A prospective comparative evaluation of wound healing and scar formation using surgical sutures, surgical staplers, and tissue glue

INTRODUCTION

Cutaneous wounds are as old as humanity. The earliest record of wound closure dates back to 1100 BC when abdominal incisions on mummies were closed with leather ligatures. Since then, there have been very few additions to the armamentarium of wound closure devices, including synthetic sutures, staples, adhesive tapes, and, most recently, cyanoacrylate tissue adhesives.^[1] Techniques for closing wounds have progressed from early developments in suturing material to advanced resources, including skin staplers, skin glue, and adhesive tapes. Based on the efficacy of advanced suturing techniques, patients may benefit from better cosmetic outcomes, reduced post-operative pain, fewer wound infections, and shorter hospital stays. Therefore, our study compared adhesive glue with suture materials in terms of outcome.^[2]

Surgical site infection represents a significant postoperative complication in 1–3% of cases. Multiple factors contribute to its development, including advanced age, underlying health conditions (such as the American Society of Anesthesiologists [ASA] score of three or higher, malnutrition, reduced serum albumin levels, diabetes, prior radiotherapy, and corticosteroid usage), excess body weight, compromised immune function, tobacco use, the site of the incision, and the degree of wound contamination. The nature and complexity of the surgical procedure, the duration of the surgery, and the surgical approach methodology are additional significant risk factors. Wound dehiscence is another post-operative complication that can prolong hospital stays, resulting in increased expenditures, and is associated with a 9.6% attributable mortality rate. Surgical wounds may result in additional complications, including the development of hypertrophic or keloid scars. The esthetic outcome of the scar following the healing process constitutes a significant factor influencing PS. A meticulous surgical technique is imperative to mitigate local swelling, wound dehiscence, and suboptimal cosmetic results.^[3] The methodologies and materials utilized for wound closure exhibit considerable variation, contingent on factors such as the nature of the surgical procedure, the extent of the wound, and its anatomical location.^[4]

In this study, we compared the outcomes of using tissue glue, sutures, and staplers regarding suturing time, surgical site infection, post-operative scarring, post-operative pain, and wound cosmesis.

MATERIALS AND METHODS

Our study was conducted in a tertiary care postgraduate teaching hospital. We carefully selected 225 patients with surgical incisions and clean lacerated wounds and randomly allocated them into three groups (A-tissue glue, B-skin stapler, and C-suture material) using a computer-generated random number table. This approach guaranteed that each patient had an equal and independent chance of assignment to any group, minimizing selection bias and ensuring the groups were comparable.

This study concentrated on elective surgical incisions and clean, linear lacerated wounds on the back and extremities. Wounds over areas with high moisture or mobility, such as the perineum, axilla, hands, feet, joints, and mucosal surfaces, were excluded due to their different healing properties and higher risk of complications. This standardization facilitated fair comparison of cosmetic and healing outcomes across the three closure methods. Patients with jagged or stellate lacerations, bites, puncture or crush injuries, contaminated wounds, mucosal surfaces, and high-moisture areas such as the perineum and axillae were excluded. In addition, cases with poor surrounding skin conditions or allergy to materials were omitted. Furthermore, Patients with conditions known to impair healing, such as diabetes, malnutrition, poor skin health, immunosuppression, prior radiotherapy, corticosteroid use, or high ASA scores, were excluded. This rigorous selection process enhances the reliability and validity of our results, ensuring the quality of our research.

In our study, all patients had their subcutaneous tissue (beneath the skin) closed with absorbable polyglactin 3–0 sutures to maintain consistency across groups. The skin was then closed using the method assigned to each group – glue, stapler, or sutures. In the suture group, skin closure was performed with non-absorbable monofilament nylon 3–0 sutures in a simple interrupted stitch. To reduce variability, the same suture material and size were used for all patients, as differing suture types or calibers can influence scarring. Evaluations examined various aspects of the cosmetic outcome after wound closure, including esthetic appearance, scar quality, closure time, cost-effectiveness, infection rates, pain during and after the procedure, and any complications such as wound dehiscence. We recognize that post-operative pain may originate from deeper tissues or the surgical process itself. To minimize this confounding factor, pain was directly measured at the wound site with the visual analog scale (VAS) during the follow-up. As surgical techniques and handling of deeper tissues were consistent across all groups, differences in pain during suture or stapler removal versus tissue glue application primarily reflected the skin closure method. Thus, although all groups experienced some background surgical pain, the extra pain related to the skin closure technique, especially during suture or stapler removal, could be directly compared. This comprehensive evaluation process ensures a detailed understanding of the outcomes and reassures us about the quality of our research. All closures were performed by surgeons who received uniform training, under direct supervision, following standardized protocols to reduce variability. This approach ensured that differences in outcomes were attributable to the closure material itself, not to operator differences.

