the dermal layer in either continuous or interrupted patterns, resulting in minimal visible scarring.
Surgeons choose between two main suture types based on wound characteristics and patient needs:
Two Main Types
- Absorbable sutures: Made from polyglactin or poliglecaprone, these dissolve naturally over time, eliminating removal needs
- Non-absorbable sutures: Typically polypropylene, requiring removal but offering extended wound support
Core Clinical Benefits
- Superior cosmetic outcomes with minimal "train track" scarring
- Elimination of painful staple removal procedures
- Reduced patient anxiety throughout recovery
- Better long-term aesthetic results, particularly important for visible surgical sites
- Higher patient satisfaction rates (52.4% vs 42.7% for staples)
Technical Execution Requirements
Subcuticular suturing demands meticulous surgical technique and takes longer than stapling—typically 5-10 minutes for a standard abdominal incision.
The technique requires good visualization, precise needle control, and proper wound edge eversion to achieve optimal results.
Understanding these technical demands helps identify which cases benefit most from subcuticular closure.
Use Cases of Subcuticular Sutures in GI Surgery
Optimal Scenarios
- Clean or clean-contaminated wounds (Class I-II surgical classifications)
- Patients with high cosmetic concerns or visible incision sites
- Pediatric patients who may be traumatized by staple removal
- Patients with keloid predisposition or history of hypertrophic scarring
- Cases where follow-up access for staple removal is uncertain or challenging
Clinical Evidence
A study published in The Lancet demonstrated that hypertrophic scar formation at 6 months was significantly lower with subcuticular sutures (16.7%) compared to staples (21.6%), with p=0.004 showing statistical significance.
Practical Considerations
- Surgeon learning curve requires practice and mentorship
- Adequate hemostasis must be achieved before closure
- Proper wound edge eversion technique is critical for optimal healing
- May not be ideal in contaminated wounds where drainage is anticipated
What Are Surgical Staples?
Surgical staples are metal clips—typically stainless steel or titanium—that rapidly bring together wound edges through mechanical compression. A disposable stapling device deploys these clips through both skin edges, creating immediate wound closure.
Mechanism of Action:
Staples penetrate the epidermis and dermis, creating a "crimped" closure that holds wound edges together. The metal clips provide structural support but create visible puncture sites on both sides of the incision.
Core Operational Benefits:
- Rapid deployment: 1-2 minutes for standard abdominal incision
- Approximately 7 times faster than manual sutures
- Minimal technical skill required for deployment
- Reduced anesthesia time in lengthy procedures
- Ease of use in emergency situations
Clinical Drawbacks:
- Visible "train track" scarring from skin puncture sites
- Patient discomfort during both wear and removal
- Necessity of follow-up visit for removal (typically 7-14 days post-op)
- Higher rates of hypertrophic scarring (21.6% vs 16.7%)
- Lower patient satisfaction with cosmetic results (60.5% satisfied vs 63.7% with sutures)
Despite these drawbacks, staples remain valuable in specific clinical scenarios where speed takes priority over cosmetic outcomes.
Use Cases of Surgical Staples in GI Surgery
Optimal Scenarios:
- Emergency surgery where speed is absolutely critical
- Long incisions requiring rapid closure (extensive laparotomies)
- Situations with limited surgical time or OR availability constraints
- Patients with anticipated good wound healing and low keloid risk
- Settings where follow-up access is reliable and guaranteed
Time Efficiency Data
Research shows staples save 5-8 minutes per procedure compared to sutures. In one specific study, mean closure time was 4.55 minutes for staples versus 11.22 minutes for sutures.
With OR time costing approximately $36-37 per minute, facilities can save $180-296 in operative time per case.
Teaching Hospital Advantages
- Ease of delegation to residents and junior surgeons
- Standardized technique with minimal variation
- Reduced fatigue during long operative cases
- Faster skill acquisition for trainees
Subcuticular Sutures vs Staples: Which is Better for GI Surgery?
Rather than declaring a universal winner, evidence supports a framework for decision-making based on multiple factors:
Decision-Making Framework:
- Wound classification: Clean (Class I) vs clean-contaminated (Class II) vs contaminated
- Patient risk factors: Diabetes, obesity, immunosuppression, smoking status
- Cosmetic priorities: Visible incision location, patient concerns about scarring
- Institutional resources: OR time pressures, follow-up clinic capacity
- Surgeon expertise: Comfort level with subcuticular technique
Clinical Evidence: Wound Complications and Cosmetic Outcomes
The Tsujinaka et al. 2013 Lancet study—a phase 3, multicenter randomized controlled trial involving 1,080 patients—found that 30-day wound complications occurred in 8.4% of the subcuticular suture group versus 11.5% of the staple group. While this favored sutures, the difference was not statistically significant (p=0.12).
However, long-term cosmetic outcomes significantly favored sutures, with hypertrophic scarring at 16.7% versus 21.6% (p=0.004).
A 2021 meta-analysis of 7 RCTs including 3,705 patients confirmed no significant difference in surgical site infection rates between the two methods (OR = 0.85, 95% CI = 0.66–1.09).
Cost Considerations Beyond Materials
Beyond clinical outcomes, financial factors influence closure method selection. While material costs are similar, the total cost picture differs substantially:
- Staple removal visits incur facility and professional fees of approximately $225-250 per visit
- Patient time off work adds indirect costs
- OR time savings with staples (5-8 minutes) equals $180-296 at $36-37/minute
- Net analysis: Sutures may be more cost-effective when removal visit overhead is factored in
Patient-Centered Outcomes:
Studies consistently show higher patient satisfaction with sutures (52.4% vs 42.7%), driven by elimination of painful removal, reduced anxiety, and better cosmetic results.
