Exploratory laparotomy remains an essential operation for perforation peritonitis, intestinal obstruction, abdominal trauma, intra-abdominal sepsis, bowel ischemia, and malignancy. Although definitive control of intra-abdominal pathology is the central objective, the abdominal wound itself influences postoperative pain, wound infection, dressing requirements, scar quality, hospital stay, and patient satisfaction. Skin staplers are attractive in long abdominal incisions because they are rapidly applied and provide uniform wound-edge approximation. Conventional monofilament nylon sutures are inexpensive, familiar, and allow the surgeon to adjust tension at each point. Published comparisons consistently show faster closure with staplers, but findings for infection, wound dehiscence, pain, and cosmesis remain inconsistent across surgical settings [1–6]. This uncertainty is clinically relevant in emergency laparotomy, where contaminated wounds, sepsis, diabetes, obesity, and delayed presentation are common. The present study compared Ethilon 2-0 interrupted sutures with stainless-steel skin staplers after exploratory laparotomy, focusing on closure efficiency, SSI, postoperative wound morbidity, scar outcome, satisfaction, and cost.

Study design and participants A prospective randomized comparative study was conducted over 18 months in the Department of General Surgery of a tertiary-care teaching hospital. Adults older than 18 years undergoing emergency or elective exploratory laparotomy with planned primary skin closure were eligible. Patients requiring delayed primary closure or open abdomen management, those with skin loss or pre-existing incision-site infection, patients requiring re-exploration before primary wound assessment, ASA grade V patients, and those with inadequate follow-up were excluded. Institutional Ethics Committee approval and written informed consent were obtained. Randomization and intervention Eighty eligible patients were allocated by a pre-generated simple randomization method into two equal groups. In the Ethilon group, skin was closed using Ethilon 2-0 monofilament nylon in a simple interrupted pattern. In the stapler group, stainless-steel staples were applied at regular intervals after accurate approximation and eversion of the wound edges. All other operative and postoperative care followed institutional protocols. Outcome assessment Closure time was measured from placement of the first skin suture or staple until completion of the final knot or staple. Incision length was measured and closure time per centimetre calculated. Wounds were assessed on postoperative day (POD) 3, at suture/staple removal, and on POD 30. SSI was diagnosed using CDC-based clinical criteria. Pain was recorded on a 0–10 numerical rating scale. Day-30 scar outcome was assessed using the Patient and Observer Scar Assessment Scale (POSAS). Direct material cost, wound discharge, erythema, site reaction, seroma/hematoma, wound gaping, hospital stay, overall wound outcome, and patient satisfaction were documented. Statistical analysis Data were analysed using Microsoft Excel and SPSS. Continuous variables are presented as mean±standard deviation and categorical variables as number and percentage. Continuous variables were compared using the unpaired Student t-test; categorical variables were compared using the chi-square test or Fisher exact test, as appropriate. A two-sided p-value <0.05 was considered statistically significant.

All 80 enrolled patients were analysed, with 40 in each group. The groups were broadly comparable for age, sex, diabetes, tobacco use, emergency/elective status, wound class, incision length, and operative duration. Categorical BMI distribution differed between groups (p=0.039), with a greater obesity burden in the Ethilon arm; mean BMI, however, was not significantly different. Table 1: Baseline and operative characteristics Characteristic Ethilon (n=40) Stapler (n=40) p-value Age, years 43.58±14.06 45.23±14.37 0.605 Male sex 29 (72.5%) 26 (65.0%) 0.630 BMI, kg/m² 25.51±4.13 24.01±3.11 0.071 Diabetes mellitus 7 (17.5%) 6 (15.0%) 1.000 Smoking/tobacco use 7 (17.5%) 5 (12.5%) 0.755 Emergency surgery 24 (60.0%) 27 (67.5%) 0.642 Contaminated/dirty wound 21 (52.5%) 21 (52.5%) 0.461* Incision length, cm 16.65±3.55 16.89±3.17 0.746 Duration of surgery, min 111.55±25.72 114.50±22.52 0.588 *p-value relates to the full four-category wound-class distribution. Table 2: Closure efficiency and direct material cost Outcome Ethilon (n=40) Stapler (n=40) p-value Closure time, min 10.53±2.57 3.24±0.90 <0.001 Closure time per cm, min/cm 0.64±0.13 0.19±0.04 <0.001 Direct material cost, ₹ 120.00±0.00 650.00±0.00 <0.001 Staplers reduced mean total closure time by 7.29 minutes and required approximately 30% of the time per centimetre needed for interrupted Ethilon closure. This efficiency was accompanied by a more than five-fold increase in direct material cost. Table 3: Postoperative wound morbidity Outcome Ethilon (n=40) Stapler (n=40) p-value POD 3 erythema 7 (17.5%) 9 (22.5%) 0.781 Stitch/staple-site reaction 10 (25.0%) 6 (15.0%) 0.401 Wound discharge 6 (15.0%) 4 (10.0%) 0.737 Seroma/hematoma 4 (10.0%) 4 (10.0%) 1.000 SSI by CDC criteria 6 (15.0%) 3 (7.5%) 0.481 Wound gaping 3 (7.5%) 2 (5.0%) 1.000 SSI and other wound complications were numerically less frequent in the stapler group in several categories, but none of these differences reached statistical significance. Table 4: Pain, scar assessment and recovery Outcome Ethilon (n=40) Stapler (n=40) p-value POD 3 pain NRS 5.30±0.91 5.22±0.95 0.719 Pain at removal, NRS 3.15±0.80 2.90±0.81 0.169 Day of removal 9.90±1.35 9.90±1.26 1.000 POSAS observer score, POD 30 13.53±3.30 12.25±2.67 0.061 POSAS patient score, POD 30 12.85±2.92 11.55±2.55 0.038 Hospital stay, days 7.28±2.09 7.65±1.58 0.368 Patient-rated scar scores at 30 days favoured staplers, while observer-rated scores showed a similar trend that narrowly missed statistical significance. Early pain and length of stay were comparable. Table 5: Cosmetic outcome, satisfaction and overall wound outcome Outcome Ethilon (n=40) Stapler (n=40) p-value Excellent cosmetic outcome 0 (0.0%) 3 (7.5%) 0.086* Good cosmetic outcome 24 (60.0%) 27 (67.5%) Satisfied/very satisfied 24 (60.0%) 32 (80.0%) 0.086* Healed primarily 16 (40.0%) 17 (42.5%) 0.822* Minor wound morbidity 17 (42.5%) 18 (45.0%) Complicated healing 7 (17.5%) 5 (12.5%) *p-values relate to the complete categorical distributions.

