What Are Surgical Staples

Laceration - sutures or staples - at home Information

An incision may be closed with. 1. Sutures, stitches, on the outside of the body. 2. Surgical staples, which provide added strength to the incision. 3. Sutures on the inside, underneath the skin. Small sticky strips, called Steri-strips, may be placed on your skin across the incision line. These strips will fall off when the incision has healed.

What Are Surgical Staples?

What Are Stitches?

Cuts and incisions are closed by means of stitches. The medical term for stitches is “sutures,” generally used by doctors and other healthcare providers. A doctor can give a patient stitches with the help of specialized needles and thread. There are primarily two types of stitches; absorbable and non-absorbable. Absorbable stitches dissolve on their own with time, and they do not require to be taken out by a doctor. However, a doctor is required to remove non-resorbable stitches after a few days because they do not dissolve.

What Are Surgical Staples?

Like stitches, surgical staples are a method of closing cuts and incisions during or after surgery. Surgical staples used in the body differ greatly from those used over the paper. Doctors use a specialized stapler to put surgical staples. In some cases, staples may be advised over stitches or sutures. The local inflammatory response, the size of the wound, and the healing period are all reduced when staples are used instead of sutures.

Unlike most sutures, surgical staples do not get resorbed as the incision or wound heals. So, a doctor must take them out after the incision has healed. Staples also require special care. Surgical staplers seal wounds on the inside and outside (skin) of the body. A disposable stapler is typically used to apply skin staples, and a specialized staple remover is used to remove them.

What Are Surgical Staples Made Of?

Surgical staples can be made up of the following materials:

Titanium Staples: Titanium is less susceptible to inflammation or infection than steel and is known to attach to bone and body tissues easily.

Plastic Staples: Plastic staples are used in patients allergic to metals.

Stainless Steel Staples: The initial commercial staplers were constructed of stainless steel, and the titanium staples were placed inside reloadable cartridges.

Polylactide-Polyglycolide Copolymer Staples: This material is readily absorbed in the body. It rarely leaves any significant scar on the skin, so it is very popular amongst plastic surgeons.

What Are the Indications for Surgical Staples?

The following are the indications of surgical staples:

Big wounds or surgical incisions on a patient's skin or scalp are closed outside the body using surgical staplers and staples.

To seal or close surgical incisions or wounds that are too large or complicated to close with conventional stitches.

After a major surgery because staples are easier, faster, and simpler to heal.

Resection (after removing a part of an organ).

How Are Surgical Staples Advantageous to Sutures?

The advantages of surgical staples include the following:

Easy and fast placement.

Minimum tissue damage and resection.

Reduced risk of contracting infections.

Strong closure of the wounds.

How Long Do Surgical Staples Stay In?

Before they can be removed, surgical staples must be left in for a few days or even up to 21 days (in some instances). Where the staples are positioned, and a few other factors determine how long they must remain in place. These factors include:

Size of the incision.

The direction of the incision.

Type of surgery the patient is undergoing.

The complexity of the wound or incision.

The severity of the wound or incision.

How fast the incision area heals.

In case of a C-section, staples that close low transverse incision can be taken out after three to four days. However, surgical staples that close a vertical incision cannot be removed for at least seven to ten days (or more). Moreover, several indicators suggest when it is safe to remove a surgical staple. These indicators are:

The incision or wound area shows signs of being completely healed.

The wound or the incision does not require staples to remain closed.

Absence of pus or blood drainage from the area of the incision or wound.

No symptoms of infection or inflammation are reported.

Can Surgical Staples Be Removed at Home?

No, surgical staples should never be attempted to be removed at home. Always have staples removed by a trained medical practitioner. The doctor will follow special protocols and use specialized tools to securely remove surgical staples without creating complications.

How Are Surgical Staples Placed?

Surgical staples are placed with the help of a surgical stapler. Surgical staplers are very different from standard staplers used to clip papers. Surgical staplers have a handle and a lever that the healthcare provider pushes down to insert the staples, and they closely resemble construction staplers of commercial grade. Using these uniquely designed staplers, surgeons can quickly, accurately, and securely apply surgical staples to an incision or a wound. Because the staples are quickly inserted, the procedure is much quicker than stitching or suturing.

How Are Surgical Staples Removed?

The exact procedure to remove staples depends on the following factors:

Location of the staples on the body.

Type of surgery the patient has undergone.

Whether the staples are placed internally or over the skin.

A doctor should always remove surgical staples, and they are removed in the following ways:

Remove any coverings, such as wound dressings, from the wound or incision area.

Check the wound for any abnormalities like infection, etc.

Sterilize the area with the help of an antiseptic.

On either side of the stapled region, slide the lower portion of a staple extractor under the outermost staple.

Move the staple in a gentle and wiggling motion to remove it.

Place the removed staple safely aside.

Repeat this process till each staple has been removed.

Areas from where staples were removed should be covered with a steri strip.

Some staples may be left inside the body forever. Internal organ tissues are frequently kept attached and protected in this way to prevent further damage.

What Are the Risks Associated With Surgical Staples?

According to the FDA (U.S. Food and Drug Administration), there are certain risks associated with surgical staples. Some of the common risks associated with the use of surgical staples are:

Infection can occur if the wound is not properly taken care of. However, this is a rare occurrence.

The wound may not completely seal or heal poorly due to improper staple positioning.

If the staples are removed too early, the wound will not heal completely and re-open.

Allergies to the staple materials.

What Are the FDA Recommendations for Surgical Staples?

In letters to healthcare professionals published in March 2019 and October 2021, the FDA outlines issues that have been reported. The letters also include several suggestions and new FDA methods regarding the safe use of surgical staples for internal use.

