Open surgical or trauma wounds are closed using a number of devices. Sutures are the oldest form of wound closure. However, staplers, ligating clip appliers, strips and tissue adhesives compete against sutures with their time-saving benefits, ease of use and better aesthetics. The closure device market has been driven and limited by laparoscopic procedures. The reduced exposed area means that fewer closure devices are needed; however, more specialized delivery mechanisms are required in order to access internal tissues through trocar sites. Wound closure devices continue to be required for closing incisions made by trocars. Sutures are a long thread used for holding the edges of blood vessels, organs, skin and other tissues of the body together. The body’s natural healing process seals these edges together and eventually, the sutures can be removed or absorbed. Suturing is also used as a mechanical technique to achieve hemostasis by compressing blood vessels. There are two categories of staplers: internal surgical staplers and external skin staplers. Skin staplers are completely disposable and include a plastic device and stainless steel staples. Surgical staplers can be disposable or reusable, using a refillable cartridge of titanium staples. Furthermore, this market includes endocutters and endostaplers. Endocutters simultaneously staple and cut to seal incision points, and are used in surgeries involving the resection and transection of organs or tissues. Endostaplers are normally used for connecting tissues together when performing procedures such as bowel resections or applying mesh in hernia repair. Endocutters are preferred over endostaplers because they can reduce the amount of bleeding during operations, and therefore decrease complications and reduce the recovery time for the patient. These instruments are used in either open or laparoscopic surgeries. Laparoscopic staplers are longer, thinner and can be adjusted to different angles to allow for access from a restricted number of trocar ports. Ligating clips can be used for permanently or temporarily closing off vasculature or vessels.
Like staplers, this mechanical form of wound closure reduces operation times and costs to hospitals. Appliers have traditionally been reusable, which also provides cost savings for hospitals, as only the refillable clips or cartridges need to be purchased. However, disposable multi-fire appliers have become increasingly popular, especially in laparoscopic procedures, as they are able to place several clips in a patient with a single entry into the trocar site. These devices hold the edges of skin together, facilitating wound healing. They can be used in addition to traditional suturing to supplement skin closure of shallow lacerations or surgical incisions. Strips can also be used alone to replace removed sutures or staples or when the wound is small. When no suture or staple is used, strips greatly improve the cosmetic results as they leave less scarring on the skin. Strips cover the wound area and limit the risk of infection. Since they are applied externally over the skin, they are more comfortable for the patient during application and removal, as well as easier for the healthcare provider to use. In situations where skin may swell or become taut, it is not recommended that strips be applied. Loss of adherence is also another disadvantage of this device. Topical skin adhesives utilize cyanoacrylate (CA). These are fast setting, high tensile strength polymer adhesives capable of binding and sealing the skin with a transparent, waterproof, flexible and durable coating. Skin adhesives are convenient, quick to apply and have better cosmetic results over sutures and staplers. Similar to skin closure strips, skin adhesives are used externally to repair lacerations and incisions. Tissue adhesives have also been used in a number of medical procedures including bronchopleural fistula repair, high-risk gastrointestinal anastomosis, middle ear surgery and mesh fixation for hernia repair. In approximately two and a half minutes, the monomeric units of the tissue adhesive polymerize when they come into contact with the skin’s moisture, forming a strong but flexible bond that naturally sloughs off the skin in five to seven days. The bond is sufficiently water-resistant to allow showering 48 hours after the adhesive has been applied. A disadvantage of tissue adhesives is that they cannot be used in areas of high tension or movement.
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