Primary Closure of Surgical Wounds - Essay Example

Topic:  Compare and contrast literature regarding primary closure of surgical wounds and its effect in wound healing Wound healing is defined as a biological process that starts with trauma and ends up with the formation of scar. It is a process of complex and dynamic cellular restoration of structures and layers of the tissue (Mercandetti 2008). Mercandetti described that wound healing comes in various categories, and repair of tissue defect has been the ultimate outcome of the process of healing. The major contributors to postoperative morbidity are infection and dehiscence of the wound. Altogether, this literature study is conducted using several research studies to provide principles to guide surgical wounds, surgical techniques and materials of primary closure, and wound healing. From February of 1996 to July of 1996, Singer et al (2002) examined 814 patients having 924 wounds. In this study, they suggested that wound infection was associated with the presence of extensive wounds and adjacent trauma in the skin. Suboptimal appearance of the wound was increased with its location in the extremity, the size of the wound, its apposition, associated trauma in the tissue, use of electrocautery, and the presence of infection. Singer et al (2002) suggested that minimizing electrocautery use and other surgical techniques traumatizing the skin as well as ensuring complete apposition of the wound with minimal tension during closure of the wound help achieve a cosmetically appealing scar. This study is limited due to its nature being a secondary prospective analysis study. Moreover, wound care was not standardized and only showed small number of poor outcome (12 infections being treated with systemic antibiotics, 9 of which belong to the adhesive group and 3 belongs to the group that uses standard sutures). Another study done by Zeplin, et al (2007) on the comparison of various materials for treatment of lacerations of the skin by means of a pig experiment using OPTOCAT 3 – dimensional scanning technique with 10 Goettinger minipigs as experimental animals to examine wound healing process and development of scar in full incision of the skin. Suture materials used were skin adhesive, absorbing and nonabsorbing suture materials from the following companies: (1) Braun companies (Histaocryl, Monosyn, Safil, Premilene); and (2) Ethicon (Dermabond, Monocryl, Vicryl, Prolene). Zeplin et al (2007) reported that in all wounds that were treated, dehiscence occurred in about 2.5%. Histoacryl skin adhesive shared 15% of the wounds that were treated. From this research study, Zeplin et al (2007) concluded that with an increasing wound length, wound closure treated with common suturing technique must be enhanced by using intracutaneous suture. Skin adhesive is a substitute for common suturing materials and methods under certain circumstances. The efficacy of the study by Zeplin et al (2007) was not tested in the human population and only utilized single session. Unlike the study of Singer et al (2002) which was tested in 814 patients of varying age group with a time period of 5 months. Another study by Lazar et al (2008) mentioned a new technique of skin wound closure to minimize inflammation of the tissue and foreign material as well as to decrease morbidity after harvesting saphenous vein. In this study, Lazar et al (2008) concluded that compared to the traditional subcuticular technique of skin closure, 3M Steri – Strip S Skin closure improved healing of the wound in the saphenous vein site. Unlike the standard method of wound closure, Lazar et al (2008) noted that adhesive skin closure devices eliminates the occurrence of intracutaneous layer foreign bodies thereby decreasing the incidence of colonization of bacteria in the wound. On the other hand, Lazar et al (2008) noted that Steri – Strip S Surgical Skin Closure has made its advantages over other types of adhesive devices since it is made up of polyurethane and polymeric firms with nonlatex materials making it pressure – sensitive, hypoallergenic skin adhesive, thereby decreasing any chances of acquiring hypersensitivity skin reactions. Moreover, Steri – Strip allows wound alignment and accurate tension adjustment decreasing the chances for dehiscence of wound and its transparency allows easy postoperative monitoring, faster closure of skin, less edema and erythema, and superior cosmetic result. Unlike the study of Singer et al (2002), the sample size of the study of Lazar et al (2008) was so small with only 26 participants. This study also limits long term assessment of formation of scar. Another prospective study by Gabel et al (2000) aimed to compare absorbable from non absorbable sutures to close punch biopsy sites. This study was performed among 10 healthy volunteers whom 3 mm punch biopsy was performed in each arm. In each of these subjects, polyglactin 910 and nylon were used to compare closure of biopsy sites. It was found out in the study that no statistically significant difference was observed among the two sutures. Gabel et al concluded that for primary closure of skin biopsy sites, absorbable sutures can be used as a good alternative. On the other hand, Hamada et al (2006) studied the effects of monofilament nylon coated with basic fibroblast growth factor