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Revolutionary Advances in Skin Stapling and Tissue Adhesives Released: January 2006 Sponsored by Dannemiller Memorial Educational Foundation  Supported by an unrestricted educational grant from 
Faculty: Kant Y. Lin, M.D. Professor of Plastic Surgery Chief of Division of Craniofacial Surgery University of Virginia Health Systems Charlottesville, Virginia William B. Long III, M.D. President and Medical Director Legacy Verified Level I Shock Trauma Center for Children and Adults Portland, OR Richard F. Edlich, M.D., Ph.D. Distinguished Professor Emeritus of Plastic Surgery Biomedical Engineering, and Emergency Medicine Founder of the DeCamp Burn and Wound Healing Center University of Virginia Health Systems Director of Trauma,Prevention, Education and Research Trauma Specialists, LLP, Legacy Verified Level I Shock Trauma Center for Pediatrics and Adults Legacy Emanuel Hospital, Portland, OR Statement of Need: Continuing research into present and future techniques of skin stapling and tissue adhesives during surgery makes it important for surgeons and surgical specialists to stay informed about recent advances in the design of skin staples as well as tissue adhesives. Surgeons must be able to restore the physical integrity and function of the injured tissue using either skin staples or tissue adhesives. Goal: The broad mission of this continuing education program is to teach the surgeon and surgical specialists the scientific basis for selecting surgical staples as well as tissue adhesives in surgery. Objectives: At the completion of this activity, the participant should be able to:
To receive credit, participants should, in order, view the objectives, read the educational material, then go to the link at the end of this activity to complete the post-test, evaluation, and then print the CME certificate. This activity should take approximately 1 hour to complete. This activity is available through January 31, 2009. No credit will be awarded after this date. Target Audience: This educational program is intended for general surgeons as well as other surgical specialists or physicians involved in wound closure. Accreditation Statement: The Dannemiller Memorial Educational Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation of Credit: The Dannemiller Memorial Educational Foundation designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. The Dannemiller Memorial Educational Foundation is an approved provider of the California Board of Registered Nursing. Provider approved by the California Board of Registered Nursing, Provider Number 4229 for 1.2 contact hours. RNs outside California must verify with their licensing agency for approval of this course. Faculty Disclosure: Kant Y. Lin, M.D. in accordance with ACCME requirements Dr. Lin has nothing to disclose. William B. Long III, M.D. in accordance with ACCME requirements Dr. Long has nothing to disclose. Richard F. Edlich, M.D., Ph.D. in accordance with ACCME requirements Dr. Edlich has nothing to disclose. Sponsor's Disclosure: In accordance with the Accreditation Council for Continuing Medical Education (ACCME), the Dannemiller Memorial Educational Foundation requires that any person who is in a position to control the content of a CME activity must disclose all relevant financial relationships they have with a commercial interest. Accordingly: The Dannemiller Memorial Educational Foundation staff that was involved in the development of this activity has no financial relationships with any commercial interests that are relevant to this activity. Disclaimer: The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of the Dannemiller Memorial Educational Foundation or US Surgical/Division of Tyco Healthcare. This material is prepared based upon a review of multiple sources of information, but it is not exhaustive of the subject matter. Therefore, healthcare professionals and other individuals should review and consider other publications and materials on the subject matter before relying solely upon the information contained within this educational activity. INTRODUCTION During the last four decades, there have been revolutionary advances in the development of skin staples as well as tissue adhesives. One of the purposes of this continuing education course is to provide an overview of recent advances in the development of skin staples and tissue adhesives. We will provide technical considerations in the use of skin staples and tissue adhesives during surgery. In addition, we will provide scientific information that will allow you to select skin staples and tissue adhesives that have the least risk for infection and allow wound closure to be achieved with the most aesthetically pleasing scar. SKIN STAPLES The use of mechanical means for wound closure first appeared in ancient Hindu medicine. Insect mandibles were employed for wound closure in the jungles of southern Bhutan at the foot of the Himalayas.1 Victor Fischer, an ingenious designer of surgical instruments, was the inventor of the first surgical stapler that used metal staples.2 He designed and developed different gastrointestinal staplers for Hümér Hütl, one of the leading surgeons at the St. Rokus