Stapling devices are used to rapidly close straight, sharp-edged lacerations when cosmetic closure is not needed.
- Relatively straight, sharp-edged lacerations of the trunk or an extremity, and superficial lacerations of the scalp
- Anticipated MRI, because the magnetic field can tear staples from the skin
- Lacerations on the face or neck because the cosmetic result is often inferior to that with suturing
- Lacerations on hands or feet because pain is more often increased
- Anticipated head CT because tissue staples create scan artifact
Wound closure of any type may be contraindicated for wounds that are contaminated, relatively old, or that would be at higher risk of infection if closed, such as small bites to hands or feet, puncture wounds, or high-velocity missile wounds.
Wounds involving deep structures (eg, nerves, blood vessels, ducts, joints, tendons, bones) may require specialized techniques or referral to a surgical specialist, as should those covering large areas or involving the face or hands.
- Improper wound edge apposition leading to poor wound closure and cosmetic result
- In patients who scar easily, a larger scar
- Worse cosmetic effect, particularly if staples are left in too long
Wound hygiene and closure techniques need not be sterile procedures. Although instruments that touch the wound (eg, forceps, needles, suture) must be sterile, clean nonsterile gloves as well as clean but not sterile water may be used in immunocompetent patients. Some operators prefer the better fit and better barrier protection of sterile gloves.
Clean procedure, barrier protection
- Face mask and safety glasses (or a face shield), head caps, gowns, gloves
- Sterile drapes, towels (for wound debridement and suturing)
- Antiseptic cleaner such as chlorhexidine
- Syringes, needles, and local anesthesia
- Tissue forceps
- Stapling device (including removal device)
- Antibiotic ointment
- Nonocclusive dressing
- Suturing and stapling have comparable healing outcomes, wound tensile strength, complication rates, patient tolerance, efficiency of closure, scar width, color, general appearance, suture or staple marks, infection rates, cost, and patient acceptance. In animal studies, staples had less wound inflammation and greater resistance to infection in contaminated wounds.
- The major advantage to using staples is faster time to close the wound. (It is 3 to 4 times faster than using sutures.)
- If wounds have significant underlying tension, place deep, absorbable sutures before stapling to decrease tension.
- Position the patient comfortably reclined or supine.
- Adjust the stretcher height so that you will be comfortable either sitting or standing at the bedside.
- The laceration should be well lit, preferably with an overhead procedure light.
Step-by-Step Description of Procedure
(See How To Cleanse, Irrigate, Debride, and Dress Wounds for step-by-step descriptions of wound preparation, anesthesia, and dressing.)
- Cleanse, anesthetize, irrigate, and debride the wound as necessary.
- Place a sterile fenestrated drape over the wound. Place additional drapes nearby as needed to provide a large enough sterile work area.
- Begin at one end of the laceration.
- Evert the edges of the wound using forceps, preferably done by a second operator. Sometimes, the skin can be everted simply by pinching it between the your thumb and forefinger.
- Once the edges are in eversion, gently place the staples across the wound.
- To ensure the best closure, place the center of the staple device perpendicular to and over the center of the wound.
- Once the stapler handle is squeezed, the staple is automatically placed into the wound and bent to the proper configuration. When placed properly, the crossbar of the staple is elevated a few millimeters above the surface of the skin.
- Work from one end of the laceration to the other, placing each staple about 0.5 to 1 cm from its predecessor, as needed to achieve proper apposition of the edges along the entire length of the wound.
- Apply antibiotic ointment if desired, then leave uncovered or cover with a sterile bandage.
- Have the patient remove the dressing and gently cleanse the wound in 24 to 48 hours. Scalp lacerations can be cleansed by showering within a few hours.
- Remove staples using the same time interval as sutures. (See How To Repair a Laceration With Simple Interrupted Sutures: Aftercare.) To remove staples, use a dedicated instrument made specifically by the manufacturer of that stapling device. Place the lower jaw of the staple remover under the crossbar and squeeze the handle.
Warnings and Common Errors
- Improper wound edge apposition (causing wound edges to overlap) and failure to evert the wound edges are the most common errors. Align the middle of the staple with the center of the wound.
- Pressing too hard on the device when stapling can place the staples too tightly, causing wound ischemia.
- Removal of staples can be more uncomfortable than removal of sutures.
- Staples can cause significant scarring if left in place too long.
Tips and Tricks
- Rather than starting at one end of the laceration, many practitioners find it easier to start in the middle and then place subsequent staples in the middle of each open section, until there are no remaining gaps in the wound.
- If forceps are not available, the skin can be everted by pinching the skin (eg, with thumb and forefinger).