The principal finding of this randomized comparison was the large reduction in abdominal skin-closure time achieved with staplers. The difference remained pronounced after adjustment for incision length: 0.19 minutes/cm with staplers compared with 0.64 minutes/cm with Ethilon. Similar time-saving has been reported in laparotomy and other operative wounds [2–6]. This advantage is clinically meaningful in long incisions, emergency surgery, and physiologically compromised patients in whom reducing anaesthesia and operating-room time is desirable. The faster technique was not associated with a statistically significant increase in SSI, wound gaping, discharge, seroma/hematoma, or early inflammatory change. SSI occurred in 15.0% of the Ethilon group and 7.5% of the stapler group, but the study was not powered to establish a modest difference in infection rates. Contemporary reviews have likewise found that staplers reliably reduce closure time, whereas evidence for superiority of either method in preventing infection remains inconsistent and procedure-specific [4–7]. The inclusion of a substantial proportion of contaminated and dirty wounds in both groups makes these findings relevant to real-world emergency general surgery. Early postoperative pain was similar. At 30 days, patient POSAS scores were significantly lower with staplers, and observer scores showed a favourable trend. Staples may avoid the cross-hatching produced by interrupted sutures and distribute approximation more uniformly; however, scar quality also depends on infection, wound tension, body habitus, skin type, and timing of removal. The short 30-day follow-up limits conclusions regarding mature scar appearance. The principal disadvantage of staplers was cost. Direct material expenditure was ₹650 compared with ₹120 for Ethilon. The study did not monetize operating-room time saved or all downstream costs of wound care, so these figures represent direct acquisition cost rather than a full economic evaluation. In resource-constrained settings, Ethilon therefore remains a rational choice when a few additional minutes of closure are acceptable. Conversely, staplers may offer better value in long incisions, high-throughput emergency theatres, or unstable patients where speed has greater clinical importance. The groups were generally balanced, although categorical BMI distribution differed and more obese patients were allocated to the Ethilon group. This may have modestly influenced wound morbidity because obesity is a recognized SSI risk factor [8–10]. Nevertheless, mean BMI, diabetes, wound class, incision length, surgery type, and operative duration were comparable, supporting the internal validity of the main closure-time finding. LIMITATIONS This was a single-centre study with a modest sample size. Surgeons and patients could not be blinded to closure technique. The 30-day follow-up assessed early scar quality rather than mature cosmesis. The analysis recorded direct material cost but did not perform a full cost-effectiveness model incorporating theatre time, staff time, or long-term wound-care costs. The BMI-category imbalance may have introduced residual confounding.

Both Ethilon 2-0 interrupted sutures and skin staplers were safe and effective for abdominal skin closure after exploratory laparotomy. Staplers produced a substantial and statistically significant reduction in closure time and a modest improvement in patient-rated scar outcome, while SSI and other wound complications were comparable. Ethilon was considerably less expensive. Staplers are particularly useful when rapid closure is clinically valuable; Ethilon remains appropriate when cost containment is the dominant consideration.

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