Hospital in Budapest. Hütl operated on his first patient with the stapler on May 9, 1908. The stapling instrument was very bulky and cumbersome, weighing 5 kg and taking two hours to assemble. In 1920, Aladár von Petz, a young surgical assistant at the University of Budapest, designed a stapler weighing only 1 kg that became the prototype for future GI staplers. Subsequently, a great impetus to mechanical stapling devices was given by the Institute for Experimental Surgical Apparatus and Instruments in the mid-1950s.3 The early experience of Steichen and Ravitch4 with the original Soviet staplers convinced them of their potential uses in surgery, which provided the stimulus for American designers and manufacturers to create a family of staplers. Although many of the original staplers were developed from the basic principles utilized in the Soviet instruments, the skin stapler was a totally new kind of instrument in conception. This stapler, manufactured in the United States (AutosutureTM, U.S. Surgical, Div. Tyco Healthcare, Norwalk, CT), utilized a disposable, preloaded, presterilized magazine that contained 25 staples. A small sterile disposable cylinder containing carbon dioxide provided the driving force for the formation of rectangular skin staples. Steichen and Ravitch4 reported that this instrument saved considerable time during the operative procedure. The first major change in the design of this skin stapler was to replace the carbon dioxide cartridge with a mechanical power source, a movable handle.5 By compressing the movable handle against a fixed handle, the surgeon generated sufficient force to form the rectangular staple. This metal stapler, which had to be cleaned and autoclaved before each surgical procedure, employed a sterile, disposable cartridge containing 25 to 35 staples that were easily positioned in the delivery end of the stapler. The time required to clean and autoclave these staplers was circumvented by then developing sterile disposable skin staplers.6 It is one of the purposes of this report to describe the scientific basis for the selection of skin stapling techniques. By understanding the influence of these staple closure devices on the biology of wound repair and infection, the surgeon can accomplish staple closure with the most aesthetically pleasing scar and with the lowest incidence of infection. METAL SKIN STAPLES Metal skin staples are one of the most common techniques of approximating the skin. When selecting a metal skin stapler, the surgeon must consider the following features: design specifications and surgical performance. Design Specifications The surgeon's selection of a disposable stapler is determined by several important parameters of mechanical performance, including 1) handling characteristics, 2) maximal angle of visual access to the staple, 3) angle at which the staple enters the tissue, 4) ease of positioning, 5) prepositioning mechanism for staple, 6) staple release mechanism, 7) texture, and 8) weight. Stapler design must strive to diminish energy expenditure.7 The weight of the stapler is an important consideration to avoid hand fatigue. Using light tools for light tasks is a worthwhile rule. The investigations of Comaish and Bottoms8 and Naylor9 provide a basis for including texture among the important design elements of staplers. A slippery finish demands energy expenditure for retention in the surgeon's hands. Texture that is too coarse can lead to discomfort, skin irritation, and diminished efficiency. Actuating the stapler should be accomplished with ease. Strength differences between men and women provide a basis for using women's strength as a standard when determining forces needed to form staples. Once the staple is formed, all stapler handles are spring-loaded, which returns them to their resting position, reducing work expenditure. Staplers operated by grip activity with a rotating head remain the most popular skin closure staplers. All staplers are designed with fixed and movable handles. For skin staplers operated by grip activities, the surgeon usually compresses the movable handle with the index, long, ring, and little fingers against the fixed handle, which is stabilized against the plane of the hand.10 The distance between the movable and stationary handles is an important consideration in stapler design. Surgeons prefer to compress a movable handle whose contact surface is 5.5-8.0 cm from the contact surface of the stationary handle, because they can exert maximal grip strength at these distances without becoming fatigued.11 When this distance is short (≤3.0 cm), the surgeon's grip strength on the movable and fixed handles is limited, predisposing to fatigue after repeated staple formations. A surgical skin stapler should have a rotating head to provide optimal visualization of the underlying wound. By rotating the stapler head, the stapler can be adjusted so that the instrument does not obstruct the surgeon's view of the wound edge. An important additional feature of the skin stapler is its prepositioning mechanism, which allows the surgeon to hold the staple in various positions during its formation. A clutch-like mechanism has been incorporated into the stapler, which allows the