The FDA released the following guidance in October 2021 to help secure patient safety and lower the number of errors, accidents, and fatalities related to the use of surgical staplers for internal use:

A final order was issued to re-classify surgical staples used for internal use. These staples should be classified from Class I to Class II medical devices.

Labeling guidelines were issued to assist manufacturers in creating labeling that contains details about particular risks, restrictions, and instructions for the safe use of surgical staples and staplers.

Conclusion:

Surgical staples are excellent for sealing or closing a wound or incision. These staples heal quickly and easily and do not cause local inflammation or infections. However, there are certain risks associated with the use of surgical staples. The FDA is still monitoring the safety rating for surgical staplers and staples. Additionally, the FDA keeps up its work with medical facilities and trade associations to promote training and instruction to support the safe use of surgical staples and staplers. Surgical staples should never be attempted to be removed at home.

Article Resources

Surgical Staplers and Staples
https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/surgical-staplers-and-staples

Scientific basis for the selection of surgical staples and tissue adhesives for closure of skin wounds
https://pubmed.ncbi.nlm.nih.gov/21284596/

Comparison of Skin Staples and Standard Sutures for Closing Incisions After Head and Neck Cancer Surgery: A Double-Blind, Randomized and Prospective Study
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4871820/

An effective method for removing surgical staples during endoscopic submucosal dissection for early gastric cancer on the suture line of remnant stomach

Associated Data

Supplementary Materials

Video 1 The video shows the method for removing surgical staples during endoscopic submucosal dissection for early gastric cancer on the suture line of remnant stomach. The staples were removed one by one using the knife in EndoCut mode while pulling out the staple.

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Video

Video 1:

The video shows the method for removing surgical staples during endoscopic submucosal dissection for early gastric cancer on the suture line of remnant stomach. The staples were removed one by one using the knife in EndoCut mode while pulling out the staple.

Click here to view.(102M, mp4)

Abbreviation:

ESD, endoscopic submucosal dissection

Introduction

There have been several reports on the safety and efficacy of endoscopic submucosal dissection (ESD) for gastric cancer in a remnant stomach.1, 2, 3, 4 ESD for residual gastric cancer in the suture line poses some specific technical difficulties owing to the limited working space, severe fibrosis in the suture line or anastomosis, and the presence of staples.

Given that staples in the suture line pose a risk of perforation, most surgeons aim to dissect directly above the staples. However, a shallower dissection layer can damage the specimen, leaving behind tumor remnants. On the other hand, dissecting below the staples poses a risk of perforation. Furthermore, dissection in the layer containing the staples results in a continuous flow of current through the staple, increasing the time required for the dissection or possibly increasing the risk of delayed perforation. For these reasons, staples may need to be removed using a tip-type knife to expose the exfoliated layer during ESD.

Case report

The patient in this case was a 68-year-old man who had undergone distal gastrectomy with Billroth I reconstruction 21 years earlier. Routine surveillance gastroscopy revealed a 10-mm depressed lesion in the lesser curvature of the remnant stomach, which was confirmed to be adenocarcinoma on biopsy.

The lesion was located on the suture line of the remnant stomach, and EUS confirmed disruption of the submucosal layer and the presence of staples on the right side below the lesion ( A-C). The muscular layer lay flat under the staples ( D). Preoperative CT revealed no lymph node metastasis, so we decided to perform ESD with the patient under general anesthesia (Video 1, available online at www.giejournal.org).

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The ESD procedure was performed using a Dual Knife (KD650Q; Olympus Medical Systems Corp, Tokyo, Japan). A VIO 300D system (ERBE, Tübingen, Germany) was used as the electrosurgical unit. During the dissection, extensive fibrosis and staples were found in the suture line. The staples were removed one by one using the knife in EndoCut mode while pulling out the staple so that it could be removed immediately ( A-D). There was no perforation or bleeding due to electrification of the staples. The lesion was resected en bloc in 160 minutes with a total operating time of 180 minutes. ESD was completed without adverse events. The post-ESD defect did not close after the procedure, and the patient was discharged on postoperative day 6 after satisfactory wound examination results.

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Histopathology evaluation showed a poorly differentiated adenocarcinoma (por) and signet ring cell carcinoma (sig) with a moderately differentiated adenocarcinoma (tub2) component (por > sig > tub2) measuring 15 × 13 mm without lymphovascular invasion or pathologic ulceration. The depth of tumor invasion was pT1a, and the surgical margins were clear, indicating that complete en bloc resection had been achieved. We evaluated the ESD site at 8 weeks postoperatively and have performed follow-up gastroscopy and CT at 6-month intervals. At the time of writing, the patient is well without local recurrence or distant metastases.

Discussion

Suturing methods for gastrectomy include varus suture and valgus suture. In the case of a valgus suture, it is common to perform the serosal muscular suture from the outside, so it is theoretically possible to remove staples if the surgical procedure is confirmed in advance of ESD and the staples are confirmed to be on the lumen side of the muscular layer by EUS.

The Dual Knife was used to conduct EndoCut electrosurgical current into the staple. The current through the staple results in an EndoCut effect on the tissue that is in contact with the staple, which will then release the staple if some tension is placed. This could have also been achieved by grasping the suture with coagulation forceps or any other knife (eg, hook knife: KD-620QR; Olympus) while applying EndoCut current. Removal of the staples allowed us to secure a better endoscopic view and more reliable ESD, which resulted in safer treatment.

This technique has some limitations. It may be necessary to refrain from removing staples by electrifying the knife because scar formation is often not complete until a few months after surgery.

Removing staples by electrifying the Dual Knife in EndoCut mode is a technique that facilitates ESD on the suture line of the remnant stomach.

Disclosure

All authors disclosed no financial relationships.

Supplementary data

Video 1:

Click here to view.(102M, mp4)

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