Stitches that go under the skin for closing wounds after surgery

What is the aim of this review?

The aim of this review was to find out whether subcuticular sutures (stitches placed under the skin) are effective for closing wounds after surgery. We were interested in all types of surgery except obstetric surgery (operations related to childbirth, e.g. caesarean sections). Cochrane researchers collected and analysed all studies related to this question and found 66 relevant randomised controlled trials. Randomised controlled trials are medical studies where patients are chosen at random to receive different treatments. This type of trial provides the most reliable health evidence.

Key messages

In terms of wound infection following surgery, there is no clear difference between stitches that go under the skin and other methods of closing surgical wounds, such as standard stitches that go over the skin, surgical tape, staples, or glue. Stitches that go under the skin probably reduce wound complications compared with staples and improve patient satisfaction compared with stitches that go over the skin or staples. However, glue may improve patient satisfaction, and stitches that go over the skin and staples may be quicker for surgeons.

What was studied in the review?

Surgeons have various options for closing surgical wounds at the end of an operation. Skin closure can be carried out with stitches (sutures) that go under the skin, stitches that go over the skin, staples (clips), tissue adhesives (glue), tapes or other devices. Sutures can be absorbable (the stitches dissolve into the body as part of the healing process and do not need removing) or non-absorbable (the stitches need removing once the wound has healed).

Surgical site infections are a common problem after surgery and can cause a range of problems for patients. Surgical wounds can also cause unsightly scars if they do not heal correctly. We wanted to find out how stitches that go under the skin compare with other methods of closing surgical wounds in terms of infection, scarring, patient satisfaction, cost, pain, length of hospital stay and quality of life.

What are the main results of the review?

In March 2019, we searched medical databases and identified 66 studies that compared stitches that go under the skin with other methods of skin closure such as standard stitches, skin staples, tissue adhesive, tape, or surgical zippers. Sixty-four of these studies (involving 7487 participants) were used in our analysis. On average, each study involved 115 people. Most participants were adults (20 to 75 years) undergoing surgery in a hospital setting. Most studies did not state funding sources.

The majority of studies compared stitches that go under the skin with standard stitches, skin staples or tissue adhesives.

The main outcome of interest was whether wounds became infected. There was no clear difference between stitches that go under the skin and other closure methods in the number of people whose wounds became infected.

Compared with stitches that go over the skin, stitches that go under skin probably improve patient satisfaction. There is evidence that stitches that go under the skin probably prevent wound complications and improve patient satisfaction compared with skin staples. Stitches that go under the skin may prevent wound breakdown (skin separation) compared with staples or tissue adhesives, but tissue adhesives may improve patient satisfaction. However, alternative methods may be quicker for surgeons to use than stitches that go under the skin. There was no clear difference between stitches that go under the skin and the alternative closure methods for re-closure, pain, length of hospital stay and quality of life.

The studies we analysed often involved small numbers of participants and, in many cases, were not reported in a way that meant we could be sure they had been conducted robustly. We cannot, therefore, make conclusive statements about the effectiveness of stitches that go under the skin, and for all comparisons except the comparison with staples, better quality research is needed to form stronger conclusions.

How up to date is this review?

We searched for studies that had been published up to March 2019.

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