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Commentary on: Tsujinaka T, Yamamoto K, Fujita J, et al. Subcuticular sutures versus staples for skin closure after open gastrointestinal surgery: a phase 3, multicentre, open-label, randomised controlled trial. Lancet 2013;382:1105-12. ContextPostoperative wound complications can occur in 9-26% of gastrointestinal operations. 1-3 Skin closure with subcuticular sutures in clean operations, such as caesarean sections, are associated with decreased wound complications and increased patient satisfaction when compared with skin closure using staples. 4 5 Whether these results are applicable to clean-contaminated operations is unknown. Tsujinaka and colleagues examined the incidence of wound complications after open gastrointestinal operations in patients undergoing skin closure with subcuticular sutures versus staples. MethodsThis multicentre unblinded randomised controlled trial included patients, aged ≥20 years and with adequate organ function, undergoing elective open gastrointestinal operations. Exclusion criteria included emergent operations, prior midline laparotomy, corticosteroid therapy, concomitant infections and comorbidities such as insulin-dependent diabetes. A computerised program randomised patients to skin closure with subcuticular sutures or staples. Surgeons used standardised interrupted suturing and stapling techniques.The primary endpoint was occurrence of wound complications in the first 30 postoperative days. In addition to superficial surgical site infections, wound complications also included abscess from a stitch or metal allergy, and seroma or haematoma. The secondary endpoint was a hypertrophic scar identified at the 6-month postoperative visit. The investigators used Fisher's exact test for primary and secondary outcomes, and adjusted for potential confounders in their post hoc analysis. FindingsOf 1072 patients, 558 underwent skin closure with sutures and 514 with staples. While the difference in overall wound complication rate in the sutured versus stapled groups (8.4% vs 11.5%) was not significant, subgroup analysis of lower gastrointestinal operations demonstrated that sutured closure led to half the rates of overall complications (10.2% vs 19.8%, p=0.0301) and superficial surgical site infections (7.4% vs 15.8%, p=0.0399) compared with stapled closure. Investigators also found that sutured closure reduced wound complication risk in male patients with operative time greater than 220 min, and postoperative anticoagulant therapy. Finally, patients undergoing sutured skin closure after upper gastrointestinal surgery had a lower rate of hypertrophic scar formation (17.3% vs 23.7%, p=0.0282). As the study failed to demonstrate a 5% decrease in overall wound complications, the authors do not advocate that subcuticular sutures be adopted as the standard for open gastrointestinal surgery. CommentaryTsujinaka and colleagues present a timely prospective trial examining the effect of skin closure method on wound complications in cleancontaminated operations. In our era of heightened cost-consciou...