(A) Wound closure using tissue glue: Sterilized package containing a single-use vial of N-octyl cyanoacrylate. It consists of an outside plastic casing with an inner glass ampule containing 0.5 mL of adhesive that can be expressed through the applicator tip. As the adhesive moves through the applicator tip, it mixes with an initiator and begins the chemical change from monomer to polymer. Moisture on the skin’s surface adds the final catalyst to create the strong polymer bond that bridges the wound edges.

The patient was positioned so that the wound was exposed optimally, and excessive glue spillage to the surrounding area was avoided. The wound margins were manually aligned and uniformly arranged. In case of any uncertainty, suturing was to be done instead. The vial containing N-octyl cyanoacrylate was compressed between the thumb and forefinger and then turned upside down. After gently squeezing the vial and allowing the adhesive to flow from the vial to the application tip, the flow was such that squeezing would stop once a drop began to form at the application tip. The glue was gently brushed onto the opposing wound edges once it reached the application tip. The application tip was not pushed too deep into the wound. After applying the glue, the edges were kept together for at least 30 s before release. For added strength, more glue was smeared around the incision in an oval pattern. At least three layers were used to achieve optimal wound closure strength. The first layer reaches its maximum strength in nearly 150 s (2.5 min). Subsequent layers take somewhat longer because less moisture is available beneath them. Excessive wound seepage before closure prevents good bonding to the epithelial layer and produces excessive heat during polymerization. The adhesive must not go deep into a wound, as it may lead to a foreign body reaction, preventing routine wound healing or causing dehiscence.^[5-7] The adhesive functions as a waterproof dressing, eliminating the need for additional protective coverings. Patients were instructed to maintain their regular showering routine and gently dry the treated area. The adhesive will naturally detach within 5–10 days. It is imperative to avoid applying any topical antibiotics to the sealed wound, as this would compromise the adhesive’s integrity and result in premature detachment.

(B) Wound closure using surgical sutures: Our study applied simple interrupted sutures to the wounds. Surgical sutures are provided in sterile packaging. It is a single-use package. Local anesthesia was given along the edges of the wound. The suturing procedure was initiated by inserting a needle through one side of the wound, traversing the entire dermal layer. The suture was subsequently passed through the whole thickness of the dermis. On the contralateral side of the wound, the needle was reintroduced at an equivalent depth and emerged through the epidermis at a distance from the wound margin equal to that of the initial entry point. The depth of the wound, denoted as x, determined the magnitude of tissue engagement on each side, which was also x. The interval between consecutive sutures was established at ×2. To facilitate proper wound closure, eversion of the edges was accomplished using forceps or manual manipulation. Knots were secured bilaterally to the wound margin.^[8,9]

The patient was made to sit in a well-lit spot for suture removal. The first knot was lifted, and the suture was cut with scissors. The thread was then pulled through. The exact process was repeated for all the stitches. The wound was then cleansed with an antiseptic solution.

(C) Wound closure using surgical staplers: To ensure consistency, we used the same brand of disposable skin staplers (preloaded with 35 pins) in sterile packaging for all patients in the stapler group. Employing a single brand ensured uniformity in staple size, deployment, and removal method, which helped eliminate variability caused by different device designs. Local anesthesia was applied along the edges of the wound. Edges were approximated with the help of forceps. Eversion of edges was ensured during the approximation process. An arrow mark guided the application of the staplers. Keeping the arrow in the centre of the margin of the wound, the staplers were applied sequentially, one by one, with care to keep the margin everted.^[10,11]

Regarding removal, a stapler remover is available on the market and can also be removed with artery forceps. The suture line was cleaned with the antiseptic solution. The larger metallic end of the remover was passed under the applied staple. When the remover was pressed, the smaller metallic end was pressed against the larger one, inverting the stapler pin. The stapler pin was picked with the forceps and removed. The wound was cleaned with the antiseptic solution.

After the procedure, patients were followed up on the 2^nd, 14^th, 30^th, 60^th, and 90^th days. Wounds were assessed using various scoring systems, including the ASEPSIS score, VAS, Vancouver, Hollander, PS Score, and surgeon satisfaction (SS) score, and observations were recorded.

RESULTS

The final analysis was conducted on 225 patients. Evaluations were conducted considering esthetic results post-wound closure, quality of scar formed, duration needed for wound closure, the cost-effectiveness of the method, the incidence of infection, pain during and post-closure of the wound, and any complications such as wound dehiscence.