on endogenous intrasynovial flexor tendon. In their study, they were able to conclude that basic Fibroblast Growth Factor – coated nylon suture (bFGF – coated nylon suture) provided exceptional results in delivering selectively a drug to tendon. Moreover, Hamada et al (2006) noted that bFGF – coated nylon suture induced biochemical strength increase and epitenon layer increase in vivo during a 3 – week research period. Hence, accelerating proliferation of cells in the periphery (initially) and centrally (later). Hamada et al (2006) further noted that bFGF – coated nylon suture has become useful as a therapeutic tool in hand surgery. Unlike the study of Singer et al (2002) that involves 814 patients, the study of Gabel et al (2000) is only composed of 10 healthy volunteers. However, the study of Gabel et al is somewhat similar to that of Singer et al due to the length of time considered to observe the formation of hypertrophic scar. A randomized, blinded, prospective trial done by Austin et al (1994) using eleven sprague-dawley rats to determine whether buried, absorbable, subcuticular sutures has increase the degree of inflammation in wounds that are noncontaminated. Austin et al (1994) concluded that in a noncontaminated wound, absorbable subcuticular sutures 6-0 polyglactin 910 do not increase significantly the degree of inflammation. The same study was done by Gabel et al (2001) on absorbable polyglactin 910 suture and both proved to be effective in closing wounds. However, the study of Austin et al (1994) can still be looked at as inconclusive since absorbable polyglactin 910 sutures was not tested in a human population. Also, the study made by Austin et al (1994) made no follow – up for any chances of infection or hypertrophic scar formation as compared to the study of Gabel et al (2000) in which a follow – up was made after six months. Furthermore, another study using coated polyglactin 910 sutures with triclosan was made by Ford et al (1989). In their study, it was noted that in pediatric patients who underwent general surgical procedure, coated polyglactin 910 sutures with triclosan produced a better result than the traditional coated polyglactin 910 suture. The incidence of pain was also much lesser using polyglactin 910 suture with triclosan and was therefore recommended in patients who have high risk of “SSI.” In contrast with the study of Gabel et al (2001), the study of Ford et al (1989) illustrated the reduction of pain incidence using polyglactin 910 sutures with triclosan, which was not observed using the traditional coated polyglactin 910 sutures. On the other hand, the study of Bourne et al (1980) concluded that polyglyconate (Maxon) suture, a monofilament absorbable suture, demonstrated the best in-vitro knot security compared with the braided absorbable sutures polyglycolic acid (Dexon Plus), polyglactin 910 (Vicryl), and polydioxanone (PDS). To further support the claim of Bourne et al (1980), Elliot and Mahaffey (1996) stated in their study that compared to conventional interrupted sutures, subcuticular polyglycolic acid did not achieve scar reduction in one year. Moreover, Rodeheaver et al (1989) noted in their study that monofilament sutures (biosyn) were found to have superior strength than the braided synthetic absorbable suture (Vicryl). It was further observed that monofilament sutures have first-throw hold, security of knot, passage through tissue, repositioning of knot, and ease of handling. On the other hand, Debus et al (1988) noted in his study that polysorb, a braided absorbable surgical material, reached a high quality. The quality of this suture comes close to be an optimal suture since it has been observed to combine with the positive characteristics of monofilaments with multifilament materials. Bourne et al (1980), Elliot and Mahaffey (1996), and Rodeheaver et al (1989) noted in their studies that monofilament sutures were more effective in wound closure compared to the braided sutures. However, Debus et al (1988) remarked in his study a different claim noting that braided absorbable surgical material reached a high quality. Furthermore, the study of Gabel et al (2001), Ford et al (1989), and Bourne et al (1980) made use of polyglactin 910 sutures. However, the focus of study of Gabel et al and Ford et al was mainly in the efficacy of polyglactin 910 sutures in closing the wound and did not go further to the knot security or the tensile strength of the sutures which was done by Bourne et al (1980) in his study. In contrast with the study of Ford et al (1989) who noted a better result using polyglactin 910 sutures with triclosan, On the other hand, Deliaert et al (2008) made a different claim with regards to the effect of triclosan – coated sutures. In their study, they concluded that the effect of triclosan - coated sutures in wound healing among the 26 patients were not beneficial. Among the 26 patients, 16 cases of wound dehiscence were reported in women who used triclosan coated suture (TC) and 7 cases of wound dehiscence were reported in the control group. Deliaert et al (2008) suggested that TC suture must be used with caution. Another study using the upper extremities (hand) of fifty patients who underwent operations was made by Sinha et al (2001) via a randomized study using tissue adhesive (Indemil) or sutures. This