surgeon to release pressure on the moveable stapler handles without losing control of the partially formed staple. The delivery end of the skin stapler cartridge should assume a 60° angle with the underlying skin, which provides intimate contact with the skin with only a 1 mm deep recess in which the staple is formed. When the staple is delivered to the wound at this 60° angle, it tends to assume an upright position that is perpendicular to the wound. This additional space allows the entrapped tissue to expand during healing without contacting the staple topspan, thereby decreasing the likelihood of the development of transverse skin scars (cross-hatching) beneath the topspan. Once the staple is formed, the stapler should have an automatic release system that separates the staple from the stapler. After firing all of the staples in a cartridge, the cartridge should be removed from the instrument and replaced with a new cartridge if additional staples are needed to staple the incision or graft. Finally, the handling characteristics of the stapler should be such that the surgeon can easily implant a large number of staples without becoming fatigued. Like surgical needles, the configuration and position of the pointed legs of the staple may influence the performance of the stapler. The geometry of the staple should assume a rectangular shape in the tissue. The uniform geometry of the stainless steel staples has been attributed to both the position of dimples, or indentations, in the staple wire and to the geometry of the staple wire. Dimples or indentations in the wire have been inset at the junction of the topspan and its legs. These dimples facilitate the positioning of the wire on the anvil and the creation of a uniform staple. In addition, the flattened topspan of the staple gains intimate contact with the anvil, which contributes to uniform staple geometry. In our extensive experience with skin stapling, we prefer rotating head skin staplers. Rotating Head Skin Staplers Rotating head skin staplers are now produced by two different manufacturers. AutosutureTM, U.S. Surgical, Div. Tyco Healthcare, produces the AutosutureTM Multifire PremiumTM, while Ethicon, Inc. (Somerville, NJ) manufactures the Proximate RHTM. AutosutureTM Multifire PremiumTM The AutosutureTM Multifire PremiumTM disposable skin stapler is unique in that it allows its cartridge to be reloaded, allowing multiple uses during a single surgical procedure (Figure 1). This stapler functions like a pistol stapler and is lightweight, weighing less than 98 g. Each Multifire PremiumTM disposable skin stapler has two components: a loading unit and a cartridge. The instrument has a fixed and movable handle that is attached to the stapler delivery body through which the cartridge is loaded. The stationary handle of the loading unit extends from the fixed handle at a 45° angle resulting in an 8.0 cm distance between the contact surfaces of its handles. The contact surface of the movable handle has a deep scallop that accommodates the surgeon's index finger.  The delivery end of the loading unit has a stationary component that is attached to a rotating hollow plastic nose through which the cartridge is inserted. The plastic nose is tapered and short (4.8 cm), so that it does not interfere with the surgeon's sight of the wound. The loading unit accepts cartridges containing either wide or regular size staples, both of which have a rectangular shape with a beveled delivery end. The length and thickness of the cartridge for the regular and wide staples are identical, being 10.1 cm and 7 mm, respectively. The width (1.6 cm) of the cartridge with the regular size staples is smaller than that of the cartridge with the wide staples (2.1 cm). The delivery end of the Multifire PremiumTM disposable skin stapler cartridge assumes a 60° angle, which provides intimate contact with the skin with only a 1 mm deep recess in which the staple is formed. When the staple is delivered to the wound at a 60° angle, it tends to assume an upright position that is perpendicular to the wound. This additional space allows the entrapped tissue to expand during healing without contacting the topspan, thereby decreasing the likelihood of the development of skin scars (cross-hatching) beneath the topspan. Directional arrows made of paper with an adhesive backing are attached to the top and bottom surfaces of the cartridge to indicate the site to which the staple is delivered. The Multifire PremiumTM disposable skin stapler was designed for multiple uses during a single operative procedure. The most obvious advantage of this feature is that it substantially reduces the cost of skin stapling during surgery that involves multiple cartridges. The need for multiple cartridges is especially evident in the fixation of multiple skin grafts during reconstructive surgery. Today the Multifire PremiumTM stapler is limited to only one cartridge change before getting a new skin stapler. Forceps approximate the skin edges before stapling. Stapling is accomplished in a manner so that there is sight of each formed staple. With the surgeon standing at the patient's right side, skin stapling is begun at the cephalad end of incisions. Stapling from the caudad