Surgical Staple

Aka: Surgical Staple, Skin Staple, Wound Closure with Staples, Laceration Repair with Staples, Skin Stapler, Surgical Stapler, Closure by Staple

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II. Indications: Skin Staple

  1. Skin closure in regions where tendons and nerves are deeper (Scalp Lacerations)
  2. Rapid closure in actively bleeding wounds (e.g. Scalp Lacerations in multi-Trauma patients)
  3. Partial staple closure as adjunct to suturing other layers
    1. Sutures may be used to close deep layer and reapproximate superficial layer (stay Sutures)
    2. Staples may be used for final closure once deep layers and skin is well approximated

III. Contraindications: Skin Staple

  1. Planned imaging (see imaging interference under complications as below)
  2. Deep wounds (may Suture deep layers, and use staples for skin closure)
  3. Non-linear wounds
  4. Mis-matched irregular wound edges
  5. Face or neck wounds
  6. Hand or Foot Wounds
  7. Extensor surface wounds
  8. Flexor surface wounds

IV. Background: Advantages

  1. Staple placement can be significantly faster than Suture placement
  2. Eliminates Needlestick Injury risk (except when staples need to be removed and replaced)
  3. Cosmetic results are typically similiar to Sutures

V. Complications: Skin Staple

  1. Infection
    1. Higher risk of infection when used for post-operative orthopedic and cesarean skin closures
    2. Figueroa (2013) Obstet Gynecol 121(1):33-8 [PubMed]
    3. Smith (2010) J Bone Joint Surg Am 92(16):2732 [PubMed]
  2. Imaging Interference
    1. Creates "shadows" on CT imaging
    2. MRI appears safe after Skin Staples
      1. Gayton (2011) J Trauma 70(5):1279-81 +PMID:20664378 [PubMed]
  3. Misplaced Staples
    1. Staple placement can be more difficult to direct (esp. larger staplers)
  4. Dog Ear
    1. Occurs when one wound edge is longer than the other
    2. Laceration may be extended into the redundant skin edge, with the extra skin resected, then closed

VI. Technique: Skin Staple

  1. Prepare wound site
    1. See Wound Repair
    2. See Wound Irrigation
  2. Precautions
    1. Evert skin edges while stapling
    2. Stapler midpoint should sit over the Laceration line (between the wound edges)
    3. Avoid excessive would pressure while stapling
  3. Procedure
    1. Assistant approximates and everts each skin edge with toothed forceps (one in each hand)
      1. Non-assistant workflow is demonstrated by Dr. Baladi in YouTube Video below
    2. Align midline of stapler directly over the Laceration line
    3. Stapler should be applied gently against skin (without excessive pressure)
    4. Fire the stapler
      1. Do not release the trigger until the forceps are repositioned
      2. Apply slight lift on the stapler to ease skin approximation at the next position
      3. Release the staple trigger once the forceps are repositioned
    5. Assistant moves their forceps to the next position, staple and repeat as needed
    6. Apply wound bandage (e.g. Bacitracin, wound covering)
  4. Disposition
    1. Precautions to return for signs infection
    2. Give clear date by which staples should be removed
      1. See Suture Removal Timing
      2. Delayed staple removal results in worse cosmetic results
    3. Use staple remover (instead of hemostat) for best results

VII. Resources

  1. Skin Stapling Without an Assistant (Dr. Baladi)
    1. https://www.youtube.com/watch?v=5UqwcASNYp8
  2. Staples (Brian Lin, MD)
    1. https://lacerationrepair.com/techniques/alternative-wound-closure/staples/

VIII. References

  1. Warrington (2017) Crit Dec Emerg Med 31(2): 16-7

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