The wound infection was calculated using the ASEPSIS Score [Table 1]. The patients mainly had mild erythema. No additional treatment was given to patients with erythema or wound infection-related problems. None had a prolonged hospital stay because of wound closure problems. The mean asepsis score was found to be lowest for Group A, with values of 12.28 (7^th day), 9.88 (14^th day), 6.48 (30^th day), and 3.92 (60^th day). However, no significant difference was found between groups considering wound infection rates on subsequent follow-up. Tissue glue spreads over the wound margin and acts as an antimicrobial barrier, contributing to a lower infection rate than the other two groups.

Pain levels were measured using a VAS [Figure 1]. The pain was found to be least in patients where tissue glue was used with a VAS score of 6.8, 5.76, 4.12, 2.48, and 1.36 on the 0, 7^th, 14^th, 30^th, and 60^th day, respectively, and maximum in patients where surgical sutures were used for skin closure with a VAS score of 8.28, 7.52, 7.88, 4.72, and 2.44 on the 0, 7^th, 14^th, 30^th, and 60^th day, respectively. The pain was found to be more on the 14^th day of the procedure in Group B and Group C patients, as they were called for suture and stapler removal on day 14. Removing staplers and sutures was a comparatively painful procedure for the patients; moreover, the patients needed an additional visit to the hospital. However, in Group A patients, tissue glue was used, and no additional visit to the hospital was required.

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Figure 1:

Mean Visual Analog Scale (VAS) score on different follow-up days.

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Scar formation was assessed using the Vancouver scale [Figure 2]. The maximum Vancouver Score of 5.24, 3.96, 2.96, and 1.6 was observed in the group using surgical sutures on the 7^th, 14^th, 30^th, and 60^th days, respectively. In contrast, the minimum scores for the tissue glue group were 4.28, 3.24, 2.4, and 1.04 for the respective days. Pigmentation and scar height were the most common sub-criteria of the Vancouver scale, which was seen as a distortion from routine healing. After the 60^th-day follow-up, 15 patients in Group A, 7 in Group B, and 5 in Group C developed standard color as the surrounding skin. There was a significant difference between the groups; the one using glue showed a better cosmetic outcome.

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Figure 2:

Average Vancouver score on various follow-up days.

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PS scores were calculated on the follow-up, and Group A received a higher value on most follow-up days than Group C. Further, the surgeon’s satisfaction score was assessed, and it was observed that Group A’s score was the highest, with values of 7.92, 8.20, 8.80, and 9.24 on the 7^th, 14^th, 30^th, and 60^th days, respectively [Table 2].

During our study, a few patients developed wound complications. Complications occurred in one instance in Group C and in two cases in Group A. In Group A, one patient with a lacerated wound exhibited wound dehiscence on the 7^th day of application. The skin margins were separated, exposing the underlying soft tissue. The patient’s wound required suturing with monofilament polypropylene. Another patient in the glue group experienced erythematous changes near the application site, which resolved on their own within 5 days without further treatment. No instances of pruritus, urticaria, or systemic allergic reactions were observed. Therefore, although allergy is a known but uncommon risk associated with cyanoacrylate adhesives, its occurrence in our group was very low.

DISCUSSION

In this study, we evaluated the efficacy of three different wound closure methods–tissue glue, surgical staplers, and surgical sutures–by comparing them in terms of infection rates, pain, scar formation, closure time, cost-effectiveness, satisfaction and overall patient and overall patient and surgeon satisfaction. Our findings contributed to understanding these closure techniques’ relative benefits and limitations.

The VAS scores indicated that pain was significantly lower in patients whose wounds were closed with tissue glue than in those using sutures or staplers. This reduction in pain can be attributed to the absence of suture or staple removal, which is usually linked to discomfort and additional follow-up visits. While pain levels were similar between staplers and sutures, the discomfort experienced during and after the use of sutures and staples was considerably higher, especially on the 14^th day, coinciding with the timing of their removal. In the study conducted by Farion et al.,^[6] it was concluded that tissue glue was an acceptable alternative to staplers and sutures. However, there were no significant differences in cosmetic outcomes; nonetheless, the outcomes were better regarding pain and procedure time. Another study by Ananda et al.^[12] concluded that tissue glue is superior to staplers and sutures regarding wound infection, post-operative pain, cost, and cosmesis. Therefore, our study is consistent with the prior literature on this aspect.