to cephalad direction is technically more challenging because the surgeon's hand and stapler will interfere with sight of previously formed staples, accounting for errors in staple placement that may result in misalignment of the wound edges. By rotating the stapler handles toward the surgeon, sight of the skin edges becomes easier. The rotated delivery end of the stapler is positioned above the divided skin edges. An important additional feature of the Multifire PremiumTM disposable skin stapler is its staple prepositioning mechanism, which allows the surgeon to hold the staple in various positions during its formation. A clutch-like mechanism has been incorporated into this stapler, which allows the surgeon to release pressure on the movable staple handle without losing control of the partially formed staple. Precocking of the instrument occurs when the topspan of the unformed staple rests against the anvil with exposure of the staple legs beyond the stapler delivery end. Precocking of the stapler requires only a small degree of rotation (squeeze) of the movable handle (9.5 ) with insignificant force, because the staple is not deformed. Consequently, the surgeon can precisely and repetitively expose the staple legs, which are strong enough to be used as skin hooks that facilitate approximation of the divided skin edges. Once the staple is formed, the stapler has an automatic release mechanism that separates the staple from the stapler. The Multifire PremiumTM disposable skin stapler cartridges contain 12, 25, or 35 staples. After firing all of the staples in a cartridge, the cartridge should be unloaded from the disposable instrument and replaced with a new cartridge if additional staples are needed to staple the incision. Proximate RHTM Stapler The Proximate RHTM stapler has an external surface made of a smooth polished plastic and functions like a pistol stapler (Figure 2). It is lightweight, weighing less than 122 g. The stapler has a fixed and movable handle that is attached to the delivery end of the stapler, which has a rotating head. The stationary handle of the Proximate RHTM stapler attaches to its delivery end at an oblique angle of 30° from the vertical axis. The longest distance between the contact surfaces of the stationary and movable handles of the Proximate RHTM stapler is 8.0 cm. A shallow scallop, or flare, is evident on the contact surface of the movable handle to facilitate positioning of the surgeon's index finger.  The delivery end of the Proximate RHTM stapler has a stationary part that is attached to its rotating end. Its rotating end has two components. Its proximal position has a tapered plastic sleeve (length 4.0 cm) through which a planar-shaped cartridge (length 6.3 cm) passes to become the delivery end of the stapler. The cartridges for the regular and wide staples of the Proximate RHTM stapler are the same size. The cartridge has a linear slit that allows sight of the number of staples. Once all the staples are fired from the stapler, the surgeon must use a new stapler because its cartridge is fixed to the delivery end of the stapler and is, therefore, not reloadable. The delivery end of the Proximate RHTM cartridge has two distinct parts. Its distal portion (1.8 cm width) with a 1 mm deep recess is flat and contacts the skin surface so that the stapler delivers its staples at a 90° angle to the tissue. The remaining portion is recessed 3 mm from the distal portion (1.6 cm width) and has a flat surface that does not contact the skin. An engraved black arrow on the top of the cartridge indicates the site to which the staple is delivered. The 90° angle at which the Proximate RHTM staple delivers its staples has several implications. This staple delivery angle limits the surgeon's ability to visualize the staple as it penetrates the tissue. Consequently, the surgeon cannot easily control the depth that the staple legs penetrate the tissue. The surgeon may implant the staple deeply in the tissue with its topspan flush with the skin. Such a deeply implanted staple may induce several damaging effects on the tissue. First, it can strangulate the entrapped tissue, and thereby reduce its resistance to infection. Second, it may abrade the underlying skin, which may result in permanent transverse scars. The Proximate RHTM stapler forms a rectangular-shaped staple. Its unformed staple has a unique configuration. V-shaped legs extend from its straight topspan. For this unformed staple to assume a rectangular shape, its legs must rotate 120 . Its unique unformed shape permits an in-line staple-to-staple stacking arrangement which, by itself, seems quite reliable. This stack, however, requires a mechanism to transfer the lead staple to the firing position, and thereby introduces an additional mode of failure (e.g., jamming). Precocking of the Proximate RHTM stapler to a site at which the staple legs are visible beyond the staple delivery end requires considerable force and movement of the movable handle. In contrast to the Multifire PremiumTM stapler, the unformed staple must be deformed to allow visualization of the staples pointed legs. This staple deformation is associated with substantial rotation (16.5-19.5 ) of the stapler's movable