study was performed by tissue viability nurse who was blinded with the closure method. Five dehiscences were reported. Three of which were from adhesive group and two in the suture group; however, no infection was reported from these groups. Sinha et al (2001) concluded that tissue adhesive and sutures have the same level of efficacy. Sinha et al further noted that unlike the standard suture, tissue adhesives needs to be used with extra care as this would result to impaired wound healing and occurrence of foreign body reactions (cited from Edlich et al 1971; Toriumi et al 1991). On the other hand Sinha et al noted that when used properly, this would result in fewer foreign body reactions than the standard sutures. This study bears similarities with the study of Singer et al (2002) since both studies resulted in a certain reaction in adhesive group. It can be recalled that in the study of Singer et al, 9 out of 12 infections came from the adhesive group. In connection with this, the study of Sinha et al also noted 3 out of 5 dehisce from the adhesive group. On the other hand, the study of Sanni and Dunning (2007) made use of subcuticular suture (Dixon) and staples in closing wounds. It was noted in the study that the complication rate of wounds using continuous subcuticular suture (Dixon) was lower compared with staples. Sanni and Dunning further noted that regarding cosmesis, sutures remained superior. The result of this study is quite similar with other studies as suture remains in its position to be more effective than staples and other adhesive groups, having less likelihood of dehiscence (as reported in the study of Singer et al 2002 and Sinha et al 2001). However, in the study made by Lazar (2008), he noted that 3M Streri –Strip S Skin has made its advantage over other forms of adhesive devices due to its hypoallergenic content. Another randomized study on the comparison of skin stapling devices and standard sutures for pediatric scalp lacerations done by Kanegave (2001) concludes that in repairing uncomplicated laceration in the pediatric scalp, stapling is recommendable since it is faster and less expensive process compared to suturing with no complications reported. Compared with the study of Sanni and Dunning (2007) noting that subcuticular sutures produced less complications using staples, the study of Kanegave (2001) that recommended stapling devices for the scalp was also acceptable for the reason that scalp needs a strong material to appose its tissues. Toriumi et al (1998) made use of a study using tissue adhesive Octyl-2-Cyanoacrylate or sutures for closing skin in facial plastic surgery in 111 patients who underwent elective surgical procedures by the same surgeon. In this study, no infection or dehiscence of wound or hematoma were observed in both groups. Toriuma et al (1998) reported that in 1 year, a superior cosmetic outcome was observed with octyl-2-cyanoacrylate as compared with sutures using lower visual analog scale score. Moreover, it was noted that in the group treated with octyl-2-cyanoacrylate, very high satisfaction rate among patients was reported. The study of Singer et al (2002) and Sinha et al (2001), also made use of tissue adhesive materials and sutures in closing wounds, but sutures resulted in less complications compared with the adhesive materials, which resulted in dehiscence of tissues and infection. On the other hand, Toriuma et al (1998) were more successful in using tissue adhesive octyl-2-cyanoacrylate compared with sutures in closing skin in facial plastic surgery, probably because of its location (face), as compared with the study of Singer et al and Sinha et al which made use of extremities having its high likelihood of scar formation due to its location. Moreover, another study was made by Osmond et al (1995) on the economic comparison of tissue adhesive and suturing in the repair of facial lacerations in the pediatrics. In the study, Osmond et al reported that the preferred method of closing facial lacerations in the pediatrics is the usage of tissue adhesive since it is most efficient to be used and preferred by most parents. In contrast with the study of Singer et al (2002) and Sinha et al (2001), Toriuma et al (1998) and Osmond et al (1995) were more successful in using tissue adhesive materials in the face for the same reason presented (location). From another point of view, a study on butyl-2-cyanoacrylate fixation (a bioresorbable, noninfective glue) of mandibular osteotomies by Shermak et al (1998) made a conclusion that “butyl-2-cyanoacrylate does not offer the biomechanical stability afforded by plates and screws in bone subject to large forces.” Probably because, the location of the mandible is quite movable and plates and screws affords fixation as compared to the butyl-2-cyanoacrylate fixation. To further support the study of Shermak et al (1998), Forseth et al, (1992) found out in his study that butyl-2 cyanoacrylate (Histoacryl) is used as an adhesive with an excellent binding strength for closure of the skin. In addition, to further support the study of Shermak et al (1998) and Forseth et al, (1992), Quinn et al (1990) made a randomized, controlled trial study to compare tissue adhesive with suturing in the repair of facial lacerations in 81 children. In the study, it was found out that