Scar quality, evaluated using the Vancouver scale, indicated that tissue glue produced the best cosmetic results, with the lowest average scores for scar formation. This implies that tissue glue delivers superior esthetic outcomes, as demonstrated by fewer cases of hypertrophic or keloid scarring. In separate studies conducted by Ananda et al.,^[12] Lee et al.,^[13] and Bruns and Worthington,^[14] it was also observed that the tissue glue provided better cosmetic results than skin staplers or surgical sutures. These findings reinforce the notion that tissue glue is advantageous in achieving better wound cosmesis.

Our study demonstrated that tissue glue is the fastest method for wound closure, requiring significantly less time than sutures and staplers [Table 3]. This efficiency in closure time can reduce overall procedure duration and may be beneficial in high-volume surgical settings. Surgical staplers also offered a quicker closure than sutures, though they were slower than tissue glue. The speed of closure with tissue glue is advantageous for both the surgical team and the patient, potentially enhancing the efficiency of surgical procedures. In a study conducted by Bruns and Worthington,^[14] it was concluded that tissue glue is faster than the standard wound closure methods in our research. Similarly, in other studies such as Bozkurt and Saydam,^[15] Gilat et al.,^[16] and Chitrambalam et al.,^[17] it was concluded in a similar way that tissue glue was the fastest among the three methods.

Cost analysis revealed that tissue glue is the most expensive option, followed by surgical staplers and sutures. Similar studies, such as Farion et al.,^[6] Göktas et al.,^[18] Khan et al.,^[19] and Bozkurt and Saydam^[15] have also concluded that tissue glue costs more than the standard wound closure techniques. Despite its benefits in terms of time and pain reduction, the higher cost of tissue glue may limit its use in resource-constrained settings. Surgical sutures, being the least expensive, remain a cost-effective option, mainly when economic factors are a primary concern.

Tissue glue scored the highest in PS scores, reflecting its benefits in terms of reduced pain and improved cosmetic outcomes. SS also favored tissue glue, particularly on the 30^th and 60^th days, due to its ease of application and minimal complications. These results highlight the advantages of tissue glue from both patient and surgeon perspectives, reinforcing its utility in clinical practice. Studies like Göktas et al.^[18] and Chitrambalam et al.^[17] also, back our results, showing that tissue glue garners higher satisfaction scores from both patients and surgeons. Furthermore, it aligns with our research, showing that tissue glue has a higher satisfaction score for the patient and the surgeon.

Wound infection rates were assessed using the ASEPSIS score, which indicated that tissue glue had the lowest mean infection scores compared to sutures and staplers [Figure 3]. This suggests that tissue glue may reduce the risk of infection by forming a protective antimicrobial barrier over the wound. However, it is essential to note that the differences in infection rates were not statistically significant across the groups, indicating that all three methods effectively prevent infection when appropriate aseptic techniques are followed. In a study conducted by Mudd et al.,^[20] it was found that two out of 52 patients in the stapler group developed wound infections requiring multiple debridements. Still, no patient in the tissue glue group had any such complication. There was no significant difference between the tissue glue and the stapler group on evaluation. In another study conducted by Chitrambalam et al.,^[17] it was evaluated that tissue glue had the least chance of wound infection among glue, stapler, and suture. Both of these studies further align with the final outcome as indicated by our research.

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Figure 3:

Comparing wound infections across different closure methods: The current study versus published studies.

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Complications were infrequent, with a few cases of wound dehiscence and erythema in the tissue glue group and one accidental needle prick injury in the suture group. While the incidence of complications was low, the findings emphasize the need to apply each closure method carefully to minimize risks.

In our study, all three methods proved effective. However, tissue glue emerged as a significantly superior option, reducing the time needed for wound closure and minimizing the patient’s pain. Its distinct advantage of eliminating the necessity for an additional visit for suture or stapler removal provided practical convenience for both medical professionals and patients, reinforcing its validity. Furthermore, the higher PS with tissue glue supports its effectiveness. This study has limitations, as larger sample sizes are needed to confirm these findings and address any potential bias due to the small study group.

CONCLUSION

Tissue glue offers several advantages over surgical staplers and sutures, including reduced pain, faster closure time, and better cosmetic outcomes. However, its higher cost and the necessity for careful application to avoid complications are essential considerations. Surgical staplers offer a middle ground, balancing moderate cost and efficiency, while sutures, although cost-effective, present challenges related to pain and closure time. Specifically, the scars formed with tissue glue were rated significantly better in appearance and texture than those created with sutures or staplers. The wound closure method should be tailored to the specific clinical scenario, balancing cost, time, and the desired cosmetic outcome. Further research may focus on optimizing the use of tissue glue and exploring strategies to mitigate its higher cost, potentially enhancing its accessibility and application in various surgical settings.