handle. Because prepositioning of the Proximate RHTM staple leg involves considerable handle movement by substantial forces, it precludes delicate manipulation of the divided skin edges by the exposed staple legs. Once the staple is formed, the Proximate RHTM stapler has an automatic release mechanism that separates the staple from the stapler. A comprehensive study by Jones and colleagues12 compared the performance of the Multifire PremiumTM and Proximate RHTM disposable skin staplers in an experimental and clinical investigation. Experimental Evaluation Stapler performance for the Multifire PremiumTM and Proximate RHTM was determined by four parameters: force required to form the staple, staple sharpness, uniformity of the staple geometry, and clinical performance. The force required to form the staple is an important factor in assessing stapler performance. Ideally, staple formation should be accomplished with relative ease and without fatigue. Although the distances between the contact surfaces of the movable and stationary handles of the Multifire PremiumTM and Proximate RHTM staplers were remarkably similar (8.0 cm), the investigators reported significant differences between the forces required to form their regular and wide staples using these staplers.12 The forces required to form the Multifire PremiumTM regular and wide staples were significantly less than those needed to form the corresponding Proximate RHTM regular and wide staples (P<0.05). The forces needed to form the Proximate RHTM wide staples were the greatest. Point-sharpness of the skin staple was determined by measuring the maximum vertical force required for it to penetrate a thin synthetic membrane.12 Although the diameter of the regular size staples was less than that of the wide staples, the forces required for the regular and wide staples to penetrate the thin synthetic membrane did not differ significantly. However, the manufacturing process appeared to have considerable influence on staple sharpness, as measured by the penetration forces. The Multifire PremiumTM regular and wide staples encountered significantly lower penetration forces than the regular and wide Proximate RHTM staples (P<0.05). The metal staples had similar composition, being made of 316 L stainless steel. The surfaces of staples may be coated with polymers to facilitate passage through tissue. The manufacturers did not identify the presence of surface coatings and their exact composition. The dimensions of the unformed and formed staples from the staplers were determined by measurements made with a Model TM 20 Nikon Toolmaker Microscope (Tokyo, Japan). The uniformity of the geometry of random samples of the formed staples and the pointed legs was ascertained by photographs at 10 × and 25 × magnifications, respectively. The Multifire PremiumTM regular and wide staples formed by the stapler, without penetrating the skin, had a remarkably uniform geometry.12 In contrast, the geometry of the regular and wide staples formed by the Proximate RHTM stapler showed considerable variability. This disparity in the shapes of the staples had considerable influence on the position of the pointed legs underlying the staple topspan. In some cases, the distances between the pointed legs of the Proximate RHTM staple varied, while in other cases the pointed legs were not in or on the same geometric plane. Clinical Evaluation Five surgeons during surgical procedures that involved skin closure accomplished a clinical evaluation of the Multifire PremiumTM disposable skin stapler and Proximate RHTM stapler.12 For each stapler, the surgeon commented on the staple prepositioning mechanism, visibility of staple during its formation, uniformity of staple geometry, relative force required to form the staple, frequency and type of stapler malfunction, as well as any perceived advantages and disadvantages of the staplers. In this clinical study, the Multifire PremiumTM disposable skin staplers were favored over the Proximate RHTM staplers for closure of incisions. They felt that the major advantage of the Multifire PremiumTM disposable skin stapler was that its cartridge could be reloaded. This reloading capability of the Multifire PremiumTM disposable skin stapler did require limited training of the user to prevent unnecessary malfunction of the stapler. They preferred the handling characteristics of the Multifire PremiumTM disposable skin stapler to the Proximate RHTM skin stapler. They felt that they could preposition (precock) the Multifire PremiumTM disposable skin staplers with less force than the Proximate RHTM stapler, allowing them easier use of the pointed legs of the Multifire PremiumTM staples as skin hooks to facilitate approximation of the divided edges of skin. They favored the delivery end of the Multifire PremiumTM disposable skin stapler over that of the Proximate RHTM stapler, because the beveled delivery end of the Multifire PremiumTM disposable skin stapler delivered the staple at a 60° angle to the wound surface. As the staple rotated to a 90° angle, it left a space between the skin and topspan, allowing easy staple removal. In contrast, the surgeon usually held the delivery end of the Proximate RHTM stapler perpendicular to