histoacryl blue provides a faster and less painful method in repairing facial laceration with similar cosmetic results using sutures. Hence, one can reach an agreement that butyl-2 cyanoacrylate (Histoacryl) is effective when used in the skin and facial wounds. To appreciate the effectiveness of histoacryl, Toriumi et al (2002) made another study regarding the use of surgical adhesives. In their study, Toriumi et al noted that histoacryl results to minimal histotoxic effect aside from its ability in good bone graft-cartilage binding, whereas Krazy Glue demonstrated severe histotoxicity. However, despite of availability of the less toxic histoacryl, many surgeons still uses ethyl-2-cyanoacrylate (Krazy Glue). The study made by Toriumi et al (2002) somehow supported the study of Shermak et al (1998) on its claim in mandibular osteotomies and can therefore conclude that histoacryl can be effective in bone graft-cartilage binding than mandibular osteotomies. On the basis of favourable mechanical properties, Schwab et al (2007) reported that for onlay repair of transinguinal hernias, mesh fixation using fibrin sealant can be recommended. The study made by Scwab et al (2007) that establishes favourable mechanical properties can be used as the reason for failure of butyl-2-cyanoacrylate in mandibular osteotomies. In addition, Aydin et al (2007) studied on the effects of different temporary techniques of abdominal closure on fascial healing of the wound and postoperative adhesions in experimental secondary peritonitis. In this study, Aydin et al (2007) concluded that in terms of fascial wound healing, primary, Bogota bag, and polyprolen mesh closures are safe to use than skin closure technique only since it sets in deleterious effects due to fascial retraction. Moreover, Aydin et al noted that Bogota bag can cause increased formation of intraperitoneal adhesion. On the hand, Murray and Abrams (1992) noted that the self – sealing iris fixation suture eliminates the need for entry site closure. This instrument was found to be helpful for iris fixation sutures’ rapid, atraumatic placement. The studies of Shermak et al (1998), Scwab et al (2007), and Murray and Abrams (1992) affords the same reason why butyl-2-cyanoacrylate was not effective in mandibular osteotomies, why mesh fixation using fibrin sealant was recommended, and iris fixation sutures was effective, and that is due to its location. A unique study done by Leknes et al (2005) on the reactions of tissues to sutures, silk and expanded polytetrafluoroethylene (ePTFE), in the presence and absence of anti – infective therapy (AT) in the oral cavity of 6 beagle dogs. In this study, Leknes et al (2005) concluded that AT reduced the formation of biofilm and inflammation on the suture track. Regardless of control of infection using AT, it was concluded that among the two sutures, braided silk elicited severe reaction of tissue compared to ePTFE. The subjects that were used in this study specifically the location utilized, gingiva of a beagle dog, poses high likelihood of acquiring inflammatory reaction. Leknes et al (2005) noted that braided silk suture enhanced invasion of bacteria compared with the monofilament ePTFE suture. Another study uses retention suture in a buried technique was done by Tejani and Zamora (1994) and based on that study, the suture material was not in contact with the skin such that no damage in the skin, abscess produced by stitches, and exit point infections were noted since retention suture only encompasses the fascia, muscle and subcutaneous tissue and remains below the skin, extraperitoneally. This study was successful in minimizing severe postoperative pain that was related to retention sutures. Smit et al, (2005) concluded that minimizing trauma in the surgery should be considered as more important factor in physiologic healing of the wound compared to the use of biocompatible sutures. Moreover, Reiter (1995) reported that the roles of oxygen, nutrition, and growth factors are rapidly revealing to the researchers who are experimenting in wound healing, and a scientific basis in managing wounds has been emerging. However, Reiter added that before one can determine an exact method of closing wounds, specific tissue characteristics that need to be closed must be considered together with the anticipated wound healing interval. References Austin P, Daunn K, Eily – Cofied K, 1995, ‘Subcuticular Sutures and the Rate of Inflammation in Noncontaminated Wounds’, Annals of Emergency Medicine, 25(3): 328 – 332. Aydin C, Aytekin F, Yenisey C, et al, 2007, ‘The effect of different temporary abdominal closure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis’, Langenbecks Arch Surgery 393(2008):67–73. Bourne R, Bitar H, Andreae P, 1980, ‘Vicryl, Dexon Plus, Maxon and PDS’, Chirurg, 51(12):768-73 Debus E, Geiger D, Sailer M, 1988, ‘Physical, biological and handling characteristics of surgical suture material: a comparison of four different multifilament absorbable sutures’, Canadian Journasl of Surgery, 31(1):43-5. 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Zeplin P, Schmidt K, Laske M, et al, 2007, ‘Comparison of Various Methods and Materials for Treatment of Skin Laceration by a 3-Dimensional Measuring Technique in a Pig Experiment’, Annals of Plastic Surgery, 58(5): 556 – 572. Read More