Situational Recommendations:
Choose subcuticular sutures when:
- Cosmetic outcome is a priority
- Patient follow-up is uncertain
- Wound is clean (Class I)
- Patient has keloid predisposition
Choose staples when:
- Operative time is critical (emergency settings)
- Very long incisions require rapid closure
- Follow-up access is reliable
- Contaminated wound may benefit from easier drainage
Bioabsorbable Subcuticular Closure Systems
Bioabsorbable subcuticular closure systems represent a third option that addresses limitations of both traditional methods. The SubQ It! Bioabsorbable Skin Closure System, for example, combines rapid deployment (7 seconds per fastener, approximately 7X faster than manual sutures) with subcutaneous placement that eliminates train track scarring.
With FDA clearance (K131563) and ISO 13485 certification, these systems provide staple-like speed with suture-like cosmetic outcomes, while eliminating removal requirements entirely.
Clinical Evidence and Real-World Outcomes
The Tsujinaka et al. 2013 Lancet Study:
This phase 3, multicenter, open-label RCT involving 1,080 patients undergoing open GI surgery provided high-quality evidence:
- 30-day wound complications: 8.4% (sutures) vs 11.5% (staples); OR 0.709, p=0.12 (not significant)
- 6-month hypertrophic scar formation: 16.7% (sutures) vs 21.6% (staples); p=0.004 (significant)
- Implication: While short-term complication rates are similar, long-term cosmetic outcomes favor sutures
Additional Clinical Evidence
A 2021 meta-analysis analyzing 7 RCTs with 3,705 patients found no significant difference in SSI rates (OR = 0.98) but noted that staples may increase adverse events by two times (7.3% vs 3.5%; RR 2.00).
A 2020 systematic review concluded that while staples are faster, evidence for superiority in reducing infections is insufficient, and they may increase readmission risk.
Limitations in Current Evidence:
- Many studies lack robust patient satisfaction data
- Long-term cosmetic outcome studies beyond 6 months are limited
- Significant variation in surgical technique affects comparability
- Lack of standardization in outcome reporting across studies
- Most studies don't account for total cost including removal visits
These gaps in the literature highlight the need for real-world data that captures both clinical outcomes and practical implementation factors.
Real-World Implementation Example
Northern Vermont Regional Hospital conducted a clinical evaluation of 50 patients across 16 different surgical procedures using the SubQ It! bioabsorbable closure system. Results showed a 2% infection rate and favorable patient-reported pain scores on a 0-10 scale.
The hospital's decision-making process focused on eliminating removal visits while maintaining rapid closure times, ultimately achieving both improved patient satisfaction and reduced total cost of care.
Innovative Bioabsorbable Solutions:
Systems like SubQ It! address the traditional speed-versus-cosmetics trade-off in wound closure. The device deploys bioabsorbable fasteners subcutaneously in 7 seconds per fastener—approximately 7X faster than manual sutures—while eliminating train track scarring since the external skin is never pierced.
With FDA clearance (K131563) and ISO 13485 certification, these systems provide validated alternatives for closing incisions in abdominal, thoracic, gynecologic, orthopedic, plastic, and reconstructive surgery.
For surgical teams evaluating wound closure options, bioabsorbable subcuticular systems offer a third alternative that combines stapler efficiency with the cosmetic benefits of traditional sutures.
Conclusion
Both subcuticular sutures and surgical staples remain effective wound closure methods in GI surgery, each offering distinct advantages in specific clinical contexts. The optimal choice depends on multiple factors:
- Wound classification and contamination level
- Patient factors (diabetes, keloid predisposition, immunocompromised status)
- Institutional priorities balancing speed, cosmetics, and cost
- Individual surgeon expertise and preference
No single method represents a universal "best" approach.
As surgical practice evolves, emerging bioabsorbable technologies offer promising alternatives that resolve the traditional trade-off between closure speed and cosmetic outcomes. Systems like SubQ It!'s bioabsorbable subcuticular closure combine stapler-like speed (7X faster than manual sutures) with superior cosmetic results, eliminating both the "train track" scarring of metal staples and the time burden of removal appointments.
Surgeons should stay informed about these innovations while maintaining rigorous evidence-based evaluation of all closure methods. The future of wound closure in GI surgery lies not in choosing between speed and aesthetics, but in adopting technologies that deliver both.
Frequently Asked Questions
Which closure method has lower infection rates in GI surgery?
Current evidence shows no statistically significant difference in wound infection rates between subcuticular sutures and staples. Infection rates depend more on wound classification, patient factors like diabetes or immunosuppression, and surgical technique than on closure method.
How much time does each closure method add to surgery?
Staples take 1-2 minutes for a standard abdominal incision, while subcuticular sutures take 5-10 minutes. However, total cost analysis should factor in post-operative staple removal time versus no removal needed for absorbable sutures.
Do patients prefer sutures or staples for wound closure?
Patient satisfaction studies favor sutures (52.4% vs. 42.7% for staples), driven by elimination of painful removal procedures and better cosmetic outcomes with less visible scarring.
What are the cost differences between sutures and staples in GI surgery?
While material costs are similar, staple removal visits incur facility and professional fees of approximately $225-$250, plus patient time and transportation. When these downstream costs are included, sutures become more cost-effective despite slightly longer initial closure time.
When should staples be avoided in abdominal surgery?
Staples should be avoided in patients with high cosmetic concerns, keloid predisposition, pediatric patients who may be traumatized by removal, and situations where follow-up is uncertain. They're less ideal when long-term aesthetic outcome is a priority.
Are there alternatives to traditional sutures and staples?
Yes, bioabsorbable subcuticular closure systems combine rapid deployment with buried placement beneath the skin, eliminating removal while achieving superior cosmetics. FDA-cleared systems like SubQ It! deploy fasteners 7X faster than manual sutures while eliminating train track scarring.