the underlying wound, making it difficult to visualize and control the depth of penetration of its staple legs. Surgeons could repeatedly use the Multifire PremiumTM disposable skin staplers with either wide or regular staples as well as the Proximate RHTM staplers with regular staples without fatigue. However, surgeons noted that the forces to form Proximate RHTM wide staples were excessive and predisposed to fatigue. Moreover, they were impressed by the uniform geometry of the formed regular and wide Multifire PremiumTM staples that facilitated meticulous approximation of the divided skin edges. In contrast, they noted the non-uniform geometry of the regular and wide Proximate RHTM staples appeared to distort the wound edges. In addition, one out of three Proximate RHTM staplers became jammed during wound closure so that staples could not be delivered into the skin. In contrast, staple jamming of the Multifire PremiumTM disposable stapler was not encountered, unless the surgeon did not reload a new cartridge properly. The influence of staples and their configuration on the biology of skin wound repair and infection has been the subject of increasing numbers of scientific studies. Jewell and colleagues13 compared the healing of sutured wounds to that of the stapled wounds in the rat. The skin incisions in one experimental group were closed with regular-sized Proximate RHTM staples implanted at 5 mm intervals, whereas interrupted 4-0 monofilament nylon sutures approximated skin incisions in the remaining group at 5 mm intervals. Staples and sutures were removed from the wounds on the seventh postoperative day. No significant difference was reported between the mean breaking strength of the wounds with either staples or sutures at 10, 42, and 180 days after closure. However, there was a significant difference in the breaking strength at 21 days, the sutured wounds being slightly stronger than the stapled wounds. There is uniform agreement that skin wounds closed by staples exhibit a superior resistance to infection than skin wounds contaminated by the least reactive suture. In an experimental study, Johnson and colleagues14 compared the resistance to infection of contaminated wounds approximated by tape, staples, or sutures. Skin wounds closed by tape exhibited the greatest degree of resistance to infection, followed by the stapled wounds, and then the wounds approximated by the least reactive nonabsorbable sutures. The superiority of tape closure was evident at all levels of contamination, except 5x107, at which all wounds were destined to develop infection regardless of the closure technique. In the presence of lower bacterial inocula, wounds approximated by staples exhibited a lower rate of infection than the least reactive nonabsorbable suture, monofilament nylon. The infection rate in these wounds correlated with the wound bacterial counts. Sutured wounds exhibited the highest bacterial counts, followed by stapled wounds and then taped wounds. The superior resistance of stapled wounds to infection as compared with the resistance of sutured wounds was confirmed by the experimental study of Stillman and colleagues.10 In contaminated wounds in mice, stapled wounds displayed a lower incidence of infection than wounds approximated by either percutaneous sutures (4-0 silk, 4-0 monofilament nylon, and 4-0 polyglycolic acid suture) or subcuticular sutures (4-0 polyglycolic). In a busy clinical setting, there exists a need for fast, safe, and cost effective methods of wound repair. In animal models, stapled and sutured wounds displayed similar mechanical and histologic characteristics, and contaminated wounds demonstrated lower infection rates when stapling was employed.15 Staple repair also provided other advantageous results, including decreased inflammatory response, wound width, and wound closure times, as well as promotion of wound-edge eversion, formation of an incomplete loop with decreased tissue strangulation, and a lack of residual cross marks.16,17 Kanegaye and colleagues18 conducted a study of a pediatric Emergency Department to determine the cost effectiveness and timesaving benefit of staples in place of sutures. It was determined that staples were six times faster than standard sutures in the closure of scalp lacerations and eight times faster per cm. The results of staple use demonstrated a 29% decrease in the cost of surgical supplies, and an overall 30-40% decrease in the combined costs of supplies and physician compensation. The results of this study are comparable to studies involving adult patients.19,20 Orlinsky and colleagues21 also studied the costs related to both equipment and personnel time in stapling and suturing procedures and found staples to be cost effective for all surgical procedures examined. TISSUE ADHESIVES In the last 20 years, surgeons have become increasingly interested in replacing sutures by means of adhesive bonds in the closure of surgical wounds. Cyanoacrylate tissue adhesives have been used for a number of medical applications including bronchopleural fistula repair, endoscopic treatment of ulcers, high-risk intestinal anastomoses, middle ear surgery, and a mesh fixation for inguinal hernia repair.22-24 The most extensive use of adhesive bonds is, however, for repair of traumatic lacerations in the Emergency Department. There are several advantages for the use of adhesive bonds compared with the conventional sutures. First, tissue union can be achieved rapidly. Second, the need to remove sutures is eliminated. Third, application of adhesive bonds is significantly less painful than suturing, and the cyanoacrylate adhesives have a significant antimicrobial effect against Gram-positive organisms.25 Doraiswamy et al.26 studied the three available tissue adhesives comparing their performance. These tissue adhesives included the following: N-butyl-1,2- cyanoacrylate (Histoacryl, B. Braun, Melsungen, Germany), 2-octyl-cyanoacrylate (DermabondTM, Ethicon, Inc., Somerville, NJ), and N-butyl 2-cyanoacrylate (Indermil®, SynetureTM, U.S. Surgical, Div. Tyco Healthcare, Norwalk, CT). Histoacryl has been available for nearly fifteen years; Indermil® and DermabondTM were introduced to the market during the last decade. Children presenting with uncomplicated wounds <2.5 cm and <6h since the injuries were studied. There were 17 children in each group. Results were compared for the individual tissue adhesive and the technique. The tissue adhesives were applied according to the manufacturer's instructions. For DermabondTM, the outer container had to be squeezed to break the inner container that releases the adhesive, and the adhesive is applied over the approximated wound edges by smearing in contact with the wound. For Histoacryl, the adhesive is squeezed and smeared over the approximated wound edges by the spatulous tip. In the case of Indermil®, the adhesive is squeezed and applied over the approximated wound edges by droplet installation without contact. The caregiver's responses were recorded by direct questioning immediately after the procedure. The use of tissue adhesives was, in general, satisfactory to all concerned: children, caregivers and staff. The glue effect was similar in all of the three tissue adhesives. It was found to be advantageous to use gloved fingers to approximate the wound edges. In the unfortunate event that the glove was stuck to the tissue adhesive, the glove had to be cut and left at the wound site, without disrupting the wound while attempting to release the stuck glove. Use of the glove also helped to prevent adhesion of the user's finger directly to the edges of the wound as the glue finger on removal might disrupt the approximated wound edges. The investigators believe that Indermil® was the best choice among the three tissue adhesives. Parents should be warned of the persistence of scabs for scalp wounds for a maximum of 3.5 weeks in spite of washing hair. Pelissier27 provides comprehensive investigations of the use of Indermil® for wound closure of dorsal wounds with rabbits. A 4 cm long and 1 cm wide incision was created bilaterally on the back of fifteen rabbits. A partial wound dehiscence occurred in the wound subjected to Indermil® in one animal at 2 weeks. In all other animals, no seroma, partial dehiscence, or wound infection occurred. Histopathologic analysis revealed that Indermil® induced edema and a mild acute inflammatory reaction and reabsorbed completely in two months when applied to well vascularized tissue. The investigators concluded that the application of Indermil® on the cutaneous wound edges is a fast and easy procedure that does not seem to delay or inhibit the healing process or its quality. Sinha et al.28 studied 50 patients who underwent a variety of hand operations and were randomized for wound closure either with tissue adhesive (Indermil®) or sutures. The two treatment groups had similar demographic characteristics and similar outcomes at the 2- and 6-week postoperative assessments, which were performed by a designated tissue viability nurse blinded to the method of closure. Five minor wound dehiscences occurred: three in the adhesive group and two in the suture group. No infection occurred in either group. In conclusion, their study demonstrated tissue adhesive was as effective as suture in this type of hand surgery. When cyanoacrylate tissue adhesive is topically applied to a wound site as a liquid, it polymerizes to a firm, pliable film that binds to epithelium and bridges the edges of a wound together. This film is sufficiently water resistant to permit showering by the patient after 48 hours and typically sloughs with keratinized epithelium 5-10 days after applications. When compared with traditional skin closing techniques (sutures, staples, and adhesive tapes), certain cyanoacrylates have been repeatedly reported to be equal in effectiveness and safety for repair of lacerations and surgical incisions. Unlike sutures, cyanoacrylate tissue adhesives do not require special instrumentation or routine use of anesthesia for a removal procedure. They can also be applied more rapidly, and they decrease the amount of wound care from patients by serving as their own dressings. In addition, Osmond et al.29 reported that cyanoacrylate tissue adhesive was more cost effective compared with absorbable and non-absorbable sutures for closing of pediatric facial lacerations. REFERENCES
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